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Psychiatric consultation in plastic surgery: The psychiatrist's perspective
PAUL C. MOHL, M.D.
Psychiatric consultation in plastic surgery: The psychiatrist's perspective Plastic surgeons seek routine psychiatric consultation for many of the same management and diagnostic issues for which any surgeon might call in a psychiatrist, such as postoperative delirium or depression. In addition, the plastic surgeon can benefit substantially from psychiatric consultation during the initial screening and evaluation phase before agreeing to operate on a particular patient seeking elective cosmetic surgery. Effective preoperative collaborative work requires that the liaison psychiatrist overcome some important biases common to many psychiatrists, If he can do so, a new and highly interesting clinical world of body image, object relations, and psychopathology issues unfolds. This world includes the opportunity for collaboration with an unusual group of surgeons and the opportunity to perform much-needed clinical services for both patient and physi-
ciano Goin and Goin I in their masterful textbook, which should be mandatory reading for all plastic surgeons and for the liaison psychiatrists who strive to assist them, describe this process as "taming a psychiatrist." Four possible biases on the part of the psychiatrist that are listed below should be considered in the light of the accompanying commentary. Bias No. I: It is inherently suboptimal and often antitherapeutic to attempt to solve psychological problems with biologic interventions. In
fact, patients can often benefit psychologically by bringing their bodies more closely in line with their body images. The vast majority of patients neither improve nor deteriorate psychologically although a few do have untoward psychiatric reactions. Rare, dramatic instances of this 1,2 have tended to reinforce the psychiatric bias
Dr. Mohl is associate prOfessor of psychiatry at the University of Texas Health Science Center and staff psychiatrist at the Audie Murphy VA Hospital. Reprint requests to him in the department ofpsychiatry at the center, 7703 Floyd Curl Drive, San Antonio, TX 78284.
that surgery is always contraindicated for psychological phenomena. If one conceptualizes the problem not as a generic psychological conflict, but as a conflict between long-standing preferred body image and perceived body, then surgery becomes a reasonable, effective, and even economical option for treating the problem. Bias No.2: A request for elective cosmetic surgery is invariably a symptom of psychopathology and any psychopathology is a contraindication to the surgery. Most seekers
of cosmetic surgery do have conflicts between their preferred body image and their perceptions of their bodies. This may cause disturbed self-esteem and depression, perhaps even relationship problems. Patients may also have varying degrees of other, incidental psychopathology. But if the patient's goal is surgically possible, consonant with the body image, and that person is capable of establishing a collaborative relationship with the surgeon, understanding, accepting, and tolerating the risks, then the surgery is likely to be successful (continued on page 474)
JUNE 1984 • VOL 25 • NO 6
471
Surgeon's perspective
surgery, and who have the opportunity to explore the reasons for the requested change in body image, tend to have a smoother postoperative course and to be more pleased with their new body image than those who do not. The psychiatrist should schedule follow-up contact with these patients six to 12 weeks postoperatively to better under-
stand any further developments in attitudes toward the cosmetic surgery and its results. In conclusion, understanding of the motivations, expectations, and desires of a patient seeking cosmetic surgery is at least as important as manual dexterity for achieving consistently satisfactory results. The psychiatrist oriented to this
Psychiatrist's perspective regardless of what related or unrelated psychopathology is present. Teasing out authentic body image issues from psychopathology is a fascinating, challenging task for the liaison psychiatrist. Bias No.3: Cosmetic surgery is indicated if and only if the patient's perceived defect is objectively realistic. In fact, quite the opposite may be the case. Body image is a wholly internal schema. A patient citing external evidence for a body defect, even if the examiner shares the perception, may be responding to social pressures, seeking changes in interpersonal relationships or other externals via the surgery. The patient whose statements are related entirely to inner satisfaction issues is the better candidate. Comments like "I just don't look (or feel) like myself with this nose" (or this face or these breasts) are good signs. The choice of words, symbols, and referents is the best clue as to the presence or absence of authentic body image issues. Bias No.4: A patient who can clearly articulate motivations for cosmetic surgery is a better candidate than one who cannot. Body image issues are preverbal. The patient who is vague and uncertain may be less defended, struggling 474
area of modern medicine will be professionally challenged. 0 REFERENCES: 1 Meyer E. Jacobson WE. Edgerton MT, et al: Motivational patterns in patients seeking elective plastic surgery. I. Women who seek rhi· noplasty. Psychosom Meet 22: 193-203, 1960. 2. American Medical Association. Proceedings of the House of Delegates: Adoption of Resolu· tion 78 (A-74). 28th Clinical Convention. Port· land. Ore. Dec t-4, 1974.
(continued from page 471) openly with an important issue, while the glib, articulate patient's authentic motivation may be less easy to discern. Implied in my comments on these biases is my understanding of what one must evaluate prior to plastic surgery: the patient's body image, object relations, consonance between preferred body image and
The liaison psychiatrist facilitated the dialogue about goals between the plastic surgeon and the patient. perceived body, feasibility of surgical goals, inner-directedness, frustration tolerance, understanding of risks, and capacity to work with the particular plastic surgeon. If all of these are acceptable, then I give a clear go-ahead to the surgeon. Thus, my colleague has successfully operated on patients with severe personality, anxiety, psychosexual, dysthymic, .and other psychiatric disorders. 2 I advise against operating on patients with untreated schizophrenia, psychotic affective disorders, or paranoid disorders. If any of these three problems are present but treated, I am still wary
but continue to carefully evaluate the situation, communicating at length with the treating psychiatrist.
Assessment options If any of the above issues do not fit-for example, if there are object relations difficulties that relate to the request for body image surgery, or if the patient has unrealistic goals or cannot get along with the surgeon-a number of options are available. One is outright refusal. This is most common in situations where the body image goal is surgically unfeasible, bound up with other psychopathology, externally motivated, or when the patient is unable to understand the procedure or collaborate with the surgeon. Also, if either the surgeon or I have a persistent gut-level feeling of discomfort with the patient's outlook, we do not proceed, regardless of whether we can identify a specific appropriate body image problem. The following are examples in which surgery was not advisable. I. An emotionally healthy 28year-old married Turkish woman wanted a small turned-up Caucasian-like nose after a one-year stay in the United States. She was rePSYCHOSOMATICS
turning to Turkey to live, and had no prior history of identification with western culture nor dissatisfaction with her nose. It was not clear what her motivation was, but it was not a body image conflict. 2. A 45-year-old man seeking a repeat foreskin reconstruction was articulate and open. He had thought that his penis just did not look right without a foreskin, but he was unhappy with fairly minor defects in his prior reconstruction. He seemed to want a perfect phallus. His air of inner rage left us all feeling very uncomfortable. We suspected an occult paranoid disorder. In any event his goals were surgically unrealistic. 3. A 28-year-old Hispanic man sought a blepharoplasty so he would "look less like an Oriental and more like a Mexican." He was diagnosed as schizophrenic. His motivation probably was body image related and an operation might have been undertaken had he been willing to accept a referral for psychiatric treatment. 4. A college-age man sought foreskin reconstruction. He did not yet have a firm identity and hoped that his family relationships would improve after his surgery. His goals seemed more related to interpersonal issues. This absence of a clear identity made any body image issues subject to later change. Another option if the patient is not 'clearly acceptable for surgery is, "Let's all think this over for a few months." For example, a 52-yearold man sought foreskin reconstruction so that he could be more "macho." He also expressed longstanding dissatisfaction with his circumcised phallus, feeling "incomplete." We all agreed that he needed further working through of his motivation. Six months later he JUNE 1984 • VOL 25 • NO 6
returned no longer concerned about the macho issue and had uneventful surgery with a good result. A third option is, "Let's all sit down together and be sure our goals and communications are consonant." For example, chordee in a 39-year-old man had been operated on by another surgeon. A fold of skin which made the penis look shorter than it was previously remained afterwards. The patient said, "That took away my pride,"
Plastic surgeons differ from other surgeons in that they focus more on esthetic and quality-of-life issues. and sought correction of the fold of skin. He was an inhibited, socially isolated man who was very anxious around women. It was not clear whether his concern about penis size was an authentic body image issue, a rationalized defense for avoiding interpersonal intimacy, or a symptom of a self-esteem problem. He was vague about what he actually wanted done. First we referred him for psychotherapy. Four months later, at the request of his psychiatrist, we reevaluated him. All three of us sat down together, drew numerous pictures, and finally agreed on a realistic goal. The liaison psychiatrist facilitated the dialogue about goals between the plastic surgeon and the patient. The surgery proceeded uneventfully. A fourth option is continuing involvement of the psychiatrist during the surgery and follow-up. For example, the above patient was followed supportively by the liaison psychiatrist owing to our concern that his authentic body image
problem was intertwined with conflict about sexual aspects and selfesteem. Ongoing recommendations about how to relate to the patient were provided. A fifth option is referral to another plastic surgeon. We do this most often when the patient is a good candidate but has a poor personality fit with the particular surgeon. My colleague does best with patients who assume much responsibility for themselves and communicate openly and directly. Excessively histrionic and dependent patients are referred to a surgeon who likes to assume a fatherly role with his patients. Occasionally, we have violated our own criteria for what seemed to be appropriate reasons at the time. Inevitably, we have come to regret our decision, as with an emotionally healthy 48-year-old man who sought a face-lift at the recommendation of his literary agent. He was a writer and the agent thought that he could arrange better publicity (especially TV appearances) and better sales if the patient's craggy features were softened, making him more photogenic and seemingly youthful. This appeared surgically and socially realistic and we agreed to proceed despite our awareness that no authentic body image issue existed. However, even before surgery could be done, the patient began missing appointments, caused problems on the ward, argued with the nurses and hospital administrators, and disrupted the schedule. Eventually a blepharopiasty was completed but we refused any further surgery. In another case, an extremely intelligent patient requested foreskin reconstruction, believing that he was incomplete without one. He was a very angry man who was 475
Psychiatrist's perspective
unable to modulate his rage despite two lengthy empathic interviews. Since he seemed to have authentic body image concerns, we decided to go ahead with the surgery as long as he saw the liaison psychiatrist regularly. Our hope was that the liaison psychiatrist would be able to help regulate the self and object relations pathology, at a minimum becoming a lightning rod for the anger. This decision only heightened the patient's rage. He became more difficult to deal with, developed complications, and never completed all of the stages. Although he had authentic body image concerns, his object relations and self-pathology prevented an alliance with the surgeon or psychiatrist. We relearned an old lesson of surgery: don't make "deals" with demanding patients.
challenging case. I can communicate with such surgeons at a more sophisticated level, and they seem more interested in increasing their understanding of psychiatric issues. On the other hand, like most surgeons, they prefer a direct, concrete response. Diagnoses and psychodynamic formulations are of limited utility in this situation. They can become very impatient with the traditional psychiatric role of neutrally providing information but
WorIdng with the surgeon
not expressing a clear opinion or behavioral prediction. Another area that sets plastic surgeons apart from other surgeons is the issue of elective surgery. This enhances the need for clear communication about goals, motives, complications, and fees. It puts both the surgeon and the liaison psychiatrist in the role of gatekeepers and can distort the' therapeutic alliance unless carefully and honestly handled from the start. The alliance begins on the telephone or in a letter with a clear discussion of the purposes and Costs of the psychiatric evaluation. It is no easy task to establish an alliance
Working with plastic surgeons is different from working with other surgeons. Other surgeons are more concerned with survival and functional issues, but the former focus more on esthetic and quality-of-life issues. This facilitates sensitivity and sophistication about psychological issues, especially self-esteem and body image. One of the effects of this is that they screen out many of the more obvious psychiatric problems in their own initial evaluations. When I receive a request for a consultation from a plastic surgeon, I can be assured that I will be seeing a difficult, complex, and
476
If done appropriately, even a refusal ofplastic surgery can be experienced by the patient in the context ofneeds and wishes being understood and respected.
based on, "Let's look together at your goals and motives for this surgery to ensure that it really is best for all concerned," when the patient thinks that he or she has already made that decision. But, if done appropriately, even a refusal of plastic surgery can be experienced by the patient in the context of needs and wishes being understood and respected. I generally request payment in advance since the patient's primary alliance is inevitably with the surgeon and we are not always perceived as a team. Thus, the patient often has little motivation to pay the psychiatric consultant's bill. Since most elective plastic surgery is not covered by insurance, I have found patients receptive and comfortable with this arrangement. They often make similar arrangements with the surgeon and anesthesiologist. In summary, by approaching the plastic surgeon and the patient with an open mind; by attending to and considering issues of body image, object relations, and self psychology; and by creatively approaching the therapeutic alliance, the liaison psychiatrist can playa useful role in a clinical world with its own set of distinctive problems and satisfactions. 0 REFERENCES: 1. Goin JM, Goin MK: Ct>anging the Body.' Psychological Effects 01 Plastic Surgery. Banimore, Williams & Wilkins. 1981 2. Mohl PC. Adams R. Greer OM. et al: Prepuce restoration seekers: Psychiatric aspects. Arch Sex Behav 10:383-393. 1981.
PSYCHOSOMATICS
Psychiatric consultation in plastic surgery: The psychiatrist's perspective Plastic surgeons seek routine psychiatric consultation for many of the same management and diagnostic issues for which any surgeon might call in a psychiatrist, such as postoperative delirium or depression. In addition, the plastic surgeon can benefit substantially from psychiatric consultation during the initial screening and evaluation phase before agreeing to operate on a particular patient seeking elective cosmetic surgery. Effective preoperative collaborative work requires that the liaison psychiatrist overcome some important biases common to many psychiatrists, If he can do so, a new and highly interesting clinical world of body image, object relations, and psychopathology issues unfolds. This world includes the opportunity for collaboration with an unusual group of surgeons and the opportunity to perform much-needed clinical services for both patient and physi-
ciano Goin and Goin I in their masterful textbook, which should be mandatory reading for all plastic surgeons and for the liaison psychiatrists who strive to assist them, describe this process as "taming a psychiatrist." Four possible biases on the part of the psychiatrist that are listed below should be considered in the light of the accompanying commentary. Bias No. I: It is inherently suboptimal and often antitherapeutic to attempt to solve psychological problems with biologic interventions. In
fact, patients can often benefit psychologically by bringing their bodies more closely in line with their body images. The vast majority of patients neither improve nor deteriorate psychologically although a few do have untoward psychiatric reactions. Rare, dramatic instances of this 1,2 have tended to reinforce the psychiatric bias
Dr. Mohl is associate prOfessor of psychiatry at the University of Texas Health Science Center and staff psychiatrist at the Audie Murphy VA Hospital. Reprint requests to him in the department ofpsychiatry at the center, 7703 Floyd Curl Drive, San Antonio, TX 78284.
that surgery is always contraindicated for psychological phenomena. If one conceptualizes the problem not as a generic psychological conflict, but as a conflict between long-standing preferred body image and perceived body, then surgery becomes a reasonable, effective, and even economical option for treating the problem. Bias No.2: A request for elective cosmetic surgery is invariably a symptom of psychopathology and any psychopathology is a contraindication to the surgery. Most seekers
of cosmetic surgery do have conflicts between their preferred body image and their perceptions of their bodies. This may cause disturbed self-esteem and depression, perhaps even relationship problems. Patients may also have varying degrees of other, incidental psychopathology. But if the patient's goal is surgically possible, consonant with the body image, and that person is capable of establishing a collaborative relationship with the surgeon, understanding, accepting, and tolerating the risks, then the surgery is likely to be successful (continued on page 474)
JUNE 1984 • VOL 25 • NO 6
471
Surgeon's perspective
surgery, and who have the opportunity to explore the reasons for the requested change in body image, tend to have a smoother postoperative course and to be more pleased with their new body image than those who do not. The psychiatrist should schedule follow-up contact with these patients six to 12 weeks postoperatively to better under-
stand any further developments in attitudes toward the cosmetic surgery and its results. In conclusion, understanding of the motivations, expectations, and desires of a patient seeking cosmetic surgery is at least as important as manual dexterity for achieving consistently satisfactory results. The psychiatrist oriented to this
Psychiatrist's perspective regardless of what related or unrelated psychopathology is present. Teasing out authentic body image issues from psychopathology is a fascinating, challenging task for the liaison psychiatrist. Bias No.3: Cosmetic surgery is indicated if and only if the patient's perceived defect is objectively realistic. In fact, quite the opposite may be the case. Body image is a wholly internal schema. A patient citing external evidence for a body defect, even if the examiner shares the perception, may be responding to social pressures, seeking changes in interpersonal relationships or other externals via the surgery. The patient whose statements are related entirely to inner satisfaction issues is the better candidate. Comments like "I just don't look (or feel) like myself with this nose" (or this face or these breasts) are good signs. The choice of words, symbols, and referents is the best clue as to the presence or absence of authentic body image issues. Bias No.4: A patient who can clearly articulate motivations for cosmetic surgery is a better candidate than one who cannot. Body image issues are preverbal. The patient who is vague and uncertain may be less defended, struggling 474
area of modern medicine will be professionally challenged. 0 REFERENCES: 1 Meyer E. Jacobson WE. Edgerton MT, et al: Motivational patterns in patients seeking elective plastic surgery. I. Women who seek rhi· noplasty. Psychosom Meet 22: 193-203, 1960. 2. American Medical Association. Proceedings of the House of Delegates: Adoption of Resolu· tion 78 (A-74). 28th Clinical Convention. Port· land. Ore. Dec t-4, 1974.
(continued from page 471) openly with an important issue, while the glib, articulate patient's authentic motivation may be less easy to discern. Implied in my comments on these biases is my understanding of what one must evaluate prior to plastic surgery: the patient's body image, object relations, consonance between preferred body image and
The liaison psychiatrist facilitated the dialogue about goals between the plastic surgeon and the patient. perceived body, feasibility of surgical goals, inner-directedness, frustration tolerance, understanding of risks, and capacity to work with the particular plastic surgeon. If all of these are acceptable, then I give a clear go-ahead to the surgeon. Thus, my colleague has successfully operated on patients with severe personality, anxiety, psychosexual, dysthymic, .and other psychiatric disorders. 2 I advise against operating on patients with untreated schizophrenia, psychotic affective disorders, or paranoid disorders. If any of these three problems are present but treated, I am still wary
but continue to carefully evaluate the situation, communicating at length with the treating psychiatrist.
Assessment options If any of the above issues do not fit-for example, if there are object relations difficulties that relate to the request for body image surgery, or if the patient has unrealistic goals or cannot get along with the surgeon-a number of options are available. One is outright refusal. This is most common in situations where the body image goal is surgically unfeasible, bound up with other psychopathology, externally motivated, or when the patient is unable to understand the procedure or collaborate with the surgeon. Also, if either the surgeon or I have a persistent gut-level feeling of discomfort with the patient's outlook, we do not proceed, regardless of whether we can identify a specific appropriate body image problem. The following are examples in which surgery was not advisable. I. An emotionally healthy 28year-old married Turkish woman wanted a small turned-up Caucasian-like nose after a one-year stay in the United States. She was rePSYCHOSOMATICS
turning to Turkey to live, and had no prior history of identification with western culture nor dissatisfaction with her nose. It was not clear what her motivation was, but it was not a body image conflict. 2. A 45-year-old man seeking a repeat foreskin reconstruction was articulate and open. He had thought that his penis just did not look right without a foreskin, but he was unhappy with fairly minor defects in his prior reconstruction. He seemed to want a perfect phallus. His air of inner rage left us all feeling very uncomfortable. We suspected an occult paranoid disorder. In any event his goals were surgically unrealistic. 3. A 28-year-old Hispanic man sought a blepharoplasty so he would "look less like an Oriental and more like a Mexican." He was diagnosed as schizophrenic. His motivation probably was body image related and an operation might have been undertaken had he been willing to accept a referral for psychiatric treatment. 4. A college-age man sought foreskin reconstruction. He did not yet have a firm identity and hoped that his family relationships would improve after his surgery. His goals seemed more related to interpersonal issues. This absence of a clear identity made any body image issues subject to later change. Another option if the patient is not 'clearly acceptable for surgery is, "Let's all think this over for a few months." For example, a 52-yearold man sought foreskin reconstruction so that he could be more "macho." He also expressed longstanding dissatisfaction with his circumcised phallus, feeling "incomplete." We all agreed that he needed further working through of his motivation. Six months later he JUNE 1984 • VOL 25 • NO 6
returned no longer concerned about the macho issue and had uneventful surgery with a good result. A third option is, "Let's all sit down together and be sure our goals and communications are consonant." For example, chordee in a 39-year-old man had been operated on by another surgeon. A fold of skin which made the penis look shorter than it was previously remained afterwards. The patient said, "That took away my pride,"
Plastic surgeons differ from other surgeons in that they focus more on esthetic and quality-of-life issues. and sought correction of the fold of skin. He was an inhibited, socially isolated man who was very anxious around women. It was not clear whether his concern about penis size was an authentic body image issue, a rationalized defense for avoiding interpersonal intimacy, or a symptom of a self-esteem problem. He was vague about what he actually wanted done. First we referred him for psychotherapy. Four months later, at the request of his psychiatrist, we reevaluated him. All three of us sat down together, drew numerous pictures, and finally agreed on a realistic goal. The liaison psychiatrist facilitated the dialogue about goals between the plastic surgeon and the patient. The surgery proceeded uneventfully. A fourth option is continuing involvement of the psychiatrist during the surgery and follow-up. For example, the above patient was followed supportively by the liaison psychiatrist owing to our concern that his authentic body image
problem was intertwined with conflict about sexual aspects and selfesteem. Ongoing recommendations about how to relate to the patient were provided. A fifth option is referral to another plastic surgeon. We do this most often when the patient is a good candidate but has a poor personality fit with the particular surgeon. My colleague does best with patients who assume much responsibility for themselves and communicate openly and directly. Excessively histrionic and dependent patients are referred to a surgeon who likes to assume a fatherly role with his patients. Occasionally, we have violated our own criteria for what seemed to be appropriate reasons at the time. Inevitably, we have come to regret our decision, as with an emotionally healthy 48-year-old man who sought a face-lift at the recommendation of his literary agent. He was a writer and the agent thought that he could arrange better publicity (especially TV appearances) and better sales if the patient's craggy features were softened, making him more photogenic and seemingly youthful. This appeared surgically and socially realistic and we agreed to proceed despite our awareness that no authentic body image issue existed. However, even before surgery could be done, the patient began missing appointments, caused problems on the ward, argued with the nurses and hospital administrators, and disrupted the schedule. Eventually a blepharopiasty was completed but we refused any further surgery. In another case, an extremely intelligent patient requested foreskin reconstruction, believing that he was incomplete without one. He was a very angry man who was 475
Psychiatrist's perspective
unable to modulate his rage despite two lengthy empathic interviews. Since he seemed to have authentic body image concerns, we decided to go ahead with the surgery as long as he saw the liaison psychiatrist regularly. Our hope was that the liaison psychiatrist would be able to help regulate the self and object relations pathology, at a minimum becoming a lightning rod for the anger. This decision only heightened the patient's rage. He became more difficult to deal with, developed complications, and never completed all of the stages. Although he had authentic body image concerns, his object relations and self-pathology prevented an alliance with the surgeon or psychiatrist. We relearned an old lesson of surgery: don't make "deals" with demanding patients.
challenging case. I can communicate with such surgeons at a more sophisticated level, and they seem more interested in increasing their understanding of psychiatric issues. On the other hand, like most surgeons, they prefer a direct, concrete response. Diagnoses and psychodynamic formulations are of limited utility in this situation. They can become very impatient with the traditional psychiatric role of neutrally providing information but
WorIdng with the surgeon
not expressing a clear opinion or behavioral prediction. Another area that sets plastic surgeons apart from other surgeons is the issue of elective surgery. This enhances the need for clear communication about goals, motives, complications, and fees. It puts both the surgeon and the liaison psychiatrist in the role of gatekeepers and can distort the' therapeutic alliance unless carefully and honestly handled from the start. The alliance begins on the telephone or in a letter with a clear discussion of the purposes and Costs of the psychiatric evaluation. It is no easy task to establish an alliance
Working with plastic surgeons is different from working with other surgeons. Other surgeons are more concerned with survival and functional issues, but the former focus more on esthetic and quality-of-life issues. This facilitates sensitivity and sophistication about psychological issues, especially self-esteem and body image. One of the effects of this is that they screen out many of the more obvious psychiatric problems in their own initial evaluations. When I receive a request for a consultation from a plastic surgeon, I can be assured that I will be seeing a difficult, complex, and
476
If done appropriately, even a refusal ofplastic surgery can be experienced by the patient in the context ofneeds and wishes being understood and respected.
based on, "Let's look together at your goals and motives for this surgery to ensure that it really is best for all concerned," when the patient thinks that he or she has already made that decision. But, if done appropriately, even a refusal of plastic surgery can be experienced by the patient in the context of needs and wishes being understood and respected. I generally request payment in advance since the patient's primary alliance is inevitably with the surgeon and we are not always perceived as a team. Thus, the patient often has little motivation to pay the psychiatric consultant's bill. Since most elective plastic surgery is not covered by insurance, I have found patients receptive and comfortable with this arrangement. They often make similar arrangements with the surgeon and anesthesiologist. In summary, by approaching the plastic surgeon and the patient with an open mind; by attending to and considering issues of body image, object relations, and self psychology; and by creatively approaching the therapeutic alliance, the liaison psychiatrist can playa useful role in a clinical world with its own set of distinctive problems and satisfactions. 0 REFERENCES: 1. Goin JM, Goin MK: Ct>anging the Body.' Psychological Effects 01 Plastic Surgery. Banimore, Williams & Wilkins. 1981 2. Mohl PC. Adams R. Greer OM. et al: Prepuce restoration seekers: Psychiatric aspects. Arch Sex Behav 10:383-393. 1981.
PSYCHOSOMATICS