‘There’s no art to find the mind’s construction in the face.’ William Shakespeare, 1606

This line from Macbeth suggests caution when considering modifying appearance in order to change the mind. Cosmetic procedures have increased greatly in number and variety over the years, and the costs associated with such interventions to public and private purses are considerable. Factors associated with adverse outcomes after plastic surgery include unrealistic expectations, delusions and not being happy with previous surgery. Psychiatric disorders to keep in mind include body dysmorphic disorder (BDD), amputee identity disorder (AID), body sculpting and delusional states. BDD is usually ‘explained’ as involving overvalued ideas. BDD cases may change the focus to different parts of their bodies, have (rarely) attacked their surgeons, are often unhappy with past surgery, may insist that an incorrect operation was undertaken, that the end result is worse than the original ‘defect’, and they may try to end their lives or operate on themselves. Milder symptoms and lower expectations of BDD patients favour a better surgical outcome. The factitious SHAFT syndrome (sad, hostile, anxious, frustrating and tenacious) consists of patients who manipulate plastic surgeons into performing surgery. AID involves the wish to have limbs or digits removed and patients may damage the body part in order to force surgery or they may amputate the limb themselves. They often live as if disabled, eg. by using a wheelchair. They do not view the body part as ugly but they believe that they will be able to cope better without the part. Psychiatric treatment has no effect. Apotemnophilia, sexual attraction to disabled persons, is a different phenomenon. Body sculptors alter their bodies for artistic reasons or they may wish to take on animal form (eg. the ‘Tiger man’, Dennis Smith, of San Diego, changed his name by deed poll to ‘Cat Man’ and claimed to ‘feel like a tiger’). Rejection is possible with facial transplants. The psychological effects of this undertaking need to be anticipated, planned for and managed. Suicide rates are increased in women after cosmetic breast augmentation. A recent Norwegian 13-year study of adolescent females found that depressive and anxiety symptoms, parasuicide and use of illicit drugs predicted cosmetic surgery and those who had surgery were more likely to experience anxiety, depression and eating problems, and to drink more alcohol, than were females who did not have surgery. None of the above is meant to take from the marvellous work done by plastic surgeons for people disfigured by disease or trauma.