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Is it possible for a procedure to be just ‘skin deep’?

02 April 2024
Volume 13 · Issue 3


Dr Deborah Auer discusses why practitioners should consider a robust assessment process

This piece discusses the complexities that sometimes underlie a patient's request for procedures, highlighting the importance of practitioners having a robust and ethical assessment process in place. Research that links psychology with requests for procedures, more often than not, will consider how to assess for body dysmorphia in particular. This does have benefits in identifying patients for whom having a procedure may result in a poor outcome. However, often these measures and/or screening tools do not highlight the more nuanced difficulties a patient may have regarding their relationship with their body. Procedures have a twofold impact: firstly, on the external body that is shown to the world, and secondly, the internal part — an individual's psyche, self-esteem, body image and confidence (Auer, 2018). Therefore, it is paramount that practitioners consider both the physical and psychological wellbeing of their patients.

Dr Auer is specialised in working with individuals with appearance-related distress and those seeking cosmetic procedures. Dr Auer provides consultation to surgeons and practitioners to review their current assessment processes. She also provides training to practitioners to help them better understand how to implement measures and/or screening tools safely and ethically.

The key to recognising why specific individuals request procedures lies in understanding how the relationship we have with our body forms and develops. This will be discussed in the context of body image development, shame, and adverse childhood events (ACE).

The risks of aesthetic procedures and ‘tweakments’ are often minimised in the way they are portrayed in the media. This causes patients to think these procedures may be a ‘quick fix’ to more deep-seated psychological issues. The responsibility then sits with the practitioner to ensure the patient fully understands what they are consenting to, especially in terms of the expected psychological outcome.

Body image development

Body image development is a complex, psychological and physical process. It is impacted by several factors from peer, parental to media influences as well as interpersonal experiences.

In a study by Naraghi and Atari (2016) the scores of 42 patients from the Rosenberg Self-Esteem Scale were analysed preoperatively and postoperatively. A total of 21 patients were having aesthetic rhinoplasties and 21 were having functional rhinoplasties. The findings from their study suggested that rhinoplasty candidates have lower levels of self-esteem in comparison with functional patients (ibid.). Other studies (Sarwer et al. 1998) have also shown that women with higher self-esteem levels exhibit less interest in cosmetic surgery. This is consistent with research findings from Constantian (2019), where a correlation between a more negative, shame-based body image is associated with lower levels of self-esteem and more dissatisfaction postoperatively. Higher anxiety means that an individual is more susceptible to internalising beauty ideals portrayed in the media, as well as being more deeply affected by negative cultural, parental and peer influences (Hardit and Hannum, 2012).

The perception we have of ourselves is constructed by the experiences we have throughout our lives. It is not just our reflection in the mirror that can result in potential shame-based feelings, but also the imagined effect that our appearance has on others (Cooley, 1902). We try to imagine what others think, how they might judge, and how they might view our appearance. This is what gets played out when someone is seeking the opinions of others on how they look; this gauging of reaction is the very behaviour that individuals use when trying to assess how their appearance will be perceived by another. These factors then have a further impact by causing a favourable attitude towards cosmetic procedures (Menzel et al. 2017).

The brain's perception of how it puts composite parts together in patients who have body dysmorphic disorder (BDD) is also key. For those with BDD they will not necessarily see the bigger picture, but instead will zoom in on individual parts, with a tendency to to hyperfocus (Clarke et al., 2014). There is also a close correlation with attention deficit hyperactivity disorder (ADHD) and body dysmorphia (Van Eck et al. 2018). A patient could be misdiagnosed with BDD, when in fact, their way of processing information is just different. It does not mean someone with ADHD or someone suspected of having it should be excluded, but instead, the tendency to hyperfocus needs to be taken into consideration when exploring expectations regarding the surgical outcome. Patients do not often consider their decision to pursue procedures in the context of their life history (Locatelli, et al, 2017). However, body image is not static (Schilder, 1935), which is why it is important to establish what prompts patients to seek procedures at a particular time in their life. Practitioners who ask the question of ‘why now?’ will likely discover a triggering event or experience.

» The risks of procedures are sometimes minimised by the way aesthetic procedures and ‘tweakments’ are portrayed in the media. This causes patients to think it may be a ‘quick fix’ to more deep-seated psychological issues «

The difference between body shame and body dissatisfaction

It is important to differentiate between body shame and body dissatisfaction. Body shame is about self-worth and will often be described by patients in terms of inferiority, embarrassment, vulnerability and feeling inadequate (Constantian, 2019). This is about more than just dissatisfaction with a particular body part. ‘Body shame cannot co-exist with healthy self-esteem’ (Constantian, 2019). A patient with a high level of body shame is unlikely to be a suitable candidate for aesthetic procedures, given that their expectation of surgery is likely to be more invested in shifting shame than the actual physical outcome of surgery. It is indicative that the lower a patient's self-esteem, the increased risk of body shame. Practitioners can begin to gain some insight into a patient's level of self-esteem by providing a self-esteem questionnaire.

» The responsibility then sits with the practitioner to ensure the patient fully understands what they are consenting to, especially in terms of the expected psychological outcome «

Early shame-based processes like negative comments from parents, siblings and/or peers, can result in a vulnerability to outside influences regarding how we look and relate to others. Patients may then seek procedures in the hope that if they look a certain way, they may then ward off further distressing comments (Lemma, 2010 and 2009). Assuming that others are judging us to be visually offensive or unacceptable may give rise to feelings of shame; however, whether or not shame becomes an embodied feeling will depend on the fragility of our sense of self, body image and attachment history. It is important to recognise when a patient may have experienced shame in their childhood, as this may be a critical factor in their decision to pursue a procedure.

The cosmetic industry often portrays itself as a route for people who want to feel comfortable and confident in themselves again. The industry then unconsciously taps into the individual's shame, and the individual begins to feel that these types of procedures are the way to change what it is they feel ashamed about (Northrop, 2012).

For practitioners, it is important to explore with patients their existing relationship with their body to find out more about the narrative that runs alongside the request for procedures. How often do they look at themselves in the mirror? How do they feel when they look at themselves in the mirror?

Adverse childhood events (ACE): connecting trauma with requests for procedures

Parker (2009) found that patient and surgeon communication greatly influences the outcome and postoperative satisfaction. This is largely due to the relationship that is established between a surgeon and their patient (Constantian, 2019). This leads onto the importance of understanding a patient's attachment history and how, based on their past experiences, they may or may not be able to trust their practitioner. All practitioners should have an understanding that patients would benefit from psychological input before, after or during their procedures.

Performing any procedures on patients who have a history of trauma, specifically early childhood trauma, could result in a patient who is dissatisfied postoperatively. As mentioned earlier in this paper, this is due to the likelihood of a shame-based process (Constantian, 2019). However, this is not always easy or straightforward for practitioners to navigate. To appropriately assess how a patient's past experiences have impacted them, it is important that the assessing clinician has the necessary skills and training to not only ask questions in an empathic manner, but to also ensure the patient is not destabilised when discussing past experiences, especially if they were traumatic. Research indicates that discussing trauma potentially retraumatises patients (Levine, 2010 and van Der Kolk, 2014). Therefore, this needs to be done in the care of a suitably trained professional such as a psychologist.

» Practitioners should ask more exploratory questions with their patients to further understand how they relate to their body «

Practitioners do not want to find themselves offering procedures to patients who have unresolved early relational trauma without doing further psychological assessment. However, if a practitioner chooses to take on the patient knowing they have experienced an ACE, they need to be mindful that the surgical process from consultation, through to postoperative care, could trigger early trauma experiences. The patient may view the surgeon as the carer they longed for. The surgeon may be placed on a pedestal and held in high regard. If this is the case, and the surgery is unsuccessful or there are complications, this may trigger the patient to have an adverse reaction that is not proportionate to the surgical outcome (Constantian, 2019).

Conclusions and considerations

Practitioners should ask more exploratory questions with their patients to further understand how they relate to their body. For example: ‘what will be different for you after having this procedure?’ This can provide a useful insight as to the psychosocial expectations an individual may have. Is it a psychological change they are hoping for? For example: ‘I will feel more confident’. Within this narrative we hear that the patient's hope is that their relationship with their body will change — but if the relationship developed out of a traumatic experience, there is a possibility that the procedure will not deliver on the anticipated psychosocial change. It is important to highlight to patients that psychosocial change from procedures cannot be guaranteed, and if the procedure is temporary, such as botox or filler, an improvement in confidence is likely to last only as long as the physical change is present. Patients need to be supported and helped to consider the longevity of what they are doing.

Having a robust and holistic care pathway for patients has been shown to deliver better outcomes (Undakat et al. 2021). Practitioners can support their practice and how they assess patient suitability by choosing to include various suitable body image screening questionnaires (Paraskeva et al. 2014). These can help to open discussions around how patients feel about their bodies. However, before including these questionnaires, it is important that practitioners are suitably trained to interpret the outcomes. They also need to have an appropriate referral pathway if they do come across a patient that requires additional support.

Practitioners need to keep in mind that how and what they say to patients will have an influence in how the patient feels and whether they decide to proceed. Patients can be in a vulnerable psychological state, therefore it is important for the practitioner to keep this in mind (Parker, 2009). Specifically, when it comes to helping patients decide whether to have a particular procedure, practitioners should, wherever possible, avoid agreeing or disagreeing with patients about how they look. This prevents additional procedures being requested or suggested which can lead to difficulties postoperatively if the patient is unhappy (Blum, 2003). This better manages patient expectation and remains in line with the patient's original request.

Despite evidence suggesting that there are psychological factors motivating people to undergo procedures, to date there is still limited to non-existent psychological input in place for these patients (Perrson et al. 2018). Patients report that many healthcare professionals do not have sufficient knowledge to helpfully discuss psychosocial issues regarding appearance difficulties (Moi and Giengedal, 2008). Therefore, it is important for practitioners to consider upskilling themselves and their team to more deeply understand the psychological connection to procedures.

Reflective questions

What causes some individuals to desire change in terms of their body?

Is there such thing as only ‘skin deep’ in terms of requests for and expectations of aesthetic procedures?

Should practitioners working in the field of aesthetics be making considerations beyond the physical bodies they are working on — is psychological change an expectation that needs further consideration?