How Do Artificial Intelligence, Social Media Platforms and Photo Editing Applications Influence Cosmetic Surgery Choices—Literature Systematic Review and Prospective Study

: Background: In recent years, social media and AI have indirectly taken control of our daily lives. We bring attention to the impact that social networks, photo-editing applications, and artificial intelligence have on potential patients when they are looking for a surgeon for a possible cosmetic surgery, as well as the criteria they consider in relation to the interest in the use of the internet by surgeons. Methods: A systematic review of the past 10 years (2014–2024) was conducted following the PRISMA structure. PubMed and Google Scholar were searched for articles containing the following terms: plastic/esthetic surgery, social media, AI, filters, dysmorphia. All articles were saved using Zotero software version 6.0.37. We reported a prospective study including a 141 patients applying for esthetic surgical interventions in the time interval between February and October 2021. It also involved 44 esthetic surgeons from Tunisian clinics. The influence of social media was evaluated using questionnaires made based on the literature. Results: Using the keyword search, 71 articles were found. A total of 19 articles were selected for data extraction. It was observed that in the last 3 years, the literature has focused on photo-editing and AI in the cosmetic surgery field. A total of 107 patients chose their surgeon based on a surgeon’s social medias rather than their reputation and their website. Conclusions: The increased advancements of the internet have clearly influenced decision making in the field of cosmetic surgery.


Introduction
Social networks (SN) contribute to highlighting esthetic and plastic surgery [1] in addition to increasing education and safety in esthetic practice [2].SN can also bias people's perception of esthetic surgery and they no longer accurately represent this specialty as a public health service [3].An overall view of what is happening in the world leads us to say that the influence of SN on the practice of esthetic surgery is real and well established.
Recently, alarm signals have been raised regarding the use of photo-editing applications and filters commonly found on Snapchat and Instagram.Many patients come to their consultations with filtered photos of themselves, wanting to look exactly the same as this distorted version of themselves [4].Traditionally, the decision-making process in esthetic surgery has heavily relied on the expertise and subjective judgment of surgeons.However, AI brings a new dimension to this process by leveraging data-driven algorithms and machine learning techniques to analyze vast amounts of patient information by incorporating factors, such as facial symmetry, skin texture, and anatomical proportions.
To test our hypothesis, a rigorous review of the literature was conducted and a cross sectional study was performed in Tunisian esthetic surgery clinics to show the impact social media, photo-editing applications, and AI have on the decision of undergoing cosmetic surgery procedures

Materials and Methods
A literature review of the past 10 years (2014-2024) was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) structure.PubMed and Google Scholar were searched for scientific articles containing the following terms: ("Plastic surgery" or "Aesthetic surgery") and ("social media" or "AI", "filters" or "dysmorphia").Criteria of inclusion were as follows: studies about social media and its influence on the potential patient, studies about artificial intelligence and its influence on modern plastic surgery, studies about photo editing, self-esteem and dysmorphia, and all articles in French or English language.Exclusion criteria: articles for which the entire text was not available, and articles for which only the abstract was valid.All articles were saved using Zotero software, and they were sorted by title, abstract, and keywords.If the articles matched our study criteria, they were selected for a full reading.
Additionally, we relied on statistical results from a descriptive cross-sectional study conducted in Tunisian esthetic surgery clinics through patient and surgeon questionnaires to highlight the influence of social media on esthetic surgery.The data were entered and analyzed using SPSS software version 23.0 for Windows.The study of the correlation between two variables was made by Pearson coefficient.p was significant when <0.005.It included 141 patients applying for esthetic surgical interventions in the time interval between February and October 2021; it also involved 44 esthetic surgeons from Tunisian clinics who accepted to be part of it.The influence of social media was evaluated using questionnaires that were made based on a literature review of articles with similar topics.Questionnaires were in French, as most of Tunisian esthetic clinic patients speak French (Supplementary Material Files S1 and S2).Informed consent of the patients was not required because the questionnaires were anonymous.

Results of Systematic Review
The analysis was conducted following the PRISMA diagram (Figure 1).Using the keyword search, 71 articles were initially found.After reviewing the abstracts, 31 articles were eliminated.Upon full-text examination, 19 articles were further excluded.A total of 19 articles were therefore retained for data extraction.
All the articles were summarized by subject.Table 1 summarizes articles regarding the influence of social networks on cosmetic surgery patients.All articles have been arranged chronologically based on their publication date.The article's aim, conclusion, and our commentary are all included in Table 1.
To investigate deeply the influence of photo editing on the plastic surgery patient, we summarized all the articles in a table (Table 2).The article's aim, conclusion, and our commentary are all included in Table 2.
In this systematic review, in articles written between 2022 and 2024, the specificity of the articles was notable, with one primarily focusing on women in their fifties-an initial exploration into this age group-another providing a summary of the literature concerning this subject and attempting to identify future topics for advancement, and a third endeavoring to propose a solution for reducing Instagram's impact on self-esteem.All other articles predated 2021 and presented results similar to those in our descriptive study.What are new and interesting in this article are the technological advancements, including AI, which could also influence the desire for cosmetic surgery.The article's aim, conclusion, and our commentary are all included in Table 3. Table 1.Articles regarding the influence of social networks on cosmetic surgery patients.

Author Aim Conclusion Auto-Comment
Perloff R.M. (2014) [5] The article discusses the relation between social media and self-esteem among young women in the USA.The article provides an overview of all the necessary resources and tips aimed at aesthetic surgeons to enable them to engage on social media platforms.
Social media should be used by plastic surgeons to engage with their patients and their societies.Furthermore, social media should be used to educate the public and to raise the profile of the practitioners of plastic surgery.
This article is very interesting because it was published at the very beginning of the use of social networks by plastic surgeons.We can see the initial intentions in it.For this article, we were able to compare how this usage has become much more significant over recent years.
(2018) [1] The article is a systematic literature review on the use of networks in the field of plastic surgery.It is one of the first studies to seriously delve into the subject.
It is critical for leaders in plastic surgery to proactively work toward a more concrete definition of online professionalism in order to maintain our reputation and effectiveness in the long term.
This article is one of the first asking for guidelines of how to use social media in a professional way considering the influence it can have on patients.
Basa K. et al.
(2018) [6] The article discusses the multiple trends that patients want to see on social media and how the surgeon can use them in his practice.
Instagram is an important communication tool for facial plastic surgeons to engage in promotion and education.It is important to understand what trends tend to attract followers and engagement.
Even if the number of analyzed accounts is low (33), this article was interesting as it shows similar results to our descriptive study, where patients would primarily be interested in posts related to before-and-after photos of surgeons.The article, through forms distributed to patients, was able to highlight, via an analytical study, the real association between photo-editing applications, self-image, and the desire to undergo plastic surgery.
These data suggest that higher investment in social media and the use of specific social media and photo-editing applications are associated with increased acceptance of cosmetic surgery.
This was the most important article in our systematic review, as it shows many analytical results proving the influence that social media and photo editing can have on self-esteem and cosmetic acceptance.The article discusses the use of social media by plastic surgeons, particularly for the education of young surgeons.
Plastic and reconstructive surgery as specialty fields generate a great degree of public interest.
This article was important to our systematic review to show that plastic surgeons do not use social media only to have more patients, but also to educate young surgeons.

Rekawek P. et al. (2021) [8]
The article discusses the transition to minimally invasive cosmetic treatment and the role of social media for this transition.
The ability of social media to impact the future of oral-maxillofacial surgery cosmetic treatment should not be disregarded but instead embraced to maximize practice prosperity.
This article is recent, and it was really useful for our study to show the impact that social media influencers such as Kylie Jenner can have in this field.

Ravikumar V. et al. (2021) [9]
The article discusses the use of TikTok in aesthetic surgery, and how surgeons start using this platform in order to target younger population.
In comparison to Instagram, TikTok holds the potential to engage a greater audience and provide educational content to a younger population, which can be a novel addition to the plastic surgeon's social media presence.
What is really interesting about this article is the comparison between Tiktok and Instagram, showing the engagement that some surgeons can have in educating the younger population.The article discusses the use of photo-editing applications, even in CV and job interviews.
Callback rates are statistically significant higher for attractive women and men than unattractive ones.Racial discrimination appears to be statistically relevant, but less than discrimination based on the physical features, especially for women.
Before the overuse of social media, people already used Photoshop to modify their profile picture in CV and job interviews as appearance counts a lot.

Tiggemann et al. (2014) [11]
The article shows the correlation between positive comments on Instagram posts and self-esteem.
Comments on an important and integral part of Instagram imagery, one that has implications for body image in its own right.
Articles from 2014 are really important in this study because they show that body dissatisfaction's correlation with social media was present and detectable earlier.
Perloff R.M. (2014) [5] The article discusses the relation between social media and self-esteem among young women in the USA.
Social media and contemporary digital technologies are the playing field of today's youth, and are places where lessons are learned, attitudes are formed, and body image concerns can be cultivated and metastasized into convictions.
The article was one of the first to show alarm signals about social media and body concerns, before even the overuse of platforms by plastic surgeons.It was important for our study to have a reference from 2014 so we could compare over the years the influence of social media.The article shows the danger of snapchat filters on the patient's self-esteem and their desire to undergo cosmetic procedures.
The risk of these patients turning to Snapchat and Instagram filters as a source of inspiration for their desired plastic surgeries is a big issue.
This article was really important for our study as it discusses Snapchat dysmorphia; this article would have been more interesting if it has proposed issues and guidelines for early detection of this dysmorphia, and this is what encouraged us to add this to our study.
Chen J. et al.
(2019) [7] The article, through forms distributed to patients, was able to highlight, via an analytical study, the real association between photo-editing applications, self-image, and the desire to undergo plastic surgery.
These data suggest that greater investment in social media and the use of specific social media and photo-editing applications is associated with increased acceptance of cosmetic surgery.
This was the most important article in our systematic review, as it shows many analytical results proving the influence that social media and photo editing can have on self-esteem and cosmetic acceptance.
It is important for practitioners to recognize and understand Snapchat and selfie dysmorphia in addition to knowing how to manage these patients.
The article was interesting for our study, as it discusses the impact that overtaking selfies can have on the patient.
Othman S. et al.
(2021) [13] The article discusses how photo-editing applications can be a threat to self-esteem and induce the need to undergo cosmetic procedures.
Photo-modification applications play a role in patient decision making to pursue cosmetic surgery through multiple avenues.
This article focusses on self-esteem; as the correlation between self-esteem and aesthetic surgery is confirmed, it was important to analyze this article in order to find solutions to this low self-esteem.
(2022) [14] The article represents a very interesting systematic review of the influence of photo editing on body concerns.It represents a new reference highlighting multiple aspects of this influence.
The review highlights a potential mixed set of findings relating to the association between photo-editing and body concerns among women.It also highlights the fact that articles in this field are repetitive and what aspects future researches should focus on.
What we liked the most about this article was the fact that it is a very similar idea to ours.In addition, it is very recent.It addresses ideas for future articles to try to solve issues of body dissatisfaction and social media.
Balanji S. ( 2023) [15] The article discusses solutions to dissociative Instagram usage and its influence on body image.it presents FINSTA (a type of Instagram account only for very close friends where people can share all their pictures without caring about strangers' points of view).
FINSTA users do not show the same associations between body satisfaction and self-photo activities as Instagram users without a FINSTA.
The article shows a new trend in the young population, using it to try to find a correlation with less body dissatisfaction.
Rodgers R.F. (2024) [16] Empirical data, predominantly from young women, suggest photo-based social media use is associated with greater body dissatisfaction.The present study aimed to extend these findings to midlife women and identify risk profiles for maladaptive appearance-focused social media use.
The findings indicate that midlife women who use photo-editing applications and social media may be at high risk for appearance concerns, warranting further research and resource development for this group.
The article was one of the first to try to find a correlation between photo editing and body satisfaction in "midlife" women; all other articles were basically focused on young women.As it is a recent article, this shows that this issue is no longer only a trend for teenagers.The article shows the innovations in plastic surgery based on AI that offer patients new ways to predict results based on machine learning.
Three-dimensional simulation models and AI models can revolutionize the practice of functional and aesthetic rhinoplasty.Simulation systems can be beneficial in preoperative planning, intra-operative decision making, and postoperative evaluation.
What is interesting in this article is that it shows the good and bad impacts of including AI in today's practice, as it can also be a good way to help the patient in decision making.
Xie Y. et al.
(2023) [18] The article tries to evaluate if ChatGPT can substitute an aesthetic surgeon for pre-operative rhinoplasty counseling.
ChatGPT can be a valuable resource for patients seeking information and surgeons in preoperative assessment and planning.However, patient selection and setting realistic expectations remain essential factors in the consultation pathway for aesthetic surgery.
The article was a blessing to the systematic review; we were happy to find a reference discussing this subject, as we think that easy access to ChatGPT can obviously affect the patient's decision.
After conducting research across various databases, very few articles were found about this subject.To address this question, we also relied on sociology articles detailing the relationship between AI filters and self-esteem.Additionally, we considered responses from the AI ChatGPT when asked about its influence on cosmetic surgery.Since the year 2022, during which time AI has progressed, numerous scientific articles have delved into the emergence of AI and its general influence on medicine, particularly in the field of cosmetic surgery.For recent studies, we have endeavored to focus on AI and cosmetic surgery.Among a total of 44 surgeons, 2 stated that they did not use social networks, representing 9%.We therefore focused on the 42 surgeons who were active on social networks to identify their patterns of use.Among the 42 surgeons, 88.1% of them were found to use social networks for professional purposes and, 90% were also found to use SN for personal and family purposes (Figure 2).The age of the surgeons of the study is represented in Figure 3.The social networks most used by surgeons were Instagram followed by Facebook (Figure 4).The reasons why cosmetic surgery surgeons use social networks are recorded in Figure 5.A total of 29.5% of all surgeons participating in the study accessed social networks daily (Figure 6).

Patients on Social Media
Our study included a total of 141 patients.The average age of these patients was 36.27 years, with a median of 33.00, a standard deviation of 12.212, a minimum of 18 years, and a maximum of 75 years (Figure 7).Unlike surgeons, the social networks used by patients were dominated by Facebook, with Instagram in second place (Figure 8).The cosmetic surgery interventions that patients were interested in were dominated by limb and figure surgery, followed by cosmetic facial surgery (Figure 9).How patients choose their surgeon for a cosmetic surgery operation is very interesting.A total of one hundred and seven patients (75.9%) reported having chosen their surgeon through social media, 79 (56%) stated that the surgeon's reputation and renown influenced their decision, 98 patients (69.5%) mentioned that the before/after photos impacted their choice of surgeon, 43 patients (30.5%) indicated that word of mouth influenced their decision, 45 patients (31.9%) credited medical tourism agencies for their choice, and 33 patients (23.4%) reported being swayed by their surgeon's website (Figure 10).The results of the study draw attention to the fact that the patients' interest in the surgeon's website was exceeded by their interest and trust in the visual information, the profile agencies and especially the recommendations made by the well-known people who had gone through a surgical experience of this kind.We found a correlation between the age of patients and the choice of surgeon: 87.2% of 18-35 year olds chose their surgeon via the RS, while 79.5% of 35-50 year olds did so thanks to the RS.For those over 50, only 36.8% chose their surgeon via the RS.The difference between these age groups is significant (p = 0.0001) (Figure 11).
Regarding the data that people were looking for when studying the website of a surgeon to whom they could turn for cosmetic surgery, they were primarily based on the before/after iconography, on the information related to the post-operative aspect and the benefits on the rates of surgical interventions, leaving the information about the surgeon's professional performance contained in their curriculum vitae (CV) in last place.The price of the surgical intervention influenced only 53.2% of the patient's decision in choosing the surgeon (Figure 12).A total of 83 patients from the study group (59%) reported using photo-editing/filter applications, while 58 patients (41%) claimed not to use such applications.Among the 83 patients who used photo-editing applications, 35 patients (42.2%) claimed to have been influenced by these applications to undergo aesthetic surgery, 27 patients (32.5%) thought these applications could have influenced them, and 21 patients (25.3%) claimed not to have been influenced by them.Among the 141 patients surveyed, 77 (54.6%) believed that these types of applications completely influence the individual's desire to undergo aesthetic surgery, 47 (33.3%) thought it is probable that these applications have an influence, and 17 (12.1%)believed there is no correlation between the two events.

Discussion
Advancements in the Internet have clearly influenced decision-making regarding cosmetic surgery.For the population, social networks influence their education and their decisions to undergo cosmetic surgery.Instagram is the most popular platform.
A study from 2018 found that more than 70% of people between the ages of 12 and 24 are regular users of Instagram [1].Instagram is particularly populare among the younger female population [2,3].The population under 35 is 3.9 times more likely to engage with surgeons on social media than their older counterparts [6].However, recent studies (2024) have shown that even body concerns of midlife women are largely influenced by Instagram and social media [16].In a study conducted in Tunisian esthetic surgery clinics, we found that 88.1% of Tunisian surgeons were found to use social networks in a professional context.Several surgeons have hundreds of thousands of followers, making them truly influential figures on social media.Regarding the networks used by surgeons, they are dominated by Instagram, similar to the reports in the literature.The use of social networks by doctors is primarily for personal purposes and then professional reasons.On the other hand, regarding patients, we found that 75.9% followed their surgeons on social networks, and 86.4% of the patients did so on Instagram specifically.This highlights the significant importance of this social network in the field of aesthetic surgery.Unlike doctors and information from the literature, potential patients use Facebook most frequently in the same proportion as Instagram.This repeated exposure could indirectly influence the desire to undergo aesthetic surgery by creating unrealistic expectations or reinforcing idealized beauty standards propagated on social media.Indeed, potential aesthetic surgery patients can fall into a vicious cycle by following multiple surgeons on social media.According to our study, surgeons typically share two to three times a week, exposing patients to numerous before-and-after results of cases similar to theirs.This repeated exposure could indirectly influence the desire to undergo aesthetic surgery by creating unrealistic expectations or reinforcing idealized beauty standards propagated on social media.A report published in 2023 highlighted a new trend used on Instagram, creating FINSTA accounts, which are accounts only for very close friends and where one can publish pictures without caring about strangers' points of view.The article proved that FINSTA users do not show the same associations body satisfaction and self-photo activities as Instagram users without a FINSTA [15].
A digital influencer is a person who creates content via digital channels, and whose authority, knowledge, or position in the online media can have the power to impact the purchasing decisions of their audience.Digital influencers are starting to have a big impact on esthetic surgery.From this perspective, a study performed by Rekawek et al. showed the impact that "Kylie Jenner", an Instagram influencer with more than 400 million followers on Instagram, has on the decision to undergo cosmetic procedures [8]."Lip filler" searches have steadily increased in popularity from 2014, exhibiting its highest peak of interest during July 2018.Related searches for "lip filler" with the greatest increase in frequency were "Kylie lip filler" and "Kylie Jenner before lip filler".Interestingly, July 2018 corresponds with when Kylie Jenner was heavily promoting a lip cosmetic product via Instagram.In addition, viral trends involving surgical procedures, such as "mewing," gained popularity, not because of sound scientific evidence but because of social influencers advertising to their followers [8].Instagram Reels are 15 to 90 s vertical videos users can create, edit, and post to their profiles within the application.Unlike Instagram Stories, Reels do not disappear after 24 h, and they are easy to save or share.Reels are proposed to users based on their preferences and what they want to see using an AI algorithm.A patient interested in esthetic surgery will have more and more videos of aesthetic surgeons on their feed, making them more addicted to these procedures.
Surgeons are increasingly using TikTok, which counts 1 billion users worldwide, with 41% of them being in the 16-24 age group.A recent study investigated this topic, highlighting this new trend used by esthetic surgeons.In 2021, Ravikumar et al. analyzed TikTok accounts related to esthetic surgery [9], and they reported that 183 verified TikTok accounts exclusively focused on esthetic surgery in the United States.All identified surgeons have Instagram accounts.The authors also compared the surgeons' posts on Facebook and Instagram and found that there were more humorous videos (33% vs. 9% on Instagram).Posting humoristic and educational videos of cosmetic surgery in social media can expose the young population to aesthetic surgery and therefore influence their decision to undergo cosmetic procedures at a young age.In our study, 83 patients (59%) reported using photoediting applications.Among these 83 patients, 35 (42.2%) claimed to have been influenced by these applications to undergo aesthetic surgery.There is a correlation between patients intending to undergo facial surgery and their use of Instagram and Snapchat filters and applications.We found that 53% of patients intending to undergo facial surgery indeed use these filters and applications.
Research on this topic was conducted, and it revealed that a phenomenon called "Snapchat dysmorphia" was addressed by several scientific articles [7,9].Long before the advent of Snapchat and Instagram (two applications created in 2011 and 2010, respectively), photo-editing tools already existed.They were notably used in advertising, for retouching celebrities or models.Today, these tools have become widely accessible, particularly through smartphones.In a matter of seconds, it is now possible to instantly retouch one's face, using, for example, the social network Snapchat.But how are these retouches performed?Some filters have the power to greatly smooth the skin, refine the nose, alter the shape of the eyes, make lips fuller, and bring total symmetry to the face: an ideal of beauty that is not always without consequences.In the literature, several studies have investigated this topic, and they attempted to highlight the correlation between the use of these applications and filters, dysmorphia, and the tendency to undergo aesthetic surgery.One study conducted by Chen et al. [7] focused on this aspect.Over a period of 2 months, online forms were sent to aesthetic surgery patients to assess their use of filters, self-esteem, and desire for surgery.Self-esteem was evaluated using the Rosenberg Scale, and the desire for surgery was assessed using a scale of acceptance of aesthetic surgery.Regarding photo editing, the study found that patients using Snapchat filters have a significantly higher acceptance of aesthetic surgery compared to non-users.Similarly, users of VSCO, a photo-editing application, were reported to have an increased inclination towards surgery.Additionally, patients who did not share unedited photos on social media platforms were found to show a clear increase in the desire for surgery [7] (Table 4).This analytical table summarizes the use of various applications and the ACSS (Aesthetic and Cosmetic Surgery Acceptance Score).It is noteworthy that the use of dating applications such as Tinder appears to correlate with the desire for aesthetic surgery.Previous literature has investigated the detrimental effect that social media can have on self-esteem.For instance, Perloff et al. described the relationship between social media and body image as a vicious circle (those with body acceptance issues tend to seek reassurance and image gratification on social media, while those who use social media excessively tend to have lower self-acceptance) [5].In the same study by Perloff, a direct correlation was found between the use of YouTube, self-esteem, and acceptance of aesthetic surgery.YouTube contains numerous videos related to beauty and aesthetic surgery.At the time of writing this article in 2014, the world had not yet discovered the photo filters introduced by Snapchat, which completely changed beauty standards worldwide.But what are these filters, and why has social media dysmorphia been attributed to Snapchat?In recent years, several applications such as Instagram and Snapchat have allowed users to use photo filters to alter their appearance as they wish.These filters can create the effect of smoother skin, wider eyes, fuller lips, whiter teeth, and a slimmer face.Users can also correct imperfections.These filters have completely changed the perception of beauty worldwide [11].People can spend time perfecting their photos to give a false impression of themselves.What has also changed is that photo editing was previously reserved for models and celebrities.But, nowadays, it is accessible to everyone with just a few clicks [12].Studies have looked into why the use of these filters and applications influences patients' desire to undergo aesthetic surgery.Othman et al. [13] found that several patients use these modified photos for professional purposes, such as having a more attractive photo on their CV, as several studies have shown that appearance also matters in job interviews [10].In the same study, other patients admitted to using these editing applications, especially in dating applications such as Tinder and Bumble, to share on social media, and others use them just for fun [13].All these reasons somewhat explain why aesthetic surgery patients using these applications want to resemble the ideal they have created online.Indeed, in our study, several patients admitted that these editing applications have an impact on their desire to undergo esthetic surgery.Many surgeons raise the alarm when they detect "Snapchat Dysmorphia", which is, as defined earlier, when patients bring photos of themselves with Snapchat/Instagram filters to their surgeon wanting to look exactly like the filtered photo [4].Surgeons can detect Snapchat dysmorphia and low self-esteem by paying attention to patients' behavior, communication, and motivations during consultations.Signs may include: excessive focus on filter, unrealistic expectations, repetitive procedures (in fact, patients who undergo multiple surgeries without achieving satisfaction may indicate deeper psychological issues related to body image distortion and low self-esteem), negative self-talk exhibited or dissatisfaction expressed with their appearance, regardless of the surgeon's reassurance or realistic expectations.By recognizing these signs and collaborating with mental health professionals when necessary, surgeons can provide better care and support to patients struggling with Snapchat dysmorphia and low self-esteem.
A study from 2017 showed that 55% of surgeons encounter patients who undergo cosmetic surgery to enhance their appearance in selfies.The same study demonstrated that an increasing number of patients share the results of their surgery on their social media accounts [13].What are these selfies, and why have they become so important for both the cosmetic surgeon and the patient?As defined by the dictionary, the term "selfie," originating from English, refers to a self-portrait photograph, usually taken with a smartphone and intended for publication on social media platforms.Several studies have focused on these selfies and their significance in cosmetic surgery.Studies, such as the one conducted by Shome et al. [19], have investigated the influence of excessive sharing of selfies on social media on the development of body dysmorphic disorder and, consequently, the inclination towards cosmetic surgery.Other studies have addressed these selfies from a different perspective, acknowledging their near-automatic daily occurrence [13].
AI-simulated aesthetic surgery results refer to the use of artificial intelligence technology to predict and visualize the potential outcomes of cosmetic procedures.These simulations utilize advanced algorithms and computer graphics to generate realistic images or videos depicting how a person's appearance might change after undergoing specific cosmetic surgeries, such as rhinoplasty, facelifts, breast augmentation, or liposuction.
These simulations serve several purposes such as visualization; they allow patients to visualize the potential results of cosmetic procedures before undergoing surgery, helping them make more informed decisions and manage their expectations.These simulators also facilitate communication between patients and surgeons by providing a visual reference for discussing desired outcomes and potential modifications.They also improve customization, as surgeons can use them to tailor treatment plans to meet the unique preferences and aesthetic goals of each patient, and of course, they can enhance education, as patients can learn more about different cosmetic procedures and their potential effects on their cosmetic treatments.Overall, AI-simulated aesthetic surgery results can enhance the consultation process, improve patient satisfaction, and contribute to more successful outcomes in cosmetic surgery.A study reported by Eldaly et al. showed that 3D simulation models and AI models can revolutionize the practice of functional and aesthetic rhinoplasty.Simulation systems can be beneficial in preoperative planning, intraoperative decision-making and postoperative evaluation.In addition, AI models can be trained to carry out tasks that are either challenging or time-consuming for surgeons [17].The fact that patients can previsualize their result based on their plastic surgeon's work can largely encourage them to undergo cosmetic surgery.What is new with AI is the new filter that utilizes sophisticated algorithms to modify images in real-time, creating transformation effects such as aging, rejuvenation, or even radical changes in physical appearance.While these filters are often designed to entertain and stimulate creativity, their excessive use can negatively influence self-esteem.Indeed, these filters can create unrealistic beauty standards by proposing unattainable ideals of perfection.When users are repeatedly exposed to modified images corresponding to these standards, it can lead to constant comparison with unattainable ideals and, consequently, a decrease in self-esteem.Moreover, frequent use of these filters can create dependency on the modified appearance, leading to an altered perception of one's own face without filters.This can result in feelings of body dissatisfaction and a negative perception of one's natural appearance.It is, therefore, essential to raise awareness among users, especially young people, about the potential impact of filters on their self-esteem, and to promote responsible and conscious use of these digital tools.Bold Glamour, a filter launched in February 2023, perfectly illustrates this problem.Before Bold Glamour, most filters were overlaid on the face.They were therefore easy to spot because their quality decreased with the slightest movement.But Bold Glamour changed the game: thanks to advanced AI and machine learning, this filter completely recreates the user's features.So, you can move your head or wave your hand in front of your face while maintaining the illusion.A month after its launch, the filter was viewed 400 million times on TikTok.The platform was flooded with images of users in "model" mode-an interesting but worrying phenomenon.Renee Engeln, director of a laboratory on body and media at Northwestern University, emphasizes that "the blur between reality and fiction can have a lasting effect on self-image."Following the launch of Bold Glamour, several users spoke out on TikTok to deconstruct the beauty standard imposed by the filter."Natural is when we are most beautiful", reminds one of these individuals.Filter or reality?It is clear that social media complicates the experience of today's youth, and the popularity of filters like Bold Glamour does nothing to simplify matters.We have to take time to explain to young people that AI gives filters a more convincing appearance, but that there is a significant difference between fiction and reality.We have to help them sharpen their critical thinking skills and distinguish between truth and falsehood.One can test different filters with them to show them the difference, ask them how this experience makes them feel, and then talk about one's own feelings (social media also has repercussions on adults).By experimenting with them and creating a space for an honest dialogue, you can limit the negative effects of filters on the mental health and self-esteem of young people [20].Another tool based on AI that facilitates access to plastic surgery is ChatGPT; it is an open-source artificial large language model that uses deep learning to produce human-like text dialogue.This observational study evaluated the ability of ChatGPT to provide informative and accurate responses to a set of hypothetical questions designed to simulate an initial consultation about rhinoplasty [18].When we ask ChatGPT how it can influence the decision to undergo cosmetic surgery procedures, here is the answer: "It's important to note that ChatGPT's primary goal is to provide information and facilitate informed decision-making rather than actively influencing individuals to undergo aesthetic surgery procedures.However, ChatGPT can indirectly impact patients' decisions through the information it provides.By offering comprehensive and accurate information about aesthetic surgery procedures, including potential risks, benefits, alternatives, and considerations, ChatGPT empowers patients to make educated choices based on their individual needs, preferences and circumstances.Through open dialogue and the exchange of knowledge, ChatGPT can help patients better understand the implications of aesthetic surgery, manage their expectations realistically and explore alternative options if ap-propriate.Additionally, ChatGPT can address common misconceptions or concerns surrounding aesthetic procedures, thereby fostering a more informed and confident decision-making process for patients.Ultimately, while ChatGPT can provide valuable insights and guidance, the decision to undergo aesthetic surgery remains deeply personal and should be made in consultation with qualified healthcare professionals who can offer personalized advice and support based on the patient's unique circumstances and goals" [21].What is interesting is the final part, where ChatGPT emphasizes that nothing in the world can replace a consultation with a specialized surgeon, who is the only one able to provide advice and either encourage or discourage a patient from undergoing a surgical procedure.Xie et al. attempted to determine if ChatGPT could indeed replace a preoperative consultation in aesthetic surgery for rhinoplasty.The study relied on nine important questions published by the American Society of Plastic Surgeons.The results of this study showed that ChatGPT could provide consistent and comprehensive individual responses; however, the study also highlighted the limitations ChatGPT had in providing personalized advice [18].ChatGPT can be a valuable resource for patients seeking information and surgeons in preoperative assessment and planning.However, patient selection and setting realistic expectations remain essential factors in the consultation pathway for aesthetic surgery, an area in which the role of current-generation AI remains limited [18].

Conclusions
Advancements in the Internet have evidently influenced decision-making in the field of cosmetic surgery, confirmed by the present study.The most used networks used by the population and doctors are Instagram and Facebook.Regarding the relationship between social media, self-esteem, and the decision to undergo cosmetic surgery, both our study and the literature show that a greater investment in social media and the use of photo-editing/filter applications are associated with a more favorable acceptance of cosmetic surgery.The choice of the surgeon for a potential cosmetic surgical intervention is mostly based on the visual information gathered from social networks or from the surgeon's website, and not the professional or scientific activity included in a CV.Our study has been able to redefine the relationship between social media, self-esteem, and the decision to undergo cosmetic surgery and has highlighted warning signs to detect body dysmorphic disorders for optimal management of cosmetic surgery patients.Also, this research is among the first to discuss the emergence of new artificial intelligence-based filters and their potential impact on patients' self-esteem and inclination towards cosmetic surgery.Furthermore, factors like ChatGPT and the ease of accessing information could also influence patients' decision-making process.
Social media and contemporary digital technologies are the playing field of today's youth, as places where lessons are learned, attitudes are formed, and body image concerns can be cultivated and metastasized into convictions.This article was one of the first to show alarm signals about social media and body concerns, before even the over use of platforms by plastic surgeons.It was important for our study to have a reference from 2014 so we could compare over the years the influence of social media.Gould D.J. et al. (2017)[3]

3. 2 .
Results from a Descriptive Cross-Sectional Study Conducted in Tunisian Esthetic Surgery Clinics through Patients' and Surgeons' Questionnaires to Highlight the Influence of Social Media on Esthetic Surgery 3.2.1.Plastic Surgeons and Social Media

Figure 2 .
Figure 2. Use of social media by plastic surgeons in our study.

Figure 4 .
Figure 4. Social networks used by surgeons.

Figure 5 .
Figure 5. Reasons why surgeons use social platforms.G1-Information about own surgical procedures and techniques, G2-Sharing before/after photos, G3-Correcting misconceptions that the general public has about plastic surgery, G4-Information about own non-surgical activity, G5-Sharing scientific articles/conferences/webinars, G6-Recruiting patients by promoting my latest achievements.

Figure 6 .
Figure 6.Frequency of use of social networks by surgeons.

Figure 7 .
Figure 7. Distribution of study patients by age group.

Figure 8 .
Figure 8. Social networks used by potential patients.

Figure 9 .
Figure 9. Types of cosmetic surgery interventions that the study patients were interested in.

Figure 10 .
Figure 10.How did the patients choose their surgeon in the study.

Figure 11 .
Figure 11.Relationship between patient age and the choice of surgeon.

Figure 12 .
Figure 12.Information that the patient is looking for on the surgeon's website.

Table 2 .
The influence of photo editing on the plastic surgery patients.

Table 3 .
The technological advancements, including AI, which could also influence the desire for cosmetic surgery.