A prospective controlled
outcome study of
psychological change
following plastic surgery
Dr Tim Moss
Chartered Health Psychologist
Centre for Appearance Research
UWE (Bristol)
Tim.moss@uwe.ac.uk
Mr David Harris
Consultant Plastic Surgeon
Derriford Hospital
Plymouth
Overview




Evidence of plastic surgery benefits?
Design and measures
Participants and attrition
Outcomes



Depression
Anxiety
Appearance adjustment
Evidence of plastic surgery success

Honigman et al 2004 review



Bolton et al (2003)




Mixed methodologies
Patient satisfaction good
Abdominoplasty, pre- and post-op
B.I. satisfaction increased
B.I. investment, general psych function not improved
Sarwer et al (2005)


General aesthetic plastic surgery
Satisfaction with surgery and ‘feature’ change over 12 months
Methodological issues

Measures
Sarwer (1998)
 Interviews demonstrate psychopathology in
cosmetic surgery patients
 Standardised general measures not identify this


Designs - comparison groups . . .
Dissonance
 Hawthorn effect
 Demand

Our study: Design

Prospective, Controlled, quasi-experimental

Plastic surgery patient group


Comparison surgery group


T1 (pre op), T2, (3 months post op), T3 (12 months post op)
T1 and T2
Participants


Adults, English speaking
Patients:


Plastic surgery admissions – nose, breasts, upper limb
Comparison group:



Non-appearance altering surgery group
General surgery, ENT, Maxillofacial surgery
Randomly allocated “nose”, “breasts”, “upper limb”
Measures

Generic psychological functioning


Crown Crisp Experiential Inventory- Anxiety
Beck Depression Inventory
Test-retest reliability high
 Good internal validity
 Criterion validity with other measures and clinical
observation high

Measures
Derriford Appearance Scale 24
www.derriford.info

24 items examine frequency of avoidant behaviours and
distress related to appearance concern

Example items:



I feel self conscious of my appearance
I avoid going to pubs/restaurants
Psychometric properties



Internal consistency; Cronbach's = 0.92
Test-retest r = 0.68 (6 months)
Moderate correlations (r=0.5) with NA, social anxiety, shame
Participant numbers
All
Time one
only
Time one and
two only
Time one and
three only
Time one,
two and three
Control
105
61
Plastics
51
4
All
156
65
44
10
54
n/a
8
8
n/a
29
29
Participants by condition
Ctrl
Plastics
All
Rhin Breast Arms Rhin Breast Arms Rhin Breast Arms
All time one
36
33
36
18
18
15
54
51
51
Time one only
19
17
25
1
1
2
20
18
27
Time one and
two only
17
16
11
4
2
4
21
18
15
Time one and
three only
n/a
n/a
n/a
2
2
4
2
2
4
Time one, two
and three
n/a
n/a
n/a
11
13
5
11
13
5
Participant by sex
(% Female)
All time one
Time one
only
Time one &
two only
Time one &
three only
Time one,
two & three
Ctrl
58
54
Plastics
67
75
All
60
55
63
60
63
n/a
75
75
n/a
66
66
Gender similar across times and patient group
Participant age
Control
Plastics
Mean
nose
Std
Count Mean
Std
Count
Deviation
Deviation
28.11
8.00
36 30.67 10.13
18
breasts 33.25
12.14
33
30.00
10.29
18
upper
limb
6.44
36
25.87
8.89
15
27.08
Age comparable across groups and conditions
Impact of Attrition
Group
Control
Sample
T1 only
Percent
44.3
54.1
36.4
Sample
Group
T1 only
Female
T1 only
Male
Female
T1 and T2
Male
Female
T1 T2 and T3 Male
63.6
25.0
75.0
40.0
60.0
34.5
Female
Male
Female
65.5
25.0
75.0
T1 and T2
Plastics
T1 and T3
only
Gender
Male
Female
Male
Std. Dev
T1 and T2
Ctrl
Plastic
Ctrl
Mean
age
29.3
28.0
29.5
only
T1, 2, and 3
Plastic
Plastic
26.0
30.6
4.6
11.7
T1 and T3
only
ALL
Plastic
27.6
8.2
Both
29.2
9.5
8.6
8.3
10.4
Neither age nor sex differentially affected by attrition
Depression
Time x feature x
group
10
9
F(2,77) = 1.3, p=0.28
8
Depression reduction not
significantly greater in
plastics
F(1,77)=2.3, p=0.13
7
6
T1
5
T2
Controls
Plastics
Anxiety

8.0
7.5

7.0
Time x group x
feature
F(2,75)=3.1, p>0.05
6.5

6.0
5.5
5.0
T1
4.5
T2
Control
Plastics

Anxiety reduction
post op greater in
plastics patients
F(2,75)=3.3, p=0.02
Derriford Appearance Scale 24
DAS24
60

50

40


Time x feature x
group
F(2,77)= 10.2, p<0.005
Group X time
F(1,77) = 69.8, p<0.005
30
DAS24T1
20
DAS24T2
Control
Plastics

Plastics patients
significantly better
DAS post op
Derriford Appearance Scale
by feature
50


40

30
T1
20
T2
rhino
breasts
upper limb
Feature x time
F(2,23)=7.1, p<0.005
DAS improvements
post op only
significant for rhino
and breasts at T2
Patients only: DAS at T2 - T3

70
60
Stability of
adjustment levels
rhino and breasts
50

40
30
T1
T2
20
T3
rhino
breasts
upper limb
Delayed improvement
in upper limb
adjustment:
significant T2 – T3
change
Criticisms of design

Quasi-experimental design



Potential confounding of group
Limitation of plastics patient conditions
impacts on generalisability
Groups numbers reduce analytical power
Conclusions


Plastic surgery: psychological benefits for the
three conditions studied
Plastic surgery specific, not generalised surgical
intervention effect

Not demonstrated in depression

Small and significant effect in anxiety

Clear effect detected for DAS24


Delayed benefit for upper limb
Use of appearance specific measures preferable to
generic?
Further work



Components of poor appearance adjustment
benefiting from surgery?
Relationship between anxiety/DAS24/depression
and Patient Satisfaction?
Impact of surgery on components of
(multidimensional) BI - and which of these
mediate outcome variables above?