Body Image 101: The 50% Factor

Body Image 101 

The Fifty Percent Factor

September 1960 (Note date at which time my work on this essay was begun)

Body Image in Medical Practice: The Beauty of Medicine

Theory of Body Image

Body image is the term used in plastic surgery for self-esteem. Body image is important – so important that it is considered to be fifty percent of what we deliver to the patient. When I began a career in plastic surgery fifty-one years ago, I reacted with surprise to that statistical fact. And you too may have reacted by thinking, ‘Did you mean to say, in all seriousness, that plastic and reconstructive surgery is half surgery and half psychiatry?’ The answer is, surprisingly, “Yes! Body image is that essential!”

Body Image is what we think other people think of us

You are born with a body image. This innate body image is what you think of yourself.  But in our discipline – Plastic and Reconstructive Surgery – the definition of body image is what we think other people think of us. We deal with body image by altering it for the better. Our field is based on the premise that when the body is altered, the body image is changed in a corresponding way (Fig.1).

             The triangle above demonstrates the fact that improvement of the body and body image leads to enhanced productivity.1

Extending this, I feel that not only does the person benefit but society also reaps a profit from this outcome because people are more happy – they make more money and are better able to contribute to society.

Consequently, plastic surgery contributes to the betterment of the world. This is the basis of plastic surgery, how it is different from other specialties and professions and why we feel good about our place in the world.

1  Personal teaching on August 20, 1963 by Robert Berner, MD – top surgeon in1964 between San Francisco and Santa Barbara; Location – Stanford University Hospital Locker Room before heading into an operation. Other than our physical appearance, Body Image obviously involves other things that we do not directly change. However, as we begin to deal with the unwritten agenda in plastic surgery, we then become responsible for some of the other factors – job, salary, family, friends, reputation – that have to do with body image. The size of our paycheck reflects what others feel we contribute to society.

In this first installment, Body Image 101, I would like to go over the basic tenets of body image in the practice of plastic surgery. The method of demonstrating this in the post will be through several stories. I’ll give you four patient examples and couple additional examples from heroes in my life, which will be helpful in understanding the nuances. The subsequent series of posts will present a collection of stories, sixteen in total, that show many further nuances of body image and how it affects patient satisfaction, recovery and transformation.

These aspects have been of immense help in improving care and relationship with the patient. The beauty of medicine is enhanced when armed with these experiences.

Practice: Factors that affect Body Image

For purposes of discussion in our field, we know that what other people think of us constitutes our body image. In other words: Body image is the esteem that we perceive other people have of us. Your reputation is important; your reputation is your body image.

In most instances, however, the influences of parents, peers and the media – in that order, make indelible marks on an individual’s body image. Prior to sharing all of the tips on body image, I have a number of cases for your consideration. In this first case, we see that the person’s basic spirit is of primary importance! In the same story we shall see that the mother and peers share in some of that very basic importance.

Tomas Dominguez

I want to tell you the story of Tomás Dominguez because it is the perfect example of how your body image may be the most important thing in your life.

Tomás was born in a dump in the seepage of the Tijuana River in northern Mexico, just below the U.S. border. This particular dump is one of the least attractive dumps in Tijuana, and the poorest of the poor live there. Tomás’s father was absent. He had moved up to Westminster in Orange County, California to learn a trade as an apprentice carpenter in order to support his family back in Mexico. Tomás and his mother, sister, and brother were struggling to make it, just as his father was, but on the other side of the border. In this awful place they made it by pure force of will.

Tomás was at an age where peer evaluation was all-important. Peer evaluation, what you think your friends think of you, is a very important item when you are age six. Any time prior to age four you don’t really care how your friends evaluate you, but after age six, as you know with second graders making fun of the protruding ears on an unfortunate boy by calling him Dumbo, is a powerful negative. His peers can really stick it to him whether in an affluent or non-affluent society.

When you live in a dump and are without money or technology, your physical features become more important.  Your status among your friends does not depend upon whether your new clothes are in style. Rather, physical appearance is the only thing going for you. And actually appearance is more important in a poorer society than in a more affluent society. In a very poor place, such as a slum, it is not the most important thing; it is the only thing. And therefore, how you look determines your status among your set of friends. Tomas was in good shape in this regard because he was a handsome guy, likeable and the leader of the gang of friends. And Tomás’s mother was an excellent caretaker; she had good maternal instincts and a remarkable sense of the social aspect of relationships between people. This is an important point for the rest of the story.

Here in the Tijuana dump, Tomás had been almost entirely dependent on his mother. Her children were like the baby birds in a nest where the mother bird is the sole source of food and everything else: psychological and physical development included. The mother of Tomas was the source of all the things necessary for life. You know that few amenities were enjoyed by the family, and no luxuries.

When Tomás reached age 6 ½, his friends around his home of the same age were everything to him.  The magic of the group became the joy of life. Praise vs. derision from the members of his little band of boys meant everything. The peer group had replaced his mother as the source of his body image prior to his burn.

In their dump, the boys’ game was to show who was the bravest by jumping through fire; they would set a conflagration inside a huge truck tire turned up on its side among the debris. Tomás had a strong instinct to be number one, Alpha, in his little gang, and he tried to be the toughest and manliest even though he wasn’t the most senior.

One day he got hold of some flammable paint thinner, which he threw into the tire. But some of the thinner made a puddle inside the tire. It had not caught fire and one of Tomás’s friends scooped some up in the palm of his hand and splashed it onto Tomás in a gesture of fun. But when Tomás then lit the fire, the flames ignited his face. Terror and pain caused Tomás to run. The kids tried to help him by making him run faster and splashing water on him, and all of it made things worse.

Fortunately the ambulance brought Tomás to the municipal hospital and was transferred to Clinica Materno Infantil in Tijuana, built nearby by Jim Turpin, M.D., one of my personal heroes and founder of Project Concern. Tomas received very good treatment at both hospitals. Initial treatment in the resuscitation phase was with large amounts of intravenous fluids, which were needed to replace the large amounts that are transferred to burn tissue when it is severely wounded. The next concern in burns was to ward off or combat the infection, which is prone to a burn tissue. Tomas received the newest, most up-to-date approach: daily cleansing of the burn and dressing changes with application of Sulfamylon creme, a sulfa drug especially developed for burns  and designed specifically to successfully eliminate the Achilles heel of the burn patient, the pseudomonas aeruginosa bacterial infection resistant to all topical antibiotics at the time before Silver nitrate solution and then Sulfamylon were recent additions to our weaponry to control the big enemy Pseudomonas. Unfortunately, Sulfamylon is  significantly irritating to skin and causes the body to react with excessive scar tissue even keloid. Tomás was indeed disfigured by thick “hypertrophic scar.”

Fig.3 After discharge from hospital in Tijuana

Despite some plastic surgery of excellent quality by Dr. Jaime Caloca, our colleague from Tijuana, who placed thin rapidly healing split skin grafts, it was evident that scar tissue had an active life of its own, and the keloid scarring process exerted its contractile properties upon his eyelid, mouth, and nose.  The lower eyelid of Tomas began to pull down, the scarring on the cheeks and around the mouth and nose had become thick (probably 1.5 cm.) and the scar’s ability to contract had pulled his mouth out of place so that he couldn’t open it properly. Before the burn he had the makings of a handsome young man, but now his most visible part of the body was disfigured beyond recognition.

The important part of this story is that when they brought Tomás home, handing the burned boy to his mother’s arms. Years later in a television interview, his mother was asked what her thoughts were when she first saw her injured son.  She said, “I thought that I must never let Tomás know that he is anything but a normal person. I must behave as if his looks are normal and never give him the idea that he is different.” She knew by instinct how to handle the situation; she knew that Tomás, with his face burned to a crisp was going to turn out “ugly” no matter what happened. Other children ridiculed her son and mistook his distorted face for a grotesque “mask.” His high flying body image had sunk to a very low level as a result of a deep facial burn and excess, gnarly keloid scar formation. The mother realized that she herself would have to protect Tomas.


Tomás, with his father’s help, somehow made it up to the U.S. and was brought to the attention of Mrs. Castillo of Niños Lisiados, who marshaled her social resources to help Tomás.  The personality of Tomas Dominguez unlike the face of Tomas was well preserved and delightful. He was outgoing, forthright, and had a good sense of humor.

He then found his way to Henry Alfaro, a TV evening news reporter for Los Angeles Channel 7, ABC. Henry came to interview Tomás for a possible story. Tomás obliged and was happily interviewed for TV on tape, not a live interview. Henry himself had past experience with a badly burned victim who brought a lawsuit against the Ford Motor Company for gas tank explosions in the Pinto. That man had experienced a very large burn but Henry had shown an unprecedented ability to successfully bring a safety and health issue before a wide television audience, knowing well that the American TV audience will tolerate gore, even atrocious gore and catastrophes, if at the end of the movie everything turns out all right and happiness reigns once again – this being a peculiarity of the American psyche.

Henry then flew up to Stanford and had a tete –de- tete with Tomas’ surgeon.  Henry put his cards on the table disclosing  his plan to interview me, and to follow  all the way through the various stages of surgery on Tomás, including the details  in the operating room: excision of scar tissue-very much bleeding, harvesting and application of skin grafts and tubed skin flaps —reminiscent of scenes in ghastly torture —fracturing of the body image. Henry cited his unique experience in going through a similar sequence   in surgery for the Pinto burn person. I said absolutely not, that the American public will have a visceral reaction, would feel sick to their stomachs, and it would not be successful television. The plan to broadcast a real life photographic view of Tomás and his surgical reconstruction caused me to have trepidation. Television viewers in L.A. would be treated to the excision of the scar tissue and all the blood and gore that accompanies the taking of split-thickness skin grafts with the Reese dermatome, applying the grafts, post-op care, and much more.

I remember saying to Henry Alfaro, the evening news reporter, “The American public cannot tolerate looking at real ugliness or stories that are sad and awful. They will have a visceral reaction. They will feel sick to their stomachs,” I said, “This can’t be done to the public.”

Henry reassured me and the other plastic surgery confreres: “If the result turns out good and happy, the American public can get through the gory parts.  I tell them to look away when they are about to have a visceral reaction.”

“I’m going to lose two pints of blood on the TV screen. I’m going to take a skin graft from his backside. This will remind the audience of a Medieval or WWII torture. You’re out of your mind, Henry.”

We argued it out and Henry won.

So we went through the clinic and to the OR, with Tomas and myself memorialized on Henry’s tape. Tomás on video clips were shown on Channel 7 news in Los Angeles each evening. Well, we began the saga of Tomás with excision of scar tissue of the face on television.  After the wound had stopped oozing blood for 72 hours, and was in readiness to accept a graft, we returned to “our stage” to apply refrigerated skin grafts from the back and buttocks. The surgery was a bloody one and quite a few units of blood were used. It wasn’t a pretty sight.

Henry conscientiously recorded it, including the removal of graft tissue from the patient’s back by hand with the Rees dermatome, another unpleasant procedure to watch. Tomás came through it all with good spirits.

At this stage in the Tomas project, we consulted the visiting Russian surgeons regarding the question of further reconstruction. Tomas had survived, healed from his burn without significant infection and had a life for himself. His assets were a fantastic personality, supportive friends and family, medical resources, and a good body. He was a strong boy who was smart and possessed high mental abilities. Despite spending some significant time in two different countries – Mexico and U.S. – he stayed engaged in his schooling. He had spiritual assets, as well as, emotional and social assets. The negative aspects for Tomas included his face; although it had healed, the texture was not very good. His face could not fully express his personality, and the facial muscles were unable to provide the public with the nuances of his feelings in his mind. We consulted everybody, including all experienced plastics and reconstructive surgeons within our reach, at the top of which was Joel Feldman.[2]

I remember when we presented Tomás to grand rounds in plastic surgery on Wednesday afternoon as an enigma for some visiting Russian plastic surgeons to ‘please solve.’  We asked them for their concerted opinions on this case. What would they do? Would they prefer skin grafts or skin flaps? The enigma is that skin flaps look better because they bring in both skin and fat; they’re supple, soft, and look more natural.

But on the other hand, skin grafts “take” better; the wound heals readily and more quickly. An intermediate compromise might be full-thickness skin grafts, but these are a little more difficult to heal than a split-thickness graft, and require the wisdom of experience.  The Russians noticed that we were arguing among ourselves during the grand rounds, so it was interesting that they gave us a diplomatic answer: “We suggest partly split-thickness and partly full-thickness skin grafts.”

[2] Feldman was from Boston’s Children Hospital, Harvard University, who had presented at national meetings his expertise in surgical restoration of burns, scar, deformity in children. His abilities were truly one or two standard deviations above others.

We wanted to resurface Tomas’ face but there were many options: free microsurgery flaps, a Mustardé flap, and the Bakamjin flap (advancing neck and the cheek tissue in front of the ear in to the main cheek area towards the middle of the face). Of course, none of these were really easily workable. We had already taken the skin graft approach and gave Tomas skin grafts, and then had thick split-thickness skin grafts. The Mustarde flap was done on the right side. The free microvascular flap was impossible unless we would do two of these flaps, which would strip the skin and soft tissue from the front of both forearms completely and cause significant scarring to have skin flaps replace the donor area. Other alternatives were not enough

So we turned to the top of the heap, Joel Feldman – master surgeon in children’s facial burns who was also my mentor, teacher, and colleague – responded to my plea for help and came over from the burn center of Boston Children’s Hospital. I sent him photographs and he spent time to mark in detail the tissue to be excised and reconstructed. We elected to do the impossible: to prepare one of the largest Bakamjin skin flaps, a flap of both skin and subcutaneous tissue, with preservation of a single arterial blood supply. It was a regular Bakamjin flap x 3, triple the amount of tissue usually brought up to the face with a regular flap. Utilizing the technique of flap delay (gradually interrupting the blood supply to increase survival rate of flap), we kept the feeding arterial intact and began to demand that more and more tissue be supplied by the single artery with successive operations as the body responded to the greater need for oxygen. We moved both sides of the entire chest in one piece and gradually brought up to his face, supported by a single artery in a “tube” of skin and subcutaneous tissue – a great example of the Bakamjian thoracodorsal technique. Incredible!

The Los Angelino viewers taught me a lesson. I learned that the viewers in Los Angeles were not tortured by the gore seen on TV. They regarded Tomas as a hero and they awarded an Emmy to Henry Alfaro on ABC television. The nightly presentations clearly depicted the scar excision, all sorts of manipulation to put the lips back into position and move the lower eyelid around, removal of huge amounts of skin, the application of the grafts with the team suturing in several locations simultaneously, then applying the dressing bandages. And in clinic we removed the bandages in view of the public.

Tomas received extensive media exposure. After successive surgeries, Tomas was still disfigured.

Nevertheless, when he visited Disneyland, courtesy of one of the agencies that volunteered to help Tomas, many young kids, his peers, recognized him from TV and begged him for an autograph – this “ugly” kid whom they had seen on area-wide television was their hero! There is a moral to this story. His body image was rehabilitated by the media and by Henry Alfaro, the investigative reporter, who more or less adopted Tomas. The public’s encouragement and praise for Tomas’ courage nurtured a positive body image, which helped the recovery process for Tomas. The acceptance by his peers marked a beginning of a new life.

When I was taking care of Tomás, I was enthusiastic because it was “a good case.” I felt privileged to be able to take care of such difficult human pathology, especially in this situation where there was more than simply skill and compassion needed to make the child better. In the early years of our development of plastic surgery at Stanford, there had been a search for “good cases”, the sine qua non for teaching.  Later, we in the ivory tower of Stanford soon realized the obvious: that the results were so fantastic that an uncultivated field of teaching the great possibilities available with plastic surgery was within our present capacity.

We could do good in the world by spreading out or leveling the mountain-high pile of skill and knowledge here to those who had not: eg those in the desert- the real desert -only 614 miles south of us – an inequity that was within our own field.  We had the ability to treat others with advanced plastic and reconstructive surgery techniques.

The geographical distance between Mexico and the U.S. was a only a yard in the north and south measurement ( the width of the Tijuana-U.S. border fence), but the professional distance was 2500 miles.

So we began to see right at that time with Tomás the necessity to develop the project to help with the world-wide need for treatment of bad burns. Tomás taught me the power of one person. Tomas was the one person.[3]

[3] “Power of the person: “A Smith and Wesson beats four aces every time” – American proverb

Mary Nucleoside

Mary Nucleoside was a nineteen year old girl with a very mild case of Down syndrome (Trisomy 21 aka mongolism) whose parents were both PhD rocket scientists at the jet propulsion laboratory at the California Institute of Technology. These were not unintelligent parents. I can’t imagine more left brain development. But we consider the basic parental instincts which are endowed by a particular  culture, the package of behavior  acquired over several hundred years of people learning how to live together. Mary came with her parents . She sat in the corner chair in my exam room while her parents requested that we go to any extent – confront any barrier, spend any money,obtain any consultation – to make their own daughter (pointing to her) look “more normal, not ugly.”  Now this girl was a student at Cal State Long Beach and was doing pretty well in school. Her Down Syndrome was not severe, had not held her back severly. Mary had a little extra fatty tissue around the eyelids and under the jaw. As in the Down situation Mary’s tongue was larger than normal. I was able to like her – both in her looks and in her personality. In fact, I subsequently performed surgery on her to reduce the size of the tongue, change the eyelid slant a little bit, and rearrange the fatty tissue.

But that day in office, when her parents pointed at her, virtually “jabbing” their fingers in her direction and used the word “ugly” in front her. I saw that her lowered head bowed downward perceptibly more. I imagined her body image was receiving some stab wounds right then. In contrast, Tomas, who was physically wounded almost beyond recognition, was psychologically empowered when he was asked for an autograph by his peers at Disneyland. His body image was boosted by his new role as a television “star”.

Mary’s was not empowered by her parents. Although armed with high education, her parents were ignorant of how their actions would effect the body image of their daughter. The chink in their armor is that their “culture”, the culture of America, is only now developing. We have much to learn on our visits to the so called “developing” countries. We indeed have come upon an educational interchange: science to the developing world and culture (how to act interpersonally) to the U.S.

And we are thankful for this.

Steve Jobs

Steve Jobs was a child adopted (born out of wedlock ) by the working class couple from Mountain View. Jobs always knew he was adopted but still very sensitive to his past history. He shared a memory of when he was seven years old, telling the girl who lived across the street that he had been adopted. And she said, “So does that mean your real parents didn’t want you?”

He remembers, “Oh lightning bolts in my eyes, I remember running into the house. Crying, asking my parents. And they sat me down and they said, ‘No, you don’t understand. We specifically chose you out of many.’ From then on I realized that I was not just abandoned, I was chosen. I was special.” This is the key to understanding Steve Jobs and his success. The words bestowed upon Steve by his adopted parents  was an important factor  in elevating his body image and helped him to accomplish his unparalleled achievements.*

The body image of young Jobs was elevated by his parents and helped him realize his full potential growing up. His own understanding of “being special” instilled in him a rock-solid determination that he was right and made him defy detractors and skeptics when making important decisions. The mountain View parents possessed  c.u.l.t.u.r.e.

His inborn spirit was the real key, but these passive infusions from parents put the intrinsic body image on “turbo.”

Body Image, My Hero Muhammad Ali

Sense of Entitlement is that you deserve something that you did not work for. So you want something you didn’t earn.

Muhammad Ali, although not a patient of mine, was my hero who possessed a strong and huge body image. Even before he won the decisive match against George Foreman, making him the world champion, he claimed to be the very best. “I am the greatest!” were words that came out of his mouth so many times that his exuberant declarations offended some hard-line skeptics who felt that he was overstating the facts. Ali had nothing to prove that he was the best. People criticized him for having a false sense of entitlement. However, this was his own conviction, not a result of others’ flattering him into thinking he was the greatest. Actually, he was the greatest.

Ali knew that he was the greatest. Ali’s early self-confidence propelled him to achieve the impossible against Foreman, a mighty person who was an unquestionably stronger boxer. Ali realized he was up against a superior opponent at the end of the first round – his life and reputation was at stake. This was a perfect example of body image being right in question. In that instant he resorted to plan B, relying on tactics, such as psychological warfare (constantly talking while boxing to unnerve the opponent) and the practice of “rope-a-dope” (in which he had “secretly” trained), to tire his opponent. He allowed Foreman to punch his midsection repeatedly with full force. But Ali was actually bouncing off the rope, cushioning himself from constant blows. Foreman exhausted himself. Ali then went for the knock-out in the 8th round, winning the World Heavyweight Championship. A positive body image was critical to his success. He had a personal conviction to mold himself into greatness. It allowed him to reach his full potential and become a more productive, distinguished member of society. Moreover, he was a splendid role model, philosopher and a “king” in the world of boxing.

Among the factors that can influence a young person whose body image is in the process of developing, the most important is the opinion of the mother and father. After a few years, your teachers and the peers play that role also. As the personality of the young person develops, the quantity and the quality of the opinion and the praise given by those others may be very helpful, such as in the case of Steve Jobs.

We as plastic surgeons are very important “other” people and our opinion re appearance is considered as expert by many patients. The comment: “You look great” carries considerable weight with our patient. We must be careful to have a positive and optimistic outlook and not be afraid to complement the result, particularly when it is true.

In Part 2 of this  blog dealing with Body Image, issues helpful in plastic surgery practice are questioned. In order to ignite discussion, we select from the Plastic Surgery Body of Knowledge the following:

1)Is overpraising harmful in development of body image?

2)Why do we consider the non-verbalized  agenda to be the 50%factor?

3)Is the optimistic positive attitude, on the part of the surgeon helpful or is it false?,

4)Is the Gorney Equation  a nuance or is it core information?

5)Are unrealistic expectations of the patient as important as training of the surgeon?


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