Psychological investigations in cosmetic surgery: a look back and a look ahead

Eating Disorders and Aesthetic Plastic Surgery: A Systematic Review of the Literature

INTRODUCTION

Eating disorders (ED) and plastic surgery are two areas of healthcare that have gained significant attention in recent years. The goal of this review is to provide an overview of the existing literature concerning the interplay between ED and aesthetic surgery, identifying existing questionnaires and providing suggestions for the future research on the psychological aspects of these group of patients.

METHODS

We conducted a systematic review on PubMed. We included studies that examined the type of ED, surgical procedure, outcome measures used, patients' motivations as well as physical and psychological outcomes of individuals with ED seeking or undergoing aesthetic surgery. Three independent reviewers examined each potential study.

RESULTS

Eleven studies met the inclusion criteria. These studies involved 5510 patients, addressing a spectrum of ED such as Anorexia nervosa, Bulimia nervosa, and Binge eating. The primary focus was on body contouring procedures like liposuction, breast surgery, and abdominoplasty. The assessment tools employed in these studies for evaluating ED included the Eating Attitude Test (EAT), Eating Disorder Inventory (EDI), Eating Disturbance Scale (EDS), Sociocultural Attitudes Toward Appearance Questionnaire-Eating Disorder (SATAQ-ED), and the Eating Disorder Examination Questionnaire.

CONCLUSIONS

There is a complex interplay between ED and aesthetic surgery, underscoring the significance of comprehending and dealing with the psychological and sociocultural factors that impact patients in this context. The optimal management for these patients and the most effective tool for plastic surgeons to assess their psychological condition remain unclear. It is, therefore, crucial to standardize the evaluation and approach to this patient subgroup, closely aligned with psychological support, to achieve the best outcomes.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Relevance of Self-Consciousness of Appearance on Patient Satisfaction in Primary Rhinoplasty: a 12-Month Follow-up Prospective Study

BACKGROUND

Rhinoplasty procedure has a strong impact on patient quality of life. Plastic surgery patients show a degree of appearance-related distress higher than general population, especially patients undergoing rhinoplasty. Relationship between patient-reported outcome after rhinoplasty and self-consciousness of appearance needs further studies. The aim of this study is to investigate this correlation, considering the surgeon external evaluation as well.

MATERIALS AND METHODS

A total of 50 consecutive patients underwent primary cosmetofunctional rhinoseptoplasty. Appearance-related distress and surgical outcome were assessed by DAS59 (Derriford Appearance Scale 59) and SCHNOS (Standardised Cosmesis and Health Nasal Outcomes Survey), administered before and after surgery. Follow-up period was 12 months. Third-party clinical outcome was evaluated by three plastic surgeons by a scale ranging from 1 (poor outcome) to 5 (excellent outcome).

RESULTS

A first division in Group 1 (satisfied) and Group 2 (unsatisfied) was done. DAS59 mean score in Group 1 showed to be statistically lower than Group 2 (p value < 0.05). Spearman's test showed a large strong positive correlation between preoperative and postoperative DAS59 and SCHNOS-C score variations (Delta 0-12 months) (r = 0.7514, p<0.001), as well as between DAS59 and SCHNOS-O (r = 0.5117, p<0.001) and between SCHNOS-C and SCHNOS-O (r = 0.6928, p<0.001).

CONCLUSION

Rhinoseptoplasty has a significant impact on the patient self-consciousness of appearance, in both negative and positive terms. We emphasize the surgeon's burden, who need to carefully assess and address the patient's expectations during the first evaluation. This distinction is crucial since unrealistic expectations may lead to dissatisfaction even after a properly performed procedure.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Complications of toxins and fillers in facial aesthetics

Dermal filler and botulinum toxin injections are among the most performed non-invasive procedures for rejuvenation and contouring, internationally. Although most dermal fillers and approved botulinum toxins are well tolerated with a high safety profile, adverse events and/or complications can happen. Injection-related sequelae and side effects are usually rare, mild, transient, and self-limiting in nature. However, devastating and life-changing complications, such as intravascular occlusion, skin necrosis, permanent visual impairment, and stroke, have been reported. Risk reduction measures include an in-depth knowledge of anatomy, physiology, and pharmacology, correct patient selection, correct identification of clinical indications, and, fundamentally, the importance of appropriate skill and training. In this paper, some of the complications are discussed and advice on how to minimise adverse events and complications from these injectables is provided.

Comparison Between Patient and Plastic Surgeon Aesthetic Analysis in Rhinoplasty Consultation

The surgeon's aesthetic analysis of the nose is based on scientific measures of its proportions and dimensions. Because the primary aim of rhinoplasty is targeted at the patient's satisfaction with self-image, patients' perception and satisfaction are of paramount importance. The aim of this study was to evaluate surgeon versus patient nasal aesthetic analysis.

Method

A cross-sectional study was conducted on 57 primary rhinoplasty consultations during the period June and September 2017 at the Plastic Surgery Clinic in King Fahad Hospital-Hofuf. The surgeon and the patients were handed identical questionnaires before the consultations. The questionnaire has 27 components regarding the nasal appearance.

Results

The surgeon's and the patients' perceptions regarding reliability was assessed by Cohen's Kappa and Pearson's correlation coefficient. There was moderate agreement with the overall appearance of the nose (κ = 0.2-0.39). The most agreed-upon components were "dorsal hump" (κ = 0.6, P = 0.001) and "tip drops down" (κ = 0.41, P = 0.002). The columella and the suitability of the front part of the nose had the largest disagreement (κ = -0.06 and κ = -0.09, respectively). The level of agreement among most of the questionnaires' components was slight or nonexistent (κ = 0.004-0.39).

Conclusions

The surgeon and patients have a minimum agreement regarding the view of nasal appearance, mostly with the suitability of the front part and the columella. The parts of the nose agreed upon the most were "dorsal hump" and "tip drops down". Exploring the differences between patient and surgeon aesthetic analysis of the nose will aid in addressing the discrepancies and improving surgical outcome and satisfaction.

Prevalence of Body Dysmorphic Disorder in an Otolaryngology-Head and Neck Surgery Clinic

OBJECTIVE

To analyze the prevalence of body dysmorphic disorder (BDD) in a general otolaryngology population presenting to an outpatient clinic.

STUDY DESIGN

Prospective prevalence study.

SETTING

Single tertiary academic otolaryngology clinic.

SUBJECT AND METHODS

New patients over 18 years of age who presented to an academic otolaryngology clinic between August 2018 and May 2021 completed a questionnaire including demographic questions and the validated Body Dysmorphic Disorder Questionnaire (BDDQ). Data collected from the questionnaires were analyzed to assess demographics and prevalence of BDD in an otolaryngology clinic.

RESULTS

Of the 242 patients queried, 15 patients screened positive for BDD. The screened prevalence of BDD was determined to be 6.2%. None of the patients had previously been diagnosed with BDD. The prevalence of prior mental health diagnoses was 34.3%. These patients had initially presented for a variety of otolaryngologic concerns and had pre-existing diagnoses of anxiety, depression, obsessive-compulsive, bipolar and eating disorders.

CONCLUSION

The prevalence of BDD in our population of new patients presenting to an academic otolaryngology practice (6.2%) is higher than that of the general population (1.9%).

Assessment of functional and aesthetic outcomes in septorhinoplasty

PURPOSE

The aim of this study is to review the aesthetic and functional outcomes of septorhinoplasty using questionnaires that have never been collectively used, as well as surgeons' evaluation.

MATERIALS AND METHODS

Our study was conducted prospectively among 100 patients who underwent septorhinoplasty operation. We evaluated the effects of septorhinoplasty's functional and aesthetic outcomes on patients' emotional status using a combination of NOSE, ROE, DAS-24, and GBI questionnaires as well as surgeons' evaluations.

RESULTS

Our study did not detect any significant difference between preoperative and postoperative levels of patient satisfaction with regard to age, sex, and surgery type and the number of surgeries. Our study, on the other hand, revealed significantly higher postoperative GBI scores among patients with higher preoperative DAS-24 and NOSE scores. However, we showed no significant difference between the preoperative ROE score and postoperative GBI score CONCLUSION: This study demonstrated that septorhinoplasty can not only significantly alter a nose's functional and aesthetic appearance, but it can also boost patient satisfaction.

Body image, cosmetic surgery, and minimally invasive treatments

Over the past 60 years, a growing body of research has investigated the psychological aspects of cosmetic surgery and related minimally-invasive treatments. While the earliest studies were influenced by psychoanalytic thinking, much of the work over the past several decades has been influenced by Thomas Cash's cognitive-behavioral theory of body image and has focused on the appearance concerns of patients who seek these procedures. The majority of individuals interested in the procedures report heightened dissatisfaction typically focused on the feature being considered for treatment. Studies from around the world also have suggested that between 5-15% of patients who present for cosmetic procedures meet diagnostic criteria for body dysmorphic disorder (BDD). While individuals with BDD typically do not report a reduction in their BDD symptoms following a cosmetic procedure, the great majority of patients without the disorder do report improvement in body image. The paper reviews this literature and also discusses the role of body image in three newer areas of plastic surgery-body contouring after massive weight loss, genital procedures (either for cosmetic purposes or as part of gender reassignment), and vascularized composite allotransplantation, including face and hand transplantation.

How Patient Decision-Making Characteristics Affect Satisfaction in Facial Plastic Surgery: A Prospective Pilot Study

BACKGROUND

The main objective of this study was to prospectively analyze which personality traits, clinical psychiatric states, and patient decision-making characteristics predict who will be less satisfied after facial plastic surgery.

METHODS

This prospective study enrolled 60 adult subjects into one of three groups: aesthetic, functional, and reconstructive facial plastic surgery procedures (n = 20 in each group) from November of 2011 to February of 2016. Self-report surveys of personality traits (i.e., NEO Personality Inventory-Revised), psychiatric state (i.e., Patient Health Questionnaire, Generalized Anxiety Disorder, Health Anxiety Inventory-Short Form), and decision-making characteristics (maximizer/satisficer survey) were given during the preoperative clinic visits. In postoperative follow-up, satisfaction questionnaires at 3, 6, and 12 months were administered. Data analysis examined associations between patient satisfaction, decision-making characteristics, and psychiatric variables.

RESULTS

Bivariate analyses showed that maximizer/satisficer decision-making style was significantly related to patient satisfaction scores in the year following surgery. This difference reached statistical significance at 6 months and remained a strong trend at 12 months. Patients who were less than extremely satisfied at both postoperative time points were more likely to portray the maximizer decision-making style. No other variables were associated with patient satisfaction at any time point. Maximizer/satisficer survey scores were not associated with self-reports of depression, anxiety, or illness anxiety. Mean scores on the maximizer/satisficer survey did not differ among the aesthetic, functional, and reconstructive groups.

CONCLUSIONS

The maximizer/satisficer survey captures an aspect of patient care not traditionally measured by standard clinical psychometric screening tools to help predict satisfaction. A short questionnaire targeting consumer decision-making may be a helpful tool for preoperative counseling.

Self-reported Patient Motivations for Seeking Cosmetic Procedures

Importance

Despite the growing popularity of cosmetic procedures, the sociocultural and quality-of-life factors that motivate patients to undergo such procedures are not well understood.

Objective

To estimate the relative importance of factors that motivate patients to seek minimally invasive cosmetic procedures.

Design, Setting, and Participants

This prospective, multicenter observational study was performed at 2 academic and 11 private dermatology practice sites that represented all US geographic regions. Adult patients presenting for cosmetic consultation or treatment from December 4, 2016, through August 9, 2017, were eligible for participation.

Exposures

Participants completed a survey instrument based on a recently developed subjective framework of motivations and a demographic questionnaire.

Main Outcomes and Measures

Primary outcomes were the self-reported most common motivations in each quality-of-life category. Secondary outcomes were other frequently reported motivations and those associated with specific procedures.

Results

Of 529 eligible patients, 511 agreed to participate, were enrolled, and completed the survey. Typical respondents were female (440 [86.1%]), 45 years or older (286 [56.0%]), white (386 [75.5%]), and college educated (469 [91.8%]) and had previously received at least 2 cosmetic procedures (270 [52.8%]). Apart from motivations pertaining to aesthetic appearance, including the desire for beautiful skin and a youthful, attractive appearance, motives related to physical health, such as preventing worsening of condition or symptoms (253 of 475 [53.3%]), and psychosocial well-being, such as the desire to feel happier and more confident or improve total quality of life (314 of 467 [67.2%]), treat oneself or celebrate (284 of 463 [61.3%]), and look good professionally (261 of 476 [54.8%]) were commonly reported. Motivations related to cost and convenience were rated as less important (68 of 483 [14.1%]). Most motivations were internally generated, designed to please the patients and not others, with patients making the decision to undergo cosmetic procedures themselves and spouses seldom being influential. Patients younger than 45 years were more likely to undertake procedures to prevent aging (54 of 212 [25.5%] vs 42 of 286 [14.7%] among patients ≥45 years; P < .001). Patients seeking certain procedures, such as body contouring (19 of 22 [86.4%]), acne scar treatment (36 of 42 [85.7%]), and tattoo removal (8 of 11 [72.7%]), were more likely to report psychological and emotional motivations.

Conclusions and Relevance

This initial prospective, multicenter study comprehensively assessed why patients seek minimally invasive cosmetic procedures. Common reasons included emotional, psychological, and practical motivations in addition to the desire to enhance physical appearance. Differences relative to patient age and procedures sought may need further exploration.

[Body dysmorphic disorder : Diagnostics and treatment in cosmetic dermatology]

People with a body dysmorphic disorder (BDD) suffer from excessive preoccupation and anxiety about an imagined or to others a negligible defect in their appearance. They cannot bear to look at themselves, feel ugly, are convinced that their nose, their physique and their skin are disfiguring. The more concerned they become about their appearance, the more their attention is drawn to the ostensible blemishes and reinforces the impression of their own unattractiveness. Those affected do not consider themselves to be ill, but are convinced that it is a real physical defect which forces them again and again to stand in front of the mirror. Such patients may consult a dermatologist, some even a plastic surgeon, in order to get closer to their ideal of beauty, which perforce remains unattainable for patients because of a distorted perception of their body.

Healing Childhood Psychological Trauma and Improving Body Image Through Cosmetic Surgery

Cosmetic surgery is an interdisciplinary field involving cosmetics and medicine that stems from the early modern obsession with disfigurement. The "correcting" of facial features and body parts was very likely because beauty was at the heart of most reconstructive desires. Cosmetic surgery patients typically experience improvements in body image, and some are very satisfied with the impact of cosmetic surgery in changing their behaviors and improving self-esteem. The doctrine of mind-body connection supports the concept of healing the heart through the body. However, some people feel disgraced after revealing their experiences of cosmetic surgery. It is known that people who experience childhood psychological trauma, such as abuse and school bullying, may opt for cosmetic surgery later in life. The present study aimed to explore the relationship between childhood psychological trauma, cosmetic surgery, and body image. Three female adults who had undergone different types of cosmetic surgery completed the Acceptance of Cosmetic Surgery Scale (ACSS), the Fear of Negative Appearance Evaluation Scale (FNAES), and the Multidimensional Body-Self Relations Questionnaire (MBSRQ), followed by semistructured face-to-face interviews. According to the results, 1) undergoing cosmetic surgery can enhance self-confidence, reduce body dissatisfaction, resolve inner conflicts, and somewhat relieve psychological distress; 2) self-esteem and body image obtained from cosmetic surgery can resolve the distressing aftereffects of childhood trauma that occur later in life; and 3) the perceived sense of beauty achieved from cosmetic surgery contributes to a certain degree of self-confidence in the short term and promotes appearance-enhancing behaviors while increasing the distress of others discovering their cosmetic surgery experiences. The implications of this study are that undergoing cosmetic surgery can have healing effects on childhood trauma; however, there are certain drawbacks that can occur, such as distress and an insatiable desire for or an "addiction" to surgery.

Prevalence of Depressive Symptoms in Patients Requesting Cosmetic Breast Surgery in Midwestern Brazil

Background

The prevalence of depressive symptoms (DS) before cosmetic breast surgery was analyzed in the public (PbI) and private (PrI) institutions, comparing types of surgery and patients' sociodemographic characteristics.

Methods

A cross-sectional, observational, analytical study to evaluate the prevalence of DS in 185 patients of 18-71 years of age requesting 4 different cosmetic breast surgeries (with and without implants) at public and private institutions. Patients were assessed using the Beck Depression Inventory and analyzed for statistical comparison.

Results

The most common surgical procedures were reduction mammoplasty in the PbI and augmentation mammoplasty in the PrI. The prevalence of the positive risk for depressive disorder (≥15 points in Beck Depression Inventory) in the PbI was 25.8%, whereas in the PrI: 11.4% (P = 0.012). Moderate and severe DS were, respectively, 120% and 242% higher in the PbI than in the PrI. No patients requesting mastopexy without implants had DS. The highest prevalence (51.4%) of DS occurred in patients with breast implants indications (augmentation mammoplasty and mastopexy with implants). The presence (P = 0.12) or absence (P = 0.33) of implant did not demonstrate a higher risk of DS. Among all patients, 7% answered positively to the statements on suicide ideation, with predominance within the group of implants (54.5%). There were significant differences between the PbI and PrI.

Conclusions

The prevalence of DS was high (18.9%), with the risk being 2.3 times greater in the PbI. Patients from PbI and PrI showed significant different profiles. Patients for breast implants showed a higher score for suicide ideation.

Gender-Affirming Surgery in Persons with Gender Dysphoria

The landscape of gender dysphoria has changed dramatically in recent years secondary to increased societal acceptance, legislative changes, and medical providers' increased awareness of the associated psychosocial burden associated with the diagnosis. National and global advocacy efforts, in conjunction with expanded third-party insurance coverage, have resulted in new health care opportunities for patients suffering from gender dysphoria. Delivering quality, streamlined health care to these patients requires a complex multidisciplinary approach, involving multiple medical and mental health disciplines, including plastic surgeons. To accommodate the expanding demand for gender-affirmation surgery, academic medical centers specializing in these procedures are gradually emerging. Advancing surgical techniques in the setting of rising patient demand encourage plastic surgeons to increasingly provide high-quality health care to this diverse patient population in an effort to optimize psychosocial functioning and minimize the burden of gender dysphoria. Although the current literature is replete with the evolving surgical and technical approaches to gender-affirming surgery, there remain critical gaps in the plastic surgery literature describing the delivery of comprehensive care to these patients. To address these gaps, the authors establish a framework that plastic surgeons can use to guide their management of patients with gender dysphoria to optimize surgical and psychosocial outcomes. First, the authors describe a timeline of events that have shaped present-day transgender medicine and characterize the current role of the plastic surgeon in the management of gender dysphoria. Subsequently, the authors discuss psychosocial and ethical considerations surrounding gender dysphoria. Finally, the authors discuss the future scope of transgender medicine.

Motivational Factors in Women Seeking Augmentation Mammoplasty Across Different Age Groups: A Cross-Sectional Survey

BACKGROUND

Augmentation mammoplasty is one of the most common esthetic procedures worldwide. A wide range of motivations leads women to undergo this procedure, among them socioeconomic status and age group. The aim of this study was to identify the motivation spectrum for augmentation mammoplasty through different age groups.

METHODS

We conducted a cross-sectional prospective survey given to Israeli women seeking augmentation mammoplasty consults in a hospital and private clinic settings, using a 17-item Motivation for Augmentation questionnaire. Three motivation domains were examined: appearance, sexuality and social. Study participants were divided into three age groups: 18-29, 30-39 and over 40 years.

RESULTS

A total of 101 women participated in the study. Motivations were rated similar among all age groups. Appearance and sexuality domains were rated significantly higher compared with the social domain throughout all age groups (3.28 ± 0.91 and 3.15 ± 1.03 vs. 1.88 ± 1.16, p < 0.001, respectively).

CONCLUSIONS

Motivations in Israeli women seeking breast augmentation do not change with age. The desire to improve one's appearance and sexuality is more prominent than improving social and work status.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Does self-consciousness of appearance influence postoperative satisfaction in rhinoplasty?

BACKGROUND

Facial plastic surgeons and patients benefit from knowledge about how psychological aspects can influence the outcome of cosmetic surgery. The influence of preoperative self-consciousness of appearance and its effect on benefit after surgery in rhinoplasty patients has not been explored before in other studies.

METHOD

A prospective study was conducted on patients undergoing (septo)rhinoplasty for a combination of cosmetic and functional problems. Before the operation subjects were asked to complete two questionnaires, the Derriford Appearance Scale (DAS59) to measure distress associated with self-consciousness of appearance and the Rhinoplasty Outcome Evaluation (ROE) to measure satisfaction with their nose. Three months after surgery, they were asked to complete the ROE again and the Glasgow Benefit Inventory to measure benefit of the surgery in daily life. Scores of the pre- and postoperative questionnaires were analyzed and compared. Statistical analysis was performed to determine change after surgery and correlations between the scores.

SUBJECTS

Fifty-five consecutive patients undergoing (septo)rhinoplasty received a letter in which they were asked to participate in the study. Thirty-three patients completed both pre- and postoperative questionnaires. Their mean age was 28 years.

MAIN FINDINGS

Patient satisfaction improved significantly after the surgery. Lower self-consciousness of appearance before surgery was positively correlated with more benefit after the surgery and a greater change in patient satisfaction with their nose. Males have a lower benefit scores than females.

CONCLUSIONS

Patients seeking rhinoplasty have more distress associated with self-consciousness of appearance than a general unconcerned population. They can benefit a lot from a well-executed procedure. A significant improvement in quality of life can be achieved by rhinoplasty. Although males are equally satisfied as females, they benefit less from the surgery in daily life.

Health-Related Quality of Life and the Desire for Revision Surgery Among Children With Cleft Lip and Palate

PURPOSE

Children with cleft lip with or without palate (CLCP) require multiple reconstructive procedures, however, little is known about their desire for surgical revision. The purpose of this study was to examine the relationship between health-related quality of life (HRQOL) and the desire for revision.

METHODS

The authors surveyed children with CLCP (n = 71) and their caregivers regarding general and cleft-specific HRQOL and the desire for revision surgery. The authors used logistic regression models to evaluate the relationship between HRQOL and the desire for revision stratified by age, and determined the level of agreement between caregivers and children.

RESULTS

In this cohort, 54.9% of children desired revision, primarily of the nose (n = 23), lip (n = 20), and dentoalveolar structures (n = 19). Children 11 years or older were more likely to desire revision than younger children (OR 3.39, 95% CI [1.19, 9.67], P <0.05). Children who reported poorer HRQOL with respect to appearance (OR 2.31, 95% CI [1.25-4.29], P = 0.008), social development (OR 0.91, 95% CI [0.84-0.99], P = 0.02), and communication (OR 0.94, 95% CI [0.89-0.99], P = 0.02) were significantly more likely to desire revision than children who reported more positive HRQOL. Caregivers' and children's desires for revision were only modestly correlated (r = 0.41).

CONCLUSIONS

Children with CLCP who report poorer HRQOL are more likely to desire revision than children with higher HRQOL; these differences are further magnified among older children. Given the modest correlation between patient and caregiver goals for revision, it is important to evaluate both perspectives when considering revision surgery.

A qualitative study of life events and psychological needs underlying the decision to have cosmetic surgery

Objective A thorough psychological assessment of patients requesting cosmetic surgery can help to protect them from the risk of postoperative dissatisfaction and the onset and/or aggravation of psychiatric disorders. This study seeks to shed more light on why people desire cosmetic surgery and thus help surgeons, psychiatrists, and psychologists to conduct assessments before surgery. Methods In-depth interviews were conducted with 35 subjects who requested cosmetic surgery. The interviews were recorded and transcribed and then analyzed qualitatively with Grounded Theory. Themes and categories were identified and compared in logical order, to build a consistent theoretical model. Results In each interview, we identified one or more recent events that the subjects considered to be contributing factors in their decisions to have cosmetic surgery. We observed that 33 of 35 patients said they sought cosmetic surgery at a time when they were experiencing, or had just experienced, one or more major changes in their bodies or their relationships. Recent life events triggered or strengthened specific psychological needs in the subjects: to cope with the past and with change, attain a consistent identity, find or regain a positive self-image, alter others' perceptions, define themselves in relation to others, or please themselves or others. Patients said that they chose plastic surgery to fulfill one or more of these needs. Conclusions This study identifies the role of recent events in inciting individuals to resort to cosmetic surgery. This factor provides new perspectives for surgeons to understand those patients and opens new avenues for research.

Body Image and Body Contouring Procedures

Dissatisfaction with physical appearance and body image is a common psychological phenomena in Western society. Body image dissatisfaction is frequently reported by those who have excess body weight, but also is seen in those of normal body weight. For both groups of individuals, this dissatisfaction impacts self-esteem and quality of life. Furthermore, it is believed to be the motivational catalyst to a range of appearance-enhancing behaviors, including weight loss efforts and physical activity. Body image dissatisfaction is also believed to play a role in the decision to seek the wide range of body contouring procedures offered by aesthetic physicians. Individuals who seek these procedures typically report increased body image dissatisfaction, focus on the feature they wish to alter with treatment, and often experience improvement in body image following treatment. At the same time, extreme body image dissatisfaction is a symptom of a number of recognized psychiatric disorders. These include anorexia nervosa, bulimia nervosa, and body dysmorphic disorder (BDD), all of which can contraindicate aesthetic treatment. This special topic review paper provides an overview of the relationship between body image dissatisfaction and aesthetic procedures designed to improve body contouring. The review specifically focuses on the relationship of body image and body weight, as well as the presentation of body image psychopathology that would contraindicate aesthetic surgery. The overall goal of the paper is to highlight the clinical implications of the existing research and provide suggestions for future research on the psychological aspects of body contouring procedures.

Body dysmorphic disorder in different settings: A systematic review and estimated weighted prevalence

Our aim was to systematically review the prevalence of body dysmorphic disorder (BDD) in a variety of settings. Weighted prevalence estimate and 95% confidence intervals in each study were calculated. The weighted prevalence of BDD in adults in the community was estimated to be 1.9%; in adolescents 2.2%; in student populations 3.3%; in adult psychiatric inpatients 7.4%; in adolescent psychiatric inpatients 7.4%; in adult psychiatric outpatients 5.8%; in general cosmetic surgery 13.2%; in rhinoplasty surgery 20.1%; in orthognathic surgery 11.2%; in orthodontics/cosmetic dentistry settings 5.2%; in dermatology outpatients 11.3%; in cosmetic dermatology outpatients 9.2%; and in acne dermatology clinics 11.1%. Women outnumbered men in the majority of settings but not in cosmetic or dermatological settings. BDD is common in some psychiatric and cosmetic settings but is poorly identified.

Prevalence of body dysmorphic disorder on a psychiatric inpatient ward and the value of a screening question

The aim of this study was to estimate the prevalence of body dysmorphic disorder (BDD) on an inpatient ward in the UK with a larger sample than previously studied and to investigate the value of a simple screening question during an assessment interview. Four hundred and thirty two consecutive admissions were screened for BDD on an adult psychiatric ward over a period of 13 months. Those who screened positive had a structured diagnostic interview for BDD. The prevalence of BDD was estimated to be 5.8% (C.I. 3.6-8.1%). Our screening question had a slightly low specificity (76.6%) for detecting BDD. The strength of this study was a larger sample size and narrower confidence interval than previous studies. The study adds to previous observations that BDD is poorly identified in psychiatric inpatients. BDD was identified predominantly in those presenting with depression, substance misuse or an anxiety disorder. The screening question could be improved by excluding those with weight or shape concerns. Missing the diagnosis is likely to lead to inappropriate treatment.

Negative predictors for satisfaction in patients seeking facial cosmetic surgery: a systematic review

BACKGROUND

Facial cosmetic surgery is becoming more popular. Patients generally indicate they are satisfied with the results. Certain patient characteristics, however, have been described as negative predictors for satisfaction. Psychopathology such as body dysmorphic disorder and personality disorders are notorious. Psychosocial and cultural factors are more difficult to distinguish. This systematic review defines the predictors, other than body dysmorphic disorder, of an unsatisfactory outcome after facial cosmetic surgery. The authors are also interested in whether valid preoperative assessment instruments are available to determine these factors.

METHODS

An extensive systematic PubMed/MEDLINE and Cochrane Library search was performed. In addition, relevant studies from the reference lists of the selected articles were added. There were no publication-year restrictions, and the last search was conducted on July 20, 2014. All factors described as negative predictors for patient satisfaction after facial cosmetic surgery were identified.

RESULTS

Twenty-seven articles were analyzed, including 11 prospective studies, two retrospective studies, one case study, eight reviews, and five expert opinions. The following factors were identified: male sex, young age, unrealistic expectations, minimal deformities, demanding patients, "surgiholics," relational or familial disturbances, an obsessive personality, and a narcissistic personality.

CONCLUSIONS

This review indicates the possible demographic and psychosocial predictors for an unsatisfactory outcome of facial cosmetic surgery. A brief personality assessment tool that could be used to address predictors preoperatively was not found. The authors suggest use of the Glasgow Benefit Inventory to assess patient satisfaction postoperatively. Further research is being undertaken to develop such an instrument.

Long-term psychosocial impact of otoplasty performed on children with prominent ears

Objectives:

To investigate the psychosocial impact of prominent ears on children, and evaluate the outcomes of otoplasty two years after surgery, using the Child Behavior Checklist to comparatively evaluate patients' psychosocial profiles.

Method and results:

A total of 198 otoplasty procedures were performed in 107 patients (85 per cent bilateral procedures). Otoplasty was performed solely in 86 patients and concurrently with other procedures in 21 patients. All children who underwent surgery obtained good post-operative results, with satisfactory correction of the deformity reported by the patients and their parents or guardians. There were statistically significant decreases in Child Behavior Checklist scores in the domains of: anxiety and depression (p = 0.028), social problems (p = 0.018), difficulties in thinking (p = 0.012), total behavioural problems (p = 0.012), internalising problems (p = 0.020) and externalising problems (p = 0.044), and near-significant decreases in scores for attention problems (p = 0.055) and aggressive behaviour (p = 0.078). There was a statistically significant increase in the score for total social competence (p = 0.031).

Conclusion:

Psychological problems associated with anatomical deformities such as prominent ears can be reduced by means of appropriate corrective surgery. Psychological support is necessary for the patient.

Development and psychometric evaluation of the FACE-Q Aging Appraisal Scale and Patient-Perceived Age Visual Analog Scale

BACKGROUND

The primary outcome measures for patients who undergo aesthetic facial procedures are quality of life and satisfaction with appearance. The FACE-Q, a new patient-reported outcome (PRO) instrument composed of independently functioning scales, is designed to measure a broad range of important outcomes in patients who undergo cosmetic surgical and/or nonsurgical facial procedures.

OBJECTIVES

The authors describe the development and psychometric evaluation of the FACE-Q Aging Appraisal Scale and the FACE-Q Patient-Perceived Age Visual Analog Scale (VAS).

METHODS

International guidelines for creating PRO instruments were strictly observed throughout development of the FACE-Q scales. Qualitative methods were used to identify the concepts most important to patients who received aesthetic facial procedures. These were turned into "items"-and the resultant FACE-Q Aging Appraisal Scale was field tested, along with the Patient-Perceived Age VAS, in 288 patients who underwent cosmetic surgical and/or nonsurgical facial procedures.

RESULTS

Rasch measurement theory and traditional psychometric methods confirmed the reliability and validity of the scales.

CONCLUSIONS

The FACE-Q Aging Appraisal Scale and Patient-Perceived Age VAS are psychometrically sound, condition-specific PRO instruments with excellent reliability and validity. They enable accurate outcome assessments in patients who undergo aesthetic facial procedures.

Aesthetic analysis in rhinoplasty: surgeon vs. patient perspectives: a prospective, blinded study

OBJECTIVE

To determine how patients seeking cosmetic rhinoplasty analyze themselves compared to their surgeon's analysis. Simply stated, "Does your surgeon view your nose the same as you?"

STUDY DESIGN

Prospective, blinded study.

METHODS

All primary rhinoplasty consultations completed a nasal analysis questionnaire. The patients' facial plastic surgeons completed an identical questionnaire. The results were compared and analyzed.

RESULTS

Data underwent statistical analysis and subsequent factor analysis was performed. 132 patients participated in the study. Questions were grouped together based on factors: overall appearance, skin quality, tip dimensions, straightness, nostril show, and width. The only factor with reasonable surgeon/patient correlation was factor 1, overall appearance, with correlation 0.6473, p<0.001.

CONCLUSIONS

Surgeons and patients are in agreement with the overall appearance of the nose, but differ in their analysis regarding the details. This information can be used to guide future discussions during consultations and most importantly help to better gauge and manage patient expectations.

Psychological screening measures for cosmetic plastic surgery patients: a systematic review

With the increasing popularity of cosmetic surgery procedures, preoperative psychological assessment of cosmetic surgery patients may improve outcomes by highlighting patient expectations and motivations, as well as by identifying those who may require psychological referral. In this article, the authors describe a systematic literature review to identify and evaluate current self-report tools used in the psychological screening of cosmetic surgery patients prior to surgery. Articles related to the preoperative mental health assessment of cosmetic surgery patients were identified by searching MEDLINE, EMBASE, HAPI, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials through November 2010. The full text of potentially relevant articles was examined by 2 reviewers, and articles that met the inclusion criteria were reported. Close reading of 100 full-text articles showed that although a variety of instruments are currently being used as preoperative assessment tools, there are limitations to their validity and usefulness in the screening of cosmetic surgery patients. To properly assess cosmetic surgery patients, a scientifically sound and clinically useful instrument is needed.

A study of postural changes after breast augmentation

BACKGROUND

A number of factors, including body mass and one's mood, may influence posture. Breast augmentation results not only in a significant improvement in body image-related feelings and self-esteem but also in a sudden change in body mass. The aim of this study was to assess postural changes following breast augmentation by studying body position, orientation through space, and center of pressure.

METHODS

Patients with breast hypoplasia who underwent breast augmentation were enrolled. Posture evaluation was performed before and 1, 4, and 12 months after surgery by quantifying the center of mass using the Fastrak™ system and the center of pressure using stabilometry. The Wilcoxon signed-rank sum test was used to compare value modifications.

RESULTS

Forty-eight patients were enrolled in the study. A retropositioning of the upper part of the body, confirmed by baropodometric analysis, was evident in the early postoperative period. We subsequently observed a reprogramming of the biomechanical system, which reached a state of equilibrium 1 year after surgery, with a slight retropositioning of the head and a compensatory anterior positioning of the pelvis.

CONCLUSION

We believe that with respect to posture, the role played by psychological aspects is even more important than that played by changes in body mass. Indeed, hypomastia is often associated with kyphosis because patients try to hide what they consider a deficiency. Following breast augmentation, the discovery of new breasts overcomes the dissatisfaction with the patient's own body image, increases self-esteem, and modifies posture regardless of the changes in body mass due to the insertion of the implants.

Quality of life among Iranian adults before and after rhinoplasty

BACKGROUND

Despite developments in the therapeutic field of cosmetic surgery, there is a little information about the effects of cosmetic procedures on quality of life (QOL), especially in Iran. Rhinoplasty is one of the most common cosmetic surgeries. This type of surgery has remarkable effects on physical and mental health and also improves nasal functioning. The purpose of this study was to survey QOL among Iranian adults before and after rhinoplasty.

METHODS

In this descriptive and analytical cross-sectional study, from March 2009 to March 2010, data were collected from 75 subjects, 16 years old and above, before and 6 months after rhinoplasty. A trained interviewer interviewed and completed standardized questionnaires investigating QOL, including the SF-36 version 2, NOSE, and Rosenberg questionnaires. Data analysis was conducted using SPSS ver. 16. Results before and after surgery were compared.

RESULTS

The mean age of the subjects was 26.05 ± 7.78 years, with a median of 24 years. The female-to-male ratio was 4.35:1. In all cases and all questionnaires, QOL was improved after rhinoplasty. Significant differences were observed on the NOSE questionnaire (p = 0.005) and the Rosenberg questionnaire (p = 0.002). On the SF-36 questionnaire, significant differences were observed in four subscales, including physical functioning (p = 0.047), role of emotion (p = 0.01), bodily pain (p = 0.01), and vitality (p = 0.05).

CONCLUSIONS

According to this study, QOL is improved after rhinoplasty in Iranian adult patients. With proper patient selection and a successful operation, improvement of physical and mental health can be expected.

Mirror, mirror on the wall…: self-perception of facial beauty versus judgement by others

In 1878, Margaret Wolfe Hungerford published a simple but insightful phrase in her novel 'Molly Bawn' that was to be quoted so often it has almost become cliché: "Beauty is in the eye of the beholder". While many questions regarding the perception and neural processing of facial attractiveness have been resolved, it became obvious to us that study designs have been principally based on either facial self-perception or perception by others. The relationship between these however, remains both crucial and unknown. Standardized images were taken of 141 subjects. These 141 subjects were asked to complete the adjective mood scale (AMS) and to rank specific issues related to their looks on a visual analogue scale. The images were then shown to independent judges to rank specific issues related to their looks on a visual analogue scale. Our results show proof for a strikingly simple observation: that individuals perceive their own beauty to be greater than that expressed in the opinions of others (p < 0.001). This observation provides insight into our basic behavioural patterns and suggests that there are strong psychological mechanisms in humans supporting self-identification and thereby encouraging the self-confidence and resilience necessary to maintain one's social standing. While the psychological basis of self-confidence is multifactorial, our finding provides critical objective insight. We prove here for the first time that nothing more than the beauty of the beholder is in the eyes of the latter.

Body Image Concern Inventory (BICI) for identifying patients with BDD seeking rhinoplasty: using a Persian (Farsi) version

BACKGROUND

Dissatisfaction with appearance is most pronounced in rhinoplasty patients compared to candidates for other aesthetic procedures. We aimed to test and introduce the Body Image Concern Inventory (BICI) as a self-report screening tool for identifying body dysmorphic disorder (BDD) among patients seeking rhinoplasty.

METHODS

The surgeon completed a two-point defect severity scale in which a score of 1 represented no defect or one defect and a score of 2 represented more than one defect. Each of the 117 subjects with a score of 1 answered a questionnaire that was designed to obtain demographic data and completed the Persian version of the BICI. The psychiatrist, considering the patient's demographic data and blind to the BICI score, interviewed him/her using a semistructured diagnostic tool for BDD based on DSM-IV.

RESULTS

The validity of the Persian version of the BICI was calculated at 85%. The reliability of the Persian BICI items was tested and Cronbach's alpha was 0.90. The results of ROC analysis for the ideal cutoff point of the Persian BICI, based on the Youden index method and optimum sensitivity and specificity, revealed that the ideal cutoff point for positive or negative criterion of that questionnaire's result may be the total score of 42 (sensitivity, 93.5%; specificity, 80.8%) The diagnostic accuracy of the Persian BICI in comparison with the gold standard (psychiatric interview), according to the area under the ROC curve (AUC), was 91.4% (95% CI = 86-97%, P < 0.0001). The agreement of the results of the Persian BICI questionnaire with the psychiatric interview for diagnosis of BDD, according to kappa index, was 61.7% (P < 0.001), and the odds ratio (OR) of being diagnosed with BDD in a psychiatric interview for those with overall scores ≥42 for the Persian BICI was 47.7 (95% CI = 43-52).

CONCLUSION

The results of the present study emphasize the high rate of BDD (12.2%) in subjects seeking rhinoplasty. The BICI appears to be an internally consistent and valid brief multiple-choice instrument for assessing dysmorphic concern. To our knowledge, this is the first time that this measure has ever been used for identifying BDD patients in a rhinoplasty setting; it is also the first time that ROC analysis has been used for calculating and analyzing the results of BICI. Our study suggests that rhinoplasty surgeons could rely on the scores of the BICI to identify subjects with probable BDD among their consultants with no or one slight defect.

Body dysmorphic disorder in patients who seek appearance-enhancing medical treatments

Most patients who seek appearance-enhancing medical treatments report some degree of body image dissatisfaction, which is believed to motivate the pursuit of these treatments. However, patients with extreme body image dissatisfaction may be suffering from a psychiatric disorder known as body dysmorphic disorder (BDD). This article reviews BDD, including its clinical features and prevalence in medical settings. Although patients with BDD frequently seek cosmetic treatments to address their appearance-related distress, such treatments are rarely beneficial. The article concludes with recommendations for patient and provider safety.

The psychological aspects of rhinoplasty

PURPOSE OF REVIEW

Literature on the psychological aspects of rhinoplasty is sparse compared with publications on methods and instrumentation. Understanding the psychological aspects of rhinoplasty and, more importantly, recognizing the patient who may have an unfavorable postoperative course regardless of the objective outcome is of fundamental importance to the surgeon.

RECENT FINDINGS

Several profiles of patients with a high risk of postoperative dissatisfaction have been described and the important role of body dysmorphic disorder and its treatment has been stressed. Still, these criteria can be insufficient when facing the individual patient, as reliable screening instruments for clinical practice have not been developed and the question when not to operate is subject to controversy. The role of computer imaging as a safeguard in preoperative counseling has been highlighted.

SUMMARY

The surgeon must rely on instinct and experience to avoid overlooking any signs of psychological imbalance in the patient that may herald adversity. Archetypes described in the literature should be recognized and computer imaging should be used during the preoperative consultation.

Scar tissue

PURPOSE OF REVIEW

To examine the place of surgery and other modes of treating scar tissue given the plethora of measures that are advocated on the internet.

RECENT FINDINGS

There is good evidence to support the use of silicone sheets, pulsed dye laser (PDL), intralesional triamcinolone and dermabrasion in reducing hypertrophic scars, but each needs qualifying in terms of their timing and the type of scar tissue that they are used for.

SUMMARY

The surgical revision of scars should be delayed for at least 12 months unless there is webbing when redistributing skin tension forces with a Z-plasty or multiple Z-plasties or other local flaps negates the need to wait for the scar to mature. In a posttraumatic 'horse shoe' shaped, or a very oblique, cut an irregular contour is likely to occur. Under these circumstances a triamcinolone injection into any raised area can help and this needs to be re-evaluated after 6 weeks. With a less irregular contour dermabrasion can help if used 8 weeks after surgery. With hypertrophic scarring both silicone gel sheeting and PDL may help reduce the prominence of the scar. Most of all time helps scars to settle and fade and typical scar maturation takes 18-24 months. The role of stem cells, particularly from adipose tissue, warrants further study.

The need for preoperative psychological risk assessment

Adverse psychological outcomes are more prevalent among patients undergoing elective, appearance-altering surgery than are physical complications. Patients may experience depression, posttraumatic stress disorder, or an exacerbation of preexisting symptoms related to body dysmorphic disorder. Some have directed anger against themselves or against the operating surgeon with suicide, litigation, harassment, and homicide, all well documented. Although there are well-established protocols to conduct medical and anesthetic risk stratification, such protocols do not exist for psychological risk assessment (PRA). The literature related to this is reviewed, the need for PRA is discussed, and an approach to PRA for dentists and surgeons is proposed.