Cosmetic surgery can enhance your life as well as your looks, according to industry advertisements and television shows, such as Extreme Makeover and Nip/Tuck. The idea is that a face “lift” will also boost one’s spirits and self-confidence. The problem is that the evidence supporting this assumption is tentative. Research shows that, following cosmetic surgery, patients variously report their mental health has either improved, not changed, or diminished. Psychiatrist David Castle, a leading researcher on the psychological outcomes of cosmetic surgery, is concerned by the “gloss” applied to cosmetic surgery that “suggests you will have a new life”, he says. “But of course, it doesn’t change the person you are on the inside.” David, who is a professor at the University of Melbourne and the Mental Health Research Institute of Victoria, says that some research has shown that cosmetic surgery can enhance self-esteem, which can feed into social confidence, but the evidence for long-term effects on psychological wellbeing is scant and requires further investigation.

1. Psychological
Outcomes in
Cosmetic Surgery
Cosmetic surgery can enhance your life as well as your looks, according to
industry advertisements and television shows, such as Extreme Makeover
and Nip/Tuck.

2. The idea is that a face “lift” will also boost
one’s spirits and self-confidence. The
problem is that the evidence supporting
this assumption is tentative. Research
shows that, following cosmetic surgery,
patients variously report their mental
health has either improved, not changed,
or diminished. Psychiatrist David Castle, a
leading researcher on the psychological
outcomes of cosmetic surgery, is concerned
by the “gloss” applied to cosmetic surgery
that “suggests you will have a new life”, he
says.
“But of course, it doesn’t change the person you are on the inside.” David, who is a professor at
the University of Melbourne and the Mental Health Research Institute of Victoria, says that
some research has shown that cosmetic surgery can enhance self-esteem, which can feed into
social confidence, but the evidence for long-term effects on psychological wellbeing is scant
and requires further investigation.

3. David and colleagues recently reviewed the
literature on psychosocial outcomes for patients
seeking cosmetic surgery (Honigman, Phillips, &
Castle, 2004). The authors analysed 37 studies
that evaluated psychological and psychosocial
functioning before and after a range of elective
cosmetic surgery procedures. Breast surgery
(reduction and augmentation) was the procedure
that was most consistently associated with good
psychological outcomes. In particular, women
who had breast reductionsreported the highest
rates of satisfaction and improved mental health,
such as enhanced body image and decreased
distress. Eight studies reported improvements in
social functioning, relationships and quality of
life after cosmetic surgery, with at least half of
these results based on breast procedure outcomes.
Nose and facial procedures produced mixed outcomes. Several studies that examined
personality in cosmetic surgery patients also found mixed results, suggesting the way
personality affects the surgical experience is unclear.

4. Predictors of poor psychological outcomes
Overall, the review showed that most patients were satisfied with their results, but some
demonstrated poor psychological outcomes. One of the strongest predictors of a poor outcome was
having an extreme and unrealistic expectation of the surgery results, such as being able to find a new
job or relationship. Males had poorer outcomes, which David suggests is because the threshold for
men to seek help is higher. “Cosmetic surgery is more acceptable for women, so men have to be
worse to seek it”, he says.Younger people also tended to do worse than older people. “A lot of studies
were based on (“anti”) ageing procedures”, David says. “So younger people are more likely to be
seeking procedures for abnormalities which you and I would not see, or would think are trivial.”
Other predictors of poor outcomes include a history of numerous past procedures, depression and
anxiety, and narcissistic or borderline personality traits, although David cautions that very few
studies investigated personality systematically.
A lack of systematic studies in the literature was a general problem, making it difficult to have
confidence in the findings and reach firm conclusions. For example, the psychological concepts
measured, such as self-confidence and self-esteem, are broad and often vague terms that were
generally not clearly explained or defined. There were no randomised controlled design studies, so it
is hard to know if reported changes in psychological functioning resulted from the procedure or
other factors, such as patient characteristics. This type of study may not be possible given that
patients are unlikely to accept being in a “no procedure” control group.

5. Julie’s aim was to investigate the kind of person that would be a poor candidate for cosmetic surgery.
The factors she considered were age, type of procedure, number of previous remedies attempted,
history of previous cosmetic surgery, mental health, and level of dysmorphic concern, which is the
degree to which one is preoccupied with an imagined or perceived physical flaw.
The evidence that some cosmetic surgery
patients are dissatisfied with the results of
surgery, despite it being an objective success,
intrigued psychologist Julie Malone, who
recently completed her doctoral thesis on the
topic at the University of New England in
north-east NSW. Her study followed the
outcomes of 91 females aged 18 to 64 years
(average age 42 years) who had elective facial
cosmetic procedures, including nose
procedures, face lifts, eye surgery and other
minor procedures on areas such as chins and
teeth (Malone, 2003). Sydney-based cosmetic
surgeons handed out anonymous
questionnaires to patients to complete pre and
post (three months after) surgery.

6. Age was the only good predictor of satisfaction; older
women reported higher levels of satisfaction with
outcomes. Further investigations of this finding
revealed that young women having nose procedures
were the most dissatisfied group, Julie says. “I
researched noses further and concluded that young
people are seeking a quick fix for their image
dissatisfactions”, she says. “What I implied in my study
was that they are shopping around for a new nose
instead of accepting themselves for who they are and
seeking other sources of therapy.” Drawing on the
literature, Julie says the implications are that young
people are jumping into cosmetic treatments without
thinking and are more susceptible to media
presentations of beauty. Further, there is evidence that
younger patients are looking more for external rewards,
like a romance or better job, while older people are
looking more for internal rewards, like self-worth. As
Hongiman et al’s (2004) review showed, seeking
unrealistic rewards predicts a poor outcome.

7. High levels of
dysmorphic
concern predict
poor, occasionally
tragic, outcomes
Honigman et al’s (2004) review also found that patients with
higher levels of dysmorphic concern are less likely to benefit
from cosmetic surgery. Besides having unrealistic
expectations, the other strong predictor of a poor outcome
was with patients who had no objective deformity, a minimal
deformity, or, if they did have a deformity, were overly
concerned about it so much that it impacted on their lives
excessively. People demonstrating the more extreme
manifestations of such concerns may have Body Dysmorphic
Disorder (BDD).Between 7 per cent and 15 per cent of people
presenting to plastic surgeons and cosmetic dermatologists
have BDD, according to mainly US studies.
David, who has co-edited a book on BDD, says people with
the disorder believe that if their perceived defect is removed
then they will be happy. But, once they have a procedure
their psychological wellbeing does not improve; it often
decreases. Sometimes this leads to the pursuit of numerous
procedures, which only serves to increase distress in the
patient and surgeon, he says. “A number of studies have
found that the majority of people with Body Dysmorphic
Disorder have had cosmetic procedures, and the majority of
those are unhappy with the outcome.”
In Julie’s study, satisfaction with
outcomes was assessed three months
after surgery and results showed a
clear split between participants, with
two thirds reporting they were “very
satisfied” and one third reporting
they were “not satisfied”. Satisfied
patients reported lower levels of
dysmorphic concern compared to
dissatisfied patients. In addition,
those low on dysmorphic concern
reported post surgery improvements
in their general mental health, as
measured by the General Health
Questionnaire (GHQ-12). In
comparison, those high on
dysmorphic concern experienced no
psychological change.

8. Occasionally, people with BDD are so unhappy that
they have attacked and even killed cosmetic surgeons,
David says. “A small group really do quite badly, and
they can be litigious as well as potentially violent
towards plastic surgeons”, he says, citing the example
of a patient who attacked a surgeon with a mallet after
he was unhappy with the outcome (although,
objectively, it was a success).
On another occasion, a woman told David
of how her plastic surgeon husband was
killed by a woman he had operated on a
number of times and who had become
increasingly disgruntled.

9. Psychological screening for
cosmetic surgery
Tragic outcomes like this, although rare, highlight the need for psychological screening of
people seeking cosmetic surgery. As a minimum, this should include screening for BDD as
well as assessing motivations for, and expectations of, the procedure, David says. In reality,
screening is erratic. Some surgeons use their clinical judgement to refer patients for
screening, but there is no systematic procedure for doing so. David and colleagues are
working on developing such a procedure, he says. “My belief is it could easily become
mandated because the outcomes of operating on the wrong people are so horrible for
everybody.”
One of Julie’s research aims was to determine a statistical cut-off point on measures of
dysmorphic concern for use as a screening tool to identify potentially poor candidates for
cosmetic surgery. She found a point that attained a specificity of 80 per cent, showing
potential for an objective measure that identifies high-risk patients. Julie says the ideal
scenario is that all patients are screened, but this may not be feasible and it relies on the
cooperation of surgeons, who have demonstrated varying levels of support for the idea.

10. It seems surgeons’ awareness of the
problem is growing. David says more
surgeons are referring patients to his
team, either due to concerns that some
would not be good candidates for
surgery and might need psychological
help instead, or because a patient with an
objectively good outcome remains
unhappy. A recent survey of 265 US
cosmetic surgeons showed high levels of
BDD awareness and a reluctance to
operate on these people (Sarwer, 2002).
The fact that the Honigman et al (2004)
review was published in Plastic and
Reconstructive Surgery, a prestigious
American plastic surgery journal, is also
a good sign, and the authors have been
invited to speak at various industry
conferences, David says.
David says screening for BDD requires sensitive
questioning about how surgery candidates view
themselves and how this is impacting on their lives.

11. Psychological
Outcomes in
Cosmetic
Surgery
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