Applying psychology to routine plastic surgery practice

The prevalence of appearance dissatisfaction in the general population

An interest in looks amongst artists, sculptors, and affluent social groups has been evident since records began. Over the years, codes governing self-presentation within these groups have been prescriptive, but largely achievable. During the past decade, however, the internet and social media have provided a platform for the sharing of appearance ideals across the globe. Crossing social and cultural boundaries, these ideals are less achievable for the vast majority of the population than has previously been the case.

Influenced by a heavy diet of appearance-focused content in broadcast and print media and of digitally enhanced images on social media, in excess of two-thirds of young people and adults of all ages experience dissatisfaction (and for many, distress) with a particular feature or multiple aspects of their looks. The prevalence of appearance dissatisfaction among people of all ages is increasing year on year and is now considered normative. We all experience at least some degree of pressure to correct “faults” in our appearance and are encouraged to believe that our looks are key in the way we are judged by others and in how we should judge ourselves. Achieving looks closer to current ideals will open doors to “the good life”.

In contrast to these messages in our sociocultural context, however, a substantial body of evidence now attests to troubling associations between appearance dissatisfaction and key aspects of living, including psychological wellbeing (for example, lowered self-esteem and body image), mood (anxiety; depression ; suicidal ideation ) and patterns of behavior (disordered eating ; unhealthy exercise behaviors; the misuse of alcohol and drugs ; and self-harm ). Negative impacts also extend to education, work aspirations, and performance in occupational settings. Recent evidence that appearance dissatisfaction is far from benign has led to calls from health professionals, researchers, politicians, policy-makers, and third sector organizations to recognize the phenomenon as a pressing public health, gender, and social justice issue.

These calls are of particular relevance to plastic surgeons and their teams as dissatisfaction with appearance is the most commonly cited reason for seeking appearance-altering surgery and plastic surgery is the route portrayed in the media and perceived by the public to be amongst the most effective methods of closing the gap with appearance ideals and improving quality of life.

What are the characteristics of people who seek cosmetic interventions?

As evidence indicates that the majority of the population are dissatisfied with their looks, what differentiates those who present for cosmetic surgery from those who do not? As with other questions in this sector, a major impediment to understanding is the lack of data and as a result, a paucity of research. During the wait for data, researchers have gleaned insights from studies of the reported intentions of general population samples. Two key psychological processes – a person’s degree of susceptibility to messages in their sociocultural context – and internalization – the degree to which people perceive these messages to be personally relevant – appear to characterize those who intend to seek surgery. People who consume a large amount of social and broadcast media have more favorable attitudes about undergoing cosmetic surgery as a means of achieving appearance ideals than less frequent users of these media. These media encourage users to compare their own looks with digitally enhanced and retouched images of celebrities and influencers. People with a stronger tendency to choose unrealistic targets of comparison and to aspire to unrealistic appearance ideals are also more likely to have positive attitudes towards cosmetic surgery.

Although the results of these studies are illuminating, the gap between intention and actual behavior is widely recognized in psychology and limits confidence in the generalizability of the findings. Research with people who have translated their intention into behavior offers more authoritative insights on the motivation of prospective patients. Margraf and colleagues measured the preoperative expectations of a large sample of patients who had made the decision to undergo surgery, comparing this group with those still considering surgery and a further representative general population sample. Both of the groups actively considering surgery attributed a greater importance to improving their body image, rated their current appearance more negatively and reported a lower level of satisfaction with life generally than the general population group. The goals most commonly endorsed by the surgical group were “to feel more comfortable in my own skin”, “to eliminate a long-felt blemish”, and “to increase self-esteem”. Remaining goals focused on “external” rather than “internal” motives, including the desire to please a partner, or to have more professional success.

These findings are in line with other reports about the psychosocial nature of the changes that cosmetic surgery patients hope to achieve. Taken together, these results highlight a critical issue for surgeons. Prospective patients are motivated to seek surgery by psychosocial factors and also hold expectations of psychosocial gains as the result of an altered appearance over which the surgeon has no control. At one level, the reasons offered by prospective patients seem straightforward, but the drivers behind these reasons involve complex interactions between key psychological and social processes. For example, in saying “I just want to look normal” , prospective patients may be referring to the desire to regain a previous appearance (such as a pre-pregnancy body shape), the desire to remove a feature they perceive to be stigmatizing (for example, the visible signs of weight loss), or to achieve the size and shape of genitalia perceived as “normal” through exposure to images on the internet or social media. Their motivation will draw on their body image and/or a recollection of their appearance at an earlier life stage (this, in turn, will be biased by psychological processes) and the degree to which they buy-in to appearance ideals and perceived social norms prevalent in social and mass media, family, and peers.

A prospective patient’s susceptibility to perceived or real pressure in the sociocultural environment also extends to the business practices of some cosmetic surgery providers. Advertising and marketing strategies promoting new products and interventions as the solution to “faults” in appearance can fuel existing insecurities and create new appearance concerns. Promotional materials often include glamorous images with explicit or implicit messages about the likely psychological and lifestyle gains associated with surgery. The décor of a clinic, the “before” and “after” photos on display, and the language used by clinic staff to describe the likely outcomes of surgery will influence not only the prospective patient’s desire to undergo an intervention, but also their expectations of the likely psychosocial outcomes.

Visible differences (disfigurement) and reconstructive surgery

Living with an unusual appearance, whatever the cause, presents significant challenges. The motivation of patients to undergo reconstructive surgery and their responses to treatment will be influenced by their experiences of these challenges and by pressures in the sociocultural context described above.

Research indicates that the most frequently reported difficulties for this group of people relate to social situations. First encounters with others can be particularly troubling, either as the result of a lack of confidence, or because of perceived negativity in the reaction of others to their appearance. Moving to a new job, geographical neighborhood or social group can be particularly stressful, requiring multiple first encounters and the need to establish new social networks.

Anxieties about the potentially negative impact of a disfigurement on forming friendships or establishing longer-term relationships are also common. Recently, research has also highlighted these anxieties in sexuality and intimate relationships. These issues are rarely raised by the patient and are topics commonly avoided by professionals. As this driver for treatment frequently remains undisclosed, it is rarely factored into a treatment plan.

Widespread reports of detrimental effects of a visible difference on self-perceptions are also common. These include low levels of self-esteem and body image, aversive emotions such as perceptions of stigma (resulting from stereotyping by others on the basis of appearance) and shame. Specific cultural or religious beliefs may increase the perceived pressure to “improve” appearance. Prospective patients commonly articulate their desire to achieve a “normal” appearance to avoid attention from strangers, but their aspirations often include improved self-esteem and confidence. While surgery can directly address the goal of achieving an unremarkable appearance, broader psychological gains are likely to require a more comprehensive treatment plan.

The proportion of people who experience significant levels of distress varies between studies, conditions, and situations, but overall, about one-third seem to experience significant difficulties, either on a transitory or more enduring basis. However, perhaps the most striking aspects of adjustment to an unusual appearance are the extent of the variation in adjustment and the factors accounting for these differences. Early studies focussed on condition-specific effects, such as the etiology, severity, and extent of a disfigurement, and the body parts affected. Results have demonstrated clearly that these “physical” parameters are, in fact, poor predictors of adjustment. Neither is time necessarily a great healer. Difficulties and distress can wax and wane over the years, triggered by developmental challenges such as the imperative to form a lasting relationship, the physical or psychological changes in midlife, stressful life events, or even a casual comment that, for one reason or another, takes root. The visible difference can become a “hook” – blamed for real or imagined negativity from others, or the cause of the crisis in hand. A disfigurement resulting from trauma may leave a legacy of distress or PTSD, and the patient’s mental health before the trauma will influence how well she or he copes with the aftermath in both the short and longer term.

In sum, the influence of condition-specific factors and the passage of time is smaller than many clinicians expect and assumptions about the patient’s wellbeing should not be made on this basis. Adjustment does not rely on appearance alone and the preconception that the patient’s anomaly is the root cause of psychological difficulties should be avoided. The strongest predictors of adjustment include the degree to which the person’s disposition and outlook on life are optimistic or pessimistic, the extent to which their sense of self-worth relies on their perceptions of the reactions and opinions of others, the degree of satisfaction they report with their social connections and social support, and the extent to which they believe their life has meaning and purpose. Their level of social skill (the ability to successfully navigate social interactions with others) is also a contributory factor.

In a similar way to cosmetic procedures, psychological factors and processes play a part in all stages of reconstructive surgery. Patients may need encouragement to get off the treatment treadmill and to focus on attributes other than appearance which are more likely to lead to improvements in quality of life. People who have significant body image concerns independent of their disfiguring conditions, or mental health conditions such as depression or PTSD (e.g., after traumatic injury) may be over-invested in surgery to provide “solutions” to their broader psychological distress. Careful assessment of the anticipated benefits of surgery is crucial in guarding against unrealistic expectations of outcome.