The psychology behind cosmetic surgery. The why and how it helps and the dangers of Body Dysmorphia Syndrome.

1. Aesthetic Surgery
Creating Beauty to Cure the Soul
by Sander Gilman
1998
Review by William C. Brender, MD

2. Aesthetic Surgery
Jacques Joseph
Nasenplastik und sonstige Gesichtplastik
1931

3. Aesthetic Surgery
“We restore, repair and make whole,
those parts which nature has given but
which fortune has taken away, not so
much that they may delight the eye, but
that they buoy up the spirit and help the
mind of the afflicted.”
Jasper Tagliacozzi 1597
Father of Plastic Surgery

4. Aesthetic Surgery
(Reconstructive Surgery is) “an attempt
to return to normal,
Aesthetic surgery is an attempt to surpass
the normal.”
Harold Delf Gillies 1882-1960

5. Aesthetic Surgery
Surgeons were concerned about aesthetic results:
• careful suturing of edges of facial wounds
• nasal fractures reduced and splinted
Papyrus (3,000 BCE)

6. Aesthetic Surgery
Importance of “beautiful” suture stressed
Cornelius Celsius (25 BCE - 50 CE)

7. Aesthetic Surgery
“(Billroth performed) plastic operations with artistic
ability to correct defects of beauty...one could see his
joy when he was able to successfully improve the
appearance of a damaged person, so that that
person was no longer the object of pity or horror.”
Theodore Billroth (1829-1894)

8. Aesthetic Surgery
“Beauty is the outward and visible sign of
health - perfection - virtue….”
Jules Hericourt (1850-?)

9. Aesthetic Surgery
Beauty Myth
“The accepted wisdom is that if you
understand your body as “ugly”, you bound
to be “unhappy””

10. Aesthetic Surgery
Mens Sana in corpore sano
The mark of the healthy body is the happy soul
Mens non sana in copore insano
The mark of the unhealthy body is the sick soul

11. Aesthetic Surgery
• Modern society - attempt to change our
body - diet, cosmetics, fashion and surgeons
• Pursuit of “Body Beautiful”/“Happy Soul”.

12. Aesthetic Surgery
“Plastic surgery with the aesthetic as well
as the reparative objective, will be
commonplace in another five years, as
neatness and cleanliness are today”
Henry Schireson (1881-1949)

13. Aesthetic Surgery
Widespread Acceptance
No longer limited to “Rich”
Status symbol in South America

14. Aesthetic Surgery
Increased number of procedures performed
liposuction - #1
breast enlargement - #2
eyelid correction - #3
chemical peels - #4
facelift - #6
(breast reduction - reconstructive - #5)

15. Plastic Surgery
Male Cosmetic Surgery
1992 13%
1997 33%

16. Aesthetic Surgery
Benefit psychologically
“self conscious”
“social acceptance”
“positive” change in appearance
improve professional chances
increased admiration

17. Aesthetic Surgery
This artistic branch of surgery has long
been perceived as “frivolous” and not
“serious” medicine.

18. Aesthetic Surgery
Performed nose jobs on three members of
same family in “vaudeville” manner
People in audience fainted
Reinforcing the tasteless aspect of advertising
J. Howard Crum (1888-c.1970)
?performed first facelift

19. Aesthetic Surgery
Core of the Psychological theory of
Aesthetic Surgery:
Curing the Physically Anomalous is curing the
Psychologically Unhappy.

20. Aesthetic Surgery
“….did not claim only to cure the “pug
nose”; he claimed also to be curing his
patient’s unhappiness”
John Orlando Roe (1849-1915)
Rochester, New York

21. Aesthetic Surgery
Beautiful is a sign of the healthy and in
modernity the healthy becomes a sign
of the happy.

22. Aesthetic Surgery
Prozac nicknamed Cosmetic surgery of
the Brain
Decline in stigma associated with Aesthetic Surgery
parallels the change in stigma of mental illness.

23. Aesthetic Surgery
“People have the feeling they can’t control
their own future; that working hard and
being a good citizen won’t get you
anywhere, That’s why beauty has
become the main value in the market.”
Marcelo Hernandez
Argentinean psychiatrist

24. Aesthetic Surgery
“often…compared cathartic
psychotherapy with surgical
intervention.”
“convinced that the patients would benefit
if we were more often to hand over the
treatment of these affections to the
rhinological surgeons.”
Sigmund Freud (1856-1939)
Studies of Hysteria (1895)

25. Aesthetic Surgery
Reversal of Traditional Medical Model
• Classic model - the patient comes to the physician
who makes a diagnosis and then provides the
treatment.
• New model - the patient tells the doctor the diagnosis
and how they want it treated.

26. Aesthetic Surgery
Reversal of Traditional Model
Classic model - operation is performed on a deformed
patient to make them look normal
New model - operation is performed on a healthy patient
to enhance the way they look

27. Aesthetic Surgery
“…the idea that we get a permit to
operate on someone who is totally
normal is an unbelievable privilege. In
a way it’s the ultimate surgery.”
Joseph M. Rosen MD
Dartmouth-Hitchcock Medical Center

28. Aesthetic Surgery
Definition of heath - “a state of complete
physical, mental and social well-being.”
World Health Organization

29. Aesthetic Surgery
Cosmetics -adjunct of treatment (disguise) of
illness
Origin of “cosmetic surgery” - late 19th
century subspecialty of “medical cosmetics”
- disguise of syphilitic’s symptoms (i.e.
missing nose or ulcerated lesion )

30. Aesthetic Surgery
Medicamenti faciei
make up as a form of medication for the soul
Ovid (43 BCE - 17/18 CE)

31. Aesthetic Surgery
The study of the ugly is to the
examination of beauty what the study of
pathology is to illness.
Karl Rosenkranz (1805-1879)

32. Aesthetic Surgery
Caveat: One culture’s “normal” is another
culture’s ugly.
Rod Sterling (1924-1975)
The Twilight Zone 11/11/60
Eye of the Beholder

33. Aesthetic Surgery
“Charum”
Men who are “flat-nosed” or
snub-nosed are forbidden
from becoming priests.
Aimed against those with leprosy who were seen as
ritually unclean. The unclean is also the ugly, and the
unhappy.
Leviticus 21:18

34. Aesthetic Surgery
“absence of the nose is a horrible thing to
look at.”
Erik, the Phantom
Phantom of the Opera (1911)
Gaston Leroux (1868-1927)

35. Aesthetic Surgery
All lost noses, in the age of syphilophobia,
were signs of sin. Syphilis marked the
face of the naïve and the innocent as
well as the lecher and hypocrite.

36. Aesthetic Surgery
“Big noses” cannot mate with “little noses”
Edmond Rostand (1868-1918)
Cyrano de Bergerac 1897

37. Aesthetic Surgery
The Jewish Visage
The “unmanly” “bodily infirmity”
The tubercular Jewish woman
THE JEWISH NOSE

38. Aesthetic Surgery
Nostrility
The anatomy of the Jew in which the “hooked nose”
represents the first visual representation of the
“Primitiveness of the Semitic race”
“Dr. Celticus”
Anti-Semitic Pamphleteer

39. Aesthetic Surgery
The Nose was a Sign of the Jew’s Nature.
A sign that does not vanish when the Jew is
acculturated.
Being seen as a Jew meant being persecuted, attacked,
and harassed.
Alteration of the body through surgery was seen as the
“cure”.

40. Aesthetic Surgery
Tradition of the Sweet Sixteen Nosejob
Aesthetic Surgery comes to be understood as
“Somatopsychic Therapy”

41. Aesthetic Surgery
The Deformity affects the Conscious Mind
through the Patient’s Reception in
Society.
The Operation alters the Perception of the
Body in others and thus alters the
Patient’s Consciousness.

42. Aesthetic Surgery
The focus of the patient’s unhappiness is
on their fixed (racial) physiognomy
Image of the African Face: low forehead, flat wide nose
Enrico Morselli (1852-1929)

43. Aesthetic Surgery
“We, belonging to the higher races,
regard as ugly all noses which
approach that of the ape…”
Paolo Mantegazza (1831-1910)

44. Aesthetic Surgery
PLUMPNESS - Double Edged Sword

45. Aesthetic Surgery
PLUMPNESS - Double Edged Sword
“Normal” women can be plump and are therefore
“healthy”.
“Criminal” women, such as prostitutes are plump, a sign
of their “natural” tendency to their craft.”
Cesare Lombroso (1835-1909)

46. Aesthetic Surgery
Micromastia
? Real Diagnosis
? American Culture
“Feel less of a Woman”
Desire the fullness of pregnancy

47. Aesthetic Surgery
“Ideal patient is someone who, in the
aesthetic sense, is less than optimal,
but who otherwise is well adjusted.”
Jim Pietraszek, MD , La Jolla, CA

48. Aesthetic Surgery
Ability of the patient to tell a complete
narrative is a predictor of positive
outcome.
Inability to narrate is a sign of
psychological instability.

49. Aesthetic Surgery
“Unhappiness” is a problem of your fictive life, rather
than your ill organs.
“You are what you imagine yourself to be.”
Hans Vaihinger (1852-1933)

50. Aesthetic Surgery
“The anomaly of the unhappy patient….is
explained as a too heightened
sensitivity to beauty”
Jacques Joseph (1865-1934)

51. Aesthetic Surgery
Joseph’s Psychological Scale
Hypo-aesthetic - unfazed even by gross deformities
Ortho-aesthetic - normals who can “objectively” evaluate their
deformities
Hyper-aesthetic - “extremely unhappy” with strongly developed
sense of beauty such as painters, sculptors, and others with artistic
nature
Para-aesthetic - pathologic aesthetic sensibility focus on “imagined
deformities”. Have normal or even beautiful features that do not need
change.

52. Aesthetic Surgery
“Bad” Patient Qualities
male, unmarried, twenty to thirty-five. low self esteem,
grandiose ambitions, hyposexual with no long term
relationships, extremely obsessive yet passive with
surgeon, aggressive when not accommodated, anxious,
vague about goals of surgery, dissatisfied following
initial postop enthusiasm, minimized problem
Knorr, Edgerton, and Hoopes
John Hopkins University

53. Aesthetic Surgery
Dependent and Controlling Females who
Hate the Aging Process
Any violation of the body engenders exacerbation of
neurosis even with the normal patient.
Evidence of depressive symptoms preoperatively will
be intensified in the immediate postoperative period
Erich Lindermann (1900-1974)

54. Aesthetic Surgery
Negative Result of Surgical Intervention
Exacerbation of unhappiness through the patient’s
experience of trauma awaken existent psychic
patterns.
Helene Deutsch (1884-1982)

55. Aesthetic Surgery
“Monomania”
Male patients requested multiple nasal procedures
The “normal” nose still made the patient unhappy
1892 paper
Robert F. Weir (1838-1894)

56. Aesthetic Surgery
Polysurgery
The demand for repeated surgery
A sign of psychopathology

57. Aesthetic Surgery
Dysmorphophobia
Compulsive disorder
Anxiety about having something “obvious or comical”
about one’s body
(i.e. unusually formed nose, knock-knees, disgusting
odor)

58. Aesthetic Surgery
Dysmorphophobia
Preoccupation with some imagined defect in
appearance in a “normal”-appearing persons or the
exaggeration of a slight physical anomaly
(i.e. bald head, nose (male), ears, breast (women)

59. Aesthetic Surgery
Nasal Neurosis
male obsession
three qualities (big, ugly, asymmetrical)
Phallic Nature of the Nose (Ex Naso Viris Hastam)
Nose reveals the “Castrated”/Circumcised nature of the
man with the long nose, where you are a Jew or not

60. Aesthetic Surgery
Freud’s Little Hans
“if - says the child - I can be circumcised and made into
a Jew, can I not also be castrated and made into a
woman?”

61. Aesthetic Surgery
Nasal interventions
One cure for sexual dysfunction and hysteria was to
operate on the nose
Shared relationship embryologically between the tissue
of the nose and that of the genitalia
Male menstruation - “occasional bloody nasal
secretion”
Wilhelm Fliess (1858-1928)

62. Aesthetic Surgery
“The “surgical quack” is the surgeon who
does harm, (and) who almost kills the
patient. “
Sigmund Freud
Psychoanalysis and Quackery

63. Aesthetic Surgery
Breast Obsession
Female Equivalent of Nasal Neurosis
Large Pendulous Breasts - Mark of the Primitive
Caucasian breast - hemispherical shape
African breast - pointed breast shape

64. Aesthetic Surgery
Thersites- Complex
Compulsive sense of being seen as ugly because of a
specific quality of the body
named after ugliest man in Greek army at Troy
Homer’s Iliad - most vicious warrior, not aware of his
ugliness
Hermann Stutte (1909-)

65. Aesthetic Surgery
Body Dysmorphia Syndrome
1980 - excessive concern with an “imaginary” defect
Patients believe themselves to be “quite ugly” and are
convinced that they “could be very attractive if some
changes were made surgically”
1994 - preoccupation with a defect in appearance
which either “excessive” or “imagined”

66. Aesthetic Surgery
DMV IV - preoccupation with an
imagined defect, causing clinically
significant stress or impairment of
social, occupational, or other important
areas of functioning, not accounted for
by another mental disorder.

67. Aesthetic Surgery
BDD
Obsessive compulsive disorder
Late 20s or early 30s
Affects both men and women
Avoid describing their defects in detail
Their preoccupations are self-described as “intensely
painful” “tormenting” or “devastating”
Requires psychopharmacological intervention
?Michael Jackson - 30 operations

68. Aesthetic Surgery
Dysmorphophobia is not necessarily an
indicator to the surgeon not to operate -
but you may put your own life at risk
M Tavis MD

69. Aesthetic Surgery
Polysurgical Addiction
A compulsive need for surgical interventions
Whose search for perfection/(in)visibility, means they
will never be satisfied
“Castration anxiety” center of male desire for repetitive
surgery
Women undertake surgery to “fulfill an ungratified
infantile wish for a child”
Karl A. Menninger (1893-1990)

70. Aesthetic Surgery
“Surgeon’s intuitive response”
knowing a difficult or dangerous or unhappy patient
when one sees one

71. Aesthetic Surgery
“Recommend a Simple Interview
Question Method of Counseling
designed to Identify Underlying
Psychological Manifestations and to
control the Problem Patient.”
MR Wright and WK Wright

72. Aesthetic Surgery
Psychological Testing
Minnesota Multiphasic Personality Inventory
Patient Attitude Scale
Expectation for Plastic Surgery Scale
Esthetic Analysis Form (dentistry)

73. Aesthetic Surgery
The act of narration is one of the marks of a healthy
psyche.
“The patient’s inability to state accurately and succinctly
the thing that displeases him.”
“The more pronounced the deformity of loss, the more
apt is a reasonably good result likely to be
acceptable.”

74. Aesthetic Surgery
“Cosmetic surgery appeals to vain people.
There many idle men and women who have
nothing to do but study themselves….learn
to avoid these psychopaths.”
Charles Conrad Miller (1880-1950)

75. Aesthetic Surgery
The problem patients are dangerous and
difficult, they are never happy with the
results and they sue!

76. Aesthetic Surgery
“Anything that attracts notice to a child in
an unpleasant way is, as a rule, bad for
the child.”
Vilray Papin Blair (1871-1955)

77. Aesthetic Surgery
“..a nasal defect may produce such an
inferiority complex as genuinely to
hinder the patient’s happiness and
progress.”
Harold Delf Gillies
New Zealand reconstructive surgeon

78. Aesthetic Surgery
“Thesurgeon seeks to ease the mind by
remolding the…features to a conformity
with the normal.”
Maxwell Maltz, MD
Chicago aesthetic surgeon
New Faces, New Futures (1936)

79. Aesthetic Surgery
“The result of aesthetic surgery can be
“..an infusion of confidence, and a
losing of sensitiveness which
sometimes amounts to an inferiority
complex.”
George Warren Pierce, MD
San Francisco surgeon

80. Aesthetic Surgery
“prejudice and discrimination - real or
imagined - and the desire to “look
American” played a substantial role in
the motivation for surgery”
Francis Cooke Macgregor 1989

81. Aesthetic Surgery
“Passing” remains a major goal of aesthetic surgery
“Disfigurement becomes the last bastion
of discrimination”
Angus McGroughter
British Aesthetic Surgeon

82. Aesthetic Surgery
Body sculpture and Psychic Surgery may
be closely related.
Passing is either acquiring “health” and “happiness” or
being seen as “ill or “psychopathological”. Both are
attributed to the individual who wishes to “pass”
unnoticed.

83. Aesthetic Surgery
Tagliacozzi Myth
Condemned after his death for his “attempt to improve
upon the work of the Almighty”
Chastised for his practice of plastic surgery
This was a religious problem not exclusively a Jewish
problem
Gaspare Tagliacozzi (1545-1599)
Father of Plastic Surgery

84. Aesthetic Surgery
“Chavalah” (Wounding)
Traditional Judaism rejects surgical alteration of the
body except for reconstructive surgery
Halachic tradition would permit alteration of the shape of
the nose for men and women for psychological
reasons

85. Aesthetic Surgery
“Cosmetic Surgery” is justified if
the defect:
1/prevents a woman from finding a marriage partner
2/prevents a happy relationship with her husband
3/prevents a person from fulfilling a constructive
function in society - this applies especially to men
who without such improvement could not earn
enough to support their families
Secular Reposa

86. Aesthetic Surgery
Aesthetic surgery can be sanctioned if it
ameliorates “grave psychological
effect…such as a sense of inferiority”.
At this point it is not “only permissible but also a
necessity”
Father Charles G. O’Leary
Principle of Totality

87. Aesthetic Surgery
“Aesthetic surgery is not in contradiction
to the will of God, in that it restores the
perfection of the greatest work of
creation, man.”
Pope Pius XII

88. Aesthetic Surgery
Women and Plastic Surgery
Aesthetic surgery is seen as a means of placing the
woman in a Position of Power concerning her own
body or is seen as making her complicit with
Patriarchal Standards of Beauty.

89. Aesthetic Surgery
“The purpose of cosmetic surgery is to
improve a person’s psychological
functioning by modifying their body
image.”
Gregory Borah, MD

90. Aesthetic Surgery
Aesthetic Surgery makes patients truly happy by
restoring the ideal state that already exists in the
patient’s imagination.
Aesthetic surgery does not remove psychological
symptoms because there are none.
Aesthetic surgery does not manufacture patients
because there is no patient role and the individual
retains a sense of autonomy.

91. Aesthetic Surgery
“The surgeon, however is not a psychologist or
psychotherapist, who wants to create mental health
but rather an artist, whose “artistic ability to create”
along with “the patient’s willingness to be molded,”
assures the happiness of both. Happiness is defined
as the ability “to offer external changes which are
more compatible with the vision of the inner self.”
Sander L. Gilman
Creating Beauty to Cure the Soul

92. Aesthetic Surgery
Thank You