Plastic Surgery, Body Image and the Blind

I am writing this on the 15th of October, the designated International Day of the Blind. Last week, one of my patients tragically jumped to her death from her 14th floor apartment. She was blind. The stark reality of the circumstances leading up to her death were captured in a series of graphic images published in one of the Hong Kong daily newspapers (Fig. 1). The images are reproduced with permission. Five years ago, Madam To, a wife and mother and a beautician by training was the victim of an acid assault attack by her sister's estranged boy friend. She was admitted to hospital in the Mainland and subsequently transferred to the Prince of Wales Hospital in Hong Kong. She underwent acute and reconstructive surgery, counseling and rehabilitation but recently had become more reclusive. When shopping she would use a stick and wear hat, surgical mask and dark glasses. On the 8th of October 2007 she climbed out of a window and jumped to her death.

Acid violence is a particularly evil form of interpersonal attack where the perpetrator aims not to kill but to disfigure. Dealing with the consequences of her attack has raised many questions both personal and professional.

Madam To's principle concern was the unstable forehead scar and high hair line and her scarred and ‘pinched’ nose. This concern was not raised because of what she saw, but because of what she could feel. This was now about a year after the assault and Madam To had already become an accomplished Braille reader. It is fascinating to learn of the adaptive changes in both early and late blindness during Braille reading. Extensive engagement of the visual cortex has been observed using functional MRI scans. But how long does it take to learn to ‘see’ with the hands and how can the input be interpreted by the blind patient? There is a growing interest in the ‘Body Image’ and indeed there is a new journal devoted entirely to this subject. In this journal, Nichola Rumsey and Diana Harcourt from the Centre of Appearance Research in Bristol, UK recently presented a comprehensive review of the literature pertaining to the psychosocial implications of living with a visible disfigurement. In the same journal, David Veale reviewed the evolving understanding of body dysmorphic disorders where there is a preoccupation with an imagined defect or a markedly excessive concern with a slight physical anomaly. But how do you evaluate the concern of a person who is disfigured and can feel it but not ‘see’ what is abnormal? There have been studies of body size and self-esteem in blind children and Pierce and Wardle's study was particularly fascinating as it suggested that 9- to 11-year-old blind children could have very definite view on their body size. Pursing eating disorders in the visually impaired is also revealing. Indeed there is sufficient evidence to indicate that visual body image is not essential in the development of an eating disorder. Non-congenital blindness has been reported in anorexia nervosa and also in one reported case of bulimia. Returning to risk factors associated with developing body dysmorphia, Veale mentions the term ‘aestheticality’. This was a term introduced in 1982 by David Harris in his essay entitled ‘Cosmetic surgery – where does it begin?’. He suggested that individuals who sought cosmetic surgery may be more aesthetically sensitive than those who do not, and that aesthetic sensitivity may have two components – one related to perception and the other an emotional response. Whilst there has been significant understanding in the psychological aspects of disfigurement there is less convincing evidence about the effectiveness of cosmetic surgery as a psychotherapeutic intervention. As Cook et al. remarked, the negative conclusions in their systematic review reflect not the existence of negative evidence, but rather the non-existence of positive, methodologically-sound evidence to demonstrate the psychological benefits of ‘cosmetic’ surgery. Appearance is important though and we can find reference to this in the plastic surgery literature. But in only one paper could I find direct reference to performing cosmetic surgery in a blind person. In this case the procedure was an augmentation mammoplasty and abdominal lipectomy in a 44-year-old lady, blind since birth. In this same paper there was an indirect reference to a blind person who had a face lift. Nowhere in the published literature from the disciplines of Psychology or Plastic Surgery could I find reference to dealing with the reconstructive challenges of the blind and facially disfigured patient. How does one counsel such a patient?

What is the model in the sighted person? Fig. 2 outlines a context of reconstructive, aesthetic and cosmetic aspects of Plastic Surgery. Plastic Surgery is a specialty that uses both surgical and non-surgical techniques to make positive change in both appearance (form) and function. The starting point of intervention will be either an objective abnormality with a major component of functional loss due to congenital absence, trauma or tumour extirpation. In such cases there will be a significant element of reconstruction in the Plastic Surgery performed. On the other hand the patient may present with a more subjective concern about appearance in which case the major element of the Plastic Surgery will be cosmetic. In both aspects of Plastic Surgery the surgeon will be guided by aesthetic principles of shape and form which pertain to human concepts of beauty, attractiveness and acceptance.

With the sighted patient the surgeon can analyze the need and potential process of change and often whilst using pictures, describe to the patient the goals and outcomes to be achieved.

For the disfigured, sighted patient they will have a visual reference with regard to where they exist in relation to their concept of ‘beauty’ (Fig. 3).

But how does the blind patient assess and analyze the situation? There are many well-established and very successful blind artists and photographers. Concepts of beauty are one thing, concepts of deformity are another. The degree of aestheticality of a patient must have an important contribution to make to the process. Whilst we focused on the ‘feel’, i.e. the visualization through touch I know that I did not explore the internalized concepts of the perceived disfigurement.

To deal with what we could jointly identify, a protracted process of reconstruction began with the aims of restoring the major anatomical features and culminating in a resurfacing to bring the features together. Of note, an external prosthesis for the right eye was discussed but discounted by the patient.

The hair bearing scalp was expanded and advanced to cover the unstable forehead skin using the crane principle. Subsequently the forehead section was excised as a full-thickness layer creating a new anterior hair line and a graftable bed which was covered with a thick-split thickness sheet graft. Eyebrow grafts were inset. The nasal deformity was difficult to analyze objectively, although some comprehensive algorithms and classifications have been recently described.^,  The principle concern of Madam To was one of texture and also size of the tip. Again after considerable discussion I undertook a ‘soft tissue’ nasal reconstruction using a ‘free-style’ free flap that was subsequently thinned (Fig. 4). In the mean time the ophthalmic surgeons were trying to restore some element of visual perception in the left eye using an osteo-odonto-keratoprosthesis.

The psychology of disfigurement is indeed complex and it is essential for Plastic Surgeons and Psychologists to work together and do more to objectively understand patients as people, as complex personalities and more specifically tailor reconstructive and holistic care strategies, not just for the defect, but for the person with the defect. I think of the Myers Briggs Psychology Personality Types and reflect on how different Madam To is from another blind acid assault victim I am currently treating. I think she was far more of the Internal Sensual type with a very high regard for aesthetics and what strikes me now is that not only did she lose her sight but she also lost her eyes. Even without sight the eye is an intricate and beautifully complex structure. The plastic, reconstructive and aesthetic surgical management of the blind and disfigured patient is a wide open area requiring the attention of surgeon and psychologist alike. To conclude this editorial I leave a picture of Madam To taken some years before the assault (Fig. 5). Perhaps it was the very fact of her beauty that attracted the evil of the acid assault but there is another observation which puts in perspective the gulf between reconstructive aesthetic surgery and cosmetic surgery. In the former we are trying to restore nature, in the latter we are trying to redefine nature. In the ‘state of the art’ we are much better at redefinition than restoration. Cornette de Saint-Cyr et al. and Verpaele et al. demonstrate in the first two papers of this issue the elegance of such redefinition, focusing on the mid-face and using enhanced lifting techniques.