Cardiovascular Disease

Schnall et al. (1994) conducted an extensive review of the literature in relation to heart disease. They considered 36 studies published between 1981 and 1993 and concluded that most found a significant relationship between job strain and cardiovascular or all-cause mortality, or between job strain and risk factors for cardiovascular disease (CVD).

Epidemiological studies examining morbidity and mortality have used two main methods of classifying employees according to the job strain dimensions. A number of studies have tried to achieve a relatively objective measurement of the work stressors associated with particular jobs by using a methodology that classifies individuals on the job strain dimensions according to their job title (based on average ratings of job incumbents). Thus, for example, waiters might all be classified as having low-control, high-demand jobs. Using this occupation-level analysis, Alfredsson et al. (1982) found that hectic work combined with low control was associated with higher incidence of heart disease. Other studies have assessed job stressors using the more subjective method of asking individuals to rate their levels of demand and control. For example, Johnson et al. (1989) found the greatest risk was in high-demand, low-control isolated jobs.

Increasingly, studies have also focused on the relationship between job strain and the risk factors that are implicated in CVD such as high blood pressure (Brisson et al., 1999; Fletcher & Jones, 1993; Fox et al., 1993) or measures of adrenalin and cortisol (Fox et al., 1993; Pollard et al., 1996). For example, Fox et al. in their study of nurses found that the combination of high demands and low control predicted both blood pressure and cortisol levels. However, Fletcher & Jones (1993), in a sample from heterogeneous occupations, found no relationships between control and blood pressure, and where demands showed relationships, these were in the opposite direction to that predicted (i.e. those with lower demands had higher blood pressure). Such mixed findings seem typical of this area. For example, Schnall et al. (1994) in their review, found that in eight studies of casual blood pressure (measured in a clinic) only one found a significant association, but five out of nine found associations for ambulatory blood pressure (which is a more reliable measure). In an attempt to shed light on the possible mechanisms whereby job strain may impact on health, there are a small number of experimental studies that have manipulated levels of job strain in the laboratory. These have examined the relationship of experimental tasks to short-term physiological indicators that are implicated in CVD development. These include heart rate levels and cortisol (Perrewe & Ganster, 1989; Steptoe et al., 1993). For example, Steptoe et al. found that middle-aged men showed greater changes in blood pressure when they could not control the pace at which they performed laboratory tasks involving problem solving and mirror drawing. However, pacing had little effect on cortisol, suggesting work pace has a specific effect on cardiovascular functioning.

A review by Van der Doef & Maes (1998) of the impact of job strain on health concluded that, across different populations, measurement methods and job designs, there is substantial support for the hypothesis that high-demand, low-control jobs lead to increased CVD. However, the focus of this review is on the combined effects of demands and control rather than their independent impacts. The earlier review of Schnall et al. agreed with the conclusion of Van der Doef & Maes, but where possible they also considered the separate effects. They concluded that while 17 out of 25 studies found significant associations between job decision latitude and outcome, only 8 out of 23 studies showed significant relationships between demand and outcome. A few studies have also found an effect for demands opposite to that predicted (Alterman et al., 1994; Hlatky et al., 1995; Steenland et al., 1997).

Overall, therefore, deriving a clear message from this literature is difficult. However, where demand and control are separated, the evidence seems to point to the importance of job control more strongly than demands. While evidence here is mounting, further work is needed (including more laboratory studies) to find out what specific aspects of control may be important. For example, is it control over pace of work that is important (i.e. control that enables the employee to modify demand) or does more general involvement in decisions about work have an impact? Furthermore, research evidence needs to clarify the nature of the relationship and the effects (if any) of individual differences.

Psychological Well-Being

Many researchers have studied the effect of job control on psychological well-being, not only because psychological distress is important in its own right, but because it is assumed to be the vehicle wherebywork stressors ultimately may lead to illness (both mental and physical). As a result there is a plethora of research indicating that low job control is associated with poor psychological well-being. This is typically measured in terms of scores on the General Health Questionnaire (Goldberg, 1978) or on more specific measures of anxiety, depression or job satisfaction. Although there are many exceptions, studies also generally support the relationship between a combination of lowcontrol and high demand with poor psychological well-being, with additive effects found more frequently than moderated effects (Van der Doef&Maes, 1999). However, the majority of studies are subject to serious methodological limitations. Typically, studies are cross-sectional and based on self-reports of both control and psychological well-being. Such methods have a number of well-established difficulties, not least the fact that they are open to the alternative explanation that being anxious or depressed may cause people to describe their jobs more negatively.

The fact that people who report lowlevels of demand and control also report high levels of distress at work is likely to be important for employers. However, the assumption that these associations are causal and further that they represent the first step towards damaged physical health and serious psychiatric illness is, as yet, not well tested. In particular, while many studies use validated self-report measures of psychiatric symptoms, there is surprisingly little research looking at the associations between job control and independently verified psychiatric illness.However, a fewstudies have looked at psychiatric illness using diagnostic interview schedules. These are often designed to be administered by non-clinicians and are used to classify individuals according to well-established psychiatric criteria (e.g. DSM-III). They are typically thorough and are likely to be both more objective and more valid than assessments based on brief self-report measures. A number of such studies have found associations between low control and psychiatric symptoms. For example, Muntaner et al. (1991) and Mausner-Dorsch & Eaton (2000) found that occupations associated with lower levels of control had higher levels of depression. Furthermore, Cropley et al. (1999), in a study of teachers, found that job strain was associated with neurotic disorder.

A sizeable literature also investigates the impact of autonomy on self-reported psychological well-being using the JCM (research which also typically suffers from the limitations discussed above). The most popular outcome considered, in this context, is job satisfaction. A meta-analysis of 28 studies of the relationship between job characteristics and job satisfaction found support for this relationship and found that of all the core job characteristics, autonomy had the strongest relationship with satisfaction (Loher et al., 1985). Other outcomes considered have included anxiety, depression and general mental health. An early meta-analysis by Spector (1986) looked at perceived control (most commonly based on the measures taken from the JDS) in relation to 19 outcome variables, including some healthrelated outcomes. This supported the relationship between autonomy and emotional distress (as well as absenteeism and physical symptoms). More recently Saavedra and Kwun (2000) have used the model to predict other affective states, including positive affect, and found that autonomy is particularly associated with enthusiasm, the implication being that not only will increasing autonomy relieve job dissatisfaction but it may also serve to “energise, reinforce and maintain work behaviour” .

Health Behaviour

While the effect of job control on psychological well-being is considered to be one possible mechanism whereby job control may impact on health, an alternative mechanism is that job control may influence health by its effect on health behaviour. Thus, it would be hypothesised that having a low-control, high-demand job may lead to people perhaps smoking and drinking alcohol more, eating less healthily and exercising less. This hypothesis was confirmed by Weidner et al. (1997), who found that general health damaging behaviour (smoking, drinking alcohol, drinking coffee and failing to exercise) increased under conditions of low control, if demand was high. However, it seems that there may be different patterns of relationships depending on the health behaviour under consideration.

Smoking has been subject to the greatest amount of research but findings are nonetheless mixed. A number of studies have found that, after controlling for socioeconomic variables, men in high-strain jobs tend to smoke more (Green & Johnson, 1990; Hellerstedt & Jeffrey, 1997), yet others have failed to find this association (Alterman et al., 1994; Reed et al., 1989). Johannson et al. (1991) found that only demands and not control were associated with increased smoking. Hellerstedt&Jeffrey also found this to be the case in the women in their sample. In contrast, Alterman et al. only found that low levels of decision latitude had an impact on smoking. Similarly mixed findings exist in relation to alcohol use (Landsbergis et al., 1998).

A few studies have also looked at the effects of demands and control on exercise and diet. Johannson et al. (1991) found both demands and control were predictive of exercise, whereas Hellerstedt&Jeffrey (1997) found that decision latitude but not demandwas related to exercise. However, job demands were related to increased fat intake in men and higher body mass index in women.

One prospective study by Landsbergis et al. (1998) looked at change in job characteristics and change in health behaviour in a sample of male employees in a variety of jobs. They found that an increase in decision latitude was associated with a decrease in smoking in men over a period of three years. However, change in job characteristics was not associated with any change in weight or alcohol consumption.

Overall, as can be seen, the pattern of results remains somewhat inconsistent. It is certainly not clear that high levels of demand and control are linked to uniformly worse health behaviours, and any impact of these variables on health behaviours may be modest (Landsbergis et al., 1998). Nevertheless, Landsbergis et al. suggest that increasing job decision latitude may help reduce smoking. More research is needed into the exact mechanisms whereby job strain impacts on health behaviour. However, one longitudinal study suggests that the mechanisms may not be straightforward (Payne et al., in press). This study found that people high in job strain tended to exercise less than those in low-strain jobs (though they did not intend to do any less) and that high job demands and low control were related to low self-efficacy for exercise (a predictor of actual exercise). However, once people had formed an intention to exercise, demands rather than control disrupted these intentions.

Impacts of Job Control on Home Life and Well-Being of Other Family Members

A considerable body of research suggests that the effects of work (including the types of activities people engage in at work and their resulting affective states) spill over into the home environment. For example, Rousseau (1978) asked individuals to rate aspects of work and non-work using the JDS and found positive relationships between home and work ratings. She also found relationships betweenwork and non-work satisfaction. Karasek et al. (1987) also found that lowjob controlwas related to lower levels of social participation. This was particularly the case for women, for whom low levels of job control were associated with lower levels of participation in political and sporting activities. However, it is by no means clear that these spillover effects are caused by job characteristics rather than by other influences such as personal preferences for both low control and low activity. Furthermore, a more limited body of research supports an opposing hypothesis that employees may compensate for work stressors in their home environment and leisure pursuits (for a review see Kinman&Jones, 2001). Thiswould suggest, for example, that someone with lowcontrol at work might be expected to exert greater control in the home environment.

In addition to the spillover and compensation processes affecting the employees themselves in their home environment, it has further been suggested that work stressors may affect marital partners, a process known as crossover. For example, a number of studies have found one person’s work stressors to be associated with anxiety and depression in their spouse (e.g. Jones & Fletcher, 1993; Westman, 2001). This literature has seldom explicitly addressed the effects of job control. However, a longitudinal study by Stets (1995) specifically examines the effects of work autonomy in husbands and wives and finds that lack of autonomy not only leads to depression in the job holder, but can also lead people to compensate for the lack of control by controlling their spouse. This in turn is related to increased levels of depression in the spouse, suggesting a mechanism whereby job control at work may be implicated in the crossover of strain to partners.

Summary of Effects of Job Control

Overall, there is now mounting evidence for the importance of job control as a variable implicated in both increased coronary heart disease and reduced psychological well-being and it may even also impact on the well-being of marital partners. Nevertheless, there are many inconsistent studies that have failed to find effects and the mechanisms remain unclear. More particularly, however, there are conflicting findings in relation to the nature of the relationship. These are discussed in the following section.

Cosmetic Interventions for the Very Young, Teens, and the Very Old

CHILDREN

Cosmetic interventions as defined in this book—alterations of normal features—are rarely if ever appropriate for young children. However, children do undergo a variety of procedures to correct deformities related to imperfect development, injuries, or other causes. In many cases these deformities are corrected for the purpose of improving the child’s appearance and social integration rather than for any functional need. In this chapter I will not discuss surgery for cleft lip and related defects, microtia (severe underdevelopment of the ear), large moles, or treatment of large blood vessel abnormalities like hemangiomas because these deformities often have functional impact and do not properly belong in a book about purely cosmetic procedures.

Body image develops in childhood and evolves throughout adolescence. For the most part a child’s body image will adjust fairly easily to physical changes, although certain longer- lasting physical conditions may have more profound effects (for example, obese children may grow up to be adults who, despite normal body weight, see themselves as fat). For this reason surgeons try to complete reconstructions of congenital deformities during early childhood whenever possible.

Procedures for children that may have improvement of appearance as the primary goal include ear surgery (otoplasty) for prominent ears, excision or laser treatment of small blood vessel tumors (telangiectasias, spider angiomas, small hemangiomas), ear tags (branchial cleft remnants), treatment of port wine stains, and correction of problems related to ear piercing.

Fortunately, it is sometimes possible to obtain insurance coverage for these kinds of surgery in children, even when the same policy would not cover treatment of an adult with the same condition. In some cases, surgery can be performed with local anesthesia, although younger children and some older children do better with sedation or general anesthesia, especially for more extensive procedures such as bilateral otoplasties and laser treatment of large port wine stains.

Children should undergo procedures requiring anything more than local anesthesia only in a hospital or accredited ambulatory surgery facility that is properly staffed and equipped to take care of children. Fortunately, children usually do well after surgery. The two main categories of risks for children are those associated with general anesthesia, especially for the very young infant or any child with a respiratory illness, and those related to healing problems in a child too young to cooperate with postoperative wound care, thereby leading to poor scarring or the need for further surgery.

TEENS

Statistics

Of the roughly 333,000 cosmetic procedures performed on patients under the age of eighteen in 2005, the vast majority were performed on teens. Most of these were of the minimally invasive variety, often to treat acne-related conditions or for hair removal. Of the less than 80,000 reported invasive surgeries on minors, nearly two-thirds were rhinoplasties.

Psychological Considerations

Adolescents tend to fixate on visible body parts that fall anywhere outside the “average.” Typically, noses for boys and breasts and noses for girls receive the most self-scrutiny. Many teenagers, like adults, find the idea of a cosmetic intervention appealing and have a body feature that they feel could benefit from a little tweaking (even though most do not pursue surgery).

As a society we must be concerned about the effects of mediaperpetuated cultural “norms” on children. For those teens who do undergo cosmetic interventions, however, the psychological risks seem to be lower than they are for adults. Teenagers actually incorporate physical changes into their body image more readily than do adults.

One potentially psychologically risky practice that many cosmetic surgeons discourage is the “family combo.” Most commonly this scenario involves a mother and daughter undergoing the same operation (often rhinoplasty or breast augmentation) by the same surgeon on the same day. In the daughter’s case the procedure may be a birthday or graduation present. The emotional traps are numerous for the patients and the surgeon, especially if one patient gets a better result or has problems. Just as important, the mother who might otherwise be the designated caregiver becomes herself a patient, in competition with her daughter for attention during the recovery period.

Eating Disorders

Many parents are concerned about body image disturbances leading to unhealthy behaviors, including eating disorders, in their adolescent girls. Our culture is permeated with images of young girls that, for many parents, are too sexualized, too thin, or both. Cultural historian Joan Jacobs Brumberg (in Fasting Girls: A History of Anorexia Nervosa) and others have written at length about how our society has so successfully harnessed female sexuality to the interests of capitalist marketing.

An eating disorder is generally defined as a pattern of dangerous weight-control behavior usually associated with body image disturbance. The most well-known eating disorders are anorexia nervosa and bulimia nervosa. Although these potentially lethal medical problems can develop in members of almost any demographic group, they are disproportionately seen in young women and girls and may affect up to 20 percent of female college students. Eating disorders require aggressive psychiatric evaluation and treatment, and as a general rule cosmetic interventions are not appropriate for these patients. Having said that, there is some evidence that, in carefully selected patients, certain procedures such as breast reduction surgery may be helpful in the treatment of girls and women whose eating disorders stem from a specific body issue like overly large breasts.

Marketing to Teens

Since the dawn of the modern advertising age, the beauty industry has found teenagers, a population group already obsessed with appearances, to be an eager audience for its sales pitches. Teenagers report getting almost all of their information about cosmetic medical care from television and teen magazines. Undoubtedly, future surveys will add the Internet to this short list of information sources that exercise substantial influence over teens. There has been considerable controversy in recent years over the effects of advertising on teens, especially girls, and whether it predisposes them to eating and other body image disorders, self-esteem problems, and diffi culty handling pressures to be sexually active, among other concerns. The barrage of images of thin bodies, all irregularities airbrushed away, jar against the reality of increasing childhood and adolescent obesity in America. On top of the predatory media attention, teens watch as the adults around them seek cosmetic changes. A survey of readers of a magazine aimed at preadolescent girls asked for reader input on the topic of makeovers and managed to capture the confusion that many kids feel. One twelve-year-old wrote, “Aren’t adults always saying that ‘All that counts is on the inside’?”

Periodically, there is a mea culpa maneuver by the beauty industry to expand its imagery; for example, a decade or so ago magazines started to use more ethnic models. In mid-2005, magazines such as Seventeen, Teen People, CosmoGirl! and Teen Vogue claimed that they would be including more typically shaped girls in their pages.2 It remains to be seen how extensive this trend will be or how long it will last.

Specific Cosmetic Procedures for Children and Teens

Breast Surgery

For both girls and boys breast development during adolescence can be the source of considerable trauma. Girls are self-conscious about their budding breasts at any age, but a girl whose breasts do not develop in a way that she thinks is desirable may develop a variety of undesirable responses, including social withdrawal, posture problems, and even eating disorders. Certain breast confi gurations are the result of congenital deformities, such as Poland syndrome in which one breast, and sometimes the pectoral muscle and upper extremity on the same side, does not develop normally. Other potentially stressful breast configurations include lesser asymmetries, macromastia (a typical example of which is a twelve- or thirteenyear- old wearing a DD bra cup), hypomastia (minimal breast development), and in boys any degree of breast enlargement. These conditions are almost always within the range of what is considered normal, yet they can create great embarrassment for a teenager. Whereas timing is an important consideration for every teen who wants breast surgery, few cosmetic surgeons would debate the appropriateness of surgery for the problems just mentioned. In some cases the procedures may even be covered by health insurance. However, before agreeing to purely aesthetic requests—that is, for surgery on breasts that are developmentally within the normal or typical range and therefore should not be causing undo psychological distress—most surgeons feel that the patient should possess an additional level of maturity. The ASPS does not recommend purely aesthetic breast augmentation for girls under the age of eighteen. Hormone-induced pubertal gynecomastia in boys often subsides as the young men mature, but in some cases the breast tissue remains enlarged and will turn an outgoing, sports-minded boy into a hunch-shouldered adolescent who won’t take his shirt off in public. Breast surgery for gynecomastia in boys is sometimes, but not predictably, covered by insurance plans.

Several general rules apply to adolescents who wish to have breast surgery: (1) Pubertal growth should be complete and stable for at least one and preferably two years before surgery is performed. (2) Persis tent breast enlargement in boys and massive breast enlargement in girls warrant a hormone evaluation, usually by an endocrinologist, although most of the time the results of these evaluations will be normal. (3) Massive enlargement or severe psychological distress may warrant earlier surgical intervention, but patients and their families need to understand that early surgery includes the increased risk that a second operation may be required for the same problem in the future.

Ear Surgery

Surgery for prominent ears (otoplasty, ear pinning) can be performed with local or general anesthesia. After surgery the patient will have a head dressing for a few days and will likely have to wear ear protection twenty-four hours a day for several weeks and at night for months. Bruising and swelling are common, and final ear shape takes months to appear. Normally patients can resume full activities within a few weeks as long as the ears can be protected against injury. Boys are discouraged from future wrestling because even with headgear, ear injuries are very common in that sport. Scars are usually well hidden although occasionally will be problematic. Major complications are uncommon; irregularities, asymmetries, recurrent prominence, and need for additional surgery are quite common. Liposuction

Liposuction should not be offered to teens as an alternative to good eating and exercise habits, nor should it be used as a treatment for the residual and generally temporary fat distribution patterns of childhood.

Rhinoplasty

The shape of one’s nose changes dramatically during adolescence and can be the cause of considerable dismay for some. Rhinoplasty for adolescents is fairly common, and the results are usually quite successfully incorporated into both male and female teenagers’ evolving body images. This is a particularly important point for boys, who as teenagers tend to adjust much better to rhinoplasty than do their adult counterparts. All teenagers should defer nose reshaping surgery until facial bone growth is complete. This usually means delaying surgery until at least age fourteen or fifteen for girls and sixteen for boys. Decision Making for the Parents of Teens Making the decision to allow your teen to undergo a cosmetic intervention can be difficult, and in most cases it should be. Wanting to do it because “everybody else has done it” is not the decision of a mature individual and is not sufficient grounds to proceed. The ASPS has no formal policy on plastic surgery for teenagers but stresses that a patient should be physically and emotionally mature before undergoing a cosmetic procedure. The society reports that the most rewarding outcomes are likely to occur under the following circumstances:

• The teenager initiates the request.

• The teenager has realistic goals.

• The teenager has sufficient emotional maturity. In partic ular the teen must be able to handle temporary pain and disfigurement. Surgery is not recommended for teens prone to mood swings or erratic behavior, drug or alcohol use, depression, or other mental illness.

ELDERLY—OVER SEVENTY-FIVE

Elderly people—those over seventy- five years of age, say—do undergo cosmetic procedures, although as the available statistics do not stratify groups over age sixty- five, the numbers may not be large. Unfortunately, even the elderly cannot escape the buzzwords and images designed to convince them to buy cosmetic products and services. (My personal favorite absurdity: skin creams with calcium in them.) Several points regarding cosmetic procedures on elderly patients are worth mentioning:

• Elderly patients, properly selected, can undergo conservative cosmetic procedures safely, but one must always take into consideration their reduced physiologic reserve compared with younger patients.

• Older skin has less elasticity and less fat. Dramatic changes should not be expected, and overcorrection can lead to a very unappealing result.

• Bruising can be quite pronounced and prolonged.

• Long operations should be avoided to minimize risks of hypothermia, blood clots, excessive anesthesia, and joint stiffness leading to pain and immobility after surgery.

• A healthy person age seventy-five may have no higher risk than a person age sixty with multiple medical conditions.

• Cardiovascular disease is common in the older population and significantly adds to the risk of surgery for any patient.

 • Drugs, including painkillers, anesthetics, and sedatives, must be used carefully and in lower doses in older patients.

• Nutrition should be emphasized before and after surgery and supplemented if necessary.

• Procedures should be performed in a fully equipped, accredited ambulatory facility or a hospital rather than in an offi ce setting so that sufficient resources are available in case of emergency

. Any high-risk patient should have surgery only in a hospital.

• Extra attention should be paid to ensure that an elderly patient will have adequate care and means of transportation for as long as necessary after discharge from the medical facility.