Dr Lucy Kozłowski Bsc (Hons), Msc, Dclinpsych, Clinical Health Psychologist
The pandemic accelerated a rising trend of video-conferencing practices. Consequently, people are exposed to their appearance for more prolonged periods than ever before. Alongside this, the increased prevalence of media and social media in recent decades has heightened the emphasis on physical attractiveness in cultures world-wide, with a corresponding rise in pursual of aesthetic surgical procedures across the globe (Furnham & Levitas, 2012; Abbas & Karadavut, 2017; Niya et al., 2019; Cristel et al. 2020; Rice et al., 2021). This article presents the psychological considerations of the aesthetic surgery patient, providing clinicians with a guide to assessing patient suitability and treatment pathways.
Aesthetic surgical procedures refer to medical procedures that revise or change the appearance, structure, or position of bodily features to enhance physical attractiveness. Attractiveness is a socio- cultural construct and achievement of culturally-imposed ideals is highly desirable across modern societies (Haas et al., 2008; Abbas et al., 2017; Higgins & Wysong, 2018; Niya et al., 2019). Given that the perception of physical appearance affects psychological processes such as self- esteem, self-confidence and psychosocial wellbeing, it is unsurprising that aesthetic surgery rates have risen exponentially as the pressure to conform to societal standards of attractiveness has heightened. Indeed, enhancement of psychological wellbeing, mental health and quality oflife are often cited motivating factors for surgery (Furnham & Levitas, 2012; Margraf et al., 2013; Jones et al., 2022).
Psychological Considerations of the Pre-Operative Patient
Psychological issues such as low self-esteem, depression, anxiety, eating disorders, personality disorders and Body Dysmorphic Disorder (BDD) are highly prevalent in those seeking aesthetic surgical procedures (Jones et al. 2022) and are often driving factors for surgery (Haas et al., 2008; Furnham & Levitas, 2012; Margraf et al., 2013). Other co-morbid psychological issues may present a barrier to maximal outcomes such as needle and anaesthesia phobias. Whilst previously thought to be a contra-indication to aesthetic surgery, the presence of psychological and mental health disorders does not necessarily preclude patients from treatment.
Indeed, for the majority of patients, it is likely that they will achieve good physiological and psychosocial outcomes (Honigman et al., 2004), leading to a resolution of the presenting mental health or psychological issue (Saariniemi et al., 2012; Papadopulos et al., 2019; Nielsen et al., 2021; Katamanin et al., 2024). Further, satisfaction rates remain extremely high for the most common procedures (rhinoplasty, mammoplasty, abdomino-plasty), with patients consistently reporting significant improvements in self- esteem, psychosocial wellbeing, quality of life and enhanced functioning in leisure, social, occupational and relational domains (Papadopulos et al., 2019).
However, the literature indicates that unsuccessful identification and ineffective management of psychological factors heighten the risk of negative post-operative outcomes in a minority of patients. Such outcomes include lowered patient compliance with treatment regimens, delayed recuperation times, dis- satisfaction with surgical outcomes, litigation claims, hostility toward surgeons and triggering or exacerbation of mental health problems such as depression, anxiety and BDD cognitions (Borah et al., 1999; Castle et al., 2002; Higgins & Wysong, 2017; Kassahun et al., 2022).
Therefore routine screening for psychological distress or mental health disorders is indicated to ensure prompt identification and appropriate onward referral to specialist psychological support. Such support assists with comprehensive assessment and formulation of the presenting issues, informing treatment planning and advising of effective interventions that support the patient in both the pre and post operative phases of treatment to address risk factors and achieve maximal outcomes.
Identifying Patients At-Risk of Poor Outcomes
The literature identifies several factors associated with poor physical and psychological outcomes in aesthetic surgery patients (see box 1). Alongside psychological and mental health issues, in particular historical or current presence of depression, anxiety, personality disorder or body dysmorphia, demographic factors such as being male and of younger age, a history of previous aesthetic surgeries and minimal deformity have been found to be pertinent risk factors for poorer post-surgical outcomes. Unrealistic or unachievable surgical expectations, misaligned and external motives such as to repair a relationship or achieve occupational success can lead to heightened distress and poorer outcomes in the post- operative phase (Castle et al., 2002; Honigman et al., 2004; Sarcu & Adamson, 2017; Higgins & Wysong, 2018).
Comprehensive clinical interview can aid with establishing intrinsic versus extrinsic motivations for surgery, realistic versus unrealistic patient expectations and the presence of psychological risk factors. Obtaining the patients medical notes can aid with review of the patients medical history as well as with identifying any discrepancies in the patients self-reports.
If psychological vulnerabilities are suspected, the clinician can be aided by several standardised assessment tools. The Derriford Appearance Scale (DAS59; Harris & Carr, 2001) and the Pre-Operative Facial Cosmetic Surgery Evaluation (PreFACE; Honigman et al., 2011) both aid with identifying psychological distress and dysfunction in relation to physical appearance and body dissatisfaction. The BDD Questionnaire (BDDQ; Phillips et al, 1995) and the Body Image Disturbance Questionnaire (BIDQ; Cash et al., 2004) both possess strong psychometric properties and can aid with screening for BDD, although clinical interview is required for formal diagnosis. The Hospital Anxiety and Depression Scale (HADS; Zigmund & Snaith, 1983) is a validated and reliable tool that identifies the presence of anxiety and depression and is frequently administered in hospital settings due to its simplicity and efficiency. The Mclean Screening Instrument for Borderline Personality Disorder (MSI-BPD; Zanarini et al., 2003) screens for personality disorder characteristics commonly present in this population.
The utilisation of such tools can identify if any psychological distress or mental health issues present warrant referral to specialist, with most tools providing a clinical cut-off score that advises when psychological referral is indicated.
Post-Surgical Dissatisfaction Syndrome & Distress
Neglect of risk factors for poor outcomes can lead to the development of post- surgery dissatisfaction syndrome (Gruber et al., 2009). This is characterised by overt unhappiness with the physical results of the surgery, despite objectively satisfactory physical outcomes. In such patients, negative self-image persists and mental health symptomatology is exacerbated.
Further psychological issues that can arise in the post-operative phase include adjustment and adaptation issues, identity issues and sensory disturbance (Castle et al., 2002). Loss of identity syndrome has been reported by Knorr (1972), who
describes a change in the sense of the self after rhinoplasty. Grief reactions may also occur, even where the result is both subjectively and objectively satisfactory to the patient. The patient may mourn the loss or change to ones body and ones appearance as well as the loss of connection to ones family or ethnicity of origin (Constantian, 2012). Such responses can lead to depression, anxiety, lowered self- esteem and post-traumatic stress reactions (Borah et al., 1999). In some populations psychological responses can be fatal, with increased rates of suicide consistently documented in mammoplasty patients (Lipworth et al., 2007; Mousavi et al., 2023).
Thus routine and ongoing screening and monitoring for the presence of psychological distress and mental health disorder is indicated beyond the pre-operative phase to ensure timely identification of, and response to, emerging mental health or psychological crisis. In this phase of treatment the clinician can be aided by the Derriford Appearance Scale (DAS59; Harris & Carr, 2001) and the Glasgow Benefit Inventory (Robinson et al., 1996), which explore changes in the patients psychological status in relation to physical appearance, body satisfaction and body-image, as well as changes in self-esteem, daily functioning and quality of life.
Psychological Screening, Assessment & Intervention
To mitigate against potential negative outcomes, routine psychological screening and monitoring is evidently warranted throughout the pre and post operative phases, particularly for those who present as psychologically vulnerable or who have a history of mental health disorders (Royal College of Surgeons, 2016). The inclusion of psychologists or other suitably trained mental health professionals within aesthetic surgery Multi-Disciplinary Teams (MDTs) can aid with efficient identification and urgent assessment of such patients. Where inclusion in MDTs is not possible, developing streamlined referral pathways to specialist psychologists can aid with ensuring a prompt and efficient access route for patients. Embedded support ensures that psychological functioning and wellbeing is routinely addressed, maintained and enhanced, bolstering patient engagement in pre and post operative phases, thus minimising delays to the surgical process and ensuring maximal outcomes.
Treating psychologists can supplement the aforementioned standardised tools with clinical interviews to inform assessment and ascertain the patients suitability for the procedure. Clinical interview must entail a comprehensive exploration of motivations for, and expectations of, the surgery. Further, it should include a psychological risk assessment to identify psychological risk factors, including developmental and mental health history, current psychosocial functioning, relational issues and the patients support system (Bascarane et al., 2021). Assessment should inform an understanding of the predisposing, precipitating and perpetuating factors that may increase patient risks associated with the surgical procedure, as well as the protective factors that can be bolstered to support treatment.
Treating psychologists can be assured that the common presenting issues in this population are readily amenable to psychological treatments, with evidence-based protocols available to guide the intervention. These interventions include Cognitive Behavioural Therapy (CBT) informed approaches such as graded exposure for needle and medical procedure phobias, exposure and response prevention training for BDD and behavioural activation and cognitive restructuring for depression and eating disorders (Phillips, 1996; Harrison et al., 2016; Linardon, 2018; van Dis et al., 2020; Bascarane et al., 2021; Cuijpers et al., 2023). Incorporating relaxation techniques such as guided imagery and diaphragmatic breathing exercises is also beneficial for this population.
Psychological support may also involve providing person-centred counselling to facilitate a reflective and emotional processing space for patients to safely explore beliefs and attitudes regarding their body image, self-esteem and surgery motivations. This can facilitate the resolution of ambivalent, discrepant and erroneous cognitions as well as aid psychological risk management. Where suicidality is present, consideration of referral to MDTs for medication management and crisis support is warranted.
Conclusions
Psychological issues are common in aesthetic surgery patients. Whilst the presence of such issues can contribute to poorer post-surgical outcomes for a minority of patients, the presence of such issues should not automatically disqualify patients from procedures. Indeed, aesthetic surgery leads to profoundly positive outcomes for the majority of patients and as such can be a therapeutic intervention. Routine psychological screening throughout the pre and post operative phases is warranted to ensure early detection of psychological risk factors and prompt referral for psychological assessment and intervention. Streamlined referral pathways or the inclusion of psychologists within surgical MDTs can expedite this process. Accessing timely support mitigates against potential risks to patient and surgeon, reducing delays to the surgical process and optimising positive post-surgical outcomes.
ABOUT THE AUTHOR
Dr Lucy Kozłowski is a clinical health psychologist with 20 years of experience in supporting patients in medical settings. She provides highly specialist psychological assessment & intervention to patients with long term health conditions and patients who are undergoing elective and aesthetic surgeries.
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