Regression is a return to a previous stage of functioning or development to avoid anxiety or conflict.⁷ Regression may be seen in both healthy and unhealthy adaptations to illness. Patients have to undergo some degree of regression to allow themselves to be cared for when they are ill and to be in a dependent position. However, regression may get to a pathologic level when the patient acts in an infantile and helpless manner and is unable to participate as a partner in the medical care.

Denial is being consciously unaware of a painful aspect of reality. Through denial, patients invalidate unpleasant or unwanted bits of information and act as though they do not exist.⁷ Denial, like regression, can be adaptive or maladaptive in the medical setting. For example, a certain degree of denial can function to allow a patient to cope with an overwhelming feeling of helplessness or hopelessness in response to a diagnosis of terminal cancer. Denial becomes maladaptive when it interferes with a patient’s ability to participate in medical care. Denial need not be confronted when a patient is accepting appropriate medical treatment and participating in care. Denial can reach psychotic proportions in psychiatrically ill individuals.

Projection is when one attributes one’s unacknowledged feelings to others.⁷ Projection may be displayed by falsely attributing or misinterpreting attitudes, feelings, or intentions of others (e.g., “I’m not angry at her; she’s angry at me.”).

Repression involves keeping unwanted memories, thoughts, or feelings from conscious awareness.⁷ The patient who “forgets” unpleasant news that the physician tells her or him is likely to be repressing the disturbing thoughts or feelings.

Distortion occurs when patients grossly reshape external reality to suit their inner needs, including magical beliefs and delusional thinking.⁸

Somatization is when patients convert their psychic conflicts and conflicted feelings into body symptoms.⁸ The most common presentation of somatization is hypochondriasis.

Intellectualization is when the patient controls anxieties and impulses by excessively thinking about them rather than experiencing them.⁸ These thoughts are devoid of affect or feeling.

Rationalization is when the patient justifies his or her attitudes, beliefs, or behavior that might be unacceptable by inventing a convincing fallacy.⁸

Sublimation is the transformation of drives, feelings, and memories into healthy and creative outcomes.⁸

Perioperative psychological reactions

Even when the surgeon has preoperatively considered a patient to be a suitable candidate for surgery, it does not mean that he or she should cease to look for signs of psychological disturbance in the patient in the postoperative period. Transient episodes of anxiety or depression that last days to weeks after surgery have been reported in studies by Edgerton et al.⁹ and Meyer et al.¹⁰ A patient may experience psychiatric side-effects to various medications used preoperatively, intraoperatively, and postoperatively. The sudden onset of a new psychiatric symptom should suggest a medication-induced psychiatric side-effect. Perhaps one of the most profound reactions seen is lidocaine-induced delirium after regional limb surgery, in which a local anesthetic block was used. This can happen if there is an inadvertent intravenous injection of the anesthetic agent.

Mood improvement has been reported in a variety of cosmetic surgery patients postoperatively.¹¹^–²⁰ Even the so-called high-risk patients, those thought most likely to have a poor psychological outcome, may show benefit after cosmetic surgery.²¹ These findings have led to the conclusion that cosmetic surgery can be psychologically beneficial even to patients with psychiatric conditions, assuming that they are properly managed by their physician and psychiatrist.²²

In the discussions that follow, different personality styles and disorders are discussed relative to how they respond to surgery and recovery.

The physician–patient relationship

Surgeons are invested with strong emotions by patients who are entrusting them with their bodies and lives. Patients may develop special feelings for their surgeons that are similar to those associated with figures of authority from their past.²³ This may account for the idealization of the surgeon as the “miracle worker” or “savior”, as well as for some of the unwarranted angry feelings toward the surgeon. This is a phenomenon known as transference. The nature of the physician–patient relationship is extremely important to the success of the treatment of the seriously ill patient. Although many physicians are uncomfortable with the patients who develop feelings about them, it is important to recognize the phenomena of transference, counter-reaction, and counter-transference.

Transference can be described as recreating, in the physician–patient relationship, a conflicted relationship with a childhood figure. The transference may be of a paternal or a maternal nature, but this is not necessarily the case. Grandparent, aunt or uncle, and sibling transferences can also occur. When transference is present, the patient will react to the physician as if the physician were the transferential figure; in other words, feelings about that figure become “transferred” onto the physician. If the transference is positive, it generally does not need to be addressed. However, if the transference is negative, it does need evaluation.

An example of negative transference is the patient who treats the physician as if he or she were sadistic, uncaring, cold, and heartless, when the physician is trying his or her best to be empathic, warm, and caring. The patient is acting in an overly exaggerated fashion out of proportion to the real interaction. Often, the transference is not a total distortion of the real relationship between the physician and patient; the patient may have picked up on some aspect of the physician’s personality or behavior that has served as the foundation for the development of transferential feelings.

The physician’s emotional reaction to the patient’s expression of transferential feelings is termed counter-reaction. For example, when the patient becomes angry with the physician, the physician wishes to withdraw or may feel anger in response. Instead, the physician should try to figure out how best to respond to the patient’s feelings and behavior without personalizing them. This is not easy, as physicians, like their patients, are only human, and are prey to their own feelings and those of others towards them. Counter-reaction, which is a common or “normal” response to the patient’s emotions or behaviors, needs to be differentiated from counter-transference.

Counter-transference is the physician’s reaction to the patient based not on the real circumstances but on issues or conflictual relationships in the physician’s own life – if you will, a “neurotic” response to a patient’s transference. When these feelings occur, they may be intense for both the patient and the physician. Recognition of these feelings and their origins is an important insight and a good tool to have to improve relationships with patients and to avoid pitfalls in the treatment relationship, including the selection of specific interventions.

Personality styles and personality disorders

There are various personality types or styles that all physicians treat in clinical practice. This section focuses on the personality styles and disorders most commonly encountered by the plastic surgeon, the typical reactions to surgery or alterations of body image, and the medical management of these.

When personality traits become inflexible and maladaptive and cause either significant impairment in social or occupational functioning or subjective distress, they constitute a personality disorder.²⁴ Personality disorders are generally apparent by late childhood or adolescence, continue throughout most of an individual’s adult life, and may become exaggerated in the older years.

There are four characteristics that all personality disorders share. They are: (1) an inflexible and maladaptive response to stress; (2) a disability in working and loving that is generally more serious and always more pervasive than that found in neurosis; (3) elicitation by interpersonal conflict; and (4) a peculiar capacity to “get under the skin” of others.²⁵ Patients with personality disorders see the rest of the world, rather than themselves, as having a problem. They have little insight into their own behavior or its impact on others around them.

Obsessive-compulsive personality and personality disorder

Many individuals with an obsessive-compulsive personality are highly successful and productive members of the community. This personality style lends itself to efficiency, effectiveness, and goal-directed behavior. These individuals tend to deal with feelings by using intellectualization; are preoccupied with details, organization, and schedules; tend to be perfectionistic; are scrupulous about matters related to morality and ethics; have trouble delegating tasks to others; and can be rigid, stubborn, and miserly.²⁶

When obsessive-compulsive patients become anxious, they can quickly decompensate and become overly invested in routines or seemingly trivial information. These patients can overwhelm the physician with questions and occupy enormous physician and staff time, leading to resentment by caretakers. It is important to reassure these patients and to address their fears and anxieties; sometimes the surgeon should try to determine what may be making them anxious or fearful and provide appropriate comfort. These patients are often unaware of their feelings, and providing them with detailed medical explanations can be helpful to them. Giving them tasks to perform makes them feel like a partner in their therapeutic treatment and in decision-making. This could take the form of having them change dressings, measure their fluid intake and output, or care for scars with topical moisturizers. Even if these measures are not strictly necessary, they will help these patients manage their anxiety.

Patient example

Ms A. is an overly neat 43-year-old successful business executive who underwent a blepharoplasty. After surgery, she barraged the surgeon’s office with endless questions and details and occupied excessive amounts of staff time on the telephone. The surgeon, Dr B., had Ms A. come in for an extra postoperative visit and instructed her to prepare, in advance, a list of questions she needed answered. After answering her questions, Dr B. addressed her anxiety about the eventual outcome, reassuring her that this was a normal concern, and tried to determine how best to continue to reassure her. She was given a scheduled daily call-in time, limited to 5 min, during which she could ask her questions and receive support and reassurance.

Narcissistic personality and personality disorder

Narcissistic patients have an excessive need for admiration, an exaggerated sense of self-importance, and grandiose notions of their beauty and power. They have a sense of entitlement; can be exploitative of others to achieve their own ends; lack empathy towards others; can be envious of others or feel that others are envious of them, and may be arrogant and haughty in their behaviors and attitudes.²⁶

Because these patients place such value on their physical appearance, surgery to alter their appearance will naturally generate some anxiety. They generally find the physical effects of aging on their appearance unacceptable. Similarly, they find distressing any surgical complication or even the typical swelling and bruising that are the sequelae of surgical procedures. These patients need to be educated as much as possible about the process of healing and recovery and offered reassurance along the way about common postoperative events. They respond to being treated like equal, independent partners in their care.

Plastic surgeons should take care not to be taken in by the narcissistic patient’s idealization of them (e.g., “You’re the best plastic surgeon in the country.”). These patients can quickly switch to profound devaluation of the surgeon if the surgeon displeases them or causes them discomfort. These patients tend to become demanding when they are physically uncomfortable and anxious, and they respond best to empathic reassurance.

Dependent personality and personality disorder

These patients exhibit clinging and submissive behavior, seemingly needing endless reassurance and support. They have great difficulty making daily decisions without an excessive amount of advice and reassurance. They want others to assume responsibility for their major decisions. They experience difficulty initiating actions because of a lack of self-confidence in their judgment and abilities. They often find it difficult to disagree with others because they fear rejection or disapproval. Dependent personalities have great discomfort when they are alone and are fearful that they cannot take care of themselves.²⁶

This translates in the surgical situation to the dependent patient’s becoming clinging and fearful after surgery, in part facilitated by the regression initiated by being taken care of while ill. This behavior can sometimes alienate healthcare providers and bring about the very thing the dependent personality fears, to be alone and abandoned. The physician should try to recognize these fears and provide reassurance to the patient that he or she will not be abandoned. Warm support should be offered, but firm limits must be set on undue neediness and manipulativeness.

Paranoid personality disorder

Paranoid patients have a pervasive mistrust and suspicion of others.²⁶ They fear that motives are ill-intentioned and they suspect, with an insufficient basis in fact, that others are trying to harm, exploit, or injure them. They may attribute a malevolent intent to innocent remarks. They are unforgiving and bear grudges, even to seemingly benign slights. They perceive others as attacking their character or reputation and may respond angrily and with vindictiveness.

These patients experience surgery as an “intrusion” and attack on their bodies. They find it difficult to establish a therapeutic alliance with healthcare providers. Their lives sometimes appear to be without direction, i.e., “drifters.” They have few friendships and few social interactions. Their occupational choices are most successful when they choose professions in which they have little contact with others and can work in relative isolation.

Under stress, paranoid individuals can develop brief psychotic episodes. It is preferable not to perform elective cosmetic surgery on such an individual. If the paranoid patient requires reconstructive surgery or other nonelective cosmetic surgery, it is important to respect the patient’s distance and interact with the patient in a professional manner, not attempting to get too close or friendly, because this behavior may be viewed with suspicion. The surgeon should be direct and answer questions in a candid and honest fashion. Any distortions by the patient that are noted by the surgeon should be addressed and discussed openly. Accusations should be neither disputed nor confirmed but explained as coming from illness rather than from any attempt to injure the patient.²⁷

Histrionic personality and personality disorder

Histrionic ²⁶ patients tend to be excessively emotional and exhibit attention-seeking behavior. Although they are often lively, flirtatious, and dramatic, they continually demand to be the center of attention. If they feel the spotlight move away from them, they may do something dramatic to refocus attention on themselves (e.g., make a scene on the floor; call patient relations). They are highly suggestible and easily influenced by others and current fads. The plastic surgeon should take care in assessing this patient to ascertain the real reasons for seeking surgery.

Histrionic persons may be overly trusting, especially of physicians, whom they see as magically solving their problems. They tend to view the therapeutic relationship as more intimate than it actually is and may develop romantic fantasies about their physicians. Individuals with histrionic personality disorder are at an increased risk for suicidal gestures and may make threats to get attention and coerce better caregiving.

The surgeon should adopt a professional manner with these patients and give the appropriate amount of attention to them. The surgeon must be very careful not to become too friendly or to be drawn into their seductive behavior. Certainly, one should not be flirtatious or seductive in response. Firm limit setting with regard to the nature of the therapeutic relationship and the physician’s role in the patient’s life is necessary.

Borderline personality disorder

Borderline patients ²⁶ have a pattern of unstable interpersonal relationships. They may have an identity disturbance characterized by shifting and changing senses of self, goals, values, and aspirations. Likewise, feeling states or moods can also show wild swings and variability. Borderline patients can be impulsive and often have trouble controlling their anger and emotions. Their behavior can be self-destructive and manipulative. They may engage in gambling, excessive money spending, binge eating, substance abuse, unsafe sex, or reckless driving. At the extreme, they may perform self-mutilating acts (cutting or burning), or suicidal behavior. Completed suicide occurs in 8–10% of such patients. During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur but generally do not persist.

Such patients are best handled with strict limit setting. The physician should make every attempt to be consistent and attentive but not respond to manipulative behavior. The patient should be given a schedule for visits and follow-up plans to limit fears of abandonment.

These patients generally respond best to the corrective experience of developing a trusting, stable relationship with the physician who does not retaliate in response to their angry and disruptive behaviors.²⁸ Use of the resources of other healthcare providers, such as a psychiatric consultant for psychotherapy and psychopharmacotherapy or a nurse practitioner to “spread the transference,” can help make these patients feel adequately attended to and cared for. However, it is important for the surgeon to continue to care for them in the usual fashion because these other relationships are not a substitute for the surgeon’s relationship with them.

Strategies for management of the difficult patient

The hateful patient

The “hateful patient” is a term coined by James E. Groves in his seminal article in the New England Journal of Medicine.²⁹ These are patients who often inspire dread in their physicians when they see their names on the appointment schedule. These patients often make a provider feel angry and helpless, leading to possible retaliation or confrontation. Who are these individuals? It is helpful to recognize these patients, to understand why they inspire negative feelings, and to manage their treatment on the basis of specific principles. One cannot pretend that negative feelings do not exist because failing to acknowledge these feelings can lead to suboptimal medical care.

The dependent clinger

Dependent clingers ²⁹ range from having mild requests for reassurance to demanding requests for many different forms of attention (such as analgesics, long explanations, caring, affection). These patients may be experienced as “bottomless pits” of neediness, and avoidance behaviors on the part of the physician may ensue.

The warning signs of the dependent clinger are the overly grateful patient who idealizes the physician, professes undying “love” and admiration, and behaves in a seductive manner. The physician becomes “the inexhaustible mother”; the patient becomes the “unplanned, unwanted, unlovable child.”²⁹

Patient example

Ms T., a 24-year-old woman who is seeking augmentation mammaplasty, places several telephone calls before her surgery, asking for more information and needing reassurance about the upcoming surgery. Her plastic surgeon gives her the time she seems to need to make her feel comfortable about the procedure. Several days postoperatively, she starts to place telephone calls to the office, escalating in frequency and urgency. She is requesting office visits, despite little objective need for a visit outside of the usual postoperative follow-up. She also starts to ask for analgesic medications and to request reassurance about her breast size and her discomfort. The plastic surgeon stops answering her calls and lets his nurse field the questions and calls. As a result of not being able to reach the surgeon directly, she starts to page him in the evenings, telling his service that it is an emergency.

The best management of this patient is to set firm limits relative to appointments and telephone contacts. The physician needs to kindly but clearly state to the patient that he/she has human limitations and cannot be an inexhaustible resource to the patient, available at any time of day or night. Regular office visits should be scheduled, during which time the patient can see the physician and ask questions. The surgeon’s nurse can also schedule visits in between visits to the physician to provide reassurance. These actions should give the patient the contact needed without disrupting the office and the physician’s life. Enlisting the help of a psychiatric consultant can be helpful in providing additional support to the patient and spreading the transference.

The self-destructive denier

All physicians have patients who deny their illnesses.²⁹ Denial is pathologic when it interferes with the patient’s ability to accept proper medical care for the illness. Otherwise, denial can be adaptive in coping with the illness.

However, there is a group of patients who are self-destructive deniers. Unlike the adaptive deniers, these patients are fundamentally dependent on others and seem to revel in their self-orchestrated destruction. They appear to their physicians as taking great pleasure in putting obstacles in the path to delivery of optimal care.

Patient example

Mr B., a 49-year-old man, is an intravenous drug abuser. He has a long history of drug-related medical problems and hospitalizations. Despite multiple attempts to get him to pursue drug treatment, he has resisted attending any programs. He was admitted to the hospital with bacterial endocarditis and given intravenous antibiotics for 6 weeks. Shortly after discharge, he was readmitted with cellulitis from a fresh intravenous heroin injection site. The plastic surgeon was consulted to provide skin flaps for coverage after skin loss followed the cellulitis. After that treatment and discharge, he was readmitted with recurrence of the endocarditis and required additional skin grafting for breakdown due to new soft tissue infections. Two months later, he was admitted with sepsis and died in the hospital.

Self-destructive deniers make their physicians feel angry, helpless, used, and abused. They engender rescue fantasies, especially in younger physicians, but may also lead their physicians to have negative feelings toward them. Physicians often feel guilty about their hateful feelings towards such patients.

The best management is to see the patient’s pattern of self-destructive denial and to set realistic expectations relative to the patient’s ability to get well. It may be helpful to think of the patient as having a degenerative or terminal illness, for which there is no medical treatment and to set the goal of providing supportive care and alleviating suffering.

The entitled demander

The entitled demander ²⁹ is fundamentally similar to the dependent clinger in neediness; however, the presentation is quite different. These patients are demanding, devaluing, and intimidating. These are the patients who threaten lawsuits or contact patient relations representatives when the medical staff does not fulfill their demands as they require.

Their primary feeling state is one of entitlement. This is actually a defense against fears of loss of control and helplessness. However, when a physician is at the other end of the angry demands and entitled behavior, it is easy to understand how one could become enraged with this patient. They also make the physician feel fearful of their threats. The usual reaction to these patients is to let them know, in no uncertain terms, how undeserving they are of what they demand. This usually does not work with this population.

Groves ²⁹ speaks eloquently about how to handle such a patient, as follows:

I know you’re mad about this … and at the other doctors. You have reason to be mad. You have an illness that makes some people give up and you’re fighting it. But you’re fighting your doctors too. You say you’re entitled to repeated tests, damages for suffering and all that. And you are entitled – entitled to the very best medical care we can give you. But we can’t give you the good treatment you deserve unless you help. You deserve a chance to control this disease; you deserve all the allies you can get. You’ll get the help you deserve if you’ll stop misdirecting your anger to the very people who are trying to help you get what you deserve – good medical care.

This strategy allows the patient to fulfill the underlying wish to receive “the best” medical care and, it is hoped, will enlist the individual as an ally in the treatment. It enables the physician to tactfully address the entitled, demanding behavior in a constructive way, rather than to respond with rage or retaliation.

Manipulative help-rejecting complainers

No matter to what lengths the physician may go to help them, this is the group of patients who will try to thwart the help.²⁹ They express their hopelessness that any physician can help them. They return to the physician’s office week after week to affirm that the recommended treatment failed once again. When one physician “fails” them, they shop for the next.

Like the dependent clinger and the entitled demander, they tend to have no limits to their need. They do not seem to wish to get well; instead, they seem to wish an “undivorceable marriage” with their healthcare provider. When one symptom resolves, another appears to replace it. These patients often suffer from undiagnosed and untreated depression.

Patient example

Ms S. is a 30-year-old sales associate with intractable hand pain. She has gone for consultations all over the country and has received numerous diagnoses, including causalgia, reflex sympathetic dystrophy, and carpal tunnel syndrome. She has had hundreds of diagnostic procedures, but (fortunately) she has refused to have surgery when it was recommended. She had a 14-day hospitalization at a pain treatment center, during which time her hand pain diminished with a combination of antidepressants, relaxation therapy, behavioral therapy, and occupational and physical therapy. However, after discharge, she failed to follow any of the recommendations, and the pain recurred. She is now angry that the pain center failed to cure her and is determined to find a physician who can find the “real cause” of her pain.

This group of patients makes physicians worry that they may have overlooked a correctable illness and makes them feel anxious and uncertain about their clinical skills. It is usually not constructive to confront this patient with his or her behavior or neediness. It is important to realize that the ultimate goal of the patient is to never be abandoned and to always be connected to the physician. However, he or she is fearful of real closeness with the physician.

A good strategy for the physician is to communicate to these patients that he or she may not be able to help them and to share their pessimism that they can be “cured.” Instead, the physician could suggest treatments that may provide “some” relief (but not enough that the patient will be cured, thereby engendering fear in the patient of losing the physician). This technique was used by Ms S.’s physician, who also treated her depression and offered behavioral strategies to alleviate her pain, while telling her that he did not think that the techniques could be more than 50% helpful. Ms S. was satisfied with this approach, which allowed her to hold onto her symptom and to her relationship with her physician simultaneously but also permitted her to become more functional in her daily life. Psychiatric consultation can be helpful but not as a replacement for the primary physician; it must be presented as an adjunctive treatment.

Surgical procedures and related psychological issues

Aesthetic facial surgery

Our society seems to value youth and to associate the physical changes of aging with weakness and loss of worth. Surgery to rejuvenate the face can be of enormous benefit to the person with an aging appearance. It may allow the person to feel better and acquire acceptance, to feel sexually attractive to others, and to be viewed as more vibrant, strong, and youthful. There are clear economic, psychological, and social benefits to having a more youthful appearance.

Surgery of the aging face is done for the purpose of restoring a previously existing appearance or pre-existing image of the face. This type of surgery seems to require no dramatic body image readjustment ³⁰ because the aging face does not appear to be fully incorporated into the body image over time. This operation is generally successful and psychologically beneficial to the individual.

Procedures to rejuvenate the face are generally performed in the middle to later ages of life. This is a time of potential loss – of loved ones, of career, of friends and family, menopause, baldness, the empty nest left by children’s emancipation. In a study of facelift patients older than 50 years, Webb et al.¹¹ found that 90% had lost an important person in the 5 years before surgery. Dunofsky³¹ found the study population of women who had facial cosmetic surgery to be more narcissistic and to have more problems with separation-individuation than the control group but to have no differences in self-esteem and social anxiety. Edgerton et al.³² found that 74% of facelift patients had been diagnosed with a psychiatric disorder.

Sarwer and Crerand ³³ looked at the various preoperative studies in the literature and found that clinical interview-based investigations identified a higher incidence of psychopathology in the cosmetic surgery population. However, when preoperative studies using standardized psychometric testing as part of the assessment were evaluated, little psychopathology was uncovered.

There have been various studies that alluded to greater psychological difficulties in male than in female facelift patients.^32,³⁴ However, the percentage of men having facelifts has increased during the past 20 years, with no clear increase in psychological difficulties postoperatively.

In Goin et al.’s study,³⁵ the motivations for facelift surgery were related to feelings about aging in 70% of the patients, and most were satisfied with the results, even when they had some unrealistic expectations. Friel et al. also reported a similarly high satisfaction rate.³⁶ The study of Leist et al.³⁷ revealed that about 13% of patients were dissatisfied with their surgical results.

Postoperatively, facelift patients may experience some hypoesthesia or paresthesias of the face and neck. They may experience some sleep disturbance caused by physical discomfort. Those individuals who particularly prize their autonomy and independence may find it difficult to manage the postoperative period of physical discomfort and incapacity. However, psychological reactions are usually short-lived, and patients are generally satisfied with their results, experiencing a sense of enhanced attractiveness and self-esteem.

Aging face patients who seek facelift surgery appear to be motivated by the desire to restore their previous youthful visage. Rhinoplasty patients, on the other hand, are seeking to change their basic appearance.

Rhinoplasty

The literature is filled with articles and studies about the patients who seek rhinoplasty. In general, older studies of this group of patients suggested a great deal of psychopathology. In 1975, Gibson and Connolly ³⁸ studied rhinoplasty patients 10 years postoperatively and found a high level (38%) of psychopathology, including schizophrenia. They compared this group with a trauma and disease group, in which they found only 8% with a psychological disorder. Wright and Wright³⁹ found a high level of psychopathology based on psychological testing measures (Minnesota Multiphasic Personality Inventory) in their controlled study of rhinoplasty patients. Compared with the control group, patients seeking rhinoplasty were more self-critical, more sensitive to others’ opinions of them, and more restless. The most consistent personality diagnosis was “inadequate personality,” which probably translates into “dependent personality” by today’s diagnostic nomenclature. Hay and Heather’s 1973 study¹⁶ of 45 rhinoplasty patients demonstrated psychological disturbance in about 58% of the study group. Micheli-Pellegrini and Manfrida’s study⁴⁰ as well as Linn and Goldman’s study⁴¹ also revealed a high incidence of psychopathology. Zahiroddin et al., however, found no significant difference in the rate of psychiatric disturbance and the decision to undergo rhinoplasty.⁴²

There has been much focus in the plastic surgery literature on the so-called minimal defect rhinoplasty patient. The 1960 study of Jacobson et al.⁴³ looked at 20 consecutive men requesting cosmetic surgery for “minimal defects.” The most requested procedure was rhinoplasty. All but two of the patients (those two refused psychological evaluation) were found to have psychiatric diagnoses. Seven were found to have psychosis; four were found to be neurotic; seven had personality disorders. Half of the patients underwent the procedure, and more than 50% of these surgical patients had postoperative psychological problems, including one suicide attempt.

However, not all studies have supported a link between rhinoplasty and psychopathology, and in actual practice, a great majority of rhinoplasty patients seem to benefit from the surgery. The patients described by Linn and Goldman ⁴¹ reacted with “elation” after the surgery and shortly afterwards, were no longer preoccupied with their nose and were pleased with the cosmetic results. They found an overall improvement in the patient’s level of adjustment. They hypothesized that the anatomic changes made to the nose and subsequent change in others’ behavior toward the patient led to a release of the psychic energy attached to the nose. Goin and Goin’s study⁴⁴

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Feb 21, 2016 | Posted by admin in General Surgery | Comments Off

Plastic Surgery Key

Fastest Plastic Surgery & Dermatology Insight Engine

Psychological aspects of plastic surgery

Body image and plastic surgery

Defining body image

Body image determines emotional response and behavior

Four stages of body image development

Early childhood

Starting school

Adolescence

Aging

How plastic surgery changes body image

Personality and character formation

Defense mechanisms

Perioperative psychological reactions

The physician–patient relationship

Personality styles and personality disorders

Obsessive-compulsive personality and personality disorder

Patient example

Narcissistic personality and personality disorder

Dependent personality and personality disorder

Paranoid personality disorder

Histrionic personality and personality disorder

Borderline personality disorder

Strategies for management of the difficult patient

The hateful patient

The dependent clinger

Patient example

The self-destructive denier

Patient example

The entitled demander

Manipulative help-rejecting complainers

Patient example

Surgical procedures and related psychological issues

Aesthetic facial surgery

Rhinoplasty

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Psychological aspects of plastic surgery

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