Bruce Shack, M.D.
Proper screening key to plastic surgery success
Some plastic surgeons are expressing concern that a perception is being created that women who undergo breast augmentation will eventually become suicidal, and that appropriate consideration of a patient's psychological makeup may not be employed by surgeons as they consider potential cosmetic surgery candidates.
A study by researchers from the Vanderbilt-Ingram Cancer Center, appearing in the August issue of Annals of Plastic Surgery, reported an increased risk of suicide among women in Sweden who underwent cosmetic breast augmentation surgery between 1965 and 1993, compared with women in the general population. The study raised interesting questions about psychological aspects of breast augmentation that may warrant further exploration.
“As plastic surgeons, as individuals and as a group, we have to take the findings of these studies seriously,” said Bruce Shack, M.D., professor and chairman of the Department of Plastic Surgery. “However, plastic surgeons in the U.S. are trained, and in fact it is inculcated into our culture, to question our prospective patients, especially our cosmetic surgery patients, about any psychiatric issues.
“The increase in the incidence of suicide did not appear until 10 years post-augmentation in this study. I would defy even the best psychiatrist in the world to predict what someone's psychological condition will be 10 years in the future.”
The VICC study's findings garnered national and international media attention for authors Joseph McLaughlin, Ph.D., professor of Medicine, and Loren Lipworth, Sc.D., assistant professor of Preventive Medicine. Their findings were also consistent with four previous studies.
McLaughlin and Lipworth found that after an average follow-up of almost 19 years, the suicide rate was three times higher for Swedish women who had cosmetic breast augmentation compared with that nation's general population. The study also found that suicide rates did not increase significantly for this group until at least 10 years after implant surgery, although other studies have reported excess suicide in the first 10 years. The risks for deaths due to alcohol and drug dependence and abuse were also significantly elevated. The authors concluded that, despite reports of high levels of satisfaction among women receiving implants, the increased risk of suicide is likely related to pre-existing psychiatric illness among a subset of women seeking this elective procedure.
Shack said plastic surgeons trained in America's surgical residency programs are taught to question and explore patients' motivations and expectations when screening prospective cosmetic surgery candidates.
“If patients are seeking cosmetic surgery in hopes of obtaining some secondary gain such as saving a failing marriage, getting that job they are afraid a younger person will take from them, getting a new boyfriend, or whatever it might be, if that secondary gain does not come about, then they are going to be disappointed with the results no matter what, even though it may have been a great operation,” he said.
Shack said that patients who seek cosmetic surgery are carefully screened to make certain their motivations are internal, that they are seeking surgery for their own personal improvement.
“Many times with cosmetic surgery, secondary gains will spring from the surgery's results. The person becomes more outgoing, they become more social and perhaps happier,” he said.
A 2003 survey, reported by The American Society for Aesthetic Plastic Surgery, examined patient satisfaction for 5,000 American women after breast augmentation. The study found that 92 percent of women reported being happy with their results. The same percentage reported positive effects on their overall appearance, while 93 percent said they would recommend the procedure to friends or family members.
This same survey reported that 96 percent of respondents said they were told by surgeons what to expect after surgery, and 93 percent were told about specific complications that might be associated with breast implants.
However, this and other studies have been unable to evaluate long-term satisfaction among women with cosmetic breast implants.
“This is an extremely successful operation in most people's opinions,” Shack said. “Nonetheless, you can't ignore the findings about breast augmentation and suicide. While I think this issue does warrant additional examination, in fact, most patients who have cosmetic surgery say their lifestyle is improved by it. Their overall well-being is improved by it. They feel better about themselves.”
Shack said the key to a satisfied patient lies in the pre-operative screening process. “Every good plastic surgeon in the United States, and in most other countries around the globe I suspect, refuses to operate on someone if they suspect the patient is not going to be happy with the result, regardless of how good the outcome happens to be,” he said. “All of the expectations have to be worked out during the consultation process prior to the surgery.”
Shack said there are subtle psychological warning signs some prospective patients exhibit during the consultation process that will raise suspicion for properly trained surgeons.
“One of the first red flags is when the patient says to the surgeon, 'Doc, just look at me and tell me what I need,' ” he said. “If someone really doesn't have a concern and doesn't know what it is they want to have corrected, then that's a red flag because they may be seeking surgery not for themselves or not because they really want it. Although I think it is intuitively obvious in many cases, the questions still have to be asked such as whether the patient has had any emotional problems. If so, then this needs to be explored further.
“Someone once said that a good plastic surgeon has to be about 60 percent surgeon and about 40 percent psychiatrist,” Shack said. “I think there is some truth to this because some people seek surgical solutions to some of their problems that may not be addressed by that surgical procedure. This is what the surgeon must be able to discern. And I think most plastic surgeons are pretty good at this.”