To the Editor: Early theories regarding reasons behind patients' decisions to undergo cosmetic procedures were developed by psychologists and researchers with minimal input from affected patients. Recent works have focused on patients themselves.1Waldman A. Maisel A. Weil A. et al.Patients believe that cosmetic procedures affect their quality of life: an interview study of patient-reported motivations.J Am Acad Dermatol. 2019; 80: 1671-1681Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,2Maisel A. Waldman A. Furlan K. et al.Self-reported patient motivations for seeking cosmetic procedures.JAMA Dermatol. 2018; 154: 1167-1174Crossref PubMed Scopus (46) Google Scholar Patients with a history of major medical illness (MMI) are among the subsets of patients that have not been well-studied. Treatments for MMI, including medications, radiation, chemotherapy or immunotherapy, stem cell transplants, and surgery, may induce premature age-related changes. While some cosmetic procedures may positively affect patients’ quality of life,3Duxbury P.J. Gandhi A. Kirwan C.C. Jain Y. Harvey J.R. Current attitudes to breast reconstruction surgery for women at risk of post-mastectomy radiotherapy: A survey of UK breast surgeons.Breast. 2015; 24: 502-512Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,4Vargas C.R. Ganor O. Semnack M. Lin S.J. Tobias A.M. Lee B.T. Patient preferences in access to breast reconstruction.J Surg Res. 2015; 195: 412-417Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar their perceived utility for the broad range of MMI remains to be elucidated. The purpose of this study was to better understand the motivations of MMI patients seeking cosmetic procedures so that dermatologists may be in a better position to help them through their survivorship journey.Participants were those with (1) MMI, defined as any condition that carries a high risk of mortality and/or disease-related hospitalization; and (2) those that underwent elective cosmetic intervention. Semistructured patient interviews were conducted by a trained investigator (J.G.L.) in accordance with a previously described protocol until no new themes emerged.1Waldman A. Maisel A. Weil A. et al.Patients believe that cosmetic procedures affect their quality of life: an interview study of patient-reported motivations.J Am Acad Dermatol. 2019; 80: 1671-1681Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,5Bowen G.A. Naturalistic inquiry and the saturation concept: a research note.Qual Res. 2008; 8: 137-152Crossref Scopus (1371) Google Scholar The anticipated minimum sample size (n = 12) was based on past research studies indicating that thematic saturation almost always occurs within this number of interviews.5Bowen G.A. Naturalistic inquiry and the saturation concept: a research note.Qual Res. 2008; 8: 137-152Crossref Scopus (1371) Google Scholar Interviews were audio-taped, transcribed, de-identified, and analyzed via a constant comparative approach by 2 independent analysts (E.P and J.G.L).Adult patients were recruited until iterative qualitative analysis led to thematic saturation. Even though thematic saturation was reached by the eighth participant, interviews were continued to a total of 12 to ensure that the themes remained consistent.Participants' ages were 34-82 years (mean, 60), with 9 women, and 84% having at least a college education. The average interview lasted 41 minutes. Major medical illnesses included chronic myelogenous leukemia, breast cancer, hemochromatosis, axial spondyloarthritis, stroke, advanced melanoma, prostate cancer, advanced cervical cancer, graft versus host disease, advanced thyroid cancer, and Hodgkin's lymphoma. Most participants reported seeking cosmetic treatments directly because of their MMI diagnosis (75%) or treatment (66%). Participants' motivations fell under 6 categories: desire to protect health, maintain mental well-being, enhance social acceptance, counteract aging, alleviate impact on work success, and respond to suggestions provided by friends, family, and doctors (Table I).Table ICosmetic motivationsMotivation†Motivation.Sub-motivation‡Sub-motivation.DefinitionRepresentative commentsProtect health∗Theme. Undesirable physical symptoms/features†Motivation. ((15))Explicit desires to remove scaring, wrinkles, spots, cellulite, functional deficits etc.“I have a couple acne scars, and you don't wanna have those.” (Female, 50, stroke, spondyloarthritis, rhytids, acne scars)To fix a functional issue‡Sub-motivation. (6)Any specific reference to fixing a functional issue.“I had these 2 furrows on either side of my lips and especially the left one. I ended up drooling a lot.” (Male, 82, prostate cancer, rhytids)Looking sick‡Sub-motivation. (2)Any reference to “looking sick.”“I don't wanna look like I've been sick or I've been through something.” (Female, 54, CML/GVHD, breast cancer, rhytids) Health concerns†Motivation. ((10))Any reference to feeling concerned about one's present/future health.Reversal‡Sub-motivation. (5)Reverse symptoms of conditions/treatment (including medications).“I feel as though the medical treatments I've gone through have left me looking a little more aged, a little more tired than my peers.” (Female, 54, CML/GVHD, breast cancer, rhytids)Maintenance‡Sub-motivation. (4)A desire to maintain current appearance.“You can't stop aging, but you just wanna do it gracefully.” (Female, 50, stroke, spondyloarthritis, rhytids, acne scars)Fears that the condition will get worse‡Sub-motivation. (1)Any reference to one's condition worsening.“I've always been an attractive person, and I was beginning to see lines and wrinkles.” (Female, 73, breast cancer, rhytids, neck laxity) Concealing undesirable physical features†Motivation. ((9))Any reference to feeling stressed/burdened from a need to hide undesirable features.“Post-treatment, you look in the mirror negative-wise. You have no hair, no eyebrows, no eyelashes, nothing. My immune system was severely low, so I looked really pale and anemic. It's like you don't even recognize yourself anymore.” (Female, 34, breast cancer, rhytids, sun damage)Makeup‡Sub-motivation. (6)Any reference to fear that makeup will wear off, having to wear makeup, etc.“I tend to put more makeup on than maybe I would want to.” (Female, 54, CML/GVHD, breast cancer, rhytids)Physical‡Sub-motivation. (2)Includes references to adjusting physical attributes to hide features including body orientation, hair, etc.“I feel as though my face looks almost a little deformed in the sense that because of my transplant, I was on steroids for 15 years and it gave me that chipmunk appearance, and now that that's gone, I feel like it's left my face looking a little odd, almost like I see remnants of that look in me.” (Female 54, CML/GVHD, breast cancer, rhytids) Emotional well-being†Motivation. ((6))Any reference to poor emotional well-being due to appearance, or desire to improve emotional health.Depression‡Sub-motivation. (2)Any discussion of feeling depressed, sad, tearful, despair.“In my mind, I was either gonna die or I was gonna be fine. It didn't really occur to me that I might survive but also have life-long disabling problems that would interfere with just accomplishing regular everyday things.” (Male, 38, Hodgkin's Lymphoma/GVHD, deep scarring, contractures)Anxiety‡Sub-motivation. (2)Anxiety felt as a result of appearance/situation.“It gives me self-doubt as to how I really appear. Do I appear sickly, old, older than I should look?” (Female, 54, CML/GVHD, breast cancer, rhytids)Happy‡Sub-motivation. (2)To be happy or because was not happy.“People always assume that procedures are all vanity based, and they're not because if you take the time to really look inside and assess yourself, there are so many valid reasons for getting the work done. I have no regrets.” (Female, 66, melanoma, rhytids, sun damage, skin laxity, eyelid ptosis, excess adiposity) Improved health†Motivation. (5)Desire to improve overall health. Examples include desire to eat healthier/lose weight now that the undesirable feature is getting fixed.“Well, I think my perception is that I think when you have healthy skin, and you feel like your skin is smooth, and looks good, it almost makes you feel healthier from the inside [out].” (Female, 34, breast cancer, rhytids, sun damage) Discomfort†Motivation. (1)Any reference to physical discomfort, pain.“I couldn't do some basic things that were part of my everyday life with my arms. It was very difficult for me to reach into the back of shelves that were designed for people with normal reach or to grab objects that fell off my desk onto the floor without getting all the way out of my chair.” (Male, 38, Hodgkin's Lymphoma/GVHD, deep scarring, contractures)Maintain mental well-being∗Theme. Confidence†Motivation. (8)Any explicit references regarding a desire to improve confidence, feel self-confident, improve self-esteem, improve self-image.“It gives you the perception that you can beat this.” (Female, 34, breast cancer, rhytids, sun damage) Feeling better†Motivation. (4)Includes discussions of wanting to feel better about oneself, to feel worthy, to improve mood.“I just like to feel good about myself. I would reiterate that if I feel good about myself, then I feel better about interacting. I don't think it would affect others to me. It would be my interaction, my self-confidence.” (Female, 66, melanoma, thyroid cancer, skin laxity, rhytids) Looking better†Motivation. (4)Includes discussions of wanting to look/feel pretty, look their best, improve overall appearance of skin, and so clothes will look better.“It makes you happier because you look better; like the age spots aren't on your face.” (Female, 50, stroke, spondyloarthritis, rhytids, acne scars) Embarrassment†Motivation. (3)Any explicit reference to feeling embarrassed/ashamed.“I had a wig on, and I had makeup on, but I still looked sick. For me, it did impact me. I felt like I didn't want to—I was embarrassed.” (Female, 34, breast cancer, rhytids, sun damage) Normal†Motivation. (2)Includes explicit discussions of wanting to be/look/feel normal.“I said, ‘I wanna look like me.’ It was very mild. We took the before and after. It wasn't dramatic at all, but it was an improvement.” (Female, 63, breast cancer, hemochromatosis, eyelid ptosis, rhytids) Major life event†Motivation. (2)Example: divorce, wedding, graduation.“I really did it when [my daughter] was getting married.” (Female, 63, breast cancer, hemochromatosis, eyelid ptosis, rhytids) Self-consciousness†Motivation. (1)Any reference regarding a desire to be less self-conscious, obsession with looking good/bad.“I guess it make—it makes me feel a little vain because anybody in my position looking in from the outside would say, “You're healthy. This is all just surface.” (Female, 54, CML/GVHD, breast cancer, rhytids) Personal gift†Motivation. (1)Includes discussions of having procedure to treat, do something special for oneself.“I'm interested in doing something for myself that isn't medically necessary, but it also is generally noninvasive, and it just might make me feel a little better.” (Female, 54, CML/GVHD, breast cancer, rhytids)Positive perceptions of cosmetic procedures∗Theme. Positive reviews†Motivation. ((9))Any reference to positive experiences, reviews, or recommendations from outside sources that provides motivation to undergo procedure.Doctor‡Sub-motivation. (5)Credibility of doctor, clinic, hospital.“My dermatologist, who I respected and trusted, had suggested a couple of procedures, a couple of things we could do to lighten that up.” (Female 69, melanoma, rhytids, sun damage, vaginal dryness)Friends & Family (4)Credibility of friends or family.“Actually, a lot of my peers are looking into similar procedures.” (Female 54, CML/GVHD, breast cancer, rhytids) Procedure characteristics†Motivation. ((8))Noninvasive‡Sub-motivation. (4)Any reference to procedure being noninvasive.“They're not as invasive. Microdermabrasion's simple. It's like a cat licking your face.” (Female, 50, stroke, spondyloarthritis, rhytids, acne scars)Affordable‡Sub-motivation. (2)Procedure is affordable.“It's $700, in today's environment isn't very much.” (Male, 82, prostate cancer, rhytids)Minimal risk‡Sub-motivation. (1)Any reference to procedure having minimal risk or being less risky than alternative.“…low risk, safe…” (Female, 66, melanoma, thyroid cancer, skin laxity, rhytids)Availability‡Sub-motivation. (1)Any reference to new treatment finally available, effective, or new treatment availability“I have access in the family.” (Female, 63, breast cancer, hemochromatosis, eyelid ptosis, rhytids) Peer pressure†Motivation. ((5))Any reference to peers/family stating participant needs work done. Unspoken pressure to look good for others.“I know he was just teasing me, ’cause that was just kind of—we'd kinda go back and forth, but that actually really hurt my feelings, and I always will remember that.” (Female, 34, breast cancer, rhytids, sun damage)General Societal motivation‡Sub-motivation. (3)Any reference to societal motivation specifically.“It's not easy, especially in today's—how everyone has to look a certain way. They don't make it easy on women to age gracefully. The only thing I can tell you is that people treat you better in public if you look better.” (Female, 50, stroke, spondyloarthritis, rhytids, acne scars)Enhance social acceptance∗Theme. Responses†Motivation. (7)Any reference to the ways in which others respond to one's appearance.“Days when I go out, I look a little rough, people are not as nice than when days, when you go out, and your makeup's done, and your hair is done. Maybe because maybe you feel better when all that is done, so you're a little happier, and people are happier with you.” (Female, 50, stroke, spondyloarthritis, rhytids, acne scars) Photographs, mirrors, and videos†Motivation. (4)Any reference of avoiding photographs, or wanting to look good in photographs, videos or mirrors“I think looking at photographs and things like that, when you see yourself and you're like, ‘Gosh, I feel like I'm looking older.’” (Female, 34, breast cancer, rhytids, sun damage) Romantic motivation†Motivation. ((2))To attract a mate.Relationship confidence‡Sub-motivation. (2)Any reference pertaining to confidence or self-esteem in a current relationship.“It's like, to look good and feel good from your skin perspective, your face, your just overall cosmetic appearance is really important with the relationship with your husband, ’cause if you feel better about yourself, your relationships with other people are gonna be better.” (Female, 34, breast cancer, rhytids, sun damage) Social avoidance†Motivation. (1)Any reference to avoiding social situations.“I looked like a cancer patient. It does impact your wanting to be social when you feel like you look ill and not well. People get awkward around you.” (Female, 34, breast cancer, rhytids, sun damage)Counteract aging∗Theme. Enhanced vitality†Motivation. ((7))Any motivations regarding a desire to look vital, fresh, energized; to have flawless, smooth skin.“I notice that on certain areas of my body, my skin seems to be getting more—it's getting crêpe-y. It doesn't seem to have the elasticity as it once had. I think it's just a sign of aging and sun damage.” (Male, 55, prostate cancer, excess adiposity, skin laxity)Look healthy‡Sub-motivation. (2)“I tend not to think of myself as older. I feel like I feel young. I feel good. I feel healthy. I just wanna look as healthy as I feel.” (Female, 54, CML/GVHD, breast cancer, rhytids) Look younger†Motivation. (4)Any reference describing a desire to look younger/enhance youthfulness.“I'm concerned about my physical appearance, not in a vain way, I just wanna look nice. I want my teeth to be white. I want my forehead to be clear.” (Female 68, cervical cancer, rhytids, sun damage, eyelid ptosis)Alleviate impact on work success∗Theme. Work performance†Motivation. (1)Any reference that one's appearance hinders their ability to perform at work.“Just little things about moving stuff around the office or just the random little physical things that come along with office work, those things have gotten in the way.” (Male, 38, Hodgkin's Lymphoma/GVHD, deep scarring, contractures) Looking good professionally†Motivation. (1)Any reference that the procedure will make them look good professionally.“The younger you look, it's like you can work later in life to a lot older ages, but look younger and more youthful so people aren't gonna think, ‘Oh, she needs to retire,’ type of thing. You can just keep going if you want to, if you're passionate about it.” (Female, 34, breast cancer, rhytids, sun damage)CML, Chronic myelogenous leukemia; GVHD, graft versus host disease.Themes listed in order of frequency discussed.(()) = Total number of patients mentioning this motivation plus the sub-motivations.() = Number of patients mentioning this sub-motivation.∗ Theme.† Motivation.‡ Sub-motivation. Open table in a new tab Patients diagnosed with MMI sought cosmetic procedures to maintain their physical and mental well-being and to become comfortable in social settings. Of importance to patients with MMI is the belief that cosmetic procedures will help their reintegration into society and reinvigorate their relationships, without standing out or looking sick.All participants reported receiving a cosmetic intervention after MMI onset and a few underwent cosmetic interventions while receiving MMI treatment. Many cited the safety of noninvasive cosmetic procedures as a feature that made these more attractive. Finally, several participants stated it was important for their doctor, friends, and family to endorse particular cosmetic treatments before they proceeded.Choosing a cosmetic procedure to mitigate the visible signs of disease is a well-thought-out and deliberate choice made by many patients with MMI. Improved physician-patient communication and shared decision-making may help patients with MMI who are considering cosmetic procedures to arrive at solutions that best meet their needs while ensuring safety. To the Editor: Early theories regarding reasons behind patients' decisions to undergo cosmetic procedures were developed by psychologists and researchers with minimal input from affected patients. Recent works have focused on patients themselves.1Waldman A. Maisel A. Weil A. et al.Patients believe that cosmetic procedures affect their quality of life: an interview study of patient-reported motivations.J Am Acad Dermatol. 2019; 80: 1671-1681Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,2Maisel A. Waldman A. Furlan K. et al.Self-reported patient motivations for seeking cosmetic procedures.JAMA Dermatol. 2018; 154: 1167-1174Crossref PubMed Scopus (46) Google Scholar Patients with a history of major medical illness (MMI) are among the subsets of patients that have not been well-studied. Treatments for MMI, including medications, radiation, chemotherapy or immunotherapy, stem cell transplants, and surgery, may induce premature age-related changes. While some cosmetic procedures may positively affect patients’ quality of life,3Duxbury P.J. Gandhi A. Kirwan C.C. Jain Y. Harvey J.R. Current attitudes to breast reconstruction surgery for women at risk of post-mastectomy radiotherapy: A survey of UK breast surgeons.Breast. 2015; 24: 502-512Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,4Vargas C.R. Ganor O. Semnack M. Lin S.J. Tobias A.M. Lee B.T. Patient preferences in access to breast reconstruction.J Surg Res. 2015; 195: 412-417Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar their perceived utility for the broad range of MMI remains to be elucidated. The purpose of this study was to better understand the motivations of MMI patients seeking cosmetic procedures so that dermatologists may be in a better position to help them through their survivorship journey. Participants were those with (1) MMI, defined as any condition that carries a high risk of mortality and/or disease-related hospitalization; and (2) those that underwent elective cosmetic intervention. Semistructured patient interviews were conducted by a trained investigator (J.G.L.) in accordance with a previously described protocol until no new themes emerged.1Waldman A. Maisel A. Weil A. et al.Patients believe that cosmetic procedures affect their quality of life: an interview study of patient-reported motivations.J Am Acad Dermatol. 2019; 80: 1671-1681Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,5Bowen G.A. Naturalistic inquiry and the saturation concept: a research note.Qual Res. 2008; 8: 137-152Crossref Scopus (1371) Google Scholar The anticipated minimum sample size (n = 12) was based on past research studies indicating that thematic saturation almost always occurs within this number of interviews.5Bowen G.A. Naturalistic inquiry and the saturation concept: a research note.Qual Res. 2008; 8: 137-152Crossref Scopus (1371) Google Scholar Interviews were audio-taped, transcribed, de-identified, and analyzed via a constant comparative approach by 2 independent analysts (E.P and J.G.L). Adult patients were recruited until iterative qualitative analysis led to thematic saturation. Even though thematic saturation was reached by the eighth participant, interviews were continued to a total of 12 to ensure that the themes remained consistent. Participants' ages were 34-82 years (mean, 60), with 9 women, and 84% having at least a college education. The average interview lasted 41 minutes. Major medical illnesses included chronic myelogenous leukemia, breast cancer, hemochromatosis, axial spondyloarthritis, stroke, advanced melanoma, prostate cancer, advanced cervical cancer, graft versus host disease, advanced thyroid cancer, and Hodgkin's lymphoma. Most participants reported seeking cosmetic treatments directly because of their MMI diagnosis (75%) or treatment (66%). Participants' motivations fell under 6 categories: desire to protect health, maintain mental well-being, enhance social acceptance, counteract aging, alleviate impact on work success, and respond to suggestions provided by friends, family, and doctors (Table I). CML, Chronic myelogenous leukemia; GVHD, graft versus host disease. Themes listed in order of frequency discussed. (()) = Total number of patients mentioning this motivation plus the sub-motivations. () = Number of patients mentioning this sub-motivation. Patients diagnosed with MMI sought cosmetic procedures to maintain their physical and mental well-being and to become comfortable in social settings. Of importance to patients with MMI is the belief that cosmetic procedures will help their reintegration into society and reinvigorate their relationships, without standing out or looking sick. All participants reported receiving a cosmetic intervention after MMI onset and a few underwent cosmetic interventions while receiving MMI treatment. Many cited the safety of noninvasive cosmetic procedures as a feature that made these more attractive. Finally, several participants stated it was important for their doctor, friends, and family to endorse particular cosmetic treatments before they proceeded. Choosing a cosmetic procedure to mitigate the visible signs of disease is a well-thought-out and deliberate choice made by many patients with MMI. Improved physician-patient communication and shared decision-making may help patients with MMI who are considering cosmetic procedures to arrive at solutions that best meet their needs while ensuring safety. None disclosed.