This paper outlines the ways in which the body is capable of ‘holding’ traumatic experiences (Van der Kolk, 2014). Psychologists noticed that many patients seeking surgery to their nose were doing so as a result of being bullied at school, or where there is or has been physical trauma to the nose.
When people are bullied at school about their apperance, particularly the nose, it can communicate a message that their appearance does not meet societal and/or certain standards of beauty, motivating individuals to seek out surgery as the solution to this feeling of othering (Macgregor, 1967; Goldblatt, 2003).
If there is a physical trauma to the nose, there may be a need to perform surgery to fix structural issues that could be impacting breathing, for example, but patients will often hope that by physically repairing damage to their nose, they will also eradicate the memory and psychological experience of the experienced trauma. This is particularly true in cases when people have been attacked and were unable to the protect themselves, resulting in their nose being injured in the process. The nose can then act as a visual reminder of the attack. However, without working on the psychological reminder, surgery alone is often not enough to help the individual move on from the traumatic experience.
This paper discusses a clinical case regarding a patient who is considering undergoing a septorhinoplasty for cosmetic reasons. The aim of discussing this case is to encourage practitioners and surgeons to take a reflective position when considering whether or not to operate. The clinical case is based on information gathered by a surgeon at an initial consultation, which lasted approximately 30 minutes. The patient then met with a psychologist pre-surgery, and information from that consultation will also be presented.
» The material event of trauma presents a dissonance of belief, which the bodymind may not easily absorb. In some individuals, this forces a temporal splitting between present and past, in which (without appropriate treatment) the trauma event continues to replay in an interminable present. This severing can be likened to a separation between body and mind dissociation” (Baum, 2012) «
Please note, this paper is not implying that every patient considering cosmetic surgery should have a consultation with a psychologist. Instead, it highlights why it is important that practitioners are fully informed about the psychological changes that can be expected after surgery. Based on this knowledge, patient psychological wellbeing should be considered as part of the process.
However, for more invasive surgery, particularly surgery involving the face, where it cannot be hidden, involving a psychologist is a recommendation.
Case study: the patient
- ‘Janet’, a 35-year-old female
- non-smoker
- no known health issues
- presents to an experienced craniofacial plastic surgeon seeking a primary septorhinoplasty.
The patient is considering a primary surgery with no functional issues present due to her deviated septum. This patient has provided consent for their case to be discussed. To ensure confidentiality, all identifiable details have been changed. Janet says she has been wanting this surgery since the age of 16 years old. Janet states she started to notice a ‘hump’ on her nose, and the general size of her nose, soon after she started puberty. Janet states she has not been in a financial position to undertake the surgery before now. She states that she is in stable relationship, is steadily employed and has the financial means to pursue surgery.
Expectations from the outcome of surgery
Janet would like her nose to be ‘straighter, the hump removed and a subtle dip/ski slope’ where the ‘hump’ is currently located.
The surgeon asks all patients to complete a brief psychological screening questionnaire regarding their expectations from surgery and investment in the outcome. According to the score on the questionnaire, Janet has a mild to moderate investment in her appearance and the aesthetics of her nose. But the results are not near the cut off score for somebody indicating signs of body dysmorphic disorder (BDD). On the health questionnaires and in the consultation, Janet does not disclose any concerning factors for the surgeon and therefore the surgeon believes she could potentially be a good candidate for surgery. He deems her physical expectations from the outcome as realistic. However, as it is normal practice in this clinic for all patients considering a rhinoplasty or septorhinoplasty to meet with a psychologist before surgery, the surgeon refers her accordingly.
Psychology consultation
As part of the consultation with the psychologist, the narrative underlying the motivation for wanting the surgery is further explored.
The psychologist discusses with Janet what prompted her to become more aware of her nose at age 16. Janet shares that when she started puberty, she saw that her nose was beginning to change in size and shape. She stated that noses have always been discussed in her family, particularly by her mother and grandmother.
Janet explained that her mother was born in Greece, but moved to Britain when she was 15. Her father is British. Janet states that for as long as she can remember, her mother has disliked her own nose and her grandmother dislikes hers too. Her mother was also bullied at school regarding her nose, with classmates making comments such as ‘you have a big nose, it must get in the way when you eat and drink’. The nose was used by the classmates of Janet's mother as a way of ‘othering’ her, because they saw her as different (Goldblatt, 2003).
Janet was asked by the psychologist if her nose looks similar to either her mother or grandmother. She says yes, her nose is similar to both in terms of size and presence of a ‘hump’, and therefore her mother has been very supportive of her pursuing surgery. Janet's mother has stated, according to Janet, that Janet is receiving the opportunity that she never recived to be happy with the appearance of her nose. On further exploration, Janet then shares that her grandmother ‘hates’ her own nose and will often joke that she was ‘at the back of the line when looks were being given out’.
The psychologist asks Janet whether she dislikes the appearance of her grandmother's nose. Janet, states that she does not dislike her grandmother's nose. She states that she thinks it suits her grandmother's face shape and that the nose she posesses is how she has always known her. She was tearful when sharing how much she perceives her grandmother to dislike her own looks, especially her nose. Janet said she likes her grandmother's nose, as it represents her connection to her Greek heritage. By exploring this further, Janet started to realise that her nose, even though she dislikes it, provides a physical identifier and anchor of connection with her grandmother, and in turn, her Greek heritage.
The psychologist highlighted to Janet that the changes she is seeking from surgery, having the ‘hump’ removed and a ‘slope’, means she would lose these physical features that she feels identify and connect her with her grandmother and the maternal side of her family. At this point, Janet began to tear up and stated that she had not considered that before, and that merely thinking about such a scenario causes her to feel a sense of loss. She stated that she had always just assumed it ‘would only be a physical change to my nose, then I would be happier about the way I look’. As a result of this psychology consultation, both Janet and the psychologist agreed that she should perhaps have a further discussion with her mother and grandmother about how she is feeling and what she feels she may lose by having the surgery. Janet then considered that if she decides to have the surgery, she may not proceed with all of the original anticipated changes, particularly having a ‘ski-slope’ shape created.
As standard practice, the psychologist wrote a letter to the surgeon summarising what was discussed in the psychological consultation to help provide the surgeon and patient with further insights for the follow up consultation.
Conclusion
This case was chosen for discussion because it demonstrates how transgenerational body shame can be passed on from grandmother to mother and now to daughter (Constantian, 2019). Keeping in mind how body image development occurs from several different contributing factors (Thompson et al, 1999; Auer, 2020), one specifically being parental and familial influences, we can see how Janet's sense of her own appearance is not solely of her own making. Gilman (1999) highlights that the nose is a central symbol in western history of aesthetic surgery and can be directly linked to erase moral markers and racial signs betrayed by its shape. If this aspect of the motivation for surgery is left unexplored, it can sit within the psyche as a ticking time bomb waiting to surface, especially if a loss of identity occurs post-rhinoplasty. Patients are often not aware of the possible losses in making such a significant change to their face. However, the difficulty is that this aspect of surgical change may not always surface in a consultation between a surgeon and patient. As demonstrated here, this is not something that was originally within Janet's conscious awareness.
Surgeons are not psychologists and vice versa. Surgeons do not have the necessary skills and training to psychologically support patients through all aspects of surgery. Other than referring all patients to see a psychologist, the recommendation for surgeons is to consider reviewing their current assessment process with the help of a specialist psychologist, to see if there is room for improvement and to increase the psychological safety of their patients.
CPD reflective questions
- Would you consider the patient in the first scenario a good candidate for surgery and be comfortable operating on them?
- Based on the additional information shared in the consultation with the psychologist, would you still consider the patient to be a suitable candidate for surgery? If yes, would anything change in terms of the patient's journey through surgery with the new information provided by the psychologist?
- If you were to decline surgery to this patient, how would you do this in terms of explanation to the patient?