It has been recommended that the assessment of. COSMETIC Outcomes Article

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1 COSMETIC Outcomes Article Psychosocial Characteristics of Young Norwegian Women Interested in Liposuction, Breast Augmentation, Rhinoplasty, and Abdominoplasty: A Population-Based Study Iiná Márjá Javo Tore Sørlie, M.D., Ph.D. Tromsø, Norway Background: The present study investigated various psychosocial factors expected to predict an interest in liposuction, breast augmentation, rhinoplasty, and abdominoplasty. Methods: Questionnaire data were obtained from 1862 participants who responded to a survey distributed to a representative sample of 3500 women from northern Norway aged 18 to 35 years. Results: Liposuction was the most popular procedure (25 percent), followed by breast augmentation (15 percent), rhinoplasty (7.0 percent), and abdominoplasty (5.6 percent). Most of the women interested in rhinoplasty and breast augmentation reported interest in more than one procedure, whereas the vast majority of women interested in abdominoplasty were not interested in any other procedure. Multiple regression analyses showed that a low level of education, indicators of social acceptance of cosmetic surgery, and negative appearance evaluation were predictors of an interest in all procedures. Body dysmorphic disorder like symptoms, appearance orientation, and teasing history were predictors of an interest in all procedures except for abdominoplasty, whereas having children was a predictor of all procedures except for rhinoplasty. Divorce rate and eating disorder were predictors of an interest in liposuction only. Univariate regression analyses showed that the Big-Five personality traits were associated with all procedures except abdominoplasty. Conclusions: It appears that women interested in abdominoplasty may be motivated by a desire to repair the bodily changes occurring after childbirth, whereas women interested in liposuction, breast augmentation, and rhinoplasty may have more complex psychological factors associated with their interest in cosmetic surgery. The findings of this study provide increased knowledge about psychosocial factors characterizing women interested in liposuction, breast augmentation, rhinoplasty, and abdominoplasty. (Plast. Reconstr. Surg. 125: 1536, 2010.) It has been recommended that the assessment of patients psychological suitability for cosmetic surgery should focus on three areas: (1) identifying motivations for and expectations about surgery; (2) assessing physical appearance and body image; and (3) collecting psychiatric history and evaluating current psychosocial functioning. 1 3 From the Institute of Clinical Medicine, Faculty of Medicine, University of Tromsø, and the Department of Specialized Psychiatry, University Hospital of North Norway. Received for publication August 17, 2009; accepted December 3, Copyright 2010 by the American Society of Plastic Surgeons DOI: /PRS.0b013e3181d5135a Studies indicate that there are psychological differences among women with an interest in the different cosmetic procedures. Body dysmorphic disorder is relatively frequently reported in rhinoplasty patients, 4 whereas preoperative depressive symptoms, 5 psychiatric history, 6 admissions to psychiatric hospitals, 7,8 use of psychotropic drugs, 9 and an excess of suicide 8,10 15 are all reported more frequently among breast augmentation patients Disclosure: The authors have no financial interest to declare in relation to the content of this article

2 Volume 125, Number 5 Psychosocial Characteristics than among patients having other types of cosmetic surgery. Furthermore, an interest in cosmetic surgery in general has been found to be related to various psychological constructs, such as personality features, self-esteem, self-assessed attractiveness, 16 body dysmorphic disorder like symptoms, 17 and body image 17,18 ; and sociodemographic variables such as teasing history, knowing someone who has had cosmetic surgery, having been recommended cosmetic surgery, 17,18 education, having children, and quality of relationship with parents. 17 Given the disturbed body image in patients with eating disorders, the assessment of eating disorders has been considered central to preoperative psychological evaluation of patients seeking cosmetic surgery. 19 It has further been suggested that an insecure style of interpersonal attachment might be implicated in the cause of body dissatisfaction 20 and might therefore also be a motivation for cosmetic surgery. Psychosocial factors found to be associated with cosmetic surgery in general may be common or, to a varying degree, may differ between the specific procedures. It is important to study women at different motivational stages of the process of having cosmetic surgery, as women with a preliminary interest in cosmetic surgery may differ from women who are already scheduled to undergo and those who have undergone surgery. The latter groups have gone through the evaluation procedures of the plastic surgeon, and a number of patients may have been left out because of psychopathologic characteristics or other reasons incompatible with cosmetic surgery. The aim of the present study was to identify psychosocial factors characterizing women in the normal population interested in the four most common cosmetic procedures: liposuction, breast augmentation, rhinoplasty, and abdominoplasty. SUBJECTS AND METHODS Samples and Procedure This study is an elaboration of a previous study published 17 in Plastic and Reconstructive Surgery, with an identical sample and procedure. The first article focused on current attitudes in the society toward cosmetic surgery in general, whereas the present study is focused on specific procedures. By studying women from the normal population rather than from a clinic, we wanted to obtain a representative sample of those interested in the different procedures. A clinical sample from the few cosmetic surgery clinics that exist in northern Norway would have become strongly selective. We restricted the sample to women aged between 18 and 35 years because the pure cosmetic motives may be easier to detect among younger women, who may be less inclined to change their appearance because of concerns about aging. Three thousand five hundred women were randomly drawn by Statistics Norway from the female population of the two northernmost Norwegian counties, Troms and Finnmark. A questionnaire with 113 items was sent by mail in June of 2006, and a reminder was given twice. The study was anonymous and approved by the Regional Medical Ethics Committee and the Norwegian Social Science Data Services. The informants consented by returning the completed questionnaires. Measures Previous and Future Cosmetic Surgery Cosmetic surgery was defined as surgery without a recommendation and referral by a physician because of deformities, trauma, or other medical indications. We asked whether or not they would consider having cosmetic surgery and, if so, which type of procedure. Our main outcome variables were an interest in liposuction, breast augmentation, rhinoplasty, and abdominoplasty. Finally, we asked whether or not the respondents previously had undergone cosmetic surgery. Body Dysmorphic Disorder Like Symptoms Body dysmorphic disorder is defined as a preoccupation with an imagined defect in one s appearance. Alternatively, where there is a slight physical anomaly, the person s concern is markedly excessive. Similar to previous studies, 21,22 we used the Mini-International Neuropsychiatric Interview for the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for diagnosing body dysmorphic disorder, 23 for self-rating of what we labeled as body dysmorphic disorder like symptoms (yes/no questions): Are you constantly thinking that there is something wrong with your appearance? Has this concern continued despite the fact that people (including your general practitioner) sincerely think that your dissatisfaction with your appearance is exaggerated? Has this concern caused significant distress or impairment in social functioning or in any other area? A yes on all three questions was needed. Personality A 10-item version of the Big-Five personality inventory was used. 24 It has shown adequate levels in terms of (1) convergence with the widely used Big-Five measures in self, observer, and peer re- 1537

3 Plastic and Reconstructive Surgery May 2010 ports; (2) test-retest reliability; (3) patterns of external correlates; and (4) convergence between self and observer ratings. Score range for each subscale is 2 to 10. Cronbach values were as follows: extraversion, 0.70; agreeability, 0.21; conscientiousness, 0.49; emotionally stable, 0.52; and openness, Cronbach is a measure of internal reliability of the items of a scale. When using this instrument, relatively low Cronbach values are expected. 24 Interpersonal Attachment Security The respondents were asked to define their level of intimate interpersonal functioning within one of three levels 25 : 1. I find it easy to have close relationships. I like to depend on others and like that others depend on me. I am seldom concerned that others will leave me or come too close to me. 2. I feel somewhat uncomfortable when having others close to me. I find it difficult to trust them completely and to depend on them. I feel uneasy when others are coming too close and my lovers wish more intimacy than I do. 3. I feel that others are reluctant to be as close as I want. I often feel worried that my partner does not love me or does not want to continue the relationship. I want to fuse together with another person. This wish often frightens them away. Self-Esteem We used a Norwegian translation of Tafarodi and Swann s Self-Liking and Competence Scale to measure global self-esteem, 26 which constitutes (1) a self-liking dimension, based on perception of feedback from the social environment (score range, 10 to 50; Cronbach 0.91); and (2) a self-competence dimension, based on internal conceptions of success and failure in performing tasks (score range, 10 to 50; Cronbach 0.88). Body Image Body image was measured by two subscales of the Multidimensional Body Self-Relations Questionnaire 27 as translated into Norwegian by Loland. 28 We used the seven-item appearance evaluation subscale measuring the overall satisfaction with one s appearance (score range, 7 to 35; Cronbach 0.83) and the 12-item appearance orientation subscale measuring the individual s perceived importance of her own appearance (score range, 12 to 60; Cronbach 0.90). In both subscales, the difference of the mean value between women interested in cosmetic surgery in general and those without such an interest was approximately 5. To obtain clinical meaning to a one-unit change in the logistic regression analyses, both subscales were divided by Satisfaction with Sexual Life Satisfaction with sexual life was rated on a fivepoint measure ranging from 1 (very dissatisfied) to 5 (very satisfied). Eating Disorder A five-item scale (Eating Disturbance Scale) was used to measure disordered eating behavior (score range, 5 to 25; Cronbach 0.83). A cutoff value of 16.0 was used, indicating pathologic values from 16.0 and above. 30 Results suggest that the Eating Disturbance Scale is sensitive to distorted eating behavior and is suitable for screening purposes in community samples. 30 Emotional Distress The Symptom Check List is a five-item version of the anxiety and depression subscales of the Hopkins Symptom Check List (score range, 5 to 25; Cronbach 0.88). A cutoff value of 2.0 was used, indicating pathologic scores from 2.0 and above. 31 Sociodemographic Variables Educational level was defined as high (university/college) or low (junior school/high school). Relationship status was categorized as being in a long-term relationship, married, divorced/separated, or none of the above. Having children was coded yes/no. Perceived Quality of Social Network and Family Relations One yes/no question assessed whether or not the respondent felt that she had enough good friends. A five-point scaled measure assessed whether the respondent wished a better relationship with their father and their mother, which was later unified into a single variable, quality of relationship with parents. Teasing History One yes/no question recorded the respondents experience with being repeatedly teased for appearance. Indicators of Social Acceptance of Cosmetic Surgery Two yes/no questions recorded whether or not they knew someone who had undergone cosmetic surgery, and whether or not they had been recommended for cosmetic surgery 18 (r s 0.14). Physical Exercise One yes/no question recorded whether or not the respondents exercised regularly. Height and weight were also recorded and used to calculate body mass index. 1538

4 Volume 125, Number 5 Psychosocial Characteristics Statistical Analyses Missing values ranged from 0 to 2 percent and were replaced by series means. In all regression analyses, the groups with an interest in the different procedures were compared with women not interested in cosmetic surgery. Those variables that were significant (p 0.01) in the univariate logistic regression analyses were included in multiple logistic regression analyses by stepwise regressions. Correlations involving dichotomous predictors were tested by the Spearman r s, and those between continuous predictors were tested using the Pearson r. Except for the correlation between the self-liking and self-competence scales (r 0.72) and between appearance evaluation and self-liking (r 0.69) and self-competence and appearance evaluation (r 0.56), all correlations between the different predictor pairs were below The strength of the predictors was expressed as odds ratios with 95 percent confidence limits. For the continuous predictors, the odds ratio indicates the effects of a one-unit change in the predictor. 29 All statistical tests were performed as two-tailed tests, and the significance level in the multiple regression analyses was set at p SPSS for Windows 16.0 (SPSS, Inc., Chicago, Ill.) was used for all statistical analyses. RESULTS Of 3500 questionnaires, 208 were returned because of wrong address, giving a final sample of 3292 subjects. One thousand eight hundred eighty subjects returned the questionnaire, of which 18 had to be removed because too many values were missing. Thus, 1862 subjects represents a response rate of 56 percent. The prevalence of an interest in the listed procedures was as follows: liposuction, 25 percent (mean age, years); breast augmentation, 15 percent (mean age, years); rhinoplasty, 7.0 percent (mean age, years); and abdominoplasty, 5.6 percent (mean age, years). We found an interest in more than one type of procedure among 69 percent of those interested in rhinoplasty, 57 percent of those interested in breast augmentation, 35 percent of those interested in liposuction, and 17 percent of those interested in abdominoplasty. We further found that 4.8 percent of those interested in liposuction, 4.3 percent of those interested in breast augmentation, 3.8 percent of those interested in abdominoplasty, and 2.3 percent of those interested in rhinoplasty reported having undergone cosmetic surgery previously. As shown in Table 1, low educational level, having been recommended cosmetic surgery, and low appearance evaluation were significant predictors in the multivariate analyses of all four procedures. Low educational level had the strongest association with an interest in breast augmentation, whereas having been recommended cosmetic surgery had the strongest effect on an interest in rhinoplasty. When predicting an interest in abdominoplasty, the odds ratio of appearance evaluation was twice the strength as compared with predicting an interest in breast augmentation. Table 1 further shows that body dysmorphic disorder like symptoms, teasing history, and appearance orientation were predictors of an interest in all procedures but abdominoplasty. The odds ratio of body dysmorphic disorder like symptoms was twice as high when predicting rhinoplasty compared with liposuction. The effect of appearance orientation was strongest in an interest in breast augmentation, whereas the odds ratios of teasing history had more even values. Interests in all of the procedures, except rhinoplasty, were predicted by having children and knowing someone who had undergone cosmetic surgery, both of which were strongest in the abdominoplasty group. The odds ratio of having children was five times greater for abdominoplasty than for liposuction. Being divorced/separated and having an eating disorder were significant predictors of an interest in liposuction only. Agreeability and exercising, in contrast, were significant predictors of rhinoplasty only. The predictor variables significant only in the univariate analyses and those not significant at all are listed in Table 2. DISCUSSION We found a relatively high interest in the different cosmetic procedures, with liposuction being the most popular (25 percent), followed by breast augmentation (15 percent), rhinoplasty (7.0 percent), and abdominoplasty (5.6 percent). Many reported an interest in more than one procedure, especially among those interested in rhinoplasty and breast augmentation. Consequently, many of the respondents were included in the analysis of more than one group. In the multiple regression analysis, we found that low educational level was a strong predictor of an interest in all of the procedures, and strongest among women interested in breast augmentation, which is in line with Brinton et al., who found that women with breast implants had a lower educational level than women who had undergone other types of cosmetic surgery. 32 Similar to pre- 1539

5 Plastic and Reconstructive Surgery May 2010 Table 1. Multiple Logistic Regression Analyses of Predictors of an Interest in Breast Augmentation, Rhinoplasty, Liposuction, and Abdominoplasty Breast Augmentation (n 1221) Rhinoplasty (n 1070) Liposuction (n 1407) Abdominoplasty (n 1044) 95% CL 95% CL 95% CL 95% CL OR Lower Upper p OR Lower Upper p OR Lower Upper p OR Lower Upper p Education Having been recommended cosmetic surgery Appearance evaluation* BDD-like symptoms NS Knowing someone who has had cosmetic surgery NS Having children NS Teasing history NS Appearance orientation* NS Divorced/separated NS NS NS Eating disorder NS NS NS Agreeability* NS NS NS Exercising NS NS NS CL, confidence limits; OR, odds ratio; BDD, body dysmorphic disorder; NS, nonsignificant. *Continuous variable. Table 2. Univariate Logistic Regression Analyses of Predictors of an Interest in Breast Augmentation, Rhinoplasty, Liposuction, and Abdominoplasty Breast Augmentation (n 1221) Rhinoplasty (n 1070) Liposuction (n 1407) Abdominoplasty (n 1044) Nonsignificant BMI, extraversion, agreeability, having enough friends, being married, in a long-term relationship, divorced/separated Significant positive predictors Significant negative predictors Emotional distress, eating disorder Age, conscientiousness, emotionally stable, openness, interpersonal attachment security, self-liking, selfcompetence, exercising, satisfaction with sexual life, quality of relationship with parents BMI, body mass index; BDD, body dysmorphic disorder. BMI, age, having children, having enough friends, being married, in a long-term relationship, divorced/separated Emotional distress, eating disorder, knowing someone who has had cosmetic surgery Extraversion, conscientiousness, emotionally stable, openness, interpersonal attachment security, self-liking, selfcompetence, satisfaction with sexual life, quality of relationship with parents BMI, age, extraversion, being married, in a long-term relationship BMI, extraversion, agreeability, conscientiousness, emotionally stable, openness, interpersonal attachment security, appearance orientation, having enough friends, in a longterm relationship Emotional distress Emotional distress, eating disorder, Agreeability, conscientiousness, emotionally stable, openness, interpersonal attachment security, self-liking, selfcompetence, exercising, satisfaction with sexual life, having enough friends, quality of relationship with parents BDD-like symptoms, teasing history, being married, divorced/separated, age Self-liking, self-competence, exercising, satisfaction with sexual life, quality of relationship with parents 1540

6 Volume 125, Number 5 Psychosocial Characteristics vious studies with larger age spans, 18,33 age was not significant in any of the multivariate analyses, although women interested in abdominoplasty were older and women interested in breast augmentation were younger than their peers. As predicted, 18 we found that having been recommended cosmetic surgery and knowing someone who has had cosmetic surgery were significant predictors of an interest in all of the procedures. However, among those interested in rhinoplasty, only having been recommended cosmetic surgery was significant in the multivariate analysis. Recent studies using validated measures of body image together with satisfying comparison groups have found that overall body image is a strong predictor of an interest in cosmetic surgery in general. 17,18 In the present study, appearance evaluation was a negative predictor of all of the procedures and was strongest in abdominoplasty. Appearance orientation, in contrast, was a significant predictor in all procedures except abdominoplasty. This is in concordance with Bolton et al., who studied a sample of abdominoplasty patients. 34 It appears that women interested in abdominoplasty have the lowest satisfaction with appearance but at the same time consider their own appearance less important than women interested in other procedures. This is further demonstrated by the fact that the presence of body dysmorphic disorder like symptoms was a strong predictor of an interest in all of the procedures except abdominoplasty. The presence of body dysmorphic disorder like symptoms was the strongest predictor of an interest in rhinoplasty, which is in concordance with previous findings of the nose being the most common preoccupation in body dysmorphic disorder patients. 4,35 The presence of body dysmorphic disorder like symptoms was based on the same criteria that are used in the Mini-International Neuropsychiatric Interview for the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) for diagnosing body dysmorphic disorder, but it is not designed for self-reporting and our results must therefore be interpreted with caution. Having children was strongly associated with an interest in abdominoplasty and moderately associated with an interest in liposuction and breast augmentation, which can be explained by the bodily changes occurring after pregnancy affecting breasts, fat deposits, and the abdominal wall. Previous studies suggest that teasing history is associated with an interest in breast augmentation 36 and in cosmetic surgery in general. 17,18 However, together with body image variables in the final model, teasing history did not reach statistical significance in two of the above-mentioned studies. 18,36 In the present study, teasing history was a significant predictor of an interest in all of the procedures, except for abdominoplasty, even with body image variables included in the model. Studies from the earlier era of cosmetic surgery revealed that women with breast implants had a higher divorce rate than controls In our study, we found no such association, which may partly be attributable to the age limit of 35 years in the sample. However, women interested in liposuction had a remarkably higher divorce rate than controls, which also turned out to be the strongest predictor of an interest in liposuction. Women with breast implants appear to have below-average body weight, 32,36,40 43 which has led to the concern that there is an increased prevalence of eating disorders among these women. Alagöz et al. found disordered eating behavior in 10.2 percent of a sample of 75 patients having cosmetic surgery other than for body fat. 44 In the present study, body mass index was not a significant predictor in any of the univariate analyses, which is in line with Henderson-King and Henderson-King 45 but contrary to the findings of Frederick et al. 33 Nevertheless, eating disorder was a significant predictor in the univariate analysis of an interest in breast augmentation, but when introducing body dysmorphic disorder like symptoms into the final model, the effect of eating disorder diminished. In the multiple regression analysis of an interest in liposuction, eating disorder remained a significant predictor, even with body dysmorphic disorder like symptoms included in the model. Zojaji et al. studied rhinoplasty candidates and found them to have certain personality dispositions. 46 In the present study, all the Big-Five personality traits were significant in the univariate analysis of an interest in rhinoplasty, but only agreeability remained significant when the presence of body dysmorphic disorder like symptoms was introduced into the model. None of the Big-Five personality traits was associated with any other procedure in the multivariate analysis. Abdominoplasty was the only procedure where none of the personality variables was significant in the univariate analysis. Exercising turned out to be negatively associated with all of the procedures, but lost significance when introducing having children into the model, except in rhinoplasty, where having children was nonsignificant. These findings could generate a hypothesis that people who are exercising on a regular basis and thus doing something actively to keep in shape are less inclined to seek 1541

7 Plastic and Reconstructive Surgery May 2010 more passive surgical solutions for their appearance dissatisfaction. Both self-esteem subscales (self-liking and selfcompetence) were significant in the univariate analysis of all the procedures, but none remained significant in the end. This is in concordance with previous studies where the significance of self-esteem variables has diminished when introducing body image variables. 17,18 Emotional distress and quality of relationship with parents were associated with all of the procedures in the univariate analyses, and interpersonal attachment security was associated with all procedures but abdominoplasty. However, when introducing other predictors, the effect of these variables diminished in the multivariate analysis. A weakness of the study is that the sample was collected from a limited geographic area, with cultural differences limiting generalization. The large sample size, the great variety of potential predictor variables included, and the use of validated instruments provide strength to the study. Among the 43 percent that did not respond, there was an overrepresentation among the youngest women in Finnmark County. This may reflect the fact that relatively many of these women migrate from Finnmark to get an education and therefore are not currently living at their official address. Women with less interest in cosmetic surgery may have been less inclined to respond. The results of this study may lead to a better understanding and increased awareness of psychosocial factors characterizing women seeking liposuction, breast augmentation, rhinoplasty, and abdominoplasty. It appears that in contrast to an interest in abdominoplasty, where having children is a strong predictor, an interest in liposuction, breast augmentation, and rhinoplasty may be relatively strongly associated with various psychosocial factors. As proposed by Solvi et al., 47 this suggests that there are differences between women wanting to repair their body after having children and women that simply want to create or improve a physical feature. The associations of divorce rate and eating disorder with an interest in liposuction should be further tested in future studies. Tore Sørlie, M.D., Ph.D. Institute of Clinical Medicine Faculty of Medicine University of Tromsø N-9037 Tromsø, Norway tore.sorlie@unn.no ACKNOWLEDGMENT This study received financial support from the Institute of Clinical Medicine, Faculty of Medicine, University of Tromsø. REFERENCES 1. Sarwer DB. Psychological considerations in cosmetic surgery. In: Goldwyn RM, Cohen MN, eds. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. Philadelphia: Lippincott Williams & Wilkins; 2001: Sarwer DB. Psychological assessment of cosmetic surgery. In: Sarwer DB, Pruzinsky T, eds. 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