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More Than Meets the Eye The Psychosocial Benefits of Cosmetic Surgery
MORE THAN MEETS THE EYE:
THE PSYCHOSOCIAL BENEFITS OF COSMETIC SURGERY
BY SINEHAN B. BAYRAK, MD
Our world has become an increasingly more visual place. In 2018, an estimated one trillion photos were taken.1 Other reports have shown that a significant portion of photos are selfies. Ultimately, we are constantly being bombarded by images of faces – including our own. With the COVID-19 pandemic and subsequent popularity of online video meetings, this effect has further been magnified and is likely responsible for the upsurge in cosmetic surgeries over the past two years.
As this evolution has taken place, we have become both more aware of our physical features but also more critical of them. A spur-of-the-moment selfie may have drawn your attention to the size of your nose or a Zoom meeting may have you tugging at extra skin under your neck. According to the 2021 American Academy of Facial Plastic and Reconstructive Surgery survey, 79 percent of facial plastic surgeons identify patients seeking procedures for an improved appearance on video conferences as a rising trend, compared to only 16 percent in 2020.2 With the increased flexibility of remote work and the ever-decreasing stigma of plastic surgery, more and more individuals are opting to pursue surgical interventions for facial features that they dislike.
Additionally, individuals are, on average, living longer. More importantly, most individuals are maintaining careers and active social lives well past the traditional age of retirement at 65. Unfortunately, our physical bodies have continued to age at the same rate, and our increased social and professional longevity only adds pressure to maintain an appearance of youthfulness. Per the AAFPRS, an estimated 1.4 million surgical and non-surgical procedures were done in 2021, with plastic surgeons performing an average of 600 more procedures than they did in 2020, a 40% increase.2
But does putting a fresh coat of paint on change anything beneath the surface? A variety of studies suggest that it might. A meta-analysis of 37 studies suggests that patients have improvements in body image and quality-of-life after cosmetic surgery, especially those pursuing augmentation mammaplasty and aging face surgeries (e.g., face lifts).3 Another meta-analysis of 36 studies showed a positive effect of cosmetic surgery on “self-worth,” “self-esteem,” “distress and shyness,” and “quality of life.”4 Finally, a third meta-analysis of seven studies showed improvement in body image; however, no improvement was observed with regard to self-esteem, anxiety, and depression.5 Unfortunately, most of these studies suffer from small sample sizes, lack of diversity, the role of body dysmorphic disorder (BDD), and short-term follow-up; however, there is still inherent value in the questions they ask.
Anecdotally speaking, cosmetic procedures do seem to play a positive role for most patients undergoing them. Our selfperception of attractiveness seems to strongly correlate to our overall sense of happiness. In my experience as a facial plastic surgeon, the three most common anatomic areas with the greatest psychosocial improvement are periorbital rejuvenation (e.g., upper
Before
after
Patient that had a temporal brow lift, upper blepharoplasty, lower blepharoplasty, and periorbital CO2 laser resurfacing.
and lower blepharoplasty, brow lifts, etc.) and cervical rhytidectomy (i.e., neck lift). Patients who undergo these rejuvenative procedures seem to have the most significant gains when it comes to body image and selfesteem.
There is truth to the old adage of “eyes are the windows to the soul.” Eye-tracking studies have shown that most people exhibit gaze patterns that follow the eye-mouth gaze continuum.6 Simply put, during face-to-face conversation most participants alternate their gaze between the other individual’s eyes and mouth. The adoption of masking during the COVID-19 pandemic drew increased attention to the periorbital area – the intersection of the brow, upper eyelid, and lower eyelid. While upper blepharoplasty has been performed for functional vision impairment due to dermatochalasis, cosmetic upper blepharoplasty patients often present with complaints of looking tired, appearing older than their actual age, or feeling a sensation of heaviness on their upper eyelids.
Women, specifically, often endorse difficulty applying eyeshadow or mascara. Descent of the eyebrow or brow ptosis can often accompany excess skin of the upper eyelid, further exacerbating the complaints listed above. With regard to the lower eyelids, candidates for lower blepharoplasty typically have physical exam findings of lower eyelid dermatochalasis and fat herniation. They often complain of “crepiness” of the lower eyelid skin and “bags” under their eyes. Periorbital procedures like brow lifts and upper and lower blepharoplasties can address all of these concerns and complaints. Lightening the “load” on the upper eyelid not only manifests physically as increased eyelid space and a well-defined supratarsal crease; the decrease in hooding and the sensation of heaviness makes patients feel more well-rested. Similarly, addressing the undereye “bags” due to intraorbital fat herniation frequently results in a decreased perception of tiredness. Essentially, when we look less weary, we tend to feel less weary.
The popularity of virtual meetings via platforms like Zoom, Microsoft Teams, etc., has undoubtedly increased the amount of time we spend looking at ourselves. The neck, in particular, has received a spike in attention, likely exacerbated by the typically suboptimal angle of most webcams (i.e., angled upwards on laptops). Moreover, most of us are not as diligent when taking care of the neck. For example, think of all the times you’ve put sunscreen on your face but not your neck. Unfortunately, nonsurgical anti-aging treatments for the neck are limited when compared to the face. In my practice, there has been a distinct uptick in the number of patients bothered by the redundant skin and muscle dehiscence of the cervical region. Like most aging processes, this is commonly due to a tincture of factors, including genetics, environmental exposure, time, and gravity; however, there is some thought that the increased use of handheld electronics (resulting in the advent of “tech neck”) has amplified these physical changes. Thanks to our cell phones, tablets, and smart watches, we spend far more time looking downwards than our parents and grandparents.
While non-surgical therapies like neurotoxin injections, hyaluronic acid injections, and radiofrequency skin-tightening devices exist and may be appropriate options in the younger patient with realistic expectations, results achievable with these interventions are often underwhelming and, frankly, inappropriate in the older patient with moderate-to-severe skin laxity and platysmal banding. Patients often come in with stories of seeing a candid photo of themselves taken from the side (i.e., a profile view) and being bothered by this visual. Events like these lead to magnified self-consciousness regarding that particular feature. After a surgical neck lift, these patients often report high levels of happiness regarding their surgical results and their newfound freedom from their previous insecurity regarding their appearance.
When we feel good about how we look, we feel good about other aspects of our lives as well. Positive body image translates into positive interpersonal relationships, increased productivity, and a higher quality of life. It is worth mentioning, of course, that cosmetic treatments and procedures do not treat BDD or other deep-rooted psychological issues. In these situations, therapy and medication under the guidance of a mental health professional are paramount. In the absence of these circumstances, peer-reviewed studies and personal experience suggest that the effects of plastic surgery are more than skin deep.
References: 1. https://www.forbes.com/sites/petersuciu/2019/10/24/a-photo-used-to-beworth-a-thousand-words-but-thanks-to-social-media-photos-have-lost-theirvalue/?sh=2ff74c5b607f 2. https://www.aafprs.org/Media/Press_Releases/2021%20Survey%20Results. aspx#:~:text=An%20estimated%201.4%20million%20surgical,2020%2C%20a%20 40%20percent%20increase. 3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1762095/ pdf/nihms12727.pdf 4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1851945/ pdf/nihms12692.pdf 5. https://pubmed.ncbi.nlm.nih.gov/35766540/ 6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5844880/pdf/41598_2018_ Article_22726.pdf
