Previous research has examined factors thought to influence individuals’ interest in cosmetic surgery, yet few studies have examined these issues among midlife women. This study examines predictors of cosmetic surgery attitudes among midlife women (N = 114; age = 45–65 years; M_age = 53.7) and considers a previously unexplored variable: fear of negative appearance evaluation. Results indicated that lower weight and appearance esteem were associated with more positive cosmetic surgery attitudes and greater fear of negative appearance evaluation. Furthermore, fear of negative appearance evaluation mediated the relationship between appearance and weight esteem and cosmetic surgery attitudes. We conclude that fear of negative appearance evaluation is an important factor to consider in examining cosmetic surgery attitudes.