1. Features most attractive in young women (those that remind us of babies)₁: 

• Soft clear skin and hair
• Big eyes and cheeks
• Small noses

2. Relative facial proportions of beautiful women in their late teens and early 20s have been those typically observed at chronological age of 6 – 7y. o according to computer assessment₁
3. For men, the ideal face is₁:

• Dominant
• Rectangular
• Prominent chin
• Deep set eyes, and heavy brow

4. Lustrous and abundant hair and clear skin are signs of beauty in both men and women₁
5. Teenager’s preference for physical enhancement may change although procedures designed to correct their supposed imperfections may not be easily reversed. Therefore, consultation with young patient’s parents are recommended to provide insight into appropriateness of any intervention₁

• Per Honigman et. al., young age is a predictor of poor surgical outcomes₂

6. In western society, ratings of physical attractiveness decline with advanced age for both men and women with more steep decrease for women₁

References

1. Alam, M, Dover, JS: On beauty: evolution, psychosocial functioning, and personality: how different are adolescents and young adults applying for plastic surgery. Arch Dermatol, 2001; 137 (6): 795-807
2. Honigman, RJ, Phillips, KA, Castle, DJ: A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004; 113 (4): 1229-1237

1. Terino recommends use of personality profiles in practice of cosmetic surgery because₂:

• Can quickly identify patients who demonstrate high likelihood of dissatisfaction
• Avoid substantial loss of profit
• Personality profile can predict postoperative behavior

2. Preoperative psychological screening assessments

• The Derriford Appearance Scale (DAS59) – intended for use in research
  • Consists of 59 statements / questions with response categories that include frequency of symptoms (“almost never” . . . “almost always”) and severity (“not at all distressed . . .extremely distressed”)_3,4
  • Intended for use 16years old and above.₄
  • Screening has good test-retest reliability and internal consistency_3,4
  • Screening measures psychological distress with appearance instead of formal psychological diagnosis_3,4
• The Derriford Appearance Scale (DAS24)-short form intended for clinical use
  • Consists of 24 instead of 59 questions₃
  • Generates 1 score instead of 5 factorial scores and 1 total score per the DAS59₃
• The Preoperative Facial Cosmetic Surgery Evaluation (PreFACE)₃
  • A self-report questionnaire composed of questions designed to evaluate many of the psychosocial characteristics thought to be associated with unsatisfactory outcomes. (psychiatric disturbance, anxiety, depression, self-esteem, dysmorphic concerns, and body image)₃
  • Scoring system ranges from 0 – 28, author (Honigman et.al.2011), recommended preoperative psychological counseling for score of 11 or more
• Prime-MD
  • Developed for use in primary care to identify patients with psychiatric disorders₃
  • Used in study Thomas et.al. in cosmetic patients₃
    • 9.3% of patients diagnosed with psychiatric disorder
    • Limit: can only diagnosis 16 possible psychiatric conditions (mood disorders, anxiety disorders, eating disorders, somatoform disorders, and alcohol abuse/dependence)₃
    • Also missing some conditions that tend to be prevalent in plastic surgery patient’s (i.e. body dysmorphic disorder)₃

3. Postoperative screening tools:

• DAS24: can use pre and postoperatively₃
• FACE-Q: goal to provide plastic surgeons with instrument to evaluate patient psychological, functional, and aesthetic surgical outcomes_3,5

4. Use of so many different instruments to screen cosmetic surgery patients suggests a lack of consensus about which instruments are most appropriate₃
5. Various instruments measure different health concerns of patients (i.e., anxiety, depression, self-esteem, body image, body dysmorphic disorder) but not all studies measured all of these concerns₃
6. Use of a battery of instruments to measure the range of symptoms considered to be important for screening patients is simply not practical in clinical setting (i.e., too costly, too time-consuming, and difficulty to score)₃
7. Ask open ended questions: may expose latent depression, unhappiness, or poor self-image₁
8. “Subcognitive perception” is often more valuable than any attempted quantitative analysis “trust your instincts”₁
9. Preoperative Problem Personality types₁:

• Unrealistic Expectation
• Unhappy patients
• Body Dysmorphic disorder
• Poor Self-Image
• Overflattering patients
• Rude patients
• Very important patients (“VIPs”)
• Unfocused desires
• Know-it-all

10. Dealing with potentially difficult patient₁

• Schedule a 2nd visit / consultation
• Schedule minimally invasive reversible procedure (i.e. Botox / filler) and monitor patient perception of results (good indicator if patient reaction to more invasive procedure
• If surgeon feels patient is a poor surgical candidate; do not proceed with surgery

11. Postoperative evaluation₁: 

• Dealing with patient dissatisfaction
  • Avoid impulse to immediately suggest a solution rather listen carefully and express compassion with the patient
  • Cause of patient dissatisfaction is usually result of unmet expectations

References 

1. Sykes, J: Managing the psychological aspects of plastic surgery patients. Current opinion in Otolaryngology Head and Neck Surgery. 2009;17 (4): 321-325
2. Terino, E: Psychology of Aesthetic Patient: The Value of Personality Profile Testing. Facial plastic surgery clinics of North America. 2008; 16:165 – 171
3. Wildgoose, P et.al. Psychological Screening Measures for Cosmetic Plastic Surgery Patients: A Systematic Review. Aesthetic Surgery Journal. 2013; 33 (1): 152-159
4. Harris, DL, Carr, AT: The Derriford Appearance Scale (DAS59): a new psychometric scale for the evaluation of patients with disfigurements and aesthetic problems of appearance. Br J Plast Surg. 2001; 54 (3): 216 – 222
5. Klassen, AF et al: Development and Psychometric Evaluation of the FACE-Q Scales for Patients Undergoing Rhinoplasty. 2016: JAMA Facial Plast Surg; 18 (1): 27 - 35

Case 1:   25 y.o. female presents with her husband as a self-referral for rhinoplasty.  Patient stated based on her internet research you are the best Rhinoplasty surgeon in the area.  Pt is not seeking drastic change just refinement. After obtaining complete history and physical exam, preliminary surgical plan is discussed with the patient. Patient calls clinic daily for the next two weeks pending surgery scheduling /out of pocket cost. A follow up preoperative appointment is scheduled. At this appointment, the patient stated she thinks about undergoing rhinoplasty daily and that her concern with her nasal appearance prevents patient from wanting to go to public areas. Pt also reported that her thoughts regarding her nasal appearance prevented her from completing her Bachelor’s degree. And, a psychologist had previously diagnosed the patient with body dysmorphic disorder a few years ago. Patient was referred to a Psychiatrist specializing in body dysmorphic disorder.

• Predictors of poor surgical outcome: Being male, young age, history of Depression / Anxiety, prior diagnosis of body Dysmorphic Disorder (BDD), being motivated by relationship issues, previous surgical dissatisfaction, Minimal deformity (difficult to quantify)₁

• When to refer to psychiatrist: 1. Pt reports preoccupation with perceived appearance flaw (thinks about flaw at least 1hr/day), 2. If concern has any behavioral consequences (i.e. social avoidance), 3. If concern causes significant distress or impairment in functioning, 4. Prior diagnosis of Body Dysmorphic Disorder, 5. Severe Depression / Psychosis₁

• Three criteria for diagnosis in DSM-IV/V₂

  • Preoccupation with some imagined or slight defect in their appearance

  • The obsession and concern interferes with normal life functions (i.e. employment, schooling, social and marital relationships)

  • Other psychiatric diagnoses do not apply i.e. obsessive-compulsive disorder (OCD) or bulimia

References

1. Honigman, RJ, Phillips, KA, Castle, DJ: A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004; 113 (4); 1229-1237

2. Ende, KH, Lewis, DL, Kayaker, SS: Body Dysmorphic Disorder. Facial plastic surgery clinics of North America. 2008; 16:217 – 223 

Review Questions

1. What patient characteristics are poor predictors of psychosocial/psychological postoperative facial plastic and reconstructive surgery outcomes?

2. When should a facial plastic and reconstructive surgery candidate be referred to a psychiatrist?

3. What are the 3 criteria for the diagnosis of body dysmorphic disorder according to DSM IV/V?

Case 2:   Pt is a 16 y.o. female who presents with her parents for evaluation of her eyelids which patient states makes her appear older than her stated age. Patient’s parents present at appointment have no concerns with patient’s appearance however will agree to proceed with patient’s decision. 

• Features most attractive in young women: soft clear skin and hair, big eyes and cheeks, and small noses₁

• Per Honigman et.al., young age is a predictor of surgical outcomes₂

• Consultation with young patient’s parents are recommended to provide insight into appropriateness of intervention as teenager preferences may change₂

References

1. Alam, M, Dover, JS: On beauty: evolution, psychosocial functioning, and personality: how different are adolescents and young adults applying for plastic surgery. Arch Dermatol, 2001; 137 (6): 795-807

2. Honigman, RJ, Phillips, KA, Castle, DJ: A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004; 113 (4); 1229-1237

Review Questions

1. What features are considered attractive in young women?

2. What patient characteristics are poor predictors of psychosocial / psychological postoperative facial plastic and reconstructive surgery outcomes?

3. If you elect to proceed to surgery what preoperative precautions should be undertaken?

Case 3:   Pt is a 65y.o male referred for evaluation of nasal obstruction. During evaluation, patient states that he is here to discuss surgery for his hypernasal voice.  And, that because his voice is hypernasal, he has not been respected by his peers and family all his life. On physical exam, pt has external nasal deviation to left, septal deviation to right, shows improvement in bilateral nasal respiration with modified cottle maneuver, baseline nasal endoscopy is negative for any additional nasal or nasopharyngeal abnormalities and the patient’s voice is noted not to be hypernasal. Patient is prescribed nasal steroid trial and instructed to f/u in clinic in 1month.  Pt keeps scheduled f/u and endorsed stable nasal obstruction.

• Asking open ended questions during initial consult may expose depression, unhappiness, or poor self-image₁

• Dealing with potentially difficult patient: schedule a 2nd visit, schedule minimally invasive reversible procedure and monitor patient perception of results, if surgeon feels patient is a poor surgical candidate; do not proceed with surgery₁

• Predictors of poor surgical outcome: Being male, young age, history of Depression / Anxiety, prior diagnosis of body Dysmorphic Disorder (BDD), being motivated by relationship issues, previous surgical dissatisfaction, Minimal deformity (difficult to quantify)₂

References

1. Sykes, J: Managing the psychological aspects of plastic surgery patients. Current opinion in Otolaryngology Head and Neck Surgery. 2009; 17 (4): 321-325

2. Honigman, RJ, Phillips, KA, Castle, DJ: A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004; 113 (4); 1229-1237

Review Questions

1. What additional history should be obtained from the patient?

2. If concerned about poor postoperative psychological outcomes what additional steps can be taken in evaluating this patient?

3. What patient characteristics are poor predictors of psychosocial / psychological postoperative facial plastic and reconstructive surgery outcomes?