The Augmentation Mammoplasty Patient: Psychological Issues

Rebecca Cogwell Anderson

Jason C. Levine

The breast is a universal symbol representing nourishment, nurturing, love, femininity, and sexuality. The symbolic function of the breast dates to artifacts found in cave drawings (1). By 3,000 BC, external breast prostheses similar to brassieres and corsets were being used by women as a means of altering breast appearance in a culturally desirable manner (2). Throughout history, every civilization has established its standards regarding physical appearance. In American culture (with the exception of the flat, boyish chest popular during the 1920s), full, firm breasts have almost always been considered ideal as a physical attribute for women (3). The vital statistics of the first Miss America in 1921 were 30-25-32. In 1970, they were 34-21-34, and more contemporary winners have reported measurements of 36-21-36 (4). A view of Western culture clearly indicates that prizing women for their appearance is many centuries old. The size and shape of the breasts have classically been included in these appearance standards. The petite early Victorian figure, with its hourglass shape, grew taller and sturdier through the 19th century. In the 20th century, the perfect beauty became tall and statuesque, and breasts were emphasized in the well-developed bosom (5). Allen and Oberle observed that as early as 1946, in an issue of Cosmopolitan, an advertisement referred to the lines of a woman’s figure as her “Lifeline… target of all eyes.” The advertisement further implied that a wrong line above the waist could spoil a first impression, impairing the way a woman feels and works. The Life bra was touted as a product that “lifts, holds, corrects, and molds” (6). In 1962, also in a Cosmopolitan advertisement, the Bleumette bra was hailed as “the ultimate in bosom loveliness” for it lifted and built “youthful, high lines” (6).

With such a cultural and media focus on the breast, it is not difficult to understand why women have opted to undergo breast enhancement procedures such as augmentation mammoplasty. This chapter deals with the psychological profile of the woman seeking breast augmentation, as well as possible reasons for seeking the procedure. It assesses patient satisfaction with the procedures, both short and long term, and discusses the evolution of the breast implants.

Psychological Profile of Women Seeking Augmentation Mammoplasty

Numerous studies have assessed personality factors associated with patients seeking augmentation mammoplasty. Beale et al. (7) attempted to evaluate the effect of augmentation mammoplasty on women seeking the procedure. They looked for predictors of women who would benefit most from the procedure, and their findings indicated that women who received augmentation mammoplasty were a homogeneous group who experienced very similar breast difficulties. The augmentation mammoplasty patients were noted to be different from the control group in terms of personality and childhood experience. Beale et al. concluded that with the use of personality tests it would be possible to predict which women would benefit most from augmentation mammoplasty. They further concluded that those who scored low on a scale of neurotic tendencies were most likely to be satisfied with the results. Meyer and Ringberg (8) reported that augmentation mammoplasty patients were not psychologically abnormal, apart from their negative evaluation of their physical attractiveness. The augmentation mammoplasty patients in their study generally came from insecure homes with conflicts between parents and unsatisfactory emotional relationships with parents.

Descriptions of women seeking augmentation mammoplasty are very consistent, with a common thread being their doubts about their femininity, which motivate them to request the surgery. It is further postulated that preoccupation with breast size in women seeking augmentation mammoplasty does not arise suddenly, but usually either dates to adolescence or develops after childbirth (1,4,9). Among women seeking augmentation mammoplasty, there is a higher incidence of divorce, unhappy marriages, emotional discomfort, diminished feelings of femininity, and elevated levels of depression than in the general population (1,4,9). Most women seeking augmentation mammoplasty do so while in their 30s and are likely to report concerns about their appearance and preoccupation with inadequate breast size. The typical augmentation mammoplasty patient usually presents as articulate, stylishly dressed, and charming; she is usually wearing a padded brassiere. She projects self-confidence that is believed by some to conceal her insecurities (10,11).

In 1981, Goin and Goin (12), in their comprehensive text regarding the psychological effects of plastic surgery, indicated that it is difficult to truly understand the nature of the augmentation mammoplasty patient. They described the typical patient as likely to be in her early 30s and to have one or more children. She is frequently middle to upper middle-class socioeconomically and has experienced at least one previous aesthetic surgical procedure. They further reported that many augmentation mammoplasty patients have experienced depressive episodes, and they identified three concerns regarding these patients:

They believed that an unrecognized depression was often masked by the patient’s fixation regarding her breasts.
They believed that these patients tended to think obsessively about their physical appearance and to view their self-worth in terms of the physical body.
They described these individuals as charming, attractive, outgoing, and socially secure, but noted that this demeanor may act as a protective shell to guard them from their underlying lack of self-esteem.

Sarwer et al. evaluated body image concerns of augmentation patients. They hypothesized that breast augmentation candidates would report greater dissatisfaction with their breasts, greater avoidance of social situations, more frequent appearance-related teasing, and lower self-esteem (13). Results indicated that breast augmentation patients reported a greater investment in their physical appearance. They also reported greater frequency of appearance-related teasing than controls and suggested that this may represent a variable that describes women who seek cosmetic surgery. The majority of breast augmentation patients (77%) reported a significant life change in the year prior to seeking the operation, and 87% reported experiencing increased stress, anxiety, or depressive symptoms during that time, suggesting that the vast majority of breast augmentation candidates may be experiencing psychological distress, which should be assessed and evaluated preoperatively. Cash et al. demonstrated that, despite the fact that women seeking cosmetic breast augmentation often experience body image issues and psychological concerns prior to surgery, they experience improvements in body image following breast augmentation (14).

Most research examining the presence of psychopathology of the breast augmentation candidate has relied heavily on clinical interviews and self-report questionnaires. The findings are limited due to methodological problems and challenges to validity (15) and therefore should be interpreted with caution. Research using actuarial data from the Minnesota Multiphasic Personality Inventory and spanning 34 years has found little or no significant differences in personality and/or clinical psychopathology between breast augmentation candidates and controls (16). Nonetheless, breast augmentation candidates were found to have higher rates of previous psychiatric hospitalizations (17) and higher rates of outpatient psychotherapy and/or psychopharmacologic treatments than other women in the general population (16).

Kjoller et al. cited characteristics of women with cosmetic breast implants compared with women with other types of cosmetic surgery and population-based controls in Denmark (18). They discovered that women with breast implants had a significantly lower body mass index and reported a twofold greater incidence of chronic smoking than the general population and women who had other cosmetic surgery. Women with implants were not statistically more likely to report a history of diseases, including connective tissue diseases, cancer, or depression, before their implant surgery.

In summary, there seems to be a common thread of preexisting depression identified in the research regarding augmentation mammoplasty patients (8,12,13). In addition, low self-esteem and difficulty with social relationships were also identified (1,19,20). Edgerton et al. (1) and Edgerton and McClary (20) suggested that difficult childhoods, particularly those involving conflict with the parents, and lack of security in childhood were common in women seeking augmentation mammoplasty. With these factors in mind, an examination of the motivations reported by women for seeking breast augmentation is warranted. However, at this time, the literature finding a common thread of unfavorable mental health characteristics conflicts with the limited number of studies using actuarial data.

Motivations or Reasons for Seeking Augmentation Mammoplasty

Each individual reports a variety of factors that impact self-esteem and body image. When conflicts arise between the idealized body image and the perceived body image, psychological distress, lower self-esteem, and elevated depression frequently occur (20). Cash (21) indicated that the psychology of physical appearance can be divided into two perspectives: (a) the external or social body image of the individual and (b) the individual’s subjective appearance or personal body image. Sexual differences may also affect body image and body attitudes. In 1969, Kurtz (22) hypothesized that women should have a more clearly differentiated notion of their bodies because women are able to draw a finer evaluative distinction about various aspects of their bodies and are less inclined to respond to their bodily appearance in a global manner. Thompson and Thompson (23) documented that a significant global distortion of body image was negatively correlated with self-esteem in women, noting that the higher the distortion, the lower is the individual’s self-esteem. Women, therefore, appear to be more sensitive to body image changes and react to them with heightened monitoring of the affected area.

The average augmentation mammoplasty patient has had concerns about the appearance of her breasts since adolescence (10). When asked about her motivation for surgery, she frequently responds, “to look better in clothing” or “to look more normal.” Most women are not seeking to outdo other women in breast size; rather, they want to catch up. A number of researchers have evaluated the reasons that women seek augmentation mammoplasty, which cluster around the basic theme of doubts regarding femininity. Most women seeking breast augmentation have had small breasts since their teens, with a second, smaller group becoming concerned about the appearance of their breasts after giving birth and/or breast-feeding.

Goin and Goin (12) described three distinct groups of women seeking augmentation mammoplasty:

Those uncertain about their femininity, feeling incompletely realized as women. These women may have felt inadequate because of their small breast size.
Those who considered their breasts to have been adequate before pregnancy but found them to have diminished as a result of postpartum involution. These women seek to restore their breasts to an earlier state.
Those patients who seek augmentation for purposes of exhibitionism.

Kaslow and Becker (24) reported that common psychological reasons for seeking breast implants included the following: (a) to increase the size of breasts that are small, (b) to acquire better shape when firmness is lost due to childbearing and/or weight gain or loss, (c) to increase self-confidence, (d) to look better in clothing, (e) to improve physical appearance, (f) to feel more feminine, (g) to obtain better proportions, and (h) to increase sex appeal and look better in the nude. Of interest, many women seeking augmentation mammoplasty admit to feeling uncomfortable in the nude, either with their spouse or significant other or with other women, such as in gym class or when trying on clothing (25). Anderson (26) reported that women seeking augmentation mammoplasty do so for a variety of reasons, including increasing sexual self-confidence, satisfying
their partners, expanding clothing options, enhancing their sense of femininity and sexual identity, providing a more proportionate figure, and improving self-confidence. She stressed that evaluation of the potential augmentation mammoplasty patient should include assessment of her motivation for surgery, discussion regarding her expectations of surgical outcomes, consideration of her satisfaction with her life in general, recognition of signs of depression or anxiety, and evaluation of potential difficulties associated with body image. Anderson proposed a list of questions for the aesthetic surgeon to consider when evaluating the potentially concerning patient. These are given in Table 108.1.

Table 108.1 Questions to Consider When Evaluating the Potential Augmentation Mammoplasty Patient

Does the patient have difficulty describing the desired change?
Does the patient have only minimal deformity?
Is the patient’s support system (friends and family) opposed to the procedure?
Does the patient display bizarre behavior suggestive of possible schizophrenia or psychosis? (Such behavior might include lack of appropriate affect, hallucination, or failure to orient in time and space.)
Does the patient have unreasonable expectations, make frequent demands of surgeon and/or staff, and display a sense of urgency?
Does the patient appear extremely depressed or anxious, as evidenced by psychomotor retardation or agitation?
Is the patient in the midst of a major life change or crisis?
Has the patient had a history of dissatisfaction with cosmetic surgery or frequent cosmetic procedures?
Does the patient have concerns regarding gender/sexual identity issues?
If the answer to one or more of these questions is yes, a follow-up appointment for clarification before scheduling surgery is recommended.

Adapted from Anderson RC. Aesthetic surgery and psychosexual issues. Aesthet Surg Q 1996;16(4):227–229, with permission.

In addition, Matarasso (27) identified two categories for rejecting a patient seeking aesthetic surgery: anatomic unsuitability and emotional inadequacy. Matarasso suggested that potential problem patients included the patient with unrealistic expectations, the obsessive-compulsive patient, the patient acting on a sudden whim, the indecisive patient, the rude patient, the overflattering patient, the patient with minimal or imagined deformity, the poor historian, the self-important patient, the uncooperative or noncompliant patient, the depressed patient, the “plastic surgaholic” patient, and the patient involved in litigation.

In short, many women seek augmentation mammoplasty, and most report satisfaction with the results. This procedure seems to offer women an answer to some significant concerns regarding body image.

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