Think Twice

Cosmetic surgery special:
When looks can kill

19 October 2006

Exclusive from New Scientist Print Edition. Rachel Nowak

Last year, 291,000 American women had bags implanted in their breasts, 324,000 Americans had fat vacuumed out of their bodies, and 231,000 had fat, skin and muscle cut from around their eyes. Add less common operations such as buttock lifts, pectoral implants and vaginal rejuvenations, as well as "minimally invasive" procedures such as Botox injections, and the American Society of Plastic Surgeons estimates that Americans underwent at least 10.2 million cosmetic surgery procedures last year. Cosmetic surgery has gone mainstream.
Like any other surgical procedure, cosmetic operations can never be completely free of risk. Although anyone contemplating cosmetic surgery is likely to have talked over with their surgeon the risks to their physical health, there are some forms of ill health associated with the procedures that are far less likely to be mentioned. In particular, people who go under the knife in the quest for a more attractive body or face are more likely than the average person to be suffering from psychiatric problems. There is mounting evidence that those who choose to undergo cosmetic surgery are more likely to commit suicide. What isn't known is just how much people's mental health is being placed at risk by the burgeoning nip and tuck culture.
A related question is whether cosmetic surgery brings any long-term mental health benefits. After all, implicit in the advertisements and promotional TV shows is the promise not merely of bigger breasts or flatter stomachs, but also the idea of a psychological lift. "We have to believe that cosmetic surgery will improve our self-esteem and body image, and make us feel better about ourselves. If not, we're wasting an awful lot of time, effort and money," says David Sarwer of the Center forHuman Appearance and the University of Pennsylvania School of Medicine in Philadelphia. Yet while cosmetic surgery is booming, research into the mental well-being of recipients has not kept pace, says Katharine Phillips, a psychiatrist at Brown Medical School in Providence, Rhode Island.
The results of the few quality studies that have been done are equivocal. Perhaps unsurprisingly, cosmetic surgery patients are more likely than average to have a poor body image. More striking is Sarwer's finding that 18 per cent of a sample of patients having cosmetic surgery were taking drugs to treat a psychiatric condition, typically an antidepressant (Plastic and Reconstructive Surgery, vol 114, p 1927). Only 5 per cent of patients undergoing non-cosmetic plastic surgery were taking similar drugs.
That in itself doesn't mean cosmetic surgery is a bad idea, says Sarwer. These patients also invest more than others in their appearance, fitness and health, and the greater use of psychiatric medicines may be a sign that they pay equal attention to their mental health.
Short-term satisfaction
Numerous studies have found that most patients seem satisfied with their procedures, at least in the short term, and surgery might even improve body image. A 2002 study led by Thomas Cash of Old Dominion University in Norfolk, Virginia, found a woman's perception of her body image improves for at least two years after she has had breast implants, while a 2005 study of general cosmetic procedures by Sarwer's team found it improves for at least one year (Aesthetic Surgery Journal, vol 25, p 263). Whether such improvements in body image last longer than a few years is not known, and studies of patients' self esteem, depression rates and perceived quality of life are inconclusive.
However, findings from epidemiological studies of a link between cosmetic surgery and suicide are firmer and more disturbing. Five recent studies, including a US study of over 13,000 women who received breast implants and another from Canada of 24,000 (American Journal of Epidemiology, vol 164, p 334), set out to investigate the alleged link between silicone breast implants and cancers, autoimmune diseases and other disorders. Though they failed to confirm any such connection, another striking link did emerge: women who have received breast implants are two to three times as likely to kill themselves as those who have not. "The only consistent finding from all the studies has been the unexpected one of suicide," says Joseph K. McLaughlin, director of the International Epidemiology Institute in Rockville, Maryland, who ran some of the studies.
The suicide risk revealed by these studies could turn out to be an underestimate, as deaths due to suicides are frequently attributed to other causes. For example, an update to the US study this year found that women with breast implants also have a higher risk of suffering a fatal road accident and some of those deaths could be suicides, suggests study leader Louise Brinton of the National Cancer Institute in Bethesda, Maryland (Epidemiology, vol 17, p 162). Meanwhile, McLaughlin has been re-examining death notices of Swedish women with implants. He says that early indications suggest that suicide may turn out to be even more common than reported in these women (BMJ, vol 326, p 527).
Other surgical cosmetic procedures may also be associated with a suicide risk, although it has yet to be quantified for most of them. The largest mortality study, conducted in Canada, found the suicide risk was almost doubled for the 25,000 women who received breast implants and 16,000 women who underwent other cosmetic procedures. A Danish study also found a moderate increase in suicide risk in breast reduction patients (Archives of Internal Medicine, vol 164, p 2450).
There is also anecdotal evidence to suggest that it's not just women who are at risk. According to Leroy Young, a plastic surgeon in private practice in St Louis, Missouri, the patients most prone to violence against themselves, and their surgeons, are young, narcissistic males who have had nose or penis surgery. "There's a plastic surgery aphorism - don't operate on the male mid-line," he says.
Trying to get at the reasons behind this increased risk of suicide is difficult. Some commentators even argue that the findings so far may not be relevant to women currently considering breast implants, as most of the women in the studies got their implants decades ago. "It's a very different world now," says James Wells, a plastic surgeon in private practice in Long Beach, California. "The implants are better, how we assess the patients is better, and implant failure rate is lower." This does not reassure epidemiologists such as Brinton and McLaughlin, who have continued to search for clues to what is behind the increased risk of suicide.
One possibility - admittedly very remote, but not yet ruled out - is that leaks from implants can alter women's brain chemistry, triggering suicide in some. Another idea is that women with breast implants commit suicide more often because they are also more likely to use drugs or alcohol. The findings of the US study are consistent with that hypothesis, as it found that women who had breast implants were more likely than other women to die for reasons related to drug and alcohol use.
A more plausible explanation is that women who receive implants have personality traits or psychiatric disorders that go undetected by surgeons or are ignored by them, and that these put the women at risk of suicide. This view is backed up by the Danish study, which discovered that 8 per cent of women who had breast implants had earlier been admitted to a psychiatric hospital, the most common diagnoses including "neurosis and personality disorders" and "substance or alcohol abuse". Half the women with breast implants who committed suicide had been admitted to a psychiatric hospital before their surgery. It is unclear whether these women were predisposed to suicide and were tipped over the edge by a poor response to cosmetic surgery. "There are some who contend that patients who receive implants demonstrate a host of psychological problems that put them at risk for eventual suicide," says Brinton. "Whether this is the sole explanation or whether patient dissatisfaction after the operation is also involved is not yet clarified."
Another condition that is common among people having cosmetic surgery is body dysmorphic disorder or "imagined ugliness".