eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery

Psychological Aspects of Plastic Surgery

Author: Anthony P Sclafani, MD, Director of Facial Plastic Surgery, The New York Eye and Ear Infirmary; Professor of Otolaryngology, New York Medical College
Coauthor(s): Kyle S Choe, MD, Staff Physician, Department of Otolaryngology-Head and Neck Surgery, New York Eye and Ear Infirmary, New York Medical College
Contributor Information and Disclosures

Updated: Nov 5, 2008

Introduction

As aesthetic surgery becomes increasingly popular across all sections of the population, proper patient selection becomes even more important to the entire surgery process. Aesthetic surgery is unique because, unlike any other surgical procedure, it is initiated by the patient and not the physician. In addition, this surgery elicits a more acute reaction from its patients than any other type of surgery. Because aesthetic surgery is initiated by the patient, surgeons are required to recognize the potentially complex psychological milieu of aesthetic procedures. Before proceeding to the operating room, evaluating the patient's psychological condition is essential. This can be effectively accomplished by carefully evaluating a patient's general demeanor and personality, recognizing the patient's true motive, knowing good from poor prognostic indicators, and using accurate assessment techniques.

General Demeanor

A surgeon's first impressions within an evaluation of a patient often prove most useful for gauging the suitability of a surgical procedure. The patient's general appearance, demeanor, and behavior can also serve as indicators of a concealed psychic disturbance. Diagnostic acumen requires an awareness of subtle signs suggestive of potential problems, and the surgeon must practice intuitive observation of the patient at all times. Is the patient's dress provocative and alluring? Does the patient retreat from physical contact or actively avoid eye contact? How is the patient's affect and mood? Is the voice monotone or easily excitable?

Surgeons can expect their patients to be nervous and self-conscious during consultation; however, such patients may need additional observance because nervousness may be an indicator of some emotional disturbance. Anxiety is common at the first meeting and can hamper retention, expression, and comprehension of the goals, benefits, and complications of surgery. Consider a follow-up visit for any patient with suspected emotional instability.

Personality Disorders and Body Dysmorphic Disorder

Many different personality traits and behavioral clues exist. The categorizing of personalities does not imply an abnormality. In fact, the traits associated with certain personality types can be useful and adaptive because they allow the patients to tolerate anxiety, solve problems, and cope with a variety of life's stresses.

However, patients with some personality types are not well suited for cosmetic surgery; these personality types are categorized according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as personality disorders.¹ They include schizoid, paranoid, histrionic, and depressive personality disorders. Patients with these personality disorders deserve closer attention because the personality disorders are often associated with psychiatric complications, and the patients are unfit for cosmetic surgery.

Schizoid personality disorder

Individuals with schizoid personality disorder are described as being socially withdrawn, introverted, eccentric, and uncomfortable with others. Such patients often express vague reasons for wanting aesthetic surgery and are unable to supply precise goals for the procedure even after further questioning. The patient may request surgery because "it would be better to look that way." Characteristically, these patients avoid eye contact, show little emotion, and have difficulty relaxing during consultation with the physician. They make few, if any, spontaneous comments, and they answer questions without elaboration.

Paranoid personality disorder

Paranoia refers to a pervasive and unwarranted skepticism of others. The individual with paranoid personality disorder is most commonly a young, unmarried male. The patient is often a loner and hypersensitive. Individuals with paranoid personality disorder are likely to have an unstable work history, to present themselves as innocent victims of unfairness, and to place blame on others (eg, previous doctors). Patients with this disorder can appear tense, guarded, and secretive. They are often argumentative or even belligerent and highly moralistic. During consultation, patients with paranoid personality disorder are likely to be overly concerned with keeping themselves "all together" and very businesslike. They may anxiously scan the room and have great difficulty relaxing and are often preoccupied with minor details and overcoming their suspicion.

Histrionic personality disorder

Individuals with histrionic personality disorder are often excessively emotional and seek constant attention. They are colorful with labile and shallow emotional responses, from laughing easily to bursting into tears. These patients can use their fantastic displays of emotion and appearance to control others. For example, a person with histrionic personality disorder may use an inappropriate seductive demeanor to solicit special services from the surgeon. Patients with histrionic personality disorder tend to be noncompliant, disorderly, and nonpunctual. They have an intense need for attention, and they seek it through their external appearance, about which they are excessively worried. During an interview, patients with histrionic personality disorder constantly seek reassurance, approval, or praise. They often have a style of speech that is highly impressionistic. For example, when the patient is asked to describe his or her mother, the answer may not be more specific than, "She was a beautifulperson."

Depressive personality disorder

Patients who have depressive personality disorder do not necessarily desire cosmetic surgery; rather, they may be prone to seek it believing that an enhanced physical appearance will improve their feelings about themselves. They have multiple somatic symptoms, constriction of the thought process, and diminished spontaneous behavior. They anxiously repeat questions, demand guarantees, and do not appear optimistic even with assurances. When evaluating a potential depressive patient, specific questions about life stressors are important. Loss of a loved one is the most common inducer of depression.

Body dysmorphic disorder

Unlike different personality traits and normal concerns about one's appearance, the preoccupation with appearance in body dysmorphic disorder (BDD) is excessively time-consuming and associated with significant distress or impairment in social, occupational, or other areas of functioning. BDD is a psychiatric illness. The defect in appearance is either imagined or slight. The preoccupation is also not better accounted for by another mental disorder.

Concerns about appearance can involve imagined or slight flaws of the whole body as well as single parts such as the skin, nose, eyes, hair, ears, breasts, or genitals. Most individuals with BDD often describe their preoccupation as "tormenting" or "devastating" and difficult to control. They often spend hours each day thinking about their "defect," and significant impairment in many areas of functioning may occur. The patients typically engage in various ways to hide their defect such as camouflaging it with makeup, clothing, or body position. They may frequently request reassurance about the defect. Individuals with this disorder often think that others are taking special notice of their supposed flaw.

BDD begins during adolescence but may not be diagnosed for many years and has a continuous course. A review of BDD illustrates an approximately equal sex ratio. However, men and women show differing concerns for different body parts. For instance, women are more likely to be preoccupied with weight and hips, while concerns about hair thinning and size of genitals are more common in men.^2,3 BDD is also associated with different patterns of comorbidity and psychiatric illnesses. BDD is more likely to be associated with bulimia, panic disorder, and generalized anxiety disorder in women. BDD can manifest itself in many other psychiatric disorders including schizophrenia, depression, hypochondriacal psychosis, and severe neurosis.

Male Patients

Although males are less likely than females to seek cosmetic surgery, men who seek it are responsible for a significant proportion of problems a surgeon experiences. For example, in contrast to females, male patients seem to lack a clear body concept and an in-depth awareness of their physical appearance. As a result, they often have difficulty articulating their objectives for cosmetic surgery. Also, many authors believe that male patients are generally less psychologically stable and demonstrate more pathologic features. To avoid problems with males, it is believed that different aesthetic concepts have to be applied. For instance, in rhinoplasty, a more conservative approach with less resection and correction is advised.

Motivational Patterns

Proper selection of patients for aesthetic surgery must start with an effective assessment of the psychology, of which motivation is perhaps the most important part. Patients' motives for seeking aesthetic surgery are as numerous as the patients themselves, and not every reason or person desiring the surgery is suitable. Motivation may stem from various sources. According to Edgerton and Knorr, patients seeking cosmetic surgery are motivated by internal or external pressures. Because aesthetic surgeons typically do not receive formal training in psychiatry, they often have difficulty in correctly diagnosing the true motives. Consequently, aesthetic surgeons attempting to distinguish patients as emotionally appropriate or inappropriate often rely on their own experience, teachings of their mentor, or simply a gestalt approach.

Not all internal or external motivations are appropriate for surgery. Several examples of external motivation deserve a closer examination. The need to please others (eg, husband, relatives, lover, strangers) often arises from the false belief that a change in outward appearance will produce results such as saving a marriage or improving a relationship. Of course, this notion is rarely true and may indicate something more serious with the patient. Furthermore, patients who are pressured into cosmetic surgery may be passive about the procedure and are not suitable candidates. The appropriate patient is active in deciding to pursue surgery and is not influenced by others.

The intensity of the motivation has been demonstrated to be negatively correlated with postoperative pain and positively associated with a shorter postoperative course and satisfaction.

Seeking cosmetic surgery as a way to advance one's career often results in more disappointment than satisfaction after surgery. Despite the generally held notion that more attractive persons are more successful, using plastic surgery as the means to such an end is often ill-advised. Conversely, if the patient is aware that successful surgery does not ensure career advancement, the patient may use the enhanced appearance more effectively.

Patients citing internal motives for aesthetic surgery are generally considered good candidates. Internal motivations may be described as long-standing feelings about deficiencies in physical appearance and a strong commitment to physical change.

However, the definition of a facial deficiency differs widely among patients and needs an individualized elucidation. A condition that appears as a slight consequence to the surgeon may not appear as such to the patient. The line separating a genuine deficiency from a perceived deficiency is often indefinite. No proportional relationship exists between the disfigurement and the mental attitude it engenders in the patient.

Candidates with the appropriate internal motivation temporarily seem to lack adaptation to a particular situation. The psychological state reflects a definite physical defect, and surgical restoration relieves the anxiety. This is very different from a patient for whom the disfigurement is the only focus. For such a patient, once one part of the face is fixed, the patient quickly finds another symptom through which to channel the neurosis.

Diagnostic Indicators

Impressions based on demeanor and personality cannot guarantee proper patient selection. Information obtained from expressed internal motives and initial impressions may make some unsuitable patients appear to be appropriate candidates for surgery. However, when this initial method fails, a thorough study of the patient's history and sufficient time with the patient should expose several diagnostic indicators useful for classifying the patient.

The positive diagnostic clues in a patient include the following:

• An actual disfigurement is clearly noticeable to both the patient and the physician.
• Disfigurement is minor, and corrective surgery has been planned for a long time.
• Occupational appearance is important.
• An emotionally stable patient is aging and wants to look younger.

Poor prognostic indicators include the groups below.

• Patients with repetitive psychiatric illnesses or use of psychiatric medications: This group does not include all psychiatric patients. Indeed, many patients with psychiatric illness are well suited for cosmetic surgery and benefit from it. Yet, patients who have been repeatedly admitted to psychiatric centers may not be emotionally stable and may have illusory meanings of cosmetic surgery.
• Patients who have multiple cosmetic surgeries and are dissatisfied each time: Such patients often seduce the unwary and inexperienced surgeon into seeing the case as a challenge to try the surgeon's skills.
• Patients who "surgeon shop": Although consultation between patient and surgeon is often necessary for comparing prices, techniques, experience, and settings, patients who are indecisive after meeting with 2 or 3 surgeons are often difficult and unhappy patients in the end.
• Patients who believe that correction of a surgical defect is the solution to all of their problems: These patients usually have an underlying psychiatric illness that becomes evident only after surgery. Careful examination of the patient's medical and psychological histories should reveal one or more significant stressors that the patient has learned to channel to a personal facial defect.
• Patients who have not carefully and thoroughly considered the procedure for a significant amount of time: Deciding to pursue cosmetic surgery on a whim may indicate a manic or hysterical impulse.

Assessment Technique

Every aesthetic surgeon should develop an assessment technique or a preoperative screening method to review clients for emotional and psychological stability. No quick solutions or tests exist, and a method that may work well for one surgeon may not work well for another. Every aesthetic surgeon has different opinions about who is appropriate for surgery.

Despite the absence of an established procedure for preoperative screening, several methods of evaluation are available. The most conservative is a formal psychological or psychiatric evaluation. However, this method should be reserved for patients who are psychotic or emotionally unstable. Such consultation with every client seems impractical, expensive, and inconvenient. Psychological testing (eg, Minnesota Multiphasic Personality Inventory [MMPI]) also appears to have shortcomings. Studies have found that the MMPI yields inconsistent results and fails to detect psychopathologic patients. These failures are because patients can easily manipulate the test depending on how they answer its questions. Research into other standardized instruments (eg, California Personality Inventory, Eysenck Personality Inventory) also exposed similar limited usefulness. In addition, the results from these standardized assessments are usually not available for several weeks.

Perhaps the most effective method of assessing a patient's psychological suitability for aesthetic surgery is simply to spend time with the patient gathering information. An astute aesthetic surgeon, like any other physician, must devote significant time to an examination into the patient's family, medical, and surgical histories. Knowledge of any possible allergies, medication being taken, and smoking and alcohol use is significant for identifying specific impacts of potential complications (eg, aspirin use, suitability of patient with significant heart disease). In addition, a thorough study of the patient should demonstrate concern for the total patient, which can possibly ease anxieties and improve communication; the surgeon should not view the patient as merely a cosmetic client.

Questions aimed at assessing a patient's psychological suitability should be open-ended to allow for elaborate and informative answers. Asking open questions, such as "How long have you wanted this change?" rather than asking a direct question, such as "Why do you want this done?" may reveal much more information about issues such as the patient's motivations and psychological well-being. The open question is less threatening and offers more opportunity to elaborate on other issues. Other important questions may be, "Do you think this surgery will make any other things different or better for you?" and "Does anyone else want you to have this surgery?" Furthermore, ascertaining a patient's current life situation, which is often related to the psychological condition of the patient, is also helpful. Questions regarding martial status, work type, and job satisfaction can provide further vital information to the surgeon when assessing the patient's overall psychological suitability.

Given information about the client, the surgeon must be able to answer 4 basic questions, as follows:

• What specifically does the patient want?
• Why does the patient want it performed?
• Why does the patient want this procedure performed now?
• Why has the patient chosen this particular surgeon?

The interview process should enable the surgeon to identify any dangerous symptomatology from unrealistic responses. In addition to being totally candid, the surgeon must clarify what plastic surgery can and cannot accomplish for the patient. Patients must be led to a mutual contract of responsibility. Often, the presence of a spouse or parent is advisable to avoid any possible decisional problem and to validate the genuineness of the patient's motivations.

Summary

The increased popularity of cosmetic surgery among virtually all demographics has compelled the identification of unsuitable candidates. A patient's psychological health is pivotal to predicting his or her satisfaction with the surgery. Emotional and psychological evaluation begins when the patient enters the surgeon's office. A careful assessment of the patient's general demeanor and personality type is essential. In addition to the technical excellence, perhaps the most important predictor of a successful outcome is having the right motivation for surgery. Internally derived pressure, not externally derived pressure, is the healthiest motivation. Proper assessment and management through precise questions and alertness to diagnostic clues should lead to an informed opinion about a patient's psychological suitability for cosmetic surgery and the potential for a successful outcome.

Keywords

psychological aspects of plastic surgery, psychological evaluation, body dysmorphic disorder, BDD, plastic surgery, personality disorders, personality disorder

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