Cosmetic Surgery of the Body

David B. Sarwer PhD

Elizabeth R. Didie PhD

Lauren M. Gibbons BA

This chapter was supported, in part, by funding from National Institute of Diabetes and Digestive and Kidney Diseases (Grant #K23 DK60023-03) to Dr. Sarwer.

This chapter reviews the research that has examined the psychological characteristics of patients before, and after, undergoing cosmetic procedures of the body. The greater part of this work has focused on the preoperative and postoperative characteristics of women who have undergone cosmetic breast augmentation. As a result, the majority of the chapter will address these issues. Given the relatively high rates of complications associated with breast augmentation, it is surprising that few studies have investigated the relationship between postoperative complications and psychological outcomes. We also will discuss the thought-provoking results from several epidemiological studies that have found a relationship between cosmetic breast implants and suicide.

Body contouring procedures such as lipoplasty and abdominoplasty have long been popular; however, the psychological aspects of these procedures have received little attention. Less common procedures, such as body contouring implants, as well as cosmetic genital procedures, also have received little empirical study. Intuitively, individuals who seek these procedures may display psychological characteristics that are different from those of individuals who seek the more common procedures. The chapter will conclude with a discussion of eating disorders and muscle dysmorphia (thought to be a subtype of body dysmorphic disorder). These syndromes may be both the most common and relevant psychiatric disorders among individuals who pursue cosmetic procedures for the body.

COSMETIC BREAST AUGMENTATION

The American Society of Plastic Surgeons reported that 264,041 women underwent cosmetic breast augmentation surgery in 2004 (1). This represents an increase of almost 600% in the past decade. These numbers do not capture procedures being performed by the increasing number of non-plastic surgeon physicians who offer breast augmentation. Thus, while the numbers are substantial, they likely underestimate the number of augmentation procedures performed annually.

The dramatic increase in the popularity of cosmetic breast augmentation is somewhat remarkable considering that in 1992 the Food and Drug Administration issued a moratorium on the use of silicone-gel filled implants. Then FDA Commissioner David Kessler called for further study of the physical safety and psychological benefits of breast implants. Several studies and literature reviews since have suggested that silicone breast implants are not associated with specific diseases, including cancer and connective tissue disease (2, 3, 4, 5, 6). Yet, in 2003, following an application from a breast implant manufacturer to return silicone-gel filled implants to the American
marketplace, the FDA upheld its previous decision, arguing that sufficient data on potential long-term complications were still lacking. Silicone-gel filled implants remain widely available in almost every other country throughout the world. Their fate in the United States, however, remains uncertain at the present time.

Over the last several decades, numerous studies have investigated the psychological characteristics of women who undergo cosmetic breast augmentation. Some studies have provided important descriptive information on the psychological characteristics of women interested in the procedure. Others have investigated the psychological changes typically experienced postoperatively.

Demographic and Descriptive Characteristics

The stereotypical breast augmentation patient is widely thought to be a single, European-American woman in her early 20s to mid-20s who is interested in breast augmentation surgery as a way to facilitate the development of a romantic relationship. Several studies, however, have suggested that the typical patient is quite different from this stereotype. She is most often European-American, but is frequently in her late 20s or early 30s and is married with children (7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17). While these characteristics may describe the “typical” patient, women from their late teens to mid-40s of varying ethnic backgrounds and relationship status present for breast augmentation surgery. Furthermore, the characteristics of these women likely vary based upon region of the country, characteristics of a surgeon’s practice, as well as other variables.

Women who receive breast implants differ from other women on a variety of unique characteristics. Women with breast implants are more likely to have had more sexual partners, report a greater use of oral contraceptives, be young at their first pregnancy, and have a history of terminated pregnancies as compared to other women (18, 19, 20, 21). They have been found to be more frequent users of alcohol and tobacco (19, 20, 21). They also have a higher divorce rate (16, 17). Finally, they have been found to have a below average body weight (18, 19, 20, 21, 22, 23), leading to concern that some of these women may be experiencing eating disorders (discussed in more detail below).

Motivations for Breast Augmentation

Several factors likely motivate women to undergo cosmetic breast augmentation (24). Intrapsychic factors describe the internal motivations for surgery and the resulting effects of surgery on psychological status. Interpersonal factors concern the importance of the appearance of the breasts in marital, sexual, and social relationships. With regard to these factors, women who seek breast augmentation report anticipating improved quality of life, body image, and self-esteem, as well as increased marital and sexual satisfaction postoperatively (11,16, 17,22,25, 26, 27, 28, 29). Informational and medical factors also are thought to play a role in the decision to seek augmentation. Women who undergo breast augmentation obtain a great deal of information about breast implants from the mass media (22,30, 31) and appear to be aware of many of the risks associated with implants (22,26,32).

Studies of Preoperative and Postoperative Psychological Status

Numerous studies have investigated the preoperative psychological status of women interested in breast augmentation. They were undertaken, in large part, to further understand the psychological characteristics of the typical patient, but also to potentially identify women who were psychologically inappropriate for surgery. As has been reviewed in greater detail elsewhere (24), the early generations of research in this area primarily relied on clinical interviews to assess preoperative and postoperative psychological functioning. Later studies have been more likely to use valid and reliable psychometric measures to assess relevant characteristics. The methodology employed has, more often than not, predicted the outcome of the investigation.

Clinical Interview Studies

Initial investigations of the psychological characteristics of breast augmentation patients relied heavily on unstructured clinical interviews of women prior to surgery. Appearance-related concerns were frequently interpreted as symbolic displacements of intrapsychic conflicts by psychiatrists who were trained in the psychoanalytic model of personality and psychopathology, the dominant theoretical orientation at that time. Not surprisingly, breast augmentation patients, as well as most cosmetic surgery candidates, were seen as highly psychopathological (15, 16, 17,33). Clinical interview investigations have described breast augmentation patients as experiencing increased symptoms of depression, anxiety, guilt, and low self-esteem (15, 16, 17,33). In one such investigation, 55% were described as being “in need of therapy” (17) and 70% in another study as “deviating from the normal picture” (15). The majority were reported to have personality disorders (34).

Interview-based reports tended to focus on the character structure of prospective breast augmentation patients. Relatively few examined the effects of breast augmentation on psychological functioning. The majority of these studies have reported improvements in self-esteem and depressive symptoms postoperatively (8,33) or at least no change from the preoperative status (15).

Psychometric Investigations

Studies that used standardized psychometric tests typically have found significantly less psychopathology than the interview-based investigations. Two studies of breast augmentation patients that used psychometric measures, including the Minnesota Multiphasic Personality Inventory, found little evidence of psychopathology (10,13). In contrast, only one investigation found greater symptoms of depression in breast augmentation patients as compared to controls (11). Investigations that used other standardized measures also found few differences in personality characteristics as compared to controls (13).

Studies that have used psychometric measures to assess changes in psychological status following cosmetic surgery have typically reported improvements in a variety of domains. Few, however, have examined postoperative changes among breast augmentation patients. The two reports of breast augmentation patients that used psychometric measures found mixed results. One found a decrease in symptoms of depression from preoperative status (35); the other reported increased symptoms of depression in 30% of patients in the immediate postoperative period (36).

Summary

The results of the clinical interview and psychometric investigations are contradictory. Unfortunately, both sets of investigations have suffered from a variety of methodological limitations that makes drawing definitive conclusions from this research difficult, if not impossible. The clinical interviews were typically not standardized and did not include inter-rater reliability of the symptoms or diagnoses. Furthermore, the theoretical biases of the psychiatrist-interviewers may have influenced the degree of psychopathology reported. The psychometric investigations suggest far less psychopathology among breast augmentation patients; however, this research also suffers from methodological problems. Several failed to include preoperative assessments and reported only postoperative results, including those immediately after surgery, when women may not have yet achieved their final aesthetic result. Most psychometric investigations did not include appropriate control or comparison groups. Therefore, it is unclear if the frequency of psychological conditions found among surgical candidates represents increased psychopathology above and beyond that found in the general population.

Despite the methodological problems and contradictory findings, two tentative conclusions can be drawn (37, 38, 39). First, breast augmentation candidates likely present for surgery with a variety of psychological symptoms and conditions. Whether some of these conditions serve as contraindications for surgery has yet to be established. Second, although an increasing number of studies have demonstrated improvements in psychological functioning following cosmetic procedures, relatively few have specifically investigated this issue in breast augmentation patients. Therefore, it is likely premature to definitively conclude that cosmetic breast augmentation confers psychological benefits.

Studies of Body Image Dissatisfaction

Within the past decade, an increasing amount of attention has been paid to the relationship between body image and cosmetic surgery (38, 39, 40, 41). Body image dissatisfaction has long been thought to motivate many appearance-enhancing behaviors, from weight loss and exercise to clothing and cosmetic purchases (42). A theoretical model has been proposed which suggests that body image dissatisfaction may be the primary motivational factor in the pursuit of cosmetic surgery (41). Several empirical studies have suggested that cosmetic surgery patients report increased body image dissatisfaction prior to surgery (22,40,43, 44, 45, 46). Others have found improvements in body image postoperatively (26,47, 48, 49, 50, 51).

Several clinical reports over the past several decades have described the body image concerns of breast augmentation patients (10, 11,13,28). Breast augmentation candidates typically report less dissatisfaction with their breasts compared to breast reduction patients (52). However, greater than 50% of breast augmentation patients reported significant behavioral avoidance, such as camouflaging their breasts or avoidance of being seen undressed, in response to negative feelings about their breasts.

Two more recent studies have compared breast augmentation candidates to small-breasted women not seeking breast augmentation. Women who sought breast augmentation, as compared to controls recruited from a university community, reported greater dissatisfaction with their breasts, as well as greater investment in their overall appearance and greater concern with their appearance in social situations (45). Augmentation candidates also rated their ideal breast size, as well as the breast size preferred by women, as significantly larger than did controls. Finally, prospective patients reported more frequent teasing about their physical appearance and more frequent use of psychotherapy than did controls. These later results suggest that some women interested in breast augmentation may be experiencing negative emotional consequences as a result of their breast dissatisfaction.

In the second study, breast augmentation candidates were compared to healthy women similar in age, body mass, and breast size recruited from a gynecology outpatient clinic (22). Women interested in breast augmentation again reported greater dissatisfaction with their breasts. As compared to controls, however, they did not report greater investment or dissatisfaction with their overall appearance. Women pursuing breast augmentation reported being motivated for surgery by their own feelings about their breasts, as also found in other studies (26). Romantic partners and sociocultural ideas of beauty played less of an influential role in the decision to seek surgery.

Women who undergo breast augmentation experience improvements in their body image postoperatively, as suggested by clinical reports (10,12,15) and empirical studies (26,48,50). In one of the largest studies of psychosocial outcomes following breast augmentation, greater than 90% of patients reported an improved body image 2 years postoperatively (26). The beneficial role of breast implants on body image may be best illustrated by women who have had their implants removed. These women report less subsequent satisfaction with their appearance, fewer positive appearance-related thoughts, and greater discrepancy between their ideal and current body size (53). Removal of breast implants without replacement, much like
a loss of a breast to cancer without subsequent reconstruction, appears to a have a dramatic, adverse impact on women’s body image.

Psychological Functioning and Postoperative Complications

Clinical reports suggest that the majority of women are satisfied with the outcome of breast augmentation surgery (12,35,54, 55). For example, one prospective investigation (26) found surgery satisfaction rates to be 94%, 92%, and 91% at 6 months, 12 months, and 24 months, respectively, after surgery. As detailed above, an increasing number of studies suggest that women experience psychological improvements postoperatively (26,48,50). These benefits, however, may be tempered by the experience of a postoperative complication. Between 10% and 25% of women are reported to experience a surgical or implant-related complication (56, 57, 58). The most common complications are implant leakage or rupture/deflation, capsular contracture, discomfort or pain, breast asymmetry, scarring, loss of nipple sensation, and breast-feeding difficulties (2, 3, 4, 5, 6,56, 57, 58, 59, 60).

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