Surgical Psychotherapy

Dimitrije E. Panfilov

Any patient asking for any aesthetic surgery does not feel well beneath his/her skin. Psychological suffering is the only true indication for every aesthetic plastic surgery operation and so it is valid for facial aesthetic operations. I know from my experience that no person without great distress would seek treatment from a plastic surgeon. Patients have usually been carrying their suffering around with them for years. In our consultation rooms we often hear stories which have been related more than twice. A certain degree of patience is necessary when listening to them.

The most common questions which we put to our patients are:

  • quot;What is disturbing to you about your appearance?"
  • quot;Do you have a precise idea of how the outcome should look?" A clearly defined idea of the aspired correction is desirable. Experience has shown that these patients are the happiest ones at the end of the treatment. The worst imaginable answer to this question would be: "Just give me a beautiful nose."
  • quot;Why do you wish to have this operation?" This question is supposed to provide information about the patient's motives.
  • quot;How long have you entertained the thought of having this correction done?"
  • quot;Do you expect your life to change as a result and in what way?"
  • quot;Have you observed that others have noticed your defect and/or commented on it?"
  • quot;How important to you is the opinion of others?"
  • quot;How important is attractiveness to you?"
  • quot;How many surgeons have you already consulted?"
  • quot;Do you have problems at work or in the family?"
  • quot;Are you often depressed, anxious, nervous?"
  • quot;How do you spend your spare time? What are your hobbies?"

This psychoanalytic probing is very important for us. Sometimes the wishes and ideas of the patients are objectively just not feasible. The best combination is a genuine, correctable deformity and a stable personality. And the most difficult case is the genuine defor

Sex Distribution (N=118)

Fig. 5.1. The number of female patients is predominant, but the percentage of male patients is rising

mity with an unstable personality. Advice is given against having a minimal, and in effect hardly correctable, deformity surgically corrected, no matter whether the personality is stable or unstable.

Body image is the psychological, three-dimensional image of the individual's own body and is essentially based on the experience of an integrated feeling of the person himself/herself. The psychoanalyst Sigmund Freud says: "The ego is first and foremost bodily ego; it is not merely a surface entity, it is itself the projection of a surface." For Freud the ego is the mediator between person and reality.

Sensitive people suffer from their physical defects. They usually try out everything possible, and they have often concerned themselves for some time with the idea of undergoing aesthetic surgical correction. However, adapting to a new body image becomes more difficult with advancing age.

Nudism and sauna habits have contributed towards a considerably stricter assessment of imperfections of the body. In advanced age, the traces of time are judged to be signs of weakness, which can in turn lead to devaluation and isolation. This problem is particularly important for people who are in the public eye professionally or in a partnership with greater age differences.

Female Group Profile N=87






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Fig. 5.2. Male and female groups of patients have a different emotional index (Plutchik)

Male Group Profile N=25












Fig. 5.2. Male and female groups of patients have a different emotional index (Plutchik)

I received the following letter from a female patient:

Over the last year, my skin has started to sag, especially around my neck and face. I am extremely unhappy about this, it is making my life go downhill. I am no longer coping. I am accustomed to moving in diplomatic circles, going to receptions, participating in dinner occasions, paying visits, and would like to look better, more beautiful - just like anyone else would. I have lost my self-confidence when it comes to going out. I would rather not go. I am 45 years old and married with three daughters. My marriage is not in a crisis, but time and again I catch my husband's eye scrutinizing, as I see it, exactly that part of my face which has started to sag and become wrinkled. I feel terribly depressed.

This patient's story prompted me to measure psycho-metrically the changes brought about by aesthetic operations, for we plastic surgeons frequently have the feeling that the majority of our patients really "bloom" after the operation. I also wanted to create a psychometric "portrait" of these patients. We know all too well that not everybody who has a physical "defect" also suffers from it and yearns for an aesthetic surgical correction. So what characterizes our patients?

Over 100 patients with the six most common corrections carried out by aesthetic surgery were tested for assessment before the operation and 6-12 months afterwards. Three personality tests were evaluated; the character traits and neurovegetative and emotional characteristics were examined. Pre- and postoperative questionnaires especially designed for these purposes were completed. A total of 44,990 answers were recorded.

Our typical patient is:

  • Extroverted, i.e. liberal-minded
  • Socially active
  • Outgoing
  • Emotionally sensitive
  • Very critical and self-critical
  • Strives for perfection

Less than 5% of the average population fall under this type. They are not understood by the other 95%, and when they wish for surgical correction they are sometimes even confronted with a lack of understanding by their doctors. They are best understood by their own sort, and they are in a minority. That is the reason why these patients seek the direct route to a plastic surgeon and why they afterwards withhold the fact that they have undergone aesthetic surgery. They know quite rightly that they will have to justify them-

5 Surgical Psychotherapy 17

Preoperative Group Profile N=112















Postoperative Group Profile N=59






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Depression 20/73

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Fig. 5.3. There are remarkable changes of emotional status after aesthetic surgery selves repeatedly before people who do not understand them anyway.

The outcome of surgery was also interesting in these patients:

  • An increased feeling of self-esteem and an increased level of concentration at work are found in 40%.
  • Professional success was improved in 22% and social acceptance was improved in 20%.
  • 30% entered new emotional, and 19% new sexual, relationships.
  • The number of personal encounters was increased in 20% and the frequency of sexual contacts was raised in 9%.
  • No negative changes were observed.

Only the persons operated on were taken into account in this study, not those who were advised against surgery.

Julien Reich analysed 750 patients who requested correction of their appearance. He discovered that 36% were normal persons with realistic ideas about the outcome of the operation, 2% had unrealistic ideas, and 62% were emotionally unstable. Reich found not only aesthetic factors amongst the motives, but also emotional and psychosocial factors. The following motives are revealed in this study:

  • 59% desire the removal of an inhibiting defect which has given cause for undesired attention and comments.
  • 16.5% desire the removal of an obstacle preventing social acceptance for the purpose of a friendship or marriage.
  • 5.6% want to start a new phase in their life.
  • 4.1% want to incite admiration or wish to be admired once again.

Psychologists distinguish between the two extremes of "having a body" and "being a body". In-between these two poles there are eight types of relations to one's own body, as Blankenburg (1983) writes in his work Der Leib Als Partner (The Body As a Partner). The body can be:

  1. The prerequisite for a psychopathologic existence
  2. The baseline for a psychological subject orientation
  3. The source of spontaneity or for the feeling of "I can"
  4. A means of observation
  5. The source of suffering and nausea
  6. An organ of expression
  7. The place of articulation between oneself and the world
  8. An equal partner
Fig. 5.4. Patients and surgeon judge the success of the surgery in a different way (manner)

Particularly the last variation is, of course, to be evaluated in a positive light. But when the body is regarded as the only aspect of the self, this can degenerate into hypochondria and narcissism. An exaggerated instrumentalization of the body can lead to neurotic manipulation of bodily functions as a means of relating to the environment.

In the final instance, an operation can only be recommended to the patient if, on the basis of his/her experience, the operating surgeon can predict that a more or less significant improvement will at least be reached after the operation. The experienced plastic surgeon will exercise caution when defining the indication for surgery in cases:

  • Of minimal deformity with considerable emotional overlay
  • Of unrealistically high expectations
  • Where the outward appearance is held exclusively responsible for professional failures
  • Where a male patient wishes to look more feminine
  • Where there is a wish to satisfy the partner or save a dysfunctional marriage

The operating surgeon will be just as careful when the motives are exaggeratedly kept a secret, as when there appears to be an exaggerated hurry to be operated upon. Acute events in patients' lives might give rise to rash reactions which they may later regret. Such patients should be given a few weeks' time to reconsider.

Then there are also those patients who are mentally ill. The various authors do not agree whether neurotics and psychotics should be operated upon, even if they are receiving psychiatric treatment. Those in favour of psychiatric-surgical coordination cite the following reasons:

  • The patient is offered a further alternative apart from the operation.
  • In cases of severe mental disturbances, the psychiatrists can justify why surgery is out of the question.
  • The opportunity to express their emotional situation could lead to a calmer postoperative phase for some of the patients.
  • Patients in need of psychotherapy are more prepared to undergo such therapy after an aesthetic operation.

It will become clear after what has been said that plastic surgeons should also equip themselves with psychological and psychiatric knowledge to be able to provide optimal assistance for their patients. These might then be more content, more self-assured, indeed happier, after the treatment. If a young woman no longer suffers from nervous, sweaty hands after successful corrective surgery of her nose, then we have helped, via a mental roundabout route, in bringing her autonomic nervous system under control. This is why Rosner says: "The plastic surgeon is a psychiatrist with a knife." Hinderer writes that aesthetic surgery is "surgical psychotherapy".

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