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J. ANDERSON                 THOMSON,                 JR.,     M.D.
NORMAN              J. KNORR,              M.D.
MILTON            T. EDGERTON,                    JR.,      M.D.

Cosmetic    surgery:
The psychiatric      perspective
ABSTRACT:      Increased                   use of cosmetic               surgery         has     led to a                    approval           the patient       fantasied
growing   concern       with               its psychiatric             aspects.         This     paper  reviews              others were denying              him.
psychiatric           evaluation            of candidates              for   surgery;           considers       the              The concern           that serious          psy-
rhinoplasty            patient          as a prototype;              examines           psychiatric                          chopathology            may       underlie        re-
complications               of the        surgery;          and    summarizes             the     outcome         in         quests       for cosmetic           surgery         is
                                                                                                                             valid. The accumulated                   findings
these cases.
                                                                                                                             of the past several            decades,       how-
                                                                                                                             ever, have shown              that such con-
 During          the l940s,          about        15,000           aid Schaffner”           held that the mo-                cern is not usually           borne out, and
 cosmetic          surgery       operations         were           tives for seeking              such surgery               that even when it is, cosmetic                  sur-
 performed            each year.’ By 1973, an                      could be found in an unconscious                          gery is not automatically                      con-
 estimated            1,041,000         plastic      sur-          denial      of deeper         psychological               traindicated          on that account.           Pa-
 gery operations               had been done, a                    conflicts.       Stekel5      believed           that     tients requesting          cosmetic       surgery
 large       percentage             of them          cos-          feelings       of guilt      resulting          from      may be referred             to a psychiatrist
 m#{233}tic.2 The development                   of such            inner      conflicts       were      being        dis-    by a concerned             family     physician
 procedures             and their increasing                       placed       and symbolized                  in the       or pediatrician,           or by the plastic
 availability           and popularity             in re-          chief complaint           of physical         defor-      surgeon       the patient      has consulted.
 cent years have led to a growing                                  mity, the psychological                  formula-         We will here review                the general
 interest        in the motivation                of pa-           tion here being: “One can tell my                         approach          to the psychiatric          eval-
 tients seeking             such treatment            and          disgrace      by looking        at me.” Meer-             uation of such patients;               look spe-
 the psychological                benefits,      if any,           1006 took the extreme              position       that    cifically at the rhinoplasty               patient
 of cosmetic           surgery.                                    patients        who seek surgery                    for   as a prototype;          review the psychi-
     Initially,        great skepticism               was          minimal           disfigurements               have       atric complications               of cosmetic
 expressed           about the value of cos-                       serious psychopathology                   and that        surgery;       and summarize          studies of
 metic        surgery.           Updegraff           and           therefore       the surgery         is contrain-          outcome         in these cases.
 Menninger3             stressed      that a person                dicated.       He believed          that plastic
 with a sense of inferiority,                    partic-           surgery       “intervenes         in a compli-               Psychiatric        evaluation
 ularly      a feeling          of sexual        inade-            cated      psychological           battle,”       and         Schilder7     was the first to draw
 quacy,         is apt to seek and find                            often the patient’s           real desire was             attention       to the concept     of the
justification              for this feeling              in        to have the surgeon                   refuse       the    “psychological        body image,”     de-
 some physical               defect. MacGregor                     operation         and thereby             give the        scribing      how it is elaborated    and

PSYCHOSOMATICS                                                                                                                                                                   7
Cosmetic            surgery

altered      during       the course of mdi-                 mity relates          to his psychological               whether          this desire is predornin-
vidual development:                                          state.     Hay’2        provided        objective        antly generated                 from “external”
     “Our own beauty                   or ugliness           evidence         that patients            seeking        or “internal”            pressures.’4
will not only figure in the image                            cosmetic       surgery       could indeed          be         Surgery        will be ineffective              ifhe
we get of ourselves,                 but will also           identified      as a group on the basis                  patient       is responding             primarily          to
figure in the image others build up                          of their deformity.              Using a scale           external          pressure-seeking                     sur-
about us and which will be taken                             of disfigurement,             observers        corn-     gery as a way of pleasing                         others;
back again into ourselves.”                                  pared      the pictures         of a group          of   saving         a deteriorating                 relation-
     He pointed           out that the body                  such      patients         with     those       of a     ship; decreasing               delusionally            per-
image        a person         has may be an                  matched        control group and found                   ceived       threats        from the environ-
identification           with, or mcorpora-                  those      who sought            surgery       were      ment;       furthering           social or career
tion of, part of the body image of                           significantly        more disfigured            than     goals;       or masking              cultural          con-
that person’s          parent;       and that one            the controls.         There was no corre-                flicts. The prognosis                  for cosmetic
part of the body may symbolize                               lation between            the results       of psy-      surgery         is good,          however,           when
another.        Szaszt noted            that an in-          chological        testing     and the degree             the patient’s            motivation           is “inter-
dividual       may relate to a part of his                   of disfigurement.                This      finding       nal,” and arises from long-stand-
or her own body in much the same                                                                                      ing feelings              about        a deformity
way as he or she relates                     to other                                                                 that has interfered                with the devel-
people.       According          to Hartmann,9               Cosmetic swgery              will be                     opment         ofmature           self-esteem           and
 the kind of emotional                  investment           ineffective     jfthepatient         is                  self-acceptance                     of the          body
 in the physical                self, the body                                                                        image.
                                                             Nspondingprimarily                to
 image, depends             on the pleasure            or                                                                  Certain         types of patients                have
 displeasure        found in the develop-                                                                             been       found          to present             unique
 ing child’s         appearance             by those         surgeiy     as a way ofpleasing                          problems:             the paranoid              patient;
 emotionally          important          to him.             others.                                                  the patient            with involutional                 de-
     The effects of bodily defects on                                                                                 pression;           the hysterical               woman
 the psychological              development             of                                                            patient;        the male patient;                the “in-
 an individual           have been well doc-                 supports       Barsky’s’3    earlier conclu-             satiable”           cosmetic           surgery           pa-
 umented.         Easson’s’#{176}    four cases of           sion that the degree             of disfigure-            tient; and the adolescent.
 eongenital        defect showed              how the        ment      has no inevitable              propor-              The paranoid              patient      has a ten-
 limitation         of emotional               growth        tional relationship           to the mental               dency to externalize                   painful        con-
 and stability          imposed          by the de-          distress      it might      engender.         The         ificts, especially             those connected
  fects led to psychological                   deficits      degree of disfigurement               is of little        with      feelings           of inadequacy.
  more handicapping                 than the orig-           aid in psychiatric            evaluation         of       These       conflicts         may focus on a
 inal physical          deficit. According              to   such patients.          In evaluating          pa-        real or imagined                 defect,       possibly
  Schonfeld,”          gynecomastia              in ad-      tients     requesting        cosmetic         sur-        reaching         the stage in which a de-
  olescent      males is particularly              dev-      gery, the psychiatrist            must deter-             lusion is formed.              It is important             to
  astating       in its effect             on body           mine          whether            whatever                 identify       such somatic             delusions.”
  image       and personality               develop-         psychopathology            may be present                 All the characteristics                   of a delu-
  ment; the presence                 of pendulous            is secondary         to the deformity           (as       sion will be present-denial,                           pro-
  breasts      creates        extreme          anxiety       in patients         with congenital            de-       jection,       concretization,             and preoc-
  over masculine            adequacy          and can        fects) or is primary          (as in patients             cupation.          Denial        will be evident
  lead to pseudohomosexuality,                         an    whose       complaint         of being         de-        in the belief that an actually                           in-
  acceptance          of feminine            roles, or       formed is the manifestation                 of the        significant            deformity            is highly
  acting-out       in order to prove mas-                     psychopathology).            The most im-                conspicuous,            that features           that are
  culinity.                                                  portant      thing to examine           in order          in fact attractive             appear        ugly, and
      The question          arises whether            the    to clarify        such questions           is the         that     the impressions                    all other
  person       who seeks cosmetic                   sur-     patient’s       motivation        to have the             people        have of one’s appearance
  gery is in truth deformed                     and, if      feature      changed.      It should       be de-         are wrong.             The individual                  who
  so, whether          the degree           of defor-        termined            by the         physician              blames        any failure he or she may

8                                                                                                                                                       JANUARY              1978
have solely on the real or fanta-                             brief psychotherapy               to clarify her            messages:           failure        to identify          with
sied defect is clearly using projec-                          motives       for seeking          surgery       and        the father;           and failure              to master
tion onto a body part, and con-                               her expectations           ofit. When this is               intense           ambivalent                    feelings
cretization.            Such         persons          are     done, a high percentage                   will re-          toward       the mother.
usually       totally       preoccupied            with       port subjective           and sustained          sat-           The psychiatrist                   learns,       as he
their complaint.                                              isfaction      as a result of surgery.                      takes the personal                   history       of such
     In the absence                of gross delu-                 The     woman           with      hysterical            men,       that        these        conflicts          were
sion, other warnings                  may appear,             personality         traits     may seek cos-                reactivated           in adolescence               and re-
such as expectation                 of magical         re-    metic surgery            as she gets older.’                mained         in the background                      in all
sults from the proposed                       surgery;        Hitherto        successful         ways of in-              relationships,                  especially            those
shifting,       bizarre,         exaggerated,            or   teracting      with people,         particularly            with women,                 leading         to extreme
overtly      sexualized           descriptions           of   those emphasizing                seductiveness              sensitivity               to any            perceived
 the defect;            a conviction                that      and sexual appeal,             no longer serve              threats      to male effectiveness.                      The
others are continually                  laughing         at   her, and underlying                her determi-             cosmetic         complaint              is a symbolic
or talking           about        the disfigure-              nation      to have surgery               may be            representation,                and an alternative
 ment;       or an insistence                 that the        desperation          about      restoring      their        to more           direct         ways of dealing
 proposed          surgery          make       the pa-                                                                    with these conflicts.                  Cosmetic          sur-
 tient into the likeness                     of some                                                                      gery should be performed                          for men
                                                               Men in our culture rarely
  famous        personality.            Surgery        for                                                                only       after         careful           psychiatric
 the paranoid              patient         should        be    seek cosmetic       surge,y      (about                    evaluation.            Intense         negative         feel-
 avoided.”’6                                                   one tenth as often as                                      ings toward             the father can lead to
      It is difficult           to evaluate            the     women),      and those who do                              a strong           negative             transference
 older woman             who is depressed.                A    are more apt to be                                         toward       the surgeon,                and this pos-
 depressed             woman             is usually                                                                       sibility,     along with other motiva-
                                                              psychologically          ill than their
  preoccupied          with herself, and this                                                                             tional       difficulties,              makes         for a
                                                              female     counterparts.
  preoccupation            may turn to exces-                                                                             poor prognosis.
  sive concern          with a real or imag-                                                                                  The “insatiable”                   cosmetic          sur-
  ined physical          defect. Ruminations                   effectiveness.            Expectations            that     gery patient              described            by Knorr
  about the past are filled with re-                           surgery      can restore           the charm         of    and associates2#{176}is usually                     a man
  morse,      and the request                  to have         youth and the ability to seduce are                        with low self-esteem,                     hyposexual-
  surgery      may be made for the sake                        generally       unrealistic,         and give ev-          ity, grandiose                plans for his post-
  of self-punishment                    and atone-             idence that a predominantly                       “ex-     operative           life, little aptitude                  for
  ment for guilt.’ Surgery                   is clearly        ternal”       motivation             offers      poor      interpersonal                 relationships,             and
  contraindicated             if the request            for    prognosis        for surgery.                               an obsessive             concern          for appear-
  it is associated             with severe             de-         Men in our culture                 rarely seek          ance. Diagnostically,                      many        such
  pression       or with hypochondriacal                       cosmetic       surgery       (about one tenth               patients       are in the range of bor-
  concerns,         fatigue,         or vegetative             as often        as women),              and those           derline        personality               or ambula-
  signs.’7                                                     who do are more apt to be psy-                              tory/latent             schizophrenia.                They
      Nevertheless,           surgery        will help         chologically          ill than their female                 have      often          undergone                one or
  many       depressed            women.          Webb         counterparts.            Jacobson        and asso-          more       previous             operations,             and
  and associates’8             reported          on 106        ciates’9 studied            men seeking           cos-      thus further                surgery          is seldom
  women         who had face-lifts;                    the     metic surgery            and found that they                beneficial.
  best results         were among               women          often have a conscious                    desire      to        The adolescent                patient       has a far
  over 40. But the majority,                     having        dissociate         themselves            from the           better prognosis                 for cosmetic           sur-
  lost a significant          person within the                undesirable          traits of their fathers,               gery than do those in the catego-
  five years         before         obtaining         sur-     and an unconscious                 desire to dis-           ries just described.                The adolescent
  gery,     still exhibited               unresolved           sociate themselves              from primitive              is more preoccupied                       with bodily
  grief. It is wise to extend                 the eval-        rage at the mother             from whom the                changes         than those in any other
  uation       of the depressed                    older       father failed to rescue them. The                           group;       however,             the body image
  woman        candidate           and to provide              cosmetic         concern          contains         two      is constantly               changing,            and the

 PSYCHOSOMATICS                                                                                                                                                                            9
Cosmetic            surgery

establishment            of self-identity           is in     surgery     situation        in general.       The           Surgery         should        be performed             on
the formative               stages.         Physical          face is obviously           the most impor-                  such a patient            only after the crisis
changes         resulting         from cosmetic               taut physical        representative         of our           upsetting         her is resolved              and the
 surgery      can be more easily inte-                        emotions,       and the nose is its most                     motivation           is recognized           as being
 grated2’     than in adults.                                 prominent         feature.      Feelings     of in-          primarily         “internal.”
     The existence              of extremes              of   adequacy,         particularly         of sexual                  The younger            woman          candidate
 psychopathology                is not a direct               inadequacy,            may be displaced                      for rhinoplasty                is also likely            to
 contraindication             for cosmetic           sur-     onto the nose in ways determined                             have been concerned                       since ado-
 gery; the psychotic               palient       with a       by physiological,               cultural,      and           lescence         about       the shape           of her
 disfigurement            of disproportioned                  historical     circumstances.           The nose             nose.     It is common                   for such a
 features        who is concerned                   only      contains      erectile      tissue similar        to         woman          to identify           her nose with
 about this can be helped.22 Clark-                           that of the genitals?                Sexual     cx-          her father’s,          and to have failed to
 son and associates                   give case re-           citement,       intercourse,          menstrua-              experience           her mother           as an ade-
 ports     of cosmetic              surgery         per-      tion, and pregnancy                 are accom-               quate model for the feminine                        role,
 formed         on psychotic                patients,         pamed       by changes            in the nasal               especially          as it encompasses                any
 stressing       that the criterion             for en-       mucosa:        hyperemia,           hypersecre-              confident          pleasure          in being        sex-
 dorsing       such surgery              “is the de-                                                                       ually attractive.            In such a case, the
 gree to which the patient’s                    overall                                                                    father is apt to be the candidate’s
                                                               The existence       ofextremes      of
 appreciation            of the possibilities                                                                              amiable         ally, someone            with whom
                                                              psychopathology           is not a                           she identifies             intensely          in ways
 and limitations             of the procedure
 are consonant               with        reality        no    ibct     contraindication        for                         discordant           with the development
 matter      how disturbed                 he or she          cosmetic      surgery;      the                              of a comfortable               femininity         as she
 may otherwise             be.”                               psychotic     patient    with a                              matures.3’           The sequestered                 am-
     The      psychiatrist              evaluating            disfigurement         who is                                 bivalence           toward          the mother            is
 candidates           for cosmetic             surgery                                                                     central      to the patient’s             conviction
                                                              concerned      only about this
 must be aware of his own attitude                                                                                         of being           ugly;       thus the young
 toward       t.24     He is likely to hold
                                                              can be helpeS                                                woman          who seeks rhinoplasty                      is
 more definite            views, negative                or                                                                often seeking            a way to reduce              her
 positive,      about his patient’s               desire      tion, and nasal stuffiness.2628                     The      identification           with her father and
 for such surgery             if he has himself               ancient        Romans           associated           the     to grow into more secure feminin-
 suffered          because          of problems               size and firmness             of the nose with               ity. Her demand                 should be evalu-
 concerning           his own appearance.                     virility.     The penalty            for adultery            ated according                to the guidelines
 An awareness               of these           feelings       was amputation                 of the nose in                described.          The evaluating              psychi-
 will help prevent             interference           in a    cultures       as widely            separated          as     atrist should          also learn whether                 a
 rational      assessment           of the patient.           those of India 3,000 years ago and                           young       or adolescent               female      can-
  It is known          that deterioration                in   Germany           in the Middle            Ages.29           didate is acting to please a mother
  mental     health       has taken place in                      Patients        requesting         rhinoplasty           who has had a rhinoplasty                        herself
  patients       for whom           a psychiatrist            are, as a group,               more disturbed                or has been interested                     in obtain-
  refused      to endorse            cosmetic         sur-    than      controls.’2’3#{176} The               older        ing one. Surgery                   should        be de-
 gery for an objectively                        evident       woman         who seeks reconstruction                       layed until this imitative                     motiva-
 deformity2’                                                  of her nose usually                    does so in            tion can be ruled out or clarified
                                                              response        to interpersonal              stress-         for patient         and mother.
      Rhhioplasty                                             often       marital          difficulties-al-                     As with male                candidates            for
     Rhinoplasty           is the cosmetic                    though       she may have been dissat-                       cosmetic          surgery         in general,         the
 proce4ure             most       commonly                    isfied        with         her        nose         and        male      rhinoplasty                candidate           is
 sought.2      The dynamics              likely to            preoccupied            with what she con-                     usually       psychologically              more dis-
 underlie       requests      for this proce-                 siders its ugliness              since her ado-               turbed       than his female                 counter-
 dure, and the way such requests                              lescence.       The demand               for rhino-           part. It is wise for him routinely                      to
 are evaluated          psychiatrically,        are           plasty           thus         may         mask           a    have     psychiatric              evaluation          be-
 representative            of the cosmetic                    depression           over a midlife              crisis.      fore he has surgery.                  The underly-

 10                                                                                                                                                        JANUARY              1978
ing dynamic              is usually       sexual.        mammary               augmentation                  com-          of 86 patients         who had cosmetic
Dissatisfaction            with the nose has              monly suffers transient                    postoper-             rhinoplasty         and compared              them
been related           to defenses         against        ative      depression            more         intense            with 108 whose nasal reconstruc-
homosexuality             by several      investi-        than the reactive             depression            asso-        tions had been necessitated                  by in-
gators32’3;       the patient      may uncon-             ciated with other types of general                              jury. Ten years after surgery,                  32 of
sciously       fear that his unaltered                    and cosmetic            surgery.2’                              the cosmetic          patients       had psychi-
facial profile is effeminate.               Of in-             There      seem        to be few long-                      atric disorders           (five had schizo-
terest, with our male rhinoplasty                         range       psychiatric           complications                  phrenia);        but only eight             of the
patients,      is the absence        of requests         secondary            to cosmetic              surgery,            injured      group had psychiatric               ill-
to make         their noses larger            or to      but Knorr38 has identified                        a syn-          ness and none was schizophrenic.
have a hump               added     to the dor-          drome        of “feminine             loss of iden-               These       investigators            concluded
sum.      The       relationship         between          tity” among            some adult              women             that rhinoplasty              did not cause
homosexual              defenses        and      the      who had rhinoplasty.                    They even-               serious psychological              disturbance.
high       frequency             of paranoia              tually      had       multiple           procedures              They found that it was often ben-
among male candidates                 for plastic         done, always             in the hope of re-                      eficial, even if only for a limited
surgery,      however,         has not to date            gaining        the longer              length         and        time, but that it was probably                      a
been        explored            in terms           of     larger size of the original                       noses.         waste in some cases, inasmuch                      as
Freud’s          theory      of paranoia        and       The psychiatric             profile is like that                 it failed to remedy             an underlying
latent homosexuality.                                     seen in polysurgery                addiction.                    illness      of more         sinister      conse-
                                                              The favorable            response          of most           quence.
    Psychiatric       complications                       patients      to their cosmetic                surgery
    Psychiatric         problems         may ap-          is reflected       in the affirmative                  cdi-         Conclusion
pear in the period                 immediately            torials that have appeared                        in the            Those     who seek cosmetic                  sur-
following        the cosmetic         operation.          leading         medical           journals.24’39                gery, especially              men, are more
These        are usually            short-lived           Many        studies’8”9’”#{176}’35’37’’#{176}’3      con-       disturbed         psychologically               than
manifestations            of reactive       anxiety       vey endorsement.                 The vast ma-                   controls.     The degree of their emo-
and depression                thought        to de-      jority ofpatients             who have under-                    tional illness is independent                  of the
velop in response                to the sudden            gone       cosmetic          surgery           report,          degree ofphysical              deformity.        Psy-
challenge        to the body image and!                   independently              of any psychiatric                   chiatric     evaluation           is an appro-
or the release of affects previously                      diagnosis,        subjective           satisfaction,            priate adjunct           to this type of sur-
bound       by the preoccupation                with      improved          self-esteem,            and relief            gery,     screening            out those           for
the deformity.              Reich35       reported        from       depressive            symptoms.                A     whom it is unsuitable,                  and help-.
such reactions            in 185 (31%) of a               consistent            observation               is im-          ing clarify         the perceptions               and
sample       of 599, and felt that they                   provement           in interpersonal                 rela-      expectations            of the patient              in
were best handled                  by the sup-            tionships        without        any significant                 ways that enhance                 the generally
portive       attitude        of the surgeon.             change       in basic personality.                    Hay       favorable       results of such surgery.
Three       (10%) of 30 consecutively                     and Heather,42            who made a quan-                      Psychiatric         focus is most profit-
studied        female        rhinoplasty           pa-    titative      follow-up            study,        found          ably directed           toward        the candi-
tients      who had been                carefully         improvement                in psychological                     date’s      motivation           and      expecta-
screened         before      undergoing           sur-    test results unrelated                to the initial            tions. When the patient                 sees his or
gery exhibited             such a postopera-              degree of deformity.                                            her need for corrective                surgery       as
tive syndrome.36               A higher         inci-         Gipson        and Connolly4’                offer a         primarily       to improve           self-esteem,
dence          (55%)           of transient              less optimistic               view,         however.             and self-acceptance                of his or her
emotional          disturbance         was noted         They were concerned                       about        dys-      body image,            then surgery            has a
 in a series of 98 male and female                        morphophobia-the                      fear that             a   reasonable         likelihood         of produc-
 patients.37         Psychotic          reactions         basically        normal          feature          is re-        ing lasting          benefit.       Severe       psy-
 have      been        reported32           among        garded        with disgust              by others-               chological       disturbance           is not nec-
 screened       patients,       but seem to be           and its significance                   as an early               essarily     a direct contraindication
 rare. It is, incidentally,           interesting        sign of schizophrenia.                       They        re-     for surgery.        Psychiatric         complica-
that the young              woman         who has         ported on the long-term                    follow-up            tions of cosmetic             surgery       are not

PSYCHOSOMATICS                                                                                                                                                                11
                                                                                                                                                                                    Cosmetic                   surgery

common        if the surgeon        is know!-                             65:238-243,   1944.                                                               York, Paul B. Hoeber, 1959.
edgeable       about     the motivational                             14. Edgerton    MT, Knorr                         NJ: Motivational                29. Holden HM: Noses. Cleveland,                               World
                                                                            patterns          of        patients        seeking       cosmetic                Publishers,          1950.
patterns     of his patients,       and if he
                                                                            (esthetic)            surgery.          Plast      Reconstr        Surg     30. Linn         L, Goldman      JB: Psychiatric         oh-
utilizes   psychiatric       collaboration                                  48:551-557,                 1971.                                                 servations       concerning         rhinoplasty.
in offering       surgery     to the more                             15. Druss             RG,          Symonds              FC,    Crikelair                Psychosom       Med 1k307-3         14, 1949.
disturbed      patients.    When postop-                                    OF:        The problem                  ofsomatic        delusions          31.   Jacobson     WE, Meyer E, Edgerton                MT,
erative     emotional        reactions      do                              in    patients              seeking        cosmetic           surgery.            Ct al: Screening       of rhinoplasty       patients
                                                                          Plast Reconstr Surg 48:246-250,                                    1971.            from the psychologic             point of view.
appear,    they are usually          mild and
                                                                      16. Editorial: Hazards    ofcosmetic                                surgery.            Plast Reconsti’       Surg 28:279-281,         1961.
transient.                                    0                           Brit MedJ 1(537):381,       1967.                                             32.   Hill G, Silver AG: Psychodynamic                  and
                                                                      17.   Book       HE:              Psychiatric assessment     for                        esthetic   motivations       for plastic surgery.
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  1. Bittle      RM:       Psychiatric         evaluation        of         55,     1971.                                                               33.   Saul LI: Feminine           significance      of the
      patients     seeking      rhinoplasty.         Otolaryn-        18. Webb WL, Slaughter                 R, Meyer E, et                                   nose. Psychoanal         Quart    17:51-57,      1948.
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 3.   Updegraff         HL, Menninger              KA: Some           19. Jacobson        WE, Edgerton          MT, Meyer E,                                  chological           Works                 Freud
                                                                                                                                                                                                of Sigmund
      psychoanalytic            aspects      of plastic sur-               et al: Psychiatric          evaluation       of male                               London,        Hogarth           Press,  vol 12.
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Dr. Thomson            is assistant     professor      of psychiatry,         Dr. Knorr      is professor        of                                     44. Gipson        M, Connolly       FH: The inci-
psychiatry,     and Dr. Edgerton         Is professor and chairman             of the department       ofplastic                                            dence of schizophrenia          and severe psy-
surgery     at the University        of Virginia     School      of Medicine.      Reprint    requests      to Dr.                                          chological        disorders     in patients       10
 Thomson,       Box 203, Department               of Psychiatry,      University      of Virginia       Medical                                             years after cosmetic rhinoplasty.            Bra I
 Center,    Charlottesville,        VA 29O1.                                                                                                                Plast Surg 28:155-159,          1975.

 PSYCHOSOMATICS                                                                                                                                                                                                                  15

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