Interventions to enhance people’s cosmetic appearance are common across the UK, and the number of cosmetic interventions undertaken in the UK has increased substantially over the past decade. Cosmetic interventions range from non-surgical treatments such as tooth whitening and hair removal, to more complex surgical interventions such as botulinum injections, facelifts and breast implants. Following the events surrounding Poly Implant Prothèse (PIP) complications, the Department of Health called for evidence to support the clinical safety and regulation of cosmetic interventions.
The aim of this systematic rapid evidence review was to locate, assess, describe and organise findings from the existing research literature to inform the following questions:
- What factors (e.g. socio-economic status (SES), age, gender, psychological factors, relationship status, exposure to advertising, previous cosmetic surgery) are associated with requesting and/or undergoing cosmetic interventions?
- What factors (e.g. SES, age, gender, psychological factors,) are associated with poor post-procedure psychological outcomes in people undergoing cosmetic interventions?
- What are the effects of cosmetic interventions on post-procedure psychological outcomes?
- What is the accuracy/sensitivity of pre-intervention assessment for identifying those who would not benefit from surgery (i.e. those who have factors associated with poor post-procedure psychological outcomes)?
- For patients requesting cosmetic procedures who have body dysmorphic disorder or other disorders with a body image component, does psychological therapy result in better psychological outcomes than cosmetic interventions (or no intervention)?
- What issues have been identified in the literature related to achieving informed consent for cosmetic procedures from vulnerable patients?
The following results are based on information extracted from 192 studies (13 systematic reviews and 179 primary studies), reported in English and conducted within the last ten years. Systematic reviews were prioritised as the highest level of evidence for answering each research question. Where less than three systematic reviews were located, relevant primary studies were used.
What factors are associated with requesting and/or undergoing cosmetic interventions?
Only two systematic reviews were identified as evidence to address this question. One review considered the psychological profile of those seeking facelifts (Shridharani et al. 2010). The second review considered which factors motivate orthognathic surgery patients to seek treatment (Alanko et al. 2010). In terms of patient characteristics, Shridharani and colleagues (2010) found that most UK patients were female, with male patients an almost unchanged minority (approximately 10 percent between 1998 and 2003). The mean ages of patients ranged between approximately 35 and 50 years; no evidence was located to suggest that UK patients’ ages were decreasing between 1998 and 2003. In relation to social predictors of uptake of cosmetic surgery, demand for some procedures appeared to change in frequency according to macroeconomic factors such as interest rates. Psychosocial and behavioural predictors appeared more influential in predicting cosmetic surgery use than demographic characteristics. Both intimate partner violence and dieting were strongly associated with undergoing cosmetic surgery. Women who had been verbally abused, smokers, those taking medication for sleep or nervous conditions, and those with private medical insurance were also more likely to undergo cosmetic surgery. Alcohol use, higher stress and poorer mental health were moderately associated with cosmetic surgery. Obese and overweight women were significantly less likely to have had cosmetic surgery. No research literature was located that examined the impact of advertising on requests for cosmetic surgery.
In examining factors related to orthognathic surgery, Alanko and colleagues (2010) concluded that the results of the studies included in the review were conflicting with regard to pre-operative levels of psychological distress. However, they found that while patients cited aesthetic concerns as a major motivation for seeking surgery, they did not appear to have differences in body image compared to population means or controls. Improving self-esteem (38 percent of patients) and confidence (68-85 percent of patients) were cited as a motivation for seeking surgery, but there was evidence to suggest that self-esteem did not differ from that of the general population. Overall, the results of the included studies suggest that patients were not depressed pre-operatively; nor did their pre-operative anxiety levels differ from normal scores for the population or controls.
Given the lack of systematic review evidence, a descriptive analysis of the identified 104 primary research studies was undertaken. This suggested that approximately 75 percent of studies investigated a broad range of psychological and psychiatric characteristics as predictors of cosmetic intervention. Satisfaction with body image, self-esteem or self-confidence and the existence of body dysmorphic disorder (BDD) were the most commonly assessed predictive variables.
What factors are associated with poor post-procedure psychological outcomes in people undergoing cosmetic interventions?
Three systematic reviews were identified which examined predictors of poor psychological outcome in people undergoing cosmetic interventions. This review concludes that the evidence base is small and of low quality, and that given the variety of psychological outcomes measured, direct comparisons between studies is difficult. Indicative findings suggest that male gender, relationship issues and unrealistic expectations may be associated with poor outcomes. Overall, the reviews’ authors conclude that the nature of the evidence base makes it difficult to confidently identify both which factors lead to a poor psychological outcome, and whether the psychological status of patients is a predictor of poor outcomes.
What are the effects of cosmetic interventions on post-procedure psychological outcomes?
Evidence from six medium- to high-quality systematic reviews considering a range of cosmetic interventions found that patients had high satisfaction levels when undergoing LASIK (laser-assisted in-situ keratomileusis) eye surgery, breast augmentation surgery and breast reduction surgery. However, in relation to breast augmentation, it should be noted that the positive psychological and social outcomes reported may have been biased by questionable study methods. Regardless of these methodological limitations, it is important to note that three of the breast augmentation studies suggested an association with suicide.
With regard to breast reduction, the reliability of both the high satisfaction scores noted earlier, and trends toward improved psychological and social outcomes, may be rendered suspect due to the methodological limitations of the included primary studies. Similarly, findings were unclear about the extent to which patients were satisfied with cosmetic botulinum toxin type A.
Abdominoplasty patients reported limited effectiveness with regard to post-operative psychological or social outcomes. Likewise, there was limited evidence to suggest improved self-esteem and decreased anxiety following orthognathic surgery. Mixed results were found when examining post-operative rhinoplasty outcomes. These suggested high levels of satisfaction but mixed results for psychological disturbance, with some limited evidence to suggest improved self-esteem and decreased anxiety.
What is the accuracy/sensitivity of pre-intervention assessment for identifying those who would not benefit from surgery (i.e. those who have factors associated with poor post-procedure psychological outcomes)?
Evidence from one systematic review and four relevant primary studies on the accuracy of pre-intervention screening tools revealed a small evidence base which varied in quality and was heterogeneous enough to make firm conclusions difficult. A lack of follow-up assessments made it difficult to assess the screening tools’ predictive value. The majority of review authors recommended the use of a brief self-report measure that could be easily and efficiently administered to patients.
For patients requesting cosmetic procedures who have body dysmorphic disorder or other disorders with a body image component, does psychological therapy result in better psychological outcomes than cosmetic interventions (or no intervention)?
No studies were found that directly compared patients with body image disorders undergoing cosmetic surgery versus alternative therapies. However, we identified two systematic reviews and one primary study which evaluated alternative therapies to cosmetic surgery for people with BDD. These studies revealed that both psychological (i.e. cognitive behavioural therapy) and pharmacological (i.e. serotonin reuptake inhibitors) interventions were useful in treating BDD. They also concluded that psychological and pharmacological interventions were effective at reducing co-morbid disorders such as depression and obsessive-compulsive disorder symptoms.
What issues have been identified in the literature related to achieving informed consent for cosmetic procedures from vulnerable patients?
One systematic review and six primary studies examined the issue of informed consent in vulnerable patients who request or undergo cosmetic procedures. Almost none of the research related to non-surgical procedures, and the type of cosmetic procedure was often poorly reported. Overall, these studies revealed poor reporting on the characteristics of study participants, and none of the studies reported outcomes for vulnerable patients. Women, doctors or documents were most often studied, and patients were most often women in their mid-forties. Pre-procedure consultations were the setting most often described for informed consent to take place. These consultations revealed issues related to both the content of the discussion and the ways patients and practitioners approach one another. Consultations appeared to be influenced by doctors’ perception of which risks merited discussion, and their need to manage professional ethics, reduce litigation risk and (in the private sector) facilitate profit.
As well as discussion of all medical risks, women undergoing cosmetic breast surgery indicated an additional need for information about how having surgery (or not having it) would affect their future social and childbearing lives. The decision-making process in cosmetic surgery consultations appears to be shared: patients want doctors to understand what information they need in order to make a decision; and doctors want patients to understand why they provide the information that they do (i.e. so that patients can understand how to interpret the information). The decision-making processes described in the research literature may differ from what doctors are currently obliged or deem necessary to provide, in ensuring that informed consent has taken place.
This work identified over 13,000 references, of which 78 percent were screened within the rapid evidence schedule. To ensure that the most likely included citations were assessed within the timelines imposed by this rapid evidence assessment, we used contiguous text mining, targeted free-text searching of the remaining unscreened references and prioritising the retrieval of systematic reviews.
Several primary studies were retrieved but not fully assessed where an adequate number of systematic reviews were available to inform our research questions; these potentially await further synthesis in a future systematic review.
The systematic reviews were most often heterogeneous in nature, and limited by the mixed quality of their included primary studies. These flaws included no control/comparison groups, small sample sizes, limited follow-up of outcomes and susceptibility to response bias. The heterogeneity of outcomes made synthesis difficult. A considerable number of additional primary studies were identified which could not be fully synthesised in the rapid timelines necessitated here, but they may shed additional light on these research questions.
In summary, the poor overall quality of the primary studies included within existing systematic reviews suggests a potential lack of good-quality research into psychosocial predictors of poor psychological outcome in cosmetic interventions. While this limits the extent to which conclusions can be drawn about predictors and outcome in cosmetic interventions, it also highlights promising areas for future primary research. This includes further research synthesis: the rapid nature of this review identified several hundred primary studies that could not be assessed in time, but which may inform these questions in future.
Conclusions and recommendations
This rapid evidence systematic review identified a wide variation in the quality of primary studies included in reviews. This suggests a need for considerable co-ordination and academic collaboration in order to establish better regulation within the cosmetic procedures industry, particularly with respect to the obligatory collection of standard measures, using agreed methods.
Future primary research designs across these research questions should ensure that appropriate control/comparison groups are used, with adequate power calculations for adequate sample sizes. Further, prospective and longitudinal studies are needed to apply both short and longer follow-up periods.
A research gap exists in addressing these issues in relation to less-often performed cosmetic surgeries and other non-surgical procedures (such as dermabrasion, hyaluronic acid or botox injections).
Authors should declare conflicts of interest related to for-profit practice.
Evidence from systematic reviews and selected primary studies provide some potential characteristics of vulnerable patients which merit further examination. A systematic review of this literature could identify other characteristics of vulnerability.
Future research exploring and confirming associations between male gender, relationship issues, level of expectations and poor post-cosmetic procedures outcomes is urgently needed to confirm whether these are characteristics of vulnerable populations. Similarly, more rigorously conducted research on the relationship between breast augmentation surgery and post-operative suicide is needed in order to inform future assessment and treatment of such patients.
At present, a wide variety of psychological outcomes are measured, using multiple constructs. This impedes knowledge accumulation, as the resulting findings are too heterogeneous to combine. A priority task should be to gain consensus on the core psychological outcomes to be measured in patients undergoing cosmetic procedures.
Studies measuring satisfaction in patients undergoing cosmetic procedures vary in definition and measurement. These need to clearly define what aspect of satisfaction is being measured (e.g. satisfaction with procedure; with results; with body image) and use validated tools. Satisfaction should be measured pre- and post-procedure, with an appropriate separate control or comparison group.
A small number of heterogeneous studies of varied quality show that most screening tools assess BDD only; most authors recommended brief, self-report measures that could be easily and efficiently administered. The development and sensitivity testing of brief self-report measures of other aspects of psychological health, such as depression or obsessive-compulsive disorder, is recommended.
For patients with BDD or co-morbid disorders, specific psychological and pharmacological treatments were effective; their use in these patients requesting cosmetic procedures should be evaluated. Further evaluation is warranted, comparing the use of alternative psychological and pharmacological treatments in patients with psychological disorders requesting cosmetic procedures. However, in order to determine a diagnosis this, merits careful pre-procedure assessment of psychological status using validated tools.
Efforts to develop and facilitate a trusting, communicative relationship between patients and doctors, and whether this is clearly documented, appear to indicate the extent to which informed consent occurs (or does not). Recognition of the shared responsibility between patients and doctors during informed consent could change their exchange of information in the pre-cosmetic procedure consultation, as well as the ways in which informed consent is documented.
Future practice could examine the utility of documenting the ways in which doctors and patients approach each other in shared decision making and relationship building, as a way of indicating that conditions for informed consent were met.
This report should be cited as:
Brunton G, Paraskeva N, Caird J, Schucan Bird K, Kavanagh J, Kwan I, Stansfield C, Rumsey N, Thomas J (2013) Psychosocial predictors, assessment and outcomes of cosmetic interventions: a systematic rapid evidence review. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London.