Psychological assessment in post-bariatric plastic surgery: A scoping review
Avaliação psicológica em cirurgia plástica pósbariátrica: Uma revisão de escopo

INTRODUCTION

The World Health Organization (WHO) classifies obesity as a highly complex Chronic Noncommunicable Disease (NCD) and is considered a challenge of the 21st century, with global repercussions. According to the Atlas of the Food and Nutritional Situation in Brazil, published by the Ministry of Health in 2020, a survey involving 12,776,938 adults revealed that 63% of them are overweight. Obesity is a multifactorial condition, presenting a significant risk due to its comorbidities and psychosocial impacts that worsen with increased weight.

Social stigma is an additional factor that harms the condition of obese people¹. Psychological disorders such as depression, anxiety, binge eating, low self-esteem, and dissatisfaction with body image have been frequently associated with obesity.²,³. The importance of a multidisciplinary team in the treatment of obesity is highlighted by some studies, since, in addition to promoting health, these professionals act as support for the patient.⁴,⁵

Some authors agree that bariatric surgery is an effective and most common resource worldwide to treat morbid obesity and its results can promote psychological well-being.⁶ However, rapid and significant weight loss can result in the appearance of excess skin, causing sores and bad odors in the skin folds. This condition can be uncomfortable and affect both physical health and self-esteem. Furthermore, the changes that occur in the person’s life as a result of the surgery and the difficulty in adapting between the perception of their own thin body and their self-image can lead to psychological problems.⁷

Plastic surgery, being the only procedure that can remove excess skin resulting from major weight loss, has the potential to optimize the results of bariatric surgery. This, in turn, encourages weight control and contributes to improving people’s self-esteem and psychological well-being.⁸ However, patients with psychological distress may express dissatisfaction with the outcome of plastic surgery, even when the initially planned goal has been achieved. Patients with Body Dysmorphic Disorder (BDD) who undergo plastic surgery may experience a worsening of their psychological condition, which may compromise satisfaction with the results obtained.⁹

This study aims to alert and raise awareness among plastic surgeons, bariatric surgeons, and the interdisciplinary team about the relevance of the biopsychosocial approach in the preoperative care of patients who wish to undergo plastic surgery after bariatric surgery. During the screening phase carried out by the plastic surgeon, psychological assessment plays two important roles. Firstly, it allows you to explore the patient’s desires, expectations, anxieties, and fantasies. Secondly, the assessment process, combined with careful and transparent feedback from the doctor when the patient shows signs of psychological distress, helps the patient to recognize the need and importance of further psychological investigation, conducted by specialists. This initial approach aims to understand the person’s emotional and psychological context, promoting the patient’s mental health.

OBJECTIVE

The present study, through a scoping review, aimed to determine whether a basic psychological assessment, conducted during plastic surgeon screening, can identify psychological distress in patients seeking post-bariatric plastic surgery.

METHOD

The present study is a scoping review and is part of the project entitled “Protocolo de Atenção Biopsicossocial em Cirurgia Plástica Pós-bariátrica” (Biopsychosocial Care Protocol in Post-bariatric Plastic Surgery). This project was conducted during the Professional Master’s degree in Sciences, Technology, and Management Applied to Tissue Regeneration at the Universidade Federal de São Paulo (Unifesp). The study was approved by the Unifesp Ethics and Research Committee, with opinion number 5825924. The corresponding proof is 097949/2022, and the Certificate of Presentation of Ethical Appreciation (CAAE) has the number 62914222.2.0000.5505.

Initially, the following research question was formulated using the acronym PICO: Can biopsychosocial care for pre-operative post-bariatric plastic surgery patients identify psychological suffering related to excess skin? Segmented into P = Pre-operative post-bariatric plastic surgery patient, I = Biopsychosocial care, C = Not applicable, O = Identification of psychological suffering related to excess skin. Next, the acronym FINER was applied to assess whether the question was well formulated.

Articles published between 2013 and 2023 were searched, in Portuguese, English, and Spanish, on the database platforms: MEDLINE, Virtual Health Library (VHL), and Embase, using the Health Sciences Descriptors (DECS/MeSH): psychosocial functioning, plastic surgery, bariatric surgery and body image. The search strategy used was: [(“psychosocial functioning” OR “bariatric surgery”) AND (“plastic surgery” OR body image)]. The inclusion criteria for selecting the studies were research with adults of both sexes and with bariatric surgery and post-bariatric plastic surgery patients. The non-inclusion criteria were studies with adolescents, comments from experts, posters, theses, and incomplete articles. The exclusion criteria were duplicate articles and studies of plastic and bariatric surgeries without focusing on the psychological context. To manage references from the bibliographic survey, including identifying duplicates and applying eligibility criteria, the Rayyan.ai and Zotero.org platforms were used.

Therefore, 48 articles met the inclusion criteria. Of these selected, 18 were cited in this study, as they were directly aligned with the relevance of the topic in the research approach. Additionally, this study adhered to the recommendation of the Revista Brasileira de Cirurgia Plástica to use updated references, that is, articles published in the last 5 years. The 18 most recent references satisfactorily fulfilled the purpose established for this study.

RESULTS

The bibliographic survey conducted retrieved a total of 362 studies. Among these, 48 were selected because they met the established inclusion criteria, as illustrated in the flowchart in Figure 1.

Figure 1. - Flowchart of the bibliographic survey.

Figure 1. - Flowchart of the bibliographic survey.

Of these selected articles, 18 were cited and discussed in this scoping review, as highlighted in Chart 1.

Chart 1. - Articles included in the bibliographic survey and mentioned in this article.

DISCUSSION

The obesity treatment journey is complex and, throughout this process, the person may face clinical comorbidities, social stigmas, and negative self-judgment, which can affect their psychological state. Although the literature suggests a correlation between obesity and psychiatric disorders, research does not establish a direct connection between obesity, depression, and anxiety. Considering the controversy, for Casselli et al.³ What can be inferred is that the presence of these disorders can potentially increase the risk of obesity.

As obesity becomes a growing public health concern, bariatric surgery is gaining prominence on a global scale. This procedure provides benefits that go beyond the clinical scope, encompassing significant psychosocial advances, improved well-being, and a more positive view of body image. However, deMeireles et al.⁶ highlight a concern related to bariatric surgery and mental health, as some preoperative psychological assessments may be incipient. This means that psychological assessment is a complex process that employs a variety of techniques, methods, and instruments to collect information about a person’s psychological state. However, if the psychologist does not collect sufficient data or apply appropriate techniques, the depth and effectiveness of the assessment may be compromised.

An important aspect to be considered is that some patients do not follow the recommendation to continue psychotherapy after the procedure, as advised by the psychologist responsible for the psychological report or even by the bariatric surgeon. In addition to the process of adapting to bariatric surgery, interruption of psychological support can worsen the patient’s mental state.

Despite its many benefits, some studies, such as those by Poulsen et al.¹⁰ and Natvik et al.⁷ emphasize that the results of bariatric surgery lead to significant weight loss, which can result in an unsatisfactory adaptation to the new, slimmer body and discomfort due to excess skin. Monpellier et al.¹¹ emphasize that plastic surgery is the procedure capable of removing excess skin after massive weight loss and that patients looking for solutions to this problem may experience psychological suffering. Second Silva et al.⁹, research has indicated that 60% of people who seek plastic surgery after bariatric surgery have some psychological condition. Among the most common changes in this group, depression, generalized anxiety disorder, and body dysmorphic disorder stand out.

Considering the challenges faced in the treatment of obesity, as well as the consequences and the adaptation process after bariatric surgery, added to the discomfort caused by excess skin, there may be times when the patient is not ready to undergo plastic surgery. In these cases, it is essential to refer you for specialized mental health evaluation or treatment.

Pre-operative psychological assessment should be a fundamental element in the initial consultation for patients seeking plastic surgery. Silva et al.⁹ and Ferreres-Galán et al.¹² emphasize that the assessment aims to identify psychological disorders, such as depression, anxiety, impulsivity, binge eating, low self-esteem, and dissatisfaction with body image. A careful investigation during medical screening is necessary, as some patients adopt an attractive and seductive posture, influencing the course of the consultation and the development of the surgical plan. It may happen in some cases that the patient hides their complaints and minimizes their expectations to have their surgery approved. Psychological assessment can prevent significant postoperative losses.

The plastic surgeon must be prepared to conduct an initial psychological screening of the patient. To do this, he/she can use validated psychometric instruments that are widely applicable to health professionals from various areas, in addition to semi-structured interviews. Attentive listening skills are important so that the surgeon can identify signs of distress that the patient may not have expressed explicitly. If the doctor identifies or suspects any sign of mental disorder during the patient’s admission consultation, the recommended course of action is to refer the patient for further evaluation with specialists.

In psychological screening, the plastic surgeon can investigate factors that help to understand the patient’s motivation for plastic surgery. This is important as it can reveal possible psychological problems, especially when the motivation is predominantly external. Motivation can be divided into intrinsic factors, such as the desire for health, well-being, and resumption of social and work activities, and extrinsic factors, such as pleasing others or obtaining social benefits. Although both factors are important, the intrinsic factors, which are linked to health and quality of life, should be more significant for the patient.

Another aspect to be explored are social beliefs that often lead patients to seek bodily perfection, feeding the idea that a slender body solves all problems. Akkayaoğlu & Çelik² point out that studies on the concept of ego have focused on body image, which represents the physical aspect of the ego. This relationship between the ego and self-image is important for understanding how psychological factors can influence people’s health and well-being. In some cases, the idealized body image appears as a way to alleviate anguish and dissatisfaction. Complementing this view, Elfanagely et al.¹³ and Bennett et al.¹⁴ highlighted the importance of investigating patients’ expectations before and after surgery, making them aware of the general changes that may occur after surgery.

In this context, it is important to inform the patient about the procedure, establish realistic expectations for the recovery period, and warn about possible complications, according to Bianciardi et al.¹⁵ Such measures can significantly contribute to reducing patient anxiety, in addition to enhancing treatment adherence and optimizing postoperative results. After all, a well-informed and mentally prepared patient becomes a more active patient in their own recovery process.

Emotional support for the patient, both before and after surgery, is also effective in managing the stress and anxiety associated with the procedure. Additionally, collaboration with other healthcare professionals, such as psychologists, nutritionists, and physical therapists, can be effective in addressing all of the patient’s concerns. Another important aspect to be discussed with the patient is the clear definition of their goals and priorities, in addition to emphasizing the replacement of sagging skin with scars.

This information can help the patient establish realistic expectations and prepare more effectively for the recovery process after surgery. Psychological screening conducted by the plastic surgeon can help identify people who are less likely to benefit from surgery, as well as those who may need extra attention and guidance, as highlighted by Buer et al.¹⁶ It is worth remembering that patients with body dysmorphia regularly seek aesthetic procedures and, after carrying out these, tend to feel dissatisfied with the results. According to Silva et al.⁹, in some circumstances, the patient may develop a distorted perception of the outcome of surgery due to mental disorders. This, in turn, can lead to legal action against the plastic surgeon, even when the surgery achieved the planned objective and followed all established technical criteria.

However, this study demonstrated that excess post-bariatric skin can result in psychological distress. However, it is important to highlight that the obese patient’s journey to the body contouring procedure is permeated by numerous challenges, which, in a way, can also lead to mental health problems.

Thus, plastic surgery after bariatric surgery can help the patient control their weight. Additionally, surgery has the potential to improve body image, which can, in turn, restore or increase a person’s self-esteem and confidence. Jiang et al.¹⁷ point out that in their research, a significant improvement in these aspects was observed in patients who underwent plastic surgery after bariatric surgery, especially when compared to those who did not undergo the procedure.

Therefore, psychological research must be considered relevant and cannot be relegated to a secondary level. Ignoring it would be contradictory to the understanding that obesity is a disease with biopsychosocial causes and impacts. Appropriate treatment must adopt an interdisciplinary approach, considering not only the physical symptoms but also the psychological and social aspects involved. This perspective is supported by studies, such as that of ElAbd et al.¹⁸

This scoping review has a limitation: the lack of assessment of the methodological quality of the selected articles.

CONCLUSION

The findings of this scoping review highlight the importance of incorporating mental health assessment as a routine component in the preoperative assessment in post-bariatric plastic surgery, as basic psychological assessment has the potential to identify signs and symptoms of psychological distress that, If detected early, they can prevent mental health complications, making it easier to refer the patient to specialized mental health treatment. When the patient is in an appropriate psychological state, they are better positioned to fully benefit from the benefits of surgery. Furthermore, it is important that the plastic surgeon, in addition to having extensive clinical-surgical technical knowledge, also has a basic understanding of mental disorders.