A prospective controlled outcome study of psychological change following plastic surgery Mr David Harris Consultant Plastic Surgeon Derriford Hospital Plymouth Acknowledge Rhona Slater and Tony Carr Dr Tim Moss Chartered Health Psychologist Centre for Appearance Research UWE (Bristol) Tim.moss@uwe.ac.uk

Overview Evidence of plastic surgery benefits? Design and measures Participants and attrition Outcomes Depression Anxiety Appearance adjustment Purposes of plastic surgery – physical and psychological. Challenge own prejudice about therapy vs surgery

Evidence of plastic surgery success Honigman et al 2004 review Mixed methodologies Patient satisfaction good Bolton et al (2003) Abdominoplasty, pre- and post-op B.I. satisfaction increased B.I. investment, general psych function not improved Sarwer et al (2005) General aesthetic plastic surgery Satisfaction with surgery and ‘feature’ change over 12 months

Methodological issues Measures Sarwer (1998) Interviews demonstrate psychopathology in cosmetic surgery patients Standardised general measures not identify this Designs - comparison groups . . . Dissonance Hawthorn effect Demand

Our study: Design Prospective, Controlled, quasi-experimental Plastic surgery patient group T1 (pre op), T2, (3 months post op), T3 (12 months post op) Comparison surgery group T1 and T2 Participants Adults, English speaking Patients: Plastic surgery admissions – nose, breasts, upper limb Comparison group: Non-appearance altering surgery group General surgery, ENT, Maxillofacial surgery Randomly allocated “nose”, “breasts”, “upper limb”

Measures Generic psychological functioning Crown Crisp Experiential Inventory- Anxiety Beck Depression Inventory Test-retest reliability high Good internal validity Criterion validity with other measures and clinical observation high

Derriford Appearance Scale 24 Measures Derriford Appearance Scale 24 www.derriford.info 24 items examine frequency of avoidant behaviours and distress related to appearance concern Example items: I feel self conscious of my appearance I avoid going to pubs/restaurants Psychometric properties Internal consistency; Cronbach's = 0.92 Test-retest r = 0.68 (6 months) Moderate correlations (r=0.5) with NA, social anxiety, shame

Participant numbers

Participants by condition

Participant by sex (% Female) Gender similar across times and patient group

Age comparable across groups and conditions Participant age Age comparable across groups and conditions

Neither age nor sex differentially affected by attrition Impact of Attrition Neither age nor sex differentially affected by attrition

Depression Time x feature x group F(2,77) = 1.3, p=0.28 Depression reduction not significantly greater in plastics F(1,77)=2.3, p=0.13

Anxiety Time x group x feature F(2,75)=3.1, p>0.05 Anxiety reduction post op greater in plastics patients F(2,75)=3.3, p=0.02

Derriford Appearance Scale 24 Time x feature x group F(2,77)= 10.2, p<0.005 Group X time F(1,77) = 69.8, p<0.005 Plastics patients significantly better DAS post op

Derriford Appearance Scale by feature Feature x time F(2,23)=7.1, p<0.005 DAS improvements post op only significant for rhino and breasts at T2

Patients only: DAS at T2 - T3 Stability of adjustment levels rhino and breasts Delayed improvement in upper limb adjustment: significant T2 – T3 change

Criticisms of design Quasi-experimental design Potential confounding of group Limitation of plastics patient conditions impacts on generalisability Groups numbers reduce analytical power

Conclusions Plastic surgery: psychological benefits for the three conditions studied Plastic surgery specific, not generalised surgical intervention effect Not demonstrated in depression Small and significant effect in anxiety Clear effect detected for DAS24 Delayed benefit for upper limb Use of appearance specific measures preferable to generic?

Further work Components of poor appearance adjustment benefiting from surgery? Relationship between anxiety/DAS24/depression and Patient Satisfaction? Impact of surgery on components of (multidimensional) BI - and which of these mediate outcome variables above?