Even patients who think they look much younger after a face-lift still may not see an improvement in self-esteem, a small U.S. study suggests.

Doctors quizzed patients about their self-worth before the cosmetic procedures, asking whether they agreed or disagreed with statements like "On the whole, I am satisfied with myself," "I certainly feel useless at times," and "I feel that I have a number of good qualities."

After the face-lifts, patients typically thought they looked about nine years younger.

But average self-esteem scores were essentially the same before the face-lifts and six months later.

Responses were scored from 0 to 30, with anything under 15 considered low self-esteem and totals over 25 considered high. At the start, the average person's self-esteem rating was 24.3, and when doctors quizzed them a second time, it was 24.6.

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"Patients were generally happy with their outcomes even though their feelings of self-worth did not improve," study leader Dr. Andrew Jacono, of the New York Center for Facial Plastic & Laser Surgery said by email.

Each patient had what's known as a rhytidectomy, or face-lift, performed by the same surgeon. These procedures are becoming more popular, though they are generally not performed as often as breast augmentations, nose jobs or liposuction, according to the American Society of Plastic Surgeons.

The study included 59 patients at the start, and 50 of them completed the follow-up questionnaires after living with their new faces for six months. On average, they were about 58 years old, although ages ranged form 37 to 73. All but two of the participants who completed both sets of quizzes were women.

While the overall shift in self-esteem scores was too small to rule out the role of chance, there were some sharper differences when researchers sorted the patients based on their initial scores, according to a report in JAMA Facial Plastic Surgery.

Patients with low self-esteem at the start of the study had an average score increase of 3.7 points six months later.

People who started with high self-worth scores had an average decrease of 3.1 points at the end of the study.

Those who had an ambivalent sense of self-worth remained little changed after procedures, with an average uptick of about 0.5 points in their scores.

Shortcomings of the study include the high proportion of patients who got other cosmetic procedures in addition to face-lifts, the authors acknowledge. The additional procedures may have altered patients' feelings of self-worth in a way that makes it hard to discern if all of their feelings were related to face-lifts alone, the researchers note.

It's possible that the patients with the highest self-esteem prior to the face-lifts experienced a dip in self-worth afterwards because they felt conflicted about their decision to get the procedures, Jacono noted.

"Admitting that they needed to have something done could possibly have made them feel as if they were not as great as they previously thought," Jacono said.

The results also confirm findings from earlier research that has linked cosmetic procedures to improvements in body image without necessarily altering self-esteem, noted David Sarwer, a public health researcher at Temple University in Philadelphia who wasn't involved in the study.

"For many people, there is only a modest relationship between how they objectively look to others and how they think and feel about their appearance," Sarwer said by email. "So even if some women felt that they looked much younger, they still may not be happy or satisfied with the appearance of their face."