Body Image is what we think other people think of us. For a professional athlete, this gauge is the number of dollars on the paycheck. This is more important to the athlete thinking of what other people think of himself than earn-run average, RBIs and number of home runs.
Body image is a picture of one’s own physical appearance and many other factors – salary, job, family, friends, reputation – established both by self-observation and by noting the reactions of others. Although vastly important to the well being of all people, especially those who have suffered injury to their physical appearance, the ongoing construction of this personal picture differs subtly in men and women. In these next four case stories I examine the seat of the male body image, the factors that affect it, and ways I have learned to build and improve it.
I write this story regarding a fact that you undoubtedly already know: in a working man, one of the most important body parts is the hand. After all, it is the instrument of work, the part of his body that sustains his livelihood and produces his successes in life. The hand is therefore the seat of his body image.
Injury to the hand strikes terror into the heart and mind of the most masculine of our species, fracturing their functionality and ability to “be a man”. This terror is not conscious, but built into a male’s DNA. You may already know about this, but allow me to reminisce with the stories of Ronnie Lott and George Smith.
“Injury to the hand strikes terror into the heart and mind of the most masculine of our species, fracturing their functionality and ability to ‘be a man'”
Ronnie Lott is a hero for many of us: left cornerback, free safety, then strong safety of the San Francisco Forty Niners professional football team. During the championship era of 1982-1990, when the Forty Niners won four Superbowl trophies, Lott was considered by many people (including myself) to be one of the toughest figures in sports and a role model for aspiring players. Lott earned his distinction as the best tackler in the National Football League in a manner similar to earning an academic degree: by mastering the theory and appreciating the absolute importance of actual fieldwork. Lott “paid” for the esteem of others by virtue of the work and training of perhaps twenty-five disciplined years practicing and playing football. Through his training he created an exalted body image, possessing courage, drive, and spirit that exceeded that of his peers.
In the 1985 season finale against the Dallas Cowboys, Ronnie Lott’s heroic efforts led his team to victory, a win marred by an open fracture he sustained to his long finger at the distal interphalangeal joint, just behind the fingernail. The injury was rather significant because it would necessitate a surgery to place the bone fragments together, requiring a wire and pin to hold the pieces in place (the usual huge plaster cast would not be enough for this case). Post-surgery he would not be able to move his fingers, let alone play football, for two and a half weeks at this crucial time in the season. Ronnie obtained the opinion of the oracle of orthopedics at Stanford and at Sequoia Hospital. If the wire and pin were placed, this would put him out of action for three or four games and interfere with his path to another world championship.
“Uh-oh,” thought Ronnie. “If it amounts to three weeks out of play versus surgical removal of the damaged bone and tissue, just go ahead and cut off the end of my finger right here,” pointing to the spot at the distal joint without a blink. It was done.
But this is not the point of the story. The axiom learned from this case was demonstrated at the first dressing change of the injured hand of this “very male” guy. When the bandages were removed he was standing rather than sitting, and the magnificent Adonis, Ronnie Lott, fainted to the floor from the standing position. Unfortunately for Ronnie, this was reported in the San Francisco Chronicle sports section for all to read. In truth, a more experienced surgeon could have predicted the fainting if he knew this axiom: even though the male is tough, the hand constitutes such a large percentage of the working male body image that the patient will faint at the first sight of his own fractured body image.
The axiom continues: It is wise to prepare the patient beforehand. Sit them down: “Take a seat, sir.” Or, “Can I make you comfortable on this table? I’ll have the nurse bring you a coffee or orange juice. Which do you prefer?” And “Keep your legs high, get the blood into your upper body, keep the calf muscles working” (to avoid orthostatic hypotension). Ronnie Lott’s feinting was visceral and subconscious – even though he was a tough guy, the moment he saw his injured finger the blood in his body sank to his feet, away from his brain, and sent him crashing to the floor.
By remembering the anatomy of the male body image and the importance of functional hands to the body image whole, surgeons may better heal both the external male physique and the internal mind-set.
The perks and benefits of our great society go awry. Or do they?
George Smith, thirty years a certified carpenter, “never hammered his thumb” and always worked to serve others. He never missed a day of work. He was straight-edged, walking the middle of a narrow path.
Much like a physician or surgeon he worked his science and skill for others using his hands. He had a nice family, wife, friends – he was a good guy.
That day, the nurse reported to me, “Dr. Laub, there is a man in room two who has cut off the end of his index finger. Blood pressure 142/80, pulse 92, had a dressing on the finger. I changed it. It is only the distal 1 cm that’s missing, no serious bleeding. Bone and tendon not involved. He’s a big guy, healthy as a horse and a fine person.”
When I went to speak to him face to face, he said, “Doctor, I was using the Skillsaw and was distracted. It is only the tip. I want to get back to work ASAP.”
We reviewed the options, even though George had more or less decided on option two.
Option One: Thenar eminence flap (skin flap from base of thumb to cover tip of finger). Attach to index finger for three weeks.
- Much better sensation, nice padding over the bone. Small amount of scarring
- Four to five weeks out of work, three weeks index finger attached to thumb.
Option Two: Full-thickness skin graft.
- Some sensation begins at six months. Donor site is inside elbow from the antecubital fossa. Virtually no scar.
- Two weeks out of work.
Option Three: Split-thickness skin graft.
- Slight sensitivity or pain to impacts. Minimal scar.
- One week out of work.
I explained the three options to George. After our discussion, the patient cast his lot with option two.
On the operating table under local anesthesia, I said, “George, you may be a very distant relative of mine. Mary Smith is my great-great-grandmother, also from Wisconsin, like you.”
“That’s not likely,” George said. “My origins are in Ohio.”
“But you have impeccable work habits, the same as those in my heritage.”
The skin graft was taken from the inside of the elbow joint, without a noticeable scar. George was requested to keep his finger elevated at all times to minimize the swelling. The tie-over, light pressure dressing insured that there would be no venous pressure elevation, and as a result no hematoma at all occurred. He was given 30mg Codeine for pain, a sling for hand and forearm, antibiotics (penicillin and strep that night; then penicillin and ampicillin capsules following). I said to call per res necesita (whenever needed) for questions. See me on Friday, I said, five days from now, and then next week at 12 days post surgery. The skin graft healed in those twelve days. They all look bad at that early stage of healing, but by the end of those 12 days the skin graft healed nicely.
On his first visit I signed unemployment papers to give him paid time off for recovery. His union had great perks, and George began to receive money. On the next visit he mentioned that he was very depressed from day two until day twelve because he felt “useless” without functioning hands.
“His union had great perks, and George began to receive money. On the next visit he mentioned that he was very depressed from day two until day twelve because he felt ‘useless’ without functioning hands.”
But the codeine took his pain away and his family went fishing with him in a little group on day fifteen. This was their only real vacation, laissez faire, in several years. They loved it, and George never had such a relaxing and wonderful time.
Some days later he returned and asked me: “Can you sign these unemployment things again, Doctor?” “I still have a little pain on the tip.”
“Sure. And here is the prescription for the pain meds.”
Day twenty-nine after the surgery rolled around and George came back, saying: “Our little family has just bought a new sailboat. It’s great! You ought to go out with us. And Doctor, I’ve had a problem, a nightmare dream that you had to amputate the whole finger.”
Day thirty-nine and George was back: “The dreams have now worsened – you had to amputate half the hand. Doctor, I don’t want to go back to work. How about another month of unemployment?”
I looked at him with concern. “I can’t go over fourteen weeks out of work for you, George.” I put down another ten days of paid time off only. “Come back here in twenty days with the news that you’ve gone back to work. There’s a limit on these things.”
Again he returned with the same outlook. “Doctor, the dream is now that you had to amputate the whole arm and a bit of the shoulder. It’s a terrible nightmare. But the sailing is great. We’re going to move to the Land ’o’ Lakes where there’s great sailing for days at a time.”
“Oh my God, George. A psychiatrist can help you in this case.”
“I don’t need help as far as the sailing goes and for the family outings. We’ll be okay in northern Wisconsin. Do they have psychiatrists there?”
“Okay, no more unemployment, no more pain medication, no disability.”
“I can sail with one hand. I’ll look up the Wisconsin Smiths to see if we’re related. My retirement funds will last me eight years.”
“Send a postcard often, George,” I said, shaking my head.
Our great society, and all of its awesome advancements, had ruined a good, hardworking, almost perfect citizen. He changed from my ideal of a person to a parasite on society, seeking disability benefits and spending them on leisure time sailing with his family, refusing to go back to work.
“Our great society, and all of its awesome advancements, had ruined a good, hardworking, almost perfect citizen.”
The interesting thing is that I always wanted to be a carpenter myself, using my hands and able sometimes to gift products to my clients. I saw the carpenter as having an ideal life, eight hours of work, eight hours of pleasure, and eight hours of sleep.
Perhaps George now chose family life over work-oriented existence. All work and no play makes Jack a dull boy and George an incomplete person. Did he “go by the book” too long? Did his DNA rebel? Did his superego repress normal outlets? Did he ever get drunk on fishing trips with the boys? Or did he camp out in the woods with the Boy Scouts and liked it so much that now he’s reverted to it? There is plenty of psychology and philosophy to discuss. But this complete reversal of the compass setting in this great person prompts one to think: What is really the right thing?
I happen to remember more of our discussions. George said, “But Don, think it over. Is working for money the most important thing. Is it the only thing?”
Society can’t support the majority who happen not to work. No community, large or small, can survive with less than 50% of its people supporting the other 50%. Or can they? With robots, great machines and high technology to replace people? Or will we be worse off when most of the people are replaced and then they don’t have jobs to support themselves and enjoy perks. Will we all have to move to China or India?
On and on goes the discussion!
In one of our last meetings, George said, “No, we were meant to be nice to others, not to try to attempt to exploit others for our own gain. Let’s calm down. Let’s all love each other. Utopia is a great place.”
Before the surgery George Smith’s body image was contained in his hands and ability to work. He was a committed carpenter and a contributor to society. Yet after he lost that function his eyes were opened to the joys of the non-working world, and once he tasted that sweet time off with his family he couldn’t get enough. His body image hadn’t disappeared but rather morphed from depending on function to depending on family. While it is true that if all of society followed this path it would be unsustainable, George’s story is nevertheless a happy one, and goes to show just how closely related a male’s body image is to his ability to take action, to do things. Once this functionality is taken away, the man can change completely.
Lower extremity bilateral amputation could be body image anguish.
George Labeau is a great hero. We operated on his body image. In fact, we removed a large part of his body surgically: his lower extremities!
George had been a joy from the social point of view. In cases like these, a dichotomy usually exists between how the patient views himself and how he actually looks because of the huge body image deficit that typically follows a severe or near-fatal injury. But as I had secretly hoped, his body image was not bothered at all. In fact, in his wisdom, the boss, my mentor, Dr. Robert A. Chase, probably knew that all along. George Labeau was improved as a “whole,” bettered by this ablated invasive surgery. His body image was not contained in his body. His body image was in his job.
“George Labeau was improved as a ‘whole,’ bettered by this ablated invasive surgery. His body image was not contained in his body. His body image was in his job.”
In life we are told that we humans divide into risk avoiders and risk seekers. I am the risk taker, even seeking out risk (but never gambling or anything of the like). I am thankful to the boss and Labeau himself for keeping me grounded. Even so, the odds were tilted heavily in favor of the operation being a success. George was a likeable, happy guy, inherited from the department of physiatry, which is the medical aspect of physical and occupational therapy.
As I recall my joyous time with George Labeau, I feel his was not a cohesive story. A guy who was strong and fit and socialized and happy became paraplegic in an auto accident. Over the course of a few years he then sustained many decubitus ulcers because he had lost the gift of pain. When he sat or lay down, his weight (190 lbs) pressed against his trochanteric prominences and ischial tuberosities, the pressure points of the pelvis, and he received no signal from his lower limbs to shift the weight.
“He had lost the gift of pain…”
These poking-out bones are small compared to the entire side of the thigh or buttock. They have evolved to be suitably prepared as our pressure points. The force of the 190 pounds sustained by perhaps six or eight square inches increases the pressure immensely.
These bony points have evolved to have pressure-resistant tissues covering them: thigh fascia, gristle, plus nice bursa pockets of fluid to easily allow pressure to be shared sideways, without the motion causing the tissues to tear and shear apart.
When sitting, pressure at the point of support shuts off circulation of blood vessels, resulting in tissue necrosis, or death. Evolution has provided nerves that go back to the brain through the spinal cord to notify central control of the pending necrosis via pain. Pain is a great gift, a protective sensation, so one must not talk negatively about pain. Even when we are asleep, pain directs us to move to a different body position to relieve pressure, so circulation pours back and pain is relieved. Thank God for the pain! The shearing force of lying or sitting in a slouched position is severe in a paraplegic. It starts as a superficial skin abrasion and the tissue is slowly torn apart, only adding to the damage from a lack of circulation.
Labeau did not have any protective pain below T12 – his pain pathway had been severed in the auto accident. He had both trochanteric and ischial tuberosity pressure sores, severe decubitus ulcers that get their name from the Latin term for “lying down.” These areas of tissue necrosis result in infection that attacks the defenseless dead tissue.
Infection starts with redness of the skin and surrounding area. Physiatry research had recently (in 1964) shown that an area of pressure-caused erythematous red reaction was much more defenseless by a factor of perhaps five. From this research we declared a new Axiom of Recovery: exert much caution at the first sign of redness at any pressure point. These are parts of the paths of physiology in physiatry that cross at a useful junction. When inflammation is the symptom, the tissue is not well prepared to manage repeated bouts of pressure.
An area of osteomyelitis is the most resistant to healing because the bacteria “hide out” from the body’s powerful military, its immunological protective mechanisms. This “antibacterial military” is made up of four branches. The army: the tissue chemicals. The navy: blood-borne T-lymphocytes, granulocytes, and monocytes. The air force: intravenous antibiotics. And the marines: the nurses who effect wound hygiene, the most powerful prevention against infection.
The battle between bacteria and host, as you recall, is always decided as this triangle shows.
Whether infection thrives or the healing triumphs depends on the interaction of these three variables. However, in many cases, the virulence of the bacteria increases as a result of giving antibiotics, which artificially select for the strongest bacteria, resulting in resistant infection. In turn, more necrosis occurs. The virulence of the bacteria increases as they produce resistant strains while the antibiotic is busy killing off most of the original strain. Also, the numbers of bacteria increase logarithmically with the amount of dead tissue present. Surgery is usually the last resort, the last defense, a sort of atom bomb in our body’s armamentarium. Necrotic skin, fat, bursa cavity, fascia, periosteum, and dead bone (including the sharp points of the bones that have been acting as spear heads) are removed in the surgery. They are all resected, hemostasis obtained with the Bovie machine, drains placed, and nice thick, fresh tissue is recruited for effective healing.
The skin flap diagram here shows the beautiful solution, a rotation flap. Fresh skin, fat, and occasionally muscle is rotated in and the donor site is closed.
On a number of occasions, Labeau’s happy body image was restored: cheery good mornings, smiles, and positive thoughts. The six operations were all successful, each involving a particular pressure area.
The biomedical engineering department and the physical therapy section at Children’s Hospital, the predecessor to the Lucile Packard Children’s Hospital at Stanford, responded with their armamentarium for pressure relief: the circle bed, the air bed, the water bed, the sheepskins, the special silicone pads used as “artificial bursae,” were all brought into play to ease the pressure, and it was a magnificent effort.
I responded with a research program designed to solve the problem of why the spinal cord does not heal as the rest of the body does. It seemed as if the cerebrospinal fluid that surrounds the brain and spinal cord might be preventing the usual healing and scarring. I designed an experiment where I made cats paraplegic and exposed the healing spinal cord not to the cerebrospinal fluid milieu but to tissue. The spinal cords were then sectioned by the histochemical expert pathologist to determine if any healing had begun. Due to my technique, I think, it was difficult to tell, but I had not given up on regeneration of the spinal cord, as it would be helpful, of course, “to the world.”
Labeau responded through the surgeries without the usual dichotomy—happy at his situation, and without any loss of body image. This seemed to be a huge paradox. All the therapies hit a wall, in fact a brick wall, and Labeau would not heal, although he was still a complete person to all intents and purposes.
In conferences Dr. Chase disclosed an operation he had performed at Yale and Pittsburgh called a filet amputation of the lower extremities which produced the world’s largest vascular flap, a huge thing including all parts of the lower extremities except the bones, to be used to cover the decubitus ulcers. We elected to perform this operation, and Dr. Dibbell and I carried it out.
We prepared the patient with antibiotics and complete cleansing of the colon. The patient was placed in the posterior dorsal position. The incision was made on the dorsal side, buttocks to ankle, and on the anterior side, ankle to toes, deep down to the periosteum. Because the tissue had been without muscle action for so long, it was easy to take a laparotomy sponge and place it around the bone, strip off the periosteum and all the overlying tissue, and simply take a gigli saw and remove the bone. The ostectomies were pretty complete and included a hemipelvectomy (this was a complex operation that scared me, so I had previously asked orthopedic surgeon Dr. Gordon Campbell to assist for that part of the surgery. He did it beautifully). The flap was placed with great joy. The bleeding was controlled, a drain was placed, irrigation was made with antibiotics and copious saline, and the patient was placed in a circle bed postoperatively. Warned by Dr. Gus Harthin, we had watched closely for the shower of bacteria that may occur when you work with infected bone, yet this did not occur.
It was at this point that the optimistic attitude of the nurses, surgeons, and especially the house staff was very important to the recovery. “The surgery was successful and there was no complication. Huge infected areas have been entirely removed,” was what I told the patient post-op.
The biomedical engineering department took an impression of the bottom of George Labeau after several weeks of good healing. We used a hoist, as in an auto repair shop, and lowered the patient into a huge half-barrel of dental molding material used to make impressions of teeth.
That process made an exact negative 3-D physical form of George’s new bottom. The medical engineering department, namely chief Maurice LeBlanc, registered physical therapist, formed a replica of plastic fiberglass and covered it with the softest of his technology for George’s new custom wheelchair. In a short while, with George in his new “sitter,” we both visited the chief telephone communication supervisor and asked him to employ George. George became the telephone guy: “Hello, Stanford Hospital. How may I help you? Yes, I’ll connect you immediately.”
I want to call attention now to the attitude of the patient. Our local phone number happens to be the same as a previous business, Redwood City Wheelchair, which does not exist anymore. But the callers, probably one a day for the last two years, are all the nicest people in the world, the very nicest people. I wonder if this gives us some insight into George Labeau’s personality – how those who have lost so much of their body remain so kind and upbeat.
This George Labeau episode recounts my highest point in the new specialty of rehabilitation surgery, a field resurrected by Lars Vistnes, chief of plastic surgery from 1980 to 1986.
The specialty was a gem waiting to be reborn. It paid for my early surgical education through a grant from RSA, Rehabilitation Services Administration, in Washington, DC. In that specialty, incidentally, we did surgery for tetraplegia, or quadriplegics who needed special tendon transfers in order to be able to pick up a glass; repaired decubitus ulcers of various types; guided paraplegics’ hand surgery to enable them to grasp with the elbow muscles; and took care of traumatic injuries caused by land mines in Afghanistan. My first academic papers were on the customized, perfectly fitting silicone implants to replace defects in the frontal bone. We also helped a significant number of patients blinded by high-velocity bullet wounds in Vietnam from the Western Center for the Blind in San Francisco, via the great Walter G. Spohn, a founder and pioneer in the field of anaplastology. Perhaps rehabilitation surgery overlaps with microsurgery and craniofacial anomaly surgery. At any rate, those words, rehabilitation surgery, set a thinking pattern for the many research programs that sprung out of clinical problems.
At the start of this piece we talked about the risk-taking. We did achieve success with George Labeau, or perhaps success happened in another way. Either way, the principle remains clear. Take the risk after evaluating the odds. Following the general axiom of decision-making, the big gain is okay if the collateral damage is only moderate. However, you are then responsible for fixing any damage and other problems along the way. And you can enjoy the fruits later.
George Labeau remains a hero to this day. The strength he showed throughout such ill-fated events and unimaginable pain during the long recovery period is a testament to where he held his own gilded body image – not in his physical form but in the strength of his character and his happy relationships with everyone around him.
Befriending the patient
The call came into the plastic surgery office, R-203 in the Boswell Building of Stanford Hospital, at 3:00 p.m. on a Tuesday from the Santa Clara Valley Medical Center burn unit.
“We have an almost-18-year-old boy in the burn unit who is impossible to manage. He’s disruptive, causes trouble, makes all sorts of problems. We tell him one thing that will help him, and he does another. We’re at the end of our ropes. We have to dismiss him today.”
Furthermore, they told me that he had a 90% burn from a paint thinner and varnish explosion in his shop, where he had been smoking while painting his boat.
“You like burns and do well in managing their treatment. Could you take him? We don’t think his place is in juvenile hall, and you are our second resort.”
“Does he need surgery?” I asked.
“Yes, in a few places, but overall it’s mostly second-degree burn and may heal if infection doesn’t get him. He’s a management problem for everybody here.”
He arrived at Stanford by ambulance. We saw him first in the emergency room and admitted him to room 129-W, a semi-private room. We (myself and residents Dick Thompson, Michael T., B. Dennis, and George Commons) saw him and evaluated the situation. As a patient, Albert Sanger wasn’t an angry guy; he was a teenager who he seemed to think well of himself, a builder of teakwood boats. He resented taking orders from anybody. He was a psychological Type IV masquerading as a Type III macho man. “No! I don’t want that!” he would say, not upset but just acting like a 2-year-old child. And he was always in trouble. His body image and self-esteem were okay, but he didn’t appreciate being crushed by the rules and treaded upon and disciplined as if he were a child.
Our plan was formulated easily and immediately. I went over the plan with the residents, speaking loudly so the patient could hear: “This patient is Albert Sanger. Treat him as an adult. He is our friend. Talk to the dietitian personally. Order him a very high protein diet. He needs protein for healing. And be sure to have the servers provide him with two beers for breakfast, lunch, and dinner. Whatever he asks, the answer is ‘yes.’”
Privately, I told them to tell him jokes and enter into direct, adult conversation with him at each rounds. Be light and airy in attitude; use a no-problems, running-for-office demeanor. They said, “But you can’t order beer at Stanford Hospital.”
“Then buy some yourself at Joe’s Liquor down the street and give it to the dietitian.”
I also instructed that they change his dressings in the Hubbard tank in physical therapy after obtaining a physiatry consultation.
“Treat the guy not only as an adult, but as an accomplished tradesman, cabinet-maker, boat builder. In fact, call him ‘The Boat Builder.’”
“Treat the guy not only as an adult, but as an accomplished tradesman, cabinet-maker, boat builder. In fact, call him ‘The Boat Builder.’”
Albert fell in love with the dietitian, nicknamed “The beer lady.” He was a nice guy. Dressing changes, Hubbard tank, pain and suffering all went well. He had skin grafts and some small flaps. He was applauded for being tough and pain-resistant. Interest was shown in his work, questions asked about his boat shop. He didn’t talk very much, and there was no smile. Yet he no longer had a smirk or an act-smart attitude. He was just Albert Sanger.
A social Milwaukee beer trick happened to work on this unmanageable kid. Previously he had been told, “You’re not an adult. You can’t drink beer.” So therefore, we thought, drinking beer might make him feel like an adult and perhaps behave like one (technically he wasn’t a card-carrying adult because his burn happened not long before his eighteenth birthday). His injury was not caused by alcohol, and we avoided going to war against the patient in order to win the management game. But we didn’t allow him to be the boss. Even though we always answered “yes,” we would ease into “no” a little bit later if it was appropriate. He had to be nice and not sociopathic to get the beer. A trick of the trade.
We all learned, and it became fun. The litmus test again was: If you can believe that the patient could be your friend, your relationship will go a lot more smoothly, which is the best for both sides.
Albert’s body image went from oppressed juvenile delinquent kid acting out to a serious adult wanting to marry the dietitian. Seriously! He was living the life of a person he had seen many times in motion pictures. He was a movie star. It was the beer that was the key factor that signaled to him that at age almost-18 we thought he was an adult; and the beer was his great sign to the adult world that “I am one of you now.”
He was discharged after a lot of physical medicine and rehabilitation. He hosted a boat ride in San Pablo Bay for the entertainment of visiting surgeons from Honduras and El Salvador, Jorge Martin Saybe and Hector Gomez, whose countries were at odds (in reality, at war) at the time. On the boat ride we drank some Tecate and had a good time, pretending the Honduran was throwing the Salvadorian into the drink. They both appreciated the day on the Bay, courtesy of Albert Sanger, the good guy.
Albert did require a few touch-up operations from time to time, and after many years one of the burn scars that would not heal with skin grafts required an actual free flap. I wish I knew the outcome finally. I think of him often, and what always comes to mind is his complete body image turn around, from unmanageable teenage patient to likeable adult friend, affected simply by changing the way the doctors and nurses approached and treated him. An important lesson we can learn from Albert is that one’s perception of oneself, one’s personal body image, is intimately and inextricably tied to how others view them. Thus a key part of any recovery regime should include the conscious, purposeful, and positive attitude that the care providers take toward their friend the patient
 185 lbs divided by 7 sq” = 22.5 lbs per inch squared, rather than 185 lbs over a 7 x 12”, or pressure of 84 lbs per square inch.
 See Anaplastology Program at Stanford in separate blog.