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Psychosocial Factors Within the

Realm of Aesthetic Plastic Surgery

Hilary McCord, [email protected]

Advisor: Professor Powdrill

Spring 2008



My Audience

Plastic Surgery

Psychiatry

Dermatology Primary Care



Growth of the Industry American Society of Plastic Surgeons reports

~ 11 million aesthetic procedures were performedin 2006.

NONSURGICAL

BotoxRestylane

Microdermabrasion

SURGICAL

Breast Augmentation #1Rhinoplasty

Liposuction



Breast Augmentation #1

330,000 in 2006

55% increase since 2000

Expected to increase in the future due tothe FDA reapproval of silicone implants

Invention of the “Gummy Bear” implant



Growth of the industry: Why?

Sociocultural theories emphasize the

interaction of the mass media and cultural

ideas of beauty with notions of Self-Ideal

Discrepancy and Social ComparisonTheory.



Influence of Reality T.V.

Crockett (2007)

concludes 4 out of 5

patients reported

plastic surgery RealityT.V. directly

influenced them to

pursue an elective

cosmetic procedure.

Didie (2003) reports

70% of cosmetic

breast augmentation

patients studied,endorsed T.V. as a

significant source of

knowledge for the

procedure.



Influence of Reality T.V.

In 2005, the American Medical Association issued anamendment to its constitution and bylaws addressing

concerns arising from reality television programs’

influence on patient expectations regarding medicalcare and standards to guide physicians’ participation

in such programs



Breast Augmentation

Psychiatric Disorders: yet, another

prevalent factor:

Sarwer (2003) reports 40% of women

seeking breast augmentation were under

the care of a mental health provider. Meningaud (2001) similar results

A f h B



Assessment of the Breast

Augmentation Candidate:

the PA’s Role

Identify the motivating factors for the

intervention and expectations of thesurgical outcome

Recognize Body Dysmorphic Disorder and

consult with Mental Health Services Elicit a psychiatric history to determine risk

for post-operative suicide



Identify Motivating Factors to have

Breast Augmentation

Body Image

Dissatisfaction

may be theprimary

motivational

factor (Cash1996)



Identify Motivating Factors to have

Breast Augmentation

Valence is the measure of the importance

of body image to a person’s self -esteem.

Value is the degree of dissatisfaction with

one’s appearance.

Breast augmentation patients have high

valence and high value. (Sarwer, 1998b)



Body Dysmorphic Disorder

DSM-IV (ICD-10:F45.2)

Extreme body image dissatisfaction

A psychiatric illness of perceived ugliness

Absolute contraindication for breast

augmentation or any cosmetic surgery

Avoid litigation



B d D hi Di d



Body Dysmorphic Disorder:

Recognize It and

Consult Mental Health 15% of cosmetic surgery patients

2% general population

57% of BDD patients attempt suicide

Patient’s treatment of choice: mo’ surgery

Psychiatrist’s treatment of choice: SSRIsand Cognitive Behavioral Therapy



Post-operative Suicide: the

importance of a psychiatric history

Six international epidemiological studies

have found an unexpected relationship

between cosmetic breast augmentationand suicide

(Brinton, 2001) (Koot, 2003) (Pukkala, 2003) (Jacobson, 2004)

(Brinton, 2006) (Villeneuve, 2006).

Designed to investigate overall mortality inwomen who underwent breast

augmentation.



Death by suicide associated with:

Breast augmentation vs. other forms of cosmeticsurgery

Older age at implantation >40 years old Women who had their implants for longer

periods of time

History of psychiatric hospitalization with breast

augmentation vs. other forms of plastic surgery Suicide rate approximately twice that expected

from estimates of the general population.



Conclusion

The aesthetic plastic surgery PA:

must be aware of the influence television

and western culture has on a patient’s

desire to invasively alter their appearance

has the duty to ameliorate the patient’s

body dissatisfaction with surgical

intervention while providing info on

benefits and risks of the procedure.



Conclusion

The aesthetic plastic surgery PA:

should decide the appropriateness for

surgery on a case-by-case basis and

include collaboration with Mental Health

should consider results of existing studies

on suicide’s link to breast augmentation.



Conclusion

The plastic surgery physician assistant

has the right to refuse a surgical

intervention if it is perceived as causing

future harm to the patient

PRIMUM NON NOCERE



For Fun

Association of Plastic Surgery Physician

Assistants www.apspa.net

BDD VIDEO

http://www.youtube.com/watch?v=Kfcohe

wREYc

Reality TV and Cosmetic Surgery VIDEO

http://www.msnbc.msn.com/id/20068105/

http://www.apspa.net/

http://www.youtube.com/watch?v=KfcohewREYc






http://www.apspa.net/



References

American Medical Association, Council on Ethical and Judicial Affairs, Ethics of physician

participation in reality television for entertainment (Resolution 607, I-04). Nov 23, 2005,http://www.ama-assn.org, accessed on 3/1/2008.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders

fourth edition. 2000.

American Society of Plastic Surgeons, National plastic surgery procedural statistics for

2006 (Press Release). March 23, 2007, http:// www.plasticsurgery.org, accessed on 3/1/2008.

American Society of Plastic Surgeons, New reality television programs create unhealthy, unrealistic expectations of plastic surgery (Press Release). March 30, 2004,

http:// www.plasticsurgery.org, accessed on 3/1/2008.

Brinton, L., et.al. Mortality among augmentation mammoplasty patients. 2001; Epidemiology 12:321-326.

Brinton, L., et.al. Mortality among augmentation mammoplasty patients: an update. 2006;Epidemiology 17: 162-169.

Cash, T., et.al. Development of the Appearance Schemas Inventory: a new cognitive body-image

assessment. 1996; Cognitive Therapy and Research 20: 37-50.Castle, D., et.al. The outcome of cosmetic surgery in psychosocial terms. 2002; MJA 176: 601-604.

http://www.plasticsurgery.org/

http://www.plasticsurgery.org/



References

Crerand, C., et.al. Body dysmorphic syndrome and cosmetic surgery. 2006; Plastic andReconstructive Surgery

118: 167-180.

Crerand, C., et.al. Psychological considerations in cosmetic breast augmentation. 2007;

Plastic Surgical Nursing 27: 146-154.

Crockett, R., et.al. The influence of plastic surgery reality television on cosmetic surgery

patient expectations and decision making. 2007; Plastic and Reconstructive Surgery 120: 316-

324. Didie, E., et.al. Factors which influence the decision to undergo cosmetic breast

augmentation. 2003; Journal of Women’s Health 12: 241-253.

Festinger, L. A theory of social comparison processes. 1954; Human Relations 7: 117- 140.

Harth, W., et.al. Psychosomatic disturbances and cosmetic surgery. 2007; Journal of the

German Society of Dermatology 5: 736-743.

Higgins, E. Self-discrepancy: a theory relating self and affect. 1987; Psychological Review 94:

319-340.

Hodgkinson, D. Identifying the body dysmorphic patient in aesthetic surgery. 2005; Aesthetic Plastic Surgery 29: 503-509.

Hollander, E., et.al. Comorbid social anxiety and body dysmorphic: managing the complicated

patient. 1999; J Clin Psych 60: 27-31.

Honigman, R., et.al. A review of psychosocial outcomes for patients seeking cosmetic surgery.

2004; Plastic Reconstructive Surgery 113:1229-1237.



References

Jacobson, P., et.al. Mortality among Canadian women with cosmetic breast implants. 2006; Am J Epidemiology 164: 334-341.

Koot, V., et.al. Total and cause specific mortality among Swedish women with cosmetic breast

implants: a prospective study. 2003; BMJ 326: 527-528.

Meningaud, J., et.al. Depression, anxiety, and quality of life amongst scheduled cosmetic surgery

patients: multicenter prospective study. 2001; J Craniomaxillofacial Surg 29: 177-180.

Phillips, K., et.al. Suicidality in body dysmorphic disorder: a prospective study. 2006; Am J Psychiatry 163: 1280-

1282.

Phillips, K., et.al. Body dysmorphic syndrome: A guide for dermatologists and cosmetic surgeons. 2000; American

Journal of Clinical Dermatology 1: 235- 243.

Pukkala, E., et.al. Causes of death among Finnish women with cosmetic breast implants. 2003; Ann Plastic

Surgery 51:339-342.

Sarwer, D., et.al. Cosmetic breast augmentation and suicide: a review of the literature. 2007; American Journal of

Psychiatry 164: 1006-1013.

Sarwer, D., et.al. Body image concerns of breast augmentation patients. 2003; Plastic Reconstr Surgery 112:83-

90.

Sarwer, D., et.al. The psychology of cosmetic surgery: A review and reconceptualization. 1998; Clinical Psychology Review 18: 1-22.

Sarwer, D., et.al. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients.

1998; Plastic Reconstructive Surgery 101: 1644-1649.

St. John, D. Imagined ugliness: body dysmorphic disorder. 2003; Physician Assistant 27:15-28.

Veale, D., et.al. The psychopathology of mirror gazing in body dysmorphic disorder. 2001; Behavior Research and

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Villeneuve, P., et.al. Mortality among Canadian women with cosmetic breast implants. 2006; Am J Epidemiology

164: 334-341.

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