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To the middle-aged woman seated in the office of psychologist David Sarwer, PhD, the scar on her face left from a childhood bicycling accident loomed large. She was often late for work because she spent so much time applying and re-applying makeup to hide it. And she didn't want to go out with her husband for fear that others would stare at what she saw as a deformity. But to Sarwer and the plastic surgeon the woman had consulted, the scar was nearly invisible.

Sarwer diagnosed the woman with body dysmorphic disorder, a mental illness characterized by obsessive concern about a supposed bodily flaw that may not even be visible to others. The solution? Not plastic surgery, but psychotherapy.

"The evidence is pretty conclusive that greater than 90 percent of people with body dysmorphic disorder who get these procedures either report no change or worsening of symptoms, which means they're spending time, energy and money seeking a treatment that ultimately isn't going to benefit them," says Sarwer, now associate dean for research and director of the Center for Obesity Education in Temple University's College of Public Health. "Whereas with psychotherapy, oftentimes in combination with pharmacotherapy, patients can experience improvements and relief from their symptoms."

Body dysmorphic disorder doesn't just affect patients' own lives. It also affects the lives of the plastic surgeons they frequently turn to for help. "These are patients who will typically want to spend a lot of time in your office and will call frequently," says Johns Hopkins University plastic surgeon Lisa E. Ishii, MD, an associate professor of otolaryngology and head and neck surgery. Because they're so often dissatisfied with the results of surgery, they'll sometimes demand additional surgery. And many studies have shown that they're more likely to be litigious and aggressive toward their surgeons than other patients, says Ishii.

There's no requirement that plastic surgeons screen cosmetic surgery candidates for body dysmorphic disorder or other psychological problems, says Ishii, and plastic surgeons typically receive no training in how to detect such issues. And they're not as good at detecting potential problems as they think they are, she adds.

In a multi-site study published in 2016 in JAMA Facial Plastic Surgery, Ishii and colleagues found that the prevalence of body dysmorphic disorder in cosmetic surgery patients is about 10 percent, compared to just 2.4 percent in the general public. "The study also showed that surgeons were routinely terrible at identifying these patients in their casual conversations," says Ishii. Of the 402 patients screened for body dysmorphic disorder by both an objective screening instrument and a surgeon, 43—or 10.7 percent—screened positive on the instrument. The surgeons correctly identified only two of them as having the disorder.

Body dysmorphic disorder is just one of the psychological problems that can complicate cosmetic surgery and recovery. Eating disorders and depression can also pose problems, for instance, and certain populations—such as adolescents—are especially vulnerable to questionable motivations for seeking surgery and unrealistic expectations about its outcomes. And with the number of cosmetic surgery procedures surging, the need for presurgical psychological screening by psychologists and other mental health professionals is growing.

The number of people seeking cosmetic procedures—invasive cosmetic surgery as well as such minimally invasive procedures as Botox, chemical peels and laser hair removal—has more than doubled over the last 15 years, with 7.4 million procedures in 2000 and 15.9 million in 2015, according to the American Society of Plastic Surgeons. In 2015, there were 1.7 million invasive cosmetic surgery procedures in the United States.

People seeking cosmetic surgery sometimes have more in mind than improving their looks, says Sarwer.

"Some patients don't just want to improve their body image and self-esteem: They do it because they're in a failing romantic relationship or recently ended a romantic relationship or because they're frustrated with their career advancement," he says. "While people often report improvements in their body image, it's the rare patient who has a Cinderella-like transformation and sees their entire well-being dramatically enhanced by these procedures."

Psychological concerns

Although people sometimes question the mental health of those who seek cosmetic surgery—which, in contrast to reconstructive surgery, is purely elective and typically done in the absence of any medical condition—the majority of those who are considering or actually undergoing these elective procedures are just as psychologically healthy as anyone else, according to a 2015 study in Clinical Psychological Science.

Researchers led by Jűrgen Margraf, PhD, a professor of clinical psychology and psychotherapy at Ruhr University in Bochum, Germany, surveyed German adults: 264 of them people interested in cosmetic surgery, 546 people who had undergone such procedures and a 1,135-person comparison group. There were a few differences, with those in the first two groups tending to place more importance on body image and rating themselves as less attractive than the comparison group. They also reported less satisfaction and joy in their lives. However, they weren't any more prone to depression, social phobia or other problems than the comparison group. Most also had realistic expectations of surgery, with the most common motivation being to feel better about or in their own bodies.

Cosmetic surgeryCosmetic surgery may even improve people's psychological well-being, Margraf and co-authors found in a 2013 article in Clinical Psychological Science. After comparing those who had undergone cosmetic surgery with those who were interested but hadn't yet undergone procedures, the researchers found positive outcomes in the surgery group up to a year later. These included reduced anxiety, depression and social phobia as well as improvements in mental and physical health, self-esteem and life satisfaction.

While the evidence for the most part is positive, plastic surgeons should be concerned about certain subsets of patients. Body dysmorphic disorder is only the most obvious potential red flag, says Sarwer. Depression should also raise concerns, says Sarwer, who in a review of the literature on psychological issues among cosmetic surgery patients (see "Further reading") cites a study suggesting that about 20 percent of patients are taking antidepressants or other psychiatric medications or undergoing some other form of mental health treatment. There's also some evidence of higher rates of eating disorders among patients who seek cosmetic surgery, he adds.

Another concern is the link between breast augmentation and suicide, says Sarwer. More than half a dozen large studies have shown that women who get implants for cosmetic—rather than reconstructive—reasons have two to three times the suicide rate of other women, says Sarwer, who reviewed the literature on the topic in a 2007 article in the American Journal of Psychiatry. "There's been some additional evidence that suggests that many of the women who present for cosmetic breast augmentation surgery have a previous history of mental illness," says Sarwer.

Plastic surgeons—and the psychologists and other mental health practitioners who assist them—should also delve into potential patients' motivations.

Consider the surgical reduction of the labia. Known as labiaplasty, this is one of the fastest growing types of cosmetic surgery. According to the American Society for Aesthetic Plastic Surgery, the number of procedures in the United States jumped 49 percent in 2014.

"Why would this procedure be so popular when, unlike breast augmentation or rhinoplasty, the results of it aren't easily visible?" wondered Gemma Sharp, PhD, a research associate in Curtin University's School of Psychology and Speech Pathology in Bentley, Australia.

In a 2016 study in the Aesthetic Surgery Journal, Sharp and co-authors found that media depictions of women's bodies and hurtful comments from sexual partners were motivating some women to seek the surgery. In another study, published in Plastic and Reconstructive Surgery in 2016, Sharp has also found that while women who have undergone labiaplasty generally claim psychological benefits as a result, women who were in a sexual relationship before they had the surgery were more likely to be dissatisfied afterward. "Perhaps these women had unrealistic expectations about how the relationship might improve after surgery," says Sharp.

Presurgical evaluations

Because of all these concerns, Ishii and other plastic surgeons are taking action.

Ishii, for instance, is pushing her field to use an objective body dysmorphic disorder screening tool developed by psychiatrist Katharine Phillips, MD, at Brown University. Called the Body Dysmorphic Disorder Questionnaire, the tool is a brief self-report screening measure designed for use with prospective cosmetic surgery and dermatology patients. The questionnaire asks users how much they worry about their appearance and how those concerns affect their lives. In a single-site study published in 2015 in JAMA Facial Plastic Surgery, Ishii and co-authors found the instrument accurate and easy to administer.

Plastic surgeons are also referring patients with psychological red flags of any sort to mental health professionals, who can assist them in identifying surgery candidates for whom surgery isn't appropriate. Psychologist Chris Nikolaidis, PhD, of Newport Beach, California, for instance, is among those who conduct presurgical psychological evaluations of surgery candidates.

"Sometimes surgeons have a kind of instinctive feeling that there might be something there and want to get a second opinion from a psychologist," he says.

Body dysmorphic disorderNikolaidis screens patients for body dysmorphic disorder and other psychological problems and checks for psychological diagnoses and treatment in patients' pasts. He probes their motivations and goals for seeking surgery, making sure they are seeking changes for themselves and not others. He also evaluates whether prospective plastic surgery patients are able to articulate clear, realistic goals for what they want to look like after the surgery. He then shares his feedback with the plastic surgeon.

Sometimes, says Nikolaidis, it's not even necessary to meet with a surgery candidate after consulting with the plastic surgeon. "It can be just helping surgeons trust their instincts and reflecting back to them the psychological issues or behavioral red flags that they've pointed out to me," he says, noting that prospective patients sometimes pressure surgeons. "It may just be helping the surgeons feel confident in asserting themselves."

Surgeons should be especially leery of motivations of adolescent patients, says psychologist Gia Washington, PhD, an assistant professor of pediatrics at Texas Children's Hospital in Houston.

"Adolescents are very self-conscious about their bodies," says Washington. "They may have unrealistic expectations about what will happen following surgery—that they're going to be really popular, for example." Asking an adolescent surgery candidate to write down the risks and benefits of surgery and the pros and cons of post-surgical outcomes can help ensure adolescents know what they're getting into, says Washington.

For plastic surgeons like Ishii, this kind of assistance from psychologists is invaluable.

"It's almost impossible for us to evaluate the situation in an unbiased, objective fashion," says Ishii. "We all intrinsically want to believe we can help every patient who comes through the door."

The most common cosmetic surgeries

Of the 1.7 million cosmetic surgeries performed in 2015, the most common were:

  • Breast augmentation: 279,143
  • Liposuction: 222,051
  • Nose reshaping: 217,979
  • Eyelid surgery: 203,934
  • Tummy tucks: 127,967

Source: American Society of Plastic Surgeons

Further reading

Presurgical Psychological Screening: Understanding Patients, Improving Outcomes
Block, A.R., & Sarwer, D.B. (Eds.), 2013