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Patients’ Satisfaction following Cosmetic Procedures

The Role of App-Pain

Barone, Mauro, M.D.; Cogliandro, Annalisa, M.D., Ph.D.; Persichetti, Paolo, M.D., Ph.D.

Plastic and Reconstructive Surgery: May 2019 - Volume 143 - Issue 5 - p 1123e–1124e
doi: 10.1097/PRS.0000000000005543

Plastic and Reconstructive Surgery Unit, Campus Bio-Medico University of Rome, Rome, Italy

Correspondence to Dr. Barone, Via Alvaro del Portillo 200, Rome, Italy,, Instagram: @drmaurobarone, Facebook: drmaurobarone, Twitter: @drmaurobarone

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We read with great interest the article entitled “The Public Face of Rhinoplasty: Impact on Perceived Attractiveness and Personality” by Dr. Stephen M. Lu et al.1 We agree with the authors and consider rhinoplasty to be one of the principal cosmetic procedures to improve attractiveness and personality in multiple aspects. This study was the first to evaluate the point of view of a third person, who is not the surgeon or the patient.

We have published a lot of articles on the topic of appearance and the three considerations of beauty: subjectivism, objectivism, relationalism.2–5 What is beauty? Subjectivism holds that the reasons for the experience of beauty are a property of the subject of experience itself; that is, they are internal to the subject. In aesthetic surgery, the subjectivist approach is configured as the “medicine of desires.” Objectivism presents the problem of the concept of beauty by focusing attention on material data. Objectivism does not guarantee the universality of aesthetic appreciation: pleasure must be dissociated from beauty. Faced with this apparent dichotomy between objectivism and subjectivism, a reasonable attitude is to withdraw slightly, to affirm what we have called a relationalist position: the subjective phase of apprehension and, on the other hand, the presence of something, with its properties, which is given to the subject. The data are not created by the subject; they are learned through sensitivity. The complexity of the concept of appearance has been calculated through a lawful and useful reduction operation that requires the following two premises. Premise 1 is the concept of appearance as “perceived by me” and of how “I am perceived by others.” Premise 2 suggests that appearance becomes a dynamic reality that varies according to at least the following five indicators: (1) appearance changes in my time and in the time of the observer; (2) the whole in which I expose myself; (3) the characteristics of the observer; (4) comorbidity or pathologies; and (5) concurrent factors. Thus we introduced the concept of appearance pain, or App-Pain, which consists of the recomposed systemic view of experimental indicators of suffering, linked to one of these dimensions of one’s appearance. The importance of this potentially new nosographic entity is the possibility of inserting the logic of precision medicine or personalized medicine into cosmetic medicine, combining, according to a logic of complexity, the psychological, objective, and relational dimension of the perception of perceived beauty. Using this rationale, we completely leave Newtonian logic, where the observer was ruled out, to avoid falling into an aesthetic subjectivism that would deny the possibility of reaching a clinical indication based on scientific evidence for cosmetic surgery. All this has a considerable importance for building a best practice, which, from the point of view of applied ethics, is the doctor’s first duty. This new concept of App-Pain must be fundamental for an objective indication to cosmetic surgery.

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The authors are members of the research group “To Be and To Appear: Objective Indication to Plastic Surgery” of Campus Bio-Medico University in Rome.

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The authors have no commercial associations that might pose or create a conflict of interest with information presented in this communication. No intramural or extramural funding supported any aspect of this work.

Mauro Barone, M.D.

Annalisa Cogliandro, M.D., Ph.D.

Paolo Persichetti, M.D., Ph.D.

Plastic and Reconstructive Surgery Unit

Campus Bio-Medico University of Rome

Rome, Italy

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1. Lu SM, Hsu DT, Perry AD, et al. The public face of rhinoplasty: Impact on perceived attractiveness and personality. Plast Reconstr Surg. 2018;142:881–887.
2. Barone M, Cogliandro A, La Monaca G, Tambone V, Persichetti P. Cognitive investigation study of patients admitted for cosmetic surgery: Information, expectations, and consent for treatment. Arch Plast Surg. 2015;42:46–51.
3. Barone M, Cogliandro A, Di Stefano N, Tambone V, Persichetti P. A systematic review of patient-reported outcome measures following transsexual surgery. Aesthetic Plast Surg. 2017;41:700–713.
4. Barone M, Cogliandro A, Salzillo R, Tambone V, Persichetti P. Patient-reported satisfaction following post-bariatric surgery: A systematic review. Aesthetic Plast Surg 2018;42:1320–1330.
5. Barone M, Cogliandro A, Salzillo R, Tambone V, Persichetti P. The role of appearance: Definition of appearance-pain (app-pain) and systematic review of patient-reported outcome measures used in literature. Aesthetic Plast Surg. 2018;42:1399–1409.
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