Introduction

Over the past several decades, a now sizable body of research on the psychology of physical appearance has developed. This research has suggested that individuals who are more physically attractive are judged by others more favorably and also receive preferential treatment across a wide range of social interactions. Aesthetic surgeons have had a long-standing interest in the psychologic characteristics of individuals who choose to use medical treatment to improve their physical appearance. They also have had great interest in the psychologic benefits that patients may experience following treatment.

This chapter provides an overview of the psychology of facial aesthetics. The chapter begins with a review of the psychology of physical appearance. After considering the issue from the societal perspective, the chapter turns its focus on the psychologic characteristics of individuals who present for aesthetic treatments. The psychologic construct of body image is used as a framework to understand an individual’s motivation for an aesthetic procedure as well as the desired benefits from it. The chapter provides an overview of body dysmorphic disorder (BDD), the psychiatric condition of greatest relevance to the aesthetic surgeon. The chapter concludes with recommendations on the psychologic assessment and management of the patient who presents for aesthetic treatment.

Physical appearance and society

The discussion of the role in physical appearance in the human experience has to begin with the work of Darwin. His description of the theory of natural selection is one of the earliest scientific acknowledgments of the importance of physical appearance. According to the theory, the goal of all species is survival through reproduction. Identification of a mate who can facilitate successful reproduction is a central part of the process. To that end, specific physical characteristics have evolved to signal reproductive capability to others. These characteristics, particularly those that suggest the potential for healthy reproduction, serve as the foundation for what is considered attractive in another member of the species.

When applied to facial appearance, the characteristics of youthfulness, symmetry, and averageness have been most commonly associated with facial attractiveness. The development of adult facial features at puberty for both females and males signal reproductive potential to others. They also may suggest reproductive health as expressions of normal levels of testosterone and estrogen. Clear skin, bright eyes, and lustrous hair also draw attention to the youthful face. While a youthful facial appearance is considered attractive, an aging appearance typically is not. Ratings of attractiveness of males and females decline with age; the relationship is stronger for women than for men.

Symmetry of features across the midline of the face is associated with increased ratings of attractiveness. Evolutionary theorists believe that the ability to develop symmetrical features in a world full of environmental pathogens is conferred on only the healthiest of a population. Similarly, averageness, with respect to the size of individual facial characteristics, is also associated with ratings of attractiveness. Composite faces made up of hundreds or thousands of individual faces via computer technology (and therefore believed to represent “average” facial features) are judged as more attractive than individual faces. The most beautiful of the combined faces, however, are far from average. The highest rated composite faces for females, for example, reflect a petite face with a smaller than average mouth and jawline, full lips, and pronounced eyes and cheekbones.

With these elements of evolutionary theory in mind, the exploding popularity of minimally invasive aesthetic treatments over the past 15 years is not surprising. Add to those procedures the countless number of topical products marketed to minimize the effects of facial aging and it is quite clear that women and men around the world have some sense of the importance of a youthful facial appearance.

While some may question the use of evolutionary theory to explain the popularity of aesthetic facial procedures, there is little doubt about the role that sociocultural influences play in physical appearance. Some of these factors, such as the influence of parents and peers, begin early in life and sustain themselves into adulthood. Exposure to mass media depictions of physical beauty begin in childhood, but their emphasis appears to be greatest in adolescence and early adulthood. Similarly, early experiences in romantic relationships throughout this same period of time provide feedback to an individual on how his or her appearance is perceived, and responded to, by others.

Social psychologic research confirms these intuitive beliefs. Over the past 50 years, the role of physical appearance in daily life has been one of the most developed areas of research in the field of psychology. This research, while detailed and thorough, can be summarized with two general statements: (1) individuals who are judged to be more physically attractive are assumed to have more positive and desirable personality characteristics; and (2) individuals who are seen as more attractive receive preferential treatment in a wide range of interpersonal interactions across the lifespan.

Finally, it is important to note the role of the mass media and the entertainment industry impacting our thoughts and behaviors related to physical appearance. From print magazines to websites, television shows, and movies, consumers are bombarded by images of physical beauty continuously. While some of the images are of persons who have been blessed with youthful and symmetrical features that naturally signal attractiveness, others have been computer enhanced and photoshopped to the limits of physical reality. Studies have repeatedly shown that exposure to these images increases body image dissatisfaction which, as argued below, is believed to be the motivational catalyst to seeking aesthetic treatments. ^, Furthermore, discussion of aesthetic procedures are popular topics for mass media outlets. Thus mass media both contribute to the development of the “problem” (that the consumer does not look as good as the model) and offers the pathway to the “solution” (aesthetic treatment).

What this means and what it says about us at the societal or individual level is open to debate. Some would argue that the impact of mass media on the pursuit of aesthetic treatments is merely an example of consumer culture, perhaps no different from buying a luxury automobile—no one “needs” to buy an expensive car, but if doing so makes someone happy or improves his or her quality of life, is there a problem with it? Decades ago, mental health professionals believed that persons who underwent cosmetic procedures were suffering from significant psychopathology. From their perspective, a psychologically healthy individual would not be focused on trivial vanity. In contrast, both evolutionary theory and findings from social psychologic research could lead to the conclusion that improving one’s appearance with an aesthetic treatment is an adaptive strategy. In this regard, improving one’s appearance with an aesthetic procedure could be seen as an appropriate investment in one’s self-esteem and quality of life, perhaps not all that different from eating a healthy diet and exercising regularly.

Psychologic characteristics of aesthetic surgery patients

Patients typically present for aesthetic procedures with a number of motivations and expectations. Some of these may be expressed to the surgeon or the treatment team during the initial consultation; others may remain unspoken. Dissatisfaction with one’s facial appearance and body image is believed to be the primary motivator for facial aesthetic procedures, other cosmetic procedures, and other appearance-enhancing behaviors. ^,

Body image has been defined in several ways. A commonly used definition suggests that body image consists of perceptions, thoughts, and feelings associated with the body and bodily experience. While this definition describes the multidimensional nature of the construct, it does not highlight body image behaviors, such as changing one’s appearance through aesthetic procedures. Body image also has been defined as “the psychologic experience of embodiment.” This description conveys a sense of importance of the role of body image in larger psychologic constructs like quality of life and self-esteem.

The relationship between body image dissatisfaction and aesthetic treatments has been the focus of much of the research on the psychosocial considerations of aesthetic surgery. ^{, ,} Individuals who seek cosmetic procedures, both surgical and nonsurgical, typically report heightened body image dissatisfaction preoperatively. This dissatisfaction is typically centered on concerns about the specific feature to be improved with an aesthetic treatment. Thus some degree of body image dissatisfaction is believed to be a prerequisite to cosmetic surgery.

A number of studies have looked at a range of personality characteristics, symptoms of psychopathology, and life experiences in persons who present for aesthetic treatments. Some of these investigations have been of conceptually relevant characteristics and symptoms (i.e., history of abuse, symptoms of depression, or low self-esteem). Others have investigated constructs, such as parent–child relationships, that may be of inherent interest to some but of little clinical relevance to the treating surgeon. These studies have yet to identify consistent characteristics of aesthetic surgery patient beyond heightened body image dissatisfaction. However, several studies have suggested that the use of psychiatric medications, particularly antidepressants, is higher among patients who present for aesthetic treatments and compared with the general population. With this finding in mind and as discussed next, aesthetic surgeons are encouraged to evaluate the psychiatric status and treatment history of all new patients.

Psychologic changes following facial aesthetic treatment

The vast majority of patients report satisfaction with the results of their cosmetic medical treatments. Patients also have been found to report significant improvements in body image. Most studies have found these changes within the first 2 years of surgery. The endurance of these benefits over longer periods of time is largely unknown.

Studies of changes in other psychologic characteristics and symptoms beyond body image have produced mixed results. ^{, ,} A number of studies have looked at changes in self-esteem following cosmetic medical treatments. This is a particularly relevant construct, as these treatments are often marketed with the promise of improving self-esteem. Some studies have found significant improvements in self-esteem; others have not. Studies that have investigated the relationship between aesthetic procedures and depression symptoms also have been inconsistent in their findings. These studies have not found a worsening of self-esteem or depressive symptoms after aesthetic treatment. Rather, it appears that these domains do not appear to improve to a level of statistical significance following aesthetic treatment and as assessed with validated psychometric measures.

Body dysmorphic disorder and aesthetic facial treatments

Body dysmorphic disorder (BDD) is the formal psychiatric condition likely of greatest relevance to the aesthetic surgeon. ^{, ,} The disorder is characterized as a preoccupation with a slight or nonobservable defect in appearance that is associated with obsessive thinking and compulsive behaviors and which leads to a disruption in activities of daily life. BDD is estimated to occur in approximately 1% to 2% of the general population and is seen equally across women and men. Individuals with the disorder can be concerned with any feature of the body. Concerns about the facial skin, nose, and hair are the most common. Persons with the disorder are often convinced that they will feel better if they change their physical appearance. Thus they are seen with some frequency in aesthetic medical practices.

Identifying and diagnosing BDD in facial aesthetic patients can be difficult. According to the first diagnostic criterion for BDD in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V), an individual must be preoccupied with one or more perceived defects in appearance that are either “slight” or nonobservable to others. Most patients presenting for aesthetic treatments of the face have “normal” features, which they wish to enhance; others may desire correction of slight imperfections. Thus the majority of patients could meet this criterion. The second diagnostic criterion describes engagement in repetitive, appearance-focused behaviors, such as comparing one’s appearance with that of other people or repeatedly checking one’s appearance in the mirror. Many aesthetic patients engage in these behaviors; others report significant self-consciousness in situations where their perceived “defect” may be more noticeable to others. Still, others may avoid such situations.

These examples, while indicative of body image dissatisfaction, likely do not meet the third criterion for BDD (experiencing clinically significant distress or impairment in social, occupational, or other important areas of functioning). However, a patient who is reporting symptoms of anxiety and depression because of her nose, or who is socially isolated or unable to work because of her appearance concerns, likely would meet this diagnostic criterion. Thus in cosmetic settings, the degree of distress and impairment in functioning experienced by the patient likely differentiates a cosmetic surgery patient with BDD from one with more “normative” body image dissatisfaction.

A number of studies have investigated the rate of BDD among individuals presenting for aesthetic procedures. The most methodologically sound studies from around the world have consistently suggested that between 5% and 15% of patients who present for aesthetic treatments meet the criteria for the disorder. Thus the busy aesthetic practice is likely to encounter patients with BDD several times each month.

Other studies have examined interest in cosmetic procedures among persons with BDD. The large majority of persons with BDD has sought and received cosmetic surgical and minimally invasive treatments of the face and body. Unfortunately, evidence suggests that greater than 90% of patients with BDD reported no change or a worsening of their symptoms following a cosmetic treatment. Some reported that the level of preoccupation with the given feature was unaffected; others indicated that they became concerned about another feature of their appearance.

In addition to the risk of dissatisfaction with treatment, patients with BDD are known to have a high risk for suicide. Unmet expectations from an aesthetic procedure could fuel suicidal ideation and/or suicide attempts in some patients with BDD. Treating physicians also face risks when knowingly or unknowingly performing cosmetic procedures on patients with BDD. At a minimum, patients with BDD may present as being “difficult” or hard to manage for providers and the staff. ^, Providers may also face legal risks because patients with BDD have threatened or pursued legal action against their treating surgeons. Tragically, some surgeons have been murdered by patients with or suspected of having BDD.

Due to the safety risks for both patients and providers, along with the evidence that cosmetic treatment outcomes among persons with BDD are typically poor, BDD is believed to be a contraindication for aesthetic treatments. Encouragingly, survey studies of aesthetic surgeons and dermatologists from around the world have found that many providers have identified patients with BDD during the preoperative consultation and refused to move forward with treatment.

Psychologic assessment of the aesthetic facial patient

Surgeons and other medical professionals who perform aesthetic treatments should evaluate and monitor the psychosocial status and functioning of patients who seek these procedures. Most patients who present for aesthetic treatments are as psychologically stable as other individuals from the general population. Thus most do not need a formal psychologic evaluation with a mental health professional before receiving an aesthetic treatment.

Nonetheless, a sizable minority of individuals who present for a cosmetic procedure may have more significant psychopathology—such as BDD—that may contraindicate treatment. Thus physicians who offer these procedures, like all medical professionals, should assess and screen for the presence of psychopathology as a routine part of the initial history and physical examination. Unfortunately, most physicians (or their delegates) likely skip this part of the assessment and, as a result, likely fail to identify patients who may exhibit symptoms of significant psychopathology. We recommend that surgeons spend time in the initial consultation assessing the patient’s: (1) motivations and expectations for an aesthetic treatment; (2) physical appearance and body image concerns (with a specific focus on symptoms of BDD); and (3) psychiatric status and history. ^,

Motivations and expectations for an aesthetic procedure

The surgeon or the delegate should inquire about the patient’s motivations and expectations for treatment during the initial consultation. When assessing motivations, the provider can ask, “When did you first think about changing your appearance?” Similarly, it may be instructive to ask, “What other things have you done to improve your appearance?” These questions may reveal the presence of some obsessive or delusional thinking, as well as compulsive or bizarre behaviors, related to physical appearance. Some patients may report that they have tried several “do-it-yourself” treatments in an attempt to improve their appearance. Many of these may not be helpful and, in some cases, may be potentially dangerous.

To further assess motivations for treatment, patients should be asked how romantic partners, family members, and close friends feel about their decision to change a physical feature. Patients who seek treatment specifically to please a current partner, or attract a new one, are thought to be less likely to be satisfied with their postoperative outcomes. Thus the treatment provider should inquire about patients’ general expectations about how the change in appearance, which may be rather subtle and potentially unnoticed by others, will influence their lives. Patients who describe “internal” motivations for treatment, such as to improve self-esteem or to overcome self-consciousness in common social situations, are often appropriate candidates for cosmetic procedures. In contrast, those who articulate more “external” motivations, where the desire for a cosmetic procedure is associated with a specific secondary gain such as saving a failing marriage, are often believed to be less appropriate for treatment.

There is some evidence to suggest that individuals who undergo facial aesthetic procedures are seen as younger looking and more attractive post treatment. However, there is no evidence to suggest that these procedures directly impact interpersonal relationships. Therefore patients should be reminded that it is impossible to predict how others will respond to their changed appearance. Some patients may find that few people notice a change, whereas others may have the experience that everyone seems to notice the change. Although some patients may find this attention pleasurable, others may find it uncomfortable. To assess this issue, patients should be asked how they anticipate their lives will be different following treatment.

Physical appearance and body image concerns

Patients interested in an aesthetic procedure of the face should be able to articulate specific concerns about their appearance that should be visible to the treatment provider with little effort. Patients who are markedly distressed about slight defects that are not readily visible may have BDD. At the same time, patients who present with vague, nonspecific complaints about their appearance (“I’m just ugly. You are the beauty expert, what do you recommend?”) may have BDD.

Aesthetic providers should be prepared to ask specific questions to assess for the presence of BDD. Relevant questions include the following:

• 1.
  

  Is the patient preoccupied with the perceived appearance flaw(s)?

  
  
• 2.
  

  Does this preoccupation cause clinically significant distress—for example, anxiety, depression, or hopelessness?

  
  
• 3.
  

  Does the preoccupation with perceived appearance flaws cause clinically significant impairment in functioning—for example, difficulty with or avoidance of social, family, school, or work activities?

Based on the answers to these questions, those individuals with nonexistent or minimal appearance flaws who experience resulting clinically significant distress or impairment in functioning and who perform at least one associated repetitive behavior are likely to have BDD.

Patients with BDD are often secretive about and ashamed of their appearance concerns and the extent of their preoccupation and distress. In our experience, some patients purposely minimize their symptoms in the hope that the surgeon will not discover that they have BDD and thus refuse to operate. Thus it can be helpful to consider various other behaviors that may suggest the presence of BDD or other significant psychopathology. Patients who express beliefs that other people are taking special notice of them because of their appearance “defect” may have BDD. Performance of excessive repetitive behaviors may be a clue to the presence of BDD. For example, some patients will report obsessively checking their appearance throughout the day in every mirror or reflective surface. Others with BDD bring drawings to the consultation that detail how they would like to change their appearance or photos of celebrities to illustrate their idea of perfection; such behaviors may indicate the extensive amount of time they spend obsessing about their appearance. Patients who have had multiple procedures on the same body part and yet express dissatisfaction with treatment outcomes also may have BDD. Those individuals should be carefully queried about their satisfaction with the prior procedures, the nature of their appearance concerns, BDD symptoms, and expectations for the treatment outcome.

Assessment of general psychiatric status and history

Assessing the patient’s psychiatric history and current psychiatric status also should be done during the initial consultation. All of the major psychiatric diagnoses likely can be found among aesthetic patients. Particular attention should be paid to disorders with a body image component, such as BDD and eating disorders, as well as mood and anxiety disorders. The presence of these disorders, however, may not be an absolute contraindication for treatment. With the exception of BDD, there currently are no conclusive data on the prevalence of psychiatric diagnoses among persons who undergo aesthetic procedures or their relationship with postoperative outcomes.

To inquire about a patient’s psychiatric status and history, patients should be asked if they have a history of significant problems, such as depression or anxiety. Regardless of the answer, patients should be asked if they have ever been treated by a mental health professional. Many patients will report that they are in “therapy” or “counseling” but minimize or not disclose their diagnoses. It also is important to ask if patients have a history of use of psychiatric medications and who is prescribing these medications. As noted above, aesthetic surgery patients use psychiatric medications more frequently compared with persons in the general population. In many cases, patients are using low dosages of antidepressant or antianxiety medications that are being prescribed by a primary care physician. These physicians are often conservative in their use of these medications, and the aesthetic provider should not necessarily assume that these medications are appropriately controlling symptoms. Follow up with these providers is encouraged if the treating physician is concerned about symptoms observed in the initial consultation. This interaction can confirm and document that both providers believe that an aesthetic treatment is appropriate at the present time.

Referral to a mental health professional

Based on the information obtained from the initial aesthetic consultation, there may be times when a referral to a mental health professional is warranted. One example is when the aesthetic provider suspects the presence of BDD. Surgeons or other physicians who suspect that a patient has BDD are encouraged to inform the patient of their impressions and to provide some brief education about the disorder (e.g., “It sounds like you have a body image problem known as body dysmorphic disorder, a known and treatable condition”). We also recommend that surgeons inform patients with suspected BDD that they are concerned that the patient will be dissatisfied with the outcome of the surgery and that cosmetic procedures appear to rarely help BDD symptoms and can make them worse. Then, patients should be briefly made aware that there are effective treatments for BDD, including psychiatric/psychologic treatments, and referrals to a psychiatrist and/or psychologist can be made.

Another example of when a referral is warranted is when the provider is concerned that more general symptoms or depression or anxiety are not well controlled and could either contraindicate treatment or complicate the postoperative course. In general, it is best to be clear about why a referral to a mental health provider is being made and not to promise that surgery will be performed after the psychiatric evaluation. Surgeons are also discouraged from giving in to requests to perform minor procedures or to offer less invasive treatment options to appease the patient because patients may have a poor outcome following even minor interventions. Referrals to other surgeons are also discouraged, as this gives patients the implicit message that surgery may be helpful when in fact it appears unlikely to be.

The aesthetic physician also may want to refer a patient to a mental health professional following treatment. This typically occurs in one of two scenarios—the patient is dissatisfied with a technically successful procedure or the patient is experiencing an exacerbation of the psychopathology that was not detected during the initial consultation. Patients in each of these examples typically warrant mental health care. Cognitive–behavioral models of body image therapy are often useful with these individuals, although more diagnosis-specific treatments, including pharmacotherapy, also may be required.

Patients may react to a referral to a mental health professional with anger and defensiveness, believing that they will feel better only if they look better. Others may assume that the referring medical professional assumes they are “crazy.” Many will likely refuse to go to the consultation because they fear that it may provide indirect, confirmatory evidence that a patient is not psychologically appropriate for surgery. To increase the likelihood that the patient will accept the referral, it should be treated like a referral to any other medical professional. The patient should be informed of the specific areas of concern and the reason for the referral. This information also should be shared with the mental health professional in advance of the consultation.

Summary

Aesthetic surgeons have long been interested in the psychologic functioning of their patients. Questions about “why” individuals elect to change their appearance can be understood in the context of evolutionary theories of attractiveness, social psychologic research on the importance of physical appearance in daily life, and the psychologic construct of body image. Dissatisfaction with one’s appearance appears to be the motivational catalyst for aesthetic treatment for most individuals. Encouragingly, many patients report improvements in their body image following treatment. However, a small yet significant percentage of patients appear to suffer from BDD and not benefit from aesthetic treatment. Thus aesthetic surgeons are encouraged to assess and monitor the psychosocial functioning of their patients both pre- and postoperatively, with the goal of providing the most appropriate and comprehensive care of aesthetic patients.

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