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Med J Aust. 2002 June 17; 176(12): 601–604.

Does cosmetic surgery improve psychosocial wellbeing?

David J Castle, MSc, MD, FRANZCP [Professorial Fellow],

Mental Health Research Institute, and University of Melbourne, Parkville, VIC.
Roberta J Honigman, BComm, BsocWork, Grad Dip Conflict Resolution [Social Worker], and
School of Social Work, University of Melbourne, Melbourne, VIC.
Katharine A Phillips, MD [Director]
Body Dysmorphic Disorder Program, Brown University School of Medicine, and Butler Hospital,
Providence, RI, USA.

Abstract
Both men and women are becoming increasingly concerned about their physical appearance and are
seeking cosmetic enhancement.
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Most studies report that people are generally happy with the outcome of cosmetic procedures, but
little rigorous evaluation has been done.
More extensive (“type change”) procedures (eg, rhinoplasty) appear to require greater psychological
adjustment by the patient than “restorative” procedures (eg, face-lift).
Patients who have unrealistic expectations of outcome are more likely to be dissatisfied with cosmetic
procedures.
Some people are never satisfied with cosmetic interventions, despite good procedural outcomes.
Some of these have a psychiatric disorder called “body dysmorphic disorder”.

Cosmetic enhancement is on the rise. More and more people report being unhappy with their
appearance. In a 1997 US survey, 56% of women and 43% of men reported dissatisfaction
with their overall appearance.1 Paralleling this trend, an increasing number of both men and
women are resorting to cosmetic procedures. Figures provided by the American Society for
Aesthetic Plastic Surgery reveal that cosmetic procedures (surgical and non-surgical)
performed by plastic surgeons, dermatologists and otolaryngologists increased 119% between
1997 and 1999.2 In 1999, more than 4.6 million such procedures were performed, with the top
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five being chemical peels (18.3% of the total), botulinum toxin A injection (10.8%), laser hair
removal (10.5%), collagen injection (10.3%), and sclerotherapy (9.0%). Rhinoplasties were
performed on 102 943 people (2.2% of the total number of procedures), and there were 100
203 facelifts (2.2%), 191 583 breast augmentation procedures (4.2%) and 89 769 breast
reductions (1.9%).2 Systematic Australian data are not readily available, as there is no central
registry or reporting requirements. Furthermore, such procedures are performed by a variety
of different practitioners, including cosmetic physicians, dermatologists, and plastic surgeons.

As people generally seek cosmetic interventions to feel better about themselves, one would
anticipate that cosmetically successful procedures would lead to enhanced self-esteem, mood,
and social confidence. While studies spanning four decades have reported that most people
undergoing cosmetic interventions are satisfied with the result,3,4 what has been less studied
is the outcome in psychosocial terms. Clinicians and researchers have attempted over the years

Reprints: Professor David J Castle, Mental Health Research Institute, 155 Oak Street, Parkville, VIC 3052. [email protected].
 Castle et al. Page 2

to evaluate whether improvement in psychosocial wellbeing following cosmetic enhancement

can be objectively verified, but few methodologically robust studies have been done.
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We reviewed the literature on psychosocial outcomes following cosmetic surgery, using

MEDLINE, PsychLit, PubMed, PsychINFO, Sociological Abstracts, Social Work Abstracts,
Proquest 5000, Web of Science and CINAHL. Using the search terms “cosmetic surgery”,
“plastic surgery”, “patient assessment”, “body awareness”, “body image” and “body
dysmorphic disorder”, we identified 36 studies of varying design and quality. Most were
investigations of patients undergoing a specific procedure, including rhinoplasty (12 studies),
breast augmentation (7 studies), breast reduction (5 studies) and face-lift (3 studies), while
other studies encompassed a variety of interventions. Follow-up intervals for testing of
psychosocial outcomes ranged from immediately postoperative to 10 years after the procedure
(in one study). Only 11 studies formally included a control group5–15 — these are shown in
the Box. Other studies have used normative data from general population samples, which may
not be appropriate as reference data.

Positive effects
Overall, the studies suggest that most patients were pleased with the outcome and felt better
about themselves. This was particularly the case for women undergoing reduction
mammoplasty. Domains of functioning showing improvement included “self worth”, “self
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esteem”, “distress and shyness” and “quality of life”. However, many of these studies have
methodological limitations, including small sample sizes and potentially biased ascertainment.
Arguably, patients who agree to participate in such research, and oblige with pre-and post-
intervention interviews, represent a biased group, but none of the studies estimated the extent
of such potential bias. Furthermore, clinical interviews are potentially subject to bias on the
part of both the respondent and the interviewer, and very few studies employed “blind” raters.
Of particular concern is that not all studies used valid assessment instruments, which hampered
the interpretation of results. Finally, most studies evaluated very specific procedures, and it is
unclear how generalisable their results are to other types of cosmetic intervention.

Predicting poor psychosocial outcomes

What has been even less rigorously examined is the question of what factors are associated
with an unsatisfactory psychosocial outcome after cosmetic procedures. Few of the studies we
reviewed formally dealt with this issue. Factors identified with unsatisfactory outcomes
included being male, being young, suffering from depression or anxiety, and having a
personality disorder. However, such parameters have not been studied in a rigorous manner.
2 Other authors have suggested that the nature and degree of surgical change is an important
predictor of outcome: more extensive (“type change”) procedures (eg, rhinoplasty, breast
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augmentation) are more likely to result in serious body-image disturbance than “restorative”
procedures (eg, face-lift, botulinum toxin A injection).16 The extent of changes in sensation
following the procedure (eg, a feeling of skin tightening after a face-lift, or loss of nipple
sensation after breast augmentation) may also influence psychological outcome, with greater
degrees of sensory disturbance making adjustment to the procedure more difficult.17

The patient’s expectation of the outcome of the procedure also appears to be important. It has
been suggested that a distinction can usefully be made between expectations regarding the self
(eg, to improve body image) and expectations relating to external factors (eg, enhancement of
social network, establishing a relationship, getting a job).2 Some evidence points to externally
directed expectations being of more concern — if the person views the procedure as a panacea
for his or her life problems, the outcome is more likely to be poor.18

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Cosmetic surgery and body dysmorphic disorder

There is a particular subgroup of people who appear to respond poorly to cosmetic procedures.
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These are people with the psychiatric disorder known as “body dysmorphic disorder” (BDD).
BDD is characterised by a preoccupation with an objectively absent or minimal deformity that
causes clinically significant distress or impairment in social, occupational, or other areas of
functioning.2 People with this disorder obsess about the perceived defect, usually for hours
each day. The belief of imagined ugliness is often held with delusional conviction.19 In an
attempt to alleviate their distress, sufferers may seek reassurance from others, check their
appearance repeatedly in the mirror or other reflecting surfaces, pick their skin and try to
conceal the “defect” through use of concealing clothing, wigs, makeup, hats, and so on.20
These patients constitute 6%–15% of patients seen in cosmetic surgery settings21,22 and about
12% of patients seen in dermatology settings.23

For several reasons, it is important to recognise BDD in cosmetic surgery settings. Firstly, it
appears that cosmetic procedures are rarely beneficial for these people. Most patients with
BDD who have had a cosmetic procedure report that it was unsatisfactory and did not diminish
concerns about their appearance.24,25 Some patients resort to legal redress or are even violent
towards the treating physician.26,27 Secondly, BDD is a treatable disorder. Serotonin-reuptake
inhibitors and cognitive behaviour therapy have been shown to be effective in about two-thirds
of patients with BDD.2
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Approach to the patient seeking cosmetic surgery

So, how is the cosmetic specialist to ascertain who will do poorly in psychosocial terms despite
an objectively successful procedure? The literature is not terribly useful in guiding us, but
certain commonsense assumptions can be made. First, the individual’s attitude towards the
cosmetic problem, and the distress and disability associated with it, should be assessed. In
particular, the cosmetic specialist needs to determine whether the patient has BDD.28 This can
be done by assessing whether the perceived defect is non-existent or slight and enquiring as to
the amount of time spent each day worrying about the problem, how much distress thinking
about it causes, and whether there is any resulting functional impairment (eg, social avoidance).
If the patient reports being preoccupied with the perceived flaw (eg, thinking about it for at
least an hour a day), and if the concern with the flaw causes marked distress or impaired
functioning, BDD is likely to be present. Similarly, if the cosmetic specialist perceives the
patient’s cosmetic problem to be much more trivial than the patient believes it to be, suspicion
should be aroused. It is also illuminating to assess the patient’s expectations of the outcome of
the proposed procedure in both cosmetic and psychosocial terms. Patients should be advised
of what the cosmetic outcome is likely to be and fully informed of potential side effects and
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complications.

It is also useful to review past cosmetic interventions, including the number of previous
procedures and their cosmetic and psychosocial outcome as perceived by the patient as well
as family and friends. The cosmetic specialist should probably be most concerned about people
who have had numerous procedures performed by many practitioners, and particularly those
who report the outcome of such procedures to have been unsatisfactory. Any history of legal
proceedings or threats or overt violence towards previous cosmetic specialists should obviously
be considered very worrisome.

A patient’s psychiatric history and current mental state should also be examined. Merely having
or having had a mental illness should not of itself preclude cosmetic procedures. However, the
cosmetic specialist should be aware that certain psychiatric conditions can present with
heightened concern about appearance, which might resolve with adequate psychiatric
treatment.2 For example, cosmetic procedures should probably not be performed on people

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 Castle et al. Page 4

who are depressed or psychotic or who have BDD. Referral of such patients to a mental health
professional is strongly recommended.
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Gynaecol 1985;4:335–346.
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16. Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. The psychology of cosmetic surgery: a review
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17. Pruzinsky, T.; Edgerton, MT. Body-image change in cosmetic plastic surgery. In: Cash, TF.;
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Pruzinsky, T., editors. Body images: development, deviance, and change. New York: Guildford
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patients. J Am Acad Dermatol 2000;42:436–441. [PubMed: 10688713]
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Controlled studies of psychosocial outcomes from plastic surgical interventions

Author(s) Study Procedure Sex (mean Study design Control group Scales used Follow- Outcome Factors associated with poor
objective age) up period outcomes

Edgerton et To survey Face-lift and blepharoplasty 8 M, 64 F Cross- 7 patients age-matched to 7 Rorschach, JSC, 2 months 86% reported Age under 40
al5 patients (48 years) sectional of 8 patients selected to TAT (only 8 patients to 10 years improved
requesting undergo psychological had psychological sense of
Castle et al.

surgery to testing testing) wellbeing

ageing face
Wright and To study Rhinoplasty 90 M and F Longitudinal 25 non-cosmetic surgical MMPI 18– No major Psychosis; neurosis; decisional
Wright6 personality (30 years) (only 25 patients 24 months personality discrepancies with partner; personality
characteristics patients change; disorder(narcissism)
of people followed up) improved self-
seeking concept;
cosmetic socially more
surgery, and self-assured
degree of
change in
personality
traits after the
procedure
Shipley et To examine Augmentation mammoplasty 19 F (30.5 Retrospective 20 small-breasted women CPI, ZSSET, DPAQ 3 months Improved body
al7 the effect of years) and 19 average-breasted image; no
breast women effects on
augmentation personality or
on self-concept
psychosocial
functioning
Marcus8 To examine Rhinoplasty 5 M, 15 F Longitudinal 25 dental patients(18 M) SJBCS, ADS, SES 3 months 90% pleased
the psychiatric (23 years) with surgical
status of outcome;
patients having increased
rhinoplasty ability to enjoy
life; increased
social
confidence
Hueston et To construct a Augmentation and reduction 169 M and F Longitudinal 53 hand surgery patients MHQ, LEQ, SAS, 3 months Psychosocial
al9 psychological mammoplasty, face lift, (35 years) LCS, RSES functioning of
profile of blepharoplasty, patients in both
cosmetic abdominoplasty groups

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surgery (aesthetic
patients and procedures,
make a hand surgery)
longitudinal improved
evaluation of
effects of
surgery on
psychosocial
functioning
Beale et To determine Augmentation mammoplasty 61 F (age Subsample (n 28 women from general CMPS 12 months Personality Psychiatric problems; unrealistic
al10 whether it is unspecified) = 39) population testing is expectations; patients using surgery to
possible to followed useful in “save relationship”
predict which longitudinally predicting
women will which women
benefit most will benefit
from from the
augmentation operation; 78%
mammoplasty
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Author(s) Study Procedure Sex (mean Study design Control group Scales used Follow- Outcome Factors associated with poor
objective age) up period outcomes

were satisfied
with outcome
Hollyman To examine Reduction mammoplasty 11 F (22.4 Longitudinal 19 women not seeking CCEI, body At 2, 8, 16, Post-surgery
et al11 body years) surgery perception and 26 relief of
Castle et al.

perception apparatus, visual weeks psychological

before and analogue scales distress;
after reduction improved body
mammoplasty image
Meyer and To study Augmentation mammoplasty 38 F (38.4 Longitudinal 33 female surgical CMPS, MNT 1 year 86% satisfied, Unspecified personality characteristics
Ringberg12 preoperative years) outpatients and social and
personality, psychological
psychosocial expectations
and psychiatric fulfilled
characteristics
Robin et To assess the Rhinoplasty 31 M and F Longitudinal 31 matched controls FAST, GHQ, RMFS 6 months Marked
al13 psychological (25.8 years) reduction in
status of psychiatric
rhinoplasty symptom
patients scores(controls
showed no
change)
Klassen et To assess Reduction mammoplasty 166 F (30.5 Longitudinal General population sample SF 36, RSES, GHQ 6 months Improvement
al14 health status years) 28 in
before and psychological
after breast wellbeing
reduction post-
surgery operatively;
86% highly
satisfied with
outcome
Klassen et To assess Various cosmetic procedures 198 M and F Longitudinal General population sample SF 36, GHQ 28, 6 months Majority
al15 health status (32.6 years) RSES pleased with
after a variety outcome; gains
of cosmetic in
interventions psychological,
social and
physical
function

Med J Aust. Author manuscript; available in PMC 2007 April 12.

ADS = Anxiety and Depression Scale. CCEI = Crown–Crisp Experimental Index. CMPS = Cesarec–Marke Personality Schedule. CPI = California Psychological Inventory. DPAQ = Dress, Popularity and Activity Questionnaire. FAST = Facial Appearance Sorting Test.
GHQ = General Health Questionnaire. JSC = Johns Sentence Completion. LCS = Locus of Control Scale. LEQ = Life Events Questionnaire. MHQ = Middlesex Hospital Questionnaire. MMPI = Minnesota Multiphasic Personality Inventory. MNT = Marke–Nyman Test.
RMFS = Rochford Masculinity/Femininity Scale. RSES = Rosenberg Self-Esteem Scale. SAS = Social Adjustment Scale. SES = Self-Esteem Scale. SF 36 = Short Form 36 health survey. SJBCS = Secord–Jourard Body Cathexis Scale. TAT = Thematic Apperception
Test. ZSSET = Ziller Social Self-Esteem Test.
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