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A prospective controlled outcome study of psychological change following plastic surgery Dr Tim Moss Chartered Health Psychologist Centre for Appearance Research UWE (Bristol) [email protected] Mr David Harris Consultant Plastic Surgeon Derriford Hospital Plymouth Overview Evidence of plastic surgery benefits? Design and measures Participants and attrition Outcomes Depression Anxiety Appearance adjustment Evidence of plastic surgery success Honigman et al 2004 review Bolton et al (2003) Mixed methodologies Patient satisfaction good 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 Comparison surgery group T1 (pre op), T2, (3 months post op), T3 (12 months post op) 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 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 All Time one only Time one and two only Time one and three only Time one, two and three Control 105 61 Plastics 51 4 All 156 65 44 10 54 n/a 8 8 n/a 29 29 Participants by condition Ctrl Plastics All Rhin Breast Arms Rhin Breast Arms Rhin Breast Arms All time one 36 33 36 18 18 15 54 51 51 Time one only 19 17 25 1 1 2 20 18 27 Time one and two only 17 16 11 4 2 4 21 18 15 Time one and three only n/a n/a n/a 2 2 4 2 2 4 Time one, two and three n/a n/a n/a 11 13 5 11 13 5 Participant by sex (% Female) All time one Time one only Time one & two only Time one & three only Time one, two & three Ctrl 58 54 Plastics 67 75 All 60 55 63 60 63 n/a 75 75 n/a 66 66 Gender similar across times and patient group Participant age Control Plastics Mean nose Std Count Mean Std Count Deviation Deviation 28.11 8.00 36 30.67 10.13 18 breasts 33.25 12.14 33 30.00 10.29 18 upper limb 6.44 36 25.87 8.89 15 27.08 Age comparable across groups and conditions Impact of Attrition Group Control Sample T1 only Percent 44.3 54.1 36.4 Sample Group T1 only Female T1 only Male Female T1 and T2 Male Female T1 T2 and T3 Male 63.6 25.0 75.0 40.0 60.0 34.5 Female Male Female 65.5 25.0 75.0 T1 and T2 Plastics T1 and T3 only Gender Male Female Male Std. Dev T1 and T2 Ctrl Plastic Ctrl Mean age 29.3 28.0 29.5 only T1, 2, and 3 Plastic Plastic 26.0 30.6 4.6 11.7 T1 and T3 only ALL Plastic 27.6 8.2 Both 29.2 9.5 8.6 8.3 10.4 Neither age nor sex differentially affected by attrition Depression Time x feature x group 10 9 F(2,77) = 1.3, p=0.28 8 Depression reduction not significantly greater in plastics F(1,77)=2.3, p=0.13 7 6 T1 5 T2 Controls Plastics Anxiety 8.0 7.5 7.0 Time x group x feature F(2,75)=3.1, p>0.05 6.5 6.0 5.5 Anxiety reduction post op greater in plastics patients 5.0 T1 4.5 T2 Control Plastics F(2,75)=3.3, p=0.02 Derriford Appearance Scale 24 DAS24 60 50 40 Time x feature x group F(2,77)= 10.2, p<0.005 Group X time F(1,77) = 69.8, p<0.005 30 DAS24T1 20 DAS24T2 Control Plastics Plastics patients significantly better DAS post op Derriford Appearance Scale by feature 50 Feature x time F(2,23)=7.1, p<0.005 40 30 T1 20 T2 rhino breasts upper limb DAS improvements post op only significant for rhino and breasts at T2 Patients only: DAS at T2 - T3 70 60 Stability of adjustment levels rhino and breasts 50 40 30 T1 T2 20 T3 rhino breasts upper limb 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?