After the nip and tuck
EVE MICHAELS gave herself the 50th birthday present she had dreamed of: a lower face-lift, chin implant and nose job. It was the long-anticipated high point, she says, of nearly a decade of self-improvement: weight loss, fitness training, improved eating.
The decision to have the surgeries was so that she could “project who I really was,” says Michaels, now 52 and an image coach in Beverly Hills. “The cosmetic surgery was the icing on the cake.”
Two weeks into the healing process, though, Michaels suffered a brief, but emotional, breakdown in an all-mirrored elevator in her apartment building. Her new nose, she thought with shock, “looked like everyone else’s.”
Her son, then 13, also had difficulty accepting his mother’s new look, dismissing her actions as simple vanity.
The decision to undergo cosmetic surgery is not usually arrived at lightly, but even so, life after the procedures is not always what patients -- or their family, friends or partners -- expect. Alterations to physical appearance can have a profound effect on emotions and self-perception, changing how people interact with others and how loved ones, and even strangers, perceive them.
But only now are surgeons and researchers beginning to quantify those changes -- and asking how they can better prepare their patients, even if it requires dissuading some from having surgery.
“If we look just at the scientific studies that have been done, we know pretty conclusively that patients report improvements in body image after surgery,” says David Sarwer, associate professor of psychology at the Center for Human Appearance, University of Pennsylvania School of Medicine. “In terms of improvements in self-esteem and quality of life, the impact of surgery is less clear.”
In one of the largest studies of psychosocial outcomes of breast augmentation, for example, more than 90% of the 360 patients studied reported they had an improved body image two years later. And, the 2002 study found, 75% to 85% said that the benefits of the surgery outweighed the risks.
But a 1999 survey of 281 plastic surgeons by Dr. Gregory Borah and colleagues at the division of plastic surgery at Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey, found that almost all respondents had encountered at least some patients who had experienced disappointment, depression, anxiety issues or sleep disorders after cosmetic surgery.
Last month, Sarwer and his colleagues released a book on the psychological effects of plastic surgery on patients. While the title, “Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Clinical, Empirical, and Ethical Perspectives,” may be a bit of an eye-glazer, the book is the first scholarly text to detail the psychological aftermath of surgery.
The book notes, for example, that there have been few studies of postoperative changes among breast augmentation patients. And the two reports that used psychometric measures found mixed results: One found a decrease in symptoms of depression from preoperative status; the other reported increased symptoms of depression in 30% of patients in the immediate postoperative period.
It also suggests patient-screening guidelines that the psychologists say can help plastic surgeons determine which patients have acceptable expectations for their surgery and which ones need a reality check.
The American Society of Plastic Surgeons has also taken a keen interest in patients’ psychological outcomes. The association has increased the amount of related training available to its members, educating physicians on how to screen patients and prepare them psychologically for life post-surgery. It also has devoted a substantial portion of its consumer website to a discussion of the issues.
The need has never been greater. Reality shows often portray cosmetic surgery as a quick fix, and more Americans than ever are turning to cosmetic procedures to change their features. More than 1.7 million surgical procedures were performed last year, according to the plastic surgeons group. And more than 7 million people sought less-invasive procedures such as Botox and laser skin treatments.
Doctors have long questioned, and occasionally cautioned, patients during the initial consultation about their expected goals of surgery, but some patients nonetheless expect a happier, more rewarding existence almost immediately. Many are subsequently dismayed by the weeks, maybe months, of healing.
“There is an emotional letdown,” says Dr. Alan Matarasso, a cosmetic surgeon in New York City and a clinical associate professor of plastic surgery at Albert Einstein College of Medicine. “Patients anticipated this procedure for weeks or months or years, and that can have an emotional impact to it, and they should be prepared.”
Post-surgical emotional, or adjustment, difficulties are especially common when surgery is to the face (a primary factor in a person’s physical identity) and with breast augmentation (a major focus in sexual identity), say surgeons and psychologists.
Of course, many emotional changes brought about by cosmetic surgery are positive. Research and anecdotal reports indicate that the procedures can increase self-esteem, self-satisfaction and the sense that how patients feel on the inside matches how they look on the outside. Those changes can be reflected in improved communication and interaction with others.
But sometimes, loved ones and family members can have tremendous difficulty coming to terms with a person’s new look, worsening or creating any self-doubt the patient already may be feeling.
“Husbands or wives get insecure. Kids don’t quite know who the person is,” says Michaels, who’s seen such reactions in her clients’ families as well. “It takes time for everybody to adjust.”
Patricia Pitts, a clinical psychologist in private practice in Pasadena focusing on body image issues, says she once counseled a patient who underwent several cosmetic procedures on her face, only to have the patient’s sister exclaim when she saw her, “Now you’re the pretty one!”
“The sister was excited for her. But the one sister [who had surgery] didn’t know what her role was anymore. The label got changed,” says Pitts.
A new dynamic
Anything that changes one’s level of self-confidence, such as earning a degree, getting a promotion or undergoing cosmetic surgery, has the ability to disrupt a relationship’s balance, says Ted Grossbart, an assistant clinical professor of psychology at Harvard Medical School who has studied the reasons people undergo cosmetic surgery.
Though “a relationship that is ended by these changes has a pre-existing fault line,” he says, that can be small comfort when a change in appearance precipitates the breakup.
Altering a body’s overall shape, either through bariatric surgery or other means, can have an especially dramatic effect on a patient’s self-perception.
“They often see themselves in another way, and other people see them differently,” Sarwer says. “For some people, it can throw off the dynamic of the interpersonal relationship.”
Dawn Beber of Indianapolis knows the risks firsthand. This summer, she had nearly a dozen pounds of loose flesh removed from her 5-foot-2 frame after a dramatic diet-driven weight loss. She also had a tummy tuck and liposuction on her hips and thighs.
Now weighing 155 pounds, down from 280, Beber says she has renewed energy and all-new self-confidence. She socializes more, is meeting new people and feels comfortable wearing halter tops and hip-hugging pants.
And, she says, in terms of how affectionate she is toward other people: “I’m not nearly as hesitant to have people touch me.”
But her yearlong relationship with her boyfriend soured when she decided to have the surgery, and they broke things off before she had the procedures.
Although her surgeon had prepared her with a hefty packet of information that included the emotional changes she might face, it was too late. Though she and her boyfriend began dating after the majority of her weight loss, “he’s had a really hard time dealing with the fact that I’ve changed so much,” she says.
Change can be difficult for any family members or loved ones to handle, say psychologists. For Jill Scharff, 61, who had a face-lift three years ago, it was her adult children’s response to the change that she had to cope with.
As she began to heal from surgery, they complained that she no longer looked like the mother they knew -- she now looks about 15 years younger, she says.
“They found comfort in that old face, and they hated losing it,” she recalls.
Scharff’s children also realized that she was having the surgery because she was getting older -- a reminder of her mortality, something she says upset them as well.
The results, physical and emotional, of her procedure prompted Scharff, a clinical professor of psychiatry at Georgetown University and co-director of the International Psychotherapy Institute in Chevy Chase, Md., and her friend and colleague Jaedene Levy, who also had a face-lift, to write a joint account of their experiences. Levy is also a fellow at the institute and an instructor at the Washington School of Psychiatry.
The book, “The Facelift Diaries,” was released last October and was written “so that people would realize that this is major surgery. And that you better be prepared for a physical challenge, as well as an emotional and social challenge,” says Scharff.
For some, such a challenge is welcomed. Karen Little, 30, of Bloomington, Ind., had a breast augmentation in August that changed her size from a 34B to a 34D. The increase has resulted in an uptick of attention by her friends and strangers -- an outcome she says she did not expect nor prepare for -- but that is just fine by her. “I am more confident about how I feel,” says Little. “You go to a bar and, of course, you’re going to have comments, stares. But you stand up straighter, smile and say, ‘Thank you.’ ”
Cosmetic surgeons and psychologists say they also have had the reverse situation -- patients who bristle at the new attention they receive from strangers. Or, in the case of one patient Pitts counseled who had undergone breast augmentation, she questioned the changes she witnessed in her husband. “I know he’s always loved me, but does he love me more now that I’m more attractive?” she recalls the patient asking. “The husband was also facing his own crisis, admitting that sex with his wife after her surgery was like cheating on her,” says Pitts.
Screening patients
To date, without an industry-wide standard of patient evaluation and assessment -- something Sarwer hopes his work will change -- cosmetic surgeons are on their own in determining the questions they should pose and what warnings, if any, to pass along to patients.
Some leave it up to patients to predict how family members or a spouse may react to a patient’s surgery, while others provide written information that can include a discussion of the emotional implications.
Rita Freedman, a psychologist in Garrison, N.Y., and author of “Bodylove: Learning to Like Our Looks and Ourselves,” charges that cosmetic surgeons are unlikely to seriously screen patients, particularly in states with a plethora of surgeons, such as California, Florida and Texas.
“If you’ve got too many surgeons and not enough clients, you’ve got to figure out some way to maintain your practice,” she says, citing surgeons’ marketing efforts aimed at men and younger adults, and even children.
Cosmetic surgeons, however, argue that their primary consultation often determines a person’s goals and expectations and that they do turn a number of patients away.
“It begins with the phone call. If something doesn’t sound right, we just won’t see them,” Matarasso says.
The best candidates, surgeons say, are those who seek greater self-confidence or are looking to be less self-conscious about a body part. Some say they will refer patients to psychiatrists or psychologists if they believe patients are grappling with issues that cannot be addressed by surgery alone, such as body dysmorphic disorder, in which a person obsesses over one or more perceived flaws.
Sarwer has estimated that 7% to 15% of people seeking plastic surgery have the condition. On the flip side, an estimated half of all people with the disorder seek cosmetic surgery or dermatological treatment. “If I have someone come in and expect that it’s going to change a relationship or change a marriage or that they’ll be able to get a job they couldn’t get otherwise, that’s not the right patient,” says Dr. James H. Wells, a plastic surgeon in Long Beach for 25 years and former president of ASPS and the California Society of Plastic Surgeons.
“If a patient tells me it’s something they’ve been thinking about for a long time, that ‘Everything in my life is centered,’ then that’s the kind of person who has thought through it and is ready to do it,” he says.
Ultimately, most family members adjust to patients’ new selves. In Michaels’ case, her two daughters had cosmetic surgery at the same time that she did, which was documented by a television film crew. And her husband had previously undergone cosmetic surgery and was able to help her son and other family members adjust.
“Afterward, one by one, my family, my best friends, understood why I did it,” she says. “Now they ask, ‘Who was your doctor? I want to do the same thing!’ ”
Beber is reconciling with her boyfriend, who still struggles with the amount of attention she receives from strangers, and is planning to have a breast lift and augmentation in the next 12 months.
Despite the emotional turmoil, her procedures are “still the best thing I’ve done in my life.”
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Top procedures
The top five cosmetic surgery procedures for men and women in 2004:
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Females
Liposuction: 292,402
Breast augmentation: 264,041
Eyelid surgery: 200,667
Nose reshaping: 195,504
Facelift: 103,994
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Males
Nose reshaping: 109,971
Hair transplantation: 43,054
Eyelid surgery: 32,667
Liposuction: 32,489
Breast reduction in men: 13,963
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Source: American Society of Plastic Surgeons
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In the right state of mind?
People considering cosmetic surgery can determine if they’re a potentially good candidate by asking themselves these questions, experts say.
* Why are you interested in surgery now? If you are in the middle of a major life change such as divorce, a death in the family or are grappling with other substantial issues, wait until those are resolved. Surgically altering your appearance is permanent. Surgeons and psychologists overwhelmingly agree that you should make such a life-altering decision in a stress-free state of mind. You’ll also need the time, patience and attention necessary for a full, successful recovery.
* Do you have specific concerns about your appearance that are readily visible to others? If you have a particular feature you would like to change, and have a healthy outlook about it, you’re more likely to be happy with the results. If, instead, you have more general feelings such as, “I need a complete makeover” or “I’m the ugliest person around,” you may suffer from body dysmorphic disorder. Similarly, if you obsess about a particular physical trait -- constantly checking it in the mirror or so consumed with thoughts about it that it disrupts your daily life (you avoid certain social situations, have difficulty concentrating on other things) -- you also may have the disorder. In either case, cosmetic surgery is unlikely to provide a satisfactory result and you should seek psychological help.
* How do you think surgery will affect your life? If you seek cosmetic surgery with the hope that the results will win you a promotion, save a marriage or attract a potential partner, you’re unlikely to be a good candidate. Such outcomes are unrealistic and not usually attainable through surgical means.
* Are you trying to make someone else happy? Studies clearly show that people who undergo surgery to please a romantic partner are unlikely to be happy with the results. If, instead, your reasons for undergoing surgery are more internal, your chance of a successful outcome is dramatically increased.
* Do you have realistic expectations? Having goals that you and your surgeon agree are attainable can help ensure that your expectations are met. If you realize that some people may notice the results and others may not, you are considered a better candidate than someone who is looking for a “Cinderella-like” transformation.
* Are you depressed, anxious or having difficulty sleeping? If so, you may be suffering from other problems in your life and making a decision to have cosmetic surgery is not recommended. Not only are you likely to have a less-than-satisfying outcome, the surgery also could worsen your condition, as a number of mentally healthy patients typically experience those same reactions after surgery.
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Resources
For more information on the aftermath of cosmetic surgery, go to:
* American Society of Plastic Surgeons: The website of the largest and oldest association of plastic surgeons provides information about postoperative depression, anxiety and emotional changes. From the homepage, select “Procedures” and then “General Information.” Other sections include costs and tips on how to find a plastic surgeon. Go to www.plasticsurgery.org.
* YesTheyreFake.net: Created by Marianne Guarena, who says she has had a number of cosmetic procedures, this is one of the most comprehensive online patient support networks for all types of cosmetic surgery procedures. The site’s section on “Post-operative Depression: Know BEFORE It Happens,” found on the FAQ About Preparing for Your Surgery section, provides a substantial discussion on post-op depression, why it happens and how you can cope with it. The homepage provides links to active, moderated discussion boards. Go to www.yestheyrefake.net.
* “The Facelift Diaries,” by Dr. Jill Scharff and Jaedene Levy. Two friends and colleagues offer their first-person accounts of how they personally prepared (and didn’t prepare) emotionally and physically for their face-lifts. Scharff, a clinical professor of psychiatry at Georgetown University and co-director of the International Psychotherapy Institute in Chevy Chase, Md., and Levy, a fellow at the institute and an instructor at the Washington School of Psychiatry, also discuss how their families, coworkers and loved ones reacted.
* “Cosmetic Surgery: Before, Between and After,” by Susan Gail. This personal how-to book for new, or potential, cosmetic surgery patients is written by a professional makeup artist with 22 years of experience in working with reconstructive surgeons, dermatologists, psychiatrists and psychologists. Gail, who underwent a face-lift herself, offers a straightforward, easy-to-digest guide that also covers how to plan for the reactions of your loved ones.
* “The Smart Woman’s Guide to Plastic Surgery: Essential Information from a Female Plastic Surgeon,” by Dr. Jean M. Loftus. A plastic and reconstruction surgeon on the surgery faculty of the University of Cincinnati, Loftus provides a medically detailed step-by-step book on the implications, complications, and hidden dangers and costs of cosmetic surgery, including the emotional and psychological effects.
