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CHAPTER IV PSYCHOLOGICAL RESEARCH IN PLASTIC SURGERY

"Oh Girl will see in this almanac, you will see where it all began ..."
Buarque de Holanda Chico, Almanac.
Development of research
The
psychology of grief and CP share of reciprocal interactive processes regarding s
elf-image and self-esteem, few studies of the relationship between each other ha
ve been made or published in
journal of Psychology. In this chapter the diversity of research will be evident
, and the lack of unity of meaning between them. Also have been little studied t
he socioeconomic impacts on the demand of physical attraction between people. (D
EATON & Langman, 1986; GIDDON, 1983). GIILLIES & MILLARD (1957), quoting the ROE
(1887) and Koller (1911) had reported major psychological changes in patients u
ndergoing surgical procedures repairers or aesthetic, and a clear reintegration
of those patients with their external environment. According BULL & RUNSEY (1988
), Abel (1952) studied Seventy-four patients who were disfigured face. Everyone
had the belief that the deformity was responsible for the failures in life. Most
complained of discrimination in the workplace or in other social situations. Th
e attribution of causality in this study is well illustrated. Patients pinpointe
d the source of failure: facial deformity. MEYER (1964), studying the psychology
of male patients who sought the CP, he noticed a high incidence of
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schizoid and schizophrenic patients who expected the CP much more than she could
offer specifically. Had great difficulty in family relationships and wanted to
undo the paternal identification through the removal or alteration of facial fea
tures. According BULL & RUNSEY (1988), KNORR, EDGERTON & HOOPES (1967) investiga
ted the main difficulties of six hundred ninety-two patients who sought a CP. Th
e researchers stated that one of the most frequent complaints made by them was t
he difficulty for the development of lasting ties of friendship. Researchers HIR
SCHENFANG et al. (1969) found that twenty-five patients with internal and extern
al facial paralysis had complaints about the difficulty in making friends. All a
lleged lack of opportunities for marriage, for a family weakness and problems in
obtaining jobs (BULL & RUNSEY, 1988). According BULL & RUNSEY (1988), Andreasi
& NORRIS (1972) studied nine women and eleven men severely burned (ages 18 and 6
0). They all said they were an object of pity and curiosity. There was also refe
rence certain that attract attention (unwanted attention) and they would receive
questions or comments malevolent. GOIN et al. (1976) conducted a prospective st
udy in twenty asymptomatic women without psychiatric or psychological, that made
lifting, pointing out that 60% of patients admitted to the grounds stated in th
e presurgical evaluation were insincere (false). Most of them showed the real re
ason postoperatively. Some of these real reasons were: fear of aging, problems i
n marriage, desire to gain a better professional position. Those whose motivatio
n has not changed (sincerely held), revealed that admitted from the outset the i
ntention to alter the pattern of interpersonal relationships, considered of poor
quality. This important discovery of GOIN et al. (1976) that there is a differe
nce between the declared motivations before and after surgery is consistent with
the findings of Thomson et al. (1978). The high number of distorted motivations
(masked) demonstrated no effect on satisfaction
1st
authors did not discriminate between the group and type of CP sought. 2
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with outcome. For example: a patient who, at heart, wanted a career advancement,
despite being frustrated that expectation, showed no decrease in satisfaction w
ith the surgical outcome. The increase in the CPE has led to a growing concern f
or their psychological or psychiatric disorders, particularly the motivations of
candidates for the CPE. Thomson et al. (1978) considered the rhinoplasty patien
t as a prototype, as rhinoplasty is one of the most popular surgical procedures.
The centralized location of the nose on your face and visibility from various a
ngles are the most reasonable explanations for this search. The nose is a promin
ent element in the profile pictures and part of the face which tends to occur at
a higher rate of somatization. They also found that the vast majority of rhinop
lasty patients (90-95%) is satisfied / very satisfied with the results, with imp
rovements in self-esteem and interpersonal relationships.€Starting from the bas
ic assumption that the CPE changes the position of passivity and retreat towards
life, for the activity and participation, Belfer et al. (1979) studied forty-tw
o patients and noticed a positive correlation between the plastic and significan
t life events (marriage, career advancement, greater social acceptance and divor
ce). The vast majority of patients (36) showed strong dominance of parents and n
eed to settle conflictual interpersonal situations quickly. The authors observed
in their sample of patients an exaggerated concern with appearance and that thi
s would improve after the CP. Revealed that most patients seek to change the CPE
traits or features that cause them embarrassment, unwanted attention, nasty com
ments, or to gain social acceptance or increase their professional opportunities
. Interested interpersonal: 1) the physical characteristics have a major influen
ce on psychological and social world, 2) there are rewards and differential trea
tment for those who are physically attractive;
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us
effects
social
of
disfigurement
facial
MACGREGOR (1982) summarized their studies of physical attraction or
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3) the concepts of beauty and ugliness are variable from one culture to another
and from one era to another, but there are "standards" universal what is pleasin
g to the eyes and hands (RECTOR & THIRTY, 1990), 4) qualities considered pleasan
t increase interpersonal attraction, sexual, work opportunities and life opportu
nities, 5) cute guys tend to attract to her favorable judgments about his charac
ter, which would be quite different if they were ugly: for this reason, the tran
sgressions or crime caused by people "beautiful / attractive" tend to be assesse
d in a less negative (Amaral, 1986). Another example refers to helping behavior:
individuals 'pretty' tend to receive more aid, compared to others not so "beaut
iful" (Goldstein, 1983), 6) there is the stereotype of attractiveness: physicall
y attractive people are viewed as being more personality, more chance of success
, and smarter, 7) according to the technical advances of the CP, no one is oblig
ed to keep the legacy or face that look that nature "made" or caused any acciden
t / spoiled. The same is true for the positions of the teeth through orthodontic
corrections. The facial features are no longer a "fact of life" but rather some
thing that can be changed for the better, 8) there is a danger of believing that
the CP could solve the problems of life, as a panacea for human conflicts. This
has been discussed by AMARO (1985), who referred to possible collusion between
the surgeon and the patient's wishes, to the extent that the first wants to make
money anyway. GIDDON (1983), concerned about the high cost of surgical correcti
on and / or orthodontic, reinforced the need for more research in the area. The
suggestion offered by the researcher that there is a correct reconciling supply
and demand for the services of specialists. Three ways to lower cost procedures
are possible: 1) increasing the number of professionals, 2) demand reduction and
3) increase of taxes on products geared to Beauty.
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The collection of surplus item 3 would be applied in research or to permit an in
crease in the number of surgeries or placement of equipment for the less privile
ged classes. GROENMAN & Sauer (1983) wrote that there are two basic types of sea
rches in CP: 1) Clinical-psychiatric (UK), 2) Clinical and psychological (U.S. a
nd Europe). The first is interested in the development of psychopathological tra
its, like schizophrenia or dysmorphophobia (GIPSON & Connolly, 1978), the second
type of research investigates the motivations, expectations, self-image, postop
erative adjustment and satisfaction with surgical results, the that conforms to
one of the roles that psychologists can play, as previously described (Chapter I
I), DEATON & Langman (1986). AMARO (1985), within the Kleinian Psychoanalysis as
serts that psychological tests, interviews, studies and research could provide e
lements for a truly safer reconstructive surgery, understood as that which will
make the patient able to develop any human activity, without arouse unwanted att
ention on his appearance. For AMARO (1985), the oppositions are present in today
's world: good x ill, left x right, x less than and in the field of aesthetics,
beauty and ugliness, there is an existential opposition of man: the fight to be
equal but at the same time to be different. There are differences with the gener
al connotation of disadvantage. Examples: a crooked nose,€a cleft lip or ear ty
pe of fan is a different state with handicaps facing the "same", because unwante
d attention or arouse feelings of rejection or pity. In view AMARO (1985), there
are at least three basic solutions to address the problems of "different": surg
ical solutions, psychological and social. Thus, for example, a patient with clef
t lip out on the CPR the best way to lead you to the group "equal", the phobia w
ould receive the treatment of systematic desensitization in behavior therapy (Wo
lberg, 1967) and, finally, the neurotic, alcoholics and other social minorities
found associations for anonymous
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do not feel "different" and thus have the perception of being "equal" 2. Being a
relatively long article, you must extract the main ideas of AMARO (1985), for t
he criteria in selecting candidates for CPR: 1) candidates must be examined by a
multidisciplinary team, 2) the economic and social aspects characterize the can
didate and the type of surgeon who seek it, 3) CPR aims to contribute to the rep
arative function of personality, while also giving the man one more option to re
pair concrete, 4) is fundamental to separate true from false and repair for this
, the surgeon should be attentive to aspects bio-psycho-social self and the CP c
andidate, update to be scientifically and with determination to achieve an effec
tive remedy that will help develop the personality of the patient. With respect
to the approaches of these studies, FONSECA (1985) classified them into three ty
pes: Physiological, phenomenological and psychoanalytic. In physiological type,
the concept of body image is linked to vital functions. The second type consider
s the body as it is known and experienced by the person. The representations are
not necessarily linked with their bodily functions because of the existential m
oment will always depend on the person. The latter approach, the psychoanalytic
attempts to uncover the body image that is unknown, unconscious to the subject i
n March. Most psychological research on EPC belong to this category.
2
Berscheid & Walster (1973) describe some attempts to verify to what extent the p
hysical similarities are related to interpersonal attraction resulted in positiv
e correlations, but it is difficult to interpret them as cause and effect. The f
ew studies carried out indicate that the similarities are compelling factors and
that the differences diminish the possibilities of establishing interpersonal r
elationships. 3O test of the Human Figure by Karen Machover was used in sixteen
children 7-12 years (both sexes), suffering from asthma, for Kolck (1987), to su
ggest that any physical disease (body modification) will always bring the possib
ility of change in body image. Thus, children with asthma are likely to do drawi
ngs with the neck and trunk (site of the lungs) in focus, showing a focal area o
f the conflict through which it passes, people with cardiovascular problems may
present figures with the heart or chest area in relief. You can see here, more a
form of psychological research (projective test), not directly connected to the
CPE, but involving the body and its graphic representation. June 407626.doc
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AMARAL (1986) did a study that was about the influence of different degrees of f
acial deformities, congenital and acquired the self-assessment (self-concept), t
he assessment of other (hetero-concept) and academic achievement within and outs
ide of school. The subjects were the target thirty-six pre-school adolescents, a
ged 6 to 12 years, of both sexes and low socioeconomic status. The children were
suffering from facial deformities (face atypical) of different degrees and caus
es. Using a scale of semantic differential (SD), the design of self-image and th
e image of the other, tried to make clear that: 1) physical appearance is not an
indicator of personality trait, it is therefore predictive of behavior; 2) phys
ical appearance, for Contemporary Psychology, is an important psychosocial varia
ble, 3) social interaction is determined mainly by the image of the person, 4) i
mage of the person (real or idealized) can be decomposed into: a) self- image, b
) self-concept, c) straight-image d) straight-concept, 5) for WRIGHT, cited by A
MARAL (1986), physical appearance is a characteristic surface, pointing to the n
eed to go beyond , 6) surgical correction of the deformity can help in improving
self-image and straight, 7) the performance of students have no cause-effect re
lationship with their facial deformities;€8) the atypical face can not be consi
dered as an element of disfigurement of personality; 9) any prejudice that is st
igmatizing facial deformity should be discarded. DEATON & Langman (1986) argue t
hat psychological research in the area of CP related to self-image, self-percept
ion and feelings of self-esteem with a new look. The CP would increase the role
of such feelings. Researchers have shown thus that the role of the psychologist
can go beyond the recruitment, selection or therapy of
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candidates, this may increase the sensitivity of the plastic surgeons for psycho
logical issues. FONSECA (1988) conducted a research on the psychoanalytic approa
ch, with twenty women who underwent mastectomy, using interviews and Rorschach -
classical projective test of personality and intelligence - that might obtain,
among other things, data and experience body image body. Concluded that the remo
val of breasts or just one, including his part, is sufficient to trigger strong
reactions of grief or loss in the patients. The author reported that the vast ma
jority of patients reported changes in sexual identity. For him, these data can
only be studied for their direct effects (interviews) or indirect (projection).
Of course, the CPE is not a mastectomy but the research this author and his meth
od is appropriate in the research of self-image and body experience. Godefroy et
al. (1988) considered the request for CPE as a hysterical symptom, showing that
20-90% (sic!) Of the individuals seeking such assistance suffer from mental mis
fits that include a poor social adjustment and obsessive or schizoid personality
. The researchers hypothesized a regressive movement around the neurotic dimensi
on that is associated with the request for cosmetic surgery, with the possibilit
y of a profound narcissism that failed to keep intact the self image. HANSSON et
al. (1988) studied the cognitive style and psychological defenses of women into
several groups composed according to Table 1: Table 1 - Composition of test res
ults and second Hannson et al. (1988) 4. ANOREXIA number of women Test Dependenc
y
4
BULIMIA
29
Reduction mammoplasty
31
CONTROL GROUP
56
25
little
much
little
dependence
The table is the result of personal development and aims to clarify the results
of the author. 8 407626.doc
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Psychological Rod & Frame
dependence
dependence
dependence
average
1 - Test MCT hypersensitivity to body shape (signs and psychiatric) 2 - need for
repression of impulses
1 - signs of depression and social isolation (very frequent) and 2 - Little impu
lse control
1 - problems related to sexual identity and 2 - frequency of signs of repression
similar to the control group
not reported
The control group was also composed of female subjects. All groups were subjecte
d to the process of psychological dependence with the Rod & Frame Test and the T
est of Psychological Defence with the Meta Contrast Technique (MCT). The results
indicated in table 1, showed that bulimics are more field dependent than the ot
her groups. Anorexics and those who underwent breast reduction are more independ
ent of the field. The MCT also showed that very frequent sign of depression and
isolation in bulimic subjects, whereas anorexic individuals showed signs of susc
eptibility to become marginal. This fact can be understood as a necessity of soc
ial isolation. The anorexics showed fewer signs of internal repression. The grou
p of breast resembled the anorexics in the appearance of the most common manifes
tation of signs of hypersensitivity in the control group, but it did not differ
with respect to repression. ROBIN (1988) submitted eleven men and eleven women,
all adults, for rhinoplasty patients, and twenty-two subjects in the control gro
up to the General Health Questionnaire in order to enhance the network of direct
ories, the scale of masculinity and femininity. The subject of rhinoplasty perce
ive their appearance as similar and underestimate their own appearances to the s
ame extent that the subjects in the control group. In relation to masculinity an
d femininity, the researcher noted that patients have a sexual identity is compr
omised compared to the control group, because the vast majority expected increas
e in items related to being a man / woman with rhinoplasty. These control subjec
ts have degrees
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varied in relation to psychiatric symptoms. It is suggested that psychiatric sym
ptoms should be part of the "syndrome of an application in rhinoplasty.€Repeat
testing 6 months after surgery (including the control group) and showed that an
improvement in facial appearance can lead to a reduction of psychiatric symptoms
. There was no change in control subjects of rhinoplasty. Scalini et al. (1988)
studied the psychodynamics of CP with a sample of forty-two Italian subjects (fi
fteen men and twenty-seven women, mean age 22.5 years), who requested rhinoplast
y for aesthetic reasons. All subjects suffered from any psychotic or neurotic sy
mptoms in personality, verifying the absence of similar disorders in the sample
of normal control. While most of these features remain subclinical, the Rorschac
h test has proved an effective instrument in the psychometric clarification of w
hy CP. SIMON-Consuegra et al. (1988) conducted a study of forty women aged 18-35
years, 35 of them married, they would undergo the process of liposuction and ma
mmoplasty corrective. The results showed that the study subjects suffered from p
sychopathological ugliness (100%), inferiority, anxiety, sadness, insomnia and b
ulimia (93%). The delegates expressed their hypersensitivity to criticism, which
led them not to participate in social events and does not relate sexually. Thes
e attitudes led to individuals in a life of dissatisfaction and social isolation
. The issue of possible suicidal behavior, discussed by the researchers, suggest
s the need for medical care, psychological and psychiatric patients for this pro
file plastics. YATES (1988) presented the case of two bulimic women (one 19 and
one 20 years) who had CP in order to make their bodies more acceptable. The surg
ery was significant, but its effect was temporary in relation to remission of bu
limic symptoms. SCHWEITZER (1989) made several psychiatric evaluations of patien
ts in the pre-surgical restorative facial or CPE. The outcome of these investiga
tions said flexible and creative approach to patients can result in an authentic
understanding of problems associated with self-image and body. The psychiatrist
warned against what he called "Potential problems of patients' true
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Red signals detected in the request for an EPC. These problems may be: minimal d
efect in appearance, repetitive applications of plastic surgeries, feelings of p
ersecution or psychiatric diagnoses (schizophrenia). The secrecy required by the
men who seek the SPC and the patient in an existential crisis are worthy of gre
ater respect by the plastic surgeons, in order not to err in the diagnosis. BIRT
CHNELL (1990) tried to show the motivating factors for breast, so as to reduce t
he volume of the breasts. The author interviewed forty women between 16-50 years
who were on a waiting list for such surgery. The evaluation result of the quest
ionnaire showed that the group wanted breast reduction contained more single wom
en and women who lived alone and who were away from their families of origin. In
the group, whose bid was the breast augmentation in the volume, there was a sig
nificant number of separated and divorced. The predominant motivation was to fee
l less ashamed and embarrassed by their clothes. In both groups, women wanted to
be more feminine. LE-GOUES (1990) explored the psychodynamics of CP, particular
ly body image and self-image and how these concepts appear before the interventi
on plastic. In this context, the change request body has always had two aspects:
the anatomical and the psychological, which must be separated for better unders
tanding. This division is that it allows the delivery of aid and psychological c
ounseling before surgery. The author has shown that victims of accidents or peop
le with obvious physical defects seek to remedy the results arising from the dis
figurement. Those individuals seeking a new identity or psychological support by
changing the image of their bodies. Basically they want CP to: look more sympat
hy for themselves, a narcissistic wound repair, change the aspect body as a sour
ce of suffering or have a body image that brings pleasure and increased self-est
eem. SCHOUTEN (1991) examined the design aesthetic of CP in the current context
to determine the motives and self-concepts (dynamic) behavior of the consumer -
the patient plastic in its symbolic aspect. The transition of roles, diverse sex
ual identities, fantasies
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romantic partner's control, efficiency and body game of identity are the element
s used by patients (not reported the type of research, nor the number of patient
s who went through the interview) that seek to CP.€The author showed that the c
onsumption activities, including consultation with the surgeon carrying out some
event or plastic, are important for the development and maintenance of the stat
us quo and harmony of design itself. In the first BRAZILIAN CONGRESS OF PSYCHOLO
GY HOSPITAL (1992), held in São Paulo - Capital, was the presentation of two wo
rks directly related to CP (breast), with similar structures of research: both s
ought their data using the semi-directed, the Human Figure Test (Machover) and t
he Crown-Crisp Experimental Index (CIEC) in patients who sought breast (pre-surg
ical) in the Hospital of Clinics (SP), namely: 1) CURY (1992) evaluated five pat
ients who have mastectomy and conclude that it is of fundamental importance to b
reast reconstruction later (the breast is an attribute of femininity), regardles
s of the reconstructive technique used, and 2) FARAGE et al. (1992), within the
field of EPC evaluated Fifty-three patients who underwent primary breast, aiming
at psychological characterization of these patients. The results might show tha
t most patients are young without children, or with a (maximum) people willing a
nd self-centered, with difficulties in their sexuality and in which there is a l
ack of confidence in social contacts. The CIEC showed significant results for th
e "phobia" and "obsession", while traces of neurosis.
Comments on the research
A quick reading of this chapter will show a panel chronological extremely divers
e. The "parade" of authors, as well as the diversity of issues addressed by them
, not by accident. Our goal
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was also explaining the complexities inherent in the field of interpersonal appe
arance 5. Since GROENMAN & Sauer (1983) classified research into two major group
s (Psychiatric and Psychological), few theoretical clarifications were made. The
three approaches within the group of psychological research, proposed by Fonsec
a (1985), was extended, in our view, with studies by Amaral (1986), brought to t
he area since the fourth type: the psychosocial studies related facial deformity
, appearance physical and academic performance. The decomposition of the image o
f the person (real or idealized) in four subcategories represents growth theory,
as it ties individual concepts to the environment in which the person lives (ac
ademic achievement). Many of the researchers mentioned unfortunately did not sho
w clearly, the specific theory that guided them. Some were careful not to disclo
se the number of subjects who participated in the survey, the methodology and th
eory used in their studies. This lack of clearance methodology has resulted in i
solated studies, little research illuminating and timid attempts to understand t
he field that, unfortunately, have no continuity in time and space. The diversit
y of research as well as a variety of techniques (surveys, questionnaires, inter
views, projective tests), or comparative and prospective studies are positive in
dicators that the study of behavior in social psychology, linked to the first im
pression is highly complex. This wide range of empirical findings is always the
cultural and social values in which research is conducted. Despite the complexit
y, the vast majority of research or empirical findings addresses the difficultie
s encountered by the persons or patients regarding the area of interpersonal rel
ationships, passing through the facial or body appearance. The wide variety of b
ehaviors derived from facial deformity or those who are more disadvantaged with
respect to appearance have been described: unwanted attention; disturbances over
the first contact with people, withdrawal or social isolation;
5um
question that was always present during the preparation of this chapter is: to w
hat extent the researchers are being guided by their intuition or implicit or ex
plicit pressure from the media who value such information or findings?. 13 40762
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difficulties in making friends or keeping them, sexual or professional problems
and positive correlation with sub-clinical psychiatric symptoms. According BULL
& RUNSEY (1988), Sorell & NOWAK (1981) advocated better communication among rese
archers of the facial appearance or body, in order to concentrate and compiling
the data. The authors argued that the diversity of methods, theories, styles of
research and the variation of the same object (the person and his deformity, per
son and their self-image, relationship of friendship and marriage, motivation to
CP or style of coping with unwanted attention) need to pass through comparisons
research.€BULL & RUNSEY (1988) searched for a theoretical framework that could
encompass the results of research in Psychology of Facial Appearance. They were
behind a skeleton framework that could justify the findings. It was evident tha
t, at least for now, this structure does not exist. For the authors, yet no theo
ry deserves the first place, does it reached the base data integrity. For author
s, the so-called explanatory theories and, among them the theory of causal attri
bution, noteworthy for reviewing the findings of researchers and also seek a uni
ty of meaning between them. intercultural theoretical clarification and continui
ty
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