Clinical Psychology Review, Vol. 18, No. 1, pp.

1-22, 1998
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THE PSYCHOLOGY OF COSMETIC

SURGERY:A REVIEW AND
RECONCEPTUALIZATION

David B. Sarweq Thomas A. Wadden, Michael]. Pertschuk,

and linton A. Whitaker
University of Pennsylvania School of Medicine

ABSTRACT. This article discussesthepsychologyof cosmeticsurgery.A review of the research

on thepsycholagicalcharacteristicsof individualswhoseek cosmeticsurgmyyieldedcontradictory
findings. Interview-based investigations revealed high levels of psychopathohgy in cosmetic
surgerypatients, whereasstudies that used standardiud measurementsreportedfar less distur-
bance. [t is dtjj$culttofuliy resolve the discrepant betweenthesetwo sets of$ndings. We believe
that investigatingthe constructof bodyimage in cosmeticsurgerypatients willyield more useful
findings. Thus, we propose a model of the relationshipbetweenbody image dissatisfactionand
cosmeticsurgeryand outline a researchagendabasedupon the model.Suchresearchwillgenerate
infwmation that is useful to the medical and mental health communitiesand, ultimately,the
patients themselves.O 1998 Elsevier ScienceLtd

EACH YEAR tens of thousands of persons undergo elective, cosmetic surgery to alter
their physical appearance. In 1994, for example, the American Society of Plastic and
Reconstructive Surgeon8 (ASPRS) reported its membership performed more than
390,000 cosmetic procedures, the most common including liposuction (fat removal
from various body regions), breast augmentation, rhinoplasty (nose alteration), and
rhytidectomy (face lift) (ASPRS, 1994). This is an underestimation of the actual
number performed, as general surgeons and physicians from other specialities also
perform cosmetic procedures. Ultimately, these procedures were undertaken to im-
prove individuals’ satisfaction with their appearance, and presumably, in many cases,
their self-esteem. In this regard, cosmetic surgery can be considered a psychological
intervention or, at a minimum, a surgical procedure with psychological consequences.
Remarkably little is known about either the psychological status of persons who seek
cosmetic surgery or potential psychological changes following surgery. For example,

Correspondence should be addressed to David B. Sarwer,PhD, Universityof Pennsylvania

Medical Center, The Edwin and Fannie Gray Hall Center for Human Appearance, 10 Penn
Tower,3400 Spruce Street,Philadelphia,PA 19104.

1
2 D. B. Sarweret al,

do such individuals suffer from some degree of body image dissatisfaction, including
the clinically significant Body Dysmorphic Disorder? Alternatively, are such individuals
psychologically healthy and seek surgery to enhance an already favorable self-image?
Perhaps such persons intuitively grasp what social scientists have learned over the last
three decades — that people associate physical attractiveness with numerous highly
favorable personality traits including intelligence, competence, and social desirability
(e.g., Hatfield & Sprecher, 1986).
This article discusses the psychology of cosmetic surgery. It begins by reviewing the
psychological research on cosmetic surgery patients and then discusses recent ad-
vances in the psychology of body image. Most contemporary theorists believe that
body image concerns are central to understanding cosmetic surgery patients. How-
ever, there has been little formal study of this relationship. Thus, we propose a model
of the relationship between body image dissatisfaction and cosmetic surgery, and
provide recommendations for empirical research on this relationship. We note at the
outset that research on the psychology of cosmetic surgery patients is generally of
limited scope and quality, consisting largely of clinical reports. In light of the high
number of procedures performed annually, and given the potential for psychological
harm as well as benefit from a surgical alteration of appearance, advances in theory
and research are urgently needed.

THE PSYCHOLOGY OF COSMETIC SURGERY

In his historical review, Gifford (1972) traced interest in the psychology of cosmetic
surgery patients to Freud’s (1918) Wolf-Man, whose obsessive concern with a trivial
scar from a cyst removal became a focus of one of the most famous cases in psychiatric
annals. Soon after, surgical advances following World War I were accompanied by
enthusiastic reports of the emotional relief experienced by disfigured individuals who
underwent reconstructive surgery. These positive reports fueled the growth of plastic
surgery as an elective procedure for nondisfigured individuals.
Formal psychiatric evaluations of persons seeking elective cosmetic surgery first
appeared in the literature during the 1940s and 1950s. Typically, these reports
reflected the dominance of psychoanalytic thinking in American psychiatry and
generally characterized patients as highly neurotic and/or narcissistic (e.g., Hill &
Silver, 1950; Linn & Goldman, 1949). Patients’ appearance complaints frequently were
conceptualized in terms of intrapsychic conflicts displaced onto somatic concerns.
Surgeons were cautioned of the psychopathology of the male patient, as well as of the
“insatiable” surgery patient who sought out numerous cosmetic procedures in pursuit
of the perfect face. Although patients of the era were thought to be psychologically
disturbed, surgery rarely was ruled out, and the psychiatric outcomes typically were
described as positive (Gifford, 19’72).
The m~ority of the psychological literature on cosmetic surgery patients has been
published from 1960 to the present. T~ically, these investigations have been the
product of collaborations between plastic surgeons and psychiatrists or psychologists.
They have reflected surgeons’ interest in identifying patients who are psychologically
inappropriate for surgery, as well as psychiatrists’ interest in relating psychopathology
to specific cosmetic procedures. Plastic surgeons also perform reconstructive proce-
dures to correct congenital defects or those resulting from traumatic injury. While
these latter procedures may involve a significant psychological component, the
present review is limited to cosmetic procedures.

—.——-
 The Psychologyof CosmeticSurgery 3

We have organized the existing research into two categories. The first includes
preoperative psychological assessments of patients. The second category concerns
postoperative psychological assessments and examines patients’ psychological re-
sponses to the resulting change in appearance.

PREOPERATIVE PSYCHOLOGICAL INVESTIGATIONS

Numerous studies have assessed the preoperative psychological status of cosmetic

surgery patients. These reports, summarized in Tables 1 and 2, can be divided into
those that relied primarily on clinical interview (see Table 1) versus those that used
psychometric measures to assess psychopathology (see Table 2).

Clinical Assessments

Most studies that relied on clinical interview reported significant psychopathology in

cosmetic surgery patients (see Table 1). In one of the earliest investigations, 70$Z0of a
series of 98 patients were diagnosed with a psychiatric disturbance, the most common of
which were described as neurotic depression and passivedependent personality (Edger-
ton, Jacobson, & Meyer, 1960). Similar descriptions of psychopathology were reported in
a series of facelift patients (Webb, Slaughter, Meyer, & Edgerton, 1965), three investiga-
tions of rhinoplasty patients (Marcus, 1984; Meyer,Jacobson, Edgerton, & Canter, 1960;
Robin, Copas, Jack, Kaeser, & Thomas, 1988), and four investigations of breast augmen-
tation patients (Beale, Lisper, & Palm, 1980; Ohlsen, Ponten, & Hambert, 1978; Schle-
busch & Levin, 1983; Sihm, Jagd, & Pers, 1978).
Methodological shortcomings limit the confidence that can be placed in the above
findings. First, these studies did not use standardized assessment procedures. In most
cases, the nature of the clinical interview was not described and uniform diagnostic
criteria were not used. Patient categorizations found in these papers, such as “marked
psychological disturbance,” “ deviating from the normal picture,” and “in need of
therapy” are so vague as to make replication impossible.
Some investigations augmented the interview with self-report measures, but it is not
clear how these data were used in formulating the descriptions or diagnoses. In
addition, a majority of investigations did not include a control or comparison group.
As a result, it is impossible to determine if the reported level of psychological
disturbance was greater than that of patients who underwent other medical or surgical
procedures, or of control subjects matched on appropriate comparison variables.
Finally, the high levels of psychopathology may have been a reflection of the biases of
the primarily psychoanalytically-trained psychiatrist investigators.
Such methodological limitations can be found even in recent interview studies.
Napoleon (1993) reported that 70% of patients in a cosmetic surgery practice had an
Axis II personality disorder and 19.5% of patients had an Axis I disorder. Although
Napoleon’s study improved upon earlier investigations by using widely accepted
diagnostic criteria (Diagnostic and StatisticalManual of Mental Disordms, third edition,
muised [DSM-111-R];American Psychiatric Association [APA], 1987), the use of an
unspecified clinical interview and an absence of interrater reliability of diagnoses
could account for the high prevalence of Axis 11disorders in this sample.
In summary, clinical reports of psychopathology in cosmetic surgery patients must
be viewed with caution. Given the shortcomings noted, it is impossible to determine
whether patients truly were psychologically disturbed. The above studies also did not
 TABLE 1. Pre- and Postoperative Clinical Interview Investigations of Cosmetic Surgery Patients

Sample Assessment Control

Author Cosmetic Procedures Size Method’ Group PreoperativeResults PostoperativeResults
.
Edgerton et All 98 1,2 None 70% with diagnosis;35% per- 55% with acute emotional
al. (1960) sonalitydisorder, 16~0psy- disturbance
chotic
Meyer et al. Rhinoplasty 30 1,2 None 53% with diagnosis 45% with significantpostop-
A (1960) erativedisturbance
Webb et al. Facelift 72 1,2 None 70% with diagnosis,primarily 14 of 16 pts with improve-
(1965) personalitydisordered ment in depression
Hay & Rhinoplasty 17 1,2 None Comparisonsto norms not Decreased hostility;more hys-
Heather made terical
(1973)
Goin et al. Breastreduction 8 1 None 25% “profoundly depressed” Depressionlifted in all pa-
(1977) tients
Ohlsen et al. Breastaugmentation 37 1 None Increasedsymptomsof de- Decreasedsymptomsof de-
(1978) pression,lower self-esteem pression, improved self-
-esteem
Sihm et al. Breastaugmentation 20 1,2 None 70% as “deviatingfrom nor- “NO importantchanges in
(1978) mal picture” basic personalitystructure”
Beale et al. Breastaugmentation 25 1,2 28 medical Patientgroup with increased
(1980) patients depression and guilt
Schlebusch Breastaugmentation 20 1 20 medical Patientgroup with increased
& Levin patients depression and anxiety;55%
(1992) <‘inneed of therapy”
Marcus Rhinoplasty 30 1,2 25 oral 60% of patientswith Decreased anxiety,improved
(1984) surgery “neurotic instability”or self-concept in patient group
patients “personality disordered”
Robin et al. Rhinoplasty 31 1,2 31 surgical Patientgroup with greater Decreased anxiety,obsessive-
(1988) patients anxiety,obsessivenessand ness and paranoia
paranoia
Edgerton et All 87 1 None All patientswith psychiatric 83% positivepsychiatricout-
al. (199.1) disturbance;70% neurotic, come, 14% minimalimprove-
17% personalitydisordered, IUeIlt
13% psychotic
Napoleon All 133 1,3 None 70% withAxis II diagnosis;
(1993) 19.5% withAxis I diagnosis

al = clinical interview;2 = self-reportquestionnaires;3 = Napoleon PreoperativeTest.

 TABLE 2. Pre- and Postoperative Psychometric Assessment Investigations of Cosmetic Surgery Patients

Assessment Control
~ Author Cosmetic Procedure SampleSize Method’ Group Preo~erativeResults PostoperativeResults
Hay (1970) Rhinoplasty 45 1,2,3 45 Nurses Patientgroup more neurotic
and obsessive;18 diagnosed
with personalitydisorder
Baker et al. Breastaugmentation 10 1,2,3,4 None Normal composite profile
(1974)
Wright & Rhinoplasty 25 4 25 surge~ Pd scale significantly> in No significantdifference in
Wright patients rhinoplastygroup, no patho- pre/post scores
(1975) logical scores in rhinoplasty
group
Shipley et al. Breastaugmentation 28 2,6 28 small- Patientsscored lower on
(1977) breasted achievementand feminity;all
I women and scores with 1 SD of normative
I 28 average- sample
breasted
women
 Micheli- Rhinoplasty 65 1,4,5 None “Marked psychologicaldistur-
Pellegrini, bance”
& Man-
fi-ida
(1979)
Goin et al. Facelift 50 1,2,4,7 None None with 54% with signifi- 54% with depressivesymp
(1980) cant pathology; one described toms during postoperative
as neurotic period
Hollymanet Breastreduction 11 1,2,8 19 staffand Increaseddepression and No change at 26 weeks
al. (1986) students anxietyversusnormativesam-
ple
Goin & Rees Rhinoplasty 121 9 None BSI normal for all patients Decreased anxiety,depression
(1991) and obsessivenessby 6
months

v al = clinicalinterview;2 = self-reportquestionnaires;3 = EysenckPersonalityInventory;4 = MMPI;5 = Rorschach;6 = CaliforniaPersonalityInventory;

7 = Beck DepressionInventory;8 = Crown-GrispExperimentalIndex; 9 = Brief SymptomInventory.
8 D. B. Sarweret al.

determine whether patients who sought the same cosmetic procedure, such as a
“type-changing” rhinoplasty (in which the nose is altered to a new appearance),
shared specific psychological problems that differed from those of persons who
underwent a different procedure, such as a “restorative” face lift (in which the face
is returned to a younger, former state). Rather, the clinical literature reviewed above
concluded, perhaps prematurely, that a majority of cosmetic surgery patients were
psychologically disturbed.

Psychometric Assessments

Studies that used standardized tests to assesspsychopathology generally have reported

less disturbance, as compared with the results of clinical interview investigations (see
Table 2). The most frequently used measure of psychopathology has been the Min-
nesota Multiphasic Personality Inventory (MMPI). No significant psychopathology was
reported for 50 facelift patients who completed the MMPI preoperatively (Goin,
Burgoyne, Goin, & Staples, 1980).
Similarly, normal MMPI profiles were found in a series of 10 breast augmentation
patients (Baker, Kolin, & Bartlett, 1974), and in two separate investigations of rhino-
plasty patients (Micheli-Pellegrini & Manfrida, 1979; Wright & Wright, 1975).
Investigations that used other measures also found mild or no psychopathology.
Twenty-eight breast augmentation patienfi only differed from small- and average-
breast-size control group women on variables of “Achievement via Independence”
and “Flexibility,” as measured by the California Personality Inventory (Shipley,
O’Donnell, & Bader, 1977). Similarly, a series of 121 rhinoplasty patients scored in the
normal range on the Brief Symptom Inventory (Goin & Rees, 1991). Mild psychopa-
thology was observed in two other studies. Using a battery of tests that included the
Eysenck Personality Inventory, rhinoplasty patients were found to be more neurotic
and obsessive than a control group of hospital nurses (Hay, 1970). A sample of 11
breast-reduction patients also was found to have mild psychopathology, including
increased depression and anxiety, as compared to normative values of the Crown-Crisp
Experimental Index (Hollyman, Lacey, Whitfield, & Wilson, 1986).
While these results suggest far less psychopathology in cosmetic surgery patients as
compared with the interview investigations, these studies also have limitations. In most
cases, the measures used were not designed to tap the types of psychopathology
specific to these patients. While a measure such as the MMPI psychasthenia scale may
provide a “global” measure of worry and obsessiveness, it may not be sensitive to types
of disturbances associated with appearance concerns. In addition, several investiga-
tions failed to use control or comparison groups. Finally,investigations that compared
patients to normative samples frequently failed to describe similarities or differences
on descriptive characteristics between the two groups. As such, the appropriateness of
such comparisons is unknown.

Conclusions from the Preoperative Assessments

We believe that the results of the objective, paper-and-pencil tests generally are more
reliable and valid than those derived from clinical interview. We tentatively conclude,
based on an admittedly small number of studies, that a majority of cosmetic surgery
patients do not suffer from serious psychological disturbance. Moreover, there ap-
pears to be no clear relationship between a given cosmetic procedures and specific
forms of psychopathology.
 The Psychologyof CosmeticSurgery 9

Two alternative interpretations, however, of the disparity between the interview- and
psychometric-based findings warrant consideration. First, the nature of the cosmetic
surgery population has changed over time. Prior to the 1970s, when investigators
reported higher rates of psychopathology, cosmetic surgery was far less common.
Today, not only are more individuals seeking cosmetic surgery than ever before, but
these women and men come from a wider range of age and socioeconomic-economic
groups (ASPRS, 1994). Perhaps one had to be more psychologically disturbed to seek
out cosmetic surgery when it was not the highly marketed service that it is today. A
second possibility, as noted above, is that earlier investigators, many of whom were
skilled clinicians, uncovered more subtle psychological features in their interviews
that may have been missed by standardized measures. Unfortunately, the nature of
these traits may have been inadequately described and, therefore, lost as a result of the
comparatively vague psychiatric nomenclature of the time.

POSTOPERATIVE PSYCHOLOGICAL INVESTIGATIONS

Investigations of the psychological outcome of cosmetic surgery have not yielded

definitive results. As shown in Table 1, 6 of 10 studies that used clinical interviews
reported generally favorable psychological outcome (Edgerton et al., 1991; Goin et al.,
1977; Marcus, 1984; Ohlsen et al., 1978; Robin et al., 1988; Webb et al., 1965), while
two observed negative consequences (Edgerton et al., 1960; Meyer et al., 1960), and
two others noted no change or mixed results (Hay& Heather, 1973; Sihm et al., 19’78).
In addition to the criticisms of the preoperative interview assessments described
previously, pre- and postoperative interviews frequently were conducted by the same
interviewer, a practice that increases the potential for interviewer bias. Thus, although
the reports of positive psychological change following cosmetic surgery are encour-
aging, they should be viewed cautiously.
Table 2 shows that only four studies used standardized tests to assess psychological
outcome. One study showed favorable change (Goin & Rees, 1991) and two observed
no change (Hollyman et al., 1986; Wright & Wright, 1975). One described an increase
in depressive symptoms in facelift patients during the postoperative period, although
BDI scores, in fact, had decreased from preoperative levels (Goin et al., 1980).
As noted previously, one of the principal reasons that practitioners assessed pa-
tients’ psychological status was to identi~ those at risk of an adverse emotional
response to surgery. While clinical experience suggested the potential role of two
variables — the patient’s motivation for surgery and the patient’s gender — neither
has been empirically investigated. Moreover, there have been no studies that system-
atically examined the relationship between baseline measures of psychopathology and
either patient satisfaction with surgery or changes in psychosocial status postopera-
tively. Therefore, given the limited number of studies and the absence of method-
ologically sound investigations, we believe that it is premature to conclude that
cosmetic surgery produces psychological benefit in a majority of patients.

COSMETIC SURGERY AND BODY IMAGE

Clearly, physical appearance is a common concern of cosmetic surgery patients.

Research on the psychology of physical appearance has grown rapidly in the last two
decades, but this topic has been sparsely investigated in cosmetic surgery patients.
Some investigators contend that these patients obtain much of their self%steem from
their appearance (Napoleon & Lewis, 1989) and that when their self-esteem declines,
10 D. B. Sarweret al.

‘exceptions of
Appearance

developmental

L
Reality of Influences {
Cosmetic
Physical Surgety?
Appearance
Sociocultural
Influences

Self-Esteem

FIGURE 1. A Model of the Relationship Between Body Image

and Cosmetic Surgery.

they seek surgical change (Edgerton & Langman, 1982). Others have argued that
patients are ~sychologi~ally he~lthy “doers”- (Goin & Goin, 1987) who are highly
motivated to improve their appearance, even with the risks of anesthesia and surgery,
as well as substantial out-of-pocket expense. Regardless, the psychology of a surgical
change in appearance, as suggested by the above review, is poorly understood.
We believe that future studies of the psychology of cosmetic surgery need to focus
on body image, a psychological construct intimately connected to physical appear-
ance. Numerous investigators believe that body image has multiple dimensions (e.g.,
Pruzinsky & Cash, 1990; Thompson, 1990). For example, Thompson (1990) believes
that it involves three principal components. The first is perceptual, reflecting a
person’s estimation of body size. The second is subjective, reflecting the individual’s
attitudes toward his or her body. The final component is behavioral and concerns the
degree to which a person’s behaviors are affected by perceptions or feelings about the
body. Cash and Pruzinsky (1990) suggested that body image should be reconceptu-
alized as “body images” to more accurately capture the diversity of the external/
objective and internal/subjective components. They define body images as percep
tions, thoughts, and feelings about the body and bodily experiences (Cash &
Pruzinsky, 1990).
It is widely believed that persons who undertake cosmetic surgery do so to change
their physical appearance, and presumably their body image. Pruzinsky and Edgerton
(1990) have suggested that cosmetic surgery is body image surgery — that by modi-
@ng the body surgically, psychological improvement will occur. while a few studies
have reported improved body image following breast augmentation (Killman, Sattler,
& Taylor, 1987; Schlebusch & Mahrt, 1993), we were startled not to find a single study
that has used widely accepted and validated measures of body image with cosmetic
surgery patients. As such, little about the relationship between body image and
cosmetic surgery can be reliably asserted.
Therefore, we propose the following model of the relationship between body image
and cosmetic surgery (see Figure 1). Borrowing from several reviews of the psychology

———. —.-————-.
 The Psychologyof CosmeticSurgery 11

of body image (e.g., Cash & Pruzinsky, 1990; Thompson, 1990, 1996),1 the model
considers both physical and psychological influences on the development of body
image. The model expands upon this knowledge by specifically discussing how
thoughts and feelings about appearance may influence the decision to seek cosmetic
surgery.

A MODEL OF THE RELATIONSHIP BETWEEN BODY IMAGE

AND COSMETIC SURGERY

Physical Reality of Appearance

While body image often is seen as a “psychological” phenomenon, the physical realityof
appearance lays the foundation for an individual’s body image. Physical appe arance is a
potent determinant of person perception, as it is typically among the first sources of
information available to others to guide social interaction (Alley, 1988). Persons consid-
ered physically attractive receive preferential social treatment in virtuallyevery situation
studied, including education, employment, medical care, and partner selection (Bull &
Rumsey 1988; Hatfield & Sprecher, 1986). In contrast, those seen as ugly or disfigured,
whether by “bad genes”, congenital deformity, or traumatic accident are thought to be at
increased riskfor social and psychological problems (Bull & Rumsey, 1988). Furthermore,
one’s physical appearance is maUeablein response to stimuliboth within (such as changes
in muscle and fat mass) and beyond our control (such as physical insults and aging)
(Alley, 1988). Thus, the physical realityof appearance at any given point in time “sets the
stage” for the psychological influences on body image.

Psychological/Influences on Body Image

Several investigators have outlined the potential psychological influences on body

image (Gash, 1996; Heinberg, 1996). For example, Heinberg (1996) has divided the
theories of body image disturbance into three categories — perceptual, developmen-
tal, and sociocultural. At present, these theories have been applied primarily to
individuals who suffer from eating disorders and/or with excessive weight and shape
concerns (Heinberg, 1996). However, they also may be useful in understanding the
relationship between body image and cosmetic surgery. In addition, we believe the
relationship between self-esteem and body image is important in understanding the
pursuit of cosmetic surgery.

Pmeptual injlwnce s. Heinberg (1996) described three perceptual theories of body

image — the cortical deficit theory, the adaptive failure theory, and perceptual artifact
theory. The cortical defect theory suggests that body size overestimation results from
an interaction between visual spatial defects and both cognitive and affective influ-
ences (Dolce, Thompson, Register, & Spana, 1987; Thompson & Spana, 1991). The
adaptive failure theory suggests that individuals’ perceptions of body size do not
change at the same rate as their actual size changes as a result of weight gain or loss
(Heinberg, 1996). Similarly, the perceptual artifact theory suggests that the tendency
to overestimate one’s body size is related to one’s actual body size (Penner, Thomp-
son, & Coovert, 1991).

1The reader interestedin a more detailed discussionof body image and body image develop
ment than is possible here is referred to these reviews.

-..—
 12 D. B. Sarweret al.

The perceptual theories of body image appear to have little empirical support
beyond the studies cited. Furthermore, they are most frequently used to explain
dissatisfaction with one’s overall body size or shape (Heinberg, 1996). Thus, their
applicability to cosmetic surgery patients, who more frequently have concerns with a
discrete feature of their appearance, is unknown.
Nevertheless, we believe perceptual influences on body image are relevant in
cosmetic surgery patients. These patients often report to their surgeon that an
appearance feature is different in size, shape, or appearance from the objective reality
of the feature. These anecdotal reports are consistent with the ecological psychology
literature that suggests that the ability to perceive changes in physical appearance is
rather imprecise (Alley, 1988). However, such perceptual inaccuracies have yet to be
formally studied in cosmetic surgery populations.

Developmental influences. Developmental theories of body image disturbance focus on

the contribution of childhood and adolescent experiences to adult body image. The
theory of puberty and maturational timing suggests that girls who have early me-
narche are more likely to have a negative body image (Heinberg, 1996), as evidenced
by body size overestimation (Fabian & Thompson, 1989) and their reports of body
image dissatisfaction (Brooks-C;unn & Warren, 1985). However, this relationship may
only exist in normal weight individuals, as it was not observed in obese women
(Sarwer, Wadden, & Foster, 1997). Disparagement and teasing in childhood also
appear to predispose females to weight and shape dissatisfaction (Cash, Winstead, &
Janda, 1986). Such a relationship has been identified in adolescent and adult popu-
lations, as well as in obese and nonobese individuals (e.g., Fabian & Thompson, 1989;
Grilo, Wilfley, Brownell, & Rodin, 1994).
Early messages in childhood and adolescence, whether negative (“You’re funny
looking”) or positive (“What a beautiful girl/handsome boy”), appear to influence
the adult body image. While previous investigations have identified a relationship
between childhood teasing and overall body image dissatisfaction, we have witnessed
a similar relationship between teasing and dissatisfaction with specific body features in
cosmetic surgery patients. These individuals frequently describe how they first became
aware of their prominent nose or lack of breast development as a result of the
derogatory comments of others. As with the perceptual influences, developmental
influences have yet to be formally studied in these individuals.

Sociocultural in.uences. Sociocultural theories have stressed the influence of social

norms and expectations on both the etiology and maintenance of body image
disturbance (Heinberg, 1996). As a whole, these theories emphasize the interaction of
the mass media and cultural ideals of appearance (which frequently portray unreal-
istic, exaggerated, or unattainable body image models) with tenants of both self-ideal
discrepancy (Thompson, 1992) and social comparison theory (Festinger, 1954). Ac-
cording to this theory, people compare their appearance to that of fashion models,
Hollywood celebrities, or superstar athletes, and find that they come up short by
comparison, resulting in increased body image dissatisfaction (Heinberg, 1996). This
collection of theories has wide intuitive appeal and has received some correlational
support (e.g., Heinberg, Thompson, & Stormer, 1995; Mazur, 1986).
Not surprisingly, the social and cultural standards of beauty portrayed in the mass
media are thought to directly influence the increasing demand for cosmetic surgery
(Pruzinsky, 1993). In recent years, cosmetic surgery has become highly publicized and

———————-—
 The Psycholo@ of CosmeticSurgery 13

marketed. Both the print and electronic media routinely report on the latest cosmetic
procedure or the celebrity most recently suspected of having cosmetic surgery. Often,
cosmetic surgery is portrayed as the pathway to having a face and body just like that
of the models in magazine advertisements and television commercials, and therefore
the only way to directly address dissatisfaction with appearance. AS such, we believe
that the sociocultural influences on body image may be the most relevant to under-
standing the role of body image in cosmetic surgery.

Se~%teem. The physical body, in both structure and function, has long been consid-
ered a critical part of one’s sense of self (Fisher, 1986, 1990).2 Early psychoanalytic
theorists, such as Freud, Jung, and Adler, as well as more contemporary writers have
postulated that the physical body is actually a representation of the self (Fisher, 1990).
In one of the first empirical investigations of body-self relationship, Jourard and
Secord (1955) identified a modest correlation between satisfaction with the body and
satisfaction with the self. More recent investigations have replicated this relationship
between body image and self-esteem (e.g., Cash et al., 1986; Fabian & Thompson,
1989; Foster, Wadden, & Vogt, 1997; Sarwer et al., 1997).
Cash has proposed a cognitive-behavioral model of the relationship between body
image and self<steem (Cash, 1996; Cash & Labarge, 1996). Cognitive-schema theory,
or more specifically self-schema theory, suggests that people have schemas or cognitive
structures, derived from past experience, which organize and guide information
about current experience (Beck, Freeman and Associates, 1990; Markus, 1977). Such
schemas may exist for a variety of domains, including physical appearance or body
image (Cash & Labarge, 1996). Environmental stimuli about appearance from any
number of sources could activate this appearance-related or body image schema,
which then, in turn, influence affect and behavior (Cash & Labarge, 1996). According
to Cash and Labarge (1996), in persons with such a schema, self-esteem is closely tied
to feelings about physical appearance.
This theoretical description of the relationship between body image and self-
-esteem is intuitively pleasing, and recently has begun to be empirically investigated.
From Cash and Labarge’s (1996) explanation, however, it appears that only certain
individuals have an appearance-related or body image schema. Alternatively, it maybe
that we all have a body image schema, but that it has a differential valence that
determines its relative importance to overall self-esteem. At present, such schema
appear to be more salient to the self-image of women than men, as evidenced by
increased body image dissatisfaction in women (Cash et al., 1986). This difference
perhaps is best understood as a result of the differential socialization of women and
men about appearance-related issues (Hatfield & Sprecher, 1986).

Body Image: Valence and Value

Cash and colleagues have further suggested that the attitudinal component of body
image itself is two-dimensional, consisting of an orientation component (representing
the importance or attention given to the body) and an evaluative component (rep-
resenting the affective elements of body image) (Brown, Cash, & Mikulka, 1990). This
theory of the two-dimensional attitudinal component of body image has been sup-

2The reader interestedin a detailed discussionof the theoreticalrelationshipof the body and
the self is referred to thiswork.
14 D. B. Sarweret al.

ported by factor analysisof the Multidimensional Body-Self Relations Questionnaire in

a nationwide sample (Brown et al., 1990).
As the relationship between body image and cosmetic surgery is considered, we also
believe that attitudes about the body are two-dimensional, consisting of both a valence
(i.e., a measure of importance to one’s self-esteem) and a value (i.e., the actual degree
of satisfaction or dissatisfaction with one’s body). Body image valence and value are
similar to the orientation and evaluative dimensions of body image, respectively
(Brown et al., 1990; Cash et al., 1986). For example, individuals with a high body
image valence may derive much of their self-esteem from their body image. As such,
they may be more attentive to information about their appearance, similar to indi-
viduals with an appearance-related schema (Cash & Labarge, 1996). In contrast,
persons with a low body image valence are not as dependent upon their physical
appearance to support their self%steem. These individuals may be unconcerned or
even oblivious to issues of appearance. Similarly, body image valence may vary de-
pending upon the body part in question. For example, the number of women who
report dissatisfaction with their body weight and shape suggests that a “body shape
schema” may have a relatively high valence as compared to a “height schema, ” an
appearance feature with which women show far less dissatisfaction (Cash et al., 1986).
In addition, body image also has a value. Body image dissatisfactionis so prevalent that
it has been described as a “normative discontent” (Rodin, Silberstein, & Striegel-Moore,
1985). However, it is difllcult to determine the point at which an individual’s perceptions,
attitudes, and behaviors regarding his or her body become problematic or psychopatlm
logical. At present, there is no accepted cutoff point between “normative discontent” and
“pathological dissatisfaction.” Nevertheless, we believe the degree of body image dissat-
isfaction serves as a motivational component to cosmetic surgery.

Continuum of Body Image Dissatisfaction

In the absence of widely accepted criteria for body image dissatisfaction, we believe
that it should be considered on a continuum. Such a continuum could be anchored
on one end by persons with body image satisfaction and on the other by persons with
extreme body image dissatisfaction.

Body image sati@action. Individuals with body image satisfaction would be thought to
have an overall positive body image. Although they may dislike an aspect of their
appearance, they are not greatly distressed by it. While they might, on occasion, wish
to change an aspect of their appearance, they would be unlikely to seek out cosmetic
surgery, as their overall body image is favorable.

Body image dissatisjhdion. Potentially, there are several degrees of body image dissat-
isfaction, the first of which may be a dislike of an aspect of appearance. Such dislike
may lead to relatively frequent distress or concern and be associated with maladaptive
behavioral change. Similarly, an individual may be dissatisfied with one aspect of his
or her appearance, but may be satisfied with other features. At present, it is not clear
at what point such dissatisfaction, whether specific to one appearance feature or more
global, leads to cosmetic surgery.

Body image disturbance. The next level of dissatisfaction is body image disturbance
(Thompson, 1990), or what also has been referred to as body image disorder (Rosen,
 The Psychologyof CosmeticSurgery 15

1992, 1996; Thompson, 1992). Such individuals experience greater affective distress
and exhibit more profound behavior change, including “camouflaging” the offend-
ing body part or refusing to allow others to view it. Others may exhibit cognitive or
perceptual distortions of their appearance, resulting from a combination of irrational
thoughts and unrealistic expectations about the body (Freedman, 1990). At present,
the relationship between body image disturbance and more severe forms of body
image psychopathology is not well established.

Body dysmorphic disotrk Body dysmorphic disorder (BDD) is the only diagnostic term
in DSM-IV (American Psychiatric Association, 1994) directly addressing body image
concerns. BDD is defined as a preoccupation with a defect in appearance that is either
imagined, or if slight, leads to markedly excessive concern. The preoccupation must
cause significant distress or impairment in social, occupational, or other important
areas of functioning (APA, 1994). The preoccupation is difficult to resist or control
(Hollander & Phillips, 1993), and is thought to become more intense in social
situations in which the person feels self-conscious (Rosen, 1996). Most patients engage
in repetitive behaviors involving checking, examining, hiding, or improving the
defect. Although any area of the body maybe affected, the most common areas are the
skin, face, and nose (Phillips, McElroy, Keck, Pope, & Hudson, 1993).
The diagnosis of BDD is relatively new to American psychiatry, first appearing in
DSM-111-RIt was initially described in the European psychiatric literature over 100
years ago as dysmorphophobia — a subjective feeling of ugliness in a person of normal
appearance (Morselli, 1886). More contemporary reports have described the primary
symptom of dysmorphophobia as an excessive and distressing belief that one is
unattractive (Andreasen & Bardach, 1977), frequently coupled with depression and
extreme body image dissatisfaction (Hardy, 1982). However, there are several prob-
lems with previous descriptions of dysmorphophobia. First, given the sizable minority
of individuals who report dissatisfaction with their appearance (e.g., Cash et al., 1986),
the definition is far too broad. Second, dysmorphophobia does not meet the criteria
of a phobia, as there is no fear of physical abnormality and no avoidance of the
ugliness of others (Pruzinsky, 1990). Finally, persons with body image disturbance
typically do not recognize their concern as excessive or unreasonable, as do phobic
individuals.
BDD is classified as a somatoform disorder in DSM-lV It is most often compared to
obsessive-compulsive disorder (OCD), an anxiety disorder. Hollander (1993) has
suggested that BDD is an obsessive-compulsive spectrum disorder based on the
similarity of symptoms, etiology, comorbidity, age of onset, course of illness, and
treatment response. Differential and comorbid diagnoses of BDD typically include
OCD, social phobia, depression, hypochondriasis, eating disorders, and numerous
personality disorders (Neziroght, McKay, Todaro, & Yaryura-Tobias, 1996; Rosen,
1996; Veale et al., 1996).
The percentage of cosmetic surgery patients who meet criteria for BDD is un-
known. Andreasen and Bardach (1977) estimated from their clinical experience that
2% of patients who requested cosmetic surgery suffered from the disorder. Unfortu-
nately, no formal prevalence studies have been completed, and previous work has
been based on case reports and small case series that lacked clearly operationalized
definitions (Phillips, 1991).
The typical presentation of BDD patients for cosmetic surgery also is unknown.
Pruzinsky (1993, 1996) has suggested that patients with “minimal deformity” maybe

——
16 D. B. Sarweret al.

the most likely to meet the diagnosis of BDD. However, the “insatiable” patient, who
returns for multiple surgical procedures, also may be a candidate for the diagnosis,
using the successive surgeries (in an almost ritualistic fashion) to seek relief from
profound body image dissatisfaction. Support for this contention comes from the
observation that BDD patients typically use appearance remedies just as hypochon-
driacal patients overuse medical services (Rosen, 1996).

The Decision to Have Cosmetic Surgery

We believe that it is the interaction between body image valence and body image value
that leads to the decision to pursue cosmetic surgery. Persons with a lower body image
valence, whose self-esteem is not dependent on their appearance, would seem unlikely
to pursue cosmetic surgery. Regardless of whether such individuals are satisfied or
dissatisfied with their body image, the valence of body image in self-esteem is not great
enough to motivate a surgical change in appearance.
In contrast, individuals with a higher body image valence may be more likely to
pursue cosmetic surgery. Individuals with a high body image valence, for whom body
image is an important part of self-esteem, and who have a significant degree of body
image dissatisfaction, may well comprise the majority of cosmetic surgery patients.
These individuals place a high degree of importance on their appearance and are
dissatisfied with a feature of it..As noted above, while some degree of dissatisfaction
may be identified in most patients, extreme dissatisfaction or preoccupation may be
representative of body image disturbance or BDD. Individuals with both high body
image valence and high satisfaction with their appearance also may seek cosmetic
surgery. These individuals may represent the healthy “doers” who wish to enhance
their appearance and an already favorable self-esteem (Goin & Goin, 1987).

FUTURE RESEARCH PRIORITIES

The proposed model of the relationship between body image and cosmetic surgery
can be used to guide empirical research. Initial research efforts should investigate the
degree of body image dissatisfaction in cosmetic surgery populations. While our
model depicts body image dissatisfaction as the motivational component to a surgical
change in appearance, this has yet to be empirically demonstrated. We believe this is
an important first step in understanding the relationship between body image and
cosmetic surgery.

Assessmentof Body Image Dissatisfaction and BDD

Several measures of body image dissatisfaction could be used with cosmetic surgery
populations. The Multidimensional Body-Self Relations Questionnaire (MBSRQ
Brown et al., 1990; Cash et al., 1986) and the Body Dysmorphic Disorder Examination
(BDDE; Rosen& Reiter, 1996) maybe the most appropriate. The MBSRQis a 69-item
self-report inventory for the assessment of patients’ attitudes toward their bodies. Its
10 subscales allow for the measurement of the multidimensional characteristics of
body image. The measure has acceptable validity and 1 month test-retest reliabilities
ranging from .89 to .71 for the subscales (Brown et al., 1990). It frequently has been
used as a measure of body image dissatisfaction in nonclinical populations. More
specifically, the Appearance Orientation and Appearance Evaluation subscales of the

————
 The Psycholo~ of CosmeticSurgery 17

MBSRQ (Brown et al., 1990; Cash et al., 1986) maybe appropriate measures of both
the body image valence and the degree of body image dissatisfaction, respectively.
As a more specific measure of BDD, Rosen and Reiter (1996) developed the BDDE.
It can be used as a semi-structured interview or self-report measure of BDD symptoms
experienced within the last 4 weeks. In addition to yielding a total score for BDD
severity, there are recommended criteria for the diagnosis of BDD. The measure has
adequate internal consistency (Cronbach’s alphas ranging from .81 to .93) and
interrater reliability (r= .98) and shows promise in the assessment of BDD (Rosen &
Reiter, 1996). The BDDE may serve as a useful tool in establishing the prevalence of
BDD in cosmetic surgery populations.
For individuals with more profound body image dissatisfaction, such as BDD, the
potential benefits of cosmetic surgery are unclear. Early data suggest that some BDD
patients have an exacerbation of symptoms after surgery, while others find a new
defect to correct surgically (Phillips et al., 1993). Several writers suggest that the more
appropriate treatment for such patients is psychiatric, not surgical (Andreasen &
Bardach, 197’7; Birtchnell, 1988). Studies assessing changes in body image dissatisfac-
tion postoperatively are needed to further assess the potential for psychological
benefit for these individuals following cosmetic surgery.

Development of Body Image Disturbance

Future research should assess the role of the developmental, sociocultural, and
perceptual influences on body image. For example, for some women early onset of
physical maturation accompanied by negative verbal comments about breast develop-
ment may result in body image clissatisfaction that leads to breast reduction surgery.
Such a relationship can be empirically explored through the use of the Physical
Appearance Related Teasing Scale (PARTS; Thompson, Fabian, Moulton, Dunn, &
Altabe, 1991) to assess a history of appearance-related teasing. The PARTS has two
subscales that assess both weight and body size teasing, as well as more general
appearance-related teasing. These subscales have internal consistencies of .91 and .71,
and 2-week test-retest reliabilities of .86 and .87, respectively. Potentially useful for
both breast reduction and augmentation patients, the Breast/Chest Rating Scale
(Thompson & Tantleff, 1992) assesses satisfaction with current breast size. Using five
schematic figures of the female torso ranging in size from small to large, subjects
indicate their current breast size, ideal size, the size preferred by men and women, and
the breast size associated with a collection of personality characteristics. Test-retest
reliability ranges from .69 (for ideal breast size) to .85 (current breast size), suggesting
moderate to good reliability. This scale also may be an appropriate measure for
evaluating postoperative changes in breast satisfaction.
Similarly,sociocultural theories have described how the thinness of female mass media
images are thought to contribute to the prevalence of weight and eating disorders
(Heinberg, 1996). At present, the impact of such images on the selection of cosmetic
procedures, such as liposuction, is unknown. However, a measure such as the Sociocul-
tural Attitudes Towards Appearance Questionnaire (SATAQ Heinberg, Thompson, &
Stormer, 1995) may serve as a useful tool in the assessmentof the effects of sociocultural
influences on the pursuit of cosmetic surgery. The SATAQ is a 14item scale that assesses
recognition and acceptance of societal standardsof appearance. Its subscalesof Awareness
(which assessesthe pressures on women to appear attractive) and Internalization (which
assessesthe acceptance or rejection of these sociocuh-al messages) have internal con-
18 D. B. Sarweret al.

sistency coefficients of .71 and .88, respectively.As discussed above, while clinical reports
suggest that cosmetic surgery patients frequently display perceptual inaccuracies in esti-
mating the size and shape of bodily features, these reports have not been empirically
evaluated. Newer technology, such as visualimaging systems,which allow for the comput-
erized modification of facial and bodily features, can be used in fiture studies to assessthe
perceptual component of body image.
Future studies also should clari~ the relationship between body image and self-
-esteem. General measures of self-esteem, such as the Rosenberg Self-Esteem Scale
(Rosenberg, 1979), may be helpful, but newer measures that provide a multidimen-
sional assessment of self-esteem probably will be more useful. Developed from Cash’s
(1996) cognitive-schema model of body image and body image dissatisfaction, the
Appearance Schemas Inventory (ASI; Cash & Labarge, 1996) maybe a useful tool for
the assessment of the relationship between body image and self-esteem. The ASI
assesses core beliefs about the importance, meaning, and effects of appearance in
one’s life. It has acceptable reliability (Cronbach’s alpha = .84) and demonstrated
convergent and discriminant validity with several other measures of the cognitive,
affective, and behavioral components of body image.

Changes in Body Image Following Surgery

Although patients typically report high levels of satisfaction with their surgical result
(Wengle, 1986), long-term satisfaction has not been well investigated. Given the
proposed relationship between sociocultural influences and body image, it may be
that cosmetic surgery patients only report satisfaction during the period immediately
following surgery, while they are receiving positive reinforcement about their appear-
ance from family and friends. Future research that uses standardized measures of body
image can assess if improvements are maintained over longer periods of time, as the
rate of external reinforcement presumably decreases. Pre- and postoperative investi-
gations of body image dissatisfaction may provide the most useful evidence to date for
the utility of cosmetic surgery as a body image therapy.

Nonsurgical Treatment of Body Image Dissatisfaction

Nonsurgical treatments for body image problems are relatively new. Cognitive-
behavioral treatment has been used effectively to treat women dissatisfied with their
body image (Butters & Cash, 1987; Dworkin & Kerr, 1987; Fisher& Thompson, 1994;
Grant & Cash, 1995; Rosen, Cado, Silberg, Srebnik, & Wendt, 1990; Rosen, Saltzberg,
& Srebnik, 1989). More recently, the same treatment has been used successfully with
women with BDD (Rosen, Reiter, & Orosan, 1995). There are several reports of
successful treatment of BDD with behavioral interventions, such as exposure and
response prevention (Marks & Mishan, 1988; Munjack, 1978; Neziroglu et al., 1996;
Neziroglu & Yaryura-Tobias, 1993). There also is evidence for successful pharmaco-
logic treatment of BDD with selective (SSRIS) and nonselective serotonin reuptake
inhibitors (SRIS) such as fluoxetine and clomipramine, respectively (Hollander, Co-
hen, Simeon, Rosen, DeCaria, & Stein, 1994; Hollander, Liebowitz, Winchel, Klumker
& Klein, 1989; PhilIips et al., 1993). However, these treatments have yet to be used
specifically with cosmetic surgery populations.
The research outlined in this section has two ultimate goals. First, it should be used
to assess the relationship between body image dissatisfaction and cosmetic surgery, in
terms of both the pre-existing degree of body image dissatisfaction, as well as the utility
 The Psychologyof CosmeticSurgery 19

of surgery as body image therapy. Second, the research should be used to identifi both
patients for whom surgery may be beneficial, as well as those for whom it is contrain-
dicated. Through the use of body image construct, we will begin to better understand
the psychology of this unique population.

Acknowledgements— This researchwassupported by a Fellowshipfrom the Edwinand Fannie

GrayHall Centerfor HumanAppearance (to Dr. Sarwer)and by a NationalInstituteof Mental
Health ResearchScientistDevelopmentAward (to Dr. Wadden).

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