Female plastic surgery patients prefer mirror-reversed photographs of themselves: A prospective study

Accepted Manuscript Female plastic surgery patients prefer mirror-reversed photographs of themselves - a prospective study Antoine de Runz, M.D., David Boccara, M.D., Marc Chaouat, M.D., Ph.D., Katia Locatelli, MSc, Nicolas Bertheuil, MD, L.D. Frédérique Claudot, Ph.D., Farid Bekara, M.D., Maurice Mimoun, M.D., Ph.D. PII:

S1748-6815(15)00405-2

DOI:

10.1016/j.bjps.2015.08.023

Reference:

PRAS 4735

To appear in:

Journal of Plastic, Reconstructive & Aesthetic Surgery

Received Date: 7 May 2015 Revised Date:

12 August 2015

Accepted Date: 23 August 2015

Please cite this article as: de Runz A, Boccara D, Chaouat M, Locatelli K, Bertheuil N, Frédérique Claudot LD, Bekara F, Mimoun M, Female plastic surgery patients prefer mirror-reversed photographs of themselves - a prospective study, British Journal of Plastic Surgery (2015), doi: 10.1016/ j.bjps.2015.08.023. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Female plastic surgery patients prefer mirror-reversed

Authors:

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photographs of themselves - a prospective study

de Runz A., Boccara D., Chaouat M., Locatelli K., Bertheuil N., Claudot f., Bekara F.,

Antoine de Runz M.D.

a, b

a

Marc Chaouat M.D., Ph.D.

a

a, c

Nicolas Bertheuil MD

d

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Katia Locatelli MSc

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David Boccara M.D.

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Mimoun M.

Frédérique Claudot L.D., Ph.D. a

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Farid Bekara M.D.

b

a

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Maurice Mimoun M.D., Ph.D.

a Plastic, Reconstructive and Cosmetic and Burn Surgery Unit, Hôpital Saint Louis, Paris, France. b EA 7299, ETHOS, Faculté de médecine, Université de Lorraine, France.Université de Lorraine, Nancy, France. c Centre de Recherches Psychanalyse, Médecine et Société, EA 3522, Université Paris Diderot 7, UFR d’Etudes Psychanalytique d Hopital Sud, Department of Plastic and Reconstructive Surgery, CHU Rennes, 35200 Rennes, France

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Corresponding author:

Antoine de Runz

(Pr Mimoun) Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris

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[email protected]

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Service de Chirurgie plastique, reconstructrice, esthétique et traitement chirurgical des brûlés

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+33 (0) 1 42 38 50 39

No Conflict of interest: .

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None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript

III

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Level of Evidence:

Keywords /MeSH:

Photography; Facies; Facial Asymmetry; Self-Assessment; Outcome Studies

All

of

the

authors

adhere

to

the

STROBE

guidelines

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Summary: INTRODUCTION: The use of a patient’s image in plastic surgery is common today. Thus, plastic surgeons should master the use of the image and

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be aware of the implications of the patients’ perception of themselves. The mere-exposure effect is a psychological phenomenon in which a person tends to rate things more positively merely because (s)he is familiar with them.

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Faces are asymmetric, so faces in photos are different than those observed in

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mirrors. The main objective of this study was to assess whether patients within a plastic surgery population, particularly those undergoing facial aesthetic surgery, preferred standard photographs or mirror-reversed photographs of themselves. METHOD: A prospective study was conducted in a plastic surgery

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department, and included women who were admitted to the hospital the day before their procedures. The patients were separated into two groups: Group 1

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was composed of patients who were undergoing facial aesthetic surgeries, and Group 2 consisted of other patients who came to the plastic surgery department

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for surgery. The patients were required to rate their appreciation of their own faces and to choose between standard and mirror-reversed photos of themselves. RESULTS: Two hundred fourteen patients participated. The median age was 47.9 (IQR: 36.4-60.6) and the median face appreciation was 5 (IQR: 5-7) The preference for the mirror-reversed photograph was significantly different from chance [p <0.001, binomial (214,156, 0.5)]; 73% of the patients preferred the mirror-reversed photographs.

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The proportions of patients who preferred the mirror-reversed photograph differed significantly (p=0.047) between Groups (84%) and 2 (70%). CONCLUSION: Plastic surgery patients have a significant preference for

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mirror-reversed photographs of themselves over standard photographs. This preference is even more pronounced among patients who are undergoing facial aesthetic surgery. The manner in which the surgeon acquires and presents

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photographs may be an important factor in plastic surgery.

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TEXT:

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Introduction

The use of a patient’s image in plastic surgery is common today, in the forms of both photography and three-dimensional modelling. Working with

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images of the patient offers plastic surgeons a marvellous medium for

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communication with the patient, and permits the surgeon to follow the patient’s progress and judge the outcome of the procedure (1–5). In a study of 176 plastic surgeons, 87.5% of the surgeons stated that they used photography, particularly in patient follow-up (6).

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However, the use of images of the patient may create real problems for the surgeon and the patient, that potentially give rise to false hopes,

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disappointment, or a perception that the treatment has failed. Thus, the plastic surgeon should master the use of the image before employing it and should be

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aware of the implications of the patient’s perception of self (7). The mere-exposure effect (8) is a psychological phenomenon in which a person tends to rate things more positively merely because (s)he is familiar with them. The face is asymmetric; thus faces in photos are different than images of the face seen in the mirror.

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In 1977, Mita (9) noted that people prefer their mirror image to their true photographic image due to the mere-exposure effect because they are more accustomed to seeing themselves in mirror reversed-image.

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Patients presenting to a plastic surgery department may be a particular population, and we know nothing about the existence and importance of the mere-exposure effect on their facial image preferences.

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The main objective of this article was to assess whether a patient preference for

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standard photographs or mirror-reversed photographs of themselves existed within a plastic surgery population and particularly for patients undergoing

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operations for facial aesthetic surgery.

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Materials and Methods

A prospective study was conducted in the plastic surgery department of the

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Saint-Louis Hospital (Paris, France) and included women who were admitted to the hospital the day before their procedures from January to March 2015. The exclusion criteria were the following: male, prior facial surgery with one year before the procedure, and patients under the age of 18. The patients were separated into two groups: Group 1 was composed of patients undergoing operations for facial aesthetic reasons, and Group 2 consisted of the other patients who came to the plastic surgery department for surgery.

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The patients were photographed face-on with a neutral expression while looking straight ahead with symmetrical lighting and in front of a plain background. Two portrait photos were taken at 1280 by 720 pixels; the second was deleted

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and replaced with a copy of the first image that was flipped into a mirrorreversed image. Thus, the patients expected to view two different photos and did not expect to view a mirror-reversed image.

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Before they were shown any pictures, the patients were required to rate their

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face appreciation on a Likert-scale, according to the following question: “How would you rate your facial appearance at present on a scale from 0 to 10, 0 being absolutely awful and 10 absolutely beautiful?”

Then, the juxtaposed (side by side presentation, with the right and left side

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positions randomized) mirror and standard image were resized and presented to the patients on an LED-backlit widescreen with 440- by 900- pixel resolution.

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The patient was asked to indicate which iamge she liked better. No other questions such as like “Which photograph do you prefer?” were asked, and no

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details were given about the two pictures until after the patient had answered.

The statistical analyses were performed with IBM® SPSS Statistics 22.0 software. We used Fisher’s exact tests for the qualitative variables, and the Mann-Whitney U test for the quantitative variables. The first order risk was set at 5%.

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The Institutional Review Board approved this study (IRB 00003835, 2015/14NI), and informed consent was obtained from all of the enrolled

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patients.

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Results

Two hundred fourteen patients participated (Table 1), including 50 patients undergoing operations for facial aesthetic surgery (Group1). None of the patients who were approached refused to participate or to respond to the

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questions. The median age was 47.9 (Inter-Quartile-Range (IQR): 36.4-60.6)

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and the median face appreciation was 5.0 (IQR: 5-7).

The preference for the mirror-reversed photograph was significantly different

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from chance [p <0.001, binomial (214, 156, 0.5)]. Seventy three per cent of the patients preferred the mirror-reversed photograph. There was no significant difference in terms of age between the groups who preferred the mirror-reversed photograph and the group who preferred the standard image (respectively 49.5 (IQR: 37.2-61.9) years versus 45.1 (IQR: 35.8-57.7) years, p=0.249) and there was no significant difference in face appreciation (respectively 5.4 (median 5, IQR: 5-7), versus 5.8 (median 5, IQR: 5-7), p=0.182) (Table 2).

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The proportions of the preferences for the mirror-reversed photograph differed significantly (p=0.047) between Group 1 (84%) and Group 2 (70%) (Table 3). There were significant difference in age (p<0.001) and face appreciation

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(p=0.038) between Groups 1 and 2. The patients in Group 1 were older at 60.4 (IQR: 39.8-60.0) years, and the patients in Group 2 were younger at 45.3 (IQR: 35.4-57.1) years old; the former latter group also assessed their faces less

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favourably (5.1 (median 5, IQR: 5-6), versus 5.7 (median 6, IQR: 5 -7)) (Figure

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1).

There was no difference regarding the right- or left-sided position of the photographs. One hundred ten patients preferred the right position and, 104 patients preferred the left position. When the mirror-reversed photos were

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positioned on the left of the screen, 76 patients preferred the left position versus 30 who preferred the right position, and when the mirror reversed photos were

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placed on the right, 80 patients preferred the right position versus 28 for the left

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position (p=0.759).

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Discussion

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The significant preference for mirror-reversed photographs over standard photographs of the women undergoing plastic surgery procedures agreed with the results of the previous studies about mere-exposure. In the study by Mita et

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al. (9), mirror-reversed photographs were preferred to standard photographs by

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21 of 33 participants. In the study by Rhodes et al. this was the case for 19 of 27 participants (10). In the study by Brady et al. study for 19 of 30 (11) participants preferred mirror-reversed to regular photographs, and the same was true for 27 of 38 participants in the study by Amestoy et al. (12). Currently, due to the use

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of digital cameras, smartphones and the increasing use of photo media, people are more exposed to standard photographs of themselves than has been the case

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in preceding decades (13). Thus, in some cases, people may be exposed more often to their standard image than to their mirror image. Such exposure could

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alter the mere-exposure effect for the preference for mirror-reversed photographs or work in reverse and enhance the preference for standard images. Our results confirm that the mere-exposure effect persists at present via a preference for mirror-reversed photographs despite the omnipresence of everyday photo media. Furthermore, the preference for mirror-reversed photographs was not significantly associated with age, although we may

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eventually expect that younger persons will be more exposed to photographic media and thus exhibit a reduced preference for reversed-mirror photographs.

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The significantly higher proportion of patients who preferred the mirrorreversed photos in the facial aesthetic surgery group compared to group 2 may be due to the heightened attention of these patients to their faces. Greater

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the preference for the mirror-reversed photo.

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attention to the face may promote a greater use of the mirror and thus explain

There were significant differences in the ages and face appreciations between Groups 1 and 2. These differences in age and face appreciation between the two groups were not unexpected. Patients who undergo facial aesthetic surgery are

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often people who hope for improvements in their facial appearances. This desire for improvement comes with the effects of age on the face, and less-favourable

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perceptions of one’s own face. These two parameters do not seem to be biasing or confounding factors because there were no associations between age and face

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appreciation with the preference for the mirror-reversed photo.

None of the patients who were approached refused to participate and to respond to the questions. All of the patients chose one of the two photographs, and only nine patients, noticed that one photograph was the reversed image of the other

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after stating a preference for one of the photos. The right-left position of the photograph on the screen did not influence the choices in our study. The mere-exposure effect is based on implicit memory (14,15), even when

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preference choices are requested (14). This effect has proven to be a robust, reliable phenomenon and has been demonstrated using a variety of stimuli (16). Studies including amnesic and prosopagnosic patients offer arguments in favour

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of the postulating that the mere-exposure effect is an implicit memory manifes-

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tation (12. 17)

In our study, we only assessed this effect in women, to homogenize the results. Approximately 90% of aesthetic operations are performed on women (18). Thus, the results concerning the preference for mirror-reversed photographs over patients undergoing plastic surgery may not be

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standard photographs of

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applicable to the male population.

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To our knowledge, this is the only study that has examined the mere-exposure phenomenon in the context of plastic surgery. Many plastic surgery studies have considered the importance of standardization, position or lighting, but few have considered this effect (19–22). Given that the mere-exposure effect influences the patient’s perception of her image, it seems to be an essential parameter. The clinical influence of this effect has not yet been studied, but its consequences may raise issues. When discussing aesthetic facial surgery with a patient, and

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determining his/her perceptions and wishes, the question of whether we should work with standard or mirror-reversed photos arises. Does a more unfavourable image tend to push the patient towards undergoing surgery? Does a less

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favourable post-operative image reduce patient satisfaction? The existence of this effect in plastic surgery may change our practice in the use of photographs (7). Photographs are essential to a clinical evaluations, and are useful in

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communication with the patient about surgical strategies and the accurate

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evaluation of the outcome of the procedure. (23). Bhattacharya (24) declared that “accuracy in size, position, view, exposure, background, brightness and contrast are vital to derive conclusive results while comparing preoperative and postoperative photos”; however the use of standard or mirror-reversed

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photographs may also be significant.

Further studies are needed to assess the mere-exposure effect of the use of

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mirror-reversed photographs or standard photographs and the clinical

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applications of each type of photograph.

Conclusion

The mere-exposure effect can be observed in plastic surgery patients in terms of their preferences for photographs. Plastic surgery patients exhibit a significant preference for mirror-reversed photographs of themselves compared with

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standard photographs. This preference is even more pronounced in patients who undergo facial aesthetic surgery. The manner in which the surgeon presents

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photographs may be an important factor in plastic surgery.

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References:

1. McG. Taylor D, Foster E, Dunkin CSJ, Fitzgerald AM. A study of the

Aesthet Surg. 2008 Jan;61:37–40.

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personal use of digital photography within plastic surgery. J Plast Reconstr

2. Hoevenaren IA, Maal TJJ, Krikken E, de Haan AFJ, Bergé SJ, Ulrich DJO.

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Development of a three-dimensional hand model using 3D

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stereophotogrammetry: Evaluation of landmark reproducibility. J Plast Reconstr Aesthetic Surg JPRAS. 2015 May;68:709–16. 3. Wachter T, Edlinger M, Foerg C, Djedovic G, Mayerl C, Kinzl J, et al.

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Differences between patients and medical professionals in the evaluation of aesthetic outcome following breast reconstruction with implants. J Plast

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Reconstr Aesthetic Surg JPRAS. 2014 Aug;67:1111–7. 4. Riml S, Piontke A, Larcher L, Kompatscher P. Quantification of faults

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resulting from disregard of standardised facial photography. J Plast Reconstr Aesthet Surg. 2011 Jul;64:898–901. 5. Henseler H, Smith J, Bowman A, Khambay BS, Ju X, Ayoub A, et al. Subjective versus objective assessment of breast reconstruction. J Plast Reconstr Aesthetic Surg JPRAS. 2013 May;66:634–9.

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6. De Runz A, Simon E, Brix M, Sorin T, Brengard-Bresler T, Pineau V, et al. [Photography in plastic surgery: practices, uses and legislation]. Ann Chir Plast Esthét. 2015 Feb;60:12–8.

Surg. 2014 Jun;133:873e – 881e.

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7. Lu SM, Bartlett SP. On facial asymmetry and self-perception. Plast Reconstr

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8. Zajonc RB. ATTITUDINAL EFFECTS OF MERE EXPOSURE. J Pers Soc

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Psychol. 1968;9:1–27.

9. Mita TH, Dermer M, Knight J. Reversed facial images and the mereexposure hypothesis. J Pers Soc Psychol. 1977;35:597–601. 10.

Rhodes G. Memory for lateral asymmetries in well-known faces: evidence

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for configural information in memory representations of faces. Mem Cognit. 1986 May;14:209–19.

Brady N, Campbell M, Flaherty M. My left brain and me: a dissociation

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in the perception of self and others. Neuropsychologia. 2004 Jan;42:1156– 61. 12.

Amestoy A, Bouvard MP, Cazalets J-R. Left-right facial orientation of

familiar faces: developmental aspects of « the mere exposure hypothesis ». Front Psychol. 2010;1:39.

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The image and the internet: photography’s expanding role in the digital age. Donaldson, Jacquelyn M., M.A., SOTHEBY’S INSTITUTE OF ART NEW YORK 2014. Willems S, Adam S, Van der Linden M. Normal mere exposure effect

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14.

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Nerv Syst Behav. 2002 Feb;38:77–86.

Folia V, Petersson KM. Implicit structured sequence learning: an fMRI

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study of the structural mere-exposure effect. Front Psychol. 2014;5:41. Bornstein RF. Exposure and affect: Overview and meta-analysis of research, 1968-1987. Psychol Bull. 1989;106:265–89. Bremner JD, Shobe KK, Kihlstrom JF. False memories in women with

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self-reported childhood sexual abuse: an empirical study. Psychol Sci. 2000

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statistics. ASAPS Cosmetic Surgery National Data Bank. 19.

Wang K, Kowalski EJ, Chung KC. The art and science of photography in

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20.

Aveta A, Filoni A, Persichetti P. Digital Photography in Plastic Surgery: The Importance of Standardization in the Era of Medicolegal Issues. Plast Reconstr Surg. 2012 Sep;130:490e – 491e. Ahmad M, Ahmad N. Maintaining the standards in digital photography. J

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21.

Plast Reconstr Aesthetic Surg JPRAS. 2010 Feb;63:e208.

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for the digital photographer. Clin Plast Surg. 2010 Apr;37:213–21. Sommer DD, Mendelsohn M. Pitfalls of Nonstandardized Photography in Facial Plastic Surgery Patients: Plast Reconstr Surg. 2004 Jul;114:10–4. Bhattacharya S. Clinical photography and our responsibilities. Indian J

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24.

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Tables and Figure:

preferences for the standard or mirror reversed photo.

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- Table 1: The patients' surgical procedures, ages, facial appreciations, and the

- Table 2: Associations of the photo preference with Group, age, facial

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appreciation, and the photo’s position on the screen

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- Table 3: Associations of group with photo preference, age, and facial appreciation.

- Figure 1 : Notched boxplot comparing the face appreciations and the age of Groups 1 and 2 (above); and of group who preferred mirror-reversed photograph

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and group who preferred standard image (below)

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Patient being operated on Age

N=

Face appreciation

Preference for

% Mirror-Reversed

IQR (Q1-Q3)

Median

IQR (Q1-Q3)

Classic photo

Mirror-reversed photo

preference

214

47.9

24.2(36.4-60.6)

5

2 (5-7)

58

156

73%

Facial aesthetic surgery (Group 1)

50

60.4

26.2 (39.8-66.0)

5

1 (5-6)

8

42

84%

Facelift

16

61.4

12.7 (54.1-66.8)

6

1 (5-6)

1

15

94%

Facelift and Blepharoplasty

11

67.4

5.8(63.5-69.3)

5

3 (2-5)

1

10

Rhinoplasty

13

32.5

32.5(26.7-43.7)

5

1.5 (5-6.5)

3

10

Blepharoplasty

8

58.7

21.6(43.2-64.9)

5

0.8 (4.25-5)

3

Scar revision

2

58.2

-

4.5

-

0

Plastic surgery (Group 2)

164

45.3

21.7 (35.4-57.1)

6

2 (5-7)

50

Mammaplasty

54

40.8

25.7 (28.5-54.3)

6

2 (5-7)

Breast Reconstruction

23

49.3

8.5 (45.5-53.9)

5

2 (4-6)

Abdominoplasty

21

44.7

18.5 (36.6-55.2)

6

2.5 (5-7.5)

Breast augmentation

17

36.4

20.1 (29.9-49.9)

5

3 (4-7)

Implant change

6

54.2

14.0 (44.4-58.4)

5.5

2.3 (5-7.25)

Cutaneous surgery

11

67.2

7.9 (60.0-67.9)

5

1 (4-5)

7

38.4

19.2 (37.5-56.8)

5

7

39.8

21.5 (30.9-52.4)

6

Cruroplasty

10

46.2

16.8 (37.4-54.1)

6

Brachioplasty

2

66.7

-

6

Umbilical Hernia

2

61.4

-

Mastectomy

2

57

Nipple surgery

2

36.1

91%

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77%

63%

2

100%

114

70%

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5

19

35

65%

8

15

65%

7

14

67%

5

12

71%

1

5

83%

3

8

73%

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Scar revision Lipoaspiration

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All patients

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Median

3 (5-8)

0

7

100%

1 (5-6)

2

5

71%

1.3 (5-6.25)

5

5

50%

-

0

2

100%

5

-

0

2

100%

-

4

-

0

2

100%

-

9

-

0

2

100%

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Group1

Classic photo

Mirror-reversed photo

8

42

p=

0.047 Group 2

114

45.1 ; 21.8(35.8-57.7)

49.5 ; 24.7(37.2-61.9)

5 ; 2(5-7)

5 ; 2(5-7)

30/28

76/80

Face appreciation (Median ; SQR (Q1-Q3)) Position of the standard photo:

0.392

0.759

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Right/Left

0.249

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Age (Median ; SQR (Q1-Q3)) years

50

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42

p=

114 0.047

Classic photography

Age (Median ; SQR (Q1-Q3)) years

8

50

60.4 ; 26.2(39.8-66.0)

45.3 ; 21.7(35.4-57.1)

Face appreciation (Median ; SQR (Q1-Q3))

5 ; 1(5-6)

6 ; 2(5-7)

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0.038

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<0.001

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SC

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