Low priority? A cross sectional study of appearance anxiety in 500 consecutive referrals for cosmetic surgery

Low priority treatment guidance is used in the National Health Service to manage requests for cosmetic surgery where there is no associated functional impairment. Provision is made in this guidance to provide surgery on exceptional grounds, and this may include significant psychological distress. However, without a good understanding of the common factors that underpin requests for surgery, ideally in the local population, it is very difficult to define an exception in a clear and consistent way. A prospective study of consecutive referrals for cosmetic surgery in an NHS plastic surgery unit was therefore completed over a five-year period. Five hundred and one men and women aged between 16 and 79 (mean 34.5 years) were assessed using standardised questionnaires and clinical interview carried out by two clinical psychologists specialising in the field. Results indicated very marked impact of appearance-related anxiety with significant withdrawal from social activities particularly intimate behaviour. Coping behaviours ranged from use of concealing clothing and complete social avoidance to ominous high risk strategies such as repeated pregnancy with late termination to maintain breast size. Treatment goals were predominantly psychosocial. High levels of psychological morbidity can be characterised as typical of people requesting cosmetic procedures in the NHS rather than exceptional, making the achievement of equitable access to limited resources impossible. Rather than define this population as 'low-priority', a constructive approach is to examine the utility of psychological interventions in a design which evaluates the comparative benefits of surgical and psychological approaches to management of appearance anxiety.