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Over the past 2 decades, cosmetic surgical and minimally invasive treatments have exploded in popularity. There likely are a number of potential explanations for the dramatic increase1–4:

• Technologic advances have made many of the surgical treatments safer.

• More general advances in medicine have decreased the length of most postoperative recovery periods.

• Minimally invasive treatments have even less associated risk and recovery time, as well as lower relative cost, both of which fuel their appeal to patients.

• Cosmetic procedures, unlike other forms of medicine, readily lend themselves to direct-to-consumer advertisements in a variety of outlets such as city and regional magazines, billboards, and bus stop advertisements. Their banner advertisements on websites and other forms of mass media, as well as the entertainment industry, have all contributed to the growth of cosmetic surgery.

• Cosmetic surgery has long been a very popular topic for women’s (and men’s) beauty magazines, which often tout the latest advances in the field, and the last decade has witnessed unprecedented coverage of cosmetic surgery on television—from informative health programs to reality-based patient contests, as well as surgeon-focused shows.

• A growing number of celebrities now publically reveal their experiences with cosmetic surgery, something not seen in Hollywood decades ago.

For all of these reasons, it is safe to say that cosmetic surgery is a cornerstone of popular culture. These more overt cultural influences play against a backdrop of relentless images of physical perfection depicted in magazines, television programs, movies, and the Internet. The end result is that consumers cannot help but be exposed to depictions of physical beauty, with cosmetic surgery depicted as an acceptable step on that path to perfection.

In addition to its representation in the media, there are other potential explanations for the growth of cosmetic surgery. Evolutionary theories of physical attractiveness, which suggest that physical characteristics representing reproductive potential are the ones considered most physically attractive, have been applied to cosmetic surgery.3 Many surgical and minimally invasive treatments performed on the face are undertaken to help an individual look more youthful or enhance facial symmetry; both of these traits are well-established markers of facial attractiveness. At the same time, procedures such as liposuction and abdominoplasty can decrease an individual’s waist-to-hip ratio—another marker of reproductive potential.

Social psychological research on the importance of physical appearance in daily life can also be used to understand the growth of cosmetic surgery. Over the past several decades, this body of research has suggested that individuals who are more physically attractive are believed to have a number of more positive personality traits, which may afford them preferential treatment in a range of social situations across the life span, such as opportunities for promotions at work, as well as the development of friendships and romantic relationships in the personal sphere.³ Thus whether we like to acknowledge it or not, physical appearance does seem to matter.

Whereas decades ago an individual’s interest in improving his or her appearance may have been seen as being symptomatic of excessive vanity, narcissism, or other deep-seeded psychopathology, today it also can be seen as a more adaptive and potentially psychologically healthy behavior strategy, akin to other self-improvement strategies, such as eating a healthy diet and exercising regularly.⁵

Preoperative Psychosocial Characteristics of Cosmetic Surgery Patients

A now-sizable body of research has investigated the psychosocial characteristics of persons who present for cosmetic surgery. The following discussion provides an overview of patients’ motivations and expectations for surgery, as well as the most common forms of psychopathology likely seen by mental health professionals asked to consult on candidates for cosmetic procedures.

Motivations for Surgery: Body Image Dissatisfaction

Patients present for cosmetic procedures with a variety of motivations and expectations regarding the impact of surgery on their lives. Motivations for surgery have been described as internal or external.^6,7 Although both patients and surgeons may struggle to articulate or identify specific motivations for surgery, patients with internal motivations (e.g., desire to improve one’s self-confidence) rather than external motivations (e.g., undergoing surgery to obtain a romantic partner) are believed to be more likely to have their postoperative expectations met.⁸

Body image dissatisfaction is considered to be a primary motivation for cosmetic surgery and other appearance-enhancing behaviors.^4,5,9–12 The past several decades have witnessed an increased interest in body image, with much of the study of cosmetic surgery patients over the past 20 years focusing on this construct.^2,9,13 In its simplest form, body image refers to an individual’s perceptions, thoughts, and feelings about his or her body.¹⁴ Cash and Smolak¹⁵ refer to body image as “the psychological experience of embodiment.” Although both these definitions provide more detail and nuance to the concept of body image, recognizing how an individual’s body image can affect his or her quality of life and other psychological factors, neither addresses the ways in which body image can influence behaviors, such as the desire to have cosmetic surgery.

Because of its relationship with quality of life and self-esteem, body image, and more specifically body image dissatisfaction, has often been examined in relation to eating disorders and obesity.^10,16 Although body image dissatisfaction is often positively associated with body weight, people across genders, age groups, and ethnicities suffer from body image dissatisfaction regardless of their body weight.^12,13 This suggests that how one perceives his or her body may have little to do with how someone actually looks.¹⁵ Nevertheless, body image dissatisfaction is associated with numerous appearance-enhancing behaviors, including dieting, physical activity, and fashion and cosmetic purchases.¹⁰ Thus it should come as no surprise that individuals with body dissatisfaction may also turn to cosmetic surgery.

Numerous studies of cosmetic surgery patients have found that patients report heightened body image dissatisfaction preoperatively.^17–22 For example, breast augmentation candidates report greater dissatisfaction with their breasts compared with other small-breasted women who do not seek breast augmentation.^23,24 Similarly, individuals who seek body contouring surgery after the massive weight losses seen with bariatric surgery typically report heightened dissatisfaction with their bodies.²⁵ Although the weight loss is associated with improvements in body image, many patients report great unhappiness with the loose, hanging skin of their abdomens, thighs, breasts, and arms.²⁵ For example, 91% of adolescents who had undergone bariatric surgery reported feeling unattractive because of their excess skin.25

Nevertheless, though some degree of body image dissatisfaction is believed to be a prerequisite to cosmetic surgery, these feelings may also be representative of several forms of formal, severe psychopathology.

Formal Psychopathology

As mentioned previously, preoperative psychopathology among patients is a primary focus of cosmetic surgery research. The first studies of this issue, conducted decades ago, relied heavily on clinical interviews of cosmetic surgery candidates and described them as having high rates of psychopathology, including mood and anxiety disorders, as well as personality disorders.^26–29 All of these conditions were believed to be associated with poor postoperative psychological outcomes. More recently, studies have included the use of standardized psychometric measures rather than or in addition to clinical interviews of prospective patients; these studies typically have found less psychopathology.^23,24,30,31 Both sets of studies suffer from methodological problems that have made interpretation of these conflicting findings difficult.^4,5,20,32 Thus the rate of psychopathology among cosmetic surgery patients remains poorly understood and, perhaps more importantly, the relationship between preoperative psychopathology and postoperative outcomes is largely unknown.

Given the number and diversity of individuals who now seek cosmetic surgery, all of the psychiatric diagnoses can likely be found within the patient population. However, three disorders in particular—body dysmorphic disorder, eating disorders, and depression—warrant the greatest attention from plastic surgeons and the mental health professionals asked to consult on a patient’s psychological appropriateness for surgery.

Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is defined as a preoccupation with a slight or imagined defect in appearance that leads to substantial distress or impairment in social, occupational, or other areas of functioning.³³ The disorder often develops in adolescence, as individuals become more aware of and concerned with their physical appearance and attractiveness.³⁴

Although not introduced into the Diagnostic and Statistical Manual of Mental Disorders (DSM) until the third edition in 1987, cosmetic surgery literature included descriptions of “minimal deformity” and “insatiable” patients as early as the 1960s, and dermatology literature described case reports of patients with “dysmorphophobia” and “dermatological nondisease” in the 1980s.^35,36 Like contemporary BDD patients, these individuals sought procedures to improve slight or imagined defects and were often dissatisfied with their results postoperatively.⁴ Although the incidence rate of BDD in the general population is believed to be between 1 and 2%, a number of studies conducted throughout the world have found that 5 to 15% of cosmetic surgery patients appear to have some form of the disorder.⁴ Although persons with BDD typically report concerns with their skin, hair, and nose, any body part can become a source of preoccupation.^4,37,38

Persons with BDD commonly seek cosmetic medical treatments as a means of improving their perceived defects.^37,39–41 In a survey of 289 patients, Phillips and colleagues⁴⁰ found that 76.4% of patients with BDD sought cosmetic or dermatologic treatment, with other studies finding similar results.^39,42 A more recent survey of 234 patients visiting a facial plastic and reconstructive surgery clinic found that 13.1% of patients undergoing cosmetic surgery and 1.8% of patients undergoing reconstructive surgery who visited the clinic over a 4-month span had BDD.³⁷ The most common procedures sought by patients with BDD are surgeries like rhinoplasty, breast augmentation, and liposuction, as well as minimally invasive procedures such as collagen injections, microdermabrasion, and dental repairs.^39–41

In light of cosmetic surgery’s inherent objective to enhance physical features that to some may be considered perfectly normal, it is often difficult to distinguish patients with BBD from other patients who seek cosmetic surgery. As noted previously, many cosmetic surgery patients present with body image dissatisfaction preoperatively. Thus determining the degree of a patient’s dissatisfaction with body image, and the subsequent distress caused, is essential in discriminating between patients with and without BDD.⁴ For some patients the degree of distress can be so severe that it causes them to revert to previous habits of self-injury.

In a survey of 25 patients with BDD who had undergone 46 cosmetic procedures, researchers found that 9 patients were so distressed by their appearance that they performed “do-it-yourself” procedures in an attempt to enhance their appearance and rid themselves of their perceived deformity.⁴³ Examples of these extreme measures included a man who was so obsessed with his skin that he used sandpaper to remove scars and smooth his skin, and a woman who used a knife to cut out fat from her thighs.⁴³ Although these extreme cases of self-performed cosmetic procedures are rare, it is likely that other patients use less severe, but equally unsuccessful, measures to improve their appearance.

In contrast to most cosmetic surgery patients, individuals with BDD are typically dissatisfied with the outcome of such treatments.⁴² Although a handful of studies suggest cosmetic surgery can result in positive outcomes for patients with BDD, these findings are limited, because the studies focused on specific procedures and patients with mild to moderate BDD symptoms.^38,44 Aside from the aforementioned few, and methodologically limited, studies, most evidence to date suggests that cosmetic procedures and treatments are inadvisable for patients with BDD.⁴ Two retrospective studies have found that greater than 90% of persons with BDD report either no change or a worsening in their BDD symptoms after cosmetic treatments.39,45 Similarly, a prospective study of 166 cosmetic rhinoplasty patients found that BDD symptom scores were inversely related to postoperative satisfaction and quality of life 3 and 12 months after surgery.⁴⁶ Of even greater concern, studies have documented high rates of suicidal ideation, suicide attempts, and self-harm behaviors (e.g., “do-it-yourself” surgery) among patients with BDD.^43,47

There are also reports of patients with BDD who have threatened to sue or physically harm their treatment providers.^48,49 For example, in 2000 the New York Supreme Court, Appellate Division, saw a malpractice case in which a cosmetic surgery patient suffering from BBD sued her surgeon for malpractice, claiming her BDD symptomology prevented her from providing informed consent, her surgeon failed to inform her of other treatment options, and that the surgeon was negligent in his performance of the surgery.⁵⁰ In a recent survey of 260 American Society for Dermatologic Surgery (ASDS) members,⁴⁹ 30 surgeons reported being threatened by a patient with BDD, 24 reported a legal threat, and 6 reported a physical threat. In light of these issues, a growing consensus has developed that cosmetic medical treatments should be contraindicated for persons with BDD.^{4,10,20,51,52} Encouragingly, many surgeons refuse to perform procedures on patients who they believe to have BDD.^39,40,48 Although screening methods for BDD vary, several groups have suggested the use of both the Body Dysmorphic Disorder Questionnaire (BDDQ) and direct questions about BDD symptoms.^4,37

Eating Disorders

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