INTRODUCTION

Technology has enabled people to seek facial rejuvenation and other cosmetic procedures. It has also helped to establish firmly the parameters of what it is they are seeking. It has created the illusion that they can become part of the ‘focused, happy and beautiful’ group that Gladwell writes of. Fortunately, or unfortunately, what they end up discovering, if they are conscious enough to notice, is that there is no group. There are other people whom the seeker perceives as being members of the group, but the quality of being safe and belonging is elusive. These qualities exist and develop only as people establish real relationships with themselves. We exist as individuals, and it is by developing what is special and unique within ourselves that we become whole and contributing members of society.

We happen to exist at a time when technology has both enabled us to alter our appearance and caused us to be connected in a much more immediate way than we have ever been connected before. Ironically, this has taken from us many of the tools we used to achieve intimacy. Television has replaced conversation. Email has replaced letter writing. Instant messages have replaced telephone conversations, and, in many instances, cell phone conversations have replaced time that was formerly used to gather our thoughts and to connect with ourselves. The internet has, arguably, removed the need to actually interact directly with other human beings. At the same time that we have gained the freedom to alter our appearance, to become ‘who we want to be,’ we have been isolated from having real contact with ourselves and with others. We are being inundated with images of those whose lives are lived in the glow of the public eye and those who will stop at nothing to get there. There are reality shows that document a reality that does not exist, there are talent shows featuring people without talent and there are makeover shows that highlight the degrees to which people will go to feel like they fit in without connecting to themselves. This has a numbing effect. The message is that, in order to be happy, we should abandon what causes us to be unique, thoughtful, creative and compassionate, and do what we can to conform to current trends. We are more in each other’s faces but less in each other’s hearts. Many of those who choose another path are banished to an invisible sideline.

Obviously, there are still many people for whom appearance is not particularly important. There is no body of information yet available that compares people who seek out cosmetic intervention with those who do not. In the end, it may be that the majority of people who seek cosmetic procedures simply place a higher emphasis on improving or maintaining their appearance than those who do not. It is possible that neither group represents the majority of pathology present in the population as a whole. We will need to wait for sound scientific data before we can move forward with that discussion.

The discussion in this chapter has several parts: a discussion of the psychological and emotional context in which the profession is operating, a look at cosmetic procedures from the physicians’ perspective, a perspective on clients and some tools to help initiate some of the ideas presented. I want to begin by touching upon some of the major events that influenced how we have been thinking about and approaching the practice of cosmetic and minimally invasive plastic surgery.

A HISTORICAL PERSPECTIVE

Elizabeth Haiken did a particularly thorough job of discussing the history of the profession in her book Venus Envy: A History of Cosmetic Surgery . There were attempts made to address disfigurement as early as the 16th century, but the first concentrated effort to address cosmetic reconstruction was made in response to wounds suffered on the battlefields of World War I. The medical community was both able and highly motivated to develop new ways to treat the disfiguring wounds suffered by soldiers during World War I. Although many of these wounds were not physically life threatening, they were psychologically life altering. By the beginning of the 20th century, the work of Freud, Hall, Jung and those who followed them began to explore what it means to have an internal life – a meaningful relationship with the self – and we entered the age of psychological awareness. Against this background, medicine’s urge to ‘make whole’ seriously wounded World War I veterans takes on special meaning.

As society became aware of medicine’s ability to alter appearance, other potential clients emerged. As author Christine Rose wrote, ‘The greatest boon to modern cosmetic surgery was not the development of any particular technique or the creation of a miracle product. It was an import from psychology: the inferiority complex. Popularized by Viennese psychologist Alfred Adler in the early twentieth century, it reached an eager audience in the United States. The inferiority complex provided a crucial link: it joined individual mental health with physical appearance and thus “psychologized cosmetic surgery”. People suffering from an inferiority complex because their breasts were small or their chins droopy were ill; they required medical intervention to alleviate their psychological suffering. As Haiken notes, by the 1920s and 1930s, Americans had made this link between physical appearance and mental health permanent; as a result “their demands for surgical attention became more insistent at the same time as the new language of psychology made these demands more persuasive”. By 1940, Good Housekeeping magazine was asking, “why should anyone suffer under the handicap of a conspicuously ugly feature? Why not let modern science give him a normal face and an equal chance with other people?”’

Cosmetic procedures came to occupy an established niche in the medical field, and people seeking cosmetic intervention became patients. This secured the fit between cosmetic procedures and the standard medical model. As the field of psychology has matured, each generation of studies has shown there to be less pathology among those seeking cosmetic intervention than the early studies suggested.

According to Sarwer et al., early reports of the psychological characteristics of rhinoplasty patients date back to the 1940s and 1950s. Many of these reports, as well as studies conducted into the 1960s, relied heavily on clinical interviews and observations of patients that suggested rhinoplasty patients were highly psychopathological. One group of investigators went so far as to state that all patients desiring rhinoplasty were mentally ill and described their sample of patients as suffering from a variety of psychiatric issues, ranging from feelings of inferiority to psychosis. In another study, 53% of patients received preoperative diagnoses of personality disorders. More recent studies of patients who had rhytidectomies and blepharoplasties indicate that these patients are not as psychopathological as earlier studies suggested. In addition, results from body image studies indicate that patients seeking anti-aging procedures may place greater emphasis on their appearance and report less dissatisfaction with their overall body image than do patients who seek other procedures.

Sarwer et al. concluded that, given the popularity of other minimally invasive facial procedures, there is a need for studies of the psychological characteristics of patients who seek these treatments. I disagree. It is time for us to discard the pathology model, and for physicians who practice cosmetic and plastic surgery to understand the increasingly important role they have to play in helping their clients engage in self-care. This change in thinking can be seen elsewhere in the practice of western medicine. For example, the scientific community has begun to accept that meditation, acupuncture and other healing modalities contribute not just to healing but also to staying healthy. It is my belief that, in the coming years, our understanding of the connection between mind and body will change and play a different and increasingly important role in science and in the practice of medicine; the relationship between mind and body can be a source of health and well-being. People who feel good about themselves are often healthier than people who do not.

COSMETIC MEDICINE FROM THE PHYSICIAN’S PERSPECTIVE

Noting that the nature of medical education has not changed much in the last half century, Bloom writes, ‘Until today … this general form has persisted, producing an elite corps of highly trained specialists who are prepared to practice a science-based, technologically complex type of medicine’. It would at first appear that this group of physicians is perfectly suited to enter a field where the use of technology is rapidly changing and expanding the very nature of cosmetic medicine. However, technological expertise is but one set of skills needed to practice minimally invasive cosmetic medicine.

According to the American Society of Plastic Surgeons (ASPS), over 13.5 million plastic surgical procedures were performed in 2004. Most of them were minimally invasive cosmetic procedures, many of which did not exist in 1992 when ASPS started tracking procedures. As technology plays an increasingly important role in cosmetic practices, other professions have sought out and acquired the knowledge necessary to offer many of these procedures. The ASPS numbers are probably an underestimate because they do not account for the increasing number of non-plastic surgeon physicians, including cosmetic dermatologists, and trained aestheticians, who are also joining the pool of professionals offering minimally invasive cosmetic procedures. It would appear that the demand for these procedures is rapidly increasing, the kinds of procedures available are increasing and the number of practitioners is expanding.

Physicians practicing in the field of cosmetic surgery will be well served by acquiring interpersonal skills that are generally de-emphasized during their medical training. Sarwer et al. wrote, ‘Plastic surgeons typically have not been provided with adequate training in how to better understand the emotional and interpersonal aspects of patient functioning’. They go on to state, ‘to obtain such training and integrate these skills into their everyday practice adds to the already demanding burdens that all surgeons experience. However, compared to their investments in developing their surgical skills, the amount of time and effort needed to develop a deeper understanding of the psychological functioning of their patients is relatively small’.

I think that this last statement touches upon the very essence of what I hope to accomplish with this discussion. I believe that, as with those seeking to become surgeons, a certain amount of talent, and perhaps intuition, is needed to become an artful practitioner. Some people make gifted surgeons and others are gifted at helping people better understand themselves. Sometimes a person has both gifts and other times not. When surgeons find that they are not particularly skilled at client communication or assessment there is absolutely nothing wrong with reaching out and collaborating with someone who has been trained in those areas. It is important for surgeons to know and develop their strengths and to both acknowledge and respect their limitations.

Robert M. Goldwyn, writing in Psychological Aspects of Plastic and Cosmetic Surgery: Clinical, Empirical and Ethical Perspectives , offers the following list of ‘potentially problematic patients from a psychological perspective’:

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  the VIP patient

  
  
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  the patient who appeals to the surgeon’s ego

  
  
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  the perfectionist patient

  
  
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  the patient under psychiatric care

  
  
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  the patient thought to be in need of psychiatric care

  
  
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  the dishonest patient

  
  
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  the disheveled patient

  
  
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  the patient whose personality clashes with that of the surgeon.

I think the list suggests a problem associated with trying to standardize human behavior. Most of the judgments that need to be made when deciding whether or not a client is potentially problematic are subjective in nature. I personally feel that when a person is using a checklist to assess someone sitting across from them, they may be missing out on the best assessment tool they possess – themselves. The initial question for a surgeon to ask is: Am I comfortable moving forward with this person? If not, is there some conversation that can be had that would clarify whether client and surgeon could/should work together? Am I capable of having that conversation and, if not, can I collaborate with someone who is?

What are some of the things to look for and think about when trying to understand clients desiring cosmetic procedures? As Sarwer points out, ‘These procedures are no longer reserved for the wealthy and elite; women and men across age, racial and socioeconomic groups seek cosmetic surgery to improve their appearance and ultimately their body image’. In 2007, nearly 10 million minimally invasive procedures were performed in the USA, an increase of 81% from the number of procedures performed in 2000. According to the American Academy of Cosmetic Surgery, between 1982 and 1992 the number of people surveyed who said that they approved of cosmetic surgery increased by 50% and the number who disapproved declined by 66%. With this decline in disapproval, consumer demand for surgery has skyrocketed.