By Sarah Ford, InPsych feature writer

Cosmetic surgery can enhance your life as well as your looks, according to industry advertisements and television shows, such as Extreme Makeover and Nip/Tuck. The idea is that a face “lift” will also boost one’s spirits and self-confidence. The problem is that the evidence supporting this assumption is tentative. Research shows that, following cosmetic surgery, patients variously report their mental health has either improved, not changed, or diminished. Psychiatrist David Castle, a leading researcher on the psychological outcomes of cosmetic surgery, is concerned by the “gloss” applied to cosmetic surgery that “suggests you will have a new life”, he says. “But of course, it doesn’t change the person you are on the inside.” David, who is a professor at the University of Melbourne and the Mental Health Research Institute of Victoria, says that some research has shown that cosmetic surgery can enhance self-esteem, which can feed into social confidence, but the evidence for long-term effects on psychological wellbeing is scant and requires further investigation.

David and colleagues recently reviewed the literature on psychosocial outcomes for patients seeking cosmetic surgery (Honigman, Phillips, & Castle, 2004). The authors analysed 37 studies that evaluated psychological and psychosocial functioning before and after a range of elective cosmetic surgery procedures. Breast surgery (reduction and augmentation) was the procedure that was most consistently associated with good psychological outcomes. In particular, women who had breast reductionsreported the highest rates of satisfaction and improved mental health, such as enhanced body image and decreased distress. Eight studies reported improvements in social functioning, relationships and quality of life after cosmetic surgery, with at least half of these results based on breast procedure outcomes. Nose and facial procedures produced mixed outcomes. Several studies that examined personality in cosmetic surgery patients also found mixed results, suggesting the way personality affects the surgical experience is unclear.

Predictors of poor psychological outcomes

Overall, the review showed that most patients were satisfied with their results, but some demonstrated poor psychological outcomes. One of the strongest predictors of a poor outcome was having an extreme and unrealistic expectation of the surgery results, such as being able to find a new job or relationship. Males had poorer outcomes, which David suggests is because the threshold for men to seek help is higher. “Cosmetic surgery is more acceptable for women, so men have to be worse to seek it”, he says.Younger people also tended to do worse than older people. “A lot of studies were based on (“anti”) ageing procedures”, David says. “So younger people are more likely to be seeking procedures for abnormalities which you and I would not see, or would think are trivial.” Other predictors of poor outcomes include a history of numerous past procedures, depression and anxiety, and narcissistic or borderline personality traits, although David cautions that very few studies investigated personality systematically.

A lack of systematic studies in the literature was a general problem, making it difficult to have confidence in the findings and reach firm conclusions. For example, the psychological concepts measured, such as self-confidence and self-esteem, are broad and often vague terms that were generally not clearly explained or defined. There were no randomised controlled design studies, so it is hard to know if reported changes in psychological functioning resulted from the procedure or other factors, such as patient characteristics. This type of study may not be possible given that patients are unlikely to accept being in a “no procedure” control group.

The evidence that some cosmetic surgery patients are dissatisfied with the results of surgery, despite it being an objective success, intrigued psychologist Julie Malone, who recently completed her doctoral thesis on the topic at the University of New England in north-east NSW. Her study followed the outcomes of 91 females aged 18 to 64 years (average age 42 years) who had elective facial cosmetic procedures, including nose procedures, face lifts, eye surgery and other minor procedures on areas such as chins and teeth (Malone, 2003). Sydney-based cosmetic surgeons handed out anonymous questionnaires to patients to complete pre and post (three months after) surgery.

Julie’s aim was to investigate the kind of person that would be a poor candidate for cosmetic surgery. The factors she considered were age, type of procedure, number of previous remedies attempted, history of previous cosmetic surgery, mental health, and level of dysmorphic concern, which is the degree to which one is preoccupied with an imagined or perceived physical flaw.

Age was the only good predictor of satisfaction; older women reported higher levels of satisfaction with outcomes. Further investigations of this finding revealed that young women having nose procedures were the most dissatisfied group, Julie says. “I researched noses further and concluded that young people are seeking a quick fix for their image dissatisfactions”, she says. “What I implied in my study was that they are shopping around for a new nose instead of accepting themselves for who they are and seeking other sources of therapy.” Drawing on the literature, Julie says the implications are that young people are jumping into cosmetic treatments without thinking and are more susceptible to media presentations of beauty. Further, there is evidence that younger patients are looking more for external rewards, like a romance or better job, while older people are looking more for internal rewards, like self-worth. As Hongiman et al’s (2004) review showed, seeking unrealistic rewards predicts a poor outcome.

High levels of dysmorphic concern predict poor, occasionally tragic, outcomes

In Julie’s study, satisfaction with outcomes was assessed three months after surgery and results showed a clear split between participants, with two thirds reporting they were “very satisfied” and one third reporting they were “not satisfied”. Satisfied patients reported lower levels of dysmorphic concern compared to dissatisfied patients. In addition, those low on dysmorphic concern reported post surgery improvements in their general mental health, as measured by the General Health Questionnaire (GHQ-12). In comparison, those high on dysmorphic concern experienced no psychological change.

Honigman et al’s (2004) review also found that patients with higher levels of dysmorphic concern are less likely to benefit from cosmetic surgery. Besides having unrealistic expectations, the other strong predictor of a poor outcome was with patients who had no objective deformity, a minimal deformity, or, if they did have a deformity, were overly concerned about it so much that it impacted on their lives excessively. People demonstrating the more extreme manifestations of such concerns may have Body Dysmorphic Disorder (BDD).Between 7 per cent and 15 per cent of people presenting to plastic surgeons and cosmetic dermatologists have BDD, according to mainly US studies.

David, who has co-edited a book on BDD, says people with the disorder believe that if their perceived defect is removed then they will be happy. But, once they have a procedure their psychological wellbeing does not improve; it often decreases. Sometimes this leads to the pursuit of numerous procedures, which only serves to increase distress in the patient and surgeon, he says. “A number of studies have found that the majority of people with Body Dysmorphic Disorder have had cosmetic procedures, and the majority of those are unhappy with the outcome.”

Occasionally, people with BDD are so unhappy that they have attacked and even killed cosmetic surgeons, David says. “A small group really do quite badly, and they can be litigious as well as potentially violent towards plastic surgeons”, he says, citing the example of a patient who attacked a surgeon with a mallet after he was unhappy with the outcome (although, objectively, it was a success). On another occasion, a woman told David of how her plastic surgeon husband was killed by a woman he had operated on a number of times and who had become increasingly disgruntled.

Psychological screening for cosmetic surgery

Tragic outcomes like this, although rare, highlight the need for psychological screening of people seeking cosmetic surgery. As a minimum, this should include screening for BDD as well as assessing motivations for, and expectations of, the procedure, David says. In reality, screening is erratic. Some surgeons use their clinical judgement to refer patients for screening, but there is no systematic procedure for doing so. David and colleagues are working on developing such a procedure, he says. “My belief is it could easily become mandated because the outcomes of operating on the wrong people are so horrible for everybody.”

One of Julie’s research aims was to determine a statistical cut-off point on measures of dysmorphic concern for use as a screening tool to identify potentially poor candidates for cosmetic surgery. She found a point that attained a specificity of 80 per cent, showing potential for an objective measure that identifies high-risk patients. Julie says the ideal scenario is that all patients are screened, but this may not be feasible and it relies on the cooperation of surgeons, who have demonstrated varying levels of support for the idea.

It seems surgeons’ awareness of the problem is growing. David says more surgeons are referring patients to his team, either due to concerns that some would not be good candidates for surgery and might need psychological help instead, or because a patient with an objectively good outcome remains unhappy. A recent survey of 265 US cosmetic surgeons showed high levels of BDD awareness and a reluctance to operate on these people (Sarwer, 2002). The fact that the Honigman et al (2004) review was published in Plastic and Reconstructive Surgery, a prestigious American plastic surgery journal, is also a good sign, and the authors have been invited to speak at various industry conferences, David says.

David says screening for BDD requires sensitive questioning about how surgery candidates view themselves and how this is impacting on their lives.

Australia's cosmetic surgery industry
  • Approximately 50,000 cosmetic procedures were performed in 1998, double that of 1995's figure
  • 350 medical practitioners each conduct around 150 cosmetic surgical procedures annually
  • The most popular procedure in Australia is liposuction (about 10,000 per year), followed by breast implants (4500-6000 per year), facelifts (3000 per year), and eyelid surgery (3000 per year)
  • Consumers mainly obtain information about cosmetic surgery procedures through media stories and advertising (25 per cent), or via a friend or relative (24.6 per cent)

Source: The Cosmetic Surgery Report (1999) issued by the NSW Minister for Health

 

Treatment of Body Dysmorphic Disorder

BDD can be psychologically treated, with most evidence supporting the use of cognitive behavioural therapy (CBT). The most effective treatment is a combination of CBT and Selective Serotonin Reuptake Inhibitors (SSRIs), especially if people are depressed. The disorder has a high comorbodity with Major Depressive Disorder, Obsessive Compulsive Disorder, Delusional Disorder and Social Phobia. David says it is often difficult to engage people with BDD in “straightforward” CBT and further work is needed on the engagement process and understanding the emotional underpinnings of the disorder. “It’s a tough disorder to treat in that people do see their problem as physical and a lot of them say they don’t see why they should see a mental health professional.” But others are relieved when they realise it is a recognised disorder that other people have, and generally those people do very well in therapy.

The experience of people with BDD and other dissatisfied cosmetic surgery patients is in stark contrast with the media’s glorification of cosmetic surgery outcomes. Earlier this year, thousands of Australians applied to be cosmetic surgery patients in The Ultimate

Transformation, the Australian version of Extreme Makeover. David says there is no doubt that the media is very powerful in terms of the way people feel about themselves and the sort of things they aspire to. In his work he tries to temper those media messages by pointing out the benefits of human variety over a stereotyped, uniform look. It is also important to reinforce that although people in the media may appear perfect, elaborate techniques are used to create this unrealistic and, essentially, false image. “Perfect is quite boring”, David says. “There should be more media messages that it is okay to be okay.”

References

Honigman, R. J., Phillips, K.A., & Castle, D. J. (2004). A review of psychosocial outcomes for patients seeking cosmetic surgery. Plastic and Reconstructive Surgery, 113, 1229–1237.

Malone, J. (2003). Dysmorphic concern, psychological responses and predicting outcomes of cosmetic surgery. Unpublished doctoral dissertation, University of New England, Armidale, New South Wales, Australia.

Sarwer, D. B. (2002). Awareness and identification of body dysmorphic disorder by aesthetic surgeons: Results of a survey of American Society for Aesthetic Plastic Surgery members. Aesthetic Surgery Journal, 22, 531.

Further reading on Body Dysmorphic Disorder

Castle D.J., Phillips K.A. (Eds.). (2002). Disorders of Body Image. Hampshire: Wrightson Biomedical.

Editor's Note: The APS would like to acknowledge the information provided by Roberta Honigman during the compiling of this article, published in the June 2004 edition of InPsych. Roberta is a social worker who has completed a Masters degree at Melbourne University in the area of dissatisfaction among cosmetic surgery patients.