The patient’s motivations for surgery should be evaluated during the initial consultation. Motivations have been categorized as internal (undergoing the surgery to improve one’s self-esteem) or external (undergoing the surgery for some secondary gain, such as obtaining a promotion or starting a new romantic relationship) (7, 8, 9). To assess the nature of patients’ motivations, it may be useful to start the initial consultation by asking why patients are interested in surgery at this time. This question may help determine if patients are interested in treatment for themselves and their own sense of self-esteem or if they are seeking treatment to please others. While a clear distinction between internal and external motivations is difficult, internally motivated patients are thought to be more likely to meet their goals for surgery (10). At least three studies have suggested that being motivated for surgery in order to please a romantic partner is associated with a poor postoperative outcome (11, 12, 13).

Postoperative expectations have been categorized as surgical, psychological, and social (14). Surgical expectations address the specific concerns about physical appearance, both pre- and postoperative, and are discussed in detail below. Psychological expectations include potential improvements in psychological functioning that may occur after surgery. Social expectations address the potential social benefits of cosmetic surgery.

Many people interested in cosmetic treatments believe that the procedures will make them more attractive to current or potential romantic partners. At least two studies have suggested that following cosmetic facial procedures, patients are considered to be more physically attractive by others (15, 16). There is presently no empirical evidence, however, to suggest that patients’ social relationships improve after surgery. Thus, prospective patients should be aware that an improvement in appearance likely will not result in a change in the social responses of others. In fact, negative postoperative reactions from romantic partners, parents, or close friends
may undermine psychosocial outcomes. In their review of studies investigating psychological outcomes following cosmetic surgery, Honigman et al. (17) found three studies that suggested that unrealistic expectations are associated with poor postoperative outcomes (11, 12,18). In contrast, patients who are internally motivated and who have realistic expectations may be the most likely to be satisfied with their postoperative result. Questionnaire 16-1 provides several suggestions to assess the motivations and postoperative expectations of prospective patients.

Given the relationship between body image and cosmetic surgery (5,19, 20), the assessment of patients’ body image concerns is a critical part of the evaluation. While the surgeon may know that patients are interested in specific procedures based on information in patients’ histories, it is useful to have patients articulate, in their own words, what they dislike about their appearance. Patients should be able to describe with little effort specific concerns that are visible. Previous studies have found no relationship between degree of physical deformity and degree of emotional distress in cosmetic surgery patients (10,21, 22). Patients who are markedly distressed about slight defects that are not readily visible may be suffering from body dysmorphic disorder (BDD).

As discussed in Chapter 14, between 7% and 15% of patients who seek cosmetic surgery or related medical treatments are thought to suffer from BDD (23, 24, 25, 26, 27, 28, 29). The vast majority of persons with BDD reported experiencing no improvements in their symptoms following these treatments (30, 31). Therefore, BDD is often considered a contraindication for cosmetic procedures (2, 3, 4,32). Psychopharmacologic and psychotherapeutic treatments are thought to be more effective interventions for these patients (33).

The degree of dissatisfaction also should be thoroughly assessed. While some body image dissatisfaction is typical among most patients, those who report extreme dissatisfaction may be suffering from BDD. Asking more specific questions about the extent of the dissatisfaction, as found in Questionnaire 16-1, can indicate the degree of distress and impairment a person may be experiencing. Patients who state that they think about their appearance problem for long periods of time throughout the day, often at the expense of being able to think about other things, may be suffering from BDD. Some patients may unintentionally reveal the extent of their preoccupation by presenting the surgeon with numerous photographs of models or celebrities who have the feature(s) they desire. Others may take photographs of themselves and, either through crude pencil drawings or elaborate computer enhancements, attempt to depict the desired changes. Although these pictures may be instructive to the surgeon in specific circumstances, such behaviors only hint at the hours which patients likely have spent thinking about their appearance.

Patients also should be asked how their feelings about their appearance impact their daily functioning. These questions can indicate the degree of impairment patients may be experiencing. Those who report that their appearance concerns prevent them from maintaining employment or relationships, or concerns that prevent them from engaging in daily activities most people would do without a second thought, may have BDD. It is important to remember, however, that BDD symptoms fall on a continuum. Severe cases where individuals are unable to maintain employment or rarely leave their homes are relatively easy to recognize. In less severe forms of the disorder, individuals are able to work and maintain relationships, but their quality of life suffers dramatically. For example, they avoid various social situations or endure them with considerable self-consciousness, or they spend substantial time checking and re-checking their appearance in mirrors.

In addition, patients should be asked what types of things they have done previously to improve their appearance. Forty-five percent of cosmetic surgery patients report that they have undergone a previous cosmetic procedure (34). These numbers,
however, likely do not account for other less invasive treatments and homemade remedies patients may have tried. Among persons with BDD, 76% of 250 adults sought and 66% obtained nonpsychiatric medical treatments including cosmetic surgery and dermatological treatments (30).

To assist further in the assessment of BDD, practitioners may wish to familiarize themselves with the Body Dysmorphic Disorder Questionnaire (35), provided in Questionnaire 16-2 at the end of this chapter. This brief self-report measure derived from DSM-IV diagnostic criteria, assesses appearance concerns and their impact on daily functioning. The measure is intended as a screening tool and not as a diagnostic instrument. A modified version of the BDDQ, the BDDQ-Dermatology Version also is available (25). In Chapter 4 in this volume, Cash presents another, more recent and detailed version of this questionnaire, the Body Image Disturbance Questionnaire (36). All of these measures may be useful in both clinical and research settings.

Cosmetic surgeons are clearly aware of the presence of individuals with BDD in their patient population. A survey of cosmetic surgeons suggested that they believed that 2% of patients seen for an initial cosmetic consultation suffered from BDD (37). Greater than 80% of surgeons indicated that they had observed some of the characteristic symptoms of the disorder in patients—excessive concern with a minor appearance flaw, excessive requests for surgery, and dissatisfaction with a previous surgery. The vast majority of surveyed surgeons (84%) reported that they had refused to operate on a patient suspect of having BDD; 64% had scheduled a second consultation; and 50% had referred patients for a mental health consultation. In addition, 84% of surgeons indicated that they had operated on a patient whom they believed was appropriate for surgery, only to realize after the operation that the patient may have had BDD. Of surgeons who had this experience, 82% reported that the patient had a poor outcome with regard to BDD symptoms. Forty-three percent indicated that the patient was more preoccupied with the defect than before surgery, and 39% reported that the patient was now preoccupied with a different physical feature. Despite surgeons’ apparent awareness of the problems associated with treating patients with BDD, only 30% believed that it was always a contraindication to a cosmetic treatment.

Another important step in determining the psychological appropriateness of patients is obtaining a psychiatric history. This information should be routinely collected as part of the medical history and physical exam, no differently than obtaining a general medical history. If this information is typically collected on a preprinted form completed by the patient before the consultation, these questions should be repeated during the initial face-to-face meeting with the patient. Some patients are reluctant to candidly report mental health histories, in part out of fear that previous or ongoing psychiatric treatment will preclude cosmetic treatment. A recent investigation found that 19% of cosmetic surgery patients reported a mental health history, which was significantly greater than 4% of noncosmetic plastic surgery patients (38). Furthermore, 18% of cosmetic surgery patients reported using a psychiatric medication (almost exclusively anti-depressant medications) at the time of their initial consultation, which also was significantly greater than 5% of noncosmetic surgery patients. Many of these patients likely received these medications from their primary care physician and not from a psychiatrist. Clinical experience, as well as investigations from other surgical populations (39), suggests that primary care professionals often prescribe sub-therapeutic dosages of these medications. In situations where patients are receiving these medications from nonpsychiatrists, and psychopathology is suspected, a consultation with a mental health professional is recommended (1, 2, 3, 4,38). Questionnaire 16-1 provides a series of questions to help assess a patient’s psychiatric treatment history.

In addition to BDD, mood and eating disorders may be overrepresented among patients who seek cosmetic surgery and related treatments (6,20). Patients’ mood, affect, and overall presentation will provide important clues to the presence of a mood disorder. If one is suspected, neurovegetative symptoms, including sleep, appetite, and concentration, should be assessed. If patients endorse difficulties in any of these areas, they should be asked about the frequency of crying or irritability, social isolation, feelings of hopeless, and the presence of suicidal thoughts. As discussed in detail in the previous chapter, four epidemiological studies have found a relationship between cosmetic breast augmentation and suicide (40, 41, 42, 43). The most recent of these studies also identified a higher rate of psychiatric hospitalizations among women who received breast implants as compared to those who underwent other plastic surgical procedures (41). Although the specific psychiatric diagnoses were not identified, McLaughlin et al. have argued that mental health consultations should be considered for women interested in breast augmentation and considered to be at high risk by the surgeon (44). Affirmative answers to several of the questions assessing the presence of depression in Questionnaire 16-1 should necessitate such consultations.