Guest Editorial
Body Image: Interfacing Behavioral and
Medical Sciences
David B. Sarwer, PhD; and Thomas F. Cash, PhD
B
ody image, and more specifically body image dis- Body image has long been discussed in the context of
Downloaded from https://academic.oup.com/asj/article/28/3/357/268803 by guest on 05 October 2021
satisfaction, is believed to play a central role in plastic surgery, appearing in the seminal work of the
motivating a number of appearance-enhancing Edgerton et al2 in the 1950s and 1960s. Only within the
behaviors—including weight loss, cosmetic and fashion past decade, however, has there been empirical study of
purchases, and aesthetic surgery. The term “body the relationship between body image and cosmetic sur-
image” has been defined a number of different ways. It gery.3 A number of studies have found that body image
most commonly refers to an individual’s experiences of dissatisfaction is associated with more favorable atti-
embodiment, especially self-perceptions and self-atti- tudes toward cosmetic surgery.4 Other investigations
tudes toward one’s appearance. Body image is typically have suggested that cosmetic surgery patients typically
viewed as a multidimensional construct, consisting of report increased investment in and dissatisfaction with
perceptual, attitudinal, and behavioral components. their body image before cosmetic surgery and as com-
The two most central body image dimensions are body pared to persons not interested in aesthetic procedures.5
image evaluation (e.g., satisfaction or dissatisfaction) While some degree of body image dissatisfaction
and body image investment (i.e., the psychological appears to be common among persons considering cos-
importance of one’s appearance to his or her sense of metic surgery, some individuals may be experiencing
self or self-worth). excessive dissatisfaction with their appearance. Body
Much like the growth of aesthetic surgery, interest in image dissatisfaction is a feature of several psychiatric
the psychological construct of body image has blos- disorders, from eating disorders and depression to gen-
somed in popularity over the past few decades. Much of der identity disorder and schizophrenia. To date, there
this growth has been attributed to the increased atten- has been relatively little study of the rate of these disor-
tion on eating disorders and obesity in the mental health ders among cosmetic surgery patients or, more impor-
community. As a result, the field often has taken a rather tantly, their relationship to postoperative outcomes.
myopic view of body image, focusing primarily on The psychiatric disorder of perhaps greatest relevance
weight and shape concerns. In reality, the future of the to aesthetic surgery is body dysmorphic disorder (BDD).
field of body image likely lies at the interface of behav- BDD is characterized as a preoccupation with a slight or
ioral and medical sciences, including plastic surgery. imagined defect in appearance that leads to significant
This interaction is reflected in important peer- disruption in daily functioning. Between 1% and 2% of
reviewed publications such as Aesthetic Surgery Journal the population is believed to suffer from the disorder,
and the relatively new Body Image: An International although a number of studies conducted throughout the
Journal of Research, launched in 2004. The recent inclu- world have found that 5% to 15% of cosmetic surgery
sion of Body Image in Medline further validates the and dermatology patients present for treatment with
importance of quality, scholarly work in this area.1 From some form of the condition.6,7 Unfortunately, the vast
a clinical perspective, we also believe it is important for majority of persons with BDD who undergo these treat-
mental health and medical professionals to understand ments report either no change or a worsening in their
the psychological aspects of physical appearance and symptoms. BDD also is associated with a high rate of
body image, so that they may provide the best possible suicidality. Furthermore, anecdotal reports suggest that
guidance and care to their patients. persons with BDD may be more likely to threaten or
bring legal action against their provider, or threaten or
Dr. Sarwer is Associate Professor of Psychology, Departments of commit acts of violence directed at the surgical team.
Psychiatry and Surgery, The Edwin and Fannie Gray Hall Center For all of these reasons, BDD is increasingly seen as a
for Human Appearance, University of Pennsylvania School of
contraindication to aesthetic procedures.
Medicine, Philadelphia PA. Dr. Cash is Professor of Psychology,
Old Dominion University, Norfolk, VA. Dr. Cash is Editor in Chief Unfortunately, the recognition of BDD may be diffi-
and Dr. Sarwer is Associate Editor of Body Image: An cult for the aesthetic surgeon, because individuals with
International Journal of Research. the condition may intentionally minimize their symp-
Aesthetic Surgery Journal Volume 28 • Number 3 • May/June 2008 • 357
the polyvinyl alcohol sponge ivalon). Plast Reconstr Surg Transplant
toms of BDD during an initial consultation. There are a Bull 1958;21:279–305.
number of specific questions that surgeons can ask 3. Sarwer DB, Pruzinsky T, Cash TF, Goldwyn RM, Persing JA, Whitaker
which may reveal the excessive appearance preoccupa- LA, eds. Psychological aspects of reconstructive and cosmetic plastic
tion or disruption in daily functioning often seen with surgery: Clinical, empirical, and ethical perspectives. Philadelphia:
Lippincott Williams and Wilkins; 2006.
the disorder.3,6 Because aesthetic surgeons often obtain
4. Sarwer DB, Cash TF, Magee L, Williams EF, Thompson JK, Roehrig M,
medical clearance from a patient’s primary care physi- et al. Female college students and cosmetic surgery: An investigation of
cian before proceeding with surgery, a greater awareness experiences, attitudes, and body image. Plast Reconstr Surg
of BDD and the appropriateness or inappropriateness of 2005;115:931–938.
certain aesthetic surgery treatments among treating sur- 5. Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. Body image dis-
satisfaction and body dysmorphic disorder in 100 cosmetic surgery
geons and primary care physicians could help to avoid
patients. Plast Reconstr Surg 1998;101:1644–1649.
unsatisfactory outcomes for both patients and surgeons. 6. Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and
Patients without BDD typically report high levels of cosmetic surgery. Plast Reconstr Surg 2006;118:167–180.
satisfaction following aesthetic surgery. Others report 7. Sarwer DB, Crerand CE. Body dysmorphic disorder and appearance
significant improvements in body image.8 Evidence on enhancing medical treatments. Body Image 2008 Feb 4 [Epub ahead of
print].
the effects of cosmetic surgery on other areas of psycho-
Downloaded from https://academic.oup.com/asj/article/28/3/357/268803 by guest on 05 October 2021
8. Sarwer DB, Gibbons LM, Magee L, Baker JL, Casas LA, Glat PM, et
logical functioning, such as self-esteem and quality of al. A prospective, multi-site investigation of patient satisfaction and
life, are less conclusive. Unfortunately, the psychological psychosocial status following cosmetic surgery. Aesthetic Surg J
benefits of aesthetic procedures may be tempered by the 2005;25:263–269.
experience of a postoperative complication. This issue 9. Cash TF, Duel LA, Perkins LL. Women’s psychosocial outcomes of
breast augmentation with silicone gel-filled implants: A 2-year prospec-
has received relatively little study to date, although some
tive study. Plast Reconstr Surg 2002;109:2112–2121.
studies have suggested that the experience of a compli-
cation is negatively related to postoperative satisfaction Copyright © 2008 by The American Society for Aesthetic Plastic Surgery, Inc.
and less favorable changes in body image.9 1090-820X/$34.00
Aesthetic surgery, including minimally invasive cos- doi:10.1016/j.asj.2008.03.007
metic procedures, has exploded in popularity over the
past decade, perhaps more so than anyone could have
predicted. There is little reason to think that, as a socie-
ty, we will not continue to grow more and more comfort-
able with the idea of using medical procedures to change
our external appearance. As has been suggested by
many plastic surgeons over the years, the greatest bene-
fits of plastic surgery are psychological in nature. It
appears that most of these benefits fall into the realm of
body image. While research on the psychological aspects
of aesthetic surgery also has evolved over the past
decade, it must keep pace with the technical advances in
the field. Such research is critically important to support
the efficacy of plastic surgery—that it not only improves
individuals’ external appearance but also their internal
body image. Likewise, it is important that a broad range
of mental health and medical professionals have the
widest possible access to the latest advances in body
image research as well as aesthetic surgery, so that they
can better recognize the types of problems that may be
successfully addressed through either psychological or
surgical interventions. ◗
DISCLOSURES
The authors have no disclosures with respect to the contents of this
editorial.
REFERENCES
1. National Library of Medicine. Journals recently accepted by NLM for
inclusion in Medline. Data as of November 28, 2007. Available at:
http:://www.nlm.nih.gov.catalog.llu.edu/bsd/lstrd/new_titles.html.
Accessed March 17, 2008.
2. Edgerton MT, McClary AR. Augmentation mammaplasty: Psychiatric
implications and surgical indications; (with special reference to use of
358 • Volume 28 • Number 3 • May/June 2008 Aesthetic Surgery Journal