The Psychiatric Assessment of Ca

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					Vol. 68, No.5                                                                                           411

     The Psychiatric Assessment of Candidates for Cosmetic Surgery*
                                            ROLAND S. JEFFERSON, M.D.,
                                               Los Angeles, California

W E live in a society whose emphasis                         photographers' models, movie stars and tele-
      is on achievement, materialism, youth                  vision advertisements all condition the view-
and beauty, with the latter two King and                     er to the standard of beauty of the society.
Queen, respectively. Clothing manufacturers                  The so-called Mod look of the seventies has
must constantly change styles with the erratic               its accent on maintaining a desirable, if not
public tastes as it strives to reach a point                 enviable, appearance.
where appearance is somehow equated with
success, and success with youth. Cosmetic                                   BACKGROUND
manufacturers reap fortunes because of an                       But if the clothing and cosmetic manufac-
almost fanatical, if not desperate desire on                 turing firms have a stake in the value of
the part of citizens to retain an image that                 physical appearance, it is equally shared by
becomes them. With age becoming a factor                     the medical profession, more specifically
of considerable social significance, it will, in             the otorhinolaryngologists, maxillofacial
many cases, determine job eligibility, insur-                surgeons, plastic surgeons and dermatologic-
ance premiums, socialization, peer group or-                 al surgeons. The preoccupation of the society
ganization and, depending upon the type of                   with physical appearance has, in large part,
illness, determine the prognosis.                            been due to the ability of the cosmetic
   Man's obsession with youth and eternal                    surgeon to change, modify, conceal, add,
life can be traced back for centuries with lore              enhance or detract to or from the existing
of the Fountain of Youth and it's magical,                   physical apparatus of the individual. The
almost mystical essence having the ability to                development and refinement of surgical tech-
transform the aging process into one of per-                 niques and procedures has made available to
petual longevity. So deep is the value system                the individual virtually any change he or she
of youth and appearance, so entrenched in                    is willing to undergo provided there is an
our psyches, the fantasy that youth means                    understanding and a willingness to accept the
viability and so fearful are we of the aging                 risks along with expected results. With nose
process, that we employ the mechanism of                     jobs, hair transplants, breast augmentation,
denial to deal with the anxiety that growing                 face lifts, otoplasty's and silicone therapy
old causes. So obsessed are we that mainte-                  among the myriad of available procedures,
nance of the human body has become a na-                     the prospective candidate can literally
tional industry. Clubs and residential facili-               'change his entire image'.
ties for so-called 'Singles'; the Saunas, gyms                  The more cosmetic surgical procedures
and physical fitness programs all stress the                 done, the more widespread public acceptance
fantasy that if you take care of your body,                  is likely to take place. With this acceptance,
you will live longer. That may be true but                   the more astute the cosmetic surgeon must
the unconscious message is on youth. Motion                  become to differentiate between the neces-
pictures, magazines and books all deal with                  sary or appropriate operation from the contra-
the lives of the 'Beautiful People' of the                   indicated and ill-advised one. Because ap-
society with the emphasis on their gorgeous                  pearance is so laminated to psychological co-
and youthful appearances. Beauty pageants,                   hesion, it becomes all the more critical for
                                                             the cosmetic surgeon to assess his patient not
*Read at the Section on Dermatology at the 81st Annual
Convention of the National Medical Association, Nashville,   only for psychological soundness, but within
Tennessee., August 8-12, 1976                                the framework of the culture from which he
412      JOURNAAL OF THE NATIONAL MEDICAL ASSOCIATION                                SEPTEMBER 1976

comes and the society in which he lives.             her neck. She had been referred to the der-
Certainly it is not expected for the surgeon to      matologist by her family practitioner who felt
perform a detailed psychiatric examination or        the keloid unsightly. The dermatologist
an in depth socio-cultural history, but there       agreed and recommended removal to which
are some basic premises which, when                 the patient refused. Irritated by her decision
examined by the surgeon, will indicate the          she was referred to me. During the evalua-
advisability of immediate surgical procedures       tion it became apparent that the dermatologist
or the consideration of referral to other pro-      and family practitioner were far more con-
fessional sources for additional mental health      flicted about the presence of the keloid than
evaluation. It is these parameters with which       the patient. She had made a more than satis-
this paper concerns itself, the details of          factory adjustment to its presence, over the
which though not complicated if followed,           40 years of her life. It had not interfered in
will considerably subdue the anxiety caused         her social life or employment and indeed,
by ambivalence on the suitability of a patient      was not as unsightly to this examiner as it
for surgery.                                        was to the physicians responsible for her
                                                    care. She had no desire to undergo the proce-
                                                    dure which, had it occurred may have set in
                                                    motion the forces that would have created
   It is difficult to catagorize what constitutes   more problems than those it attempted to
an emotionally healthy patient from an un-          solve. Thus the cosmetic surgeon must make
healthy one, but there are clues that will help     certain his own value system does not con-
the surgeon make that determination. The            flict with that of the patient.
first clue to present itself is the reason the         If the patient comes because of a gross
patient seeks out the services of the cosmetic      deformity and a legitimate reaction to that
surgeon. If the patient came because of refer-      deformity is shared by the surgeon, in the
ral by another physician who was not of that        absence of a psychiatric history or any
specialty, he or she has established immedi-        psycho-social pathology, this patient must be
ate credibility provided the reason stated by       considered an excellent candidate for the pro-
the patient is substantiated by the referring       cedure. The patient's response to the options,
physician. The dermatological surgeon can           expectations and risks once explained, must
pick up the manipulative patient quite easily       indicate good reality testing and should con-
by cross checking with his colleague. If the        vince the surgeon that full and complete
reason stated is inconsistant, the patient          comprehension has been obtained. Any flaw
should be confronted if the surgeon feels           in the patient's response, outside of compre-
comfortable enough to do so. If not, he can         hension, should be a warning that further
simply say that his policy is to see that all       evaluation or delay is indicated.
patients receive the most comprehensive                The patient who presents himself for cos-
evaluations and in this case the referral to a      metic change is another matter. Unlike the
colleague in mental health is indicated.            patient who seeks correction of a disfigure-
   What are considered healthy reasons for          ment, this category of patient requires an
seeking the services of cosmetic surgeons?          even more in depth assessment of his motiva-
Certainly the most justifiable is the patient       tion because his request is predicated on self
with an obvious cosmetic disfigurement,             image which is not cosmetically visible to the
either due to birth defects or trauma. It is        public. If he wants a nose job, a dimple or an
important to assess whether or not this ob-         equivalent procedure the surgeon must equate
vious deformity is in fact grossly disfiguring      his rationale with his history. If the patient is
according to the values of the society and          in the entertainment field or some other occu-
thus to the patient or, is it disfiguring to the    pation where an attractive or pleasing appear-
surgeon. I am reminded of a patient referred        ance is essential and is the motivation for the
by a dermatologist for psychiatric evaluation       surgery, the prognosis is good if there is
because she refused treatment of a keloid on        nothing in the history or in the patient's be-
Vol. 68, No. 5               Psychiatric Assessment of Cosmetic Surgery Candidates                     413

havior to indicate psychopathology. Un-                   blacks are considerable. As Cobbs and Grier
doubtedly this is one of the most frequent                so aptly pointed out in their book 'Black
reasons given for wanting cosmetic changes                 Rage', the acceptable standard of beauty and
but the surgeon should not eliminate from his             appearance in this country and the world over
thinking the fact that persons in public and              is the individual with caucasian features and
entertainment occupations experience the                  'straight' hair. Thus, when whites seek the
same incidence of emotional instability as the            services of a cosmetic surgeon, for reasons
general population. I recall one such patient             other than deformity or trauma correction,
a prominent and well-known movie star who                 they are requesting cosmetic changes that
was brought to my office by her family when               will serve to enhance an image already estab-
it was announced that she intended to go                  lished as the acceptable and appropriate one.
through with her decision to have a nose job                 Just the opposite is true with the black
and breast augmentation. The actress, a strik-            community. From a cultural standpoint the
ingly attractive woman in appearance, was in              black experience is a paradox. In Africa it is
reality borderline in her ego functioning.                the custom to mutilate by distortion, excoria-
From a chauvinistic point of view it was                  tion or perforation, certain parts of the body
obvious that the procedures would offer no                not only for tribal identification but also be-
additional enhancement to her already well                cause it is considered a positive aspect of
endowed stature and stunning face. In fact                beauty and image. However, in this country,
her request was inappropriate in light of the             racism has been so effective in conditioning
reality. Consultation with the dermatologist              the black community into accepting the fact
who had agreed to perform the procedures                  that the only acceptable image is a white one
revealed that, as does so often happen with               or as close to it as is possible as representing
prominent political and entertainment person-             the standard of beauty. Thus blacks have as
alities, he had become so overwhelmed at                  an image of themselves, one that is muti-
having such a prominent patient, he had al-               lated, grotesque and gargoyle-like in appear-
lowed himself to be psychologically seduced               ance. With this psychic image in operation,
into accepting her own reasons as valid. Sub-             many requests for cosmetic changes by
sequent therapy helped her with reality test-             blacks are, in reality regardless of manifest
ing and she rescinded her request as her func-            reasons given, attempts to remove and or
tioning improved.                                         change the mutilated self image. Nasal tip
                                                          plasty, hump deformity correction, supratip
                 RACIAL ASPECTS
                                                          depression correction and cheiloplasty for the
                                                          reduction of pendulous lip formation, repre-
   At this point I think it appropriate to bring          sent the more common procedures that give
up the issue of race and point out the signifi-           us a clue to the rejection of the black self
cant differences in the psyche that cosmetic              image.
surgeons should understand. Cosmetic                         The cosmetic surgeon should be aware that
surgery has always been considered the pro-               since blacks tend to reject their blackness and
cedure of the idle rich, white dominant socie-            black skin, those patients with legitimate skin
ty with the statement that keloid formation               disorders reject their diseased black skin even
prevents any cosmetic procedures on black                 more. Because blacks still have a problem
individuals. The former statement is certainly            with identity in-so-far as their appearance
true. I cannot attest to the validity of the              and color, it should not be considered a contra-
latter statement except to say that the over-             indication to cosmetic surgery, but rather
whelming majority of the black patients seen              tells us how deep the conflicts lie. Because
by this examiner prior to cosmetic procedures             social awareness has helped the black com-
are requesting procedures other than keloid               munity overcome some of the conditioned
removal.                                                  negative attributes attached to being black,
   Be that as it may, the differences between             pathology and conflict can still exist and
the self image and self concept of whites and             must be considered a contraindication for
414                      JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION               SEPTEMBER 1976

surgical procedures. Case in point to illu-       the patient revealed his fantasy that facial
strate this is the fair skinned black female      moles made him appear more black than he
patient examined by me at the request of a        really was. If the mole could be removed he
dermatologist who astutely recognized that        would no longer have to see himself as
her request warranted further mental health       black. Needless to say, whether or not the
evaluation. She came from a family which          mole could be surgically removed, this pa-
prized her almost caucasian features and          tient was certainly not a candidate for it. The
straight hair. Having pursued Broadway and        fantasies and omnipotence with which pa-
several other minor theatrical careers, she       tients endow the cosmetic surgeon should not
was trying for roles in motion pictures about     be internalized to the point that good judge-
the time that black consciousness and black       ment overrides realistic expectations, espe-
awareness enlightened the black community.        cially with black patients and those seeking
As a result, she was repeatedly refused major     to remove racial traits as a way of resolving
roles in 'Black films' because the producers      deep-seated psychic conflicts.
did not consider her an 'identifiable' black
person. Subsequently she sought the services
of a dermatologist requesting that her nose be
broadened and flattened, her lips be protrud-                  ASPECTS OF AGEING
ing and insisted that pigmentation medication        Patients who request cosmetic procedure
normally given for vitiliganeous patients be      to delay the ageing process are considered
used to darken her skin. She was willing to       good risks, assuming that no history or back-
undergo and had convinced a cousin to agree       ground information related to emotional in-
to, a hair transplant from the cousin who had     stability is revealed. Hair transplantation for
kinky hair.                                       reasons of youth and appearance are legiti-
   Obviously had the dermatologist not            mate requests and have relatively little risks
recognized the inappropriateness of her re-       in the absence a psychiatric history. There
quest, a psychiatric catastrophy would have       are, however, subtle clues that the cosmetic
occurred. Subsequent psychiatric treatment        surgeon should be aware of with this pro-
helped the patient come to grips with and         cedure that are cause for further evaluation.
work through her deep-seated conflicts and        The patient who suggests that a more youth-
guilt about her color and identity. Again, the    ful appearance via transplantation will cure
issue with black patients is identity and         his impotency and improve his relationship
image based on the dominant value system of       with women, should be evaluated psychi-
white society. The dermatologist should           atrically before the procedures are done.
assess how important the changes are to the       More than likely this motive is the tip of the
black patient and whether or not the motives      iceberg that connects to a host of other psycho-
are occupational or racial in nature. As with     logical conflicts that, after the procedure fails
many whites who seek rhinoplasty to make          to produce the desired change in sexual per-
their appearance more pleasing, the under-        formance, will begin to emerge. I cannot
lying motive in reality is the removal of an      stress enough the need for the cosmetic
identifying racial trait. The most skilled der-   surgeon to confront the patient about his fan-
matological surgeon does not have the ability     tasies and expectation. Exactly what does the
to change a patient from black to white, yet      patient want to happen? In what way will he
many patients have this fantasy, thinking that    be disappointed if the procedure does not
if they can eliminate their physical character-   turn out as expected? Whose idea was it for
istics they can eliminate their blackness. I am   the procedure?
reminded of the case of a young man who              One of the poorest reasons for wanting a
had gone to the dermatologist for the removal     face life, breast augmentation or rhinoplasty
of a mole off of his face. Because of his         is to save a marriage or to help with inter-
insistance the dermatologist referred the pa-     personal relationships. Patients who fantasize
tient for psychiatric evaluation. As a result     that a different appearance is all thats needed
Vol. 68, No. 5                 Psychiatric Assessment of Cosmetic Surgery Candidates                       415

to cure a sick marriage or to increase their                their poor judgement. Usually they are look-
marketability in the heterosexual relation-                 ing for someone to tell them that the proce-
ships they have, are making serious conflicts               dures are unnecessary since in their own
about self esteem and self image and should                 minds they know the procedures are unneces-
be referred to a psychiatrist for evaluation                sary but are unable to bring themselves to the
before such procedures are attempted.                       point of decision making. This kind of pa-
Failure to do so may result in blame being                  tient needs someone else to make the deci-
placed on the surgeon when the realization                  sion for him. Usually they are never satisfied
that the marriage was doomed or that boy-                   and may persue that disatisfaction through
friends are no closer than before surgery,                  the courts. If they do, the process is repeated
begin to emerge.                                            by their shopping lawyers, etc. Even if the
                                                            surgeon feels that this category of patient
                 PATIENT CATEGORIES                         may have legitimate surgical needs, he is
                                                            best advised to delay any decision to operate
   The impulsive, immature patient may                      until he is comfortable with knowing what
present himself spontaneously with no partic-               the patient really wants and what he can
ular referral source stating that he or she                 tolerate. More than any other category, this
wants this or that procedure because they                   patient can become a headache and irritate
heard about it and figured it just might work               the surgeon to the point that he will refuse to
for whatever problems they have. Further                    continue treatment, which is usually the pa-
investigation by the surgeon will reveal the                tient's wish in the first place.
patient to have a background that is rife with                 Certainly most cosmetic surgeons are al-
indecisiveness, erratic and inconsistancies.                ready aware of the dangers and problems of
Failure to follow through on ideas or projects              the patient who requests repeated surgery be-
is usually characteristic of this type of patient           cause of dissatisfaction with a former
and while they resist psychiatric intervention              surgeon. These individuals are apt to be liti-
it is wise to delay any surgical procedure to               genous and are seldom satisfied, their per-
see how committed the patient is.                           sonalities reflecting serious emotional con-
   This category of patient should not be con-              flicts with image and identity. Emotionally,
fused with patients who spend time securing                 this behavior represents the many unmet
information before making a decision and in                 needs of the individual and is manifested by
turn must be differentiated from the patient                demands that are, for all practical purposes,
who goes from doctor to doctor to doctor                    insatiable. The surgeon would never be able
without ever committing himself. In the first               to do enough to satisfy this patient, regard-
category, there are many people genuinely                   less of skill or credentials.
interested in cosmetic procedures but their
personalities are such that they require time                       DETERMINE PSYCHIATRIC HISTORY
and information before making a decision.
Certainly this is indicative of good judge-                     I have repeatedly mentioned throughout
ment and usually by the time they are ready                  this paper the facts that one consistant criteria
to make a decision they are sufficiently well                must be met before the cosmetic surgeon
versed in the subject and have considered all                undertakes the specific procedures, that of
options and risks. Barring any serious psy-                  determining a psychiatric history. Patients
chiatric history, they are good surgical risks.              who reveal psychiatric histories are not
   In the second category of patient, the                    necessarily poor surgical risks, but they do
surgeon must be cautious with individuals                    warrant a more critical evaluation before any
who indicate that they have information from                 surgery is attempted. By and large most non-
another surgeon whose technique is different                 psychiatrically trained physicians are uncom-
or who charges a different price. These indi-                fortable with the need to suggest or recom-
viduals shop physicians out of the uncon-                    mend psychiatric consultation for their pa-
scious need to reinforce and set limits on                   tients. This usually stems from the fact that
416                      JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION              SEPTEMBER 1976

the physician is fearful of offending his pa-     present himself initially inquiring about cer-
tient because of the fantasy that a mental        tain procedures and their effects. Ultimately
health evaluation implies insanity.               the patient will reveal his delusions and
   To help the dermatological surgeon deal        suspiciousness, often times too late. I am
with his own discomfort and that of his pa-       reminded of a patient who sought the
tient, who may not mention anything about a       services of a cosmetic surgeon for the correc-
previous psychiatric experience unless asked      tion of a minor ear deformity. On question-
directly, it is always best to approach the       ing the patient simply stated that his hearing
patient in the least threatening manner. The      was poor on that side. The surgeon, taking
simplest way to get a clue to a previous          the reason as valid in light of a demonstrable
psychiatric experience is by making a             but not functionally impaired deformity,
ubiquity statement out of your question, for      agreed to undertake the surgery. Several pre-
example: 'Many people have trouble with           operative appointments were cancelled by the
their nerves and have to take medication, has     surgeon because of illness and academic pre-
your doctor prescribed any nerve pills for        sentations. At the final preoperative meeting,
you?' This question will usually reveal           the patient was irritated and complained to
whether or not such medication has been pre-      the surgeon that he did not consider his case
scribed, when and by whom. If the patient's       important enough to warrant closer attention.
answer is yes, the surgeon should feel free to    On the day of the scheduled surgery the pa-
ask whether or not the patient has ever been      tient became openly hostile and belligerent,
in a hospital for their 'Nerves'. This question   accusing the surgeon of being an agent of the
usually reveals whether or not the patient has    F.B.I. The surgeon, panicked and attempted
been admitted to a psychiatric facility for a     to forcibly remove the patient from the office
'Nervous breakdown' and will usually serve        at which time the patient pulled a gun and
as a lead in about their outpatient psychiatric   fatally wounded the physician. This is an
treatment. From this, the cosmetic surgeon        example of how dangerous a patient with
should have no hesitancy about recommend-         paranoid delusions can be if the surgeon gets
ing further evaluation. If the patient has a      incorporated into the delusional system.
psychiatric history he will more than likely         In dealing with the paranoid individual it is
appreciate the suggestion. Those patients         important to remember that reality testing is
who become offended at the suggestion may         distorted. Initial conversation should reveal
be masking underlying pathology and by vir-       the depths of the pathology at which time the
tue of their loud protest, have revealed clues    surgeon can suggest that while he does not
that warrant further investigation.               quite understand the nature of his feelings,
   Cosmetic surgical procedures on a patient      there are colleagues who do. A referral at
demonstrating blatant psychosis is contra-        that time will avoid subsequent difficulties.
indicated unless a matter of life and death          Blatant psychopathology will not present
and if so, should be performed in a hospital      itself as frequently to the cosmetic surgeon as
setting with the appropriate psychiatric per-     will personality disorders. This category of
sonnel in attendance. On those patients with      patient will comprise the bulk of candidates
a history of psychosis but in remission at the    with which the surgeon must decide on the
time of evaluation, it should be considered a     advisability of operating. Personality dis-
good possibility that the stress of surgery is    orders are fixed patterns of behavior with
likely to cause an exacerbation of the illness.   predictable actions to given situations. In and
                                                  of themselves, this category is not a contra-
                                                  indication to surgery, but the surgeon should
                                                  be familiar with the types and request psy-
   Of all the psychosis, the most frequent that   chiatric consultation if he is ambivalent.
may be seen in the cosmetic surgeon's office         Passive-aggressive individuals tend to be
is the paranoid schizophrenic. Depending on       cynical and subtlely hostile. Their anger at
the severity of the symptoms he or she may        low key, they radiate a general dissatisfaction
Vol. 68, No. 5              Psychiatric Assessment ofCosmetic Suargery Candidates                       417

with the world and their environment. Any                 relationships. With no demonstrable clinical
cooperation requested by the surgeon is like-             symptomology on presentation, it may be de-
ly to be taken as a joke and if carried out by            tectable by history only. Many times the pa-
the patient, will be done on his own terms.               tient will appear with wife or husband for
He may show up for his scheduled procedure                support, incorporating them into the proce-
several hours late, complain about the results            dure as if it were going to happen to the two
if not what expected and is not liable to                 of them.
return for follow up visits following surgery,               The emotionally unstable personality is an
regardless of the results.                                extremely poor candidate for cosmetic
   Paranoid personality is the analaga to para-           surgical procedures. This category of patient
noid schizophrenia. With suspiciousness and               is the most likely to decompensate under the
general dissatisfaction, this category of pa-             stress of surgery and needs thorough psychi-
tient does not manifest the acute symptomo-               atric evaluation before any decision is made.
tology characterized by the schizophrenic,                Again, as with the passive-dependant person-
but is generally mistrustful of others and has            ality, the diagnosis is by history but usually
a tendency to blame others for his circum-                reveals a series of emotional outbursts in
stances. The likelihood of this patient                   response to sudden or unexpected environ-
involving the surgeon in litigation is high. It           mental or personal changes in his life situa-
should also be kept in the back of the                    tion. Suicide gestures, alcoholism and drugs
surgeon's mind that there is the chance that a            may be coping mechanisms developed to
full blown schizophrenic episode may evolve               deal with these intermittant crisis. Once
from the surgery, no matter how minor.                    stable again, his behavior may appear
   The schizoid personality will appear as if             normal.
he or she is fragile. Shy, hesitant and quiet,               The hysterical personality, a type more
there will be a reluctance to discuss the                 commonly associated with females must be
reason for coming to the cosmetic surgeon.                considered every man's dream and the psy-
Questions about the anticipated procedure                 chiatrist's nightmare. Manipulative,
and it's effects may be inappropriate and re-             dramatic, flightly and seductive, the hysteric
veal the borderline ego structure of the schiz-           has mastered the use of emotions as a con-
oid patient. Rationale motivation and desire              trolling device. Rapid changes in feeling tone
may appear so diffuse and bizzare that the                on a moments notice can occur as well as
surgeon knows little more when the patient                sudden outbursts of anger and tearful rages.
leaves the office than when he first came. As             Extremely self centered and narcissistic, the
with the paranoid personality the cosmetic                hysteric will exhibit the classical 'La Belle
surgeon should consider the possibility of his            Indifference' as though the surgical proce-
surgery throwing the patient into an acute                dure has no real significance, much like the
schizophrenic exacerbation.                               superficial relationships they usually culti-
   The obsessive-compulsive personality will              vate. The cosmetic surgeon is often times
present before the cosmetic surgeon with a                quite vulnerable to this category of patient
myriad of questions, suggestions, repetitions             because the seductiveness and banter be-
and obsessive ruminations about the expected              tween them tends to inflate the surgeon's ego
results. A perfectionist par excellence, the              and pyramids his own omnipotent surgical
likelihood of ever being satisfied is nil. This           fantasies. Placing themselves in the role of a
category of patient will take a long time to              child, they relate to the surgeon as if he is the
make a decision about surgery, if at all. If              parent thereby expecting themselves to be
not satisfied with the results, the patient may           'taken care of' for whatever procedure is
be litiginous or go from surgeon to surgeon               planned. If the cosmetic surgeon elects to
looking for more perfection.                              undertake the procedure he will get all the
   The passive-dependant personality may be               cooperation he needs but should plan on
a reasonably good candidate for surgery pro-              spending twice as much time with the patient
vided they are stable in their interpersonal              before and after surgery in a supportative
418                     JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION              SEPTEMBER 1976

role. While they are considered good risk         him to pay her income taxes, he balked. This
patients, the cosmetic surgeon must weigh         brought a plethora of tear filled and
the emotional drain placed upon him by this       whimpering pleading phone calls to his office
category of patient versus his desire to oper-    until he finally realized his predicament. In
ate.                                              reality of course, one could say that the pa-
   A case in point that illustrates such          tient was really the dermatologist, and after
behavior was referred to this examiner as an      several consultations with him following the
emergency by a dermatologist. While it is         evaluation of the patient, it became clear to
certainly more reflective of the referring        him what he had allowed to happen.
physicians' vulnerability it does, however,          Patients with chronic neuroses are
demonstrate quite clearly how easily the un-      commonplace and will present themselves to
suspecting cosmetic surgeon can be caught         the cosmetic surgeon in frequency much the
up in the hysterical process.                     same as the personality disorders. While the
   The patient, an attractive 22 year old         spectrum is too broad and intricate to
single female was referred by a dermatologist     examine in detail, there are some patients
because he considered her a 'nuisance' pa-        who may be representative of this group that
tient whose numerous demands on his time          bear discussion. The depressive neurosis
were beginning to interrupt the flow of his       occurs in both acute and chronic form. The
practice. Psychiatric evaluation produced an      former is unlikely to present himself before
interesting history, most of which was veri-      the surgeon but the chronically depressed in-
fied by the referring physician. She had          dividual is frequently seeking a change in his
sought his services on the recommendation of      or her feeling tone through changes in ap-
another of his patients, for a rhinoplasty and    pearance. The rationale is usually quite ob-
dimple cleft. Her initial approach to his was     vious from the very beginning because the
one of extreme flattery at the reputation he      patient's sole concern is with the way the
enjoyed. Her need for reassurance was so          surgery will make him feel rather than any
great and her role playing so convincing that     change in his external appearance. Although
her family welcomed his presence at dinner        much ambivalence exists with this condition,
on numerous occasions prior to the surgery.       seldom does the depressed patient go through
Following the rhinoplasty the patient was so      with the procedures. When they do, it is not
ecstatic with the results that she brought        unusual for the patient to remain depressed,
seven attractive women to his office just to      even attempt suicide when the reality that
meet him. Although none of them needed            there is no change in the way they feel,
cosmetic procedures, they too, flattered him      becomes apparent.
about his competence. On a follow up visit,          Anxiety neurosis is another frequent diag-
the patient asked about her bill but was told     nostic category that presents itself before the
to "forget about it!" by the surgeon who          cosmetic surgeon seeking procedures that in
stated that he was glad that he could be of       someway will alleviate the pain of their neu-
service. Subsequently he performed the            rosis. If symptoms such as tremors, shaking
dimple cleft free of charge, agreed to per-       and agitation with halting speech are not clin-
form a blepharoplasty on her mother free of       ically present, the patient's history will
charge and was convinced to undertake a           demonstrate many somatic complaints; cardi-
breast augmentation on another friend of the      ac palpitations, hypochondriasis, hyperventi-
patient, also free of charge.                     lation and multiple organ pain such as
   She had virtual control over him eventual-     cephalgia, back pain, chest pain and
ly having so many 'freebee's' call his office     abdominal pain of unknown etiology. The
that he began to think that he was the greatest   emphasis is usually on wanting to feel better
 surgeon on the face of the earth. Pressure       rather than looking better and thinks that cos-
from his staff to collect his outstanding bills   metic surgical procedures, especially der-
was met with resistance but when the patient,     matological ones, will cure them. Surgical
over dinner one evening, attempted to get         procedures on this category of patient will
Vol. 68, No. 5                         Psychiatric Assessment of Cosmetic Surgery Candidates                                       419

usually create more problems than are                                 segment of the population whose emotional
solved, leaving the patient just as anxious                           instability or fragmentation makes it inadvis-
and emotionally crippled as before the oper-                          able to render the services requested. While
ation. Often times the focus of neurotic and                          not all persons with emotional or psychiatric
hypochondriacal complaints migrates to some                           histories are contraindications to cosmetic
other system in the body following surgery                            procedures, the incidence of subsequent
and sets itself up in some other target organ.                        mental health complications following such
While presenting no great problem to the                              procedures dictates a cautious approach. The
dermatological surgeon, he should be pre-                             cosmetic surgeon would be well advised to
pared to receive this patient back in his office                      seek the guidance and consultation of his
with additional complaints that the first oper-                       psychiatric colleague on those patients whom
ation didn't cure.                                                    he feels may not be suitable for such proce-
                                                                      dures. The discomfort and apprehension felt
                        SUMMARY                                       by the suggestion and recommendation that
                                                                      patients seek additional evaluation prior to
  In summation, cosmetic surgery is wide                              surgery, will far outweigh what may ulti-
spread in the society and has gained con-                             mately be more serious complications if the
siderable acceptance in connection with the                           surgeon elects not to do so. Mental health
value system of youth and beauty. Cosmetic                            evaluation should be seen as an adjunctive
surgeons are perhaps more vulnerable than                             tool to help the cosmetic surgeon with his
any other surgical specialty to criticism or                          decision to operate or not on a patient that
acclaim because their work is highly visible.                         may or may not be a suitable candidate for
But they are also highly vulnerable to that                           his services.

   A study of health in urban poverty and nonpoverty areas shows that, regardless where they live, racial minorities generally suffer
poorer health than do whites, the National Center for Health Statistics has announced.
   The findings come from a report on "Selected Vital and Health Statistics in Poverty and Nonpoverty Areas of 19 Large Cities,
1969-71," just published by the Center.
   For the years covered, the report shows that racial minorities in poverty areas have a higher infant mortality rate than whites (33.4
deaths per 1,000, compared with 24.2), a greater percentage of illegitimate births, greater lack of prenatal care and higher death
rates from tuberculosis and violent causes. In nonpoverty areas also, the same figures are higher for minorities than for whites.
   In general, persons living in urban poverty areas were subject to death rates 50 to 100 percent higher than persons in nonpoverty
areas, the Center reported. White infant mortality rates were 39 percent higher in poverty areas than in nonpoverty areas, while other
races in poverty areas had an infant mortality rate 24 percent higher than in nonpoverty areas.
   "The results of the study are not unexpected but nevertheless dramatic," Mrs. Dorothy Rice, Center Director, said. "Living in a
poverty area is shown to increase the odds against enjoying good health, and being in a racial minority worsens the odds."
   Area of residence seems to have a stronger impact than race on births to mothers with little schooling, the death rate for
tuberculosis, and the death rate from violent causes, Mrs. Rice said.
   The methodology used in the study is uncommon, she said, and analyzes differentials in various statistics associated with poverty
and nonpoverty areas. Since there is a close relationship between race and residence in poverty or nonpoverty areas, race and ethnic
group information is used as a control variable in the study.
   The 1969-71 years were selected for the study so that published 1970 census population data could be used. Poverty areas are
identified according to a Bureau of the Census definition.
   The 19 cities studied were Atlanta, Baltimore, Buffalo, Chicago, Cincinnati, Cleveland, Dallas, Denver, Indianapolis, Los
Angeles, Memphis, Minneapolis, New York, Philadelphia, Pittsburgh, San Diego, San Francisco, Seattle, and Washington, D.C.
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