INTRODUCTION
Plastic surgery is the branch of medicine whose objective can be defined as the recovery
of function, and restoration of some body regions, in addition to improving shape
and beautification aiming to achieve balance in the body structure.
Currently, Brazil is in second place in the ranking of countries with the highest
number of surgical procedures in plastic surgery, with 1,306,906 surgeries, representing
12.9% of the total number of surgeries performed in the world, second only to the
United States, with 1,485,116 surgeries (14.7%). The rest of the ranking is completed,
respectively, by Germany, Japan, and Turkey1.
In Brazil, the five most performed plastic surgeries are liposuction (173,420 cases,
representing 13.3%), breast augmentation (172,485 procedures; 13.2%), blepharoplasty
(143,037 procedures; 10.9%), abdominoplasty (112,186 procedures; 8.6%) and mastopexy
(105,641 procedures; 8.1%)1procedures; 8.1%)1.
In the United States, the country with the highest number of plastic surgeries according
to the International Society of Aesthetic Plastic Surgery (ISAPS), the most performed
surgeries are, respectively, breast augmentation, liposuction, abdominoplasty, mastopexy,
and blepharoplasty. When comparing the two countries, we noticed that the most performed
surgeries are the same, only changing their positions in the ranking1.
The increase in the search for plastic surgery can be explained by the collective
imagination of a standard of beauty, stimulated by globalization and the use of social
networks, permeated by a narcissistic culture in which the desire for personal success
can be personified in the materialization of the body.
Plastic surgery has been an alternative for people to improve their vision of themselves,
feeling more confident and satisfied with their body aspects. Therefore, by increasing
self-esteem in these people, surgery is capable of positively interfering not only
with body self-assessment but also in the psychosocial dimension2.
The World Health Organization (WHO), in 1946, defined health as a state of complete
physical, mental, and social well-being, and not merely the absence of disease or
infirmity. Thus, mental and social well-being are increasingly valued, leading us
to understand the importance of self-esteem in people’s lives.
Self-esteem is literally defined by the value people place on themselves3. It is the evaluative component of self-knowledge. High self-esteem refers to a highly
favorable global evaluation of oneself. On the other hand, low self-esteem, by definition,
is an unfavorable interpretation of one’s self.
Plastic surgery is the medical specialty that allows to shape and alter the silhouette
of the human body. Procedures related to this specialization can improve aesthetic
appearance and, consequently, self-esteem and self-confidence. In the last 20 years,
much of the research on the psychological aspects related to aesthetic plastic surgery
has focused on the psychological construction of body image4.
Therefore, high self-esteem can refer to an accurate, justified, and balanced assessment
of their value as a person, their successes, and competencies. Following the same
logic, low self-esteem can be an accurate and well-founded understanding of someone’s
deficiencies as a person or a distorted and even pathological feeling of insecurity
and inferiority5.
In 1965, with the aim of grading and evaluating self-esteem, Morris Rosenberg created
the Rosenberg Self-Esteem Scale, a one-dimensional instrument capable of classifying
self-esteem as low, medium, and high.
Quality of life can be defined as the individual’s perception of their insertion in
life, in the context of the culture and value systems in which they live and concerning
their objectives, expectations, standards, and concerns4,6.
With this aim, the WHO developed a questionnaire aimed at evaluating the quality of
life and personal relationships in different social groups regardless of the level
of education called World Health Organization Quality Of Life 100 (WHOQOL-100), consisting
of 100 questions divided into 24 groups. In addition to this, the WHO also developed
an abbreviated questionnaire for greater ease of application called WHOQOL-Bref.
The idea that the patient’s perception of their health must be considered when evaluating
the effectiveness of medical treatment is widely accepted, especially in plastic surgery,
in which there is an important psychological factor for evaluating post-surgical results2,7.
The positive impact of plastic surgery on patients’ self-esteem is something that
is noticeable daily, whether in the better acceptance and appreciation of bodily characteristics,
as well as in the aspect of better personal and professional relationships. This evolution
in an aspect of global relationships, whether personal or professional, leads to a
better quality of life and a better perception of positioning and importance in society7.
The search for plastic surgery by the Brazilian population is often due to discomfort
or bodily complaints8, problems in intimate relationships, as well as difficulties in starting or maintaining
personal and professional relationships, leading these people to perform worse in
their activities, including which can trigger depressive disorders9.
Through these epidemiological data, we can note that in addition to the surgical result,
the relevance of plastic surgery in a social aspect is highlighted, so that it is
a medical specialty capable of also acting in the psychosocial sphere of patients.
In a case-control study that evaluated the importance of plastic surgery for the elderly7, high levels of personal satisfaction and social life were evidenced in this group
of patients. However, it did not demonstrate significant differences in self-esteem
in elderly patients who underwent plastic surgery and those who did not (control group).
A prospective cross-sectional study8 evaluated 49 patients aged between 30 and 40 years who underwent periorbital plastic
surgery (blepharoplasty). Applying the Rosenberg Self-Esteem Scale in the preoperative
period, 30 and 90 days after surgery, an improvement in self-esteem was observed in
patients undergoing this procedure.
Another research in this line was carried out in Nicosia (Cyprus)5, which investigated through a cross-sectional and prospective descriptive study whether
plastic surgery affects an individual’s body image, body satisfaction, and general
self-esteem in the population of Cyprus. The majority of participants were women (81.9%),
with 47.6% undergoing breast augmentation. The conclusion of this study provides evidence
of improvement in individuals’ satisfaction with their body image and self-esteem
after cosmetic surgery.
OBJECTIVE
This study aims to understand the sociodemographic and clinical characteristics of
patients undergoing plastic surgery, in addition to analyzing the effect and impact
of plastic surgery on these patients’ self-esteem and quality of life.
METHOD
An observational, prospective cohort study was carried out with descriptive, analytical,
and quantitative elements.
The study was carried out from September 2021 to July 2022 with patients from the
research author’s private plastic surgery clinic in the city of Fortaleza/Ceará. The
study population was patients who underwent some type of plastic surgery. A convenience
sample (non-probability sampling) was carried out with patients who underwent plastic
surgery and who agreed to participate in the research.
Inclusion criteria: patients undergoing aesthetic plastic surgery aged 18 years or
over; patients with at least 3 months post-surgery.
Exclusion criteria: Patients under 18 years of age and patients with a postoperative
period of less than 3 months were excluded.
Patients were recruited at two stages: 1. pre-operatively (before surgery) and 2.
post-operatively - three months after the surgical procedure, a period that is the
minimum expected to obtain the final result of the procedure.
Three instruments were used for data collection:
1. A sociodemographic and clinical questionnaire developed by the research author, containing
questions about age, sex, race, education, profession, and type of procedure, among
other questions;
2. Rosenberg Self-Esteem Scale, version translated and adapted into Portuguese9,10, which
consists of 10 statements to grade the patient’s self-esteem. Statements 1, 2, 4,
6, 7, 8, and 9 portray high self-esteem. Statements 3, 5, and 10 have a characteristic
that reports low self-esteem. In all statements, 4 possible answers are arranged on
a Likert scale (strongly disagree, disagree, agree, and completely agree), with a
minimum score of 1 and a maximum of 4 in statements 1, 2, 4, 6, 7, 8 and 9 (positive
attributions), the opposite being the case for the rest of the statements (negative
attributions). The score obtained with the Scale can vary from 10 to 40, being calculated
by adding the scores obtained through the answers given to the 10 statements. Self-esteem
considered satisfactory is defined with a score equal to or greater than 30 on the
Rosenberg Scale and unsatisfactory with a score less than 309,10.
3. World Health Organization Quality Of Life - Bref (WHOQOL-Bref), version translated
into Portuguese10, consists of 26 questions divided into four domains (physical, psychological, social
relationships, and environment) aiming to assess the quality of life and social relationships.
The answers are arranged in five alternatives on a Likert scale10.
The sociodemographic questionnaire, the Rosenberg Self-Esteem Scale, and the WHOQOL-Bref
were applied in the preoperative period and, subsequently, reapplied after at least
3 months postoperatively, in person by the same professional trained by the researcher
or in an isolated environment in the private plastic surgery clinic or through an
online instrument (Google Forms), the second alternative being of great value due
to the COVID-19 pandemic, thus avoiding crowds.
Categorical data were expressed as absolute counts and relative frequency in percentages.
Continuous data were assessed for normal distribution using the Shapiro-Wilk test,
kurtosis analysis, histograms, and Q-Q plots.
Data considered normal were expressed as mean ± standard deviation and non-normal
data as median and interquartile range. For comparisons of continuous data between
2 dependent groups (before vs. after plastic surgery), the paired t-test was used,
depending on data normality. For comparison between paired groups regarding the difference
in the frequency of categorical data, the McNemar test was used. Data were analyzed
using SPSS software for Macintosh, version 23 (Armonk, NY: IBM Corp.) Values of p<0.05
were considered statistically significant.
RESULTS
Fifty-two patients (n=52) who underwent plastic surgery participated in the research,
the majority of whom were women (92.3%), with an average age of 37±11 years.
Regarding ethnicity, the most prevalent group of patients reported being white (33;
63.5%). The majority reported having an income range of 4 to 10 minimum wages (15;
28.8%).
Most patients stated that they had University education (36; 69.2%).
The majority of patients (36; 69.2%) reported having undergone more than one plastic
surgery throughout their lives, with the last surgical procedure, that is, belonging
to this research, being more present as an association of plastic surgeries ( 22;
61.1%) (Table 1).
Table 1 - Assessment of the impact of surgery on self-esteem parameters using the Rosenberg
scale with comparisons between the periods before and after surgery.
|
Rosenberg (Self-esteem) |
|
Before surgery |
After surgery |
p |
| I feel that I am a person of value at least as much as other people |
3.23±0.7 |
3.6±0.69 |
0.012 |
| I think I have several good ones qualities |
3.3±0.64 |
3.73±0.45 |
<0.001 |
| 3) All things considered, I think that I am a failure |
3.34±0.65 |
3.67±0.47 |
0.002 |
| 4) I think I am capable of doing the things as well as most people |
3.15±0.61 |
3.63±0.49 |
<0.001 |
| 5) I think I do not have much to be proud of |
3.19±0.79 |
3.52±0.75 |
0.031 |
| 6) I have a positive attitude towards myself |
2.78±0.96 |
3.42±0.72 |
<0.001 |
| 7) Overall, I am satisfied with me |
2.44±1.07 |
3.48±0.67 |
<0.001 |
| 8) I wish I could have more respect for myself |
2.33±1 |
2.88±1 |
<0.001 |
| 9) Sometimes I feel useless |
2.94±0.83 |
3.42±0.8 |
<0.001 |
| 10) Sometimes I think I am no good at anything |
3.17±0.83 |
3.57±0.72 |
0.002 |
| Rosenberg total |
29.87±2.10 |
34.92±1.84 |
<0.001 |
Table 1 - Assessment of the impact of surgery on self-esteem parameters using the Rosenberg
scale with comparisons between the periods before and after surgery.
Seventy plastic surgeries were performed on patients participating in this research,
the three most prevalent being: mastopexy (12; 17.1%), breast augmentation (18; 25.7%),
and abdominoplasty (16; 22.8%). If we consider breast surgeries (mastopexy, reduction
mammoplasty, and augmentation mammoplasty) as a single group, we will have a very
important prevalence of surgery, with a total of 34 surgeries, representing 48.5%
of the total surgical procedures performed.
There was a significant increase in self-esteem when comparing the values of the general
component preoperatively (29.87±2.10 points) and postoperatively (34.92±1.84 points).
When issues related to self-esteem were assessed separately, a significant increase
was also evident in the postoperative period, when compared to the preoperative period
(Table 1).
An important increase in quality of life was observed when comparing the values of
the general score in the preoperative period (91.59±12.68 points) and postoperative
period (108.22±9.26 points) using the WHOQOL-Bref.
The results of the four domains were evaluated, and we evidenced a significant impact
of plastic surgery on the results of these domains. The physical domain presented
a score of 3.70±0.47 preoperatively, evolving to 4.29±0.4 points postoperatively (p<0.001).
The psychological, personal relationships, and environment domains also showed increases
in their scores, all with important statistical significance (Table 2).
Table 2 - Assessment of the impact of surgery on quality of life domains using the WHOQOL-BREF
with comparisons between the periods before and after surgery.
| WHOQOL-BREF |
Before surgery |
After surgery |
P |
| Physical domain |
3.70±0.47 |
4.29±0.4 |
<0.001 |
| Psychological domain |
3.30±0.68 |
4.14±0.46 |
<0.001 |
| Social relationship domain |
3.48±0.87 |
4.15±0.64 |
<0.001 |
| Ambient domain |
3.57±0.41 |
3.97±0.48 |
<0.001 |
Table 2 - Assessment of the impact of surgery on quality of life domains using the WHOQOL-BREF
with comparisons between the periods before and after surgery.
When we reached the results of the Rosenberg Self-Esteem Scale and the WHOQOL-Bref
quality of life questionnaire, a correlation was also made between the results of
the two questionnaires, arriving at an interpretation that the increase in self-esteem
provided by the surgery Plastic surgery has a significant impact on the quality of
life of participating patients.
We were able to observe that the physical, psychological, and social relationship
domains presented the highest levels in the Pearson coefficient, leading to the interpretation
of a significant correlation between the growth of self-esteem and quality of life
after plastic surgery. The environment domain presented the lowest index in the aforementioned
coefficient, but still with statistical significance (Table 3).
Table 3 - Correlation between the variation in self-esteem caused by the surgery with the quality
of life and respective postoperative domains in the patients evaluated.
|
ROSENBERG variation |
|
n |
r* |
P |
| WHOQOL sum |
52 |
0.471 |
<0.001 |
| Physical domain |
52 |
0.460 |
<0.001 |
| Psychological domain |
52 |
0.496 |
<0.001 |
| Social relationship domain |
52 |
0.432 |
0.001 |
| Ambient domain |
52 |
0.275 |
0.049 |
Table 3 - Correlation between the variation in self-esteem caused by the surgery with the quality
of life and respective postoperative domains in the patients evaluated.
DISCUSSION
The average age of patients in this research is 37±11 years, similar to data from
the census carried out by the Sociedade Brasileira de Cirurgia Plástica in 2018, in which the majority of patients were aged between 36 and 50 years11.
The majority of patients in this study are female (92.3%), similar to the research
carried out in 2018 by SBCP, which also showed a majority of this gender (79.4%)11.
The most prevalent surgeries in this research were, respectively: mammoplasties, liposuction,
and abdominoplasty. These surgeries coincide exactly with the data referred to by
the SBCP as the most performed surgeries in Brazil, with mammoplasties coming first,
followed by liposuction and, later, abdominoplasty11.
The Rosenberg Self-Esteem Scale is a specific instrument, with psychometric properties,
that assesses patients’ self-esteem when applying the questionnaire. It is an objective
way of quantifying the results of a procedure, avoiding being subject to subjective
or examiner-dependent assessments9.
These data corroborate the research by Santos et al.2, which showed results of increased self-esteem in patients undergoing mammoplasty
through the evolution of scores applying the Rosenberg Self-Esteem Scale.
Likewise, Ishizuka7, also using the aforementioned scale, demonstrated in their research an increase
in self-esteem in patients undergoing blepharoplasty, whether the technique used was
superior or inferior.
The present study demonstrated that plastic surgery is capable of improving patients’
self-esteem, whether in the sample group used for all procedures performed, or in
the sample groups for the three most frequently performed procedures (mammoplasty,
liposuction, and abdominoplasty). In all groups of patients evaluated, there was an
evolution in scores from pre-operative to post-operative, with important statistical
significance.
In the case of evaluating the impact of plastic surgery on the quality of life of
patients participating in this research, we used the WHOQOL-Bref. The results demonstrated
by this research show us the importance of plastic surgery for the biopsychosocial
development of patients, which directly affects the quality of life of patients.
The WHOQOL must be interpreted through its four domains (physical, psychological,
social relationships, and environment). However, it is important to note the great
evolution in the scores of isolated questions regarding acceptance of physical appearance,
improvement in sleep quality, personal satisfaction, and also sexual life. All of
these topics are important aspects sought by patients when undergoing plastic surgery,
in addition to being significant for a better quality of life.
In any case, evaluating the evolution of scores in the WHOQOL-Bref domains, we can
see in this research that there was an increase in the scores of all domains with
statistical significance, reflecting plastic surgery as an important external factor
that triggers an improvement in the quality of life of patients.
When evaluating the groups of patients who underwent the most prevalent surgeries,
we also found an increase in postoperative scores compared to preoperative scores
with important statistical significance, demonstrating the uniformity of results found,
even when we evaluated the results of all patients.
Some limitations were noticed. The research was carried out during the COVID-19 pandemic,
a period in which, due to safety protocols, elective surgeries were limited, which
resulted in a decrease in the number of participants.
These data are important, as they reinforce the biopsychosocial health model suggested
by the World Health Organization (WHO) in which holistic treatment is more important
than simply focusing attention on the disease alone. In this way, psychological and
social care is extremely valuable for the patient’s health.
CONCLUSION
Through this study, we can analyze and grade the impact of plastic surgery on the
self-esteem and quality of life of patients undergoing a surgical procedure.
There was a significant increase in self-esteem when comparing the results of the
general score preoperatively and postoperatively through the results of applying the
Rosenberg Self-Esteem Scale, as well as concluding the improvement in the quality
of life of patients undergoing plastic surgery, whether through interpretation of
the general WHOQOL-Bref result, as well as the four domains of this questionnaire
demonstrated significant evolution.
With this research, we were also able to learn about the sociodemographic characteristics
of the participating patients, such as age, most prevalent sex, social class, and
skin color. Very important information to better understand the characteristics of
patients who intend to undergo plastic surgery.
Using the Rosenberg Self-Esteem Scale and the WHO Quality of Life Questionnaire (WHOQOL-Bref),
both validated and important in the medical literature, we were able to quantify the
improvement in these subjective topics reported above.
With the results achieved, we conclude that plastic surgery is an important medical
specialty that, through its surgical procedures, is capable of increasing patients’
self-esteem. And not only that. Since in this study, a statistically significant correlation
was found between self-esteem and quality of life in the postoperative period of plastic
surgery, we can, with great possibility, influence an improvement in the quality of
life of these patients.
Assessment of patients’ physical and psychosocial well-being should be routine among
health professionals. Thus, through this study, we conclude how plastic surgery itself
can be in an important position in the therapy of improving self-esteem, therefore
resulting in a better quality of life.
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1. Universidade de Fortaleza, Fortaleza, CE, Brazil
2. Universidade Estácio de Sá Idomed Canindé, Canindé, CE, Brazil
Corresponding author: Helmano Fernandes Moreira Filho Av. Santos Dumont, 7007, apto 1501, Fortaleza, CE, Brazil. Zip code: 60175-057, E-mail:
helmanom@yahoo.com.br
Article received: August 12, 2023.
Article accepted: December 05, 2023.
Conflicts of interest: none.
