All around the world, in all periods of history, aesthetic practices have been a constant for humanity.
This generally tends to be more of a women’s phenomenon, but men can also be affected, depending on the period and culture.
Aesthetic practices refer to cosmetic treatments, aesthetic dermatological procedures and surgical procedures aiming to correct or conceal an aesthetic defect or an unsightly area of the body.
These procedures build self-confidence and increase social acceptance.
Such practices can be found in all societies, regardless of social status. Improving one’s appearance enhances feelings of well-being and self-esteem.
Over the past few years, the development of validated scales has enabled these benefits to be quantified thanks to evidence-based studies.
It has thus been demonstrated that a good appearance, beauty and health are all related, with some variations observed based on cultural and societal criteria.
Key words: aesthetic practices, cosmetic care, aesthetic medicine, aesthetic dermatology, plastic surgery, hyaluronic acid, botulinum toxin, peeling, mammoplasty, rhinoplasty, laser, abdominoplasty, lifting, liposuction, dermatoses, melasma, vitiligo, cancer, measurement scales, aesthetic well-being, quality of life, self-esteem.
Aesthetics and well-being are associated with good health
The importance of skincare is not new: women and men have always attached particular importance to their beauty to magnify or even transform their appearance.
This phenomenon has been observed throughout the history of civilisations.
In ancient Egypt, the ideal female had fair, smooth, soft skin, without any blemishes or body hair.
Later on, in ancient Greece, skincare began to emerge, for women but especially for men who took baths of cold and then hot water which were followed by massages, scrubs and the application of aromatic fragrances to the entire body.
This ritual inspired the first thermal baths that intensely developed in roman times; these public relaxation centres combined philosophical discussions, pleasure, health and bodily hygiene.
Skin health and well-being were already connected at this time. In the first century AD, Criton, a Greek physician considered the father of cosmetic medicine, was one of the first people to include the notion of aesthetics in medical education.
A century later, Galien would continue this work, focusing on the quality of formulas and the pleasure associated with topical skincare formulations used for therapeutic purposes .
These aspects, clarified by modern work, led the World Health Organization (WHO) to define good health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” .
This definition confirms the notion of well- being in the area of human health, making it easier to understand the role of cosmetic products in well-being in addition to that of aesthetic procedures and plastic surgery.
DERMATOSES: BENIGN BUT CHRONIC.
THEIR IMPACT ON WELL-BEING AND QUALITY OF LIFE
Skin diseases are seldom life-threatening. however, they are visible, to the self and to others.
This visibility and the frequent chronic nature of these diseases can impair quality of life, making treatment necessary.
Hyper- and hypo-pigmentation, which involve skin colour, are two common examples, since they are negatively experienced by most patients.
This common skin pigmentation disorder is characterised by white patches that can cover the whole body.
It occurs in around 1% of population, affecting both women and men.
It frequently impacts the quality of life of patients, with loss of self-confidence, social isolation and a sense of shame when it comes to exposing their skin.
> « VitiQoL »
VitiQoL is a specific scale for vitiligo, validated by Lilly et al. in 2013 to specifically assess the impact of this dermatosis on quality of life .
A study involving 198 patients with vitiligo measured the significant decline in quality of life based on disease severity: the greater the degree of skin involvement, the greater the decline in self-esteem .
VitiQoL evaluates stigma, social embarrassment and the disease’s effects on behaviour.
Women, young adults and those with a disease duration of more than 5-10 years had significantly poorer quality of life (p = 0.02). It was thus demonstrated that this decline in self-esteem was an aggravating factor with regard to the disease’s outlook and was associated with higher risk of recurrence.
These specific standardised scales have helped clarify the connection between psychology, social relations and skin diseases.
> The Dermatology Life Quality Index (DLQI)
The oldest such scale, which is also the most widely used because it applies to all dermatoses, is the Dermatology Life Quality Index (DLQI), developed and validated by Finlay in 1994 .
This DLQI consists of 10 questions that can easily be used by clinical practitioners.
It can demonstrate not only the negative impact of a dermatosis but also improvement when appropriate cosmetic measures make skin lesions less visible.
The General Health Questionnaire 28 scale, GHQ-28 scale.
In one study(6) the authors evaluated not only quality of life with the DLQI but also psychological distress with the validated GHQ-28 scale, in 300 patients controls.
This General Health Questionnaire contains 28 items evaluating severe depression, anxiety, social dysfunction and somatic symptoms.
Psychiatric disorders were more likely to affect young, unmarried women with a disease duration of more than five years.
The overall mean DLQI score was 6.71, indicating a moderate impact on average, but for 65 patients (21.7%), there was severe impairment.
Quality-of-life impairment was higher in young single subjects with a disease duration of more than five years.
These two scales confirmed the not only emotional and social but also psychiatric impact of the disease.
Suitable make-up techniques can be used to cover vitiligo lesions, giving immediate satisfaction, as has been demonstrated in multiple studies.
In 2012, Levy et al. compiled these studies dealing with a total of 544 patients , demonstrating the essential role of these camouflage techniques in the treatment of vitiligo, regardless of the country and skin colour .
AS WELL AS MELASMA
Melasma is another common dermatosis. It is characterised by hyperpigmented patches generally occurring on photoexposed areas of skin: the face, neck, lower neckline and sometimes the arms.
This uneven pigmentation causes distress, with perceptions of dirty skin.
It constantly affects well-being and self-esteem.
In India, melasma is the leading cause of facial melanoses .
A study focusing on 104 patients demonstrated the correlation between melasma severity and the impact on self-esteem: mild to moderate disease (0-8) was associated with a low DLQI score (9.34).
Conversely, severe melasma (> 16-24) was associated with a high DLQI score (15.33).
> The Modified Melasma Area and Severity Index (M-MASI)
Using a clinical severity scale for melasma, the Modified Melasma Area and Severity Index (M-MASI), the authors concluded that females (score of 10.19) were more affected than males (score of 9.27) and that young people (score of 10.52) were more impacted than older people (score of 7.44).
But here, the DLQI was highest when the disease was recent (score of 11).
The patients who had been affected for more than five years seemed to have developed a form of tolerance for their discomfort (score of 7.71).
A simple way to prevent and reduce melasma is the daily use of a broad- band filtration sunscreen, i.e. a broad- spectrum sunscreen that effectively blocks UVA rays, thus limiting UV- induced pigmentation.
In a recent study undertaken in India , 100 patients exclusively applied, three times a day, a broad- spectrum sun cream (sPF 19, PA +++) to the affected areas (Garnier White complete r) for 12 weeks.
Their decreased from 12.38 to 9.15 on average and their quality-of-life score (Hi-MELASQOL, a specific validated scale in India) dropped from 47.2 to 38.1.
These findings confirmed the link between melasma and quality of life and demonstrated a positive impact on quality of life with appropriate cosmetic photo-protection as the sole agent for improvement.
> BeautyQoL (quality-of-life scale for cosmetic)
Using another specific quality-of-life scale for cosmetics called BeautyQoL, a study investigated 88 women with phototypes III and IV and with facial aesthetic imperfections (acne scars, chickenpox scars, melasma, etc.) .
After three weeks, thanks to the daily use of a cover cream and a loose powder concealing the lesions, a significant improvement (p < 0.05) in quality of life was observed, in particular for the “self-confidence” dimension after the first week.
These benefits induced by cosmetics may depend on social, cultural and geographic factors, which is why it is worthwhile to cite a review of 18 studies conducted in 11 different countries: France, Taiwan, Australia, Japan, Belgium, canada, etc. .
They included a total of 912 patients with vitiligo, melasma or acne scars. For seven of these studies, the DLQI significantly decreased from the first application.
This review demonstrated that regardless of the skin type ± fair, medium or dark ± and regardless of the culture, quality of life is improved through the use of cosmetics, which significantly camouflage these dermatoses.
BEAUTY, WELL-BEING AND CANCER
With serious diseases such as cancer, quality of life is impaired by the disease itself and its symptoms as well as by the often severe cutaneous effects causing aesthetic and functional discomfort.
A study from 2014, focusing on 73 women with breast cancer, quantified the impact of these side effects on quality of life (p = 0.005) .
In this specific context, the use of suitable cosmetics was essential.
After six weeks of twice- daily application, high-tolerance emollients (Baume Lipikar AP) led to a significant improvement in quality of life measured by the DLQI (score of 2 for standard care and score of 1.3 for cosmetic care).
The “symptoms and feelings” aspect was significantly improved by face care from the fourth week compared to standard care (p = 0.006).
This cosmetic care not only provides patients with comfort during their treatment but also improves compliance with cancer treatments by reducing the discomfort associated with their cutaneous side effects.
By caring for their skin and their appearance, women regain self-esteem, are better able to cope with the disease, and can maintain a sense of well-being.
Rejuvenating procedures such as hyaluronic acid, botulinum toxin and peels are widely practised and have one thing in common: they have immediate effects on well-being and quality of life.
Botulinum toxin (Botox)
Botulinum toxin (Botox) has been used in aesthetic medicine in France since 1997. It was introduced in the United States later on, in 2003.
This toxin administered in the form of injections reduces signs of cutaneous ageing, in particular facial wrinkles (frown lines, crow’s feet), and smooths the neck by relaxing unsightly platysmal bands.
An American study from 2010 showed that botulinum toxin type A improved quality of life and self-esteem for 100 patients between the ages of 25 and 73 years .
Thanks to a randomised, double-blind, placebo-controlled methodology, a significant difference was found between the treated group and the placebo group.
Injectable fillers, usually containing hyaluronic acid, are another widely used anti-ageing procedure.
Introduced in Europe in the early 2000s, these injections fill in wrinkles, correct loss of facial volume, smooth the skin’s surface and hydrate the skin.
Numerous publications have reported not only the immediate quantifiable effect of these injections in terms of wrinkle removal but also the impact on the quality of life and well-being of treated patients.
> My Skin questionnaire, BGR 2013, WHOQOL and BFI- 10
A study undertaken in 2020 used the specifically developed My Skin questionnaire to evaluate the positive impact of hyaluronic acid injections on patient’ subjective perception.
In these 57 women (aged 35-55), treated for their facial wrinkles, skin improvement was positively correlated with a better sense of autonomy (p = 0.028) and well-being (p = 0.008).
The oldest women, whether they had gone through menopause or not, showed the most significant improvements in well- being.
Also worth noting is the interesting prospective study conducted in Germany with 145 female patients, with an average age of 50, who received botulinum toxin and/or hyaluronic acid injections compared with a control group from a database (BGR 2013).
The group of women treated for their wrinkles showed lower body weights, were usually single, and had a higher level of education.
Their quality of life evaluated using the WHOQOL and BFI- 10 was higher.
These women did not show more dysmorphic patterns than the control group without wrinkle treatment.
In other situations such as facial lipoatrophy in patients treated for hIV, social stigma can be extreme.
Here again, using fillers, hyaluronic acid or autologous fat transfer to correct their appearance leads to a significant improvement in cheek atrophy and at the same time has a positive psychological impact, as clearly demonstrated in numerous studies on well-being and quality of life.
> Combined treatments have also been evaluated. Improved quality of life was reported with wrinkle treatments combining botulinum toxin and hyaluronic acid.
For six months, 60 patients (50 women, 10 men) between the ages of 18 and 64 (phototypes II to V) showed improvement in their well- being (World health organization-Five Well-Being Index, Who-5) and self- esteem (heatherton & Polivy state self- esteem scale, hPss).
These improvements in well-being were significant from the third week (p = 0.008) and persisted at six months (p = 0.037).
Similarly, for self-esteem, there was significant improvement at three weeks (p < 0.001).
It persisted four months later (p = 0.002) as well as after six months (p = 0.006).
These methodologies have also been used to assess the impact on well-being of peels, which have long been used in aesthetics.
This skin smoothing procedure exfoliates the skin to varying degrees thanks to active ingredients such as TcA and AhA, often combined with complexes of vitamins, de- pigmenters, etc.
It reduces superficial fine lines, treats hyperpigmentation marks and acne scars, and improves the appearance of the skin’s surface.
Thanks to these multiple properties, peels have non-negligible effects on quality of life.
A study undertaken in the UsA used the DLQI to demonstrate the improved quality of life of patients treated with salicylic acid peels to reduce post- inflammatory hyperpigmentation lesions .
In these patients with dark phototypes (IV-VI), treatment on half of the face significantly reduced their spots; moreover, quality of life measured by the DLQI was considerably improved (8.4 before the peel, 6.7 two weeks after treatment).
This improvement in self-esteem is also observed in adolescents, at a critical period in life when body image is very emotionally charged and when acne lesions and their scars strongly reduce self-esteem.
> The Rosenberg’s Self- Esteem Scale (RSES)
Peels used for therapeutic purposes in 67 adolescents for their acne, scars, etc., as well as for 59 other adolescents for purely aesthetic reasons (skin clarity, blemishes) led to a significant improvement in the quality-of-life scores measured using the Rosenberg’s Self- Esteem Scale (RSES), regardless of the reason for requesting the peels.
By using these validated scales, these studies confirmed the beneficial influence of peels on well-being; although this procedure has been used for a long time, it still remains relevant since there is clear evidence of patient satisfaction.
AND AESTHETIC SURGERY…
If there is one domain where facial surgery is not debatable, it is that of post-traumatic facial reconstruction.
All kinds of things have been said about the reasons for aesthetic facial surgery and the protagonists. however, while the emotional aspects of the women who undergo face lifts are indeed real, the beneficial effects on well-being are no longer disputable; they have even been quantified using validated quality-of-life scales.
In an Indian study conducted in 2014, the authors proved that aesthetic and reconstructive surgery impacted patients’ quality of life.
This study included 91 patients, 43 of whom underwent surgery for aesthetic reasons and 48 of whom underwent reconstructive surgery.
> Short Form (SF)-36, BCS (Body Cathexis Scale)
Quality of life before and then three months after surgery was evaluated using two different scales: the Short Form (SF)-36 and the BCS.
The SF-36 is a scale for evaluating mental health, vitality and social role functioning in general whereas the Bcs (Body cathexis scale) assesses satisfaction with one’s body.
The BCS showed that body image was poorer before the procedure and that changes in body image perception were near-constant.
After surgery, the scores significantly improved, increasing from 148.38 to 168.38 for reconstructive surgery and to a lesser extent for aesthetic surgery (from 153.44 to 166.81).
Regarding the SF-36 scale, the mean scores showed that as expected, well-being before surgery, in particular its emotional dimension, was much poorer before reconstructive surgery (11.81) than before aesthetic surgery (44.96).
After the operation, both scores increased to 80.56 and 86.05 respectively.
The increase was spectacular after reconstructive surgery. It is interesting to note that after the surgical procedure, levels of well-being were similar for both groups.
> The DAS-59 (59-item Derriford Appearance Scale)
A three-year study was undertaken in canada, dealing with 93 patients, including 82 women, operated via rhinoplasty (49%) or anti-ageing surgery (51%).
Quality of life was evaluated using the 59-item Derriford Appearance Scale (DAS-59).
This validated scale assesses psychological distress associated with problems of self-confidence and facial appearance.
The DAS-59 includes 57 self-report items divided into six domains:
general self-consciousness of appearance;
social self-consciousness of appearance;
self-consciousness of sexual and bodily appearance;
negative self-concept; self-consciousness of facial appearance
Following rhinoplasty, the overall scores for general self-consciousness and negative self-concept significantly improved.
For anti-ageing surgery, the DAs-59 improved for satisfaction with facial and bodily appearance.
Aesthetic surgery has a positive effect on quality of life by enhancing overall well-being and feelings of satisfaction and self- assurance.
It is clear, then, that aesthetic surgery is not a simple meaningless ”desire”; rather, it is a way to address social concerns and build self-confidence.
> A meta-analysis of compiled 20 qualitative studies and 16 quantitatives studies
Given the wide variety of scales assessing well-being and quality of life, it was relevant to conduct a meta- analysis of all these studies.
In 2016, Dreher R. et al. compiled 20 qualitative studies and 16 quantitative studies published in PUBMeD or LILAcs.
These studies, dealing with a total of 1,614 patients, showed and confirmed that aesthetic surgery improved quality of life.
Mammoplasty, the most commonly practised aesthetic operation (12 studies), improved well-being more intensely than other aesthetic procedures.
Body contouring uses surgical techniques.
It can be performed in normal-weight patients, called “aesthetic” patients, although it is usually performed in patients with massive weight loss after bariatric surgery, with at least 50% excess weight loss compared to a normal body mass index (BMI) of 25 kg/m2.
In these patients whose weight gradually returns to near-normal values, body dissatisfaction persists due to unsightly excess skin that often poses functional problems, especially in the abdominal area.
It was precisely for these situations that the Body-QoL was developed. This instrument evaluates various domains: body satisfaction, self-esteem and social performance, sex life and physical symptoms.
> The Body-QoL
The Body-QoL was used to compare the effects of body contouring surgery on the self-esteem and well-being of patients having had massive weight loss and control patients having undergone aesthetic abdominal surgery outside of this massive weight loss context (respectively 20 and 92 patients).
The surgical procedures practised were abdominoplasty, liposuction, lipo-abdominoplasty, and/or lower body lift.
Prior to surgery, the Body-QoL scores were lower for the massive weight loss cohort (33.9) than for the aesthetic surgery cohort (46.1); however, following surgery, the scores of the two cohorts were not significantly different (p = 0.223 after nine months and p = 0.1133 after 2.7 years).
It is interesting to note that a plateau effect occurred after three months and continued throughout the rest of the observation period, indicating that satisfaction was long-lasting and that there was a long-term effect on body image, including for the “aesthetic” patients.
In another study, for the first time, the authors highlighted the personal satisfaction of patients with regard to the clinical outcome of aesthetic procedures.
> The FACE-Q scale
This study focused on 31 patients whose quality of life was assessed using FACE-Q.
This validated scale took into account the results reported by the patients in terms of their satisfaction with their facial appearance and the appearance of their skin as well as their appraisal of wrinkle improvement, after laser treatment or injections of fillers or botulinum toxin. The results showed improvement in the three assessed parameters: scores increased:
From 48.4 to 73.4 for facial appearance,
From 43.7 to 66.9 for skin appearance
lastly from 55.2 to 66.8 for wrinkle appraisal.
This study using the FACE-Q scale clearly showed the importance of patient opinions in the success of cosmetic procedures as well as the positive impact of cosmetic procedures on quality of life.
This approach supplemented the numerous studies having proven the significant impact of aesthetic procedures on quality of life and self-esteem, linking it to changes in the clinical signs observed by patients.
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