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Before the makeover, DeLisa Stiles--a therapist and captain in the Army Reserves--complained of looking too masculine. But on Fox's reality TV makeover show, "The Swan 2," she morphed into a beauty queen after a slew of plastic surgery procedures--a brow lift, lower eye lift, mid-face lift, fat transfer to her lips and cheek folds, laser treatments for aging skin, tummy tuck, breast lift, liposuction of her inner thighs and dental procedures. The Fox show gives contestants plastic surgery and then has them compete in a beauty pageant, which last year Stiles won.

"The Swan" and other such plastic-surgery shows, including ABC's "Extreme Makeover" and MTV's "I Want a Famous Face," are gaining steam, but some psychologists are concerned about the psychological impact on those who undergo such drastic cosmetic surgery--and also on those who don't and may feel inadequate as a result. While such radical transformations are rare, some psychologists plan to investigate the surge in cosmetic procedures and whether these surgeries have any lasting psychological consequences.

The number of cosmetic procedures increased by 44 percent from 2003 to 2004, according to the American Society for Aesthetic Plastic Surgery. Plastic surgeons conducted a record 11.9 million procedures last year, including nonsurgical procedures like Botox and surgical procedures like breast augmentation or liposuction (see chart).

How do such procedures affect patients psychologically? A recent analysis of 37 studies on patients' psychological and psychosocial functioning before and after cosmetic surgery by social worker Roberta Honigman and psychiatrists Katharine Phillips, MD, and David Castle, MD, suggests positive outcomes in patients, including improvements in body image and possibly a quality-of-life boost too. But the same research--published in the April 2004 issue of Plastic and Reconstructive Surgery (Vol. 113, No. 4, pages 1,229-1,237)--also found several predictors of poor outcomes, especially for those who hold unrealistic expectations or have a history of depression and anxiety. The researchers found that patients who are dissatisfied with surgery may request repeat procedures or experience depression and adjustment problems, social isolation, family problems, self-destructive behaviors and anger toward the surgeon and his or her staff.

Overall, there are more questions than answers regarding psychological effects of cosmetic surgery: There are few longitudinal studies and many contradictory findings, researchers note. Many studies also contain small sample sizes and short follow-ups with patients, says Castle, a professor and researcher at the Mental Health Research Institute of Victoria in Victoria, Australia.

"We really need good, large prospective studies of representative samples of patients, using well-established research instruments," Castle says. "While most people do well in terms of psychosocial adjustment after such procedures, some do not, and the field needs to be aware of this and to arrange screening for such individuals."

In particular, the extent to which cosmetic surgery affects patients' relationships, self-esteem and quality of life in the long-term offers many research opportunities for psychologists, says psychologist Diana Zuckerman, PhD, president of the National Research Center for Women and Families, a think tank that focuses on health and safety issues for women, children and families.

"These are fascinating issues for psychologists to look at--from the cultural phenomena to the interpersonal phenomena to the mental health and self-esteem issues," Zuckerman says.

In addition, plastic-surgery issues will increasingly affect clinician psychologists, and the area will offer new roles for them--such as conducting pre- and post-surgical patient assessments, says psychologist David Sarwer, PhD, director of the Education, Weight and Eating Disorders Program at the University of Pennsylvania. He has studied appearance-related psychological issues, including cosmetic surgery, for the last 10 years.

"As the popularity of plastic surgery continues to grow, many psychologists likely already have--or will encounter--a patient that has thought about or undergone a cosmetic procedure," he says. Therefore it will be increasingly important for psychologists to be able to talk with patients about their appearance concerns and what may make some one a good or bad candidate for cosmetic surgery, he says.

Research directions

Equally pressing, however, is the need for research that sheds light on plastic surgery's psychosocial effects, many psychologists agree. To help fill in the gaps, researchers suggest further studies on the following questions:

  • Does plastic surgery make patients feel better? Studies have shown that people report increased satisfaction with the body part they had surgery on, but results are mixed on whether plastic surgery boosts their self-esteem, quality of life, self-confidence and interpersonal relationships in the long term.

In a recent study, Sarwer--also an associate professor of psychology at the Center for Human Appearance at the University of Pennsylvania School of Medicine--found that a year after receiving cosmetic surgery, 87 percent of patients reported satisfaction following their surgery, including improvements in their overall body image and the body feature altered. They also experienced less negative body image emotions in social situations. The study, which was supported by a grant from the Aesthetic Surgery Education and Research Foundation, appeared in the May/June issue of the Aesthetic Surgery Journal (Vol. 25, No. 3, pages 263-269). Sarwer and his colleagues plan to follow up with the patients next year.

However, Castle's team found in their literature review--besides some positive outcomes--a link between plastic surgery and poor post-surgical outcomes for some patients, particularly for those with a personality disorder, those who thought the surgery would save a relationship and those who held unrealistic expectations about the procedure.

Some studies have even gone as far as linking dissatisfaction with cosmetic surgery procedures to suicide. For example, in one study, the National Cancer Institute found in 2001 that women with breast implants were four times more likely to commit suicide than other plastic surgery patients of the same age as the women who underwent breast implants, says Zuckerman, who in April testimony to the Food and Drug Administration (FDA) urged the FDA to deny approval of silicone gel breast implants because of a lack of longitudinal research ensuring their safety.

The other three studies on the topic found the suicide rate to be two to three times greater. Neither of the studies, however, identified a causal relationship between breast implants and suicide. Some researchers speculate that some of the surgery recipients may hold unrealistic expectations of it or have certain personality characteristics that predispose them to suicide.

  • How does cosmetic surgery affect those around the recipients? Physically attractive people often receive preferential treatment and are perceived by others as more sociable, dominant, mentally healthy and intelligent than less attractive people, according to research by psychologist Alan Feingold, PhD, in the March 1992 issue of APA's Psychological Bulletin (Vol. 111, No. 2, pages 304-341).

"It's not like looking good doesn't have real advantages--it does," Zuckerman says. "If some people get plastic surgery and other people don't, is that going to put the people who don't at all kinds of disadvantages, such as in finding a job or spouse?"

Nearly 30 years ago, many mental health professionals viewed patients who sought cosmetic surgery as having psychiatric issues, but many studies since then suggest that those who seek cosmetic surgery have few differences pathologically with those who don't have surgery, Sarwer says.

Most people are motivated to undergo cosmetic surgery because of body-image dissatisfaction, says Susan Thorpe, a lecturer in psychology at the University of Surrey in Guildford, Surrey, who conducts cosmetic surgery research.

"They want to look normal--that is, they don't want to stand out in an obvious way or to have features which cause comment or make them feel self-conscious," Thorpe says. "They also want their physical appearance to be more in line with their personalities and feel that they want all the bits of their bodies to match."

  • What effect does plastic surgery have on children and teenagers? In 2004, about 240,682 cosmetic procedures were performed on patients 18 years old or younger, and the top surgical procedures were nose reshaping, breast lifts, breast augmentation, liposuction and tummy tucks. However, very few studies have been conducted to examine the safety and long-term risks of these procedures on adolescents--an age in which teenagers are still developing mentally and physically, Zuckerman says.

  • When does changing your appearance qualify as body dysmorphic disorder (BDD)? BDD, first introduced in the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders in 1987, is characterized by a preoccupation with an aspect of one's appearance. People with BDD repeatedly change or examine the offending body part to the point that the obsession interferes with other aspects of their life. Several studies show that 7 to 12 percent of plastic surgery patients have some form of BDD. Plus, the majority of BDD patients who have cosmetic surgery do not experience improvement in their BDD symptoms, often asking for multiple procedures on the same or other body features.

Sarwer often works with plastic surgeons to help them identify such psychological issues as BDD, so surgeons then can refer patients to mental health professionals. He encourages them to look for the nature of the person's appearance concern, such as whether a patient has an excessive concern with a body feature that appears normal to nearly anyone else. Part of that also includes accounting for patients' internal motivations for surgery--are they doing it for themselves or out of pressure from a romantic partner or friend? And, he encourages surgeons to ensure patients hold realistic expectations about the procedures, rather than expecting the surgery to end long-standing personal issues.

Psychology's role

Apart from research, psychologists can find clinical roles in aiding cosmetic surgery patients too, such as helping plastic surgeons conduct such assessments. For example, they can help plastic surgeons identify patients who may not adjust well psychologically or psychosocially after surgery, researchers say.

Castle says that empirically based screening questionnaires will help plastic surgeons select cosmetic surgery patients likely to experience positive psychosocial outcomes.

Sarwer has teamed with other psychologists and plastic surgeons to develop such screening questionnaires, which are included in the book "Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Clinical, Empirical and Ethical Perspectives" (Lippincott Williams & Wilkins, 2005). The book, to be published this month, features a chapter on how to help both surgeons and mental health professionals screen for BDD, as well as explore the relationships among physical appearance, body image and psychosocial functioning.

Sarwer believes more psychologists will begin to examine issues related to cosmetic surgery because of its increasing popularity and the link between appearance, body image and many psychiatric disorders, such as eating disorders, social phobia and sexual functioning. "Scientifically, we're just starting to catch up to the popularity of [cosmetic surgery] in the population," Sarwer says.

And, as more studies commence, Castle says they need to characterize the population being studied, clearly identify outcome variables and use standardized and state-of-the-art measures.

"There may be strong cultural pressures that are so unrealistic in terms of how we're supposed to look," Zuckerman adds. "Psychologists should...figure out why this is happening and what we need to know to make sure that people aren't going to be harmed by this."

Further Reading

  • Honigman, R., Phillips, K., & Castle, D.J. (2004). A review of psychosocial outcomes for patients seeking cosmetic surgery. Plastic and Reconstructive Surgery, 113(4), 1229–1237.

  • Rankin, M., Borah, G., Perry, A., & Wey, P. (1998). Quality-of-life outcomes after cosmetic surgery. Plastic and Reconstructive Surgery, 102(6), 2139–2145.

  • Sarwer, D.B. (2001). Plastic surgery in children and adolescents. In J. Thompson & L. Smolak (Eds.) Body image, eating disorders and obesity in youth. (pp. 341–366). Washington, DC: American Psychological Association.

  • Thompson, J.K., Heinberg, L.J., Altabe, M.N, & Tantleff-Dunn, S. (2004). Extracting beauty: Theory, assessment and treatment of body image disturbance. Washington, DC: American Psychological Association.

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