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Social Support, Self-Acceptance, and Body Image Concern in Women with and Without Cosmetic Procedures: A Comparative Cross-Sectional Study
Seyedeh Motahareh Taghavi Nia , Seyed Mostafa Mohsenizadeh , Zahra Amouzeshi , Elham Ramezani , Abbas Javadi *
Department of Health Promotion and Education, School of Health, Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran.
Keywords: Body Image, Cosmetic Surgical Procedures, Social Support
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Original Article
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Social Support, Self-Acceptance, and Body Image Concern in Women with and Without Cosmetic Procedures: A Comparative Cross-Sectional Study

Seyedeh Motahareh Taghavi Nia1, Seyed Mostafa Mohsenizadeh2 , Zahra Amouzeshi3
 Elham Ramezani4 , Abbas Javadi5 *  
1 Birjand University of Medical Sciences, Birjand, Iran; Psychologist.
2 Department of Nursing, Qaen Faculty of Medical Sciences, Birjand University of Medical Sciences, Birjand, Iran; Assistant Professor of Nursing.
3 Department of Nursing, School of Nursing and Midwifery, Birjand University of Medical Sciences, Birjand, Iran; Assistant Professor of Medical Education.
4 Department of Nursing, School of Nursing and Midwifery, Birjand University of Medical Sciences, Birjand, Iran.
5 Department of Health Promotion and Education, School of Health, Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran.
*Corresponding Author: Tel: (+98)02132381659, Email: javadi56@yahoo.com
 
Received: 20 April 2026
Revised: 25 May 2026
Accepted: 30 June 2026

Citation: Taghavi Nia SM, Mohsenizadeh SM, Amouzeshi Z, Ramezani E, Javadi A. Social Support, Self-Acceptance, and Body Image Concern in Women with and Without Cosmetic Procedures: A Comparative Cross-Sectional Study. J Surg Trauma. 2026.
DOI: jsurgery.bums.ac.ir




Abstract
Introduction: Despite the increasing prevalence of cosmetic interventions worldwide, little is known about the distinct psychological profiles, particularly regarding self-acceptance and body image, that differentiate women who pursue such procedures from those who do not. The present study aimed to investigate differences in social support, unconditional self-acceptance, and body image concern between women with and without a history of cosmetic procedures.
Materials and Methods: This cross-sectional comparative study was conducted on 426 women attending cosmetic clinics in Birjand, Iran, including 188 with a history of cosmetic procedures and 238 without such history. Inclusion criteria were: age ≥18 years, no medical necessity for procedures, and willingness to participate. Participants with incomplete questionnaires were excluded. Participants were selected using convenience sampling. Data were collected using the Social Support Appraisals Scale (SS-A), the Unconditional Self-Acceptance Questionnaire, and the Body Image Concern Inventory (BICI). Data were analyzed using independent samples t-test, Pearson correlation coefficient, and SPSS (version 23).
Results: The majority of participants were aged 20-40 years (76.9% in the non-cosmetic group and 84.6% in the cosmetic group) and held master's degrees or higher (41.6% and 47.3%, respectively). Women with a history of cosmetic procedures reported significantly higher perceived social support compared to those without such history (p<0.05). No significant differences were observed in unconditional self-acceptance and overall body image concern between the two groups (p>0.05). However, women with cosmetic procedure history reported greater interference of appearance concerns with their social functioning compared to those without such history (p<0.05). Correlation analysis indicated a positive relationship between social support and self-acceptance (r=0.204; p<0.001), and negative relationships between social support and body image concern (r=-0.377, p<0.001), and between self-acceptance and body image concern (r=-0.538, p<0.001).
Conclusion: No significant association was found between a history of cosmetic procedures and deeper psychological constructs, such as self-acceptance or global body image concern. The findings suggest that psychosocial factors play a more fundamental role in shaping body image perception..

Key words: Body Image, Cosmetic Surgical Procedures, Social Support
 
 
 
Introduction
The tendency toward beauty has long been an inherent human characteristic, especially among women (1). However, in modern societies, cosmetic procedures have increased significantly, often without medical necessity, becoming a social and psychological phenomenon (2). With the rapid growth of social media platforms such as Instagram, TikTok, and Snapchat, individuals are increasingly exposed to idealized and often digitally altered images of beauty. This constant visual comparison has intensified appearance-related concerns and contributed to what some researchers have termed "selfie dysmorphia" – a disconnect between how individuals perceive themselves in photos versus in the mirror (3). Consequently, the pressure to conform to unrealistic beauty standards has driven many, particularly women, toward cosmetic procedures as a means of achieving socially endorsed appearance ideals. Body image is a multidimensional psychological construct formed through biological, psychological, and social influences (4). It reflects how individuals perceive and evaluate their physical appearance (5). Disturbances in body image may persist even in objectively normal appearance conditions (5,6). Social support refers to emotional, informational, and instrumental assistance received from others, contributing to a sense of belonging and psychological security (6). Previous studies suggest that social support is associated with body image dissatisfaction and cosmetic surgery tendencies (7–9). Unconditional self-acceptance is defined as acceptance of oneself independent of external validation and is considered a protective psychological factor (10,11). Previous research has indicated its association with psychological well-being and reduced self-criticism (12-15). Despite extensive literature on predictors of cosmetic surgery intention, fewer studies have compared psychological constructs in individuals with actual cosmetic procedure history versus those without it. Additionally, both invasive and non-invasive cosmetic procedures have not been equally considered in prior research.
Therefore, the present study aimed to investigate differences in social support, unconditional self-acceptance, and body image concern among women with and without cosmetic procedure history.




Materials and Methods
Study Design
This cross-sectional comparative study was conducted among women attending cosmetic clinics in Birjand, Iran, between January and June 2025.

Participants
The sample included 426 participants: 188 women with cosmetic procedure history and 238 without such history. Convenience sampling was used. Participants were included if they expressed willingness to participate, had no medical necessity for undergoing cosmetic procedures, and had either undergone at least one invasive procedure (e.g., rhinoplasty, blepharoplasty, mammoplasty, abdominoplasty) or non-invasive procedure (e.g., Botox injection, dermal filler, laser hair removal, chemical peel) under professional supervision within the past five years. Participants with incomplete questionnaire data or those who declined to continue participation were excluded.

Sample Size
Sample size was calculated based on independent mean comparison (α=0.05, power=0.80, effect size≈0.35), yielding approximately 200 participants per group [16].

Data sources/measurement
Data for the present study were collected using three standardized questionnaires: social support, unconditional self-acceptance, and body image concern.
  1. Social Support Questionnaire
Social support was assessed using the 23-item Social Support Appraisals (SS-A) scale developed by Vaux et al. (1986), based on the conceptualization proposed by Cobb. Responses are rated on a 5-point Likert scale ranging from 1 (very low) to 5 (very high). The questionnaire comprises three subscales: family support (items 2, 4, 7, 9, 11, 13, 18, 22), friends’ support (items 1, 6, 10, 15, 16, 19, 23), and support from others (items 3, 5, 8, 12, 14, 17, 20, 21). Scoring: Items 3, 10, 13, 21, and 22 are reverse-scored. Subscale scores are calculated by summing the relevant items. Total social support score ranges from 23 to 115, with higher scores indicating greater perceived social support [17]. The reliability of this scale has been reported as satisfactory. In a study by Ebrahimi-Ghavam, Cronbach’s alpha for the total scale was measured at 0.90 (18).
  1. Unconditional Self-Acceptance Questionnaire
Unconditional self-acceptance was measured using the Unconditional Self-Acceptance Questionnaire developed by Chamberlain and Haaga in 2001. This instrument consists of 20 items and includes two subscales: unconditional self-acceptance and conditional self-acceptance. It is suitable for individuals aged over 14 years. Responses are rated on a 7-point Likert scale ranging from 1 (almost always untrue) to 7 (almost always true). In this questionnaire, higher scores on 9 items (2, 3, 5, 6, 8, 11, 16, 17, 18) indicate greater unconditional self-acceptance (score range: 9–63). The remaining 11 items (1, 4, 7, 9, 10, 12, 13, 14, 15, 19, 20) are reverse-scored, such that lower scores reflect higher conditional self-acceptance (score range: 11-77) (19).
In Iran, Kalantari (2013) reported reliability coefficients of 0.73 (Cronbach’s alpha) and 0.72 (split-half) (20).
  1. Body Image Concern Inventory (BICI)
Body image concern was assessed using the Body Image Concern Inventory developed by Littleton et al. (2005). This instrument includes 19 items designed to evaluate individuals’ dissatisfaction and concern regarding their physical appearance. Responses are rated on a 5-point Likert scale ranging from 1 (never) to 5 (always). Total scores range from 19 to 95, with higher scores indicating greater body image dissatisfaction.
Factor analysis has identified two significant dimensions: the first factor (items 1, 3, 5, 8, 9, 14, 15, 16, 17, 18, 19) reflects dissatisfaction, shame, checking behaviours, and efforts to conceal perceived defects; the second factor (items 2, 4, 6, 7, 10, 11, 12, 13) represents the extent to which appearance concerns interfere with social functioning (21). In a study by Mohammadi (2007), Cronbach’s alpha for the total scale was 0.93 (22).

Statistical Analysis
The collected data were analyzed using SPSS (version 23). Independent samples t-test and Pearson correlation coefficient were applied to examine group differences and relationships between variables. Given the number of independent t-tests conducted (k=9 tests: 3 social support subscales + 3 self-acceptance subscales + 3 body image concern subscales), a Bonferroni correction was applied to control for Type I error inflation. The adjusted alpha level was set at p<0.0056 (0.05/9). Effect sizes (Cohen's d) and 95% confidence intervals were calculated for all comparisons.

Results
The study participants totalled 426 individuals, consisting of 238 women without a history of cosmetic procedures and 188 women with a history of cosmetic procedures. As shown in Table 1, in both groups, the 20–40 age range had the highest frequency (76.9% and 84.6%, respectively). Additionally, the majority of participants in both groups held master's degrees or higher (41.6% and 47.3%, respectively), and the most frequent occupational category in both groups was students (47.9% and 39.4%, respectively) (Table 1).
As presented in tables 2 and 3, women with a history of cosmetic procedures reported significantly higher total perceived social support (Mean=82.53, SD=12.97) compared to women without such history (Mean=79.74, SD=13.04). This difference was statistically significant (t=2.412, i=0.016, Cohen's d=0.23). Specifically, significant differences were observed in family support (t=2.234, p=0.026, d=0.22) and significant other support (t=2.568, p=0.011, d=0.25), with the cosmetic procedure group scoring higher on both subscales. No significant difference was found for friend support (p=0.211). After Bonferroni correction (α=0.0056), none of these comparisons remained statistically significant (tables 2 and 3).
As shown in tables 4 and 5, no statistically significant differences were found between the two groups on unconditional self-acceptance (p=0.095, d=0.16), conditional self-acceptance (p=0.992, d=0.00), or total self-acceptance scores (p=0.322, d=0.10). These findings indicate that women with and without cosmetic procedure history did not differ in their levels of self-acceptance (tables 4 and 5).
Tables 6 and 7 present the results for body image concern. While no significant difference was observed in overall body image concern (p=0.195, d=0.13) or the appearance dissatisfaction subscale (p=0.577, d=0.05), a significant difference emerged in the "interference with social functioning" subscale. Women with a history of cosmetic procedures reported greater interference of appearance concerns with their social functioning (Mean=21.10, SD=7.25) compared to women without such history (Mean=19.67, SD=6.83). This difference was statistically significant (t=2.067, p=0.038, d=0.20). After Bonferroni correction, this difference did not remain statistically significant (tables 6 and 7).
Pearson correlation analysis revealed significant associations among all three variables. Social support was positively correlated with self-acceptance (r=0.204, p<0.001), indicating that women who perceived greater social support also reported higher levels of self-acceptance. Conversely, social support was negatively correlated with body image concern (r=-0.377, p<0.001), meaning that higher social support was associated with lower body image concern. The strongest correlation was observed between self-acceptance and body image concern (r=-0.538, p<0.001), suggesting that women with greater self-acceptance tended to have significantly lower concerns about their body image.
 
 

Table 1. Demographic Characteristics of Participants with and without a History of Cosmetic Procedures (n=426).
Variable Without a History of Cosmetic Procedures
(n=238)		 With a History of Cosmetic Procedures
(n=188)
Frequency Percentage Frequency Percentage
Age <20 29 12.2 8 4.3
20-40 183 76.9 159 84.6
>41 26 10.9 21 11.2
Education <Diploma 8 3.4 4 2.1
Diploma 34 14.3 20 10.6
Associate 12 5.0 10 5.3
Bachelor 85 35.7 65 34.6
Master+ 99 41.6 89 47.3
Occupation Unemployed 33 13.9 17 9.0
Student 114 47.9 74 39.4
Employed 60 25.2 71 37.8
Other 31 13.0 26 13.8
Total 238 100 188 100
 


 
Table 2. Descriptive Statistics for Social Support Subscales by Group.
Variable Group Min Score Max Score Mean Std. Deviation
Family Support With History 8 39 29.47 5.75
Without History 12 40 28.20 5.99
Friend Support With History 12 35 24.01 5.12
Without History 12 35 23.41 5.08
Significant Other Support With History 11 40 28.72 4.88
Without History 16 39 27.54 4.57
Total With History 49 109 82.53 12.97
Without History 47 111 79.74 13.04


Table 3. Independent Samples t-test Results with Effect Sizes and confidence Intervals.
Variable t df p (raw) P (Bonferroni) Mean Diff. 95% CI Cohen’s d
Family Support 2.234 424 0.026 0.234 1.277 [-0.21, 2.76] 0.22 (small)
Friend Support 1.252 424 0.211 1.000 0.604 [-0.34, 1.55] 0.12 (small)
Sig. Other Support 2.568 424 0.011 0.099 1.181 [0.28, 2.08] 0.25 (small)
Total Social Support 2.412 424 0.016 0.144 3.062 [0.57, 5.55] 0.23 (small)
Note: After Bonferroni correction (α=0.0056), no comparisons remained statistically significant.
 

Table 4. Descriptive Statistics for Self-Acceptance Subscales by Group.
Variable Group Min Max Mean Std. Deviation
Unconditional Acceptance With History 23 61 47.0053 7.06236
Without History 21 63 45.8487 7.10338
Conditional Acceptance With History 16 61 37.1604 8.37405
Without History 16 58 37.1512 9.20692
Total Self-Acceptance With History 39 122 84.1657 11.42582
Without History 37 121 82.9873 11.94709


Table 5. Independent Samples t-test Results for Self-Acceptance (Levene’s Test).
Variable Levene's Test t-test for Equality of Means
F Sig. t df p (raw) Mean Diff. 95% CI Cohen’s d
Unconditional Accept. 0.43 0.835 1.673 424 0.095 1.157 [-0.20, 2.51] 0.16 (small)
Conditional Accept. 0.105 0.306 0.010 424 0.992 0.007 [-1.64, 1.65] 0.00
Total Self-Acceptance 0.347 0.556 0.991 424 0.322 1.136 [-1.11, 3.38] 0.10 (small)

 
Table 6. Descriptive Statistics for Body Image Concern Subscales by Group.
Variable Group Min Max Mean Std. Deviation
Appearance Dissatisfaction With History 11 50 23.7979 8.81610
Without History 11 55 23.3109 9.01780
Interference with Social Functioning With History 8 40 21.0957 7.25335
Without History 8 38 19.6681 6.82722
Total Body Image Concern With History 19 90 44.8936 15.23433
Without History 19 91 42.9790 15.05193


Table 7. Independent Samples t-test Results for Body Image Concern.
Variable t df p (raw) P (Bonferroni) Mean Diff. 95% CI Cohen’s d
Appearance Dissatisfaction 0.552 424 0.577 1.000 0.488 [-1.22, 2.20] 0.05 (small)
Interference with Social Functioning 2.067 424 0.038 0.342 1.428 [0.08, 2.78] 0.20 (small)
Total Concern 1.295 424 0.195 1.000 1.915 [-0.99, 4.82] 0.13 (small)
 
Discussion
The findings of the present study provide important insights into the psychological and social correlates of cosmetic procedures among women, particularly in relation to perceived social support, unconditional self-acceptance, and body image concern. Contrary to a simplistic assumption that cosmetic procedures directly reflect or modify core psychological structures, the results suggest a more complex and multidimensional pattern of associations.
First, the absence of significant differences in unconditional self-acceptance between women with and without a history of cosmetic procedures is theoretically meaningful. This finding suggests that self-acceptance, as a relatively stable cognitive-affective construct, may not be substantially influenced by engagement in aesthetic interventions. From a cognitive-behavioural perspective, unconditional self-acceptance is conceptualized as a deep-seated evaluative orientation toward the self that is relatively resistant to situational or behavioural modifications (23,24). Therefore, individuals may pursue cosmetic procedures not because of a global deficiency in self-worth, but rather due to localized dissatisfaction with specific body features. This distinction is critical, as it challenges the assumption that cosmetic surgery seekers necessarily demonstrate generalized psychological maladjustment (25).
Second, the lack of significant differences in overall body image concern between the two groups further supports the multidimensional and persistent nature of body image-related cognitions. Body image concern is not a unidimensional construct limited to appearance dissatisfaction; rather, it encompasses cognitive, emotional, and behavioural components that may remain stable even after aesthetic modifications (26). One possible interpretation is that while cosmetic procedures may temporarily enhance satisfaction with particular physical features, they do not necessarily modify the underlying cognitive schemas related to body evaluation, social comparison, or internalized appearance ideals (27). This explanation is consistent with sociocultural models of body image, which emphasize the enduring influence of media standards and interpersonal evaluation processes (3).
However, the significant difference observed in the social functioning interference subscale provides a more nuanced understanding of the psychosocial consequences of cosmetic procedures. Women with a history of cosmetic interventions reported greater interference of body-related concerns in social and interpersonal functioning. This may indicate heightened self-focused attention or increased sensitivity to external evaluation following cosmetic enhancement. In other words, while cosmetic procedures may aim to reduce appearance-related anxiety, they may paradoxically increase cognitive monitoring of appearance in social contexts, particularly in environments where appearance evaluation is salient. This finding aligns with social evaluative threat models, which propose that individuals who invest more heavily in appearance management may also experience increased vulnerability to perceived social judgment (28).
An unexpected but important finding of the present study is the higher level of perceived social support among women with a history of cosmetic procedure. Traditional theoretical models often assume that lower social support is associated with greater body dissatisfaction and increased likelihood of engaging in appearance-modifying behaviours (29). However, the present findings suggest a more complex mechanism. It is possible that in contemporary sociocultural contexts, social networks may actively reinforce cosmetic enhancement behaviours rather than discourage them (3). Family members, peers, and partners may provide approval, encouragement, or normalization of cosmetic procedures, thereby increasing perceived social support scores. In this sense, social support may not always function as a protective factor; instead, it may operate as a reinforcing mechanism that facilitates engagement in appearance modification practices (30).
The correlation analysis further clarifies the interplay between the studied variables. The positive association between social support and unconditional self-acceptance suggests that individuals who perceive greater interpersonal support are more likely to develop a stable and accepting self-evaluative orientation. This finding is consistent with sociometer theory, which posits that perceived relational acceptance contributes to internal self-worth regulation (31). Conversely, the negative associations between social support and body image concern, and between self-acceptance and body image concern, indicate that both interpersonal and intrapersonal resources may serve as protective factors against maladaptive body-related cognitions. Nevertheless, these findings should be interpreted with caution given the cross-sectional nature of the study, which precludes causal inference.
From a broader theoretical standpoint, the present findings highlight the importance of distinguishing between global self-evaluative constructs and domain-specific appearance-related concerns. Cosmetic procedures appear to have limited influence on global psychological structures such as unconditional self-acceptance, while exerting more complex and potentially paradoxical effects on social cognition and interpersonal sensitivity. This suggests that body image-related distress is not simply a function of physical appearance but is embedded within broader cognitive schemas and sociocultural expectations (31).
Clinically, these findings have important implications. Interventions aimed at improving body image and reducing excessive reliance on cosmetic procedures should not focus exclusively on modifying physical appearance. Instead, psychological approaches, such as cognitive restructuring, self-compassion training, and reducing maladaptive social comparison processes, may better address the cognitive-emotional mechanisms underlying body dissatisfaction. Furthermore, psychoeducational programs that address sociocultural beauty ideals and social reinforcement patterns may help reduce the normalization of excessive cosmetic interventions (32).
Overall, the results emphasize that cosmetic procedures alone are insufficient to produce meaningful changes in deep psychological constructs. Rather, body image concerns and self-evaluative processes are embedded within complex interpersonal and sociocultural systems that require multidimensional intervention strategies.
This study benefits from a relatively large sample size (n=426) and inclusion of two well-matched comparison groups (women with and without cosmetic procedure history). The use of validated and widely used psychometric instruments (SS-A, Unconditional Self-Acceptance Scale, and Body Image Concern Inventory) increases the reliability and comparability of findings. In addition, inclusion of both invasive and non-invasive cosmetic procedures enhances the comprehensiveness of the study population.
This study has several limitations. First, its cross-sectional design prevents inference of causality between variables. Causal relationships cannot be determined from the current data. Second, data were collected using self-report questionnaires, which may introduce response and social desirability biases. Third, convenience sampling limits the generalizability of the findings to the broader population. Fourth, potential confounding psychological variables such as depression, anxiety severity, personality traits, perfectionism, social media exposure, and socioeconomic status were not controlled. Fifth, both groups were recruited from cosmetic clinics; therefore, the "without history" group may still desire cosmetic procedures or hold similar appearance-related attitudes, introducing potential selection bias. Sixth, psychiatric screening was not performed, and the presence of body dysmorphic disorder or other mental health conditions was not assessed.

Conclusion
The findings of the present cross-sectional comparative study revealed that cosmetic procedures were not significantly associated with deep psychological structures, such as self-acceptance and body image concern. The findings suggest that psychosocial factors, including perceived social support and its complex interplay with self-acceptance, play a more central role in shaping body-related perceptions.

Ethics Approval and Consent to Participate
The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the relevant institutional review board of Birjand University of Medical Sciences (IRB code: IR.BUMS.REC.1405.014). All participants were fully informed about the purpose of the study, assured of confidentiality, and provided written informed consent prior to participation. Participation was voluntary, and participants were allowed to withdraw at any stage without any consequences.

Consent for Publication
Not applicable.

Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.

Funding Statement
This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
 
Acknowledgements
We extend our gratitude to the Vice President of Research and Technology of Birjand University of Medical Sciences, as well as to all the participants who helped us in conducting this research.

Author's Contribution
Study design: ZA, AJ; Provided guidance on study methodology:ZA. data collection and analysis: SMT, AJ, SMM, AR; manuscript preparation: AR, SMM. All authors have read and approved the manuscript.

Conflict of Interest
The authors declare that they have no conflict of interest related to this study.

Declaration of Generative Artificial Intelligence in Scientific Writing
We have not used any AI tools or technologies in the preparation of this manuscript.

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Type of Study: Research | Subject: General Surgery
Received: 2026/04/20 | Accepted: 2026/06/30 | ePublished ahead of print: 2026/07/14
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