A prospective controlled A prospective controlled outcome study of outcome study of

psychological change psychological change following plastic surgeryfollowing plastic surgery

Dr Tim MossDr Tim MossChartered Health Chartered Health PsychologistPsychologistCentre for Appearance Centre for Appearance ResearchResearchUWE (Bristol)UWE (Bristol)

Tim.moss@uwe.ac.ukTim.moss@uwe.ac.uk

Mr David HarrisMr David HarrisConsultant Plastic SurgeonConsultant Plastic SurgeonDerriford HospitalDerriford HospitalPlymouthPlymouth

OverviewOverview

Evidence of plastic surgery benefits?Evidence of plastic surgery benefits? Design and measuresDesign and measures Participants and attritionParticipants and attrition OutcomesOutcomes

DepressionDepression AnxietyAnxiety Appearance adjustmentAppearance adjustment

Evidence of plastic surgery Evidence of plastic surgery successsuccess

Honigman et al 2004 reviewHonigman et al 2004 review Mixed methodologiesMixed methodologies Patient satisfaction goodPatient satisfaction good

Bolton et al (2003)Bolton et al (2003) Abdominoplasty, pre- and post-opAbdominoplasty, pre- and post-op B.I. satisfaction increasedB.I. satisfaction increased B.I. investment, general psych function not improvedB.I. investment, general psych function not improved

Sarwer et al (2005)Sarwer et al (2005) General aesthetic plastic surgeryGeneral aesthetic plastic surgery Satisfaction with surgery and ‘feature’ change over 12 Satisfaction with surgery and ‘feature’ change over 12

monthsmonths

Methodological issuesMethodological issues Measures Measures

Sarwer (1998)Sarwer (1998) Interviews demonstrate psychopathology in Interviews demonstrate psychopathology in

cosmetic surgery patientscosmetic surgery patients Standardised general measures not identify Standardised general measures not identify

thisthis

Designs - comparison groups . . .Designs - comparison groups . . . DissonanceDissonance Hawthorn effectHawthorn effect DemandDemand

Our study: DesignOur study: Design Prospective, Controlled, quasi-experimentalProspective, Controlled, quasi-experimental

Plastic surgery patient group Plastic surgery patient group T1 (pre op), T2, (3 months post op), T3 (12 months T1 (pre op), T2, (3 months post op), T3 (12 months

post op)post op) Comparison surgery group Comparison surgery group

T1 and T2T1 and T2

ParticipantsParticipants Adults, English speakingAdults, English speaking Patients: Patients:

Plastic surgery admissions – nose, breasts, upper limbPlastic surgery admissions – nose, breasts, upper limb Comparison group: Comparison group:

Non-appearance altering surgery groupNon-appearance altering surgery group General surgery, ENT, Maxillofacial surgeryGeneral surgery, ENT, Maxillofacial surgery Randomly allocated “nose”, “breasts”, “upper limb”Randomly allocated “nose”, “breasts”, “upper limb”

MeasuresMeasures

Generic psychological functioningGeneric psychological functioning Crown Crisp Experiential Inventory- Crown Crisp Experiential Inventory-

Anxiety Anxiety Beck Depression InventoryBeck Depression Inventory

Test-retest reliability highTest-retest reliability high Good internal validityGood internal validity Criterion validity with other measures and Criterion validity with other measures and

clinical observation highclinical observation high

MeasuresMeasuresDerriford Appearance Scale 24Derriford Appearance Scale 24

www.derriford.infowww.derriford.info

24 items examine frequency of avoidant behaviours 24 items examine frequency of avoidant behaviours and distress related to appearance concernand distress related to appearance concern

Example items:Example items: I feel self conscious of my appearanceI feel self conscious of my appearance I avoid going to pubs/restaurantsI avoid going to pubs/restaurants

Psychometric propertiesPsychometric properties Internal consistency; Cronbach's Internal consistency; Cronbach's = 0.92= 0.92 Test-retest r = 0.68 (6 months)Test-retest r = 0.68 (6 months) Moderate correlations (r=0.5) with NA, social anxiety, Moderate correlations (r=0.5) with NA, social anxiety,

shameshame

Control Plastics All All 105 51 156 Time one only

61 4 65

Time one and two only

44 10 54

Time one and three only

n/a 8 8

Time one, two and three

n/a 29 29

Participant numbersParticipant numbers

Participants by conditionParticipants by condition

Ctrl Plastics All

Rhin Breast Arms Rhin Breast Arms Rhin Breast Arms

All time one 36 33 36 18 18 15 54 51 51

Time one only 19 17 25 1 1 2 20 18 27

Time one and two only

17 16 11 4 2 4 21 18 15

Time one and three only

n/a n/a n/a 2 2 4 2 2 4

Time one, two and three

n/a n/a n/a 11 13 5 11 13 5

Participant by sex Participant by sex (% Female)(% Female)

Ctrl Plastics All All time one 58 67 60 Time one

only 54 75 55

Time one & two only

63 60 63

Time one & three only

n/a 75 75

Time one, two & three

n/a 66 66

Gender similar across times and patient Gender similar across times and patient groupgroup

Participant ageParticipant ageControl Plastics

Mean Std Deviation

Count Mean Std Deviation

Count

nose 28.11 8.00 36 30.67 10.13 18

breasts 33.25 12.14 33 30.00 10.29 18

upper limb

27.08 6.44 36 25.87 8.89 15

Age comparable across groups and conditionsAge comparable across groups and conditions

Impact of AttritionImpact of AttritionSample Group Mean

age Std. Dev

T1 only Ctrl 29.3 8.6 Plastic 28.0 8.3 T1 and T2 Ctrl 29.5 10.4

only Plastic 26.0 4.6 T1, 2, and 3 Plastic 30.6 11.7

T1 and T3 only

Plastic 27.6 8.2

ALL Both 29.2 9.5

Group Sample Gender Percent Control T1 only Male 44.3 Female 54.1 T1 and T2 Male 36.4

Female 63.6 Plastics T1 only Male 25.0 Female 75.0 T1 and T2 Male 40.0

Female 60.0 T1 T2 and T3 Male 34.5

Female 65.5 T1 and T3 Male 25.0 only Female 75.0

Neither age nor sex differentially affected by Neither age nor sex differentially affected by attritionattrition

DepressionDepression

PlasticsControls

BD

I D

epre

ssio

n

10

9

8

7

6

5

T1

T2

Time x feature Time x feature x groupx group

FF(2,77)(2,77) = 1.3, p=0.28 = 1.3, p=0.28

Depression reduction Depression reduction not significantly not significantly greater in plasticsgreater in plastics

FF(1,77)(1,77)=2.3, p=0.13=2.3, p=0.13

AnxietyAnxiety

PlasticsControl

CC

EI A

nxi

ety

8.0

7.5

7.0

6.5

6.0

5.5

5.0

4.5

T1

T2

Time x group x Time x group x featurefeature

FF(2,75)(2,75)=3.1, p>0.05=3.1, p>0.05

Anxiety Anxiety reduction post reduction post op greater in op greater in plastics patientsplastics patients

FF(2,75)(2,75)=3.3, p=0.02=3.3, p=0.02

Derriford Appearance Scale Derriford Appearance Scale 2424

PlasticsControl

DA

S24

60

50

40

30

20

DAS24T1

DAS24T2

Time x feature x Time x feature x groupgroup

FF(2,77)(2,77)= 10.2, p<0.005= 10.2, p<0.005

Group X timeGroup X time FF(1,77)(1,77) = 69.8, = 69.8,

p<0.005p<0.005

Plastics patients Plastics patients significantly better significantly better DAS post opDAS post op

Derriford Appearance Scale Derriford Appearance Scale by featureby feature

Feature x timeFeature x time FF(2,23)(2,23)=7.1, p<0.005=7.1, p<0.005

DAS improvements DAS improvements post op only post op only significant for rhino significant for rhino and breasts at T2and breasts at T2upper limbbreastsrhino

DA

S24 M

ean

50

40

30

20

T1

T2

Patients only: DAS at T2 - T3Patients only: DAS at T2 - T3

Stability of Stability of adjustment levels adjustment levels rhino and breastsrhino and breasts

Delayed Delayed improvement in improvement in upper limb upper limb adjustment: adjustment: significant T2 – T3 significant T2 – T3 changechange

upper limbbreastsrhino

Mea

n D

AS

24

70

60

50

40

30

20

T1

T2

T3

Criticisms of designCriticisms of design

Quasi-experimental designQuasi-experimental design Potential confounding of groupPotential confounding of group

Limitation of plastics patient conditions Limitation of plastics patient conditions impacts on generalisabilityimpacts on generalisability

Groups numbers reduce analytical Groups numbers reduce analytical powerpower

ConclusionsConclusions Plastic surgery: psychological benefits for Plastic surgery: psychological benefits for

the three conditions studiedthe three conditions studied Plastic surgery specific, not generalised Plastic surgery specific, not generalised

surgical intervention effectsurgical intervention effect Not demonstrated in depressionNot demonstrated in depression Small and significant effect in anxietySmall and significant effect in anxiety Clear effect detected for DAS24Clear effect detected for DAS24

Delayed benefit for upper limbDelayed benefit for upper limb Use of appearance specific measures Use of appearance specific measures

preferable to generic?preferable to generic?

Further workFurther work

Components of poor appearance adjustment Components of poor appearance adjustment benefiting from surgery?benefiting from surgery?

Relationship between Relationship between anxiety/DAS24/depression and Patient anxiety/DAS24/depression and Patient Satisfaction?Satisfaction?

Impact of surgery on components of Impact of surgery on components of (multidimensional) BI - and which of these (multidimensional) BI - and which of these mediate outcome variables above?mediate outcome variables above?