The PreFACE: A preoperative psychosocial screen for elective facial cosmetic surgery and cosmetic dentistry patients

Development of a Preoperative Psychological Screening Tool: Piloting the Cosmetic Readiness Questionnaire (Pilot-CRQ)

BACKGROUND

Patients with psychological risk factors such as body dysmorphic disorder (BDD) and unmanaged mental health concerns are considered at higher risk for dissatisfaction with aesthetic procedures. Identifying these risks before a procedure may decrease the chance of adverse outcomes for patients and practitioners.

OBJECTIVES

In this study we aimed to develop a comprehensive psychological screening tool to assess patient's psychological suitability for surgical and nonsurgical aesthetic procedures.

METHODS

Items for the Pilot Cosmetic Readiness Questionnaire (CRQ) were developed by psychologists (n = 3) and then reviewed by plastic surgeons (n = 2) and nonsurgical cosmetic doctors (n = 3). Patient interviews (n = 15) and piloting of the questionnaire (n = 69) provided data regarding the scale's initial psychometric properties.

RESULTS

Results supported the reliability and validity of the Pilot-CRQ's subscales of Body Dysmorphia, Psychological Distress, Self-Criticism, Perfectionism, and Lack of Openness. Lack of Openness was a validity scale that examined the degree that respondents might be underreporting symptoms. The CRQ predicted individuals with a BDD diagnosis, as rated by a blinded expert clinical psychologist, with high sensitivity and specificity.

CONCLUSIONS

These results provide support for the Pilot-CRQ identifying people with BDD and psychological factors related to aesthetic treatment outcomes and provide a strong basis for employing the CRQ in clinical contexts and in future research.

LEVEL OF EVIDENCE: 2 (DIAGNOSTIC)

General dentists' treatment plans in response to cosmetic complains; a field study using unannounced-standardized-patient

Background

This field study explored general dentists' treatment plans in response to the request for cosmetic services of an unannounced standardized patient (USP) in Mashhad, Iran.

Methods

The researcher, as a USP, visited 24 and 23 offices in a high-income and a low-income area, respectively. The primary complaint was that, according to her friend's comments, a dental student, her smile was "crooked and yellow" due to the congenitally missing tooth number 10 and peg-shaped tooth number 8. The dentists' treatment plans for teeth color and form and the cosmetic services expenses were recorded. The treatment plans of the two areas were compared.

Results

For dental form, most dentists' treatment plans were categorized as "No intervention" (privileged area: 37.5 %, less-privileged area: 56.53 %, and total: 46.80 %). The percentage of dentists in the privileged area who prescribed cosmetic services was twice that of the less-privileged area (33.33 % versus 17.39 %). The intervention for dental form varied from placing 1 unit of composite veneer to 10 units of ceramic laminates or orthodontics with a wide range of treatment costs ($42.09 to $1079.14). For tooth color, most dentists (privileged area: 62.50 %, less-privileged area: 30.43 %, and total: 46.80 %) were categorized as "Interventionists." For tooth color, the treatment plans varied from scaling and root planing, bleaching, and composite veneer with various costs ($7.19 to $197.84).

Conclusion

Cosmetic treatment plans and expenses varied significantly for a single USP, with many not aligning with the standard treatment plan. Some dentists offered treatments even without a chief complaint from the patient. Dentists in privileged areas were twice as likely to prescribe cosmetic treatments compared to those in less privileged areas. Therefore, cosmetic services necessitate monitoring, establishing clear diagnostic criteria, and implementing educational interventions.

Is the needle as risky as the knife? The prevalence and risks of body dysmorphic disorder in women undertaking minor cosmetic procedures

OBJECTIVES

Body dysmorphic disorder is commonly considered a contraindication for major cosmetic surgery, but whether body dysmorphic disorder relates to poorer outcomes from minor cosmetic treatment remains unknown. This study aimed to explore the prevalence of body dysmorphic disorder in clients seeking non-surgical cosmetic procedures and to examine whether body dysmorphic disorder clients are vulnerable in minor cosmetic settings. Vulnerability was explored in terms of psychological distress, unrealistic expectations and motivations for treatment outcome, and reduced satisfaction with past cosmetic procedures.

METHOD

A cross-sectional online survey was completed by 154 women seeking minor cosmetic procedures which included the Body Dysmorphic Disorder Questionnaire - Dermatology Version to screen for body dysmorphic disorder, and measures of cosmetic treatment motivation, expectations and satisfaction.

RESULTS

Roughly 25% of women in the current sample screened positive for a potential body dysmorphic disorder diagnosis. Participants with suspected body dysmorphic disorder demonstrated higher levels of psychological distress and more unrealistic expectations and motivations for cosmetic treatment, such as improving social or romantic relationships. However, body dysmorphic disorder participants reported similar levels of satisfaction with past minor cosmetic treatments to the non-body dysmorphic disorder group.

CONCLUSION

While the relationship between body dysmorphic disorder and treatment outcome warrants further investigation in prospective research tracking satisfaction and adverse reactions over time, this preliminary evidence suggests clients with suspected body dysmorphic disorder display several vulnerabilities in non-surgical cosmetic settings. Given the rapidly increasing accessibility of minor cosmetic procedures, further research is needed to determine their safety for clients with body dysmorphic disorder. Detection of body dysmorphic disorder in non-surgical cosmetic settings could facilitate earlier psychological intervention, promoting superior long-term outcomes.

Relationship of Anxiety and Depression with Perfectionism in Patients with Aesthetic All-Ceramic Repair of Anterior Teeth

Background

Many psychological problems arising from patients undergoing aesthetic repair of teeth should be considered. However, there are no published studies on the relationship between anxiety/depression and perfectionism in patients with aesthetic repair of anterior teeth.

Material/Methods

A total of 640 patients receiving aesthetic repair of anterior teeth were assessed using the Corah dental anxiety scale (CDAS), a self-rating anxiety scale (SAS), a self-rating depression scale (SDS), and the Chinese version of the Frost Multidimensional Perfectionism Psychological Scale (CFMPS). Statistical analyses included use of the independent-samples t test, correlation analysis, and multiple stepwise regression analysis.

Results

We found that 156 patients with a high dental anxiety disorder had significantly greater SAS and SDS scores than those without a high dental anxiety disorder. There were significant differences between these patients and the non-high dental anxiety group, based on 3 dimensions of the CFMPS: concern over mistakes (CM), doubt about action (DA), and organization (OR). Patients with dental anxiety had a significant positive correlation with SAS in the categories CM and DA, with SDS in the categories CM and DA, and with personal standard (PS); OR was negatively correlated with SAS and SDS scores. Regression analysis showed that the CM and OR dimension scores of CFMPS and age had strong predictive effects on SAS scores, while CM, DA, PS dimension scores, and age were strong predictors of SDS scores.

Conclusions

The incidence of dental anxiety prior to anterior tooth repair treatment is high, and patients with dental anxiety have a significant tendency toward pursuing perfectionism.

Preoperative Anxiety in Patients With Nonmelanoma Skin Tumors of the Face

ABSTRACT

The manifestation of preoperative anxiety often emerges when a patient is about to experience a surgical procedure. Especially in facial plastic surgery, where the reconstruction region is very strictly confined and the visibility of the outcome is undeniable, an upcoming surgery may easily provoke the feeling of anxiety. The aim of this study is to assess the number of patients that undergo preoperative anxiety and to associate it with several factors found to be concerning for them. Two hundred twenty-eight adult (>18 years) patients with facial nonmelanoma skin tumors, from a Plastic Surgery Clinic in a major Oncology Hospital in Athens, were included in the study and were given questionnaires and a Numeric Rating Scale in order to qualitate and quantitate their preoperative anxiety. Their responses were categorized and examined using the method of content analysis. 93.8% (n = 214) reported feeling anxious preoperatively, while the remaining 6.2% (n = 14) stated the opposite. Data showed that higher scores were documented when the patients were older, had had previous surgeries or had previously undergone general anesthesia, major procedures or procedures in the periorbital area. Gender was not found to be associated with preoperative anxiety. The main concern, finally, of most patients was the success of the outcome of the surgery.

Psychiatric Assessment and Management of Clients Undergoing Cosmetic Surgery: Overview and Need for an Integrated Approach

Background  Psychiatric disorders are more common among people undergoing cosmetic procedures than the general population and evaluating mental health can be cumbersome for plastic surgeons. We aim to summarize the available literature in this regard and propose an integrated approach to psychiatric assessment and management of mental health issues among this group. Methods  Electronic search of MEDLINE, Google Scholar, and PsycINFO databases was done to identify relevant peer-reviewed English language articles from inception till April 2020. Generated abstracts were screened for their eligibility. Included articles were grouped according to their thematic focus under the following headings; prevalence of psychiatric morbidity among clients posted for cosmetic surgery, assessment tools, and management of psychiatric morbidity in relation to undergoing cosmetic surgery. Results  A total of 120 articles were reviewed. The prevalence of psychiatric disorder in patients undergoing cosmetic surgery was 4 to 57% for body dysmorphic disorder (BDD); the corresponding figures for depression, anxiety, and personality disorder were 4.8 to 25.8, 10.8 to 22, and 0 to 53%, respectively. A range of tools have been used to assess these disorders and specific measures are also available to assess clinical outcomes following surgery. Screening for these disorders is essential to prevent unnecessary surgical procedures, as well as to ensure timely management of the psychiatric comorbidity. Conclusion  Psychiatric morbidity is a common concomitant in cosmetic surgery. A structured and integrated approach to evaluation and management of psychiatric morbidity will help to optimize postsurgical outcomes.

Association Between Mental Health Status and Patient Satisfaction With the Functional Outcomes of Rhinoplasty

Importance

Mental health can have an impact on patient satisfaction with rhinoplasty. However, the association between mental health and patient satisfaction with functional outcomes of rhinoplasty is poorly understood.

Objective

To determine whether preoperative mental health is associated with satisfaction with functional outcomes of rhinoplasty.

Design, Setting, and Participants

This case-control study assessed baseline nasal function and postsurgical functional outcomes for 88 consecutive patients undergoing rhinoplasty with both cosmetic and functional goals at 2 tertiary rhinologic centers in Sydney, Australia.

Exposures

Poor mental well-being was defined preoperatively by the Optum SF-36v2 Health Survey mental component summary.

Main Outcomes and Measures

Nasal function was assessed with patient-reported outcome measures, including visual analog scales, the Nasal Obstruction Symptom Evaluation Scale (NOSE), the 22-item Sinonasal Outcome Test (SNOT-22), and Likert scales. Objective outcomes included nasal peak inspiratory flow, nasal airway resistance, and minimum cross-sectional area. All outcomes were assessed preoperatively and 6 months postoperatively. The 36-item Optum SF-36v2 Health Survey mental component summary was used to assess mental well-being, with a score of less than 40 indicating poor mental well-being and a score 40 or higher indicating normal well-being.

Results

Mean (SD) patient age was 37.6 (12.9) years and 53 of 88 (60.2%) were women. The mental component summary defined impaired well-being in n = 24 (cases) and normal well-being in n = 64 (controls). There were improvements in the total study population across most nasal function outcomes and in both groups. After rhinoplasty, benefit was seen for both groups in visual analog scale (left side mean [SD] change, 18 [30]; P < .001 and right side mean [SD] change, 24 [30]; P < .001); NOSE (mean [SD] change, 1.35 [1.21]; P < .001); and SNOT-22 (mean [SD] change, 0.81 [0.88]; P < .001) scores. Nasal peak inspiratory flow improved for both groups (mean [SD] change, 32 [45] L/min; P < .001), while nasal airway resistance and minimum cross-sectional area remained similar (change in nasal airway resistance, 0.086 Pa/cm3/s; 95% CI, -0.007 Pa/cm3/s to 0.179 Pa/cm3/s and change in minimum cross-sectional area, -0.04 cm2; 95% CI, -0.21 cm2 to 0.13 cm2). Patients with poor mental health had similar improvements in nasal function compared with controls.

Conclusions and Relevance

Rhinoplasty imparts similar benefits to nasal function assessed by patient-reported outcome measures and objective airflow measures regardless of preoperative mental health status.

Level of Evidence

3.

Changes in the Indices of Body Image Concern, Sexual Self-Esteem and Sexual Body Image in Females Undergoing Cosmetic Rhinoplasty: A Single-Group Trial

INTRODUCTION

Psychological factors play a major role in the tendency toward cosmetic surgery. Variety seeking, making changes in one's face and reducing apparent dissatisfaction, improving body image and increasing sexual self-esteem can be considered as some psychological aspects of cosmetic surgery. The present study was conducted with the aim of evaluating the changes in the indices of body image concern, sexual self-esteem and sexual body image in patients undergoing rhinoplasty.

METHOD

This study was a single-group pretest-posttest quasi-experimental design. The research data were collected from March 2015 to January 2016. For this purpose, of the patients seeking nose surgery who referred to beauty centers in Mashhad, 40 subjects were selected through purposive method sampling and completed a Body Image Concern Inventory, Sexual Self-Esteem Index for Women and Body Exposure during Sexual Activities Questionnaire before and after rhinoplasty. These data were collected after obtaining informed consent, conducting a structured clinical interview and completing the demographic checklist.

FINDINGS

Data analysis demonstrated that there is a significant improvement in the index of female body image concern after rhinoplasty (p < 0.05). In the indices of sexual self-esteem and sexual body image, the analyses showed no significant difference between the pretest and posttest scores (p > 0.05).

CONCLUSION

Cosmetic surgery leads to the reduced body image concern of women but has no effect on sexual self-esteem and sexual body image. It seems that the psychological function of patients does not change significantly by rhinoplasty dimensions.

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 .

Body dysmorphia in dentistry and prosthodontics: A practice based study

The prevalence of Body Dysmorphic Disorder (BDD) and dysmorphic concern in dentistry and prosthodontics have not been properly assessed, yet the mouth and the teeth are amongst the top preoccupation for these individuals.

OBJECTIVES

To evaluate the prevalence of dysmorphic symptoms and BDD using validated tools in patients presenting to general and specialist prosthodontic practice.

METHODS

Patients were recruited by two prosthodontics practices and three general dentist practices. Patients were given a Dysmorphic Concern Questionnaire (DCQ) integrated into a medical history form. Treating clinicians also completed a Baseline Rating Form assessing the patients´ reason for presentation. Two DCQ score cut-offs were used (9 and 12).

RESULTS

Two hundred and thirteen patients were recruited, the majority of patients showed DCQ scores below 9 (84%). The prevalence of BDD was 7% (cut-off ≥ 9) or 4% (cut-off ≥12). Women were more likely to present with high DCQ scores as well as people with a history of mental health problems. The cosmetic practice, the implant clinic, and the prosthodontic practice received a higher proportion of patients with high DCQ scores when compared with the general family practice. The type of procedure was not related to DCQ scores. The defect severity assessment and whether this was amenable to correction was moderately correlated with DCQ scores.

CONCLUSIONS

The DCQ seems to be a suitable tool to be used by dentists as part of history taking and patient examination due to its brevity, simplicity and the good sensitivity/specificity reported in the literature.

CLINICAL SIGNIFICANCE

Identifying patients with dysmorphia is important before irreversible treatment is carried out due to high levels of dissatisfaction, poor patient centred outcomes and the question of whether these individuals have the capacity to consent.

Self-Report Scales to Measure Expectations and Appearance-Related Psychosocial Distress in Patients Seeking Cosmetic Treatments

BACKGROUND

The use of screening scales in cosmetic practices may help to identify patients who require education to modify inappropriate expectations and/or psychological support.

OBJECTIVES

To describe the development and validation of scales that measure expectations (about how one's appearance and quality of life might change with cosmetic treatments) and appearance-related psychosocial distress.

METHODS

The scales were field-tested in patients 18 years and older seeking facial aesthetic or body contouring treatments. Recruitment took place in clinics in the United States, United Kingdom, and Canada between February 2010 and January 2015. Rasch Measurement Theory (RMT) analysis was used for psychometric evaluation. Scale scores range from 0 to 100; higher scores indicate more inappropriate expectations and higher psychosocial distress.

RESULTS

Facial aesthetic (n = 279) and body contouring (n = 90) patients participated (97% response). In the RMT analysis, all items had ordered thresholds and acceptable item fit. Person Separation Index and Cronbach alpha values were 0.88 and 0.92 for the Expectation scale, and 0.81 and 0.89 for the Psychosocial Distress scale respectively. Higher expectation correlated with higher psychosocial distress (R = 0.40, P < .001). In the facial aesthetic group, lower scores on the FACE-Q Satisfaction with Appearance scale correlated with higher expectations (R = -0.27, P = .001) and psychosocial distress (R = -0.52, P < .001). In the body contouring group, lower scores on the BODY-Q Satisfaction with Body scale correlated with higher psychosocial distress (R = -0.31, P = .003). Type of treatment and marital status were associated with scale scores in multivariate models.

CONCLUSIONS

Future research could examine convergent and predictive validity. As research data are accumulated, norms and interpretation guidelines will be established.

LEVEL OF EVIDENCE

2 Risk.

[Influence of the psyche on cosmetic treatments]

The wish for an attractive appearance is evident in many people. Aesthetic, cosmetic and surgical treatment is willingly made use of in order to fit into the current beauty ideal. A considerable portion of people who decide to follow this path show signs of psychological problems. One has to recognize and evaluate these for the planning or, if necessary, refusal of further treatment. In this article, the most common psychological problems in the cosmetic and aesthetic field of work are presented. A guideline for handling these patients is explained. Thus, a productive and relaxed cooperation will be possible which enables psychological and physical satisfaction for the medical team and the patients.

Psychosocial predictors, assessment, and outcomes of cosmetic procedures: a systematic rapid evidence assessment

BACKGROUND

Recent breast implant complications led to a UK government policy review of the evidence concerning cosmetic interventions. We synthesised cosmetic intervention research evidence covering psychosocial factors associated with requesting procedures and psychological outcomes, effects of procedures on psychological outcomes, preintervention assessments for identifying those at risk, alternative therapy effectiveness, and issues in achieving informed consent.

METHODS

Undertaking a systematic rapid evidence assessment, six databases and three journals were searched. Included studies were systematic reviews or primary studies of participants requesting cosmetic procedures; published 2002-2012; containing either psychological or psychosocial measures, a psychological outcome, or evaluation of informed consent. Reviewers independently assessed study eligibility, extracted data, and assessed quality, undertaking narrative synthesis.

RESULTS

Methodological quality of the included 13 systematic reviews and 179 primary studies was low, with wide variation in psychosocial measures. Findings suggest several psychosocial factors (e.g., intimate partner violence) may be associated with requesting cosmetic surgery. Multiple factors (e.g., unrealistic expectations) may predict poor psychological outcomes. Current psychological screening tools focus predominantly on body dysmorphic disorder (BDD) symptoms. Psychological and pharmacological interventions are effective alternative BDD treatments. Patients and doctors bring different needs to informed consent discussions, inconsistently matched to those required by professional ethics, litigation risk, and facilitating profit.

CONCLUSIONS

Systematically reviewing this literature for UK policy has highlighted that some groups may be at risk of poor post-cosmetic procedure outcomes. Practitioners and patients must explore reasons for seeking cosmetic procedures and discuss all potential results and alternative solutions. Future research should employ more robust methodologies to identify effects in those at risk, led by consensus on a core set of psychological outcomes.

Why simple aesthetic dental treatment in general practice does not make all patients happy

OBJECTIVE

We explored the role of personality and pre-treatment contentment with one's face and body in predicting satisfaction following simple aesthetic dental procedures.

METHODS

In a single-centre repeated measures cohort design we examined the extent to which patient personality and baseline satisfaction with one's face and body predict post-treatment satisfaction. Data were collected from 60 patients attending a UK general practice in 2012. Adults (M age = 60.7 ± 12.6 years) receiving simple, routine aesthetic dental treatment participated. Satisfaction with one's face and body was assessed pre- and post-operatively through validated self-report measures.

RESULTS

Although all participants were more satisfied post-treatment with their body overall (t [59] = 2.78, p <0.004) and with their face in particular (t [59] = 1.83, p <0.035), those scoring highly on neuroticism were generally unhappier both before and after treatment (r range = 0.277-0.360, p <0.05). In multiple regressions, post-operative facial satisfaction (R(2) = 0.475, p <0.001) was predicted by pre-operative facial satisfaction (β = 0.616, t = 5.912, p <0.001) and to a lesser extent by neuroticism (β = -0.241, t = 2.248, p <0.001). Baseline happiness with one's body (β = 0.851, t = 11.996, p <0.001) was the sole predictor of post-treatment body satisfaction (R(2) = 0.744, p <0.001).

CONCLUSIONS

Psychological variables may be important predictors of satisfaction with dental treatment and the clinical benefits of assessing them pre-operatively should be explored.

The experience of teasing in elective cosmetic surgery patients

The role of teasing as a motivator for patients undertaking elective cosmetic surgery was investigated. Pre-operative data were collected, using a range of standardized tests in addition to open ended questions about their experience of teasing, from 449 patients aged 18 to 70 undergoing elective cosmetic surgery in Australia. Just under half of the sample indicated that they had been teased or bullied about their appearance. Teased patients showed significantly higher levels of anxiety, depression and dysmorphic concern; lower levels of physical attractiveness and appearance satisfaction; and lower levels of satisfaction with discrete aspects of their appearance than nonteased patients. Teasing also contributed to longer periods of considering surgery as an answer to body dissatisfaction concerns, even when controlling for age. Prevention education initiatives on appearance-related teasing should be targeted at school students. This, along with earlier detection of the psychological impacts of weight and appearance-related teasing, fewer people, if offered strategies for coping through counseling, may contemplate surgery as a response to this teasing.

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.

Psychological characteristics and outcomes of elective cosmetic surgery patients: the influence of cosmetic surgery history

The early cosmetic surgery literature suggested that individuals re-presenting for aesthetic surgical procedures (referred to as "insatiable patients") display poorer psychological functioning and satisfaction with surgical outcomes than those who request one procedure. The aim of the study was to compare 284 patients with and without a history of cosmetic procedures on demographic characteristics, appearance concerns, expectations of surgery, psychosocial dysfunction, and postoperative dissatisfaction. There were few differences between the groups, suggesting that the group of patients with a history of aesthetic surgeries did not represent the population that has been described as "surgery insatiable." Post hoc analyses of subgroups of patients with a history of surgeries also revealed few differences except for lower self-esteem and postoperative satisfaction. Further research is required to fully explore the applicability of the "insatiable patient" label in the context of increasing societal acceptance of cosmetic surgery.