Psychosocial Factors Within the
Realm of Aesthetic Plastic Surgery
Hilary McCord, PA-S
hilarymccord@uky.edu
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 performed
in 2006.
NONSURGICAL
Botox
Restylane
Microdermabrasion
SURGICAL
Breast Augmentation #1
Rhinoplasty
Liposuction
Breast Augmentation #1
330,000 in 2006
 55% increase since 2000
 Expected to increase in the future due to
the 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 Comparison
Theory.
Growth of the Industry: Why?
The most recent example of mass media influence
is the explosion of aesthetic surgery Reality T.V.



Extreme Makeover
(ABC)
The Swan (FOX)
I Want a Famous
Face (MTV)



Plastic Surgery:
Before and After
(TLC)
Miami Slice (Bravo)
Dr. 90210 (E!)
Influence of Reality T.V.

Crockett (2007)
concludes 4 out of 5
patients reported
plastic surgery Reality
T.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 an
amendment to its constitution and bylaws addressing
concerns arising from reality television programs’
influence on patient expectations regarding medical
care 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

Assessment of the Breast
Augmentation Candidate:
the PA’s Role
Identify the motivating factors for the
intervention and expectations of the
surgical 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 the
primary
motivational
factor (Cash
1996)
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

Body Dysmorphic Disorder:
Recognize It and
Consult Mental Health
Frequent mirror gazing
 Perform repetitive time consuming
behaviors regarding the imagined defect
 “Doll-like” appearance
 Extreme rituals of camouflage
 Surgery Junky

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: SSRIs
and Cognitive Behavioral Therapy

Post-operative Suicide: the
importance of a psychiatric history

Six international epidemiological studies
have found an unexpected relationship
between cosmetic breast augmentation
and suicide

(Brinton, 2001) (Koot, 2003) (Pukkala, 2003) (Jacobson, 2004)
(Brinton, 2006) (Villeneuve, 2006).

Designed to investigate overall mortality in
women who underwent breast
augmentation.
Death by suicide associated with:





Breast augmentation vs. other forms of cosmetic
surgery
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/

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.
References




















Crerand, C., et.al. Body dysmorphic syndrome and cosmetic surgery. 2006; Plastic and
Reconstructive 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: 316324.
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: 12801282.


















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 112:8390.
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
Therapy 39: 1381-1393.
Villeneuve, P., et.al. Mortality among Canadian women with cosmetic breast implants. 2006; Am J Epidemiology
164: 334-341.