Psychological aspects of reconstructive and cosmetic plastic surgery : clinical, empirical, and ethical perspectives PDF
Preview Psychological aspects of reconstructive and cosmetic plastic surgery : clinical, empirical, and ethical perspectives
75362_chFM.qxd 7/15/05 04:36 AM Page i Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery 75362_chFM.qxd 7/15/05 04:36 AM Page ii 75362_chFM.qxd 7/15/05 04:36 AM Page iii Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery Clinical, Empirical, and Ethical Perspectives EDITORS David B. Sarwer, PhD Robert M. Goldwyn, MD Associate Professor of Psychology Clinical Professor of Surgery in Psychiatry and Surgery Harvard Medical School University of Pennsylvania School of Medicine Boston, Massachusetts The Edwin and Fannie Gray Hall Center for Human Appearance John A. Persing, MD Philadelphia, Pennsylvania Professor and Chief Plastic Surgery Thomas Pruzinsky, PhD Yale University School of Medicine Professor New Haven, Connecticut Department of Psychology Quinnipiac University Linton A. Whitaker, MD Hamden, Connecticut Professor of Surgery (Plastic) University of Pennsylvania School of Medicine Thomas F. Cash, PhD Director, The Edwin and Fannie Gray Hall University Professor Center for Human Appearance Department of Psychology Philadelphia, Pennsylvania Old Dominion University Norfolk, Virginia 75362_chFM.qxd 7/26/05 11:54 Page iv Acquisitions Editor: Brian Brown Developmental Editor: Louise Bierig Managing Editor: Julia Seto Project Manager: Fran Gunning Design Coordinator: Teresa Mallon Marketing Manager: Adam Glazer Production Services: Schawk, Inc. Printer: Edwards Brothers, Inc. © 2006 by Lippincott Williams & Wilkins 530 Walnut Street Philadelphia, Pennsylvania 19106 USA 351 West Camden Street Baltimore, Maryland 21201-2436 USA LWW.com All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above mentioned copyright. Printed in the USA Library of Congress Cataloging-in-Publication Data Psychological aspects of reconstructive and cosmetic plastic surgery: clinical, empirical, and ethical perspectives/editors. David B. Sarwer, Thomas Pruzinsky p.; cm. Includes bibliographical references and index ISBN 0-7817-5362-7 (alk. paper) 1. Surgery, Plastic—Psychological aspects. 2. Surgery, Plastic—Moral and ethical aspects. 3. Surgery, Plastic—Social aspects. I. Sarwer, David B. II. Pruzinsky, Thomas. [DNLM: 1. Reconstructive Surgical Procedures—psychology. 2. Ethics. Professional. 3. Surgery, Plastic—psychology. WO 600 P974 2005] RD118.5.P79 2005 617.9⬘5—dc22 2005016508 The publishers have made every effort to trace copyright holders for borrowed material. 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However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no war- ranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of pub- lication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reaction, the reader is urged to check the pack- age insert for each drug for any change in indications and dosage and for added warnings and pre- cautions. This is particularly important when the recommended agent is a new or infrequently em- ployed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responisibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinicial practice. 10 9 8 7 6 5 4 3 2 1 75362_chFM.qxd 7/15/05 04:36 AM Page v C O N T R I B U T O R S Barbara L. Andersen, PhD James A. Fauerbach, PhD Professor Associate Professor Department of Psychology Department of Psychiatry and Behavioral Sciences and Department of Obstetrics and Gynecology Physical Medicine and Rehabilitation The Ohio State University The Johns Hopkins School of Medicine Columbus, Ohio Baltimore, Maryland Jeffrey T. Barth, PhD Professor Carla Fenson, MEd Department of Psychiatric Medicine and Human Services Planner/Evaluator III Department of Neurological Surgery Frank Porter Graham Child Development Institute University of Virginia Medical School University of North Carolina at Chapel Hill Charlottesville, Virginia Carrboro, North Carolina Patricia Blakeney, PhD Georita M. Frierson, PhD Clinical Professor Centers for Behavioral and Preventive Medicine Department of Surgery Miriam Hospital University of Texas Medical Branch Brown University School of Medicine Galveston, Texas Providence, Rhode Island Walter O. Bockting, PhD Associate Professor Leo C.T. Fung, MD Program in Human Sexuality Associate Professor of Urologic Surgery and Pediatrics Department of Family Medicine and Community Health Director of Pediatric Urology Coordinator of Transgender Health Services University of Minnesota Medical School University of Minnesota Medical School Minneapolis, Minnesota Minneapolis, Minnesota Thomas F. Cash, PhD Lauren M. Gibbons, BA University Professor Department of Psychiatry Department of Psychology University of Pennsylvania School of Medicine Old Dominion University Philadelphia, Pennsylvania Norfolk, Virginia Robert M. Goldwyn, MD Canice E. Crerand, PhD Clinical Professor of Surgery Instructor Harvard Medical School Department of Psychiatry Boston, Massachusetts University of Pennsylvania School of Medicine Philadelphia, Pennsylvania Mark Gorney, MD Elizabeth R. Didie, PhD The Doctor’s Company Clinical Psychology Post-doctoral Fellow Napa, California Department of Psychiatry and Human Behavior Brown University/Butler Hospital Brad K. Grunert, PhD Providence, Rhode Island Associate Professor Milton T. Edgerton, MD Department of Plastic Surgery and Emeritus Professor of Plastic Surgery Department of Psychiatry and Behavioral Medicine University of Virginia Health Sciences Center Medical College of Wisconsin Charlottesville, Virginia Milwaukee, Wisconsin v 75362_chFM.qxd 7/15/05 04:36 AM Page vi vi Contributors Kathleen A. Kapp-Simon, PhD David B. Sarwer, PhD Associate Professor Associate Professor of Psychology Department of Surgery Department of Psychiatry and Surgery Northwestern University Feinberg School of Medicine University of Pennsylvania School of Medicine Chicago, Illinois The Edwin and Fannie Gray Hall Center for Human Appearance H. Asuman Kiyak, MA, PhD Philadelphia, Pennsylvania Professor Department of Oral & Maxillofacial Surgery Robert J. Spence, MD University of Washington School of Medicine Associate Professor Seattle, Washington Department of Surgery The Johns Hopkins School of Medicine Alice M. Laneader, MBe Baltimore, Maryland Senior Regulatory Advisor Office of Human Research Margot B. Stein, PhD University of Pennsylvania School of Medicine Associate Clinical Professor Philadelphia, Pennsylvania Department of Dental Ecology Elie Levine, MD UNC School of Dentistry Fellow, Division of Plastic Surgery University of North Carolina at Chapel Hill Department of Plastic Surgery Chapel Hill, North Carolina Mount Sinai Medical Center Ronald P. Strauss, DMD, PhD New York, New York Dental Friends Distinguished Professor and Chair Leanne Magee, BA Department of Dental Ecology and Doctoral Student Department of Social Medicine Department of Psychology UNC School of Dentistry and UNC School of Medicine Temple University University of North Carolina at Chapel Hill Philadelphia, Pennsylvania Chapel Hill, North Carolina Robert Obrecht, PhD, LCDR/MSC/USN Marla E. Watson, MA Head Research Assistant Neuropsychological Assessment Division BodyAesthetic Plastic Surgery & Skincare Center Naval Medical Center St. Louis, Missouri San Diego, California Linton A. Whitaker, MD David R. Patterson, PhD Professor of Surgery (Plastic) Professor University of Pennsylvania School of Medicine Department of Rehabilitation Medicine Director, The Edwin and Fannie Gray Hall University of Washington School of Medicine Center for Human Appearance Seattle, Washington Philadelphia, Pennsylvania John A. Persing, MD Professor and Chief Paul Root Wolpe, PhD Plastic Surgery Senior Fellow Yale University School of Medicine Center for Bioethics New Haven, Connecticut University of Pennsylvania Philadelphia, Pennsylvania Thomas Pruzinsky, PhD Professor V. Leroy Young, MD Department of Psychology Chief of Surgical Services Quinnipiac University Barnes-Jewish West County Hospital Hamden, Connecticut St. Louis, Missouri Mary Rose, PsyD Assistant Professor Department of Medicine, Pulmonary and Critical Care Section Baylor College of Medicine Houston, Texas 75362_chFM.qxd 7/15/05 04:36 AM Page vii F O R E W O R D Milton Edgerton, Jr., MD Only a few training programs in plastic surgery devote sufficient effort to the education of their residents in the This book will be of great assistance to plastic surgeons basic psychological aspects of appearance and deformity. as they evaluate and treat their patients. It also will give This is unfortunate. As a result, many plastic surgeons have valuable help to nurses, psychologists, psychiatrists, and minimal understanding of some of the important issues other professionals who are involved in the care of plastic that are involved in the proper choice and timing of surgi- surgery patients. The editors and authors are long-standing cal procedures. Not surprisingly, unhappy patients and un- students of their subjects and many have pioneered expected reactions may follow apparently well-executed research in the psychological aspects of plastic surgery. surgical procedures. The surgeon may be surprised and Dr. David Sarwer has been a pioneer in uncovering many of the psychological aspects of cosmetic surgery. disappointed that the patient is unhappy with the operative Drs. Tom Cash and Tom Pruzinsky are national leaders in results. Alternatively, some plastic surgeons categorically the study of body image. Drs. Robert Goldwyn and John refuse to operate on any patient with evident emotional dis- Persing are wise and experienced surgeons who have turbance, simply because the surgeon is uncertain as to contributed much to this subject over many years. Dr. how that patient will respond to the operation. Goldwyn has advised all of us who are plastic surgeons to Fortunately, a number of plastic surgeons and mental get to know ourselves, our biases, and how we make deci- health professionals have begun to address these issues. sions. Dr. Persing has brought psychological issues to the Improved (and often multidisciplined) evaluation of attention of craniofacial surgeons. Dr. Linton Whitaker’s patients seeking plastic surgery has revealed some major Edwin and Fannie Gray Hall Center for Human Appear- surprises. For example, often the amount of anatomical ance houses a multidisciplinary group of professionals change is not correlated with the amount of psychological who have made extensive contributions to our under- impact seen postoperatively. Many individuals with tiny standing of the care of patients with appearance concerns. abnormalities may be psychologically crippled, while oth- The experience and productivity of the editorial team de- ers live with severe deformity and feel no need for plastic serves your attention. The last textbook on this important surgery. subject, written by Drs. John and Marcia Goin, was pub- The plastic surgeon is now learning that he or she lished 25 years ago. A great deal has been learned since should not let “experienced” aesthetic judgment trump then. the sometimes strange anatomical change that is specifi- Every human develops a body image early in life. Some cally requested by the patient. The surgeon must listen of that image comes from looking in mirrors; and some of carefully to the exact changes desired by each patient and it is shaped by the reactions of others to our physical resist the temptation to persuade the patient to let him or appearance. If one is pleased with this image, personal her add other changes for which the patient shows little relationships are approached with confidence and a more enthusiasm. satisfying life often follows. If congenital or posttraumatic Patients presenting with severe emotional distur- deformities occur, the body image may suffer and that in- bances require preoperative evaluation by a qualified dividual may find it hard to approach life’s challenges with mental health professional. That consultation will have strong self-confidence and in an uninhibited fashion. little value unless that professional has had clinical expe- Many such individuals turn to plastic surgeons for help. rience with preoperative and postoperative plastic Strengthening an individual’s self-image is often the surgery patients. To the surprise of many, we have principal purpose and benefit of plastic surgery. This is learned that a number of such disturbed patients may be true of both reconstructive and cosmetic surgery. Thus, it helped by surgery if the plastic surgeon proceeds care- is critical that plastic surgeons understand the psycholog- fully, and when indicated, combine surgery with pre- and ical variables involved in changing (or refusing to change) postoperative psychotherapeutic assistance. a patient’s appearance. In the case of cosmetic surgery, the The timing of surgery and the amount of physical only indication for surgery is the likelihood that it will im- change may be more effective if the plastic surgeon has a prove the emotional health of the patient. Any physical solid understanding of clinical psychology. In 1953, I was change should be aimed at that goal. fortunate enough to have Dr. Eugene “Bill” Meyer as a vii 75362_chFM.qxd 7/15/05 04:36 AM Page viii viii Foreword friend and collaborator in the study of “disturbed” plastic image. Could such a program be used in place of, or surgery patients. As head of the Division of Psychosomatic perhaps as a complement to, plastic surgery? Patients Medicine at the Johns Hopkins Hospital, he would see such often tell their plastic surgeons that they just want patients before and after surgery to help me assess the “to seem lovable” (to others)—perhaps this desire is just value (if any) of operating on each patient. He acknowl- another way of saying that they want a more satisfying edged that most psychiatrists had little or no experience body image. with plastic surgery patients, other than the occasional dis- Clinical observation has suggested the curious hypoth- astrous result referred to them after an unwise operation. esis that among patients coming to plastic surgeons, those His open mind allowed him to appreciate the power of with similar physical deformities often have similar types surgery as a method of improving emotional health. At the of psychological disturbances. Examples include patients same time, he taught me much about how to evaluate the with severe acne scarring, large port-wine facial angiomas, psychological strengths and weaknesses of my patients. women with micromastia, or men with nasal deformities. Later, Drs. Wayne Jacobson, Norman Knorr, and other Those within each group tend to show similar psychologi- psychiatrists joined the faculty. In recent years Drs. Tom cal profiles. How can we explain this? Does a given defor- mity lead to a particular emotional disturbance? Or does a Pruzinsky and Ina Langman have made great contribu- given emotional disturbance tend to cause an individual to tions to the program. Every plastic surgeon would profit focus on a particular anatomical feature? So much more from such a close relationship with an interested behav- needs to be learned. ioral scientist. The surgeon who has not developed such a This book will produce a heightened awareness of the working partnership with a clinical psychologist or psy- questions that plastic surgeons and behavioral scientists chiatrist will find him or herself ill-equipped to manage must ask of themselves and their patients. I would predict those patients with serious psychological disorders who that the specialties of psychiatry and psychology will turn seek relief through surgical changes. They should know to out an increasing number of individuals (like many of refer such patients to a plastic surgeon who is part of an those contributing to this book) who will be available to experienced, multidisciplinary team. collaborate with plastic surgeons. The resulting teams will We now know that “deformity,” when not associated come to better understand the sometimes magical trans- with functional limitations, is a disease (“dis-ease”) only formations that result from surgical alterations of the when it damages the individual’s confidence in his or her face, body, or limbs. Patients who seek plastic surgery will body image. The surgeon must change this body image profit from that knowledge. perception if he or she is to help the patient. To do so, he The editors set out to produce a “must have” book for or she may, at times, have to make anatomical changes plastic surgeons. They have done an outstanding job! that might not seem entirely reasonable to others. There are some who handle significant deformity without apparent loss in social effectiveness. Somehow, Milton T. Edgerton, MD they manage to maintain a positive image. How do they Emeritus Professor of Plastic Surgery do this? Dr. Cash has developed a program that teaches University of Virginia Health Sciences Center patients how they may develop a more positive body Charlottesville, VA 22901 75362_chFM.qxd 7/15/05 04:36 AM Page ix P R E F A C E 3. To give clear, concise, and clinically effective recom- mendations for plastic surgeons (and their staffs) to This book has one primary goal: to summarize what is better care for the psychological needs of patients. currently known about the psychological experience of re- 4. To provide a review of the critical ethical and profes- constructive and cosmetic surgery patients so that plastic sional issues that plastic surgeons encounter. surgeons can more effectively help patients reduce their emotional distress and attain the highest quality of life This book is organized into four major sections, which possible. follow a foreword by Dr. Milton Edgerton. Over the course Plastic surgeons recognize, at least on some level, that of his distinguished career, Dr. Edgerton wrote many of the ultimate purpose of their work is to address the the seminal articles on the psychological aspects of cos- psychological needs of their patients—to reduce emo- metic surgery. Directly and indirectly, he has influenced tional distress and enhance quality of life. The means by the interests of the editorial team as well as much of the which surgeons pursue this purpose is, of course, through research discussed in the individual chapters of this surgery. However, surgeons can expand their effectiveness volume. His foreword is a particularly meaningful contri- as physicians by complementing their surgical skills with bution to the book. a deeper understanding of the psychosocial functioning of their patients. This book places into the hands of plastic surgeons, and Section I: Understanding the Psychology of other medical and mental health professionals, a compre- Plastic Surgery hensive, yet practical summary of the scientific and clinical The book begins with an introductory chapter written by literature on the psychological aspects of plastic surgery. the editors. This chapter provides a historical and concep- The editorial team is comprised of three psychologists and tual context for building a bridge between plastic surgery three plastic surgeons with over 150 years of combined and psychology. The second chapter of this section, au- professional experience. Chapter authors were specifically thored by Goldwyn, provides the plastic surgeon’s per- chosen because of their long-term clinical experience and spective on addressing the psychological issues in caring extensive research contributions in their particular subspe- for plastic surgery patients. In the following chapter, Sar- cialties. This book distills the wisdom of many decades of wer and Magee review the role of physical appearance in experience with literally thousands of patients and research society (i.e., the “outside” view of physical appearance) participants into a readily accessible form. and explore the relationship between this body of research Detailed questionnaires related to the topics of study and the pursuit of plastic surgery. In the final chapter of appear at the end of many of the chapters. We encourage this section, Cash provides a detailed review of the litera- you (with the express permission of the publisher) to copy ture on body image (i.e., the “inside” view of physical ap- and distribute the questionnaires in the book to your pa- pearance) and its integral relationship to plastic surgery. tients and to use them as a starting point for discussing their perceptions of their appearance and related experi- ences as well as their response to surgery. We are con- Section II: Psychological Perspectives on vinced that such a dialogue can be very helpful to you, the Reconstructive Surgery members of the treatment team, and the patient’s loved This section of the book presents a comprehensive review of ones. psychological perspectives on reconstructive surgical pro- The book is constructed to achieve four objectives: cedures. The first chapter, by Kapp-Simon, reviews the clin- 1. To articulate the relationships among physical appear- ical and scientific literature specifically relevant to ance, body image, and psychosocial functioning essen- individuals with congenital craniofacial conditions. The fol- tial to understanding the experiences and motivations lowing four chapters, on pediatric burn injury (Rose and of individuals who seek out the care of plastic surgeons. Blakeney), adult burn injury (Fauerbach, Spence, and Pat- 2. To provide a comprehensive and critical review of the terson), facial disfigurement acquired through trauma or empirical literature evaluating the psychological func- cancer (Pruzinsky, Levine, Persing, Barth, and Obrecht), tioning of reconstructive and cosmetic surgical patients. and traumatic hand injury (Grunert) all address issues ix 75362_chFM.qxd 7/15/05 04:36 AM Page x x Preface specific to patients with acquired disfigurement. The last surgery patients as performed by both the plastic surgeon four chapters in this section, on orthognathic surgery and mental health professional. (Kiyak), breast reconstruction (Frierson and Andersen), breast reduction (Young and Watson), and genital recon- Section IV: Ethical and Professional Issues struction (Bockting and Fung), describe a broad range of in Plastic Surgery psychological concerns in patients who undergo plastic sur- gical and adjunctive treatments to address objective clinical The final section of the book begins with a chapter by problems. These chapters are written by professionals who Strauss, Stein, and Fenson on the bioethical issues in re- are recognized experts in these subspecialties, and, there- constructive craniofacial surgery. Laneader and Wolpe fore presents readers with the most comprehensive discus- provide a discussion of similar issues in cosmetic surgery. sion of the relevant psychosocial issues possible. In the final chapter of the book, Gorney shares with the reader the plastic surgeon’s perspective on professional and legal issues in cosmetic surgery. Section III: Psychological Perspectives on The editors strongly believe that the clinical and scien- Cosmetic Surgery tific knowledge presented in this unique volume can lead The first two chapters of this section review the literature to a higher standard of care for both reconstructive and on the psychological aspects of cosmetic surgery of the cosmetic surgery patients. Our hope is that it will result in face (Crerand, Cash, and Whitaker) and body (Sarwer, Di- the greatest possible reductions of distress and attainment die, and Gibbons). The final chapter of this section by Sar- of the most satisfying quality of life possible for each wer discusses the psychological assessment of cosmetic patient.
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