Cosmetic surgery and associated chronic postsurgical pain: A cross-sectional study from Norway

2.1 Questionnaire, setting, and participants

To investigate the self-reported prevalence of cosmetic surgery, associated CPSP and pain management-seeking, an online questionnaire consisting of three consecutive questions (one per outcome) was constructed and, via Ipsos, a multinational market research consulting firm, distributed among adults (≥18 years of age) living in Norway [18]. Questions were conditional; while affirmative answers led to the next one, negative ones ended the survey. Below the exact wording of the questions and associated answer possibilities, translated from Norwegian to English:

1. Have you ever undergone elective cosmetic surgery? If so, which type? Facial surgery/intimate surgery/breast augmentation/breast reduction/other/do not want to answer/no.

2. Have you been bothered by persistent or recurrent pain that you associate with the surgery and that has been present for more than three months? Yes/No.

3. Have you sought treatment for this pain? Yes/No.

Furthermore, information on participants’ gender, age, and region of living was collected.

During the periods of December 8–14, 2021, and January 5–11, 2022, an initial sample of 1,098 participants was recruited from Ipsos Norway’s Web Omnibus Panel. To achieve a sample representative of the adult Norwegian population, Ipsos weighted the data based on gender and age within five regions of Norway. Weighting targets were constructed based on the most recent publicly available census data from Norway [19]. Analyses of data from this sample, however, revealed some surprising results giving reason to question the validity of the data. In response to this, Ipsos decided to recruit a second sample. To improve this sample’s representativeness of the general population, diverse sources and methods were used to contact potential participants. Moreover, a minimum of 500 individuals were sampled per source, to enable meaningful comparisons between different sampling sources. The wording of the questionnaire was left unchanged. Between November 30, 2022, and December 16, 2022, a total of 1,746 participants were recruited. Of these 527 were sampled from Ipsos’ Web Omnibus (392 from the Ipsos Web Panel and 135 from the Cint Web Panel), 721 via the Ad Hoc Survey in Ipsos’ Web Panel “Norgespanelet” and 498 were drawn from a population list from Bisnode. Participants from Ipsos’ Web Omnibus received an invitation to the study via app or e-mail and were compensated with 30 Ipsos points, one point being worth approximately 0.01 Euro. Respondents from “Norgespanelet” were invited via app and those from the Bisnode population list via SMS. Respondents from either source were offered the chance to win one of three gift cards worth 1,000 NOK each.

2.2 Statistical analyses

Data were assembled, cleaned, and anonymized by Ipsos [20]. A total of 50 respondents were manually excluded due to exhibiting response patterns categorized as unengaged by Ipsos: speeding and/or straight-lining and/or unserious answers [20]. Furthermore, Ipsos used the Random Iterative Method (RIM) to weight the data based on demographics (gender, age, and region), and educational level (primary/upper secondary school vs college/university). As with the initial sample, targets were constructed based on the most recent available Norwegian census statistics [19].

Following consultation with Ipsos, the authors decided to focus the analyses of the current study solely on the second sample. Please refer to Appendix S1 for a more comprehensive discussion of this decision.

Missing value analyses indicated that the data was complete, which aligns with the survey design implemented by Ipsos. Data were analyzed with SPSS Version 28.0 (IBM, Düsseldorf, Germany [21]). All analyses conducted were purely descriptive.

2.3 Ethical considerations

Participants declared their voluntary participation and provided written informed consent prior to survey initiation. The right to withdraw from the study at any time was emphasized. Data protection and privacy policies operated by Ipsos ensure compliance with the European Union’s General Data Protection Regulation (2016/679), and relevant national privacy legislations of the country of study conduction (here: Norway) [22]. As the present study employed anonymized data only, prior ethical approval was not required [23,24].

3.1 Descriptive statistics

For a detailed description of the sample see column one (“Total Sample”) of Table 1.

3.2 Cosmetic surgery

1.2% (N = 20) of the respondents preferred not to reveal information about prior cosmetic surgeries. Overall, 10.0% (N = 174) of the participants affirmed to have undergone cosmetic surgery in the past. The majority (N = 152; 87.3%) disclosed to have had only one of the different types of cosmetic surgeries included in the survey, whereas 12.7% (N = 22) reported to have undergone multiple of these. The most common kind of cosmetic surgery was a type other than the ones listed in the questionnaire (N = 52; 29.7%). This was followed by breast augmentation (N = 39; 22.1%), facial surgery (N = 32; 18.2%), breast reduction (N = 19; 10.7%), and intimate surgery (N = 12; 6.7%). Of all participants who reported to have had cosmetic surgery 73.3% (N = 128) were female while 26.7% (N = 47) were male. In other words, 14.7% of all female, and 5.3% of all male respondents confirmed having undergone cosmetic surgery in the past. There were proportionately more men (N = 7; 16%), than women (N = 15 11.5%) who had undergone several types of such surgery. Moreover, genders differed in the types of cosmetic surgeries they had more/less commonly performed (Table 2). About one quarter (N = 45) of cosmetic surgery customers were aged 18–29 years at survey completion (Table 1). Furthermore, about 1 in 4 individuals belonging to this age group (N = 12; 26.1%) reported to have undergone several versus only one type of cosmetic surgery included in the survey. This was more than in any other age group (30–39 years: 2 [6.7%], 40–49 years: 1 [4.2%], 50–59 years: 5 [16.7%], and 60+ years: 2 [6.2%], indicating to have undergone several vs one type of cosmetic surgery).

3.3 Chronic postsurgical pain

12.6% (N = 22) of the participants who had undergone cosmetic surgery in the past indicated to have experienced persistent or recurrent pain they associate with the surgery and that has been present for more than three months, i.e., CPSP [10]. CPSP was about four times more common among participants who had undergone several (N = 8/22 [37.3%]) compared to one type of cosmetic surgery (N = 14/152 [9.0%]). Among those who had undergone only one type of cosmetic surgery, CPSP was proportionately most common among those with prior intimate (N = 4/12 [35%]) or facial (N = 4/32 [13.1%]) surgery (Figure 1). Moreover, CPSP was more than five times more common among male (N = 14/47 [30.8%]) compared to female (N = 8/128 [5.9%]) respondents. While about two thirds of respondents affirming to have experienced CPSP after cosmetic surgery were aged 18–29 years (N = 15/22 [67.3%]), CPSP was proportionately much less common among the other age groups (Table 1 and Figure 1).

Figure 1

Chronic postsurgical pain (CPSP) per age group, type of surgery, and gender. Displayed are proportions of respondents having undergone cosmetic surgery and indicating to have experienced CPSP per age group (left figure), as well as per gender and surgery type (right figure).

3.4 Pain treatment

Out of individuals who reported experiencing CPSP, 75.6% (N = 17/22) confirmed that they had actively sought for pain treatment. 83.4% (N = 14/17) of these were male and 56.9% (N = 9/17) had undergone only one type of cosmetic surgery.

4.1 Cosmetic surgery

Since 2008, this is the first study to investigate cosmetic surgery consumption in a large sample representative of Norway’s general adult population. 10.0% of our participants reported to have undergone one or more types of such surgery, which is twice as many as reported previously (2008: 5%) [25,26]. This result is consistent with the global trend of increasing numbers of cosmetic surgeries being performed [27,28]. Furthermore, with about seven out of ten cosmetic surgery customers in the present study being female, we find the gender ratio within this group of individuals relatively unchanged since 2008 (2008: circa 70.0% females [25,29]). Consistent with this result and notwithstanding the fact that plastic surgery has become increasingly popular among men, neither global [30,31] nor European data [32,33,34] indicate the gender ratio among cosmetic surgery customers to have changed over the past decade (usually 80–93% women vs 7–20% men). Also, the rates of types of cosmetic surgery found here (other type > breast augmentation > facial surgery > combination of types > breast reduction > intimate surgery) align well with global statistics [3]. Furthermore, in the present study, about 25% of the cosmetic surgery customers were 18–29 years of age, with 1 in 4 of these indicating to have undergone several different types of such surgery, highlighting an especially high prevalence of cosmetic surgery among young adults. Findings which are consistent with figures of the International Society of Aesthetic Plastic Surgery showing that in 2020 ≥50% of breast augmentations, liposuctions, and rhinoplasties were performed on individuals aged 19–34 years [31]. Moreover, they are also in line with studies highlighting an increased interest in and acceptance toward cosmetic surgery among youth and young adults [1,2,5]. Taken together, in line with international trends, there appears to be a young and growing population of female, as well as male, cosmetic surgery consumers in Norway.

4.2 Chronic postsurgical pain

This is the first study to investigate CPSP in a large sample of individuals having undergone different types of cosmetic surgeries. The prevalence of CPSP in our sample was 12.6%, which appears rather low compared to prior reports of CPSP after cosmetic breast surgery (22–44% [11,12,13,14,15]) or other surgery (5–85% [10,35]). Surprisingly, and contrary to prior literature on CPSP [36], CPSP was about five times more common among male respondents compared to female ones. As this is the first account of CPSP after cosmetic surgery among males, and as the group of males indicating to have had such surgery was small, this result warrants further scientific investigation. Moreover, the present findings suggest that the risk of CPSP may vary depending on the type of cosmetic surgery. In our study, the proportion of individuals with CPSP appeared to be highest for intimate surgeries among both genders. Since this is the first time CPSP following cosmetic surgery on body parts other than the breast is investigated, these results remain, however, difficult to interpret. Furthermore, we found that two thirds of individuals indicating to have suffered from CPSP due to prior cosmetic surgery were young adults (18–29 years). Young age has been highlighted as a risk factor for CPSP by prior studies on cosmetic breast surgery [12,37], as well as other surgical populations [36]. Considering the growing population of young cosmetic surgery customers these results raise concern. Equally alarming was the large proportion of individuals seeking treatment for their pain, as this implies potentially bothering and/or disabling pain. Importantly, when health-compromising complications, like for example CPSP, arise after cosmetic surgery, cosmetic surgery customers turn into patients. Further medical treatment becomes necessary and will therefore be covered by public healthcare insurances. Chronic pain is notoriously hard to treat, assumed to cost the Norwegian society about NOK 135 billion annually [38], and accounting for almost half of disability pensions awarded [17]. Against this background, it is unequivocal that CPSP after cosmetic surgery is a topic warranting further scientific scrutiny.

4.3 Strengths and limitations

A strength of the present study is its large sample which closely mirrors the adult Norwegian population in terms of age, gender, region of living, and educational level. Moreover, by asking for “self-selected” surgeries, the risk of participants mistaking reconstructive plastic surgeries as cosmetic was minimized. Finally, CPSP was inquired using the most recent definition of the International Association for the Study of Pain [9].

A limitation of the present study is that we cannot ensure that all respondents were referring to truly cosmetic surgeries. A low likelihood of such misinterpretation, however, is supported by the fact that the most popular nonsurgical cosmetic procedures of the recent years mainly cover skin rejuvenating (botulinum toxin type A, hyaluronic acid) and hair removal treatments, all of which are minimally invasive and usually do not require anesthesia [3]. Furthermore, as the survey only asked about “types” of cosmetic surgery, we can neither report on the exact number of surgeries participants have had, nor ensure that all of them were treated in Norway. Moreover, does the parsimony of the questionnaire render inferences about the degree of CPSP-related disability, or specific pain treatments sought for, impossible. Arguments for potentially bothering and/or disabling pain, however, are strengthened by the fact that the first question specifically asked for “bothersome” CPSP, as well as the large proportion of participants affirming to have sought for treatment for this pain. A final limitation is that individuals registered at Ipsos or included on the Bisnode population list might differ from Norwegians not registered at any of these sources in respects other than those controlled for by applied sampling methods.

4.4 Future research

The authors acknowledge the limited character of the survey employed in the present study but are nevertheless convinced that the results strongly encourage further research on CPSP subsequent to cosmetic surgery. Considering that the categories “other” and “facial surgery” were among the three most prevalent in the present study, we recommend future studies to employ samples large enough to allow more detailed investigations within such broad categories. Moreover, as gender identity can represent an important factor in individuals’ decision to undergo cosmetic surgery, we advise future studies to further detail participants’ gender. Future studies should also aim at investigating characteristics of CPSP related to cosmetic surgery, preferably through clinical examination, to enable conclusions about the nature, clinical relevance, and demand for treatment of such pain. Finally, it also remains to be elucidated whether the treatment of CPSP after cosmetic surgery is commonly initiated within the private and/or public healthcare sector, and whether associated costs are borne by the patients themselves or the Norwegian/individual countries’ welfare system.