Plastic Surgeon as a Spiritual Healer

Abstract

Eleven papers were collected, which are focused to help healing the patients not only by surgery but also spiritually.

10.1 Hallucinations in Children with Plague: A Point of View from 400 Years Ago

Fever is one of the symptoms of coronavirus disease 2019 (COVID-19), which is prevalent both in Korea and in other countries throughout the world. Fever is defined as an oral temperature of 37.8 °C or higher or a rectal temperature of 38.2 °C or higher. There are many causes of fever, including infections such as bacteria and viruses. When the body heat rises, blood vessels dilate to lower the core body temperature, increasing sweat secretion.

In children, a high fever can cause febrile convulsions. Due to a high fever, one becomes mentally confused and unable to understand the surrounding environment, with very unstable emotions, causing conscious and cognitive disturbances such as illusions or hallucinations—that is, delirium.

How did Koreans interpret these symptoms before it was discovered that pathogens are the cause of infectious diseases that result in high fever? In the late Joseon Dynasty, many infectious diseases, such as smallpox, measles, and cholera, occurred. These “plagues” would spread suddenly and frighten the populace, but they would disappear after a while. The people’s awareness and perceptions of plagues can be seen vividly in the tales of that time.

This paper introduces an example of “child fever” from the examples of plagues described in the book Eoyuyadam, published in 1622 by Mongin Yu (1559–1623) [1]. Relevant materials were found and verified by searching the Research Information Service System provided by the Korea Education and Research Information Service [2].

In section 159 of Eoyuyadam, related to religion, the following is recorded:

In this era, if a child was afflicted with a plague and had hallucinations, people believed that the child became numinous. Since their parents only responded through prayer, due to ignorance regarding effective treatments for the disease, most children affected by this condition died (Fig. 10.1). It is truly a pity for clever children to die and disappear from a single illness. People say, “People afflicted with this disease sometimes show magical powers and in other cases engage in strange behaviors. What can they be other than ghosts?”

Fig. 10.1

A child with halluciations. If a child was afflicted with a plague and had hallucinations, people believed that the child became numinous. Parents responded through prayer. Illustration by Hye Won Hu, MA

My thoughts are as follows: Plague causes fever, and heat is fire. The nature of fire is bright, and fire controls the heart. Since the heart is inherently futile, when it has a fever, it becomes as powerful as a ghost and as bright as fire, hearing without hearing and seeing without seeing. That is why an afflicted child is able to respond to external events even in a dark, quiet room and sometimes can surprise and deceive people by revealing things they had no way of knowing about in casual talk like sleep talk.

In my opinion, both plague and measles are febrile diseases. This is because heat and fire are so bright that they can see even things that have no form. When women see such things, they put their hands together and pray to God, which is ridiculous.

People said that children affected by plagues were unusually smart and could understand things they had not seen and heard, but Mongin Yu said that even if something like this happens, it is not because the child is smart but because of the fever, which makes that mind temporarily weak. He criticized others’ viewpoints based on the theory of the five elements as the principle of yin and yang.

In fact, children with high fever and delirium can progress to encephalitis or encephalopathy, especially in cases of influenza infection. Delirium due to hyperthermia requires differentiation from benign parasomnia, which is characterized by fearful expressions, a positive past history, and autonomic nerve symptoms. Instead, in delirium, visual hallucinations occur in association with sleep. Meningeal signs and disturbed consciousness also appear. Marked slowing of the background activity of electroencephalography is a warning sign of delirium [3, 4].

When a fever above 38.5 °C persists in children, it is best to first take off all clothes and continue to wipe their head, chest, stomach, armpits, and groin, which generate abundant heat, with tepid water at about 30 °C so that the heat can gradually go down. When the body temperature rises, the basal metabolic rate increases, the heart rate increases, and water loss occurs. When the body temperature rises by 1 °C, the basal metabolic rate increases by 10–12%, the oxygen consumption rate by 13%, the heart rate by 15 beats per minute, and daily insensible water loss increases by 300–500 mL per square meter of body surface area. Therefore, it is important to drink plenty of water.

Mongin Yu was critical of the belief that children become spiritual when they are afflicted by a plague. He argued that although people said that children afflicted by a plague were unusually intelligent and could understand things they had not seen and heard, any such cases did not occur as a result of the child becoming intelligent. Instead, he said that this could be a temporary phenomenon. Although he understood the mechanism of fever differently from how it is understood in modern medicine, he recognized that fever causes “mental confusion” and hallucinations. He pointed out that the beliefs about plagues in that era were wrong and emphasized the necessity of treating sick children.

In Korea, scientific prevention and treatment measures are being implemented in response to COVID-19. However, some people vocalize unscientific and religious opinions and recommend traditional prescriptions. It is worth remembering that a Joseon dynasty scholar, although he worked within a framework based on yin and yang, argued for a relatively empirical and scientific approach to prevention and treatment 400 years ago.

10.2 A Safe Distance Between Doctor and Patient

If the distance is great, then the degree of love is great; if the distance is small, the degree of love is small. From “Measurement of Love” by Han, Yong-un (1879–1944)

When I visited Edinburgh last year, I enjoyed exploring the Surgeons’ Hall Museums. Among the many famous surgeons from that city, a surgeon with a special costume caught my eye. The costume comprised an ankle-length overcoat and a birdlike beak mask, and the surgeon was also wearing gloves, boots, a wide-brimmed hat, and an outer garment.

When the worst outbreak of the plague was ravaging Edinburgh in 1645, Dr. George Rae was appointed as the “Plague Doctor” of that city. Although the available treatments at that time were limited, he did his utmost. He lanced patients’ boils to allow the poison to drain. After the wound was cleaned, he cauterized it, thereby disinfecting and sealing the wound site. To protect himself against airborne miasmas, which were then thought to be the causative agent of the plague, Dr. Rae wore a special outfit. In addition to a long cloak, which protected his skin from the infectious air, he also wore a beak-like mask that was filled with spices and rose petals, which would prevent entry of the miasmas through his nose. The length of the beak-like mask secured a safe distance from the patient (Fig. 10.2). Although miasmas do not cause the plague, as we now know, it is remarkable to note that Dr. Rae’s outfit still did its job—by protecting him from fleabites, it enabled him to survive the plague.

Fig. 10.2

Plague doctor of Marseilles Paul Fürst, engraving, c1721

In recent months, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread throughout the world. When patients visit my outpatient clinic, both plastic surgeons and patients are recommended to wear facial masks. However, when patients with facial trauma are being examined, they must take off their masks. When a patient is sitting too close to me, a feeling of uneasiness sometimes arises.

This leads to an important question: how much distance is needed between doctor and patient?

Maintaining a certain distance from others can convey a nonverbal message. According to Hall [5], an anthropologist, doctors and patients should use a wider personal distance (90 to 150 cm) for discussions with one another. This distance is also highly convenient for discussions while sitting down. This guideline applies to situations where a doctor has a discussion with a patient who is in bed. During ward rounds, in which conversations take place at the foot of the bed, the doctor is already out of the patient’s personal distance and has entered the so-called business distance, which is no longer suitable for confidential conversations.

In airborne infections, large droplets can travel approximately 101 cm (39.9 inches). Surgical masks provide highly effective protection against large airborne droplets. For small droplets, which can travel longer distances along unpredictable paths affected by wind gusts and other factors, traditional masks are less effective, as it is possible to inhale droplets around the sides of the masks.

Compared to other physicians, plastic surgeons are especially prone to shortening the clinical distance to examine the patient’s face. As a result, we are vulnerable to small droplet infections under the current circumstances. Therefore, the patient’s history and temperature should be checked before we meet them.

Remember, doctors are no exception to sickness!

10.3 Trauma Surgeons: Heroes of a Moment

Because of COVID-19, it has not been possible for me to attend mass recently. Instead, I listen to sermons and hymns online. My favorite hymn is “The Lily of the Valley”: “He’s the ‘Lily of the Valley’, the Bright and Morning Star/He’s the fairest of ten thousand to my soul”.

This hymn was written by William Charles Fry (1837–1882) for the Salvation Army and first published in 1881. The words were arranged to the music of “The Little Old Log Cabin in the Lane.” It became a gospel standard and appears in almost all Protestant hymnals. It is generally understood that Fry took the term “Lily of the Valley” from the book of Song of Solomon 2:1 (“I am the rose of Sharon, the lily of the valley”).

However, the French novelist and playwright Honoré de Balzac (1799–1850) wrote a novel of same name about a half century before Fry (1835). Balzac wrote this novel, dealing with themes of emotionally vibrant but never consummated affection, and titled it Lily of the Valley, representing the character of Henriette de Mortsauf.

Touched by this novel portraying the theme of affection, I read Balzac’s other short stories and found a very interesting story about a great surgeon: “The Atheist’s Mass” (Fig. 10.3). The protagonist, Desplein, is a successful surgeon and an atheist. One day his former assistant Bianchon sees Desplein going into a church and alone attending a mass. Bianchon questions the priest and finds that Desplein attends a mass at the church four times a year, which he himself pays for. Years later, Bianchon again sees Desplein going into the church and questions Desplein about it. Desplein explains that the mass is in memory of a water carrier named Bourgeat, who was his friend and father figure. When Desplein was a poor medical student, Bourgeat helped to pay for Desplein’s education and did menial tasks like cutting wood. After Desplein became successful, he bought Bourgeat a horse and cart for his water-carrying work. After Bourgeat’s death, knowing that Bourgeat was a devout Catholic, Desplein decided to have four masses a year for him at church.

Fig. 10.3

The atheist’s mass and other stories (La Misa del ateo, 2013, Spanish Edition) written by Honoré de Balzac (1799–1850). Madrid: Edtorial Eneida

In this novel, Balzac defines the glory of a surgeon as follows: “The glory of a surgeon is like that of an actor: they live only so long as they are alive, and their talent leaves no trace when they are gone. Actors and surgeons, like great singers too, like the executants who by their performance increase the power of music tenfold, are all the heroes of a moment.”

When trauma patients arrive at a trauma center, we make decisions and move fast like actors. When a trauma victim’s life is saved and stabilized, our performance is over. We are the heroes of a moment like actors. As a trauma surgeon, I completely agree with Balzac that surgeons live only so long as they are alive and their talent leaves no trace when they are gone. Like a “Lily of the Valley” and the “Bright and Morning Star,” we trauma surgeons give “every care on them to roll.”

10.3.1 Keep Playing Tug-of-War Against Grim Reaper

As you all know well, the aim of the Korean Society of Traumatology (KST) is to reduce the death and disability rates of trauma victims through academic progress in the treatment of trauma patients. The KST held its first annual conference in 1986 and its 27th conference in 2012. Starting in 2013, the KST collaborated with the Armed Forces Medical Command (AFMC) to host the Pan-Pacific Trauma Congress (PPTC) annually; this continued until the seventh congress in 2019. In 2020, an online congress was held because of coronavirus disease-19; however, we will continue to host the PPTC as soon as the pandemic subsides. The KST is participating in major national projects, such as a consultation guideline for trauma patients in Korea and a quality control guideline.

The Korean government implemented a regional trauma center (RTC) project in 2012, with the goal of reducing the preventable trauma death rate (PTDR) to the level of developed countries. RTCs should organically cooperate with the Korean government and the KST to ensure that seriously injured patients are treated at regional level 1 trauma centers [6]. Owing to the efforts of our KST members, the PTDR decreased from 50.4% in 1990s to 19.9% in 2017 [7, 8].

I am honored to become the president of the KST this year. This will be my last opportunity to serve the KST, because only 2 years are left before my retirement.

In my role as president, I would like to enhance knowledge-sharing among our members by providing more opportunities for academic communication. I also hope to raise KST’s status to a higher level in the global academic community.

Of particular note, our official journal, Journal of Trauma and Injury (JTI), which published its first issue in 1988, was included in the Korean Citation Index (KCI) last year (2020). However, its impact factor is still not satisfactory (0.29). We have a long way to go to be registered in PubMed Central (PMC), Scopus, and SCIE. However, this goal is not so far off that it cannot be reached eventually. As the president of the KST and chairman of the ethics committee, I will help the editor of JTI (Gil-Jae Lee) work toward having JTI registered in more databases. I eagerly anticipate that our members will submit their valuable manuscripts to JTI and would be grateful for citations of papers published in JTI. To echo the words of President John F. Kennedy, please do not ask what KST can do for you, but ask what we can do for you and ask what we can do for our KST together.

A well-known movie entitled “Along with the Gods” (2017, starring Ha Jeong-Woo and Cha Tae-Hyun) comes to mind. This film tells the story of a firefighter (Kim Jahong) who dies while saving a girl in a fire in a skyscraper. He is led by three grim reapers who guide him through the seven trials in the afterlife. While watching the movie, I thought about the role of trauma doctors. As trauma doctors, we play tug-of-war against the grim reaper (Fig. 10.4). If we win, the trauma victim lives. If we lose, the patient dies. If we can decrease the PTDR, our winning rate increases—and to do so, we must share knowledge through academic communication. This is one of the roles of the KST.

Fig. 10.4

Holding back the grim reaper. A sculpture on the side of the Fulton County Public Health Department in Atlanta, Georgia. Available from: https://playingintheworldgame.com/2015/09/10/holding-back-the-grim-reaper/

The goal of a reaching higher level in the global academic community might not be reached while I am the president of the KST or before my retirement. However, I do believe that if we trauma doctors start building a stone bridge, one by one, to cross the stream, and if our junior trauma doctors continue the task, it will be completed someday in the future.

Here’s to trauma doctors! Keep playing tug-of-war against the grim reaper!

10.4 Wrinkle the Skin, Wrinkle the Soul

Years may wrinkle the skin, but to give up enthusiasm wrinkles the soul.—Samuel Ullman

In August of 2016, I enjoyed a movie titled Operation Chromite. Inspired by real events in Korean War, this movie focuses on a life-and-death mission of eight Korean operatives. Liam Neeson stars as General Douglas MacArthur and South Korea’s Lee Jung-jae as his lieutenant (Fig. 10.5).

Fig. 10.5

Poster of Operation Chromite (2016)

MacAuthur has been well-known worldwide since he officially accepted Japan’s surrender after World War II and served as the effective ruler of Japan for 6 years. When the communists North Korea invaded South Korea in Jun 1950, he became supreme commander of the United Nations and defended South Korea.

In this movie, MacArthur (1880–1964) led the seemingly impossible marine landing at Incheon, which eventually succeeded (Fig. 10.6). When he was sailing to Incheon through the storm, he said to his officers: “People grow old only by deserting their ideals. Years may wrinkle the skin, but to give up interest wrinkles the soul.”

Fig. 10.6

MacArthur observes the naval shelling of Incheon from USS Mount McKinley, September 15, 1950, with Brigadier General Courtney Whitney (left) and Major General Edward M. Almond (right)

This quote was from a poem of Samuel Ullman (1840–1924), Youth:

Nobody grows old merely by a number of years. We grow old by deserting our ideals. Years may wrinkle the skin, but to give up enthusiasm wrinkles the soul. Worry, fear, self-distrust bows the heart and turns the spirit back to dust.

In the center of your heart and my heart there is a wireless station; so long as it receives messages of beauty, hope, cheer, courage and power from men and from the Infinite, so long are you young.

MacArthur was so inspired that he even kept a framed copy of this poem in his office. He often quoted it in his speeches; thereafter, it became “MacArthur’s Credo.”

Wrinkles are caused by several factors: aging, ultraviolet light, smoking, and repeated facial expressions such as squinting or smiling. Plastic surgeons work to remove or at least reduce the wrinkles by “rejuvenation surgery.”

Then, can the “operation rejuvenation” reduce the wrinkles of the soul as well as skin wrinkles?

If a young woman stops suffering from nervous hand sweating after successful aesthetic surgery of the face, the plastic surgeon could say he or she helped in getting her autonomic nervous system under control via an alternate route.

In order to be a good plastic surgeon, he or she should be a good physician first. Good physician is a doctor who can solve the patient’s problems. For this, history taking and physical examination including the past medical history, social history, and systemic review are essential. When a preoperative patient has migraine headaches, instead of solely giving medications, we should take a look at all the potential factors that may be causing the person’s headaches, such as other health problems, diet and sleep habits, stress, and personal problems.

To be able to help our patient reduce the wrinkle of soul, a plastic surgeon must have psychological and psychiatric knowledge as well as operating skills.

We should neither desert our ideals nor give up our enthusiasm. Instead, we should keep beauty, hope, cheer, and courage in our hearts. I believe that there are wireless stations in my heart and heart of my patients as Ullman and MacArthur believed. As long as the hearts of our patients receive beautiful, hopeful, cheerful, and courageous message from our hearts, our patients will stay young.

Lastly, we should not forget that the plastic surgeon is a psychiatrist with a knife, and aesthetic surgery is a surgical psychotherapy [9, 10].

10.5 An Honorable Scar on the Face: A Scar Worthy of Satisfaction

The scar had not pained Harry for nineteen years. All was well.—J.K. Rowling

As a plastic surgeon, I sometimes encounter patients who want to improve the appearance of a visible scar on their face or on an extremity. In contrast, some patients do not want to undergo scar revision, despite the presence of a visibly deformed scar.

In a well-known fictional example, Harry Potter’s “lightning bolt” scar captured the wand movement required for the killing curse.

In the rhinoplasty set, we frequently use the Joseph knife and the Joseph elevator. These instruments were innovated to perform aesthetic rhinoplasty without leaving visible cutaneous scars. Jacques Joseph (1865–1934) innovated methods for aesthetic plastic surgery, especially cosmetic rhinoplasty.

In Jacques Joseph’s picture, however, I immediately noticed a horizontal scar on his left cheek just above the nasolabial fold (Fig. 10.7). I wondered why he himself did not undergo scar revision on his cheek.

Fig. 10.7

Jacques Joseph (1865–1934). Note a horizontal scar on his left cheek just above the nasolabial fold

When he was studying medicine in Berlin and Leipzig, he understood the cultural marks of honor and dishonor in that social context. As a university student, he joined a conservative dueling fraternity and was proud to receive a scar from dueling with a saber. Joseph relished the test and the adventure of the duel, which was considered manly and edifying [11]. The scars from the duel were intentionally created. Students challenged each other to duels as a matter of course, without any real need for an insult to be exchanged. Being challenged was a process of social selection. The duelists had their eyes and throat protected, but their faces were purposely exposed to the blade of the saber. When a cut was made, it was treated in a way that maximized the resulting scar. The scar that Joseph carried with him throughout his life marked him as someone who was worthy of satisfaction, someone who had been seen as an honorable equal and thus had been challenged to a duel [11]. Marked on the duelist’s face was his integration into German culture.

By the 1920s, such seemingly “false” scarring had become part of the German discourse on aesthetic surgery. An aesthetic surgeon named Levy-Lenz described the case of a young man who came to him after having won money in the lottery and wanted him to create artificial dueling scars through a “cosmetic procedure.” In this way, he could “pass” as someone who was worthy of being challenged to a duel. Levy-Lenz refused to perform such an operation; the patient then went to a barber, who scarred the patient with a razor, severely damaging his salivary glands [12]. The visible scar enabled the young man to “pass” as a man of honor.

Can we differentiate an authentic mark of honor from a merely cosmetic mark?

Before persuading a patient to undergo scar revision, the plastic surgeon should become familiar with the cause and meaning of the patient’s scar, in particular, whether it is an honorable or dishonorable scar.

10.6 Original Face for the Craniofacial Surgeons

In Zen Buddhism (禪佛敎), original face (本來面目) is a term pointing to the non-duality of subject and object [13]. The term original face originates from Huangpo’s Chuanhsin fayao (857) and the Hui-sin edition (967) of the Platform Sutra of the Sixth Patriarch (六祖壇經) [14]. A topic, “What is your original face before your parents were born?” tells us to let go of even more of our conditioning.

As Eastern Zen Buddhism seeks for the “my face before my parents were born,” a similar concept of face can be found in Western literature: “The face I had before the world was made.”

This other original face is the face of a person which she or he had before the world was made. In a poem titled “Before the World Was Made,” Irish poet Yeats writes from the perspective of a beautiful woman responding to a jealous lover. She begins by acknowledging her efforts to make herself more attractive with cosmetics.

If I make the lashes dark.

And the eyes more bright.

And the lips more scarlet,

Or ask if all be right.

From mirror after mirror,

No vanity’s displayed:

I’m looking for the face I had.

Before the world was made.

Then, what is original face of the craniofacial surgeons?

Congenital craniofacial abnormalities are a group of defects caused by abnormal growth and/or development of the head and facial soft-tissue structures and/or bones. Among them, cleft lip, cleft lip and palate, and isolated cleft palate are the most common congenital anomalies of the head and the neck, with a total prevalence of 2.1 per 1000 live births. The ultimate treatment for this malformation is surgical closure.

Dr. Millard (1919–2011), in the preface of his famous book Cleft Craft: The Evolution of Its Surgery (Fig. 10.8), emphasized surgeon should not ignore the first principle of plastic surgery; know the normal. He wrote “The plastic surgeon requires imagination for he must look into the puzzle of cleft. With this picture as transparency in his mind’s eye superimposed over the cleft patient, the surgeon is abetted in the sorting out and fitting together of the pieces of the puzzle” [15].

Fig. 10.8

Cover picture of Cleft Craft: The Evolution of Its Surgery

As Dr. Millard suggested, we craniofacial surgeons are trying repair the defect of the cleft lip patients similar to their original face using surgeon’s imagination.

As written in the journal’s homepage, the scope of Archives of Craniofacial Surgery (ACFS) is any aspect of craniofacial plastic and reconstructive surgery, operative procedures, clinical and laboratory research, and case reports. For seeking the normal or original face, I hope ACFS also welcomes anatomical studies of the head and neck and aesthetic procedures for the facial area.

10.7 What Would It be Like to Lose One’s Nose? Gogol’s the Nose and the Astronomer Tycho Brahe

The nose looked at the Major and frowned a little.—Nikolai Gogol, The Nose

Last year at the Metropolitan Opera House, I enjoyed the opera The Nose, directed by William Kentridge. In the opera, a man named Major Kovalyov woke up one morning and found that his nose had gone missing in the night. The nose had developed a life of its own (Fig. 10.9). Although a police officer returned the nose to Kovalyov, a doctor was unable to reattach the nose. On 13th day after losing his nose, he woke up to find his nose reattached.

Fig. 10.9

The poster of the opera The Nose, as performed at the Metropolitan Opera House in New York City (reproduced with permission from “Courtesy of Metropolitan Opera”)

This satirical opera by Shostakovich was adapted from the classic short story by Nikolai Gogol (1809–1852). Kovalyov’s nose acted as the source of his own pride; thereafter, the loss of his nose represented a loss of his identity. Since his identity was primarily defined by his outward appearance, the loss of that appearance devastated him.

Gogol wrote this story since he had an oddly shaped nose, which was often the subject of self-deprecating jokes in his letters [16]. Gogol opted for a comedy marked by the fantastic. However, parody is just a method of obscuring human suffering [17].

Today, an amputated nose can be reattached with microvascular anastomosis. If the stump is lost, the nose can be reconstructed with forehead flaps. In the Renaissance period, however, a nasal prosthesis was used instead.

Tycho Brahe (1546–1601) was a Danish astronomer. After his death, his assistant, Johannes Kepler (1571–1630), used Brahe’s astronomical data and proposed the three laws of planetary motion: (1) the orbit of a planet is an ellipse with the sun at one of the two foci; (2) a line segment joining a planet and the sun sweeps out equal areas during equal intervals of time; and (3) the square of the orbital period of a planet is proportional to the cube of the semi-major axis of its orbit.

When he was 20, Brahe lost part of his nose in a sword duel with his third cousin, Manderup Parsberg. Manderup’s blade cut away most of the nasal bridge, leaving the nasal cavity and septum exposed.

To hide his deformity, he constructed a prosthetic device made of wax, but it was unsatisfactory. Thus, he made a mold around the wax nose and fabricated a brass prosthesis. An artist matched the color of his skin. The prosthesis was held in place with glue. It is thought that this deformity altered his personality. He became defensive, depressive, and secretive [18].

Today, nasal prostheses made of polydimethylsiloxane are flexible and designed to move with the skin. They are retained by using an adhesive or osseointegrated implants.

A recent study found that the quality of life of patients with a facial prosthesis was reduced in comparison with a healthy group when the acquired defects were located at the eye or nose. The patients’ body image and sense of their own sexual attractiveness were diminished. Some patients even believed they gave off an unpleasant odor [19].

Plastic surgeons should reflect on the examples of Major Kovalyov and Tycho Brahe as they consider the role of psychological care for patients who have lost a body part.

10.8 Use of the Theory of Reasoned Action in Plastic Surgery

In recent years, aesthetic plastic surgery has gained popularity worldwide. The American Society of Plastic Surgeons reported that 17.7 million cosmetic procedures were performed in 2017. Of these, 1.8 million were surgical procedures and 15.9 million were nonsurgical cosmetic procedures. Compared with 2016, the number of breast augmentation and liposuction procedures increased by 3% and 5%, respectively [20]. Thus, the popularity of aesthetic plastic surgery has attracted attention from the business sector.

Recently, I read an article regarding cosmetic surgery and services in Seoul from a journal in the field of management written by researchers in the fields of business and accounting from Malaysia and China [21, 22]. The researchers collected market data on women’s willingness to undergo cosmetic surgery in Seoul. They interviewed 400 women aged 19 to 40 years using a self-administered questionnaire. Using the theory of reasoned action (TRA), they analyzed factors, such as attitudes, subjective norms (celebrities and the media), and psychological attributes (social status and self-esteem), that influence patients’ intention to undergo cosmetic surgery.

The aim of the TRA is to explain the relationship between attitudes and behaviors within human action. This theory is most often used to predict how individuals will behave based on their preexisting attitudes and behavioral intentions. An individual’s decision to engage in a particular behavior is based on the outcomes that the individual expects will come as a result of performing the behavior. In its simplest form, the TRA can be expressed as the following equation: BI = (AB)W₁ + (SN)W₂ (BI = behavioral intention, AB = one’s attitude toward performing the behavior, W = empirically derived weights, and SN = one’s subjective norm related to performing the behavior) (Fig. 10.10) [23].

Fig. 10.10

Theory of reasoned action

This theory has been also used in medicine and behavioral science, such as in attempts to predict exercise in patients across stages of bariatric surgery [24].

In the cosmetic surgery field, three interesting studies in Iran, an Islamic country, used the TRA. In a paper from Islamic Azad University, Shahrekord Branch (Iran), 296 students were surveyed and analyzed using TRA. Intention to undergo cosmetic surgery showed significant relationships with attitudes toward one’s body and subjective norms (P = 0.013). Higher body satisfaction was associated with less intention to use cosmetic surgery (P = 0.01). Surprisingly, the authors concluded that family status and feeling secure were the most important factors associated with intention to undergo cosmetic surgery. The authors argued that this intention is the result of psychological insecurity; therefore, community-oriented nurses with family support can improve these psychological traits [25].

Authors from a military medical school in Iran (AJA University of Medical Science) surveyed 233 female college students. Based on the TRA, they found a significant relationship between attitudes toward cosmetic surgery and participants’ intentions (P < 0.0001). Because attitudes are an important predictor of cosmetic surgery, the authors drew the interesting conclusion that designing and conducting interventions are essential to reduce favorable attitudes toward elective cosmetic surgery among college students [26].

Authors from the Hamadan University of Medical Sciences, Iran, believed that cosmetic surgery is performed to change people’s appearance and improve their self-esteem. They collected data from 340 female students at Hamadan University of Medical Sciences, to predict their intention to undergo cosmetic surgery, and analyzed the data using the TRA. They found a positive and significant correlation between the constructs of the TRA. Among the studied constructs, motivation for obedience, evaluations of behavioral outcomes, and behavioral beliefs played a significant role in explaining variance in behavioral intention [27].

The above three papers collected similar samples, used the TRA as a tool for the analysis, and drew similar conclusions. Although these papers appear to use TRA with the goal of finding ways to discourage people from cosmetic surgery, I still think that the TRA can be used in other parts of plastic surgery. We, as plastic surgeons, should conduct a prospective analysis of our market ourselves, instead of letting further surveys be done by marketing managers. In this analysis, TRA might play an important role.

10.9 Is Aesthetic Plastic Surgery a Form of Symbolic Consumption?

As a relatively rare example of a movie with a plastic surgeon as a major character, I love “A Woman’s Face” (1938) directed by Gustaf Molander. The cast included Ingrid Bergman, as a woman criminal with a disfigured face, and Anders Henrikson, as a plastic surgeon who operates on her. Anna Holm, the character played by Ingmar Berman, is an embittered woman with a facial disfigurement involving distortion of her eye and mouth on one side and a scar on her cheek. In childhood, her face was burned in a house fire, and she was abandoned by her parents, who were also criminals. She became a criminal herself but is glad that her ugliness prevented her from an even worse fate. As an expression of her alienation from society, she became part of a criminal gang specializing in blackmail. Being a blackmailer, Anna threatens Mrs. Wegert, a plastic surgeon’s wife. Dr. Wegert initially thinks that she is a burglar but becomes interested in the surgical problem of her disfigured face (Fig. 10.11). Therefore, he does not turn her in; instead, he hospitalizes her and operates on her face. After a successful operation, Anna becomes beautiful; her talks with Dr. Wegert also inspire her to become a different person.

Fig. 10.11

Anna (Ingrid Bergman) is looking at her disfigured face in a mirror

This storyline of this movie reminds me of a psychological theory that I believe can help understand our patients’ psychological perspective when they choose to undergo surgery.

A unique characteristic of humans, as distinct from other animals, is the ability to examine ourselves, to find ourselves lacking, and to attempt self-betterment. This sense of incompleteness leads us not only to create but also to self-create, and we consume goods and services in that process.

The psychological theory of symbolic self-completion holds that individuals seek to acquire and display symbols that are strongly related to what they perceive as the ideal self.¹ For example, relatively effeminate boys who want to appear macho may use products associated with manliness, such as a strong cologne or a silver watch, in hopes of symbolically fulfilling their self-definition of masculinity. Such cases of symbolic self-completion are seen in Internet communication, marketing and advertising, and consumer behavior.

Compared to other consumer goods and services, cosmetic surgery is irreversible, expensive, painful, and potentially dangerous. Symbolic self-completion theory provides insight into goal-striving and has been used to help explain patients’ desire for cosmetic surgery [28].

A study collected data from customers who underwent cosmetic surgery in multiple, in-depth, ethnographic interviews regarding body image, impression management, and symbolic self-completion. Major changes in informants’ roles or status often led to feelings of unconvincing role performance and then to behaviors interpretable in terms of self-completion theory. When particular physical attributes, such as a flat chest or a tired and wrinkled face, seemed incongruent with the roles they were attempting to cultivate, plastic surgery was seen to offer more appropriate bodily symbols and, consequently, greater self-confidence and self-acceptance in key role performance [29].

Of note, in “A Woman’s Face,” Anna forgets her past and starts a new life in Beijing.

The extent of a woman’s conscious or unconscious concern about her outward appearance to others is predictive of the use of appropriate symbols for self-completion. Symbolic self-completion theory emphasizes seeking control over one’s sense of self and social reality, in relation to the socially desirable female image. The extent to which a woman involves herself in this seeking is an important aspect of coping, as shown by Anna’s trajectory.

As plastic surgeons, we are suppliers of a kind of service, that is, operations. Therefore, we would be well-served by understanding the dynamics of symbolic self-completion among our patients. Aesthetic plastic surgery is a form of symbolic consumption, and a plastic surgeon is a psychiatrist with a scalpel.

10.10 Breast Cancer, Planarians, and Plastic Surgeons

…This body’s fenscape, manscaped, hills removed—the meaty joinsstill livid, tight shut mouthswhere distant territories were stitched in touch. Blood seeps in deltas over ribs…—From Self-portrait without Breasts, by Clare Best

It is generally accepted that the survival rate of breast cancer has dramatically improved, and the outcomes of breast reconstruction are also excellent. When we meet a patient who has breast cancer and is planning to undergo mastectomy, we can say, “Now it’s a simple matter of cutting out the breast cancer and restoring the breast.” However, surgical procedures intended to treat breast cancer or reduce the risk of developing the disease typically result in changes in appearance and scarring of the breast area and any donor sites [30]. Therefore, those who have not experienced these changes could never understand the indescribable pain.

Nonetheless, we might be able to sympathize with patients’ pain and hurt through protagonists in literature. I introduce two examples.

In her project Self-portrait without Breasts, Clare Best, an English poet, reclaims the “flat simple scarred chest with no extras.” In the title poem of the poem cycle she uses figurative expressions about the post-mastectomy body as a landscape (Fig. 10.12): “…This body’s fenscape, /manscaped, hills removed—the meaty joins/still livid, tight shut mouths/where distant territories were stitched//in touch. Blood seeps in deltas over ribs… [31].”.

Fig. 10.12

Photography by Laura Stevens, collaborator of “Self-portrait without Breasts” written by Clare Best. Available at: https://clarebest.co.uk/projects/self-portrait/. Accessed on Aug 27, 2021. ^©Laura Stevens. Used with permission

A Japanese writer, Fumio Yamamoto (山本文緒, 1962–), wrote “Planaria,” a collection of five stories about women without regular jobs, for which she won the Naoki literary prize in the second half of 2000 [32]. The title story is a vivid portrait of Haruka, a 26-year-old woman who is adrift in life, unable to reconnect to family and work after losing a breast to cancer 2 years earlier. A difficult person even before the operation, she sabotages her relationships with both her boyfriend and a slightly older woman who has given her part-time work at a confectionary store. In a memorable line, she says, while out drinking with friends, that she would like to be reborn as a “planaria,” a small worm living in pure streams that can regenerate itself when a part of its body is cut off. In fact, a “planarian” is one of many flatworms of the traditional phylogenic class Turbellaria. Planarians exhibit an extraordinary ability to regenerate lost body parts. When split lengthwise or crosswise, a planarian will regenerate into two separate individuals. It can be cut into pieces, and each piece can regenerate into a complete organism. Cells at the location of the wound site proliferate to form a blastema, which differentiates into new tissues and regenerates the missing parts of the piece of the cut planarian. Thereafter, it is called “immortal under the edge of a knife” [33].

The reconstructive surgery following resection also bothered Haruka. “After I had breast reconstructive surgery, a place appeared where my skin was folded and sewn like the folds on my clothes. It itches terribly when I feel hot from time to time. I can’t scratch it because it’s under my clothes. Sometimes it really drives me crazy. Am I supposed to be okay with this?”

In a study, participants were asked open-ended questions about their experiences when seeing the postsurgical appearance of their breast/breast area (and donor site, if relevant) for the first time, and four key themes emerged: “preparedness and support,” “first thoughts and emotions,” “loss and grief,” and “the reaction of others.” Some felt prepared and emotionally supported at this time, whereas others felt this element of care was missing.¹ Another study explored the decision to undergo breast reconstruction surgery after mastectomy and found that the decision was made during stressful circumstances, and many women did not feel well prepared to make this decision. The most highly ranked reasons to choose breast reconstruction were the desire for the breasts to be equal in size, the desire to wake up from surgery with a breast in place, and the perceived bother of a scar with no breast. The most highly ranked reasons not to choose breast reconstruction were related to the surgical risks and complications [34]. A third study found that most women (76 of 93) made quick, “instant” decisions to undergo immediate breast reconstruction following mastectomy, whereas the remainder (14 of 93) sought further information before making their choice [35]. Women with complications were twice as likely to report feeling less feminine and dissatisfied with the appearance of their scar than those without problems [36].

Like Haruka in the novel, many breast cancer patients struggle with severe stress. What is needed to overcome these mental and physical sequelae is social rehabilitation. Therefore, the medical staff should encourage patients to return to daily life immediately after surgery and perform breast reconstruction or provide the patient an artificial breast. Thereafter, breast reconstruction restores both the resected breast itself and patients’ communication with themselves, their family, and the society around them.

In this process, we plastic surgeons play the role of making patients who undergo mastectomy “immortal under the edge of a knife,” much like planarians. I hope that both a poetic mind and anatomical knowledge will help surgeons achieve satisfactory results [37].