INTRODUCTION
There is an endless quest for perfect bodies in contemporary society. Personal
satisfaction and physical well-being are an essential part of quality of
life1. In contrast to the excessive
effort to obtain the ideal body, the emergence of plastic surgeries presented
another possibility: achieving a perfect body rapidly2,3.
The search for standards of beauty is linked to dubious diets and uncontrolled
surgical procedures. The excessive desire for a harmonious appearance can hide
psychosomatic phenomena, such as bulimia and anorexia, and other
psychopathological traits, such as Body Dysmorphic Disorder (BDD)4.
According to researchers int his field, aesthetic surgery interferes directly and
positively in the self-esteem of patients who do not have severe BDD, as well as
improves their lives in the psychosocial aspect5. Given that the abovementioned are psychological disorders, they
must be perceived as a kind of affliction, and plastic surgery, therefore, must
be perceived as an appropriate therapeutic treatment in some cases6.
Brazil is the second country in the world that performs the most plastic
surgeries; some of the most common procedures are liposuction, dermolipectomy,
mastopexy, prosthesis, and breast reduction7.
Women tend to evaluate more positively the gains of the surgery than men because
they internalize more media messages about beauty and, therefore, undergo more
procedures, among them, aesthetic mammoplasty.
The main reason for aesthetic mammoplasty is to address disproportional breasts
or severe ptosis, perceived as defective. Augmentation mammoplasty alternates
between the first and second most commonly performed plastic surgery in Brazil
and the world, as the breast is a symbol of femininity, maternity, and
sexuality, and therefore, its augmentation carries high expectations and often
promotes improvement in quality of life8,9.
A lack of knowledge and opportunity for a new study was perceived, given that
there are few studies measuring the degree of interference in the self-esteem of
women specifically seeking cosmetic mammoplasty. Few studies have compared the
level of self-esteem between the different types of mammoplasty.
OBJECTIVE
This study aimed to measure the impact of aesthetic mammoplasty on the
self-esteem of women, to shed light on the level of expectation and motivation
in the pre- and post-operative period, as well as satisfaction in the
post-operative period.
METHODS
Population and sample
This longitudinal prospective study evaluated a population of 40 women. The
inclusion criteria for this study were women who underwent primary aesthetic
mammoplasty at two private plastic surgery clinics in a capital city in
Northeastern Brazil.
Data collection
The initial data collection was performed from December 2016 to January 2017.
To answer the pre-surgical procedure questionnaire, the participants were
approached in the waiting rooms of surgeons’ offices in the last
pre-operative consultation. The participants received information about the
research objectives and then signed the informed consent form.
Two months after surgery, there was a follow-up and a new application of the
questionnaire, in which specific questions on the level of satisfaction in
the post-operative period, interference with activities, and desire to
perform another surgery were added. In both moments, they were at total
liberty to question and clear their doubts. This study was approved by the
ethics and research committee of Tiradentes University, Aracaju, Sergipe,
with CAAE number: 629097 16.1.0000.5371.
Study site
Data collection was conducted in two private plastic surgery clinics located
in Aracaju, state of Sergipe, namely, the Clínica Integrada Homo and Clínica
Concept. Subsequently, the data analysis and drafting of the manuscript was
performed at the Tiradentes University, also in Aracaju, state of
Sergipe.
Questionnaire
Self-esteem was assessed using the Rosenberg Self-Esteem Scale. The scale is
internationally validated and widely used for assessing self-esteem. It is a
self-administered questionnaire consisting of ten close-ended sentences,
with five referring to positive self-image and five to negative self-image,
using a four-point Likert scale. The options indicate the degree of
disagreement or agreement with the proposed sentence: 0 = strongly disagree,
1 = disagree, 2 = agree, 3 = strongly agree.
The interpretation of the sum of all items of the scale (crude score) should
be made with a table of standards appropriate to sex and age. The crude
score corresponding to the 15th percentile should be equivalent
to a standard deviation (SD) below the mean. The 85th percentile
should correspond to an SD above the mean. Scores that fall below the
average indicate low self-esteem, and those above the average correspond to
high self-esteem.
Data analysis
The collected data were described by means of simple frequencies and
percentages when categorical variables, or mean and standard deviation when
continuous, discrete, or ordinal. The associations were evaluated with
Fisher’s exact test. The differences in means were evaluated by the
univariate analysis of variance (independent samples) and bivariate analysis
(matched sample). The level of significance was 5%. R Core Team2017 was used
to run the analyses.
RESULTS
Demographic characteristics
The study sample consisted of 40 female participants with a mean age of
32.825± 10.8531.
With regard to professional work, 84.8% reported being active in the labor
market. As to the level of schooling, 46.1% had completed higher education
and 35.9% high school; 7.7% completed and 10.3% did not complete primary
schooling.
Motivations, proposals, and influences for completion of surgery
The primary motivation for the completion of the surgical procedure,
considering all types of mammoplasty in the current study, was the desire to
raise self-esteem. This motivation was found in 37.5% of the participants.
When asked about who suggested surgery, 85% reported that the decision was
their own initiative. In 22.5% of cases, it was by suggestion of friends and
10% of relatives.
Among the 40 participants, 57.5% reported that the main influence was the
need for personal acceptance.
Need for a social explanation on the surgical procedure performed
Regarding the option to inform people on the surgical intervention, only 7.5%
would not provide any information.
Post-surgical satisfaction
With regard to post-surgical satisfaction regarding the breasts, 25.6%
reported moderate satisfaction and 74.4% reported high satisfaction. Among
the 40 participants, one preferred to refrain from responding. Figure 1 shows the relationship between
satisfaction and the types of mammoplasty.
Figure 1 - Post-surgical satisfaction.
Figure 1 - Post-surgical satisfaction.
Pre-surgical score of the Rosenberg Self-Esteem Scale
In the pre-surgical period, the participants had a crude score of 32.1 ± 5.3.
The mean of the pre-surgical percentile was 50 ± 26.5.
Only 10% had low self-esteem (percentile < 15) in the pre-surgical
period.
Post-surgical score of the Rosenberg Self-Esteem Scale
In the post-surgery period, the participants had a gross score of 34.9 ± 4.6.
The mean post-surgical percentile was 63.3 ± 26.6.
Of the participants who had low self-esteem (percentile < 15) in the
pre-surgical period, 50% passed to average or high self-esteem, and one of
them passed from the 5th in the pre-surgical period to
95th percentile in the post-surgical period.
Variation in pre- and post-surgical scores on the Rosenberg Self-Esteem
Scale
There was a general increase of 13.3% (variation shown in Figure 2), considered average in
accordance with Cohen’s Test, in the self-esteem of participants undergoing
aesthetic mammoplasty (p = 0.009). Considering the type of
mammoplasty performed, the variation can be seen in Figure 3.
Figure 2 - Variation of the percentile in the Rosenberg Self-Esteem
Scale.
Figure 2 - Variation of the percentile in the Rosenberg Self-Esteem
Scale.
Figure 3 - Variation of pre- and post-surgical percentile on the
Rosenberg Self- Esteem Scale according to type of mammoplasty
performed.
Figure 3 - Variation of pre- and post-surgical percentile on the
Rosenberg Self- Esteem Scale according to type of mammoplasty
performed.
Interference of mammoplasty in personal, professional, and/or social
life
In 25.6% of participants, the result of plastic surgery did not interfere in
their personal, professional and/or social life. For 74.4%, surgery
interfered positively and in different ways. There was an increase of 51.3%
in self-esteem, improvement in appearance in 12.8% and greater social
acceptance in 10.3% of participants. One of the participants preferred to
abstain from responding.
The surgery interfered in a positive manner on the aspects addressed in 44.4%
of the participants who underwent mastopexy, in contrast to 83.33% of those
who did not have the procedure (p = 0.032).
Interference in the sexual life
In relation to the interference caused by the surgery in sexual life, 60%
reported a positive influence; 20% reported a moderate level and 40%, high.
Meanwhile, 5% reported a negative interference: 2.5% reported a low negative
impact and 2.5%, moderate. There was no interference in the sexual life for
30% of the participants, and 5% reported that they had no sex life.
DISCUSSION
The mean age of the individuals included in our study was 32.825 ± 10.8531 years
(minimum age 18 years and maximum of 58), characterizing a similar sample of
women who undergo these procedures based on data reported in the 2005 Census of
the Brazilian Society of Plastic Surgery (2016).
We observed a general increase in the Rosenberg Self-esteem Scale of 13.3
percentile in the self-esteem of participants attributed to aesthetic
mammoplasty (p = 0.009), which is an average increase according to the Cohen’s
test. This result is consistent with the fact that plastic surgery is considered
an adequate therapy for the improvement of self-esteem6. Moreover, it corroborates a previous study that
demonstrated how intervention in body image results in improvements in the
quality of life and biopsychosocial aspects of patients, with a statistical
correlation (p < 0.005) between general health: 90 patients at the Ivo
Pitanguy Institute reported increased self-esteem in the post-operative period
and positive influence on their relationships8.
Several authors have also reported how body satisfaction reflects on the quality
of life and emotional and social performance of the individual in society. The
quest for beauty through plastic surgery is associated with an aim of change in
acceptance and social position10-12.
Although the average pre-surgical percentile in this study was 50 ± 26.5, i.e.,
the majority of women already had average self-esteem, there was a gain in the
post-surgical percentile, with an average of 63.3 ± 26.6. Only 10% had low
self-esteem (percentile < 15) before surgery. These participants could
represent the population of women with BDD who request plastic surgery. As they
do not believe they suffer from a mental disorder, these women, before looking
for a psychologist or psychiatrist, seek out plastic surgeons. In the
post-operative period, 50% left the low self-esteem zone and 50% remained.
In a literature review of prospective studies on patients with BDD seeking
plastic surgery, Brito et al.5 concluded
that patients with mild BDD could also benefit from the results of cosmetic
surgery.
A study of 115 women divided into groups based on the number of surgeries
performed and response to the Body Shape Questionnaire and Sociocultural
Attitudes Questionnaire Regarding Appearance reported that 30.43% of the women
who had already performed more than one surgical procedure indicated being
dissatisfied with their body image; the study concluded that this result may be
a reflection of the presence of traces of BDD verified in the study
participants, as in the post-surgical period of women with severe BDD, the real
or imaginary defects remained4. If the
surgeons are not aware of the symptoms of the disease, they can re-operate these
patients, but may always obtain a negative outcome in relation to the
post-operative satisfaction of these patients.
The two participants in the present study that continued to report low
self-esteem in the post-surgical period indicated moderate satisfaction with the
results. In addition to the possibility of undiagnosed BDD, it is reasonable to
think that the experience and external factors experienced by the participant
may have altered this personal recognition after surgery. One possibility would
be that the participants did not understand the items requested by the data
collection instrument, although this seems less likely because these two
participants completed higher education.
The literature describes the importance of investigating motivations and
influences on the indication of aesthetic surgery13. Individuals who seek aesthetic surgery for purely temporal and
external reasons may not be able to assess and understand the long-term risks
and benefits of the surgery. Surgeons need to discuss and understand the
feelings and expectations of patients related to surgery and make them
understand that it is impossible to control the feedbackthey receive on their
altered appearance.
According to the present study, the majority of the participants sought
mammoplasty for internal reasons, as the main motivation for performing the
surgical procedure was the desire to raise their self-esteem (37.5%). The
majority (85%) stated that the choice of surgery was their own initiative, and
57.5% reported that the main influence was the need for acceptance. Comparing
the motivations with the post-surgical satisfaction, the data found are
consistent with the literature: of the participants who responded on
post-surgical satisfaction, all were satisfied with the results (25.6% reported
moderate satisfaction and 74.4%, high satisfaction).
However, a relevant result in this sample was that 92.5% responded that they
would have social satisfaction with the procedure performed, which proves the
necessity to obtain approval and more affection from other people. In addition,
for 32.5% of the cases, the decision of undergoing the surgical procedure was
upon the suggestion of friends or family.
Foustanos et al.14 obtained similar
results, and their findings were confirmed by this study. A project, by means of
a questionnaire on self-image, self-confidence, and work environment applied to
100 women who underwent aesthetic plastic surgery, also reported that appearance
influences professional development and that social praise affects confidence at
work14. In the present study, 84.8%
of the participants reported having a profession. Therefore, enhancing physical
appearance was reflected as gaining vigor, youth, and self-confidence necessary
for professional self-assertion.
This study also showed that the three types of surgery (breast reduction, breast
implantation, and mastopexy) produced the same outcome in self-esteem variation.
Reductive surgery, in addition to the aesthetic issue, brings relief to the
physical discomfort caused by large breast volumes. Based on this principle, we
can imagine that reductive surgery would bring a higher gain in the variation of
self-esteem. However, this hypothesis was not tenable, considering that
surgeries of only an aesthetic nature are as impactful in improving the quality
of life and biopsychosocial aspects of participants as reparative surgeries.
In relation to post-surgical satisfaction, 60% of the participants who underwent
mastopexy were satisfied, and 40% reported positive and high interference in
their sexual life.
Of the participants who underwent mastopexy, 70% had already had children. The
literature describes the breast as a symbol of femininity and female
sexuality9. Thus, it has erogenous
power and represents a bodily identity. If the woman suffers significant
physical alterations in the breast, including those resulting from
breastfeeding, then there will be impairment of the psychological functions.
Accordingly, the main motivation of 50% of the participants who opted for
mastopexy was the increase of self-esteem.
In our sample, surgeries interfered positively on personal, professional, and/or
social life in 44.4% of the participants who underwent mastopexy. This result
was expected, as those who undergo mastopexy are usually younger, sexually and
professionally active women who have had their breasts modified by changes in
skin elasticity owing to pregnancy, breastfeeding, weight fluctuations, and
other factors. However, this positive influence was also present in 83.33% of
those who did not undergo this specific procedure (p = 0.032).
The positive influence is reflected in several procedures, among them, breast
enlargement with silicone prosthesis that revealed that 100% of the participants
showed a high post-surgical satisfaction.
On May 17, 2017, the Ibero-Latin American Federation of Plastic Surgery signed a
declaration of commitment to implement higher safety in the specialty, and with
the purpose of defining actions to reduce the number of deaths and sequels
caused by surgery, thus preserving patients’ health. This action is critical to
providing a better guarantee of satisfactory aesthetic results and to preserving
patients’ lives, in consideration of the world indices in this regard: Brazil
and Mexico make up this group, two countries that most perform plastic surgeries
in the world15.
All of the participants who participated in this study reported being
well-informed about the procedure that they had planned to undergo, the possible
therapeutic options according to their needs, and the possible risks and
disadvantages of the procedure to be performed. Of the participants in the
study, 97.5% reported understanding that aesthetic plastic surgery has no
guarantees of specific results, and 55.5% displayed optimism or tranquility
facing this situation. These data refer to the participants’ confidence in the
surgical team. These findings are relevant and show a greater concern for
clarifications to attain higher safety and promote confidence.
CONCLUSION
The study measured the impact of aesthetic mammoplasty on the self-esteem of
women. We found an average increase in the self-esteem of the participants who
underwent aesthetic mammoplasty, which could indicate that plastic surgery may
be considered an appropriate therapy for improving self-esteem.
The types of surgery produced the same outcome regarding the variation of
self-esteem. The solely aesthetic-oriented surgeries were as impactful in
improving the quality of life and biopsychosocial aspects of the participants as
reparative surgeries.
The post-operative satisfaction of a patient depends on the association between a
desire for surgically changing one’s body image with consistent and
well-structured motivations and a greater concern of surgeons for the legal
aspects in relation to providing good guidance on therapeutic options, with
clear explanations regarding the potential risks and benefits of the surgical
procedure to be performed.
ACKNOWLEDGMENTS
We thank the plastic surgeon Tirzah Wynne Cardoso for the encouragement and
support, and for entrusting their patients for this study.
COLLABORATIONS
|
GRS
|
Analysis and/or data interpretation, conception and design study,
conceptualization, data curation, final manuscript approval,
investigation, project administration, realization of operations
and/or trials, validation, writing - review & editing.
|
|
DCA
|
Analysis and/or data interpretation, data curation, realization of
operations and/or trials.
|
|
CV
|
Analysis and/or data interpretation, realization of operations and/or
trials.
|
|
RAC
|
Analysis and/or data interpretation, realization of operations and/or
trials.
|
|
GGL
|
Visualization, writing - original draft preparation, writing - review
& editing.
|
|
LS
|
Visualization, writing - original draft preparation, writing - review
& editing.
|
|
RAC
|
Visualization, writing - original draft preparation, writing - review
& editing.
|
|
DP
|
Final manuscript approval, project administration, supervision,
writing - review & editing.
|
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1. Universidade Tiradentes, Aracaju, SE,
Brazil
2. Clínica Concept, Aracaju, SE,
Brazil
3. Clínica Integrada Homo, Aracaju, SE,
Brazil
4. Universidade Federal de Sergipe, Aracaju, SE,
Brazil.
Corresponding author: Gabriel Gonçalves
Lopes Rua Manoel Andrade, nº 2576 - Coroa do Meio, Aracaju, SE,
Brazil Zip Code 49035-530 E-mail:
gabriel.pglopes@gmail.com
Article received: October 23, 2018.
Article accepted: February 10, 2019.
Conflicts of interest: none.
