Is cosmetic surgery an effective psychotherapeutic intervention? A systematic review of the evidence.
Elective cosmetic surgery (ECS) in the absence of physical indications is often performed to improve psychosocial function. Third-party funders need evidence of its effectiveness if they are to respond in an evidence-based way to increasing demand in the context of constrained resources. Our first aim was to review recent evidence of psychosocial outcome in a way that was systematic with respect to study inclusion and methodological evaluation. Our second aim was to review evidence for the validity of currently used selection criteria. Electronic and manual literature and database search identified prospective cohort or controlled studies of psychosocial outcomes of surgery performed for appearance reasons reported in English from 1992 to 2004. Data were extracted to describe outcomes and evaluate methodological quality. Twenty-three reports of 22 separate studies were reviewed. All were prospective observational studies and most provided low standards of evidence because of the absence of comparison groups, short follow-up periods and loss to follow-up. The evidence suggests that breast reduction improves health-related quality of life, but does not indicate enduring improvement in quality of life after other procedures, or enduring improvement in mental health, self-esteem or body image after any procedure. Similarly, there was insufficient evidence for the validity of criteria for patient selection. The negative conclusions reflect, not the existence of negative evidence, but methodological limitations of published research. The problem for third-party funders is that, although evidence does not justify the continued general provision of ECS in the absence of physical need, it is not strong enough to justify withholding such treatment. Even though randomised controlled trials are probably impractical, we identify several improvements in design whereby future prospective cohort studies could provide higher standards of evidence.