A review of psychological outcomes and suicide in aesthetic breast augmentation

Aesthetic surgery is an essential component of plastic surgery and has become increasingly popular in American society. In 2002, 1.8 million surgical cosmetic procedures were performed in the United States, representing a 294 percent increase from 1992. The 1992 U.S. Food and Drug Administration moratorium on silicone breast implants arose in response to numerous reports of connective tissue disease associated with silicone gel breast augmentation and has led to a decade-long battle over the safety of silicone breast implants that continues today. Numerous scientific and epidemiologic studies of the past decade have established that there is no association between silicone breast prostheses and systemic disease. Recently, a new front has opened in the conflict regarding the safety of breast augmentation: the psychological impact of breast augmentation. Quality studies assessing the psychological characteristics of breast augmentation patients and the psychological impact of breast augmentation surgery are few and most studies are flawed in their methods. Recent reports have provided corroborating evidence to support the psychological benefits of cosmetic surgery and breast augmentation. New reports citing an increased risk for suicide among women with breast implants have brought renewed concerns but are unable to demonstrate a cause-and-effect relationship between breast implants and suicide. The present challenge is to determine whether the increased risk reported in epidemiologic studies is falsely associated with breast implants or whether it represents underlying risk factors or psychopathology in women undergoing breast augmentation that puts them at increased risk for suicide. The purpose of this article is to review the literature regarding the psychological impact of breast augmentation and assesses current scientific findings, with emphasis on the validity of suicide risk in breast augmentation patients.     

The psychological outcome of constitutional delay of growth and puberty

Does being of short stature (SS) matter? Growth studies are important because endocrinologists need to be able to give not only diagnostic but also prognostic indication to those of SS, and give advice for or against treatment. Studies on body height may give significant insight into the behavioural-hypothalamic-pituitary axis underlying the surface effect on social behaviour. This research presents adult follow-up studies of 49 males who attended at a growth clinic as children and who were diagnosed as having the condition of maturational delay short stature (MDSS). From the psychological perspective, the elements of diagnosis and prognosis, attitudinal influences both social and individual, treatment, and psychological issues which could have bearing on SS are drawn together. Where there is a poor psychosocial outcome finding, the MDSS patients seem to be more like those with growth hormone (GH) deficiency. With GH deficiency (GHD), a poor psychosocial outcome of SS has been demonstrated with greater certainty. The current situation is that there remains divergence between previous SS outcome studies. Differing research SS psychosocial outcomes are analysed and a methodological explanation of past divergent outcomes is presented, being: (1) differences in sensitivity between psychological assessment tools; (2) Invalidation by confounding the psychological with sociological outcomes, and (3) confounding of results by failure to control for psychological states. An innovative new approach of changing the methodology of past SS research from the biological to the psychological perspective is employed: previous SS research has appointed height status as the independent variable, with psychosocial outcome as the dependent variable. The innovative approach in this research is to reverse that order and psychological status has been made the independent variable for both the MDSS and for a predetermined psychologically and physically healthy (PPH) comparison group of males. The results of the follow-up studies in this research indicate that there is an association between psychological distress and attained height which supports other studies where the findings indicate a poor psychological outcome associated with SS. It can therefore be concluded that the psychological status of children should be determined when they attend a growth clinic with concerns of SS.     

Do Psychosocial Variables Predict Weight Loss or Mental Health after Obesity Surgery? A Systematic Review

Objective: The objective of this study was to present a systematic review of psychological and psychosocial predictors of weight loss and mental health after bariatric surgery. This systematic review included all controlled and noncontrolled trials of the last 2 decades with either a retrospective or prospective design and a follow‐up period of at least 1 year. Research Methods and Procedures: The relevant literature was identified by a search of computerized databases. All articles published in English and German between 1980 and 2002 were reviewed. Results: Using the above inclusion/exclusion criteria, 29 articles were identified focusing on psychosocial predictors of weight loss and mental health after obesity surgery. Discussion: Personality traits have no predictive value for the postoperative course of weight or mental state. Apart from serious psychiatric disorders including personality disorders, psychiatric comorbidity seems to be of more predictive value for mental and physical well‐being as two essential aspects of quality of life than for weight loss postsurgery. However, depressive and anxiety symptoms as correlates of psychological stress with regard to obesity seem to be positive predictors of weight loss postsurgery. The severity of the symptoms or the disorder is more relevant for the outcome of obesity surgery than the specificity of the symptoms. It is also not solely the consumption of distinct “forbidden” foods, such as sweets or soft drinks, but rather a general hypercaloric eating behavior, either as an expression of the patient's inadequate compliance or a dysregulation in energy balance, which is associated with a poor weight loss postsurgery.     

Plastic surgery in pseudoxanthoma elasticum: experience in nine patients

Nine women between the ages of 22 and 56 years underwent cosmetic surgery for correction of the severe cutaneous stigmata of pseudoxanthoma elasticum (PXE). The outcome was generally favorable, and follow-up for up to 15 years showed only moderate regression of the skin manifestations. No serious intraoperative or postoperative complications occurred, although tissue friability, poor wound healing, and keloid formation were noted in a minority of persons. An unexpected problem of extrusion of calcium particles through the surgical wound occurred in two individuals. This resulted in delayed healing and unsightly scars.     

News media reports of patient deaths following 'medical tourism' for cosmetic surgery and bariatric surgery

Contemporary scholarship examining clinical outcomes in medical travel for cosmetic surgery identifies cases in which patients traveled abroad for medical procedures and subsequently returned home with infections and other surgical complications. Though there are peer-reviewed articles identifying patient deaths in cases where patients traveled abroad for commercial kidney transplantation or stem cell injections, no scholarly publications document deaths of patients who traveled abroad for cosmetic surgery or bariatric surgery. Drawing upon news media reports extending from 1993 to 2011, this article identifies and describes twenty-six reported cases of deaths of individuals who traveled abroad for cosmetic surgery or bariatric surgery. Over half of the reported deaths occurred in two countries. Analysis of these news reports cannot be used to make causal claims about why the patients died. In addition, cases identified in news media accounts do not provide a basis for establishing the relative risk of traveling abroad for care instead of seeking elective cosmetic surgery at domestic health care facilities. Acknowledging these limitations, the case reports suggest the possibility that contemporary peer-reviewed scholarship is underreporting patient mortality in medical travel. The paper makes a strong case for promoting normative analyses and empirical studies of medical travel. In particular, the paper argues that empirically informed ethical analysis of 'medical tourism' will benefit from rigorous studies tracking global flows of medical travelers and the clinical outcomes they experience. The paper contains practical recommendations intended to promote debate concerning how to promote patient safety and quality of care in medical travel.     

Establishing a multidisciplinary academic cosmetic center

The demand for cosmetic services has risen rapidly in recent years, but has slowed down with the current economic downturn. Managed care organizations and Medicare have been steadily reducing their reimbursements for physician services. The payment for reconstructive surgical procedures has been decreasing and is likely to worsen with healthcare reform, and many plastic surgery residency programs are facing fiscal challenges. An adequate volume of patients needing cosmetic services is necessary to recruit and train the best candidates to the residency programs. Self-pay patients will help ensure the fiscal viability of plastic surgery residency programs. Attracting patients to an academic healthcare center will become more difficult in a recession without the appropriate facilities, programs, and pricing strategies. Setting up a modern cosmetic services program at an academic center has some unique challenges, including funding, academic politics, and turf. The authors opened a free-standing academic multidisciplinary center at their medical school 3 years ago. The center is an off-site, 13,000-sq ft facility that includes faculty from plastic surgery, ear, nose, and throat, dermatology, and vascular surgery. In this article, the authors discuss the process of developing and executing a plan for starting an aesthetic services center in an academic setting. The financing of the center and factors in pricing services are discussed. The authors show the impact of the center on their cosmetic surgery patient volumes, resident education, and finances. They expect that their experience will be helpful to other plastic surgery programs at academic medical centers.     

呼吸道过敏性疾病与社会心理因素双向关系的Meta分析

目的：系统评价呼吸道过敏性疾病和社会心理因素的关系。方法：计算机检索Cochrance图书馆、Medline、EMbase、Pubmed、CBM、CNKI等数据库,查找包括心理社会因素对呼吸道过敏性疾病的影响或者呼吸道过敏性疾病对精神健康影响的临床研究。根据纳入和排除标准选择文献,对符合纳入标准的文献进行Meta分析,计算其合并OR值及95％CI。结果：共纳入20个病例研究（13篇文献）,其中13个研究评估心理社会因素对呼吸道过敏性疾病的影响,7个研究评估效果呼吸道过敏性疾病对心理健康的影响。在这些研究中呼吸道过敏性疾病是评估哮喘和过敏性鼻炎。Meta分析结果显示社会心理因素和呼吸道疾病的发生发展有关[OR=1．77,95％CI（1．42,2．22）],呼吸道过敏性疾病与未来不健康的心理发生发展有关[OR=1．73,95％CI（1．47,2．03）]。结论：当前的研究发现呼吸道过敏性疾病和社会心理因素有很大的关系。这支持在呼吸道过敏性疾病治疗除了传统的生理和药理干预外,心理干预呼吸道对过敏性疾病的预防和管理也发挥作用。     

Female college students and cosmetic surgery: an investigation of experiences, attitudes, and body image

This large, multisite study investigated female college students' experiences with and attitudes about cosmetic surgery. The study also assessed the relationship between several aspects of body image, including appearance satisfaction and investment and symptoms of body dysmorphic disorder, and interest in cosmetic surgery. Thirty (5 percent) of the 559 women surveyed reported that they had undergone cosmetic surgery. Two thirds of respondents reported knowing someone who had received cosmetic surgery, and approximately one third indicated that a family member had undergone surgery. Overall, participants held relatively favorable attitudes about surgery. Regression analysis suggested that a greater psychological investment in physical appearance and greater internalization of mass media images of beauty predicted more favorable attitudes toward cosmetic surgery. Fourteen women (2.5 percent) screened positive for body dysmorphic disorder based on the nature and severity of their self-reported body-image concerns. Results of this study provide new information on young women's experiences and attitudes about cosmetic surgery and how these attitudes relate to body image.     

Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty.

Although plastic surgeons have empirically "known" of the benefits of reduction mammaplasty for their patients, a paucity of outcome studies have been reported. For this study, an attempt to perform a meta-analysis of outcomes in reduction mammaplasty was undertaken. A computer literature search was performed of the MEDLINE database for the period between 1966 and September of 1997 for the Medical Subject Headings mammaplasty and outcome measures. Reference lists were used for additional reports. No trials were identified that met the criteria for meta-analysis. Seventeen publications met less restrictive review criteria that evaluated quality-of-life outcome measures. A systematic evaluation of patient-focused outcome measures demonstrated that consistent improvement in physical symptoms was found across most studies, as was a high degree of patient satisfaction (78 to 95 percent very or moderately satisfied), and some have shown improvement in body image and psychological well-being. However, although this review does identify consistent improvements in patient quality of life after reduction mammaplasty, inconsistencies among study designs do not allow formal meta-analysis.     

Prospective evaluation of late cosmetic results following breast reconstruction: II. Tram flap reconstruction

Although it is thought that transverse rectus abdominis muscle (TRAM) flap breast reconstruction produces excellent cosmetic results that are maintained over the long term, there is little objective evidence in the literature to support this. One hundred seventy-one consecutive patients who underwent TRAM flap reconstruction were prospectively analyzed over an 8-year period to assess their morbidity and late cosmetic outcome.The early patient complication rate (< 2 months) was 37.4 percent, the late hernia and fat necrosis rates (> 2 months) were 8.8 and 13.5 percent, respectively, and the contralateral symmetrization rate was 33.9 percent. The cosmetic results were evaluated prospectively using an objective five-point global scale. Each patient was scored at each visit once surgery was completed. Follow-up continued until a flap was lost, a patient died, or the point of last patient contact was reached. Six patients died during the study. The actuarial percentage cosmetic outcome remained stable during the study period, with an acceptable result in 96.4 percent of patients at 2 years and in 94.2 percent of patients at 5 years. Only five patients in this series obtained poor cosmetic outcomes, with three due to substantial flap necrosis and two because of poor flap design. Two free TRAM flaps were also lost. Log-rank analysis revealed that neither patient age nor timing of surgery significantly affected the cosmetic outcome. Single pedicle and supercharged (single pedicle) TRAM flaps produced slightly better results than bipedicle and free TRAM flaps. In this prospective longitudinal study, TRAM flap reconstructions were shown to produce aesthetically pleasing results. Moreover, with long-term follow-up, it was demonstrated that these reconstructions maintained their stability.     

Clinical determinants of patient satisfaction with breast reconstruction

The main objective of this study was to examine the relationship between specific treatment variables and patient satisfaction with breast reconstruction. A questionnaire was developed that included questions on population demographics and satisfaction with the reconstruction. Of 206 women who completed the questionnaire, 23 (11.2 percent) responded that they were not satisfied, whereas 183 (88.8 percent) indicated that they were satisfied overall. A detailed retrospective chart review permitted a comparison of the treatment received by these two groups. Variables analyzed included patient age, time since surgery, reason for surgery, method and timing of reconstruction, additional surgical procedures received (mound revisions and nipple-areola complex reconstruction), and postoperative complications. Data analysis showed that the treatment received by the two groups was similar in many respects. There was no statistical association between the method or timing of reconstruction and a patient's satisfaction with the results. Furthermore, there was no difference in the number of mound revisions or nipple reconstructions performed on satisfied versus dissatisfied patients. However, the latter group experienced a substantially higher incidence of postsurgical complications (27 percent versus 61 percent, p = 0.0015). Patients were also asked to provide a written response explaining their feelings on breast reconstruction. Satisfied patients described benefits from reconstruction such as improved appearance or feelings of normalcy and wholeness. Conversely, unsatisfied patients were displeased because of poor cosmetic results, complications with the reconstructed breast, or abdominal problems. Although overall satisfaction with breast reconstruction is undoubtedly determined by multiple and complex clinical, emotional, and psychological factors, this study suggests that postoperative complications are a particularly important indicator of dissatisfaction with reconstruction.     

Breast reconstruction in women treated with radiation therapy for breast cancer: cosmesis, complications, and tumor control.

The records of 55 patients who had breast cancer treated by mastectomy, irradiation, and breast reconstruction were reviewed for cosmetic outcome, complications, and tumor control. Median follow-up was 35 months. Local control rates were 95 percent in patients treated for high risk factors or breast conservation and 85 percent in patients treated for recurrent breast cancer. Acceptable cosmetic results were obtained in only 42 percent of patients. The incidence of complications was 55 percent. Transverse rectus abdominis muscle (TRAM) reconstructions gave superior cosmetic results compared with all other types of reconstructions. The timing of reconstruction in relation to mastectomy or radiation therapy did not significantly influence cosmetic outcome, although other factors suggest that delayed reconstruction may give better results. A majority of patients were satisfied with cosmetic outcome.     

The Impact of Coronavirus Disease 2019 on Bariatric Surgery: Redefining Psychosocial Care

The global outbreak of the 2019 novel coronavirus disease has had a tremendous psychological impact on individuals around the world. Individuals with obesity are susceptible to distress and psychological sequalae secondary to this pandemic, which can have detrimental effects on obesity management. In particular, individuals undergoing bariatric surgery could experience increased emotional distress, resulting in increased eating psychopathology, mental health exacerbation, and difficulties with self‐management. Addressing these challenges requires novel approaches to redefining psychosocial care before and after bariatric surgery. Emerging evidence suggests that the remote delivery of care using virtual care models, including mobile and online modalities, could extend the reach of psychosocial services to individuals after bariatric surgery and mitigate weight regain or impairment in quality of life. Because of this pandemic, the rapid integration of virtual psychosocial care in bariatric surgery programs to address patients’ needs will create new opportunities for clinical and implementational scientific research.     

Conservation therapy for breast cancer following augmentation mammaplasty

Breast conservation therapy (wide local excision, axillary lymph node dissection, and whole-breast irradiation) is an increasingly popular alternative to mastectomy for breast cancer patients. A sizable (and growing) number of breast cancers occur in women with prior augmentation mammaplasty. Augmented breast cancer patients are currently being treated with conservation therapy, but no study has investigated complications and cosmetic results of radiation therapy specifically in this group of women. Between 1981 and 1988, we used conservation therapy in 17 augmented breast cancer patients. Fifteen patients were available for follow-up. In 10 (67 percent), significant capsular contracture occurred in the irradiated breast an average of 12 weeks following completion of treatment. Four patients have undergone revisionary surgery to correct symptoms arising from contracture. This poor outcome contradicts the results reported in previously published studies. We conclude that irradiation of the breast for cancer in augmented women results in a high incidence of scar-tissue contracture and poor cosmetic results.     

Prophylactic mastectomy: indications, options, and reconstructive alternatives

Prophylactic mastectomy continues to be a controversial procedure as a preventive tool against breast cancer. Recent research and other scientific advances, however, have refocused attention on better risk estimation, evidence of efficacy, and improvements in reconstruction. The recently discovered genetic markers BRCA1 and BRCA2 have become increasingly important in determining risk; a BRCA1-positive patient's risk of developing breast cancer by the age of 65 is estimated at 50 percent to 80 percent. BRCA1- and BRCA2-positive breast cancers also tend to be higher grade and occur in younger women (making mammography less effective). Genetically linked breast cancers are usually estrogen receptor negative, making them less susceptible to chemoprevention. Various predictive models and recommendations by experts in the field are also available for today's clinicians to ascertain who should be genetically tested. The benefit of bilateral prophylactic mastectomy, although difficult to estimate, can be evaluated by looking at the incidence of breast cancer in studies of patients who have previously undergone prophylactic mastectomy. The estimated risk reduction from these studies is 80 percent to 95 percent. Similarly, life expectancy is believed to be increased from 2.9 to 5.3 years. The psychological benefits include a 70 percent rate of satisfaction and a decrease in emotional concern over developing breast cancer by 74 percent of women who underwent prophylactic mastectomy. Although reconstruction results may vary, most patients have been very satisfied and some may achieve cosmetic results that are better than their preoperative situation. Patient selection for specific types of reconstruction after prophylactic mastectomy and the decision to proceed should be based on surgical risk and the likelihood of a good outcome. The choice of mastectomy incision should consider the size of the breast, preexisting scars, patient risk factors, and the planned method and goal of reconstruction. The authors propose certain guidelines based on degree of ptosis and cup size when planning prophylactic mastectomies with reconstruction. In certain cases, a nipple-sparing mastectomy may provide cosmetic advantages that could outweigh the additional oncologic risk.     

Asymptomatic cervical bruits.

The diagnosis, significance and management of asymptomatic cervical bruits have been the focus of considerable controversy. The literature does not support an aggressive approach but, rather, careful follow-up of patients with this disorder. This paper reviews the available data and discusses the management options of family practitioners who may detect this disorder during a routine physical examination, during an examination prompted by an unrelated problem or preoperatively when elective surgery is being considered.     

Antibiotic use in aesthetic surgery: a national survey and literature review

Although much has been written regarding the use of antibiotics in surgery, no clear guidelines exist in the literature regarding the use of antibiotics in aesthetic surgery. To determine the pattern of antibiotic use in aesthetic surgery, a comprehensive survey was mailed to 6000 American Society of Plastic and Reconstructive Surgeons members and candidates. A total of 1767 completed responses were returned, which represents a response rate of 30 percent. The type, route, and duration of antibiotic administration are reported for 10 common cosmetic surgical procedures. The results of the survey confirmed that there is widespread use of antibiotics in aesthetic surgery. To provide guidelines for proper antibiotic use, the current literature was extensively reviewed. The authors found little or no correlation between reported clinical practice and the literature. It is hoped that this study will stimulate further investigation into this area of aesthetic surgery.     

Prospective evaluation of late cosmetic results following breast reconstruction: I. Implant reconstruction

The long-term cosmetic outcome of breast implant reconstruction is unknown. The morbidity and cosmetic outcome of 360 patients who underwent immediate postmastectomy breast reconstruction with various types of implants have been analyzed prospectively over a 9-year period. Of these patients, 334 who completed their reconstruction were suitable for evaluation of their cosmetic outcome. The early complication rate (< 2 months) was 9.2 percent, with an explantation rate of 1.7 percent. The late complication rate (> 2 months) was 23 percent, with a pathological capsular contracture rate of 11 percent at 2 years and 15 percent at 5 years and an implant removal rate of 7 percent. The revisional surgery rate was 30.2 percent.The cosmetic results were assessed prospectively using an objective five-point global scale. Every patient was scored at each visit once surgery was completed. The overall cosmetic outcome deteriorated in a linear fashion, from an initial acceptable result of 86 percent 2 years after patients completed their reconstruction to only 54 percent at 5 years. This decline in cosmetic outcome was not associated with the type of implant used, the volume of the implant, the age of the patient, or the type of mastectomy incision employed. Radiotherapy was not a significant factor because only 28 patients were irradiated. Upon Cox model analysis, pathological capsular contracture was the only factor that contributed significantly to a poor cosmetic outcome in which p < 0.0001 (relative risk 6.3). Despite a high revisional surgery rate, deterioration still occurred, suggesting that other unaccounted for variables were responsible. On photographic retrospective review of the patients without capsular contracture who demonstrated deterioration in their cosmetic scores, it became clear that a possible reason for their poor results was late asymmetry produced by the failure of both breasts to undergo symmetrical ptosis with aging.     

Satisfaction with breast reconstruction in women with bilateral prophylactic mastectomy: a descriptive study

Prophylactic bilateral mastectomy is an option for women who are at an increased risk of developing breast cancer. Prophylactic mastectomy is often performed with immediate reconstruction (i.e., at the same time and under the same anesthetic as the mastectomy). Satisfaction with reconstruction has been described previously for women with mastectomy for breast cancer. However, the authors know of no previous research that has reported on satisfaction with reconstruction in patients who have electively sought mastectomy for the prevention of breast cancer. Women in the province of Ontario who had undergone prophylactic bilateral mastectomy plus breast reconstruction between 1991 and 2000 were asked to rate their level of satisfaction with the cosmetic results of their mastectomy and reconstruction and their overall satisfaction with their decision to have prophylactic mastectomy. Women were also asked whether they experienced complications associated with their surgery and what types of complications they experienced. Thirty-seven women completed questionnaires for this study, and all of them had immediate breast reconstruction after prophylactic mastectomy. The majority of women (70.3 percent) reported being satisfied or extremely satisfied with the cosmetic results of their breast reconstruction. Women with self-reported postsurgical complications (16.2 percent) were significantly less satisfied with reconstruction than those who did not report complications (p = 0.009). Personal subjective risk of breast cancer before prophylactic mastectomy was negatively correlated with satisfaction with reconstruction (r = -0.38, p = 0.024) and with subjective risk estimation after prophylactic surgery (r = -0.54, p = 0.001). Women who did not worry about developing breast cancer after prophylactic mastectomy had significantly higher levels of satisfaction with breast reconstruction than those who continued to worry (p < 0.001). Women who reported an improved body image after reconstruction were significantly more likely to report higher levels of satisfaction than those who reported a diminished body image (p = 0.007). The majority of women were satisfied with the cosmetic results of breast reconstruction after prophylactic mastectomy. Women who overestimated their breast cancer risk had lower satisfaction levels. Correcting overestimation of breast cancer risk in women who have prophylactic mastectomy may improve satisfaction with reconstruction following prophylactic mastectomy.     

Behavioral and Psychological Factors in the Assessment and Treatment of Obesity Surgery Patients

Objective: To provide evidence‐based guidelines on the psychological and behavioral screening of weight loss surgery (WLS) candidates and the impact of psychosocial factors on behavior change after gastric bypass surgery. Research Methods and Procedures: The members of the Behavioral and Psychological subgroup of the Multidisciplinary Care Task Group conducted searches of MEDLINE and PubMed for articles related to WLS, behavior changes, and mental health, including quality of life (QOL) and behavior modification. Pertinent abstracts and literature were reviewed for references. A total of 198 abstracts were identified; 17 papers were reviewed in detail. Search periods were from 1980 to 2004. Results: We found a high incidence of depression, negative body image, eating disorders, and low QOL in severely obese patients. Our task subgroup recommended that all WLS candidates be evaluated by a licensed mental health care provider (i.e., psychiatrist, psychologist, or social worker), experienced in the treatment of severely obese patients and working within the context of a multidisciplinary care team. We also recommended development of pre‐ and postsurgical treatment plans that address psychosocial contraindications for WLS and potential barriers to postoperative success. Discussion: The psychological consequences of obesity can range from lowered self‐esteem to clinical depression. Rates of anxiety and depression are three to four times higher among obese individuals than among their leaner peers. A comprehensive multidisciplinary program that incorporates psychological and behavior change services can be of critical benefit in enhancing compliance, outcome, and QOL in WLS patients.