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cally or statistically signi¬cant differences between these extrapyramidal reactions “ have been a concern for
medications.45 clinicians, particularly when treating outpatients.
Recently, combinations of antiemetics administered
Prevention of Aspiration Pneumonitis
prophylactically appear to be more effective than either
antiemetic alone. For instance, the combination of Many patients with gastrointestinal disorders, such as
ondansetron and droperidol is more effective than either of decreased lower esophageal sphincter tone, hiatal her-
the two medications alone.46 The same is true for the com- nia, and gastroesophageal re¬‚ux, are at risk for aspira-
bination of ondansetron and dexamethasone.47 Dimen- tion of gastric contents into the lungs. When patients
hyrinate (Dramamine r) 50 mg IM or IV may also be a are anesthetized, aspiration can occur with active vom-
useful antiemetic, especially for patients prone to motion iting or passive regurgitation, most commonly during
sickness. The timing of administration of antiemetics is the induction of anesthesia, when the airway is unpro-
very important. Some medications work best when given tected. Patients must be informed of the presurgery fast-
preoperatively, and others work best when given intra- or ing requirements either by the anesthesiologist or the sur-
postoperatively. Dexamethasone administered at prophy- geon, who must also explain the possible complications if
lactic doses of 2.5“5 mg has been found to effectively pre- not followed. During the immediate preanesthesia assess-
vent nausea and vomiting48,49 and is most effective when ment, obtain information concerning the hour at which
administered before the induction of anesthesia as it peaks food or drink was ingested. For patients not at risk for
one to two hours after administration.50 aspiration, the “ASA Practice Guidelines for Preoperative
Serotonin Receptor Antagonists are most effective when Fasting” recommends that patients may ingest clear liq-
given at the end of surgery.51,52 For ondansetron, the opti- uids until two hours prior to surgery and should avoid
mal dose for prophylaxis seems to be 4 mg administered solids or nonhuman milk for six or more hours prior to
surgery.54
intravenously at the end of surgery, prior to emergence
Preanesthetic Assessment of the Cosmetic Surgery Patient 179


There is controversy concerning the administration of laboratory tests, should be obtained and reviewed in the
prophylactic medication for prevention of pulmonary preoperative period for a better and safer patient anesthetic
injury from aspiration of gastric contents. Decreas- experience.
ing the volume and pH of the gastric contents can
reduce the risk of pulmonary aspiration. The prophy-
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SUMMARY
13. Shah KB, Kleinman BS, Sami H, et al.: Reevaluation of
The preanesthetic evaluation of the cosmetic patient is one peri-operative myocardial infarction in patients with prior
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The number of patients with a variety of severe medi-
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180 Norman Levin


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39. Apfel CC, Kranke P, Eberhart LH, et al.: Comparison of
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Br J Anaesth 88:234,2002.
21. Boiven JF: Risk of spontaneous abortion in women occupa-
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of prophylactic anti-emetic ef¬cacy for postoperative nau-
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22. Mazze RI: Halothane prevents nitrous oxide teratogenic-
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38:121,1988.
41. Apfel CC, Katz MH, Kranke P, et al.: Volatile anaesthetics
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24. Mallampati SR, Gatt SP, Gugino LD, et al.: A clinical sign
Br J Anaesth 88:659,2002.
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25. Khan ZH, Kash¬ A, Ebrahimkhani E: A comparison of the propofol with and without intra-operative fentanyl in
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96:595,2003. in¬‚ammatory drugs and the risk of operative site bleeding
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31. Gold BS, Kitz DS, Lecky JH, et al.: Unanticipated admis- ondansetron combination versus droperidol alone for post-
sion to the hospital following ambulatory surgery. JAMA operative control of emesis after total abdominal hysterec-
262:3008,1989. tomy. J Clin Anesth 10:6,1998.
32. Fortier J, Chung F, Su J: Unanticipated admission after 48. Sanchez-Ledesma MJ, Lopez-Olaondo L, Pueyo FJ, et al.:
ambulatory surgery: A prospective study. Can J Anaesth A comparison of three anti-emetic combinations for the
45:612,1998. prevention of post-operative nausea and vomiting. Anesth
33. Macario A, Weinger M, Carney S, et al.: Which clinical Analg 95:1590,2002.
anesthesia outcomes are important to avoid? Anesth Analg 49. Wang JJ, Ho ST, Lee SC, et al.: The use of dexamethasone for
89:652,1999. preventing postoperative nausea and vomiting in females
34. Apfel CC, Laara E, Koivuranta M, et al.: A simpli¬ed risk undergoing thyroidectomy: A dose-ranging study. Anesth
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Anesthesiol 91:693,1999. 50. Wang JJ, Ho ST, Tzeng JI, et al.: The effect of timing of dex-
35. Sinclair DR, Chung F, Mezei G: Can post-operative nausea amethasone administration on its ef¬cacy as a prophylactic
and vomiting be predicted? Anesthesiol 91:109,1999. anti-emetic for post-operative nausea and vomiting. Anesth
36. Visser K, Hassink EA, Bonsel GJ, et al.: Randomized con- Analg 91:136“9,2000.
trolled trial of total intravenous anesthesia with propofol 51. Domino KB, Anderson EA, Polissar NL, et al.: Compar-
versus inhalation anesthesia with iso¬‚urane-nitrous oxide: ative ef¬cacy and safety of ondansetron, droperidol, and
Post-operative nausea with vomiting and economic analy- metoclopramide for preventing post-operative nausea and
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Preanesthetic Assessment of the Cosmetic Surgery Patient 181


52. Sun R, Klein KW, White PF: The effect of timing of of pharmacologic agents to reduce the risk of pulmonary
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Anesth Analg 84:325,1997. 57. Hey VMF, Ostrick DG, Mazumder JK, et al.: Pethidine,
54. Fortney JT, Gan TJ, Graczy KS, et al.: A comparison of the metoclopramide and gastro-oesophageal sphincter. Anaes-
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sus droperidol as anti-emetics for elective outpatient surgi- 58. Manchikanti L, Grow JB, Colliver JA, et al.: Bicitra r
cal procedures. S3A-409 and S3A-410 Study Groups. Anesth (sodium citrate) and metoclopramide in outpatient anes-
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15 Psychological Aspects of Cosmetic Surgery
David B. Sarwer, Ph.D., Canice E. Crerand, Ph.D., and Lauren M. Gibbons, B.A.



INTRODUCTION
COSMETIC PROCEDURES OF THE FACE
Rhinoplasty
Anti-Aging Procedures
Minimally Invasive Anti-Aging Procedures
Other Facial Procedures
Facial skeletal procedures
Acne treatment
Vitiligo
Hair Loss and Hair Transplantation
COSMETIC PROCEDURES OF THE BODY
Cosmetic Breast Augmentation
Descriptive characteristics and motivational factors
Studies of pre- and postoperative psychological status
Body-image dissatisfaction
Psychosocial outcomes and postoperative complications
Breast implants and suicide
Lipoplasty and Abdominoplasty
Lipoplasty
Abdominoplasty
Other Body Enhancement Procedures
Body-contouring implants
Genital enhancement
Tattoos and body piercing
PSYCHIATRIC DISORDERS AMONG COSMETIC SURGERY PATIENTS
Body Dysmorphic Disorder
Clinical features
Nonpsychiatric and psychiatric treatments
Variants of BDD
Eating Disorders
SUMMARY




182
Psychological Aspects of Cosmetic Surgery 183


Thus, an understanding of the psychological functioning
INTRODUCTION
of cosmetic surgery patients is an important part of max-
According to the American Society of Plastic Surgeons
imizing treatment outcomes. This chapter reviews studies
(ASPS), over ¬fteen million Americans underwent a plas-
of the pre- and postoperative psychosocial functioning of
tic surgical procedure in 2003.1 The majority of plastic
persons who seek and undergo cosmetic surgery. A review
surgical procedures consisted of relatively new, minimally
of the psychological studies of individuals who have under-
invasive, nonsurgical procedures. These numbers, while
gone the most common facial procedures begins the chap-
familiar to many plastic surgeons, are often staggering to
ter. The second major section discusses studies of persons
other medical professionals and lay persons who have little
who have undergone cosmetic procedures of the body. The
idea of the number of Americans who turn to medicine
chapter concludes with a discussion of the psychiatric dis-
to enhance their physical appearance. Nevertheless, these
orders that may be most relevant to this population”body
numbers likely underestimate the number of procedures
dysmorphic disorder and eating disorders.
performed annually, as they do not account for nonplastic
surgeon physicians who offer these treatments. In partic-
COSMETIC PROCEDURES OF THE FACE
ular, the preceding numbers do not re¬‚ect the surgical
Rhinoplasty
activity of either the American Academy of Cosmetic Sur-
geons (AACS) or the American Society of Dermatologic Rhinoplasty is traditionally one of the most popular cos-
Surgeons (ASDS). metic surgical procedures, with over 350,000 performed
in 2003.1 The psychological characteristics of rhinoplasty
The growth in popularity of cosmetic surgery and
related treatments can be attributed to several factors.2’4 patients have received as much research attention as those
Changes in the medical and surgical communities, includ- of persons who have undergone any cosmetic procedure.
ing improvements in safety and direct-to-consumer mar- The ¬rst reports date back to the 1940s and 1950s. These
keting, have likely contributed to the growth. The mass investigations, as well as studies conducted into the 1960s,
media and entertainment industries have long champi- relied heavily on clinical interviews and suggested that
patients were highly psychopathological.8,9 Early inves-
oned cosmetic surgery, perhaps no more so than dur-
ing the current era of “reality-based” television programs tigators typically conceptualized the desire for rhinoplasty
such as “Extreme Makeover” and “The Swan.” The vir- from a psychodynamic perspective, the prevailing theo-
tually inescapable bombardment of mass-media ideals of retical orientation in psychiatry at the time. The nose was
beauty, coupled with the discontent that many people, par- often thought to symbolize the penis, and the desire for
ticularly women, experience with regard to their physi- rhinoplasty was believed to represent the patient™s uncon-
cal appearance, have likely contributed as well.5,6 Finally, scious displacement of sexual con¬‚icts onto the nose.10
society™s acceptance of the use of medicine to enhance For the adolescent female patient, the desire for rhino-
appearance, perhaps paired with a greater awareness of the plasty was interpreted as an attempt to remove elements
of her father™s personality from her own.11
importance of physical appearance in daily life, has poten-
tially fueled cosmetic surgery™s increase in popularity. Plas- During the 1970s and 1980s, a “second generation”
tic surgeons and mental health professionals have long of research in cosmetic surgery began to include valid
been interested in the psychological aspects of cosmetic and reliable measures to assess patients™ psychological
characteristics.2,3 Studies of this era found less pre-
surgery. Understanding the psychological characteristics
of patients who desire and undergo cosmetic proce- operative psychopathology and several noted postop-
erative bene¬ts.12’17 For example, investigations that
dures is important for practical reasons. Cosmetic pro-
cedures are often considered analogous to psychological used the Minnesota Multiphasic Personality Inventory
interventions; many patients report increased satisfaction (MMPI), likely the most widely used measure of per-
with their appearance, as well as psychological improve- sonality, reported that the personality pro¬les of rhino-
ments, postoperatively.7 Nevertheless, these procedures plasty patients were essentially normal preoperatively, and
no changes were observed postoperatively.14,15 Unfortu-
are likely not appropriate for all individuals, particularly
those with certain characteristics or psychiatric disorders. nately, many of these studies suffered from methodological
184 David B. Sarwer, Canice E. Crerand, and Lauren M. Gibbons


Minimally Invasive Anti-Aging Procedures
problems, such as small sample sizes and the lack of appro-
priate control groups, which call into question the valid- Minimally invasive anti-aging procedures have surpassed
ity of the ¬ndings. Studies through the present have used the popularity of the more traditional anti-aging surgical
improved methodologies, including reliable and valid self- procedures. For example, nearly 2.9 million botulinum
report measures and clinical interviews with established toxin (Botox r ) injections were performed in 2003, mak-
diagnostic criteria.18’25 Most studies also have included ing it the most popular of all cosmetic treatments.1 The
pre- and postoperative assessments with appropriate con- toxin is typically injected into areas of the face (i.e., fore-
trol groups. These studies have suggested that most rhino- head creases, “crow™s feet”) in order to reduce the appear-
plasty patients are psychologically healthy individuals. As ance of wrinkling. It is also effective at treating excessive
noted by at least one study,25 the desire for rhinoplasty sweating. Other popular minimally invasive procedures
may be understood as an increased dissatisfaction with include fat injections, collagen injections, chemical peels,
the size and/or shape of the nose, rather than a symptom dermabrasion, and laser resurfacing. Like Botox r injec-
of psychopathology. These ¬ndings are consistent with the tions, these procedures can improve the appearance of
experiences of most present-day cosmetic surgeons. wrinkled, scarred, or sun-damaged skin. In 2004, the
Food and Drug Administration (FDA) approved a product
Anti-Aging Procedures speci¬cally designed to improve lipo-atrophy in persons
with HIV disease. New generations of customized facial
Rhytidectomy and blepharoplasty are two of the most pop-
implants also are being used to treat this condition.30 It
ular surgical procedures for those interested in restoring
is quite possible that these products will also be used for
a more youthful appearance. In 2003, 128,667 facelifts
cosmetic purposes in persons without HIV disease in the
and 246,633 blepharoplasty procedures were performed
in the United States.1 (As these procedures are often per- near future.
Despite their popularity, little is known about the psy-
formed concurrently, studies of these patient populations
chological characteristics or body-image concerns of the
are reviewed together.)
patients who seek these procedures. A German study of
Early reports suggested that facelift patients were quite
thirty patients who received Botox r injections for facial
psychopathological. Patients were often characterized as
lines examined post-treatment social outcomes and atti-
dependent and depressed; approximately 70% of patients
tudes toward appearance.31 Over half of those studied
received a preoperative psychiatric diagnosis.26 However,
reported improvements in their appearance and nearly
the majority reported postoperative improvements in
50% reported greater con¬dence in their appearance.31
well-being and did not experience postoperative “emo-
tional disturbances.”26 Studies that used standardized self- A recent study of 178 patients seeking laser skin resur-
facing reported that 18% received prior treatment for
report measures noted similar improvements in psycho-
depression.32 A third study evaluated the psychosocial
logical symptoms postoperatively.24,27
bene¬ts associated with alpha-hydroxy acid, a topical treat-
Other studies have examined the body-image concerns
ment that is used to reduce roughness and ¬ne wrinkling.
of these patients. In one of the ¬rst empirical studies
Patients noted signi¬cant improvements in appearance
investigating the body-image concerns of cosmetic surgery
and relationship satisfaction following treatment.33
patients, nearly half of the patients studied sought facelift
or blepharoplasty procedures.28 They reported higher lev-
els of dissatisfaction with the feature for which they sought
Other Facial Procedures
surgery, but they did not report increased dissatisfaction
with their overall body image.28 Rhytidectomy and/or ble- Facial skeletal procedures
pharoplasty patients have reported greater investment in Some patients request more “atypical” procedures that
their appearance as well as greater satisfaction with their involve bone contouring and/or grafting as well as the
overall body image as compared to women who sought insertion of cheek, chin, or other facial implants. One study
rhinoplasty.25 Postoperatively, patients reported decreases described ¬fteen patients who sought extensive symmet-
in body-image dissatisfaction for the feature that was rical facial skeletal recontouring procedures in order to
treated but no changes in overall body image.29 address discontent with facial width.34 These “facial width
Psychological Aspects of Cosmetic Surgery 185


of the acne.43 Acne patients report impairments in quality
deformity” patients reported concerns with minor, largely
unnoticeable anatomic deviations. of life on par with those of other chronic medical condi-
tions, such as epilepsy and diabetes.44
Preoperative psychiatric interviews revealed that the
majority experienced signi¬cant impairment in psychoso- Acne treatment appears to result in improvements
in psychosocial functioning.45,46 Kellett and Gawkrodger
cial functioning, though only three (of ¬fteen) received
a formal psychiatric diagnosis. The clinical descriptions reported signi¬cant reductions in anxiety and depression,
of these patients, however, suggest that some may have but not general emotional distress, following treatment
with isotretinoin.39 The authors concluded that some of
been suffering from body dysmorphic disorder, dis-
cussed in detail herein. Postoperatively, patients reported the psychological effects of acne may remain despite suc-
improvements in body image and psychosocial function- cessful treatment. This ¬nding makes intuitive sense, given
ing, although psychometric measures were not used to that acne can result in permanent scarring. Extended dura-
assess these changes.34 tion of acne and acne excoriee (skin picking) are associated
with greater likelihood of scarring.47 Even in the absence
Although requests for some of these facial-widening
procedures are rare, more patients are requesting pro- of residual cutaneous scars, emotional scars may remain.
cedures such as cheek and chin implants in order to Cash and Santos found that former adolescent acne suf-
change the structural appearance of their faces. In 2003, ferers, especially women and those recalling more subjec-
over 28,000 chin or cheek implantation procedures were tively severe acne, reported less current facial satisfaction
performed.1 The popularity of these procedures under- and more body-image dysphoria than peers who did not
have facial acne as teenagers.48 The psychosocial distress
scores the need for more research regarding the psycho-
logical characteristics and body-image concerns of these associated with acne has implications for medical profes-
patients. sionals who treat acne-related scars. These providers may
be able to assess the psychological effects of this disorder
Acne treatment and provide appropriate mental health treatment referrals
when warranted.49
Many patients present to plastic surgeons, dermatologists,
or other professionals complaining of acne or acne-related
scarring. This is not surprising, considering that acne
affects at least 80% of adolescents.35 The occurrence of Vitiligo
acne typically decreases with age; however, it may persist Vitiligo is a progressive condition characterized by loss of
through adulthood for a minority of persons.36 skin pigmentation, resulting in irregular hypopigmented
patches.50 Generalized vitiligo, the most common form, is
Historically, the psychosocial effects of acne have
been dismissed, largely as it was considered a non“ characterized by bilateral, symmetric depigmentation of
life-threatening, age-related cosmetic condition.37 More the face (particularly periori¬cial area), neck, torso, wrists,
and legs.51 The prevalence of vitiligo is estimated to be
health professionals now recognize the impact acne may
about 1“2% of the world population.52 Age of onset is typ-
have on psychological and social well-being. Up to 50%
ically childhood or young adulthood.51 Although there is
of adolescents experience psychological dif¬culties asso-
ciated with acne, including body-image concerns, poor no cure, medical treatments include topical cosmetics, use
self-esteem, social isolation, and depression.38 Studies of of psoralens and UVA light to stimulate repigmentation
(PUVA), corticosteroids, and surgical skin grafting.51,52
patients who seek acne treatment have found similar
results.37,39’41 Similar to acne, the psychological distress associated
with vitiligo is often underestimated.50 The condition
For some, the distress may become so severe that it con-
tributes to suicidal ideation or suicide attempts.40,42 Facial appears to have a negative impact on the social and emo-
tional well-being of its sufferers.53 Patients often report dif-
acne patients, compared to those with truncal acne, appear
¬culties with body image, self-esteem, and quality of life.50
to be particularly vulnerable to the psychological effects
of the disease, experiencing lower self-esteem and greater Similar psychological sequelae have been reported among
body-image dissatisfaction.41 The distress appears to be patients with other chronic skin conditions, including
eczema and psoriasis.40,54,55
related to the self-perceived rather than objective severity
186 David B. Sarwer, Canice E. Crerand, and Lauren M. Gibbons


A more extensive review of the psychological characteristics Hair transplantation is a more certain and permanent
of patients who seek dermatological treatment is beyond the method of hair replacement in less time. The popular-
scope of this chapter; interested readers are directed to these ity of hair transplantation has decreased in the past sev-
reviews and books.56’58 eral years, likely due to the availability of prescription and
Encouragingly, cognitive-behavioral psychotherapy over-the-counter medical treatments for AGA. Surpris-
appears to be a successful treatment for the psychologi- ingly, no formal studies have investigated the psycholog-
cal distress associated with these conditions.50 ical characteristics of persons who seek hair transplan-
tation or the psychological changes that may occur after
Hair Loss and Hair Transplantation treatment. Given the prevalence of AGA, studies are clearly
warranted.
Head hair possesses considerable cultural, social, and per-
sonal signi¬cance.59,60 As a result, hair loss can be a psycho-
logically dif¬cult experience for some. There are a number
COSMETIC PROCEDURES OF THE BODY
of hair-loss conditions; the most prevalent is androgenetic
Cosmetic Breast Augmentation
alopecia (AGA), or common genetically predisposed hair
Despite the controversy surrounding silicone-gel“¬lled
loss. AGA is a progressive condition mediated by andro-
breast implants, the number of American women who
genic metabolism (especially dihydrotestosterone). The
have undergone cosmetic breast augmentation (primarily
receding frontal hairline and vertex balding is visibly evi-
with saline-¬lled implants) has increased by no less than
dent in the majority of men. AGA also occurs in a signi¬-
600% in the past decade.1 The dramatic increase is remark-
cant minority of women, although the pattern of alopecia
able considering that in 1992 the FDA issued a moratorium
is one of diffuse thinning.
on the use of silicone-gel“¬lled implants because of con-
AGA can be a very distressing condition for both gen-
ders, albeit more troubling for women.61,62 Among men, cerns related to the physical safety of the implants. Several
studies and literature reviews since have suggested that sil-
increased distress is associated with earlier onset of hair
icone breast implants are not associated with speci¬c dis-
loss. It is also experienced by men who are more psycho-
eases, including cancer and connective tissue disease.68’72
logically invested in their appearance and by younger men
not involved in an intimate relationship.63,64 The effects of These ¬ndings, along with others, motivated two breast-
implant manufacturers to reapply for FDA approval for
AGA on women may be more extensive, including lower
self-esteem.64 As with many other conditions, the subjec- silicone-gel“¬lled implants in early 2005.
Many studies have examined the psychological char-
tive severity of AGA is more related to its psychosocial
impact than are objective or clinical indices of severity.61 acteristics of women who undergo cosmetic breast aug-
mentation. Some have provided important information
Most outcome data for AGA treatment comes
on the characteristics of women interested in the proce-
from large, controlled clinical trials of minoxidil and
¬nasteride.61,65,66 The psychological outcome measures in dure. Others have investigated the psychological changes
typically experienced postoperatively.
these studies have focused largely on patients™ perceptions
of, and satisfaction with, resultant hair growth and gen-
Descriptive characteristics and motivational factors
erally support the ef¬cacy of the treatments. There is a
dearth of outcomes research using more psychologically The average breast augmentation patient appears to be
sophisticated measures. One uncontrolled study of 144 quite different than the stereotypical one. The typical
men treated with topical minoxidil con¬rmed moderate woman is European-American, in her late twenties or early
thirties, and is married with children.73’83 Many of these
hair growth and improvements on hair-speci¬c quality-of-
life measures (e.g., hair-loss distress and perceived social women pursue augmentation with the goal of return-
noticeability of the hair loss) but not on more global mea- ing their breasts of their former, pre-childbirth size and
sures of anxiety, depression, or self-esteem.67 shape. In contrast, the stereotypical patient is thought to
In recent years, there have been major advances in sur- be younger, single, and interested in breast augmentation
gical methods of hair replacement, including micrograft- as a way to facilitate the development of a romantic rela-
ing and ¬‚ap techniques, especially for men with AGA. tionship. Nevertheless, women from their late teens to mid
Psychological Aspects of Cosmetic Surgery 187


forties of varying ethnic backgrounds and relationship sta- have found signi¬cantly less psychopathology than the
tus present for breast augmentation. Given the increasing interview-based investigations. For example, two stud-
popularity of the procedure, there likely is no “typical” ies of breast-augmentation patients who used psychome-
patient. tric measures, including the MMPI, found little evidence
of psychopathology.76,79 Few investigators have used psy-
Several factors likely motivate women to undergo breast
augmentation.84 Intrapsychic factors describe the internal chometric measures to assess changes following surgery.
motivations for surgery and the resulting effects on psy- One study found a decrease in depressive symptoms after
chological status. Interpersonal factors concern the impor- surgery; another reported increased symptoms in 30%
of patients in the immediate postoperative period.99,100
tance of the appearance of the breasts in marital, sexual,
and social relationships. Women anticipate an improved Although generally considered more valid and reliable
quality of life, body image, and self-esteem, as well as than the clinical interview studies, these studies have also
increased marital and sexual satisfaction following breast suffered from methodological problems.
enlargement.77,82,83,85’88 Informational and medical fac- Nevertheless, two tentative conclusions can be drawn
from this research.2,101,102 First, breast-augmentation can-
tors also are thought to play a role in the decision to seek
augmentation. Women who undergo breast augmentation didates likely present for surgery with a variety of psycho-
obtain a great deal of information about breast implants logical symptoms and conditions. Whether some of these
from the mass media85,89,90 and appear to be aware of many conditions serve as contraindications for surgery has yet
of the risks associated with the procedure.85,87,91 to be established. Second, given the limited number of
Nevertheless, women who receive breast implants dif- studies that have speci¬cally investigated the psychosocial
fer from their peers in several ways. Women with breast bene¬ts of breast augmentation, it is premature to de¬ni-
implants are more likely to have had more sexual part- tively conclude that the procedure confers more general
ners, report a greater use of oral contraceptives, be younger psychological bene¬ts.
at their ¬rst pregnancy, and have a history of terminated
pregnancies as compared to other women.92’95 They have Body-image dissatisfaction
been found to be more frequent users of alcohol and The most profound psychological effects of breast aug-
tobacco.93’95 They also have a higher divorce rate.82,83 mentation may occur in the realm of body image. An
Finally, they have been reported to have a below-average increasing amount of attention has been paid to the rela-
body weight,85,92’96 leading to concern that some may be tionship between body image and cosmetic surgery over
the past decade.2,7,102’104 Empirical studies have suggested
experiencing eating disorders (vide infra).
that cosmetic-surgery patients report increased body-
image dissatisfaction prior to surgery.25,85,96,103,105,106
Studies of pre- and postoperative psychological status
Numerous studies have investigated the preoperative psy- Others have found postoperative improvements in body
image.29,87,107’110
chological status of women interested in breast augmen-
tation. As with the studies of persons interested in facial The body-image concerns of breast-augmentation
patients have been described in several reports.76,77,79 For
procedures, the early generations of research in this area
relied primarily on clinical interviews to assess psycho- example, more than 50% of breast-augmentation patients
logical functioning.84 More often than not, these stud- reported signi¬cant behavioral avoidance (e.g., avoidance
ies described breast-augmentation patients as experienc- of being seen undressed) in response to negative feelings
about their breasts.111 Compared to women similar in
ing increased symptoms of depression, anxiety, guilt, and
low self-esteem.81’83,97,98 Fewer studies have examined breast size not pursuing breast augmentation, surgery can-
the effects of breast augmentation on psychological func- didates reported greater dissatisfaction with their breasts,
tioning. Most of these studies have reported improve- greater investment in their overall appearance, and greater
concern with their appearance in social situations.85,96
ments, or at least no change, in self-esteem and depres-
sive symptoms postoperatively.74,81,97 Subsequent studies Augmentation candidates also rated their ideal breast size,
were more likely to use valid and reliable psychometric as well as the breast size preferred by women, as sig-
ni¬cantly larger than did controls.96 Finally, prospective
measures to assess relevant characteristics. They typically
188 David B. Sarwer, Canice E. Crerand, and Lauren M. Gibbons


patients reported more frequent teasing about their phys- months after surgery, women who experienced a “socially
ical appearance and more frequent use of psychotherapy detectable” complication, such as signi¬cant capsular con-
than controls, suggesting that some breast-augmentation tracture, expressed less surgical and body-image satisfac-
candidates may be experiencing negative emotional con- tion compared to women with nonsocially detectable or
sequences as a result of their breast dissatisfaction.96 no complications. By twenty-four months after surgery,
Women who undergo breast augmentation experi- the groups did not differ in satisfaction. However, women
ence improvements in their body image postopera- with “socially detectable” complications viewed the risk-
tively, as suggested by clinical reports and empirical bene¬t ratio of surgery less favorably compared to those
studies.29,76,78,81,87,108 In one of the largest studies of with less visible or no complications.
psychosocial outcomes following breast augmentation,
Breast implants and suicide
greater than 90% of patients reported an improved body
image two years postoperatively.87 In the past few years, four large epidemiological studies
in the United States and Europe designed to investigate
Psychosocial outcomes and the relationship between breast implants and mortality
postoperative complications found an unexpected relationship between breast implants
and suicide.120’123 The suicide rate (as obtained from
Clinical reports and empirical studies suggest that the
vast majority of women are satis¬ed with the outcome patients™ death records) was two to three times greater
of breast augmentation.78,87,99,112,113 Patient satisfaction among patients with breast implants as compared to either
and body-image improvements, however, may be tem- patients who underwent other cosmetic surgical proce-
pered by the occurrence of a postoperative complication. dures or population estimates.
Up to 25% of women experience a surgical or implant- The exact nature of the relationship between breast
related complication.114’116 The most common complica- implants and suicide is unclear. Some psychological vari-
tions are implant rupture/de¬‚ation, capsular contracture, able(s), yet to be speci¬ed, may explain this relation-
pain, breast asymmetry, scarring, loss of nipple sensation, ship. Some women may enter into surgery with unrealistic
and breast-feeding dif¬culties.68,’72,114’118 expectations about the effect that breast augmentation will
Approximately 10% of women who receive breast implants have on their lives. When these expectations are not met,
for cosmetic purposes experience a complication within ¬ve they may become despondent, depressed, and potentially
years of implantation.114,115 suicidal. Alternatively, women who experience postopera-
In a study of 749 women who received breast implants tive complications, particularly those that they believe are
in the United States before 1991 (prior to the FDA ban on a consequence of their implants but that have not been
silicone-gel“¬lled implants), 23.8% experienced compli- found to be statistically associated with breast implants
cations severe enough to require additional surgery.115 (e.g., autoimmune and connective tissue diseases), may
The most common complication was capsular contrac- become depressed as a result of a lack of perceived or real
ture (73.6% of complications, 17.5% of women), fol- attention from the medical community. Although specu-
lowed by implant rupture (24.2% of complications, 5.7% lative, both of these hypotheses have some intuitive appeal.
of women), hematoma (24.2% of complications, 5.7% of As described earlier, women seeking breast augmen-
women), and wound infection (10.7% of complications, tation may present for surgery with certain unique pre-
2.5% of women). Large-scale studies in Europe have cor- operative personality characteristics that may predispose
roborated these ¬ndings.69,70,116’118 them to commit suicide. Several are, in and of them-
At least three studies have suggested that the experience selves, associated with an increased risk of suicide. Joiner
of a complication is negatively related to postoperative has argued that these personality characteristics could
satisfaction.87,91,119 In a large prospective study, Cash and actually account for an even higher suicide rate than
colleagues87 found that although women typically report found in the epidemiological investigations.124 He fur-
improvements in self-image and body image after breast ther suggests that postoperative improvements in body
augmentation, those who experienced postoperative com- image may produce a protective effect from the other-
plications reported less favorable improvements. At six wise increased risk. Jacobsen and colleagues found an
Psychological Aspects of Cosmetic Surgery 189


increased prevalence of preoperative psychiatric hospi- reduces the number of fat cells in a local area of the body,
talizations in women who received breast implants as the remaining fat cells may still expand if weight increases.
compared to women who underwent other forms of cos- The “average” person has about two million fat cells.
metic surgery or breast reduction.121 These results sug- Similarly, some patients may believe that liposuction
gest that the increased suicide rate among women who will result in “washboard abs” and smooth thighs. Unfor-
have breast implants likely re¬‚ects some underlying psy- tunately, if fat cells are not removed in a consistent fashion,
chopathology rather than a direct relationship with the residual pockets of fat may remain. Most patients, how-
implants.125’126 Obviously, additional prospective epi- ever, report satisfaction with their results and maintain a
demiological and empirical studies of the relationship more proportional shape, even if they do gain some weight
postoperatively.133,134 Between 40% and 50% reported
between breast implants and suicide are needed.
weight gain after surgery and up to 29% claimed that their
fat returned to the site of the surgery.133,134
Lipoplasty and Abdominoplasty
Persons with excessive weight or shape concerns require
The United States is in the midst of an obesity epidemic.
particular attention prior to lipoplasty. Women and men
Approximately two thirds of American adults are now
with formal eating disorders, as discussed in detail herein,
considered to be overweight or obese, as de¬ned by a body
mass index (BMI) >25 kg · m’2 .127 Obesity is associated may seek lipoplasty as an inappropriate compensatory
behavior to control their weight. In a case report of two
with increased body-image dissatisfaction as well as sev-
women with bulimia nervosa who underwent lipoplasty,
eral signi¬cant comorbidities, including coronary heart
the request for surgery was accompanied with an unreal-
disease, hypertension, type II diabetes, osteoarthritis, and
sleep apnea.128 Although Americans spend billions of dol- istic expectation that surgery would result in an improve-
ment of eating-disorder symptoms.135 Postoperatively,
lars annually in efforts to lose weight, successful long-
both women reported a worsening of their bulimic and
term weight control proves elusive for most. Although
depressive symptoms, and one woman reported a weight
designed for body-contouring purposes, many individ-
gain of twenty-¬ve pounds in three months.135 Unfortu-
uals erroneously believe that lipoplasty (liposuction)
nately, little else is known about the relationship between
and adominoplasty are permanent solutions to weight
eating disorders and lipoplasty.
problems.

Lipoplasty Abdominoplasty
Over 320,000 men and women underwent lipoplasty in The number of men and women who seek abdomino-
2003, making it the most popular surgical procedure.1 plasty has increased steadily over the past decade. The
Unlike the sizable literature on the psychological char- popularity may be a result of the increasing numbers of
acteristics of breast-augmentation patients, few, if any, individuals with extreme obesity who are now undergo-
studies have speci¬cally investigated the pre- and post- ing bariatric surgery (“stomach stapling”) for weight loss.
operative psychological status of liposuction patients. As Bariatric procedures typically result in a weight loss of
with all cosmetic procedures, patients™ expectations of the approximately one third of operative body weight. In addi-
postoperative result are critical to a successful outcome. tion, the procedure often results in signi¬cant improve-
Many patients mistakenly believe that liposuction leads ments in obesity-related comorbidities and psychosocial
status.136 Unfortunately, many patients are left with excess
to signi¬cant weight loss. The typical weight loss associ-
ated with liposuction has not been well documented. One folds of skin and fat on the abdomen, arms, and thighs
pilot study of fourteen overweight women reported a mean following the massive weight loss. This redundant skin
may contribute to increased body-image dissatisfaction128
weight loss of 5.1 kg by six weeks postoperatively, with an
additional 1.3 kg weight loss by four months.129 Studies and, as a result, may lead patients to seek abdomino-
investigating changes in lipids and insulin sensitivity fol- plasty and related procedures. In 2003, approximately
lowing liposuction have been equivocal.130’132 52,000 individuals underwent abdominoplasty and other
Many patients erroneously believe that fat deposits will body-contouring procedures following weight loss associ-
ated with bariatric surgery.1 Although no formal studies
never return to the treated areas. Although liposuction
190 David B. Sarwer, Canice E. Crerand, and Lauren M. Gibbons


exist, case reports suggest that these individuals experience to reduce the size of the labia minora. Although these
psychosocial improvements and a decrease in the physical “defects” are sometimes thought to be functional (imped-
discomfort associated with the excess skin.137 ing urination or adversely affecting sexual functioning),
Only one study has documented the psychosocial there is a signi¬cant aesthetic component. Patients typ-
changes associated with abdominoplasty. Eight weeks after ically report that they are motivated for surgery out of
the surgery, women reported signi¬cant improvements embarrassment, either when undressed or wearing tight
clothing.139’140 Little else, however, is known about the
in overall body-image dissatisfaction, abdominal dissat-
psychological characteristics of these patients.138 Consid-
isfaction, and self-conscious avoidance of body exposure
during sexual activity.107 Patients did not report signi¬- ering the nature of these procedures, it is possible that
cant improvements in self-concept or general life satisfac- a signi¬cant percentage of these patients are suffering
tion. These results are consistent with other postoperative from body dysmorphic disorder or other psychiatric dis-
studies, suggesting that the impact of cosmetic surgery orders with a delusional or psychotic component. The
procedures may be limited to speci¬c improvements of plastic-surgery literature includes several case reports of
body-image discontent but not necessarily more general individuals who have performed “do-it-yourself” surg-
psychosocial functioning.29 eries, such as injecting their genitals with various oils and
substances.141’143
Other Body Enhancement Procedures
Tattoos and body piercing
There are an almost limitless number of procedures that
can be performed to enhance the body. The following dis- Up to twenty million Americans are estimated to have
tattoos.144 Tattoos are found on 3“8% of the general
cussion will focus on body-contouring implants, genital
enhancement, and tattoos and body piercing. population and 10“13% of adolescents (ages twelve to
eighteen).145 More than half are found on women.146 Inter-
Body-contouring implants estingly, requests for tattoo removal appear to be on the
An increasing number of individuals are using pec- rise as well, perhaps because of the development of more
effective laser removal tools.146 In a study of 105 individu-
toral, calf, gluteal, and other body-contouring implants
to improve their appearance. Very little is known about als seeking tattoo removal, 61% reported embarrassment
the psychological motivations and characteristics of per- as a consequence of their tattoo(s), and 26% reported a
less positive body image.146
sons who seek these implants or the psychological changes
that may occur postoperatively.138 Many of the features Accurate estimates of the number of Americans who
shaped by these implants are typically covered by cloth- have undergone body piercing are lacking. Body pierc-
ing. As a result, the changes in appearance are not read- ing, particularly when ear piercing is considered, may be
ily visible to others. Thus, it is quite possible that some even more prevalent than tattoos, as piercings are less
individuals who undergo these procedures may be suf- expensive, less dif¬cult to obtain, and may be consid-
fering from body dysmorphic disorder or its associated ered less permanent. However, they can result in lifelong
condition, muscle dysmorphia, which are discussed later. complications such as scarring and blood-borne infec-
Some of these patients, may also be HIV positive and tious diseases, as well as more temporary complications
such as abscesses.147,148 In a study of 454 college students,
have had loss of muscle mass secondary to their disease
process. 51% had at least one body piercing (including ears), with
17% experiencing a medical complication (e.g., bleed-
ing, local trauma, and bacterial infections).149 Tongue
Genital enhancement
An unknown number of men and women who are dissat- piercings can be prone to infection and can result in
is¬ed with the appearance of their genitalia pursue what swelling, chipped teeth, speech impediment, and nerve
damage.150
has been called “genital enhancement” or “genital beau-
ti¬cation” procedures. Men may undergo procedures to The presence of tattoos or body piercings in adoles-
cents may be a marker for other risk-taking behavior.145
lengthen or widen their genitals. Women may seek surgery
Psychological Aspects of Cosmetic Surgery 191


Adolescents with tattoos and/or body piercings were more United States suggested that 7% of female cosmetic-
surgery patients met criteria for BDD.28 A recent study
likely to have engaged in risky behaviors such as drug use
and sexual activity and were at increased risk for disor- of patients seeking only facial cosmetic procedures found
dered eating and suicide.145 Crawford and Cash found that that 8% met diagnostic criteria.163 Among international
pierced and/or tattooed college students scored higher on samples, rates of BDD among cosmetic-surgery patients
range from 9% to 53%.164’167 Rates of 9“15% have been
a measure of excitement seeking and were more likely to
smoke cigarettes and engage in binge drinking relative to reported in patients seeking dermatological treatment,
their “unmarked” peers.151 Pierced/tattooed students also most commonly for acne.168’170 Methodological differ-
reported more body-image dissatisfaction, despite being ences in the assessment of symptoms are likely responsi-
very pleased with their “body art.” Perhaps body dissat- ble for the wide range of rates reported. Though preva-
isfaction is an impetus to obtain body art to “improve” lence rates are unknown, patients with BDD also request
one™s appearance. treatment from orthodontists, maxillofacial surgeons, and
paraprofessionals.171’174

PSYCHIATRIC DISORDERS AMONG COSMETIC
Clinical features
SURGERY PATIENTS
Age of onset for BDD is typically late adolescence. The
All of the major psychiatric diagnoses can likely be found disorder occurs with equal frequency among men and
within the large population of cosmetic-surgery patients. women. Most clinical and demographic features appear
to be similar between genders.175,176 Although any body
There is some evidence that body dysmorphic disor-
der may occur with greater frequency among cosmetic- part can be a source of preoccupation, patients typically
report concerns with the skin, face, nose, and hair.171,175,176
surgery populations as compared to the general popula-
Preoccupation with more than one feature is common.171
tion. Given the relationship of body-image dissatisfaction
and cosmetic surgery, eating disorders such as anorexia Although the course of BDD tends to be chronic, symp-
and bulimia also warrant consideration. tom severity, areas of concern, and insight may vary over
time.175,177
Body Dysmorphic Disorder Patients often experience intrusive thoughts about their
“defects.” Some may recognize the exaggerated nature of
Body dysmorphic disorder (BDD) is de¬ned as a preoc-
these concerns, whereas others may hold more delusional
cupation with an imagined defect in appearance (or if a
beliefs about their appearance.178,179 Patients with BDD
slight physical defect is present, the person™s concern is
often engage in compulsive behaviors, such as skin picking,
exaggerated) that results in signi¬cant emotional distress
or impairment in functioning.152 Although not recog- mirror checking, camou¬‚aging, and reassurance seeking
often as a means of decreasing their distress.177,180’184 The
nized as a formal psychiatric disorder in the United States
until 1987,152 descriptions of persons with the distinctive condition frequently results in signi¬cant emotional dis-
tress, impairment in social and occupational functioning,
symptoms ¬rst appeared in the American dermatology
and decreased quality of life.184’187 Self-harm and suici-
and plastic-surgery literatures much earlier. Reports in
dality are relatively common.175,177,181,186,187
the dermatology literature described patients presenting
with “dermatological nondisease,”154 whereas those in the
Nonpsychiatric and psychiatric treatments
plastic-surgery literature detailed “minimal deformity”
and “insatiable” patients.155,156 These patients typically Individuals with BDD often seek cosmetic and dermato-
reported dissatisfaction with their postoperative results. logical treatments as a means of decreasing their appear-
ance concerns.171,173,175,186,187 In the largest study to date of
BDD is estimated to occur in 0.5% to 2% of the gen-
the use of aesthetic treatments by BDD patients (n = 250),
eral population.157,158 Rates of 2.5% to 5% have been
reported in university samples.159,162 The condition, how- 76% sought and 66% received treatment, with dermato-
ever, appears to be far more common among patients logical procedures and cosmetic surgery being the most
popular.171 Similarly, in a sample of 200 persons with BDD,
presenting for cosmetic surgery. The ¬rst study in the
192 David B. Sarwer, Canice E. Crerand, and Lauren M. Gibbons


Eating Disorders
nonpsychiatric treatment was sought by 71% and received
by 64%.173 The most commonly received treatments were Given the disproportionate amount of concern that indi-
topical acne agents, rhinoplasty, collagen injections, elec- viduals with anorexia and bulimia nervosa place on their
trolysis, and tooth whitening.173 appearance, these disorders may occur with increased fre-
quency among those who seek cosmetic surgery.138 The
Studies suggest that nonpsychiatric treatments often are
ineffective at reducing the preoccupation with appear- distinguishing feature of anorexia nervosa is a fanatical
ance. Greater than 80% have been found to be dissatis- pursuit of thinness related to an overwhelming fear of
¬ed with the results of cosmetic treatments.187 Two studies becoming fat.152 Patients with bulimia nervosa are gen-
have indicated that the majority of nonpsychiatric treat- erally distinguished from those with anorexia on the basis
ments received by patients with BDD result in either no of relatively normal weight and the presence of binge
change or a worsening in symptoms.171,173 Following treat- eating and purging.152 The normal weight of bulimic
ment, some patients develop new appearance preoccupa- patients frequently makes them more dif¬cult to identify
tions. Others may threaten or enact legal action and/or than anorexic patients. Persons with both conditions may
violence against their surgeons.188’190 Because of these erroneously believe that cosmetic surgery will improve
issues, the presence of BDD is often considered a con- their immense dissatisfaction with their bodies and
traindication for cosmetic procedures.104,191,192 Selective- self-esteem.
serotonin-reuptake-inhibitor antidepressant medications Presently, there is no information on the rate of anorexia
and cognitive-behavioral therapy appear to be more effec- or bulimia among cosmetic-surgery patients; investiga-
tive strategies for treating BDD.193’205 tion has been limited to case reports. Women with
both disorders have experienced an exacerbation of their
Variants of BDD eating-disorder symptoms following breast augmentation,
Muscle dysmorphia, referring to a preoccupation with lipoplasty, rhinoplasty, and chin augmentation.135,210,211
being insuf¬ciently large and muscular, is considered a Interestingly, a case report of ¬ve breast-reduction patients
form of BDD.206 Patients with muscle dysmorphia tend with bulimia suggested that four of the ¬ve women
to weight lift and diet in a compulsive manner; they also experienced an improvement in their eating-disorder
engage in other checking and camou¬‚aging behaviors (i.e., symptoms and psychological distress postoperatively.212
layering clothing to appear larger). Some use anabolic Impressively, the improvement in eating-disorder symp-
steroids in order to compensate for their perceived toms was maintained ten years postoperatively.213
lack of muscularity. Individuals with muscle dysmorphia
typically experience signi¬cant social and occupational
SUMMARY
impairment, often because their exercise and eating reg-
imens are so time-consuming. The prevalence of mus- Studies suggest that persons who seek cosmetic procedures
cle dysmorphia is unknown. Estimates suggest that 5% of experience a wide variety of psychological symptoms.
nonprofessional weightlifters and 9% of individuals with Although early studies conceptualized the desire for cos-
BDD have the condition.207 metic treatments as being indicative of psychopathology,
Another possible variant of BDD, “botulinophilia,” was recent investigations utilizing improved methodologies sug-
recently described. The condition is characterized by per- gest that most cosmetic-surgery patients are psychologically
sistent demands for Botox r injections to treat excessive “normal.” This ¬nding is consistent with the experiences
sweating (hyperhidrosis), despite any clinical evidence of of most cosmetic-treatment providers today. Body-image
a physical problem.208 dissatisfaction, rather than psychopathology, appears to
In summary, a signi¬cant minority of cosmetic-surgery provide a more reasonable explanation as to why individ-
patients appear to have BDD. Cosmetic treatments, how- uals seek to change their appearance.
ever, appear to be an ineffective treatment for the condi- Future studies are needed to address the motiva-
tion. Treatment providers need to be aware of the potential tions of patients who seek cosmetic procedures (par-
for BDD in their patients and to provide appropriate men- ticularly body-contouring procedures) and the relation-
tal health referrals when necessary.191,192,209 ship of body image and preoperative psychopathology
Psychological Aspects of Cosmetic Surgery 193


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Sons, Inc. 2004;p718.
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The studies reviewed in this chapter have implications review and some clinical observations, in Goldwyn RM
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16 The Business of Of¬ce-Based Anesthesia
for Cosmetic Surgery
Marc E. Koch, M.D., M.B.A.

INTRODUCTION
CHOOSING AN APPROPRIATE CLIENT
Due Diligence and Surgeon™s Credentials
BE PREPARED
The Stark Act, Malpractice Liability, and Compliance Issues
SELF-PROMOTION
Sales, Marketing, and Business Development
WHO™S THE COMPETITION?
MAINTAINING ONE™S CLIENTELE
BILLING AND COLLECTIONS FOR COSMETIC SURGERY CASES”BILLING
AND PAYMENT
CONCLUSION




gencies, staf¬ng, training, and unanticipated patient trans-
INTRODUCTION
fers.3
In addition to the core functions of any business, OBA
The practice of of¬ce-based anesthesiology (OBA) is
nearly a century old.1 However, published articles on the possesses many unique elements compared to traditional
subject did not appear in the medical literature until 1981.2 hospital-based practice. At its core, OBA more closely
resembles any other community-based referral practice
As with traditional applications, the goal of anesthesia in
with a long list of business considerations. The bene¬ts
the of¬ce setting is to provide patients with a lack of aware-
of OBA have made it one of the fastest growing sectors
ness of surrounding events, to keep the patient still to
in anesthesiology. Patients enjoy the heightened privacy,
allow the surgery to take place, to enable access for the sur-
ef¬ciency, and familiarity of an of¬ce setting (lower costs,
geon through muscles to bones and body cavities. All cos-
too). Surgeons appreciate the increased convenience and
metic surgery avoids body cavities and is therefore, min-
control of operating in their own of¬ces. Many save time
imally curative to prevent dangerous surges in hemody-
in travel and eliminate many of the hassles associated with
namics.
hospitals and surgery centers. For an anesthesiologist, an
Compared to hospitals and licensed ambulatory surgery
of¬ce-based practice can usually provide a better lifestyle
centers, of¬ce-based medical practices currently have to
with unique challenges. Catching this wave of the future
abide by signi¬cantly fewer regulations. Therefore, it is
requires careful consideration of these unique circum-
imperative that physicians adequately investigate areas
stances, pressures, and challenges.
taken for granted in the hospital or ambulatory surgi-
There are many business issues an anesthesiologist expe-
cal facility, such as organizational structure, governance,
riences when entering the cosmetic surgery market. This
facility construction, and logistical equipment, as well as
chapter covers some of the more important business issues
policies and procedures, including ¬re, safety, drugs, emer-


199
200 Marc E. Koch


that any physician should consider before embarking in a Although not a hard and fast rule, it seems as though
career that, either in whole or in part, includes cosmetic most oral and maxillofacial surgeons tend to limit their
and plastic surgery. cosmetic surgery to the head, neck, and related structures.
If, in fact, the oral surgeon is providing service in an area
that is already somewhat saturated by cosmetic surgeons,
CHOOSING AN APPROPRIATE CLIENT

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