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look and what others think [10]. Self-esteem and self-worth also develop early, and can either be stable traits or states that are subject to change over time [20]. Research indicates that global self-worth tends to vary over time for students whose self-esteem is primarily dependent on the feedback of others, whereas those whose feelings are primarily dependent on self-approval have a more stable sense of self-esteem. This research has implications for why adolescents want plastic surgery, as well as the extent to which plastic surgery is likely to improve their self-esteem. A Dutch study examining the psychological benefit of cosmetic surgery among 12- to 22-year-olds, found that satisfaction with the body parts that the patients considered deformed improved 6 months after cosmetic surgery, especially for breast reduction and augmentation patients [21]. However, the no-treatment comparison group of Dutch adolescents with self-reported deformities also felt better about themselves 6 months later, especially among those 18 and older. These results suggest that body image improves among teenagers as they mature, whether or not they undergo cosmetic surgery. Similarly, a longitudinal study of adolescent males and females, ages 11 to 18, found body image satisfaction rates were highest at age 18 in both sexes, and that the satisfaction of individual participants varied as a function of their age and developmental stage [22]. Overall, these studies indicate that dissatisfaction with appearance decreases with age throughout adolescence, and also many adolescents who are very dissatisfied with their appearance will feel more satisfied as they mature, especially after the age of 18, even if they do not undergo cosmetic surgery. Mental Health and Cosmetic Surgery The ultimate role of plastic surgery has been described as “To alter the patient’s body image, and thus to improve the patient’s quality of life” [10]. However, research indicates a more complicated relationship between cosmetic surgery and mental health variables such as self-image and quality of life. In general, women report satisfaction with breast augmentation in the year following surgery [12,22]. However, six long-term retrospective studies indicate that breast augmentation patients are significantly more likely to commit suicide, compared to women of similar age who had other plastic surgery or represent the general population [23]. The six studies did not examine whether mental health problems developed before or after surgery, although several of the authors speculate the problems predated surgery. If mental health issues predate surgery, better screening and referrals are needed. On the other hand, if mental health problems develop or worsen after surgery, it is important to determine why this is occurring. The research literature on eating disorders provides useful clues about body image and its implications for adolescents’ motivation to undergo plastic surgery. Studies indicate that distorted body image and other mental health issues, rather than actual weight problems, are the main incentive for adolescents to go to extreme measures to lose weight [24]. It is logical to consider that similar problems may be influencing the desire for liposuction, and whether girls or women with eating disorders or distorted body image might be especially likely to seek liposuction. Distorted body image and a distorted ideal body image could also result in the desire for breast augmentation. Both the potential effects of surgery on a child’s developing body image, and the extent to which psychopathology or distorted body image may result in the pursuit of plastic surgery are important areas for study. It is generally acknowledged that it is difficult to assess adolescent body image because of the increased selfconsciousness and dissatisfaction with physical appearance 320 D. Zuckerman and A. Abraham / Journal of Adolescent Health 43 (2008) 318 –324 that is common at this stage of development [25]. However, several studies attempted to measure the specific body image issues related to adolescents seeking cosmetic surgery. The previously cited study of Dutch adolescents (ages 12– 22) presenting for plastic surgery found that these patients did not differ from other adolescents on most selfconfidence or mental health measures. However, they were slightly less confident of their physical appearance and romantic appeal, and significantly more dissatisfied with the body part for which they were considering surgery compared to adolescents in the general population [21]. A study of women 18 and older seeking breast augmentation clearly illustrates how the reported dissatisfaction with their bodies may reflect a distorted body ideal among cosmetic surgery patients [26]. Those seeking breast augmentation were less satisfied with their breast size than a matched control sample, but they did not differ significantly in their bra size. The women choosing augmentation reported a larger ideal breast size, with almost all choosing a bra cup size of C or D as ideal, compared to a B or C cup as the ideal size for the matched controls. The largest current size of the augmentation group was 34C, and the largest ideal size was 38D. This indicates that desiring breast augmentation is not necessarily a function of small breast size, but instead may reflect an unusually large ideal size.
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