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Women considering any form of cosmetic surgery, including breast implants, often wonder, "What does the desire to have surgery say about me?", "What does it say about my self-esteem and my perception of myself?" And, lastly, "What will other people think about me if I have surgery?" These questions and concerns are understandable, given the numerous myths and misperceptions about the people who consider and undergo cosmetic surgery.

In short, the research suggests that the large majority of women who consider and/or undergo cosmetic surgery are both physically and mentally healthy. They view surgery as an option to address specific appearance concerns and physical changes often caused by major life events, such as the birth of a child or significant weight loss. Contrary to popular belief, these women are not trying to achieve “perfection” or satisfy other individuals, and they don’t suffer from self-esteem or self-confidence issues (no more so than the general population).

With that said, there are a few important psychological considerations for anyone thinking about cosmetic surgery. Before any procedure, women should carefully consider what is motivating them to make changes to the specific body part, whether they are considering surgery to please themselves or another person, the potential risks and benefits of surgery, and what they expect in terms of results. They should also be aware of how other people may react to them after surgery, and consider in advance how they will manage these reactions.

Increasing Interest in Cosmetic Procedures

During the past decade, the total number of people who have undergone both surgical and non-surgical cosmetic procedures has increased on an annual basis. According to the American Society of Plastic Surgeons (ASPS), nearly 11 million surgical and non-surgical cosmetic procedures were performed in the United States during 2006 – an increase of 7 percent from 2005. Breast augmentation surgery accounted for more than 380,000 of these procedures.1 This number represents a significant increase from a decade ago – between 1997 and 2006, there was a 279 percent increase in breast augmentation procedures.

There are several possible explanations for the increased interest around cosmetic surgical procedures and treatments.2 These include a growing number of surgical and non-surgical cosmetic treatment options, increased awareness among the general public about various types of cosmetic procedures, and improved techniques and technologies that enable people to feel more comfortable undergoing specific procedures. In terms of breast augmentation surgery, advances in breast implant technology, as well as the surgery itself, mean that doctors now have more options to offer patients. This provides women considering breast augmentation surgery greater reassurance that there is a procedure and a product that is right for them and that will enable them to achieve their desired outcomes from surgery.

Who are the women considering and undergoing cosmetic procedures, such as breast aesthetic surgery, and what motivates them? The social and psychological characteristics of women interested in cosmetic surgery have long been of interest to plastic surgeons and mental health professionals.3,4 Again, contrary to popular belief, research has shown that these women have considered surgery for several years before making a decision, and are undergoing surgery as a way to make a positive change for themselves rather than to please anyone else.5 These women often will say, "Before I had my children, I had an attractive bust. I just want that back," or, "I want to remain confident about my body as I age," or finally, "I just want to feel feminine again."

In the past, concern has been raised by medical professionals that women who undergo cosmetic procedures may be motivated in part by feelings caused by certain psychiatric conditions, such as mood or personality disorders.3,4 The first studies of these issues, conducted decades ago, relied heavily on interviews conducted by medical professionals. We now understand that, for several reasons, personal interviews often are not the best way to gather this kind of data. How questions are asked, patients' desires to please physicians and provide the "right" answers, and physician bias can all impact the results of data gathered through interviews. In addition, during this era, doctors often believed patients' behaviors were influenced by unconscious conflicts with their parents and other significant figures in their lives. Not surprisingly, reports from this time described many women who were interested in cosmetic surgery as suffering from psychiatric conditions.3,4 More recent studies that used standardized paper-and-pencil questionnaires, rather than interviews, have found few psychological differences between women who decided to have cosmetic surgery and those not interested in surgery.

Several recent studies have investigated mental health treatment among women interested in breast augmentation. Women with breast implants, as compared to other cosmetic surgery patients or women from the general population have been found to report a higher rate of outpatient mental health treatment6 and psychiatric hospitalizations.7 One study, however, found no differences between breast augmentation patients and other women in treatment for depression.8 These conflicting results have made it difficult to develop any definite conclusions about the psychological status of cosmetic surgery patients before surgery.

It is interesting and important to note that cultural beauty ideals continually and naturally evolve, and this evolution can be a significant factor in the growing interest in cosmetic surgical procedures and treatments. The voluptuous figures that were desirable during the first half of the 20th century have given way to the often lean and fit figures of more contemporary society. Marilyn Monroe, the beauty ideal of her time, would be considered overweight by today's standards, although her measurements are similar to those of the average American woman today. One of the current ideals of female beauty is a thin, muscular, yet large-breasted woman. This body type does not often occur naturally without the help of regular dieting and exercise, as well as breast augmentation.2 Women who have breast implant surgery may have greater motivation to attain the lean, fit figure that is desirable today. Studies have shown that women who undergo cosmetic surgery report a strong investment in their health and physical fitness, and higher levels of physical activity, compared to those not interested in cosmetic surgery.5,6

As the interest in cosmetic surgery grows, the role of physicians and surgeons is to ensure that every woman considering a cosmetic procedure understands her options and motivations, understands potential risks and benefits, and has reasonable expectations for the outcome of her surgery.

Before Surgery: Key Topics and Research to Consider

Before you undergo any cosmetic procedure, your physician and/or your surgeon should evaluate both your physical and mental health. From a physical standpoint, you should be in good health, and free of conditions that could be complicated by surgery or delay healing.

Click here for more information on this topic, as it relates to breast implant surgery

To ensure you are mentally healthy and prepared for the changes cosmetic surgery may bring, your surgeon will ask you about your current and past mental health. It is important for you to talk openly with your physician about your medical history and your interest in cosmetic surgery, so that you can determine together how cosmetic procedures will impact you as an individual and ensure they are a good option for you.

Motivations:

It is important for women to recognize that – from a psychological standpoint – breast augmentation is most successful if you fully understand your own motivations for the surgery. There are various factors that motivate women to consider breast implant surgery. Motivations for all forms of cosmetic surgery, including breast augmentation, can be classified as internal or external. An example of an internal motivation would be undergoing breast augmentation to improve your body image for yourself. In contrast, an external motivation would be undergoing the surgery for a secondary reason, such as to please a romantic partner. It is important to note that women who are internally motivated are thought to be more likely to achieve their goals for surgery.9

Desire for a different breast size and shape is likely the most central motivation for breast augmentation surgery. As noted above, many women have come to see breast augmentation as an appealing option to help them regain or restore a figure that changed after weight loss or childbirth and breastfeeding, or to enhance the natural breast size, shape or form to feel more feminine.

Expectations:

Another key question you should consider (and your surgeon will ask) is what you expect to achieve from surgery. Women who anticipate that breast implants will lead to a "Cinderella-like" transformation in their lives are likely setting themselves up for disappointment. Research has found that cosmetic surgery results in an increased satisfaction with the specific body part that was altered, and potentially a slight overall increase in self-confidence.3,4 It is unlikely that breast implants will have a significant impact on other areas of your life, such as your job or relationships.

Body Image:

Your surgeon will be interested to know about your perceptions of your body and any body image concerns you may have. Even if the surgeon knows that you are interested in breast implant surgery, he or she may ask what, specifically, you dislike about your breasts. You should be prepared to talk about your concerns in some detail, to give the surgeon an idea of the best style of implant and type of procedure for you.

Timing:

The surgeon also may ask how you have been feeling about your life and yourself over the past few months, whether you are currently being treated for any mental health issues, and why you are interested in breast implant surgery at this time in your life. You should answer these questions honestly. Being in mental health treatment does not mean you should not or cannot have surgery; however, the surgeon may ask to speak to your mental health professional before surgery. In some cases, the surgeon may ask you to see another mental health professional in order to make sure that surgery is a good option for you at this time. In general, the best time to undergo cosmetic surgery is at a relatively stable time in your life. Women should not consider having surgery when dealing with major stressors, such as a change in employment or marital status. Changing your appearance while these things are happening may add more stress to an already stressful time.

After Surgery: What to Expect

In terms of "post-surgery" considerations, you should think about and be prepared to discuss how you think your life and body will be different after undergoing a cosmetic procedure, such as breast implantation surgery. The vast majority of women who undergo cosmetic breast augmentation report that they are happy with the result.10,11,12 A number of studies also have shown improvements in body image among women who underwent breast augmentation and other forms of cosmetic surgery.13,14,15,16,17,18

While breast augmentation may lead to increased satisfaction with the body part addressed through surgery and/or improvements in your body image, it is impossible to predict the responses of other people. While some women are pleased with increased attention related to their larger breasts, others may find the new-found attention a little unsettling. Regardless, you should keep in mind that breast implant surgery is unlikely to have a dramatic effect on how others treat you.

Ensuring Surgery is a Good Choice for You, both Mentally and Physically

As discussed above, there are many misperceptions about the mental health issues associated with cosmetic surgery, including breast augmentation. Women’s interest in cosmetic surgery is a common desire most often based on justifiable personal considerations.

With that said, it is critical that any woman considering cosmetic surgery carefully think through questions related to personal motivations and expectations for surgery, body image, and timing, and be prepared to discuss these issues openly and honestly with her surgeon. Your surgeon is your partner in decision-making, and has a responsibility to provide you with the best possible care. Part of that responsibility involves making sure that you are physically and emotionally ready for surgery and that you will likely benefit from the changes in your appearance.

Addressing Concerns About Breast Implants and Suicide

Within the past several years, several of the epidemiological studies conducted to assess whether there are any relationships between silicone gel-filled breast implants and various illnesses have raised concerns about an association between cosmetic breast implants and suicide.7,19,20,21,22,23,24 Across the studies, the rate of suicide among women with breast implants was two to three times greater than what would be expected in the general population. While one study in this area suggested that the rate of suicide among women with breast implants was greater than that of women who underwent other forms of cosmetic surgery,19 the largest study found no difference in the rate of suicide among cosmetic surgery patients.23

Scientists have offered several possible explanations for a potential relationship between breast implants and suicide.25,26 Some women with breast implants have been shown to have distinctive personality traits and life experiences.27,28,29 Many of these characteristics, such as alcohol and tobacco use, are known risk factors for suicide,30,31,32 and may reflect psychiatric problems that existed before the women received breast implants. While a history of mental health issues does not mean women should not have breast augmentation or other forms of cosmetic surgery, patients and surgeons should work together to make sure that cosmetic surgery is appropriate at any given time in a woman's life.

Another possible explanation for the relationship between breast augmentation and suicide may be that a number of women expect that surgery will lead to dramatic changes in their lives. When these expectations are not met, they may become depressed. Therefore, as noted above, women interested in cosmetic breast augmentation should consider and discuss with their surgeons the reasons they want to have surgery, and the impact that they believe breast implants will have on their lives.

It is important to note that there is no evidence in the existing scientific literature of a causal relationship between breast implants or augmentation or revision surgery and a woman's risk of suicide or the development of mental health issues. In other words, the components of the implants themselves and the surgery surrounding them are not the suspected cause of any psychological problems reported among women with implants. Rather, pre-existing mental health issues are believed to be the most likely link.

Addressing Concerns About Cosmetic Surgery and Body Dysmorphic Disorder

At least one psychiatric condition in particular occurs with greater frequency among people who decide to have cosmetic surgery.33 This is a condition known as body dysmorphic disorder (BDD), which is an obsession with a slight or imagined defect in your appearance that leads to substantial distress or impairment in daily functioning.34 A number of studies conducted throughout the world have found that between five and 15 percent of cosmetic surgery and dermatology patients have some form of BDD.35,36,37,38,39 The most common areas affected by the disorder are the head and face, but any body part, including the breasts, can be the focus of concern. While many patients with BDD believe that cosmetic surgery or other cosmetic medical treatments may improve their condition, at least one study found that more than 90 percent of people with BDD report either no change or a worsening in their BDD symptoms following cosmetic treatments.40 This result suggests that people with BDD should not undergo cosmetic procedures and, instead, should obtain mental health treatment.33

1 2006 National plastic surgery procedural statistics. American Society of Plastic Surgeons, 2007.
2 Sarwer, D.B., & Magee, L. (2006). "Physical appearance and society." In Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Empirical, Clinical, and Ethical Issues, Sarwer D.B., Pruzinsky T., Cash T.F., Goldwyn R.M., Persing J.A., Whitaker L.A. (eds), Philadelphia, Pennsylvania, Lippincott Williams & Wilkins 2006: 23-33.
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4 Sarwer, D.B., Didie, E.R., Gibbons, L.M: "Cosmetic surgery of the body." In Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Empirical, Clinical, and Ethical Issues, Sarwer D.B., Pruzinsky T., Cash T.F., Goldwyn R.M., Persing J.A., Whitaker L.A. (eds), Philadelphia, Pennsylvania, Lippincott Williams & Wilkins 2006: 251-266.
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