Beautiful

Updated 3/2017-- video and all links (except to my own posts) removed as many no longer active. 

American Idol covered Carol King's songs this past week. Haley Reinhart did “Beautiful.”  The words are a reminder of a simple way to be beautiful.

You've got to get up every morning with a smile on your face
And show the world all the love in your heart
Then people gonna treat you better
You're gonna find, yes, you will
That you're beautiful as you feel …..

Carol King puts it much more beautifully than the essay by Robert Tornambe, M.D.: What Makes a Person Ugly?
Here is Carol King singing “Beautiful” live. Enjoy

Longevity or Perfect Figure?

Updated 3/2017--  all links (except to my own posts) removed as many no longer active. 

I’ve spent some time thinking about this survey.   I couldn’t find any better information on the survey than the press release from the University of the West of England (UWE).  Perhaps in the future it will be published in a journal for better review.

The  survey was apparently done by the  new eating disorder charity The Succeed Foundation in partnership with the University of the West of England (UWE).  The editor’s notes indicate 320 women (ages 18 – 65 years, average age 24.49)  studying at 20 British universities completed The Succeed Foundation Body Image Survey in March 2011.  

Notably, the survey found that 30% of women would trade at least one year of their life to achieve their ideal body weight and shape.

The research has also found that in order to achieve their ideal body weight and shape:

•        16% would trade 1 year of their life
•        10% would trade 2-5 years of their life
•        2% would trade 6-10 years of their life
•        1% would trade 21 years or more of their life

I would love to see an age breakdown of the respondents here.  Do we women become more comfortable with our bodies as we age?  Or did as many of the over 50 year olds want to trade longevity for “the perfect body” as the 20 year olds?

In addition to longevity, the survey also notes that in order to achieve their ideal body weight and shape, 26% of the women surveyed were willing to sacrifice at least one of the following:

•         £5000 from their annual salary (13%)
•         A promotion at work (8%)
•         Achieving a first class honors degree (6%)
•         Spending time with their partner (9%)
•         Spending time with their family (7%)
•         Spending time with their friends (9%)
•         Their health (7%)

Again, I would love to see an age breakdown.  It would be interesting to see how this might differ between the younger respondents vs the older (over 50 year olds) ones.

The survey results suggest that body dissatisfaction was common among the women surveyed, with 1 in 2 women saying that more needs to be done on their university campus to promote healthy body image.

•         46% of the women surveyed have been ridiculed or bullied because of their appearance.
•         39% of the women surveyed reported that if money wasn’t a concern they would have cosmetic surgery to alter their appearance. Of the 39% who said they would have cosmetic surgery, 76% desired multiple surgical procedures. 5% of the women surveyed have already had cosmetic surgery to alter their appearance.
•         79% of the women surveyed reported that they would like to lose weight, despite the fact that the majority of the women sampled (78.37%) were actually within the underweight or ‘normal’ weight ranges. Only 3% said that they would like to gain weight.
•         93% of the women surveyed reported that they had had negative thoughts about their appearance during the past week. 31% had negative thoughts several times a day 

Yes, I know as a plastic surgeon I make a living (in part) from cosmetic procedures, but I feel strongly that my nieces and other young women should be grow up to love themselves and their bodies.  

Related posts:
Steriod Use in Girls  (February 21, 2008)
Get Girls to Focus on Skin’s Appearance  (May 19, 2010)
Maternal Influence  (January 3, 2011)


REFERENCE

30% of women would trade at least one year of their life to achieve their ideal body weight and shape; UWE press release, March 31, 2011

BDD Patients Can Get Better

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

The Science Daily article, Body dysmorphic disorder patients who loathe appearance often get better, but it could take years, discusses the The Journal of Nervous and Mental Disease (JNMD) article (full reference below, abstract available for free).  

The JNMD article reports the results of the longest-term study so far to track people with body dysmorphic disorder.  The study was conducted by researchers at Brown University and Rhode Island Hospital.

The good news:  the researcher “found high rates of recovery, although recovery can take more than five years.”

This is a small study with only 15 BDD patients who were followed over an eight-year span.

After statistical adjustments, the recovery rate for sufferers in the study over eight years was 76 percent and the recurrence rate was 14 percent. While a few sufferers recovered within two years, only about half had recovered after five years.

The subjects were a small group diagnosed with the disorder out of hundreds of people participating in the Harvard/Brown Anxiety Research Project (HARP). Study co-author Martin Keller, professor of psychiatry and human behavior and principal investigator of the HARP research program which has been ongoing for more than 20 years, said that because the BDD sufferers were identified through this broader anxiety study, rather than being recruited specifically because they had been diagnosed with BDD, they generally had more subtle cases of the disorder than people in other BDD studies. In comparing the HARP study with the prior longitudinal study of BDD, it is possible that the high recovery rate in the HARP study is due to participants having less severe BDD on average.

Body Dysmorphic Disorder

• In its simplest definition, it is an obsessive preoccupation with a slight, imperceptible, or actually nonexistent anatomic irregularity to the degree that it interferes with normal adjustment within society.
  
• This disorder may be present in varying degrees. It is the most common aberrant personality characteristic seen by the plastic surgeon.
  
• When postoperative dissatisfaction occurs (and in most cases, it will), it almost always is based on what the patient understood rather than what was actually said.
  

….
Related posts
Suitability (January 3, 2008)
The Barbie Syndrome  (March 25, 2010)
….

REFERENCE

The Clinical Course of Body Dysmorphic Disorder in the Harvard/Brown Anxiety Research Project (HARP); Andri S. Bjornsson, Ingrid Dyck, Ethan Moitra, Robert L. Stout, Risa B. Weisberg, Martin B. Keller, Katharine A. Phillips;  The Journal of Nervous and Mental Disease, 2011; 199 (1): 55 DOI: 10.1097/NMD.0b013e31820448f7

Body Dysmorphic Disorder; eMedicine Article, September 3, 2010; Iqbal Ahmed, MBBS and Lawrence Genen, MD, MBA

The Barbie Syndrome

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Interesting article in the Huffington Post last week by Dr. Glenn D. Braunstein:  Oh, You Beautiful Doll: Plastic Surgery Risks and Rewards.  The article discusses the “Barbie Syndrome” or more accurately “Body Dysmorphic Disorder.”   I love this line

And, finally, try to have realistic expectations--it is unlikely that cosmetic enhancement is going to drastically change your life--after all, you are human, and not a plastic doll.

The article reminded me of my post Suitability.  Not all patients should have surgery.  Their reasons for desiring surgery, goals, and expectations should be discussed during the consultation.  Risks and benefits must be weighed.

 

Body Dysmorphic Disorder

• In its simplest definition, it is an obsessive preoccupation with a slight, imperceptible, or actually nonexistent anatomic irregularity to the degree that it interferes with normal adjustment within society.
• This disorder may be present in varying degrees. It is the most common aberrant personality characteristic seen by the plastic surgeon.
• When postoperative dissatisfaction occurs (and in most cases, it will), it almost always is based on what the patient understood rather than what was actually said.

“Suitable” for Plastic Surgery?

A few years ago I wrote about the “Suitability” of a patient for plastic surgery. I was reminded of this topic by two cases in the recent lay media:

The first involves Heidi Montag, 23, who in November had multiple surgical procedures and is being compared to Joan Rivers.

According to People, Montag even kept her family in the dark about her intended transformation to become her “best me.” Telling only her husband Spencer Pratt, Montag had a nose job revision, chin reduction, mini brow lift, Botox in her forehead and frown area, fat injections in her cheeks, nasolabial folds and lips, neck liposuction, ear pinning, liposuction on her waist, hips, inner and outer thighs, buttock augmentation and breast augmentation revision.

The other involves Annette Edwards, 57, who has had multiple procedures so she could look like Jessica Rabbit. 

My post “Suitability” remains relevant. Here is part of it:

The bottom line is: Not everyone is a candidate for aesthetic surgery. Nor is it possible to eliminate every possibility of dissatisfaction or conflict that might arise. Here are some suggestions for doctor and patient
First

• Surgeon--Be a complete physician, not just a skilled technician.
• Patient--Be a partner in your care. Give a full and honest medical/surgical history. Don't leave out any medications. What you do when recovering often will have major impact on the final result.

Second

• Surgeon--Avoid hyping your "unique" talent.
• Patient-- Be honest about your reasons and expectations.

Third

• Surgeon--Strive to maintain good communication and rapport with your patient. Listen.
• Patient-- Do your part in maintaining that good communication and rapport. Listen. If you don't understand, say so. Have your surgeon try to explain in another way.

Fourth

• Surgeon-- Be honest about your skills. We are all better at some procedures than others.
• Patient -- Let your surgeon refer you to someone else, if they feel it is in your best interest. Don't "massage" his/her ego to try to get them to do it (I only want you to do it. I feel so comfortable with you. I know you are the best.)

Body Image and Facial Burns – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I came across this article, Body Image and Facial Burns, in the journal Advances in Skin & Wound Care.  It is a short, but interesting article.  I came away feeling they had fallen short on my expectations from the title and what the authors state as the purpose of the article:

This article reviews the literature (PubMed, Medline, and Ovid databases) on the effect of facial burns on body image and discusses the theory and research behind normal and altered body image. Facial burns illustrate the clinical application to provide efficacious treatment strategies for people with disfigurement.

There are 58 articles listed in their reference, but in the body of the article they don’t state the total number of  articles they did find with their search.  Nor do they define the criteria for the articles they did review, only that

Although body image models have been proposed, only a small body of literature relating to facial disfigurement exists. These models, although theoretical, provide a framework for managing altered body image.

I did enjoy the section on the theory of body image. 

Schilder defined body image as "the picture of our body which we form in our mind, that is to say the way in which our body appears to ourselves."
Schilder noted body image was fluctuant, varying with age, mood, or clothing.
Price proposed the body image model, comprising body reality, body presentation, and body ideal.
Body reality is an individual's phenotype and depends on genotype and environmental factors.
Body presentation refers to an individual's dress, adornment, and behavior.
Body ideal is how an individual desires to appear. It comprises various facets including physical dimensions and body function.
Body reality and presentation are compared with the body ideal, consciously and subconsciously. Body ideal, in accordance with Schilder, alters with time and environment and may be emotionally influenced. These factors are suggested to be in a state of balance; altering one may cause compensatory change in the others.

The article goes on to discuss primary and secondary socialization and several different models (ie fear-avoidance model of psychosocial difficulties following disfigurement).  The article goes on to discuss the importance of faces:

Faces facilitate understanding of our identity and ancestry and provide clues to age and mood.  A person's face is the main point of focus during social interaction-providing conscious and unconscious expressions.   Approximately two-thirds of communication is nonverbal, mediated principally by facial expression.

Facial disfigurement describes the visual effect of scars, skin grafts, asymmetry, or altered pigmentation. It may cause disruption to body image and, especially if there is loss of self-recognition, constitute a major life crisis.

Then tries to condense the findings from the reviewed articles, but it left me with little to “hand my hat on”.

Some researchers have found more psychological problems in adolescents and persons in their early 20s. 

However, Robinson et al  found no correlation of patient age or duration of disfigurement with levels of anxiety and depression, although only 13 participants younger than 27 years were included in their study.

Yet, this supports other work suggesting that the development of effective coping mechanisms determines psychosocial outcomes.

If  Sir McIndoe is correct (as quoted in the article), then have we gone backwards by getting rid of wards and having only private rooms?  Is the need for infection control harming the treatment of psychological aspects of facial trauma?

Sir Archibald McIndoe made groundbreaking advances reconstructing allied air-force pilots who were burned in World War II. He noticed that the burns of the men on the ward healed better than the officers who had been kept in cubicles: "Camaraderie was the obvious answer. The officers on their own tended to fret, lose their appetite, and think too much about their disfigurement.’

The conclusion section is better in my opinion.

Body image models, although they have limitations, provide a framework for the analysis and treatment of disfigured individuals. For some, a blemish may cause huge anxiety; others with far more disfiguring burns may cope well.

Experiences and levels of perceived social support sculpt an individual's self-esteem and interpretation of specific situations. This seems to alter emotional and behavioral responses more than demographic or physical characteristics. Those who do well tend to confront their anxieties, whereas those who avoid them develop negative coping strategies and fare worse.

Various modalities can be used in the management of facial disfigurement, including surgery and psychosocial therapies. Efficacious psychological interventions must target specific cognitive and behavioral elements that predispose individuals to experience distress as a consequence of their disfigurement.

Future research using qualitative and longitudinal techniques needs to be conducted to rigorously evaluate these psychosocial interventions and enable the demolition of this last bastion of discrimination.

Actually, I got more out of the article going back through it a second and third time to write this review.  Still I wanted more of a black and white conclusion and there can’t be at this time (and maybe never will be).

…………………………………………………………….

A comment from the second article listed below:

Patients undergoing cosmetic surgery, like most of the general population, have emotional and social concerns specific to aspects of facial appearance, albeit to a greater degree.  Perhaps this greater level of concern is a cause for action to undertake cosmetic surgery. For the most part, these concerns do not represent pathologic states, and, in fact, the incidence of body image psychosocial disorders is quite low in this population.

This study validates the fact that a positive change in a feature of concern is accompanied by a resultant lessening of concern related to that feature. This "cause and effect" phenomenon stands in stark contrast to a true body image disorder wherein no amount of surgical alteration will yield the preferred decrease in associated distress.

REFERENCES

Body Image and Facial Burns; Advances in Skin and Wound Care,  Vol 22, No 1, pp 39-44, January 2009;  David CG Sainsbury, BMedSci (Hons), MBBS, MRCS (Eng)

Impact of Cosmetic Facial Surgery on Satisfaction With Appearance and Quality of Life; Arch Facial Plast Surg. 2008;10(2):79-83; Jason A. Litner, MD, FRCSC; Brian W. Rotenberg, MD, FRCSC; Maureen Dennis, BA, RN; Peter A. Adamson, MD, FRCSC

Suitability

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

There are definable risks and benefits in every surgical procedure. This risk/benefit ratio is particularly important for the cosmetic or aesthetic patient. This patient starts out "well" and will be put into a temporarily "unwell" state to ultimately help them "feel better".

Most training programs do not teach "patient selection" and not everyone is born with the "sixth sense" that will help you know who might not be a good candidate for the procedure requested.

Patients I need to watch for when doing aesthetic procedures
Inflated Expectations

• Patient tends to be "deaf" to any attempt to educate them as to what their surgery will entail.
• They seem to have difficulty digesting the fact that there any major procedure carries some degree of inherent risk.
• Will use the results of computer imaging as a warranty, rather than the possibility intended. Computer imaging does not take into account healing quirks, skin thickness/elasticity, etc.

The Demanding Patient

• The patient who brings you celebrity photographs with modifications that they want you to duplicate even though the celebrity is a completely different body type (apple vs pear).
• The patient who brings you a picture of themselves with overlays of the changes they would like. If they can be made to understand that the human body is not clay, but tissue that heals with scars (sometimes predictable, but not always) then this can be a good start to a discussion.
• The patient who demands no scar. Plastic surgeons are not magicians. When skin it cut, there is always a scar.

The Surgiholic

• Patients who have had multiple (There does not seem to be a good number to put here. Is three too many or is six?) previous aesthetic surgeries.
• The patient who had multiple surgeons for their previous surgeries. You will be compared to Dr. X.

Marital or Family Disapproval

• Yes, the adult patient seeking aesthetic surgery does not require anyone's approval or consent, but ... Secrecy from a spouse or significant other can add stress for both the patient and the surgeon. Someone will need to know how to care for them in the postop period. It helps if they know what was done.

Capitulation

• The other side of the coin. No patient should be pushed into surgery to please someone else. That other person may not be around in five years, whether by divorce, separation, or death. Will the patient still be glad they had the procedure?

Incompatibility

• There are some people with whom you just don't feel comfortable. This may be for a variety of reasons. And it may be true from the patient side also. Both may be "nice" people, but may not be comfortable with each other.

Body Dysmorphic Disorder

• In its simplest definition, it is an obsessive preoccupation with a slight, imperceptible, or actually nonexistent anatomic irregularity to the degree that it interferes with normal adjustment within society.
• This disorder may be present in varying degrees. It is the most common aberrant personality characteristic seen by the plastic surgeon.
• When postoperative dissatisfaction occurs (and in most cases, it will), it almost always is based on what the patient understood rather than what was actually said.

The bottom line is: Not everyone is a candidate for aesthetic surgery. Nor is it possible to eliminate every possibility of dissatisfaction or conflict that might arise. Here are some suggestions for doctor and patient

First

• Surgeon--Be a complete physician, not just a skilled technician.
• Patient--Be a partner in your care. Give a full and honest medical/surgical history. Don't leave out any medications. What you do when recovering often will have major impact on the final result.

Second

• Surgeon--Avoid hyping your "unique" talent.
• Patient-- Be honest about your reasons and expectations.

Third

• Surgeon--Strive to maintain good communication and rapport with your patient. Listen.
• Patient-- Do your part in maintaining that good communication and rapport. Listen. If you don't understand, say so. Have your surgeon try to explain in another way.

Fourth

• Surgeon-- Be honest about your skills. We are all better at some procedures than others.
• Patient -- Let your surgeon refer you to someone else, if they feel it is in your best interest. Don't "massage" his/her ego to try to get them to do it (I only want you to do it. I feel so comfortable with you. I know you are the best.)

References
Recognition of the Patient Unsuitable for Aesthetic Surgery; Aesthetic Surgery Journal, 2007 Vol 27, No 6, pp626-620; Gorney Mark MD
Streamlining Cosmetic Surgery Patient Selection-Just Say No!; Plastic & Reconstructive Surgery, 104(1):220-221, July 1999; Rohrich, Rod J. M.D.
Of Chickens and Red Flags; Plastic & Reconstructive Surgery, 112(2):684-685, August 2003; Edelstein, Jerome M.D.
Dr. Vazquez Añón's last lesson; Aesthetic Plastic Surgery, Volume 2, Number 1 / December, 1978, pp 375-382; Ulrich T. Hinderer
Body Dysmorphic Disorder and Cosmetic Surgery; Plastic & Reconstructive Surgery, 118(7):167e-180e, December 2006; Crerand, Canice E. Ph.D.; Franklin, Martin E. Ph.D.; Sarwer, David B. Ph.D.
Body Dysmorphic Disorder: Diagnosis and Approach; Plastic & Reconstructive Surgery, 119(6):1924-1930, May 2007; Jakubietz, Michael M.D.; Jakubietz, Rafael J. M.D.; Kloss, Danni F. M.D.; Gruenert, Joerg J. M.D.
Inspired by
Everything Health's -- 2008 Resolutions for Patients and Doctors