Cosmetic Surgery Patients Research Articles

Narcissism, Perfectionism, and Interest in Cosmetic Surgery

Sir: Cultural commentators argue that we live amid an “age of narcissism,” where narcissistic self-absorption and perfectionistic striving encourage interest in cosmetic surgery.1 Case studies and media reports also suggest that narcissism (vanity, exhibitionism, superiority, and entitlement) and perfectionism (ceaselessly demanding perfection of oneself) foster interest in cosmetic surgery.2 Such observations, although provocative, have yet to be subjected to empirical scrutiny. To address this shortcoming, we recruited 305 undergraduate women (mean ± SD age, 19.48 ± 3.26 years) who completed reliable and valid self-report questionnaire measures of narcissism,3 perfectionism,4 and interest in cosmetic surgery.5 Our study was approved by an institutional ethics committee, and participants provided informed consent in writing. A moderated multiple regression analysis predicting interest in cosmetic surgery explained a moderate amount of variance (R2 = 0.05, p < 0.05) and indicated that narcissism (β = 0.07, p > 0.05) and perfectionism (β = 0.10, p > 0.05) were unrelated to interest in cosmetic surgery. However, narcissism interacted with perfectionism (β = 0.14, p < 0.05) such that interest in cosmetic surgery was greatest among individuals with high levels of both narcissism and perfectionism (Fig. 1).Fig. 1.: Individuals characterized by high levels of both narcissism and perfectionism appear especially interested in cosmetic surgery.Our results lend credence to observations implicating narcissism and perfectionism in cosmetic surgery1,2 and refine this literature by suggesting that a synergistic relation between narcissism and perfectionism may underlie and motivate interest in cosmetic surgery. Narcissistic perfectionists (individuals characterized by extreme levels of both narcissism and perfectionism) may strive to perfect their bodies through cosmetic surgery in an effort to garner attention, demonstrate superiority, or augment a grandiose but unstable sense of self.3,4 Although not all cosmetic surgery patients are narcissistically pursuing bodily perfection, important implications for cosmetic surgeons nevertheless arise from our results. Narcissistic perfectionists may be particularly challenging and potentially hostile patients. Indeed, a vain, entitled, and grandiose patient demanding a perfect (and therefore unrealistic) outcome may be nearly impossible to satisfy—even if an objectively successful and aesthetically pleasing surgical outcome is obtained. Pairing surgical procedures with psychological interventions may assist narcissistic perfectionists in overcoming barriers to a satisfying surgical experience. Skye Fitzpatrick Simon Sherry, Ph.D. Nikola Hartling Paul Hewitt, Ph.D. Gordon Flett, Ph.D. Dayna Sherry, Ph.D. Department of Psychology Dalhousie University Halifax, Nova Scotia, Canada

Special Considerations in History and Physical Assessment of the Plastic, Cosmetic, and Reconstructive Surgery Patient

One of the most important tasks of the perioperative nurse is to obtain a thorough history and physical assessment before surgery. The nurse should be able to assess the patient, obtain a history of the patient, and observe for any potential problems.

The PreFACE

Currently no brief and objective screening protocol exists to assist surgeons and dentists in the identification of patients who are likely to report unsatisfactory outcomes after cosmetic surgery interventions. The aims of this study were to (1) investigate the relationship between postoperative dissatisfaction and preoperative characteristics (psychiatric disturbance, anxiety, depression, self-esteem, dysmorphic concern, and body image), and (2) empirically derive a preoperative psychosocial screening instrument to identify patients who may require preoperative assessment or counseling. The sample composed of 84 patients (69 women and 15 men) undergoing elective cosmetic facial surgery or cosmetic dentistry. Before surgery, a self-report questionnaire was administered to the patients, which comprised questions designed to evaluate many of the psychosocial characteristics thought to be associated with unsatisfactory outcomes. Six months after surgery, a questionnaire was administered to the patients, which included items evaluating postoperative satisfaction. The findings revealed that preoperative psychiatric disturbance, anxiety, depression, low appearance evaluation, and body areas dissatisfaction are psychosocial risk factors that indicate an increased likelihood of patient dissatisfaction with surgical outcomes. The PreFACE (Preoperative FAcial Cosmetic surgery Evaluation), a brief objective preoperative screening questionnaire that can be easily and efficiently administered to elective facial cosmetic surgery and cosmetic dentistry patients, was empirically derived. It is able to identify most patients who are likely to express dissatisfaction and minimizes the selection of those who will express satisfaction. The PreFACE is recommended for validation using other cosmetic surgery populations. The routine use of PreFACE is recommended for identification of patients who may benefit from preoperative counseling.

How Important Is “Pseudogynecomastia”?

“If male breast enlargement is caused by glandular proliferation, it is defined as gynecomastia. If it is caused by increased fat deposition, it is defined as pseudogynecomastia [1].” “Pseudogynecomastia is an ideal condition for ‘liposuction alone’, whereas gynecomastia can be treated by surgical excision, liposuction, or a combination of both.” These quotes seem to represent the current beliefs of the medical fraternity about enlarged male breasts. Presumably based on such beliefs, patients are advised to undergo radiologic investigations such as ultrasound scanning, mammography, contrast-enhanced computed tomography (CT scan), and magnetic resonance imaging (MRI) to differentiate pseudogynecomastia from gynecomastia. Moreover, these patients are treated by applying liposuction alone for pseudogynecomastia and surgical excision for gynecomastia. Some surgeons routinely apply liposuction alone to treat both gynecomastia and pseudogynecomastia patients. However, they likely have encountered some patients who have a partial recurrence of breast enlargement a few months after liposuction [2–4]. In addition, a close look at published “satisfactory” results of treatment using “liposuction alone” shows some breast enlargement remaining in some patients, irrespective of whether they had pseudogynecomastia or gynecomastia preoperatively. Liposuction alone, indeed, is a simple procedure for the treatment of enlarged male breasts. However, some breast enlargement is known to return after the procedure for some patients. Neither the cause nor the prevention of this recurrence is known [4]. Excisional surgery for both pseudogynecomastia and gynecomastia, with or without added liposuction for contouring of the chest and upper abdomen, ensures flat chests and no partial return of breast enlargement [5]. Liposuction alone, however, can be applied for those patients with pseudogynecomastia or gynecomastia who are willing either to accept the possibility of some enlargement returning in their breasts after surgery or to undergo “touch-up” operations at a later date. Cosmetic surgery patients are concerned about the appearance of their breasts, not their contents. From an appearance point of view, pseudogynecomastia does not exist. The patients seek flat chests irrespective of whether their breasts contain glands or fat. Some of these patients are dissatisfied by the partial return of enlargement of their breasts after liposuction alone. The term “pseudogynecomastia” seems to be the culprit that misleads surgeons because it is used almost synonymously with the treatment method of applying liposuction alone. Avoidance of the term “pseudogynecomastia” could be doubly beneficial. On the one hand, radiologic investigations to differentiate pseudogynecomastia from gynecomastia could be drastically reduced [6, 7]. On the other hand, the incidence of residual gynecomastia resulting from “liposuction alone for pseudogynecomastia,” could be significantly reduced or even eliminated. The author has no intention to ignite a controversy but fondly hopes to block or break the chain of unnecessary radiologic investigations, diagnoses of pseudogynecomastia based on these investigations, treatment of pseudogynecomastia with liposuction alone, and the risk for resultant unhappy patients because of residual gynecomastia. The author humbly appeals to the medical fraternity to consider discouraging usage of the term “pseudogynecomastia,” at least until the causes of residual gynecomastia are elucidated, and measures to prevent residual gynecomastia after liposuction alone are established.

Photometric Evaluation of Inframammary Crease Level After Cosmetic Breast Surgery

The effect of surgery on the level of the inframammary crease, a long-standing landmark in cosmetic breast surgery, has not been previously investigated. There has been speculation that breast augmentation may lower this level and that vertical mastopexy may raise it, but no confirmation of these opinions has been published. The author measured the preoperative and postoperative levels of the inframammmary crease in an effort to document the movement of the crease after four types of cosmetic breast surgery. The inframammary crease level was measured prospectively in 40 consecutive cosmetic breast surgery patients who presented to the author's clinic for breast augmentation, mastopexy, augmentation mastopexy, or breast reduction. The vertical mastopexy and reduction technique was implemented in all patients. The Canfield Mirror 7.1.1 imaging system (Canfield Scientific, Fairfield, New Jersey) was utilized for calibration, standardization, and orientation-matching of photographs, and for measurements of crease level. The single-sample t test was utilized to compare the changes in the level of the inframammary crease, where a P-value < .05 was considered significant. The level of the inframammary crease was significantly lowered by breast augmentation and significantly elevated by vertical mastopexy or breast reduction. Augmentation mastopexy resulted in either lowering or raising of the crease level, and no change in one patient. The level of the inframammary crease is dynamic; it typically descends after breast augmentation and is raised by a vertical mastopexy or reduction. Therefore, the lower pole is recommended as an alternative (and more static) landmark.

An old „new” disease: body dysmorphic disorder (dysmorphophobia)

Body dysmorphic disorder causes significant suffering and serious impairment in psychosocial functions. However, this disease with dangerous risks is scarcely mentioned in the Hungarian medical literature. The objective of the author is to give a detailed review about this almost unknown, but relatively common disorder. The serious disorder of body perception is in the centre of symptoms, leading to social isolation, anxiety, depression and obsessive-compulsive phenomena. The disorder often remains unrecognized because of the lack of insight of disease. Comorbidity with affective disorders, anxiety disorders, personality disorders, eating disorders, alcoholism and substance use disorders is common. The life quality of affected patients is bad, the risk of suicide or violence is high. Biological, psychological and sociocultural factors play an important role in the etiopathogenesis of the disorder. Imaging techniques and neuropsychological measures revealed changes characteristic for the disease. Childhood abuse and neglect, appearance-related critical remarks, stressors and the impact of media are also supposed to have role in the development of the disorder. The point prevalence is 0.7-2.5% in the general population, however, in special groups such as in tertiary students, psychiatric, dermatological and cosmetic surgery patients the prevalence rates may be much higher. Typically, the disease begins in early adolescence, and it persists and deteriorates without treatment, showing a chronic course. By means of pharmacotherapy and/or psychotherapy long-during improvement or full recovery can be achieved within a relatively short period of time.

Depression in the Cosmetic Surgery Patient

Studies show that patients seeking cosmetic surgery are more likely to suffer from depression than is the general population. Thus it behooves the cosmetic surgeon to be familiar with the diagnosis of depression and the unique challenges that it poses to a cosmetic practice. Does depression affect surgical outcomes? Could a surgical procedure improve or exacerbate depressive symptoms? When is referral to a mental health professional warranted? This article attempts to deal with these questions, and in doing so we suggest possible means for managing depression in the cosmetic surgery patient.

Evaluation of coexistence of the Human Herpesvirus type 8 (HHV‐8) infection and pemphigus

Human Herpesvirus type 8 (HHV-8) is a new member of the herpes virus family, first found in the tissue of acquired immune deficiency syndrome (AIDS)-related Kaposi's sarcoma. Environmental factors including viral infection may play a role in the onset and/or development of pemphigus. Some studies based on polymerase chain reaction findings suggest an association between HHV-8 and pemphigus. The aim of this study is investigation of the association of pemphigus with HHV-8 and the relationship between inflammatory and acantholytic cells with HHV-8 infection. Tissue-extracted DNA from 41 paraffin-embedded skin tissues from patients first presenting with pemphigus was tested using nested PCR for the presence of HHV-8. A total of 37 cases had pemphigus vulgaris (PV) and 4 patients had pemphigus foliaceus (PF). For our control group, normal skin of 21 cosmetic surgery patients were included. Furthermore, microscopic slides with H&E staining were evaluated for the number of inflammatory and acantholytic cells per microscopic field. Skin lesions from 13 of 37 patients (35.1%) with PV and 2 of 4 cases (50%) with PF were positive for HHV-8 DNA. All specimens in our control group were negative for this virus. HHV-8 infection might be a contributing factor in the initiation or development of pemphigus.

The Male Cosmetic Surgery Patient

Plastic surgeons have traditionally perceived male patients as more psychologically disturbed than female patients. This study employed a matched sample design to explore the psychosocial experiences of 50 male and 50 female elective cosmetic surgery and cosmetic dentistry patients. It also aimed to compare male and female patients on preoperative psychosocial dysfunction on standardized measures (psychiatric disturbance, anxiety, depression, low self-esteem, dysmorphic concern, and low body image) and postoperative dissatisfaction. The findings revealed that there were many similarities between the self-reported appearance concerns, motivations for surgery, and expectations of surgery between male and female patients. Although male patients did not report higher levels of preoperative psychosocial dysfunction than their female counterparts, they were more likely to report postoperative dissatisfaction. Preoperative screening is recommended to identify the minority of male patients who will report an unsatisfactory outcome despite a technically good result.

Patient Preference for a Clinical Chaperone in Breast and Body Cosmetic Surgery

Introduction:The use of a clinical chaperone in clinically intimate examinations has always been recommended. This study investigates patients' views on the use of a clinical chaperone in breast and body cosmetic surgery.Materials and Methods:One hundred two female patients who underwent breast and body cosmetic procedures were offered the questionnaire, and all patients responded to the Web-based blog questionnaire as to their preference for a clinical chaperone during their clinic experience on 3 different occasions. These occasions comprised the initial cosmetic surgery consultations, preoperative markings, and postoperative visits. All patients involved in this study were treated by male clinicians, except 1 patient who had a female clinician.Results:t-test P-value significance was achieved at .05; the effect size was .4 (medium conventional effect size, in which responses were due to noise interference, where a small effect size is approximately .2), and the observed power was noted to be .835 where the responses collected reflected the population. A total of 33.3% ( n = 34) of the patients indicated preferring a clinical chaperone be present on all 3 occasions. A total of 31.4% ( n = 32) indicated they would prefer not to have a clinical chaperone present on these occasions. However, 11.8% ( n = 12) had no preference as to whether a clinical chaperone was present on all 3 occasions. The remainder of the patients had mixed opinions on 1 or more of these occasions.Conclusions:Variable views on the use of a clinical chaperone among cosmetic surgery patients reflect the importance of the surgeon's judgment and discretion in dealing with the individual patient. In addition, offering the presence of a clinical chaperone allows patients to decide which is the optimal environment for them at a given time. Informing patients in advance regarding the components of the examination also helps to ease patients' anxiety.

Motivational Narratives and Assessments of the Body After Cosmetic Surgery

Cosmetic surgery can be conceptualized as part of a spectrum of contemporary body projects whereby the individual uses body work to achieve some social and personal goal. In this article I examine individual motivations for undergoing cosmetic surgery as well as assessments of the outcomes of those surgeries. Drawing on in-depth interviews, I explore how cosmetic surgery patients understand and ascribe meaning to their own experiences and discover how the respondents evaluate their surgeries in both personal and social contexts. I found that motivations for undergoing surgery are often articulated in both physical and psychosocial terms, with the expectation that physical alterations will facilitate social or emotional changes. Additionally, outcomes are assessed in a similar fashion, with interviewees expressing not only their evaluations of the aesthetic changes to their bodies, but also how these changes made them feel about themselves and their relationships with others.

On norms and bodies: findings from field research on cosmetic surgery in Rio de Janeiro, Brazil

Brazil has the second highest rate of cosmetic surgery worldwide, provided in a large number of public and private clinics and hospitals, especially in the southeast. This qualitative field research in Rio de Janeiro included participant observation and in-depth interviews with 18 women cosmetic surgery patients, 10 key informants (e.g. psychologists and sociologists) and 12 plastic surgeons. Fifteen of the women were either pre- or post-operative; three had not decided whether to have surgery. When asked about their motivations and expectations of the surgery, the majority of the women said they wanted to be “normal”. Most of the surgeons said they acted as empathic companions from decision-making through surgery and beyond. Many of the key informants were critical of what was happening to medical ethics in relation to cosmetic surgery. With the growth in a consumer culture, they saw ethics in medicine becoming more bendable and subject to the “law” of the market. The cult of the body has become a mass phenomenon and taken on an important social dimension in a society where norms and images are broadcast widely by the media. The trend towards body-modification by cosmetic surgery at an early age is increasing dramatically. What demands critical thinking and further investigation are the consequences of cosmetic surgery for physical and mental health.

Transtorno dismórfico corporal em dermatologia: diagnóstico, epidemiologia e aspectos clínicos

São cada vez mais frequentes as queixas cosméticas, uma vez que objetivam a perfeição das formas do corpo e da pele. Os dermatologistas são consultados para avaliar e tratar essas queixas. Sendo assim, é importante conhecer o Transtorno Dismórfico Corporal, inicialmente chamado de "dismorfofobia", pouco estudado até recentemente. Esse transtorno é relativamente comum, por vezes, incapacitante, e envolve uma percepção distorcida da imagem corporal, caracterizada pela preocupação exagerada com um defeito imaginário na aparência ou com um mínimo defeito corporal presente. A maioria dos pacientes apresenta algum grau de prejuízo no funcionamento social e ocupacional, e como resultado de suas queixas obsessivas com a aparência, podem desenvolver comportamentos compulsivos, e, em casos mais graves, há risco de suicídio. O nível de crença é prejudicado, visto que não reconhecem o seu defeito como mínimo ou inexistente e, frequentemente, procuram tratamentos cosméticos para um transtorno psíquico. A prevalência do transtorno, na população geral, é de 1 a 2% e, em pacientes dermatológicos e de cirurgia cosmética, de 2,9 a 16%. Considerando a alta prevalência do Transtorno Dismórfico Corporal, em pacientes dermatológicos, e que os tratamentos cosméticos raramente melhoram seus sintomas, o treinamento dos profissionais para a investigação sistemática, diagnóstico e encaminhamento para tratamento psiquiátrico é fundamental.

Diagnosing Culture: Body Dysmorphic Disorder and Cosmetic Surgery

A recent clinical literature on the psychology of cosmetic surgery patients is concerned with distinguishing good from bad candidates. Body Dysmorphic Disorder (BDD) — a mental disorder marked by a pathological aversion to some aspect(s) of one’s appearance — is typically understood in this context as a contra-indication for cosmetic surgery, as it marks those with inappropriate motivation who are unlikely to be satisfied by the surgery’s outcomes. This article uses Foucault’s genealogical work to argue that both the attempt to provide diagnostic conditions for BDD itself, and the broader attempt to demarcate normal and psychopathological concern with appearance are, in part, effects of disciplinary power. Although often presented as a way of making cosmetic surgery more ethical and restrained, this epistemic project inadvertently defends cosmetic surgical interests. Specifically, it contributes to legitimizing the image of an ethically suspect sub-specialty of medicine, and supports its commercial expansion and effective profit-making by displacing its negative sequelae onto patient psyches.

Teaching and Learning Guide for ‘Beauty Work: Individual and Institutional Rewards, the Reproduction of Gender, and Questions of Agency’

Teaching and Learning Guide for ‘Beauty Work: Individual and Institutional Rewards, the Reproduction of Gender, and Questions of Agency’

Risk reduction in cosmetic surgery

Cosmetic or aesthetic surgery is defined as ‘operations or other procedures that revise or change the appearance, colour, texture, structure or position of bodily features to achieve what patients perceive to be more desirable’. It differs from reconstructive surgery in that patients do not suffer from surgical pathology, but come to a surgeon desiring alteration of appearance to achieve an improvement. It has been said that cosmetic surgery patients differ from those presenting to other surgeons, in that instead of hoping that they do not need an operation, in cosmetic surgery the wish to undergo surgery is the patient's primary motivation for the consultation. There are distinctive risks in cosmetic surgery. The focus is on an individual surgeon, rather than a system of institutional care delivery. The surgeon's assessment and selection of patients is crucial to the avoidance of subsequent dissatisfaction. Mainstream surgical training concentrates on the acquisition of knowledge and technical competencies: the cosmetic surgeon's armamentarium must include in addition superlative communication skills and a degree of psychological awareness which will allow exclusion of those patients for whom it is unlikely that satisfaction can be achieved. It may circumvent disaster for the surgeon to say ‘no’. Awareness of inherent clinical risks and the ability to manage them are crucial to successful practice, as is the surgeon's commitment to support and encourage the patient throughout the entire process. There is, however, the potential for extremely high levels of satisfaction for both surgeon and patient if pitfalls are avoided, and risks are managed appropriately within a positive doctor–patient relationship.

Preoperative Use of Alpha Tocopherol Does Not Increase the Risk of Hematoma in the Face Lift Patient: A Preliminary Report

Antiplatelet therapy and nutritional supplements are factors that may increase the risk of hematoma after routine face lift. This has led to the often-repeated instruction "do not take any vitamins, herbs, aspirin, and any medications that may increase bleeding for 10 days before your face lift operation." At odds and diametrically opposed to this goal is combating the increased risk of deep venous thrombosis and venous thromboembolism associated with surgery. On the basis of clinical observations, the author has incorporated the routine use of preoperative oral alpha tocopherol (vitamin E) into his preoperative instructions. The cohort included 146 patients scheduled for elective face lift enrolled in this study from February of 2007 to April of 2008. Aspirin and clopidogrel were stopped before surgery. Patients were instructed to take 400 IU of alpha tocopherol daily 3 weeks before surgery. No hematoma developed in any of the 146 patients. The time for routine drainage was not prolonged. No clinically evident case of deep vein thrombosis or venous thromboembolism occurred. The clinical impression was that increased bruising was not observed. A recent landmark article has documented the efficacy of alpha tocopherol in the prevention of venous thromboembolism in over 39,000 patients. The addition of this readily available, over-the-counter medication may have profound effects in the prevention of a potentially devastating complication in the elective cosmetic surgery patient. Future prospective studies may further elucidate the efficacy of alpha tocopherol in the prevention of venous thromboembolism.

Cosmetic surgery and the relationship between appearance satisfaction and extraversion: Testing a transactional model of personality

Few studies have tested potential explanatory mechanisms for the high stability of extraversion. In this study, the relationship between extraversion, appearance evaluation, and cosmetic surgery was investigated to examine such mechanisms. The “Big Five” personality traits were assessed in 155 female cosmetic surgery patients prior to and 6 months after surgery, as well as from a representative sample of 907 women. Patients showed higher extraversion scores prior to surgery than were found in the representative sample; further, extraversion scores increased after surgery, while the increase diminished when controlled for appearance evaluation. The results are in accordance with a transactional model, whereby extraverts engage in actions that reinforce extravert tendencies, which may account for the high stability of extraversion.

Becoming/Being a Cosmetic Surgery Patient: Semantic Instability and the Intersubjective Self

Against approaches that center the subject—the cosmetic surgery patient—as the primary site of inquiry regarding the “truth” of cosmetic surgery, I argue that we must rethink the positioning of the subject in considering cosmetic surgery's meanings. Here I offer a brief discussion of various feminist theories of the cosmetic surgery patient, as well as an account of my own experience of cosmetic surgery, to explore how the cosmetic surgery patient is semantically unstable, named and identified through a variety of discourses and social relations. This semantic instability suggests a need to examine the ongoing processes by which cosmetic surgery comes to have meaning and by which the subjectivity of the cosmetic surgery patient is produced.

A Systematic Review of Patient-Reported Outcome Measures after Facial Cosmetic Surgery and/or Nonsurgical Facial Rejuvenation

Patient satisfaction and improved quality of life are the predominant considerations determining success in cosmetic surgery. However, few studies have examined patients' perceptions of their appearance following cosmetic facial surgery and/or nonsurgical facial rejuvenation. This study identified patient-reported outcome measures developed and validated for use in patients undergoing surgical and/or nonsurgical cosmetic procedures. A systematic review of the English-language literature was performed. Patient-reported outcome measures designed to assess patient satisfaction and/or quality of life following surgical and/or nonsurgical cosmetic procedures were identified. Qualifying instruments were assessed for content and adherence to international guidelines for development and validation. From 442 articles, 47 patient-reported outcome measures assessing facial appearance after a cosmetic procedure were identified. Only nine questionnaires satisfied inclusion and exclusion criteria. These measures were subdivided into the following categories: rhinoplasty (Rhinoplasty Outcomes Evaluation, Glasgow Benefit Inventory, Facial Appearance Sorting Test), skin rejuvenation (Facial Lines Treatment Satisfaction Questionnaire, Skin Rejuvenation Outcomes Evaluation, Facial Lines Outcomes Questionnaire), face lift (Facelift Outcomes Evaluation), blepharoplasty (Rhinoplasty Outcomes Evaluation), and general appearance (Derriford Appearance Scale 59). None of these measures satisfied all guidelines. All measures were limited by either their development, their validation, or their content. Valid, reliable, and responsive instruments designed to measure patient-reported outcomes following surgical and nonsurgical facial rejuvenation are lacking. A patient-reported outcome measure that represents perceptions of facial cosmetic surgery patients and satisfies accepted health measurement criteria is needed. It would facilitate comparison of techniques and quantification of positive effects, and aid surgeons seeking to quantify outcomes in their own practices.