Breast Implants, Self-Esteem, Quality of Life, and the Risk of Suicide
2016; Elsevier BV; Volume: 26; Issue: 4 Linguagem: Inglês
10.1016/j.whi.2016.03.002
ISSN1878-4321
AutoresDiana M. Zuckerman, Caitlin E. Kennedy, Mishka Terplan,
Tópico(s)Reproductive Health and Technologies
ResumoBreast augmentation is the most common cosmetic surgery in the United States, with approximately 300,000 surgeries annually (American Society for Aesthetic Plastic Surgery, 2012American Society for Aesthetic Plastic SurgeryCosmetic surgery national data bank statistics: 2012.2012www.surgery.org/sites/default/files/ASAPS-2012-Stats.pdfGoogle Scholar). Many women seek breast augmentation to improve their lives, self-esteem, or relationships (Crerand et al., 2007Crerand C.E. Infield A.L. Sarwer D.B. Psychological considerations in cosmetic breast augmentation.Plastic Surgical Nursing. 2007; 27: 146-154Crossref PubMed Scopus (30) Google Scholar); however, numerous research reviews have concluded that suicide rates are higher for women with implants (Crerand et al., 2007Crerand C.E. Infield A.L. Sarwer D.B. Psychological considerations in cosmetic breast augmentation.Plastic Surgical Nursing. 2007; 27: 146-154Crossref PubMed Scopus (30) Google Scholar, Lipworth and McLaughlin, 2010Lipworth L. McLaughlin J.K. Excess suicide risk and other external causes of death among women with cosmetic breast implants: A neglected research priority.Current Psychiatry Reports. 2010; 12: 234-238Crossref PubMed Scopus (12) Google Scholar, McLaughlin et al., 2007McLaughlin J.K. Lipworth L. Murphy D.K. Walker P.S. The safety of silicone gel-filled breast implants: A review of the epidemiologic evidence.Annals of Plastic Surgery. 2007; 59: 569-580Crossref PubMed Scopus (70) Google Scholar, Rohrich et al., 2007Rohrich R.J. Adams W.P. Potter J.K. A review of psychological outcomes and suicide in aesthetic breast augmentation.Plastic and Reconstructive Surgery. 2007; 119: 401-408Crossref PubMed Scopus (22) Google Scholar, Sansone and Sansone, 2007Sansone R.A. Sansone L.A. Cosmetic surgery and psychological issues.Psychiatry. 2007; 4: 65-68Google Scholar, Sarwer et al., 2007Sarwer D.B. Brown G.K. Evans D.L. Cosmetic breast augmentation and suicide.American Journal of Psychiatry. 2007; 164: 1006-1013Crossref PubMed Scopus (47) Google Scholar). These studies raise a key question: Do implants increase the risk of suicide or do preexisting mental health problems increase the likelihood of undergoing breast implant surgery and also increase suicide risk? Several researchers and plastic surgeons have suggested that implants are a symptom of depression, rather than a cause (Lipworth and McLaughlin, 2010Lipworth L. McLaughlin J.K. Excess suicide risk and other external causes of death among women with cosmetic breast implants: A neglected research priority.Current Psychiatry Reports. 2010; 12: 234-238Crossref PubMed Scopus (12) Google Scholar, Rohrich et al., 2007Rohrich R.J. Adams W.P. Potter J.K. A review of psychological outcomes and suicide in aesthetic breast augmentation.Plastic and Reconstructive Surgery. 2007; 119: 401-408Crossref PubMed Scopus (22) Google Scholar, Sarwer et al., 2007Sarwer D.B. Brown G.K. Evans D.L. Cosmetic breast augmentation and suicide.American Journal of Psychiatry. 2007; 164: 1006-1013Crossref PubMed Scopus (47) Google Scholar) or that higher suicide rates were confounded by age, smoking, and marital status (Joiner, 2003Joiner T.E. Does breast augmentation confer risk of or protection from suicide?.Aesthetic Surgery Journal. 2003; 23: 370-375Crossref PubMed Scopus (19) Google Scholar, Spear and Heden, 2007Spear S.L. Heden P. Allergan's silicone gel breast implants.Expert Review of Medical Devices. 2007; 4: 699-708Crossref PubMed Scopus (39) Google Scholar), despite similar suicide rates when these factors were statistically controlled (Brinton et al., 2001Brinton L.A. Lubin J.H. Burich M. Colton T. Hoover R.N. Mortality rates among augmentation mammoplasty patients.Epidemiology. 2001; 12: 321-326Crossref PubMed Scopus (89) Google Scholar, Koot et al., 2003Koot V.C.M. Peeters P.H.M. Granath F. Grobbee D.E. Nyren O. Total and cause specific mortality among Swedish women with cosmetic breast implants: Prospective study.British Medical Journal. 2003; 326: 527-528Crossref PubMed Scopus (68) Google Scholar, Pukkala et al., 2003Pukkala E. Kulmala I. Hovi S.L. Hemminki E. Keskimaki I. Lipworth L. McLaughlin J.K. Causes of death among Finnish women with cosmetic breast implants, 1971-2001.Annals of Plastic Surgery. 2003; 51: 339-342Crossref PubMed Scopus (66) Google Scholar). The authors that challenged the link between suicide and implants disclosed financial ties to breast implant manufacturers or cosmetic surgery. Although suggesting the need for better research, they did not cite relevant studies of women with implants that could help to explain the link to suicide. This commentary is the first to synthesize information from the studies of suicide and breast implants with relevant studies measuring self-esteem, self-concept, mental health, and quality of life among women before and after getting breast implants. We sought to review what is known about the link between breast implants and suicide and identify credible hypotheses deserving of future study. We systematically reviewed the published literature on suicide and breast implants, searching keywords in bibliographic databases (Embase, PubMed, PsycInfo, and Scopus) to capture English-language, peer-reviewed literature. Two authors (C.E.K. and M.T.) conducted full-text review of 52 articles; seven were based on original data, and five of these had been included in at least one previous literature review. All seven studies (Table 1) found higher suicide rates among women with implants, whether compared with women of similar ages and races who underwent other plastic surgery (Brinton et al., 2006Brinton L.A. Lubin J.H. Murray M.C. Colton T. Hoover R.N. Mortality rates among augmentation mammoplasty patients: An update.Epidemiology. 2006; 17: 162-169Crossref PubMed Scopus (57) Google Scholar, Jacobsen et al., 2004Jacobsen P.H. Hölmich L.R. McLaughlin J.K. Johansen C. Olsen J.H. Kjøller K. Friis S. Mortality and suicide among Danish women with cosmetic breast implants.Archives of Internal Medicine. 2004; 164: 2450-2455Crossref PubMed Scopus (78) Google Scholar, Villeneuve et al., 2006Villeneuve P.J. Holowaty E.J. Brisson J. Xie L. Ugnat A.M. Latulippe L. Mao Y. Mortality among Canadian women with cosmetic breast implants.American Journal of Epidemiology. 2006; 164: 334-341Crossref PubMed Scopus (61) Google Scholar); compared with women of the same age using national mortality statistics from the same countries (Sweden: Lipworth et al., 2007Lipworth L. Nyren O. Ye W. Fryzek J.P. Tarone R.E. McLaughlin J.K. Excess mortality from suicide and other external causes of death among women with cosmetic breast implants.Annals of Plastic Surgery. 2007; 59: 199-223Google Scholar; Finland: Pukkala et al., 2003Pukkala E. Kulmala I. Hovi S.L. Hemminki E. Keskimaki I. Lipworth L. McLaughlin J.K. Causes of death among Finnish women with cosmetic breast implants, 1971-2001.Annals of Plastic Surgery. 2003; 51: 339-342Crossref PubMed Scopus (66) Google Scholar); in postmenopausal women with implants compared with those without implants (Rubin et al., 2010Rubin J.P. Landfair A.S. Shestak K. Lane D. Valoski A. Chang Y. Kuller L.H. Health characteristics of postmenopausal women with breast implants.Plastic and Reconstructive Surgery. 2010; 125: 799-810Crossref PubMed Scopus (12) Google Scholar) 2Because no statistical analysis was done in original study, we conducted a Fisher's exact test.; or in mastectomy patients with implants compared with mastectomy patients without implants (Le et al., 2005Le G.M. O'Malley C.D. Glaser S.L. Lynch C.F. Stanford J.L. Keegan T.H.M. West D.W. Breast implants following mastectomy in women with early-stage breast cancer: Prevalence and impact on survival.Breast Cancer Research. 2005; 7: R184-R193Crossref PubMed Google Scholar). The ratio of observed-to-expected deaths (standardized mortality ratios) for cosmetic augmentation patients ranged from 1.6 to 3.2 in five studies with those comparisons.Table 1Outcomes of Seven Studies Examining Breast Implants and SuicideAuthor (year)Study ObjectiveReason for SurgeryLocationStudy DesignComparison GroupFollow-up PeriodOutcome (suicide)Brinton et al., 2006Brinton L.A. Lubin J.H. Murray M.C. Colton T. Hoover R.N. Mortality rates among augmentation mammoplasty patients: An update.Epidemiology. 2006; 17: 162-169Crossref PubMed Scopus (57) Google ScholarExamine mortality among women with breast implantsCosmeticNorth America (United States)Mortality rates in 1) women with cosmetic breast implants (n = 12,144); 2) women with other plastic surgery (n = 3,614; via medical records and National Death Index database)Women with other first plastic surgeries (nonbreast implants)M = 20.5 years (for implants); M = 18.9 years (for control group)Implant group: 29 suicides (0.24% of group), SMR = 1.63 (95% CI, 1.1–2.3); other plastic surgery group: 4 suicides (0.11% of group), SMR = 0.85 (95% CI, 0.3–2.3)Jacobsen et al., 2004Jacobsen P.H. Hölmich L.R. McLaughlin J.K. Johansen C. Olsen J.H. Kjøller K. Friis S. Mortality and suicide among Danish women with cosmetic breast implants.Archives of Internal Medicine. 2004; 164: 2450-2455Crossref PubMed Scopus (78) Google ScholarExamine mortality among Danish women with breast implants (also: examine the baseline prevalence of psychopathological disorders)CosmeticEurope (Denmark)Mortality rates in 1) women with cosmetic breast implants (n = 2,761); 2) women who had breast reduction surgery (n = 7,071); 3) women with other plastic surgery (n = 1,736; via Danish National Mortality Files)2 groups: 1) women who had breast reduction surgery; 2) women with other plastic surgeryOverall mean = 11.5 yearsImplant group: 14 suicides (0.51% of group), SMR = 3.1 (95% CI, 1.7–5.2); breast reduction group: 22 suicides (0.31% of group), SMR = 1.6 (95% CI, 1.0–2.5); other plastic surgery group: 0 suicides (0% of group), SMR = 0.0 (95% CI, 0.00–1.5)Le et al., 2005Le G.M. O'Malley C.D. Glaser S.L. Lynch C.F. Stanford J.L. Keegan T.H.M. West D.W. Breast implants following mastectomy in women with early-stage breast cancer: Prevalence and impact on survival.Breast Cancer Research. 2005; 7: R184-R193Crossref PubMed Google ScholarExamine mortality of women with breast implants following mastectomyReconstruction after mastectomyNorth America (United States)Mortality rates in 1) breast reconstruction patients (n = 1,018); 2) breast cancer patients without reconstruction implants (n = 3,950; via Surveillance, Epidemiology and End Results Breast Implant Surveillance Study)Women who had been diagnosed with breast cancer, had a mastectomy, but did not receive breast reconstruction implants4–11 years since breast cancer diagnosisImplant group: 3 suicides (0.29% of group); no implant group: 1 suicide (0.03% of group); implant group's suicide rate significantly higher than that of no implant group (p = .02)Lipworth et al., 2007Lipworth L. Nyren O. Ye W. Fryzek J.P. Tarone R.E. McLaughlin J.K. Excess mortality from suicide and other external causes of death among women with cosmetic breast implants.Annals of Plastic Surgery. 2007; 59: 199-223Google ScholarExamine mortality among Swedish women with breast implantsCosmeticEurope (Sweden)Mortality rates in women with cosmetic breast implants (n = 3,527; via Swedish Inpatient Registry and official Swedish death statistics)No comparison group (compared with the general female population's rates, using age and calendar year specific person-years)M = 18.7 years (range, 0.1–37.8)Implant group: 24 suicides (0.68% of group), SMR = 3.0 (95% CI, 1.9–4.5)Pukkala et al., 2003Pukkala E. Kulmala I. Hovi S.L. Hemminki E. Keskimaki I. Lipworth L. McLaughlin J.K. Causes of death among Finnish women with cosmetic breast implants, 1971-2001.Annals of Plastic Surgery. 2003; 51: 339-342Crossref PubMed Scopus (66) Google ScholarExamine mortality among Finnish women with breast implantsCosmeticEurope (Finland)Mortality rates in women with cosmetic breast implants (n = 2,166; via medical records and nationwide mortality database of Statistics Finland)No comparison group (compared with the general female population's rates, using age and calendar year specific person-years)M = 10.3 yearsImplant group: 10 suicides (0.46% of group), SMR = 3.19 (95% CI, 1.53–5.86)Rubin et al., 2010Rubin J.P. Landfair A.S. Shestak K. Lane D. Valoski A. Chang Y. Kuller L.H. Health characteristics of postmenopausal women with breast implants.Plastic and Reconstructive Surgery. 2010; 125: 799-810Crossref PubMed Scopus (12) Google ScholarExamine the health outcomes, health behaviors, morbidity, and mortality of women with breast implantsCosmeticNorth America (United States)Health outcomes, health behaviors, morbidity, and mortality rates in 1) women with cosmetic breast implants (n = 1,257); 2) women without breast implants (n = 86,686; via NIH's Women's Health Initiative study and annual follow-up surveys)Women's Health Initiative participants without breast implantsVaried; for most, it had been 20–30 years from implant surgery to beginning of studyImplant group: 3 suicides (0.24% of group); no implant group: 20 suicides (0.02% of group); implant group's suicide rate significantly higher than that of the no implant group (p < .01)Villeneuve et al., 2006Villeneuve P.J. Holowaty E.J. Brisson J. Xie L. Ugnat A.M. Latulippe L. Mao Y. Mortality among Canadian women with cosmetic breast implants.American Journal of Epidemiology. 2006; 164: 334-341Crossref PubMed Scopus (61) Google ScholarExamine mortality among Canadian women with breast implantsCosmeticNorth America (Canada)Mortality rates in 1) women with cosmetic breast implants (n = 24,588); 2) women with other plastic surgery (n = 15,893; via medical records and Canadian Vital Statistics Database)Women with other types of plastic surgery1 year postoperative date through date of death or 12/31/97 (max possible range, 1–23 years)Implant group: 58 suicides (0.24% of group), SMR = 1.73 (95% CI, 1.31–2.24); Other plastic surgery group: 33 suicides (0.21% of group), SMR = 1.55 (95% CI, 1.07–2.18)Abbreviations: CI, confidence interval; SMR, standardized mortality ratio. Open table in a new tab Abbreviations: CI, confidence interval; SMR, standardized mortality ratio. Suicide rates were highest for the two studies not included in previous literature reviews. Our statistical analysis based on the Rubin et al., 2010Rubin J.P. Landfair A.S. Shestak K. Lane D. Valoski A. Chang Y. Kuller L.H. Health characteristics of postmenopausal women with breast implants.Plastic and Reconstructive Surgery. 2010; 125: 799-810Crossref PubMed Scopus (12) Google Scholar study found that postmenopausal women with cosmetic implants were 12 times as likely to commit suicide than postmenopausal women without implants (p < .01; Fisher's exact test). Among mastectomy patients, women with implants were almost 10 times as likely to commit suicide as women who did not undergo reconstruction with breast implants (Le et al., 2005Le G.M. O'Malley C.D. Glaser S.L. Lynch C.F. Stanford J.L. Keegan T.H.M. West D.W. Breast implants following mastectomy in women with early-stage breast cancer: Prevalence and impact on survival.Breast Cancer Research. 2005; 7: R184-R193Crossref PubMed Google Scholar). Comparisons with other cosmetic surgery patients contradict the hypothesis that low self-esteem or depression predates augmentation surgery. Two of the three studies comparing augmentation patients with other female plastic surgery patients found that the latter had lower suicide rates than augmentation patients (Brinton et al., 2006Brinton L.A. Lubin J.H. Murray M.C. Colton T. Hoover R.N. Mortality rates among augmentation mammoplasty patients: An update.Epidemiology. 2006; 17: 162-169Crossref PubMed Scopus (57) Google Scholar, Jacobsen et al., 2004Jacobsen P.H. Hölmich L.R. McLaughlin J.K. Johansen C. Olsen J.H. Kjøller K. Friis S. Mortality and suicide among Danish women with cosmetic breast implants.Archives of Internal Medicine. 2004; 164: 2450-2455Crossref PubMed Scopus (78) Google Scholar, Villeneuve et al., 2006Villeneuve P.J. Holowaty E.J. Brisson J. Xie L. Ugnat A.M. Latulippe L. Mao Y. Mortality among Canadian women with cosmetic breast implants.American Journal of Epidemiology. 2006; 164: 334-341Crossref PubMed Scopus (61) Google Scholar), and two of the three studies found other female plastic surgery patients' suicide rates to be lower than that of the general female population when controlling for age (Brinton et al., 2006Brinton L.A. Lubin J.H. Murray M.C. Colton T. Hoover R.N. Mortality rates among augmentation mammoplasty patients: An update.Epidemiology. 2006; 17: 162-169Crossref PubMed Scopus (57) Google Scholar, Jacobsen et al., 2004Jacobsen P.H. Hölmich L.R. McLaughlin J.K. Johansen C. Olsen J.H. Kjøller K. Friis S. Mortality and suicide among Danish women with cosmetic breast implants.Archives of Internal Medicine. 2004; 164: 2450-2455Crossref PubMed Scopus (78) Google Scholar) and race (Brinton et al., 2006Brinton L.A. Lubin J.H. Murray M.C. Colton T. Hoover R.N. Mortality rates among augmentation mammoplasty patients: An update.Epidemiology. 2006; 17: 162-169Crossref PubMed Scopus (57) Google Scholar). Women who underwent breast reduction surgery had a nonsignificant increased risk of suicide that was approximately one-half that for augmentation patients (Jacobsen et al., 2004Jacobsen P.H. Hölmich L.R. McLaughlin J.K. Johansen C. Olsen J.H. Kjøller K. Friis S. Mortality and suicide among Danish women with cosmetic breast implants.Archives of Internal Medicine. 2004; 164: 2450-2455Crossref PubMed Scopus (78) Google Scholar). Villeneuve et al., 2006Villeneuve P.J. Holowaty E.J. Brisson J. Xie L. Ugnat A.M. Latulippe L. Mao Y. Mortality among Canadian women with cosmetic breast implants.American Journal of Epidemiology. 2006; 164: 334-341Crossref PubMed Scopus (61) Google Scholar found an increased risk of suicide in women who had undergone other types of plastic surgery that was somewhat lower than the suicide risk for women with breast implants. Only two of the seven studies assessed depression, mental health, or quality of life. Jacobsen et al., 2004Jacobsen P.H. Hölmich L.R. McLaughlin J.K. Johansen C. Olsen J.H. Kjøller K. Friis S. Mortality and suicide among Danish women with cosmetic breast implants.Archives of Internal Medicine. 2004; 164: 2450-2455Crossref PubMed Scopus (78) Google Scholar found that Danish women who underwent augmentation surgery, particularly at public hospitals, were slightly more likely to have been admitted to a psychiatric hospital previously (8%) compared with breast reduction (5%) or other plastic surgery patients (6%). However, the difference is small, and Jacobsen et al. point out that some Danish public hospitals required a psychiatric diagnosis before the government health service would cover breast augmentation, thus creating an incentive to seek psychiatric care if women wanted free surgery. Moreover, only 7% of these psychiatric admissions were for depression or other affective disorders. Rubin et al., 2010Rubin J.P. Landfair A.S. Shestak K. Lane D. Valoski A. Chang Y. Kuller L.H. Health characteristics of postmenopausal women with breast implants.Plastic and Reconstructive Surgery. 2010; 125: 799-810Crossref PubMed Scopus (12) Google Scholar assessed depression, mental health, and quality of life for women who had implants, but did not include comparison data before the implant surgery. They reported that women with implants were more depressed and “reported overall poorer quality of life and emotional well-being” than women without implants. Demographic factors were influential, but all of the studies found increased suicide rates in women with implants compared with other women with similar demographic characteristics. The standardized mortality ratios for women with implants from Sweden (Lipworth et al., 2007Lipworth L. Nyren O. Ye W. Fryzek J.P. Tarone R.E. McLaughlin J.K. Excess mortality from suicide and other external causes of death among women with cosmetic breast implants.Annals of Plastic Surgery. 2007; 59: 199-223Google Scholar), Denmark (Jacobsen et al., 2004Jacobsen P.H. Hölmich L.R. McLaughlin J.K. Johansen C. Olsen J.H. Kjøller K. Friis S. Mortality and suicide among Danish women with cosmetic breast implants.Archives of Internal Medicine. 2004; 164: 2450-2455Crossref PubMed Scopus (78) Google Scholar), and Finland (Pukkala et al., 2003Pukkala E. Kulmala I. Hovi S.L. Hemminki E. Keskimaki I. Lipworth L. McLaughlin J.K. Causes of death among Finnish women with cosmetic breast implants, 1971-2001.Annals of Plastic Surgery. 2003; 51: 339-342Crossref PubMed Scopus (66) Google Scholar) were 3.0 or higher compared with other women in those same countries; this is almost twice the standardized mortality ratios of 1.6 to 1.7 for women with implants in the United States (Brinton et al., 2006Brinton L.A. Lubin J.H. Murray M.C. Colton T. Hoover R.N. Mortality rates among augmentation mammoplasty patients: An update.Epidemiology. 2006; 17: 162-169Crossref PubMed Scopus (57) Google Scholar) or Canada (Villeneuve et al., 2006Villeneuve P.J. Holowaty E.J. Brisson J. Xie L. Ugnat A.M. Latulippe L. Mao Y. Mortality among Canadian women with cosmetic breast implants.American Journal of Epidemiology. 2006; 164: 334-341Crossref PubMed Scopus (61) Google Scholar). Age may also be influential; the greatest increases in suicide associated with implants were in postmenopausal women (Rubin et al., 2010Rubin J.P. Landfair A.S. Shestak K. Lane D. Valoski A. Chang Y. Kuller L.H. Health characteristics of postmenopausal women with breast implants.Plastic and Reconstructive Surgery. 2010; 125: 799-810Crossref PubMed Scopus (12) Google Scholar) and mastectomy patients, whose average age was 47 years (Le et al., 2005Le G.M. O'Malley C.D. Glaser S.L. Lynch C.F. Stanford J.L. Keegan T.H.M. West D.W. Breast implants following mastectomy in women with early-stage breast cancer: Prevalence and impact on survival.Breast Cancer Research. 2005; 7: R184-R193Crossref PubMed Google Scholar). Two other studies noted that suicide risk was greatest for women who had their first augmentation surgery at the age of 40 or older (Brinton et al., 2006Brinton L.A. Lubin J.H. Murray M.C. Colton T. Hoover R.N. Mortality rates among augmentation mammoplasty patients: An update.Epidemiology. 2006; 17: 162-169Crossref PubMed Scopus (57) Google Scholar, Villeneuve et al., 2006Villeneuve P.J. Holowaty E.J. Brisson J. Xie L. Ugnat A.M. Latulippe L. Mao Y. Mortality among Canadian women with cosmetic breast implants.American Journal of Epidemiology. 2006; 164: 334-341Crossref PubMed Scopus (61) Google Scholar). Other studies of cosmetic surgery and mental health can shed light on the increase in suicides. Contrary to expectation, studies of women seeking augmentation or other cosmetic surgery have not found a higher prevalence of mental illness before the operation based on self-reports (Kjøller et al., 2003Kjøller K. Hölmich L.R. Fryzek J.P. Jacobsen P.H. Friis S. McLaughlin J.K. Olsen J.H. Characteristics of women with cosmetic breast implants compared with women with other types of cosmetic surgery and population-based controls in Denmark.Annals of Plastic Surgery. 2003; 50: 6-12Crossref PubMed Scopus (59) Google Scholar) or standardized psychometric measures (Sarwer et al., 1998Sarwer D.B. Pertschuk M.J. Wadden T.A. Whitaker L.A. Psychological investigations in cosmetic surgery: A look back and a look ahead.Plastic and Reconstructive Surgery. 1998; 101: 1136-1142Crossref PubMed Scopus (148) Google Scholar, Sarwer et al., 2000Sarwer D.B. Nordmann J.E. Herbert J.D. Cosmetic breast augmentation surgery: A critical overview.Journal of Women's Health and Gender-based Medicine. 2000; 9: 843-856Crossref PubMed Scopus (58) Google Scholar). Claims that augmentation increases self-esteem are based on studies using self-reports after surgery rather than pre/post comparisons on validated measures (e.g., Swanson, 2013Swanson E. Prospective outcome study of 225 cases of breast augmentation.Plastic and Reconstructive Surgery. 2013; 131: 1158-1166Crossref PubMed Scopus (40) Google Scholar). Although it might seem logical that women choosing plastic surgery have low self-esteem and therefore might be more vulnerable to suicidal thoughts, there is no reason to assume that depression or low self-esteem is unique to women choosing breast implants but not other cosmetic surgery patients. Yet implant patients were consistently more likely to commit suicide than other cosmetic surgery patients. Comparisons of women's self-esteem, self-concept, and quality of life before and 2 years after getting implants were analyzed in studies submitted to the U.S. Food and Drug Administration (FDA) by implant manufacturers and scrutinized by FDA scientists (US Food and Drug Administration, 2005aUS Food and Drug Administration (FDA)FDA summary panel memorandum: P020056 Inamed Corporation silicone-filled breast implants.2005www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4101b1_tab-1_fda-Inamed%20Panel%20Memo.pdfGoogle Scholar, US Food and Drug Administration, 2005bU.S. Food and Drug Administration (FDA)FDA summary panel memorandum: P030053 Mentor Corporation silicone gel-filled breast implants.2005www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4101b1_Tab-1_fda-Mentor%20Panel%20Memo.pdfGoogle Scholar). The two companies, Inamed and Mentor, each analyzed data from three groups of women with implants: augmentation patients, reconstruction (postmastectomy) patients, and women who received replacement implants for either augmentation or reconstruction. Self-esteem on the Rosenberg Scale, positive self-concept on the Tennessee Self-Concept Scale, and quality of life on the Short Form-36 Health Survey Scale (SF-36) tended to be lower 2 years after implant surgery than before. In the Inamed study, the only improvement for all three groups was self-concept regarding feeling sexy (statistically significant for augmentation patients only). Contrary to the hypothesis that women considering implants are depressed or have low self-esteem, the FDA noted that augmentation patients had higher self-esteem scores before getting implants than women in the general population. Even after women's self-esteem and positive self-concept scores decreased in most of the studies two years after getting implants, they were still higher than those of the average woman (US Food and Drug Administration, 2005aUS Food and Drug Administration (FDA)FDA summary panel memorandum: P020056 Inamed Corporation silicone-filled breast implants.2005www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4101b1_tab-1_fda-Inamed%20Panel%20Memo.pdfGoogle Scholar, US Food and Drug Administration, 2005bU.S. Food and Drug Administration (FDA)FDA summary panel memorandum: P030053 Mentor Corporation silicone gel-filled breast implants.2005www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4101b1_Tab-1_fda-Mentor%20Panel%20Memo.pdfGoogle Scholar). Breast cancer patients have an increased risk of suicide for up to 15 years after their cancer diagnosis (Riihimäki et al., 2012Riihimäki M. Thomsen H. Brandt A. Sundquist J. Hemminki K. Death causes in breast cancer patients.Annals of Oncology. 2012; 23: 604-611Crossref PubMed Scopus (84) Google Scholar, Misono et al., 2008Misono S. Weiss N.S. Fann J.R. Redman M. Yueh B. Incidence of suicide in persons with cancer.Journal of Clinical Oncology. 2008; 26: 4731-4738Crossref PubMed Scopus (421) Google Scholar). However, in the Le et al., 2005Le G.M. O'Malley C.D. Glaser S.L. Lynch C.F. Stanford J.L. Keegan T.H.M. West D.W. Breast implants following mastectomy in women with early-stage breast cancer: Prevalence and impact on survival.Breast Cancer Research. 2005; 7: R184-R193Crossref PubMed Google Scholar study, the suicide rate was 10 times higher for implant (reconstruction) patients compared with other mastectomy patients. It is inappropriate to generalize based on one study. Nonetheless, it is worth noting that the study's mastectomy patients all had early stage breast cancer; therefore, they chose to undergo what most physicians would consider a medically unnecessary mastectomy instead of an equally effective lumpectomy that would not require an implant (Fisher et al., 1995Fisher B. Anderson S. Redmond C.K. Wolmark N. Wickerham D.L. Cronin W.M. Reanalysis and results after 12 years of follow-up in a randomized clinical trial composing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer.New England Journal of Medicine. 1995; 333: 1456-1461Crossref PubMed Scopus (1295) Google Scholar). Reconstruction with implants immediately after mastectomy is often encouraged by surgeons, despite questions about its benefits (D'Souza et al., 2011D'Souza N. Darmanin G. Fedorowicz Z. Immediate versus delayed reconstruction following surgery for breast cancer.Cochrane Database Systematic Review. 2011; : CD008674PubMed Google Scholar). A federal law requires insurance companies to cover postmastectomy reconstruction with implants (Women's Health and Cancer Rights,Women's Health and Cancer Rights, 9 U.S.C. § 713 (a).Google Scholar Act of 1998), thus encouraging the procedure. Because data do not support the preexisting mental health problem hypothesis, is there evidence to support the hypothesis that breast implants may increase the risk of suicide? There are no well-designed long-term studies of implant patients to measure postoperative issues that explain or predict suicide. However, von Soest et al., 2012von Soest T. Kvalem I.L. Wichstrøm L. Predictors of cosmetic surgery and its effects on psychological factors and mental health: A population-based follow-up study among Norwegian females.Psychological Medicine. 2012; 42: 617-626Crossref PubMed Scopus (36) Google Scholar found increased anxiety and depression symptoms in young women who had undergone cosmetic surgery compared with other young women, controlling for demographic traits. In another study (Breiting et al., 2004Breiting V.B. Hölmich L.R. Brandt B. Fryzek J.P. Wolthers M.S. Kjøller K. Friis S. Long-term health status of Danish women with silicone breast implants.Plastic and Reconstructive Surgery. 2004; 114: 217-226Crossref PubMed Scopus (41) Google Scholar), women whose problem implants were removed and replaced were more likely to be taking antidepressants than women who still had their original implants. This study suggests depression could potentially stem from implant problems, but without comparison data before implants, no conclusions are possible. It may be relevant, however, that in the FDA analyses of manufacturers' studies, augmentation patients and revision patients reported lower scores on the SF-36 scale for “general health” self-concept 2 years after implants than before they underwent implant surgery (US Food and Drug Administration, 2005aUS Food and Drug Administration (FDA)FDA summary panel memorandum: P020056 Inamed Corporation silicone-filled breast implants.2005www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4101b1_tab-1_fda-Inamed%20Panel%20Memo.pdfGoogle Scholar, US Food and Drug Administration, 2005bU.S. Food and Drug Administration (FDA)FDA summary panel memorandum: P030053 Mentor Corporation silicone gel-filled breast implants.2005www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4101b1_Tab-1_fda-Mentor%20Panel%20Memo.pdfGoogle Scholar). Health problems are not likely owing to aging in this young population. In the context of the other studies, these findings suggest that healthy women who undergo cosmetic surgery might find it difficult to cope with consequences or complications related to that surgery. With millions of women with breast implants, consistent evidence that breast implants are associated with higher suicide rates requires careful scrutiny, including systematic measurement and longitudinal tracking of implant patients. Valid, reliable mental health screening should be administered before implant surgery to identify women who may be vulnerable to depression or suicide. The high suicide rate clearly suggests that breast implant surgery should not be considered a solution for low self-esteem or depression, as is sometimes suggested in advertisements and was policy in some European public hospitals and for British and Australian military women (Deans, 2001Deans J. Servicewomen given breast implants to boost morale. The Daily Mail.2001www.dailymail.co.uk/news/article-41561/Servicewomen-given-breast-implants-boost-morale.htmlGoogle Scholar, Squires, 2007Squires N. Australian navy pays for breast enlargements. The Telegraph.2007www.telegraph.co.uk/news/worldnews/1563392/Australian-navy-pays-for-breast-enlargements.htmlGoogle Scholar). Instead, implants should be considered with caution in these high-risk groups, and appropriate psychological counseling or treatment should be provided. Additionally, multiyear longitudinal studies of mastectomy reconstruction patients and cosmetic augmentation patients are needed, starting before their implant surgery, using validated depression, anxiety, and self-esteem measures, with interviews for those showing suicidal ideation. Such studies, conducted by independent researchers, would provide important information about the impact of implant surgery on women's mental health and suicides, by comparing them with women without breast implants, matched by health and demographic factors. In conclusion, scientific evidence suggests that breast implants may have risks to mental health. Although suicide among women with implants is below 1% in every study, the rates ranging from 0.24% to 0.68% are significantly higher statistically and clinically than rates for comparable women without implants. Rigorous research is needed to better understand the consistent association between implants and suicide, and to determine how to decrease those risks for the 300,000 U.S. women who undergo implant surgery annually. Diana M. Zuckerman, PhD, is the president of the National Center for Health Research. She is trained in clinical psychology as well as psychiatric and psychosocial epidemiology, with a focus on depression. Caitlin E. Kennedy, PhD, is a user experience research assistant at Adecco at Google. She received a PhD in Applied Social Psychology from the George Washington University. Mishka Terplan, MD, MPH, is a practicing physician and adjunct faculty member at the University of Maryland School of Medicine. He is board certified in Obstetrics and Gynecology and in Addiction Medicine.
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