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Teens seeking cosmetic surgery report greater dissatisfaction with specific body parts, and increased concern about their general appearance which raises questions about the extent to which they may have body-image related pathology such as body dysmorphic disorder (BDD). BDD is defined as “a preoccupation with an imagined or slight defect in appearance that leads to significant impairment in functioning” that usually starts during adolescence [27], with 16 years old as the average age of diagnosis [3]. There are few studies of BDD that include adolescent cosmetic surgery patients. Research indicates that approximately 7% to 15% of cosmetic surgery patients have BDD, and that most BDD patients seek plastic surgery; researchers report that the BDD is unlikely to improve as a result of surgery and may worsen [3]. In contrast, BDD patients are more likely to improve from therapy or psychotropic medication. Several researchers have suggested that an assessment of psychiatric status and history is an important part of the evaluation of an adolescent presenting for cosmetic surgery, with special attention to disorders with a body image component, including eating and somatoform disorders, mood, and anxiety disorders [2]. The Body Dysmorphic Disorder Questionnaire could be used as a screening tool [28]. In addition to screening for BDD, psychological testing could potentially help ensure that teenagers are mature enough to undergo cosmetic surgery. Plastic surgeons describe cautious interviews aimed at determining why the teen wants plastic surgery, saying that they reject patients with unrealistic expectations and those having the surgery to please a boyfriend or parent [29,30]. In contrast, plastic surgeons state that having surgery based on internal motivations, such as “I will feel better about myself” or “clothes will fit better” are considered appropriate responses, despite the lack of evidence that those goals will be met. Benefits of Cosmetic Surgery There are few well-designed studies examining the psychological benefits of cosmetic surgery. There are none that examine long-term benefits among adolescent patients. Postoperative studies of plastic surgery patients are primarily surgeons’ reports of their patients’ satisfaction [2]. The majority of postoperative studies of psychological changes have found psychological benefits; however, these studies had significant methodological shortcomings, such as follow-up of 6 months or less [2]. When the research design was improved, the results have indicated more limited benefits of surgery. For example, one 6-month follow-up study of 45 adult women who completed preoperative and postoperative assessments reported significant improvements in the self-rated body image dissatisfaction only for the feature surgically altered [31]. On average, the women did not report significant changes in their overall body image or satisfaction with their appearance. The impact of surgery might have been even less impressive had there been a comparison group of women undergoing nonsurgical training, enhancements, medication, or therapy to improve their appearance or body image. For example, cognitive behavioral treatments have been used successfully with women with BDD [32,33], and although many psychotropic drugs used for BDD are apparently ineffective, high doses of several serotonin-reuptake inhibitors taken for at least 10 –12 weeks were found to result in significant improvement [28]. Two well-designed 2-year follow-up studies of women 18 and older with breast augmentation found that on most measures of self-esteem, self-concept, and quality of life, the subjects showed either no improvement or statistically lower scores 2 years after augmentation compared to prior to augmentation [34]. Their only improvement was their responses regarding the attractiveness of their breasts. If the goal of cosmetic surgery is to “feel better about myself,” the results suggest that many girls and women seeking cosmetic surgery might benefit more from therapeutic approaches aimed at improving self-esteem or general body image or those aimed at decreasing depression. At this time, there are no well-designed studies that conclusively demonstrate that cosmetic surgery significantly improves body image for the surgically altered feature in the long term. Similarly, there are no conclusive studies that indicate that cosmetic surgery improves overall body image or quality of life for adolescents or adults. Short-term studies suggest that any benefits are likely to be specific to self-concept regarding the specific body part that was surgically altered, rather than a more general improveD. Zuckerman and A. Abraham / Journal of Adolescent Health 43 (2008) 318 –324 321 ment in self-esteem, self-concept, or quality of life. However, for surgeries such as breast augmentation and liposuction, any short-term benefits may decrease over time due to weight gain, aging, or common implant complications. Financial Implications The financial costs of cosmetic surgery can be substantial, because corrective surgery is rarely covered by health insurance. Many plastic surgeons offer cosmetic surgery on the installment plan [35], and more than one-third of augmentation patients undergo additional surgery to correct problems within 3 years [36,37]. Therefore, many young women who need to have a broken or
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