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vid J Castle, Roberta J Honigman and Katharine A Phillips
MJA2002; 176 (12): 601-604
Both men and women are becoming increasingly concerned about
their physical appearance and are seeking cosmetic enhancement.
Most studies report that people are generally happy with the
outcome of cosmetic procedures, but little rigorous evaluation
has been done.
More extensive ("type change") procedures (eg, rhinoplasty)
appear to require greater psychological adjustment by the patient
than "restorative" procedures (eg, face-lift).
Patients who have unrealistic expectations of outcome are more
likely to be dissatisfied with cosmetic procedures.
Some people are never satisfied with cosmetic interventions,
despite good procedural outcomes. Some of these have a psychiatric
disorder called "body dysmorphic disorder".
Cosmetic enhancement is on the rise. More and more people report
being unhappy with their appearance. In a 1997 US survey, 56%
of women and 43% of men reported dissatisfaction with their overall
appearance.1 Paralleling this trend, an increasing number of both
men and women are resorting to cosmetic procedures. Figures provided
by the American Society for Aesthetic Plastic Surgery reveal that
cosmetic procedures (surgical and non-surgical) performed by plastic
surgeons, dermatologists and otolaryngologists increased 119%
between 1997 and 1999.2 In 1999, more than 4.6 million such procedures
were performed, with the top five being chemical peels (18.3%
of the total), botulinum toxin A injection (10.8%), laser hair
removal (10.5%), collagen injection (10.3%), and sclerotherapy
(9.0%). Rhinoplasties were performed on 102 943 people (2.2% of
the total number of procedures), and there were 100 203 facelifts
(2.2%), 191 583 breast augmentation procedures (4.2%) and 89 769
breast reductions (1.9%).2 Systematic Australian data are not
readily available, as there is no central registry or reporting
requirements. Furthermore, such procedures are performed by a
variety of different practitioners, including cosmetic physicians,
dermatologists, and plastic surgeons.
As people generally seek cosmetic interventions to feel better
about themselves, one would anticipate that cosmetically successful
procedures would lead to enhanced self-esteem, mood, and social
confidence. While studies spanning four decades have reported
that most people undergoing cosmetic interventions are satisfied
with the result,3,4 what has been less studied is the outcome
in psychosocial terms. Clinicians and researchers have attempted
over the years to evaluate whether improvement in psychosocial
wellbeing following cosmetic enhancement can be objectively verified,
but few methodologically robust studies have been done.
We reviewed the literature on psychosocial outcomes following
cosmetic surgery, using MEDLINE, PsychLit, PubMed, PsychINFO,
Sociological Abstracts, Social Work Abstracts, Proquest 5000,
Web of Science and CINAHL. Using the search terms "cosmetic
surgery", "plastic surgery", "patient assessment",
"body awareness", "body image" and "body
dysmorphic disorder", we identified 36 studies of varying
design and quality. Most were investigations of patients undergoing
a specific procedure, including rhinoplasty (12 studies), breast
augmentation (7 studies), breast reduction (5 studies) and face-lift
(3 studies), while other studies encompassed a variety of interventions.
Follow-up intervals for testing of psychosocial outcomes ranged
from immediately postoperative to 10 years after the procedure
(in one study). Only 11 studies formally included a control group5-15
— these are shown in the Box. Other studies have used normative
data from general population samples, which may not be appropriate
as reference data.
Positive effects
Overall, the studies suggest that most patients were pleased
with the outcome and felt better about themselves. This was particularly
the case for women undergoing reduction mammoplasty. Domains of
functioning showing improvement included "self worth",
"self esteem", "distress and shyness" and
"quality of life". However, many of these studies have
methodological limitations, including small sample sizes and potentially
biased ascertainment. Arguably, patients who agree to participate
in such research, and oblige with pre- and post-intervention interviews,
represent a biased group, but none of the studies estimated the
extent of such potential bias. Furthermore, clinical interviews
are potentially subject to bias on the part of both the respondent
and the interviewer, and very few studies employed "blind"
raters. Of particular concern is that not all studies used valid
assessment instruments, which hampered the interpretation of results.
Finally, most studies evaluated very specific procedures, and
it is unclear how generalisable their results are to other types
of cosmetic intervention.
Predicting poor psychosocial outcomes
What has been even less rigorously examined is the question of
what factors are associated with an unsatisfactory psychosocial
outcome after cosmetic procedures. Few of the studies we reviewed
formally dealt with this issue. Factors identified with unsatisfactory
outcomes included being male, being young, suffering from depression
or anxiety, and having a personality disorder. However, such parameters
have not been studied in a rigorous manner.2 Other authors have
suggested that the nature and degree of surgical change is an
important predictor of outcome: more extensive ("type change")
procedures (eg, rhinoplasty, breast augmentation) are more likely
to result in serious body-image disturbance than "restorative"
procedures (eg, face-lift, botulinum toxin A injection).16 The
extent of changes in sensation following the procedure (eg, a
feeling of skin tightening after a face-lift, or loss of nipple
sensation after breast augmentation) may also influence psychological
outcome, with greater degrees of sensory disturbance making adjustment
to the procedure more difficult.17
The patient's expectation of the outcome of the procedure also
appears to be important. It has been suggested that a distinction
can usefully be made between expectations regarding the self (eg,
to improve body image) and expectations relating to external factors
(eg, enhancement of social network, establishing a relationship,
getting a job).2 Some evidence points to externally directed expectations
being of more concern — if the person views the procedure as a
panacea for his or her life problems, the outcome is more likely
to be poor.18
Cosmetic surgery and body dysmorphic disorder
There is a particular subgroup of people who appear to respond
poorly to cosmetic procedures. These are people with the psychiatric
disorder known as "body dysmorphic disorder" (BDD).
BDD is characterised by a preoccupation with an objectively absent
or minimal deformity that causes clinically significant distress
or impairment in social, occupational, or other areas of functioning.2
People with this disorder obsess about the perceived defect, usually
for hours each day. The belief of imagined ugliness is often held
with delusional conviction.19 In an attempt to alleviate their
distress, sufferers may seek reassurance from others, check their
appearance repeatedly in the mirror or other reflecting surfaces,
pick their skin and try to conceal the "defect" through
use of concealing clothing, wigs, makeup, hats, and so on.20 These
patients constitute 6%–15% of patients seen in cosmetic surgery
settings21,22 and about 12% of patients seen in dermatology settings.23
For several reasons, it is important to recognise BDD in cosmetic
surgery settings. Firstly, it appears that cosmetic procedures
are rarely beneficial for these people. Most patients with BDD
who have had a cosmetic procedure report that it was unsatisfactory
and did not diminish concerns about their appearance.24,25 Some
patients resort to legal redress or are even violent towards the
treating physician.26,27 Secondly, BDD is a treatable disorder.
Serotonin-reuptake inhibitors and cognitive behaviour therapy
have been shown to be effective in about two-thirds of patients
with BDD.2
Approach to the patient seeking cosmetic surgery
So, how is the cosmetic specialist to ascertain who will do poorly
in psychosocial terms despite an objectively successful procedure?
The literature is not terribly useful in guiding us, but certain
commonsense assumptions can be made. First, the individual's attitude
towards the cosmetic problem, and the distress and disability
associated with it, should be assessed. In particular, the cosmetic
specialist needs to determine whether the patient has BDD.28 This
can be done by assessing whether the perceived defect is non-existent
or slight and enquiring as to the amount of time spent each day
worrying about the problem, how much distress thinking about it
causes, and whether there is any resulting functional impairment
(eg, social avoidance). If the patient reports being preoccupied
with the perceived flaw (eg, thinking about it for at least an
hour a day), and if the concern with the flaw causes marked distress
or impaired functioning, BDD is likely to be present. Similarly,
if the cosmetic specialist perceives the patient's cosmetic problem
to be much more trivial than the patient believes it to be, suspicion
should be aroused. It is also illuminating to assess the patient's
expectations of the outcome of the proposed procedure in both
cosmetic and psychosocial terms. Patients should be advised of
what the cosmetic outcome is likely to be and fully informed of
potential side effects and complications.
It is also useful to review past cosmetic interventions, including
the number of previous procedures and their cosmetic and psychosocial
outcome as perceived by the patient as well as family and friends.
The cosmetic specialist should probably be most concerned about
people who have had numerous procedures performed by many practitioners,
and particularly those who report the outcome of such procedures
to have been unsatisfactory. Any history of legal proceedings
or threats or overt violence towards previous cosmetic specialists
should obviously be considered very worrisome.
A patient's psychiatric history and current mental state should
also be examined. Merely having or having had a mental illness
should not of itself preclude cosmetic procedures. However, the
cosmetic specialist should be aware that certain psychiatric conditions
can present with heightened concern about appearance, which might
resolve with adequate psychiatric treatment.2 For example, cosmetic
procedures should probably not be performed on people who are
depressed or psychotic or who have BDD. Referral of such patients
to a mental health professional is strongly recommended.
Controlled studies of psychosocial outcomes from plastic surgical
interventions
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References
Garner DM. Body image survey. Psychol Today 1997;
30: 30-84.
Castle DJ, Phillips KA, editors. Disorders of body image. Hampshire,
UK: Wrightson Biomedical, 2002.
Edgerton MT, Jacobsen WE, Meyer E. Surgical-psychiatric study
of patients seeking plastic (cosmetic) surgery: ninety-eight consecutive
patients with minimal deformity. Br J Plast Surg 1960; 13: 136-145.
<PubMed>
Glatt BS, Sarwer DB, O'Hara DE, et al. A retrospective study of
changes in physical symptoms and body image after reduction mammaplasty.
Plast Reconstr Surg 1999; 103: 76-85. <PubMed>
Edgerton MT, Webb WL, Slaughter R, Meter E. Surgical results and
psychosocial changes following rhytidectomy. Plast Reconstr Surg
1964; 33: 503-521. <PubMed>
Wright MR, Wright WK. A psychological study of patients undergoing
cosmetic surgery. Arch Otolaryngol 1975; 101: 145-151. <PubMed>
Shipley RH, O'Donnel JM, Bader KF. Psychological effects of cosmetic
augmentation mammaplasty. Aesthetic Plast Surg 1978; 2: 429-434.
Marcus P. Psychological aspects of cosmetic rhinoplasty. Br J
Plast Surg 1987; 37: 313-318.
Hueston J, Dennerstein L, Gotts G. Psychological aspects of cosmetic
surgery. J Psychosom Obstet Gynaecol 1985; 4: 335-346.
Beale S, Hambert G, Lisper H, et al. Augmentation mammaplasty:
the surgical and psychological effects of the operation and prediction
of the result. Ann Plast Surg 1985; 14: 473-493. <PubMed>
Hollyman JA, Lacey JH, Whitfield PJ, Wilson JSP. Surgery for the
psyche: a longitudinal study of women undergoing reduction mammaplasty.
Br J Plast Surg 1986; 39: 222-224. <PubMed>
Meyer L, Ringberg A. Augmentation mammaplasty: psychiatric and
psychosocial characteristics and outcome in a group of Swedish
women. Scand J Plast Reconstr Surg 1987; 21: 199-208.
Robin AA, Copas JB, Jack AB, et al. Reshaping the psyche: the
concurrent improvement in appearance and mental state after rhinoplasty.
Br J Psychiatry 1988; 152: 539-543. <PubMed>
Klassen A, Fitzpatrick R, Jenkinson C, Goodacre T. Should breast
reduction surgery be rationed? A comparison of health status of
patients before and after treatment: postal questionnaire survey.
BMJ 1996; 313: 454-457. <PubMed>
Klassen A, Jenkinson C, Fitzpatrick R, Goodacre T. Patients' health
related quality of life before and after aesthetic plastic surgery.
Br J Plast Surg 1996; 49: 433-438. <PubMed>
Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. The psychology
of cosmetic surgery: a review and reconceptualization. Clin Psychol
Rev 1998; 18: 1-22. <PubMed>
Pruzinsky T, Edgerton MT. Body-image change in cosmetic plastic
surgery. In: Cash TF, Pruzinsky T, editors. Body images: development,
deviance, and change. New York: Guildford Press, 1990: 217-236.
Beale S, Hambert G, Lisper H, et al. Augmentation mammaplasty:
the surgical and psychological effects of the operation and prediction
of the result. Ann Plast Surg 1985; 14: 473-493. <PubMed>
Phillips KA, McElroy SL, Keck PE Jr, et al. Body dysmorphic disorder:
30 cases of imagined ugliness. Am J Psychiatry 1993; 150: 302-308.
<PubMed>
Phillips KA. The broken mirror: understanding and treating body
dysmorphic disorder. New York: Oxford University Press, 1996.
Sarwer DB, Wadden TA, Pertschuk MJ, et al. Body image dissatisfaction
and body dysmorphic disorder in 100 cosmetic surgery patients.
Plast Reconstr Surg 1998; 101: 1644-1649. <PubMed>
Ishigooka J, Iwao M, Suzuki M, et al. Demographic features of
patients seeking cosmetic surgery. Psychiatry Clin Neurosci 1998;
52: 283-287. <PubMed>
Phillips KA, Dufresne RG Jr, Wilkel C, Vittorio C. Rate of body
dysmorphic disorder in dermatology patients. J Am Acad Dermatol
2000; 42: 436-441. <PubMed>
Veale D. Outcome of cosmetic surgery and "DIY" surgery
in patients with body dysmorphic disorder. Psychiatr Bull 2000;
24: 218-221.
Phillips KA, Grant JD, Siniscalchi J, Albertini RS. Surgical and
nonpsychiatric medical treatment of patients with body dysmorphic
disorder. Psychosomatics 2001; 42: 504-510. <PubMed>
Phillips KA, McElroy SL, Lion JR. Body dysmorphic disorder in
cosmetic surgery patients [letter]. Plast Reconstr Surg 1992;
90: 333-334. <PubMed>
Cotterill JA. Body dysmorphic disorder. Dermatol Clin 1996; 14:
457-463. <PubMed>
Dufresne RG, Phillips KA, Vittorio CC, Wilkel CS. A screening
questionnaire for body dysmorphic disorder in a cosmetic dermatologic
surgery practice. Dermatol Surg 2001; 27: 457-462. <PubMed>
(Received 29 Aug 2001, accepted 7 Feb 2002)
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