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Contents lists available at ScienceDirect

Body Image
journal homepage: www.elsevier.com/locate/bodyimage

Body image, cosmetic surgery, and minimally invasive treatments

David B. Sarwer
College of Public Health, Temple University, United States

a r t i c l e i n f o a b s t r a c t

Article history: Over the past 60 years, a growing body of research has investigated the psychological aspects of cosmetic
Received 6 December 2018 surgery and related minimally-invasive treatments. While the earliest studies were influenced by psy-
Received in revised form 21 January 2019 choanalytic thinking, much of the work over the past several decades has been influenced by Thomas
Accepted 21 January 2019
Cash’s cognitive-behavioral theory of body image and has focused on the appearance concerns of patients
Available online xxx
who seek these procedures. The majority of individuals interested in the procedures report heightened
dissatisfaction typically focused on the feature being considered for treatment. Studies from around the
Keywords:
world also have suggested that between 5–15% of patients who present for cosmetic procedures meet
Body image
Cosmetic surgery
diagnostic criteria for body dysmorphic disorder (BDD). While individuals with BDD typically do not
Quality of life report a reduction in their BDD symptoms following a cosmetic procedure, the great majority of patients
Body dysmorphic disorder without the disorder do report improvement in body image. The paper reviews this literature and also
discusses the role of body image in three newer areas of plastic surgery—body contouring after massive
weight loss, genital procedures (either for cosmetic purposes or as part of gender reassignment), and
vascularized composite allotransplantation, including face and hand transplantation.
© 2019 Published by Elsevier Ltd.

1. The popularity of cosmetic surgery and minimally
invasive treatments
According the American Society of Plastic Surgeons, 17.5 mil-
lion cosmetic surgical and minimally invasive treatments were
performed in 2017 (American Society of Plastic Surgeons, 2018;
Sarwer, 2018). The vast majority, nearly 16 million, were minimally
®
invasive procedures such as Botox injections and soft tissue fillers,
typically used to reduce the signs of aging. Over 700,000 were the
traditional cosmetic surgical procedures, including breast augmen-
tation, liposuction, and rhinoplasty (American Society of Plastic
Surgeons, 2018). These numbers, while substantial, likely under-
estimate the actual number of procedures performed annually, as
physicians from a range of medical disciplines offer appearance
enhancing procedures.
The current popularity of cosmetic medical treatments can
be explained by a number of factors (Crerand, Infield, & Sarwer,
2007; Crerand, Magee, Spitzer, & Sarwer, 2013). Medical and
surgical advances have made many treatments safer and with
shorter recovery periods than before. This is particularly true for
the minimally invasive treatments, many of which require little
recovery time. Cosmetic procedures readily lend themselves to
direct-to-consumer advertisements. Advertisements for physicians
who offer these procedures are frequently seen on billboards in
major urban areas and in local magazines. This marketing likely
has contributed to the growth. Further, cosmetic medical proce-
dures have long been a very popular topic for women’s (and men’s)
fashion and beauty magazines. Cosmetic surgery also is an aspect of
a great many popular reality-based television programs (Markey &
Markey, 2010). At the same time, consumers of popular television,
magazines, and social media are regularly exposed to images of the
physical appearance of others. The end result is that consumers
cannot help but be exposed to depictions of beauty as well as the
message that cosmetic medical treatments are part of the path to
physical perfection (Sarwer & Constantian, 2017).
The popularity of cosmetic procedures can be understood from
other perspectives as well. Evolutionary theories of physical attrac-
tiveness also are believed to play a role. Many facial procedures
are undertaken to help an individual look more youthful and/or
enhance their facial symmetry, key markers of physical attractive-
ness. Surgical procedures such as liposuction and abdominoplasty
can decrease an individual’s waist-to-hip ratio, another “signal”
of physical attractiveness and marker of reproductive potential.
Social psychological research on the role of physical appearance in
daily life also can be used to understand the popularity. This large
body of research suggests that individuals who are more physically
attractive are judged to have a number of more positive personality
traits and receive preferential treatment in a range of social situ-

E-mail address: dsarwer@temple.edu

https://doi.org/10.1016/j.bodyim.2019.01.009
1740-1445/© 2019 Published by Elsevier Ltd.

Please cite this article in press as: Sarwer, D.B. Body image, cosmetic surgery, and minimally invasive treatments. Body Image (2018),
https://doi.org/10.1016/j.bodyim.2019.01.009
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ations across the lifespan (Langlois et al., 2000; Sarwer, Wadden,
Pertschuk, & Whitaker, 1998).
1.1. Psychosocial characteristics of patients interested in cosmetic
surgery and minimally invasive treatments
Over the last 60 years, a large body of research on the psy-
chological aspects of individuals receiving cosmetic surgery and
minimally invasive treatments has developed (Edgerton & McClary,
1958; Sarwer & Constantian, 2017; Sarwer & Spitzer, in press).
Many studies have investigated the psychological characteristics of
patients who pursue these procedures; others have looked at the
relationship of these characteristics to treatment outcomes. The
first studies, conducted in the 1950s and 1960s by plastic surgeons
in collaboration with psychiatrists (many of whom appeared to be
working from a psychodynamic theoretical orientation), involved
clinical interviews of patients prior to their procedures. Perhaps
not surprisingly, these studies described large numbers of patients
as suffering from significant psychopathology—depression, narcis-
sism, and even schizophrenia (Edgerton & McClary, 1958; Edgerton,
Meyer, & Jacobson, 1961). There is no evidence, however, to
suggest that such interpretations are necessarily valid or use-
ful in determining patients’ appropriateness for surgery (Sarwer,
Pertschuk, Wadden, & Whitaker, 1998; Sarwer, Wadden, Pertschuk,
& Whitaker, 1998). Patients suffering with these issues were
thought to be likely to experience poor postoperative psychological
outcomes.
Subsequent studies often included psychometric measures
of relevant personality characteristics. These studies typically
have found less psychopathology among patients than initially
reported in the literature compared to previous clinical inter-
view/interpretation studies (Didie & Sarwer, 2003; Sarwer et al.,
2003; Young, Nemecek, & Nemecek, 1994). Nevertheless, both
sets of studies suffer from methodological problems that have
made interpretation of these conflicting findings difficult (Sarwer,
Wadden, Wadden et al., 1998; Sarwer, Didie, & Gibbons, 2006;
Sarwer, Pertschuk et al., 1998). Thus, the rate of psychopathol-
ogy among cosmetic surgery patients remains poorly understood.
Perhaps more importantly, the relationship between preoperative
psychopathology and postoperative outcomes, with few excep-
tions, is largely unknown.
2. Body dissatisfaction and motivation for cosmetic
medical treatments
Body image investment and evaluation are believed to play an
important role of the decision to undergo a cosmetic medical treat-
ment (Sarwer & Crerand, 2004; Sarwer, Pertschuk et al., 1998). The
early work in this area was directly influenced by the cognitive-
behavioral theory of body image proposed by Cash et al. (2006).
This theory includes a consideration of the role of both historical
and proximal influences on body image, as well as body image ori-
entation and evaluation. Persons interested in cosmetic procedures
typically report increased investment in their appearance as well
as heightened body dissatisfaction (Pertschuk, Sarwer, Wadden, &
Whitaker, 1998; Sarwer, Whitaker, Wadden, & Pertschuk, 1997;
Sarwer, Pertschuk et al., 1998; Simis, Verhulst, & Koot, 2001). Most
report dissatisfaction focused on a given feature rather than a more
global dissatisfaction with their entire body (Sarwer & Spitzer,
2012; Sarwer, 2007, Sarwer and Spitzer, 2015; Sarwer, Wadden
et al., 1998). For example, breast augmentation candidates report
greater dissatisfaction with their breasts compared to other small-
breasted women who do not seek breast augmentation (Didie &
Sarwer, 2003; Sarwer et al., 2003). Similarly, individuals interested
in rhinoplasty reported more appearance concerns as compared
Please cite this article in press as: Sarwer, D.B. Body image, cosmetic surgery, and minimally invasive treatments. Body Image (2018),
https://doi.org/10.1016/j.bodyim.2019.01.009
to those of age- and gender-matched controls presenting for non-
appearance altering surgery (Moss & Harris, 2009). Thus, some
degree of dissatisfaction with one’s physical appearance is believed
to be a pre-requisite to cosmetic surgery and serve as a motivational
catalyst for interest in these procedures. Similarly, a number of
studies have suggested that body dissatisfaction also is associated
with the interest in cosmetic surgery in the future (Henderson-King
& Henderson-King, 2005; Markey & Markey, 2010; Sarwer et al.,
2005).
Extreme body dissatisfaction, however, is a symptom of a num-
ber of psychiatric diagnoses, including eating disorders, gender
dysphoria, and body dysmorphic disorder (BDD). While all psychi-
atric disorders are likely to be represented among persons who
present for cosmetic treatments, BDD is probably the disorder of
greatest relevance (Crerand, Franklin, & Sarwer, 2006; Sarwer &
Crerand, 2004; Sarwer & Spitzer, 2012).
3. Body dysmorphic disorder and cosmetic medical
treatments
BDD is characterized as a preoccupation with a slight or nonob-
servable defect in appearance that is associated with obsessive
thinking and compulsive behaviors and which leads to a disrup-
tion in the activities of daily life (American Psychiatric Association
(APA), 2014). Case reports of patients who likely had the dis-
order, described as “minimal deformity” or “insatiable” patients,
appeared in the plastic surgery and dermatology literatures in the
1960s and 1970s, almost two decades before BDD appeared in the
DSM (Cotterill, 1981; Edgerton, Jacobson, & Meyer, 1960; Hardy &
Cotterill, 1982; Knorr, Edgerton, & Hoopes, 1967).
Identifying BDD in patients interested in cosmetic medical treat-
ments can be difficult (Crerand et al., 2006; Crerand, Franklin,
& Sarwer, 2008). According to the DSM-5’s first diagnostic cri-
terion for BDD, an individual must be preoccupied with one or
more perceived defects in appearance which are either “slight” or
non-observable to others (American Psychiatric Association (APA),
2014). Most patients presenting for cosmetic treatments have
“normal” features that they wish to enhance; others may desire
correction of slight imperfections. Thus, the majority of patients
could meet this criterion. The second diagnostic criterion describes
engagement in repetitive, appearance-focused behaviors. Many
cosmetic medical patients engage in these behaviors. However,
the distinction between repeated and excessive viewing of one’s
appearance in the mirror is unclear. For many, this behavior and
others may not meet the third criteria for BDD, experiencing clin-
ically significant distress or impairment in social, occupational,
or other important areas of functioning. In cosmetic settings, the
degree of distress and impairment in functioning experienced by
the patient likely differentiates a cosmetic surgery patient with
“normative” appearance concerns from one who is in fact suffering
from BDD (Crerand et al., 2006, 2008).
Studies from around the world have sought to identify the
rate of BDD among individuals presenting for cosmetic surgery
(Crerand, Sarwer, & Ryan, 2017). Among American samples, rates
of 7–13% have been reported (Crerand et al., 2004; Dey et al., 2015;
Sarwer, Wadden et al., 1998). International studies have reported
rates ranging from 2.9%–53% (Altamura, Paluello, Mundo, Medda,
& Mannu, 2001; Aouizerate et al., 2003; Bellino et al., 2006; Castle,
Molton, Hoffman, Preston, & Phillips, 2004; Ishigooka et al., 1998;
Lai, Lee, Yeh, & Chen, 2010; Vargel & Uluşahin, 2001; Vindigni
et al., 2002; Vulink et al., 2006). Studies with the highest rates of
BDD have typically used unspecified clinical interviews to establish
the diagnoses, raising concerns about their validity. International
studies which have used more rigorous methods have found rates
ranging from 3.2 to 16% (Alavi, Kalafi, Dehbozorgi, & Javadpour,
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2011; Fathololoomi, Goljanian Tabrizi, Fattahi Bafghi, Noohi, &
Makhdoom, 2013). Similar rates of BDD also have been reported
among patients who present for dermatological treatment (Bowe,
Leyden, Crerand, Sarwer, & Margolis, 2007; Calderón et al., 2009;
Conrado et al., 2010; Dogruk Kacar et al., 2014; Dufresne, Phillips,
Vittorio, & Wilkel, 2001; Hsu, Ali Juma, & Goh, 2009; Phillips,
Dufresne, Wilkel, & Vittorio, 2000; Uzun et al., 2003; Vulink et al.,
2006).
Other studies have investigated the history of cosmetic proce-
dures among persons with BDD (Crerand, Phillips, Menard, & Fay,
2005; Phillips, Grant, Siniscalchi, & Albertini, 2001; Veale et al.,
1996). The two largest studies found that over 70% of patients
had sought and more than 64% had received a cosmetic treatment
(Crerand et al., 2005; Phillips et al., 2001). These reports are not
particularly surprising. Individuals with BDD typically believe that
their appearance is truly flawed and that the only way to reduce
their distress is to change their appearance. Individuals with BDD
are nearly as likely to pursue treatments from dermatologists and
plastic surgeons as they are from psychologists or psychiatrists
(Marques, Weingarden, Leblanc, & Wilhelm, 2011).
Several retrospective studies have found that cosmetic treat-
ments rarely improve BDD, and patients are frequently dissatisfied
with treatment outcomes (Crerand et al., 2005; Crerand, Menard,
& Phillips, 2010; Veale et al., 1996; Veale, 2000). For example, a
study of 200 persons with BDD revealed that only 3.6% of 528
procedures resulted in improvement in overall BDD symptoms
(Crerand et al., 2005). A small number of studies have investi-
gated this issue prospectively. These studies also have suggested
that the vast majority of patients do not experience a reduction in
BDD symptoms, or improvements in more general psychiatric sta-
tus following a cosmetic procedure (Mulkens et al., 2012; Phillips,
Pagano, Menard, Fay, & Stout, 2005; Picavet et al., 2013; Tignol,
Biraben-Gotzamanis, Martin-Guehl, Grabot, & Aouizerate, 2007).
For these reasons, many physicians who offer cosmetic med-
ical procedures are reluctant to perform procedures on patients
with BDD. Eighty percent of plastic surgeons and 62% of derma-
tologic surgeons have refused to perform cosmetic procedures on
individuals believed to have BDD (Sarwer, 2002; Sarwer, Spitzer,
Sobanko, & Beer, 2015). Treating physicians also face risks when
knowingly or unknowingly performing cosmetic procedures on
patients with BDD. Surveys of cosmetic treatment providers sug-
gest that between 9% and 29% of physicians have been threatened
legally by a patient with BDD, and 2% of cosmetic and dermatolog-
ical surgeons have reported being threatened with physical harm
(Sarwer, 2002; Sarwer et al., 2015). Tragically, several providers
have been murdered by patients with or suspected of having BDD
(Gorney, 2006). Thus, BDD is widely considered a contraindica-
tion to cosmetic medical treatment (Sarwer & Constantian, 2017;
Sarwer & Spitzer, 2012).
4. Eating disorders and cosmetic medical treatments
Given the extreme body dissatisfaction reported by patients
with eating disorders, these disorders also are believed to be
seen with regularity among patients interested in cosmetic med-
ical treatments. Eating disorders may be a particular concern for
women (and men) who seek body contouring procedures, includ-
ing liposuction, abdominoplasty, as well as breast augmentation.
These patients may mistakenly believe that these procedures can
reshape their bodies in a way that restrictive eating and/or mal-
adaptive compensatory behaviors cannot. Women who present for
cosmetic breast augmentation are frequently below average weight
(Didie & Sarwer, 2003; Sarwer et al., 2003; Simis et al., 2001) and
report greater exercise compared to physically similar women not
seeking breast augmentation (Didie & Sarwer, 2003), both of which
Please cite this article in press as: Sarwer, D.B. Body image, cosmetic surgery, and minimally invasive treatments. Body Image (2018),
https://doi.org/10.1016/j.bodyim.2019.01.009
3
also may be suggestive of eating psychopathology. However, the
rate of eating disorders among persons who present for cosmetic
medical procedures has yet to be firmly established.
5. Changes in body image and psychosocial functioning
following cosmetic medical treatments
The great majority of patients report satisfaction with the
results of their cosmetic medical treatments (Murphy, Beckstrand,
& Sarwer, 2009; Park, Chetty, & Watson, 1996; Sarwer et al., 2005;
Schlebusch & Mahrt, 1993; Young et al., 1994). Patients also have
been found to report significant improvements in body image
(Banbury et al., 2004; Cash, Duel, & Perkins, 2002; Sarwer et al.,
2005; Young et al., 1994). Most studies have found these changes
within the first two years of surgery, although some studies have
shown improvements in body image enduring for five years after
surgery (Dayan, Arkins, Patel, & Gal, 2010; von Soest, Kvalem,
Skolleborg, & Roald, 2011). Thus, if body dissatisfaction is believed
to motivate the pursuit of cosmetic procedures, it is encouraging to
find that these benefits are experienced by patients.
Studies of psychosocial functioning beyond body image have
produced mixed results. For example, a number of studies have
looked at changes in self-esteem. Some studies have documented
the improvements in self-esteem (Dayan et al., 2010; de Aquino,
Haddad, & Ferreira, 2013; Hexsel et al., 2013); others have not
(Hedén, Boné, Murphy, Slicton, & Walker, 2006; Niechajev, Jurell, &
Lohjelm, 2007; Sarwer et al., 2008). These results may be a function
of methodology. When assessed via clinical interview, women who
underwent cosmetic breast augmentation report improvements in
self-esteem (Hedén et al., 2006; Hexsel et al., 2013; Niechajev et al.,
2007). In contrast, studies which have used psychometric measures
of self-esteem have found equivocal results (Bolton, Pruzinsky,
Cash, & Persing, 2003; Papadopulos et al., 2012; Sarwer & Crerand,
2004; Sarwer et al., 2005; Swanson, 2013).
Studies that have investigated the relationship between cos-
metic medical procedures and depressive symptoms also have
found mixed results (Kalaaji, Bjertness, Nordahl, & Olafsen, 2013;
Meningaud et al., 2003; Rankin, Borah, Perry, & Wey, 1998;
Saariniemi et al., 2012; Sarwer et al., 2008; von Soest et al., 2011).
This relationship may be confounded by use of mental health
treatment. Several studies have suggest that patients who present
for cosmetic surgery use mental health treatment at higher rates
as compared to women from the general population (Jacobsen,
Holmich, & McLaughlin, 2004; Sarwer et al., 2003; Sarwer &
Crerand, 2004). There also is concern about postoperative sui-
cide. Seven epidemiological studies investigating the relationship
between silicone gel-filled breast implants and all-cause mortality
have found an association between breast augmentation and sui-
cide (Sarwer, Brown, & Evans, 2007). These studies, which focused
on women who received these implants for cosmetic purposes and
not for breast reconstruction after treatment for breast cancer, sug-
gest that the rate of suicide is two to three times higher than rates
in other cosmetic surgery patients or estimated rates in the general
population.
Explanations of the relationship between breast implants and
suicide primarily have focused on the preoperative psychoso-
cial status and functioning of the women (McLaughlin, Wise, &
Lipworth, 2004; Sarwer, 2007; Sarwer et al., 2007). Women who
undergo cosmetic breast augmentation have been shown to have
a number of distinguishing demographic characteristics. They are
more likely to report more lifetime sexual partners and a greater
use of oral of contraceptives, be younger at the time of their first
pregnancy, and have a history of terminated pregnancies (Brinton,
Brown, Colton, Burich, & Lubin, 2000; Cook et al., 1997). They also
have been found to be more frequent users of alcohol and tobacco
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(Cook et al., 1997; Fryzek et al., 2000; Kjøller et al., 2003). Many of
these characteristics are markers of psychopathology, and in and
of themselves, risk factors for suicide. Only one of the seven epi-
demiological studies provided any information on the psychiatric
history of the women studied. This study found a higher rate of
previous psychiatric hospitalizations among women with breast
implants in comparison to both women who received other cos-
metic procedures and women who underwent breast reduction
(Jacobsen et al., 2004). A history of psychiatric hospitalizations is
one of the strongest predictors of suicide among women in the gen-
eral population (Qin, Agerbo, & Mortensen, 2003). Unfortunately,
Jacobsen et al. did not report information on diagnosis, history of ill-
ness, or other psychiatric treatments for the women in their sample
(Jacobsen et al., 2004).
Postoperative satisfaction and the psychological benefits asso-
ciated with cosmetic surgery may be negatively impacted by the
occurrence of a postoperative complication (Honigman, Phillips, &
Castle, 2004). At least one study found that breast augmentation
patients who experienced postoperative complications reported
less favorable changes in body image in the first two years follow-
ing surgery (Cash et al., 2002). Statistics from the American Society
of Plastic Surgeons indicate that approximately 50% of patients
return for a second procedure at some point in the future (American
Society of Plastic Surgeons, 2018). Unfortunately, it is unclear if
these patients are returning for a second procedure because they
are dissatisfied with the outcome of the first procedure or if they
were satisfied with the outcome and are now interested in modi-
fying another aspect of their appearance.
6. Body image and specific cosmetic procedures
While body image concerns are believed to be important to
patients who seek all forms of cosmetic medical treatments,
the relationship is of particular relevance for three developing
areas—body contouring after massive weight loss, cosmetic genital
procedures, and vascularized composite allotransplantation.
6.1. Body contouring after massive weight loss
At present, approximately 8% of the American population has a
BMI > 40 kg/m2 and, as a result, is categorized with extreme obesity
(Hales, Carroll, Fryar, & Ogden, 2017). These individuals are poten-
tial candidates for bariatric surgery. Following bariatric surgery,
individuals lose approximately 30% of their initial body weight
(Buchwald et al., 2004). They typically experience substantial
improvements in weight-related health problems and psychosocial
status, including quality of life, body image, and sexual function-
ing (Sarwer, Lavery, & Spitzer, 2012). Some patients suffer from
loose, hanging skin. In some cases, this skin leads to significant
dermatological issues; for others, it is psychologically distressing
(Sarwer & Polonsky, 2016; Sarwer & Steffen, 2015). As a result,
approximately 55,000 Americans undergo body contouring proce-
dures with a plastic surgeon (American Society of Plastic Surgeons,
2018). These procedures typically lead to improvements in both
physical and psychosocial functioning (Sarwer et al., 2012). How-
ever, patients are often left with significant scars which also may
result in body dissatisfaction.
6.2. Cosmetic genital procedures
In the past decade, cosmetic genital procedures have grown
in popularity. In women, these procedures are often performed
in response to physical symptoms (pain, itching) or psychosocial
distress (body dissatisfaction, loss of sexual desire) secondary to
prominent labia (Sharp, Mattiske, & Vale, 2016; Sharp, Tiggemann,
& Mattiske, 2016; Sharp, Tiggemann, & Mattiske, 2017). In men,
Please cite this article in press as: Sarwer, D.B. Body image, cosmetic surgery, and minimally invasive treatments. Body Image (2018),
https://doi.org/10.1016/j.bodyim.2019.01.009
they often are performed to increase the size and/or width of the
penis (Veale et al., 2015). These procedures often are performed
on individuals with gender dysphoria who are undergoing gender
reassignment procedures (Weissler et al., 2018). Individuals with
gender dysphoria also undergo both surgical and minimally inva-
sive of the face and chest and other relevant body areas as part of
their gender reassignment.
Reliable statistics on these procedures are difficult to obtain.
While many patients receive these treatments from licensed physi-
cians from a range of medical specialties, anecdotal reports indicate
that many individuals receive these and other treatments non-
licensed providers or individuals, often with disastrous results
including permanent disfigurement and death. In the hands of
reputable professionals, patients often report satisfaction with
the results and improvements in psychosocial functioning (Sharp,
Mattiske et al., 2016; Sharp, Tiggemann et al. 2016; Sharp et al.,
2017). However, there is some concern that some individuals inter-
ested in these procedures may be suffering from BDD. For example,
Veale et al. found that approximately 20% of women who had a cos-
metic genital procedure reported BDD symptoms postoperatively
(Veale et al., 2014).
6.3. Vascularized composite allotransplantation
Over the past decade, over 100 individuals around the world
have undergone a vascularized composite allotransplantation
(VCA) procedure. Typically performed following significant trau-
matic injury resulting in profound disfigurement and where the
benefits of traditional surgical procedures are limited, VCA pro-
cedures describe what are often referred to as face and hand
transplants. In recent years, the field has moved to other parts of the
anatomy, including uterine and penis transplants, with the promise
of additional procedures in the future.
Individuals who are potential candidates for VCA are believed
to suffer from a wide range of significant physical and mental
health issues and challenges (Jowsey-Gregoire et al., 2016; Kumnig
& Jowsey-Gregoire, 2016; Kumnig, Jowsey-Gregoire, & DiMartini,
2014). The profound disfigurement and/or limb loss is believed to
affect body image as well. All of these physical and mental health
issues are believed to play an important role in the medical decision
making and patient selection process surrounding these proce-
dures (Caplan et al., 2018). Anecdotal reports suggest that many
VCA recipients have done well, both physically and psychologically,
following these procedures. Their tremendous resiliency demon-
strates the great promise of the field. Others, unfortunately, have
done less well, with some individuals asking to have their trans-
planted hands removed, being non-compliant with postoperative
treatment regimens, or engaging in suicidal behavior. Understand-
ing the preoperative psychosocial functioning of patients prior to
these procedures, as well as the changes in body image and other
areas of psychosocial functioning that occur postoperatively, is
essential to the continued growth of the field.
7. Conclusion
Interest in the psychological aspects of cosmetic medical pro-
cedures has grown in parallel to the growth in popularity of the
treatments over the past several decades. While early clinical
reports from this literature suggested that most patients presented
for treatment with some form of psychopathology, more con-
temporary and methodologically rigorous studies have identified
few differences between individuals who seek cosmetic medical
treatments and those who do not. Perhaps the most consistent
difference is that those women and men who seek cosmetic treat-
ments report higher levels of body dissatisfaction, as would be
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D.B. Sarwer / Body Image xxx (2018) xxx–xxx
predicted by Cash’s cognitive-behavioral theory of body image. This
dissatisfaction is believed to motivate the pursuit of treatment and,
for most individuals, is improved following a surgical or minimally
invasive treatment.
Some individuals, however, present for cosmetic treatment with
extreme body dissatisfaction seen with body dysmorphic disor-
der. Between 5–15% of persons who seek cosmetic treatments
are believed to suffer with BDD. Few who undergo a cosmetic
treatment experience improvement in their symptoms following
treatment, leading to the belief that BDD is a likely contraindication
to cosmetic treatment. Educating physicians about the body image
concerns of patients who seek cosmetic treatments has been a focus
of the past several decades. Looking forward, this knowledge also
has to be brought to developing areas in the field, such as body
contouring following massive weight loss, cosmetic genital proce-
dures as well as other cosmetic procedures for patients with gender
identity issues, and those who undergo VCA procedures to address
profound deformity and disfigurement.
Disclosures
Dr. Sarwer currently has grant funding from the National Insti-
tutes of Health (National Institute for Diabetes, Digestive, and
Kidney Disease, R01 DK108628) and PA CURE Funds from the Com-
monwealth of Pennsylvania. He also has consulting relationships
with BARONova, Merz, and NovoNordisk. He currently is on the
Board of Directors of the American Board of Plastic Surgery and the
Aesthetic Society Research and Education Foundation.
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