While cosmetic surgery is about improving one’s face or body appearance, whether one needs such surgery or not is open to personal interpretation or desires. How one sees themselves plays a major role in the ‘need’ for cosmetic surgery. It should be no surprise then that the use of antidepressant and other psychiatric medications has been reported to be twice as high in patients seeking cosmetic treatments over those that don’t. In addition, up to 15% of cosmetic surgery patients suffer from a well known psychologic problem known as BBD or body dysmorphic disorder. (compared to 1% in the overall population) Body dysmorphic disorder is when one is overly obsessive about some aspect of their appearance or have exaggerated concerns about their appearance. This drives them to not only have cosmetic surgery but frequently repeat or revisional surgeries to achieve an appearance goal that may not be achieveable. Sometimes this involves returning to the same plastic surgeon, but if turned away, they will find another surgeon to resume their change efforts. While one assumes that screening for the BDD patient is easy, there is no standardized screening tool for it. Often the plastic surgeon only makes the diagnosis after the surgery has been done and the patient is not happy with a result that may otherwise be acceptable to most patients.
Rhinoplasty is a unique plastic surgery, not in how it changes the shape of the nose, but on its potential impact on a patient’s psyche. Rhinoplasty has long been associated with patients who obsess over apparently very small nose issues and frequently request and pursue multiple revisional surgeries from different plastic surgeons. While changes in one’s face or body can evoke a variety of patient reactions, rhinoplasty disproportionately causes a greater amount of obsessive or perfectionist reactions.
Known as body dysmorphic disorder (BDD), this is a condition in which one has an unnatural and often unreasonable preoccupation with defects in appearance. Most of the time these defects are slight to even imaginary. Some patients with the disorder complain about body parts that most people would consider to be normal. Given that the outcome of a rhinoplasty involves a lot of different and interrelated parts to create the overall look, it is no surprise that BDD occurs most commonly with this plastic surgery operation.
In the August 2011 issue of Plastic and Reconstructive Surgery, a study out of Belgium reports that a significant number of people who complain about the size or shape of their noses show signs of this mental condition. This study was based on more than 200 patients who were evaluated for rhinoplasty over a nearly 1 ½ year period. During the initial consultation, the patients were given a psychological questionnaire to assess their potential symptoms of body dysmorphic disorder. They found that over 40% of patients had symptoms of BDD that were seeking to have cosmetic changes in their nose. Conversely, only a handful (2%) of patients seeking correction of a breathing problem exhibited symptoms of the disorder. Collectively, one-third of the studied rhinoplasty patients had signs of BDD.
This study shows a surprisingly higher number of BDD symptoms in rhinoplasty patients than previously thought. Previous studies have shown that about 10 percent of patients seeking plastic surgery suffer from the condition. But there is the influence of the makeup of the questionnaire and the study and culture of the patient population being evaluated. It is also relevant that these were primary rhinoplasty patients. Patients seeking revisional rhinoplasty may or may not have a higher incidence of BDD.
When evaluating a patient for rhinoplasty, it is important to remember that they are there because they are dissatisfied with the appearance of their nose. This does not automatically make them abnormal or have BDD.I would say that the vast majority of rhinoplasty patients I see have very visible and understandable reasons for why they don’t like the shape of their nose. What can not be known in most consultations is how much the appearance of their nose disrupts the rest of their lives. Even a big deformity of the nose if it disrupts the major functions of their life is not a healthy psychological sign.
But it is very hard to pick up BDD symptoms in a primary rhinoplasty consultation. That discovery all too often is not made until afterwards. But despite this study’s findings, my own practice experiences do not show the potential numbers of rhinoplasty patients with BDD that are remotely that high. While I have never done a consultation questionnaire, the percent of rhinoplasty patients unhappy with their results is a ‘hard’ test after the fact…anda hard one to miss.
The risk of rhinoplasty and subsequent unhappiness in a patient with BDD escalates considerably in revisional surgery, particularly when you did not do the primary surgery. A knowingly unhappy patient upfront has a very diminished ability to be happy afterward. Fortunately, these patients are easier to pick up than primary rhinoplasty patients with BDD. They describe in great detail the anguish of their prior surgerie(s), how it has disturbed their everyday life, and have pictures or drawings as to what is wrong or what needs to be done. They spend a great deal of time with a mirror in their hand pointing out the flaws of the prior surgery during the consultation. This does not mean that a good surgical outcome can not be obtained, but the percentage of doing so drops precipitously.
The recent tragic demise of pop star Michael Jackson brings forthmany images and memories. I was in my youth during the height of his stardom and his music and videos will live with my generation for the rest of our lives. His music elicits memories of where we were at that time and what we were doing. Whatever one may think of him during the latter part of his career, the positive side of his talents will be remembered much longer.
As a plastic surgeon, I am also drawn and intrigued by his physical metamorphosis over the years. While the number of plastic surgery procedures that he underwent is speculative and will never be precisely known, it is fair to say that he had an extreme number of them. Much conjecture has been made as to his motivations for doing so, but only he truly knows for sure. Whatever his reasons where, however, he clearly suffered from body dysmorphic disorder (BDD), a well known form of cosmetic surgery addiction. However, Michael Jackson was not alone when it comes to this psychiatric disorder which manifests in continuous and ongoing plastic surgery procedures to the point of deformity.
BDD is a condition that can affect even an already attractive person. While it initially appears that those afflicted with the disorder appear to be overly vain, in reality they actually feel ugly inside. In essence, they have a significant misperception of reality and don’t see themselves as others do. While this difference in how we look and others see us is actually common, BDD is an extreme expression of it. As a result, BDD victims tend to be withdrawn and need constant reassurance that their looks are acceptable. Because they can never satisfactorily internalize (believe) any outward accolades, they see cosmetic surgery as the only solution to getting rid of their imagined ugliness.
Contrary to what one may think, it is not initially easy to spot a patient with BDD. Because some procedures require multiple stages or have naturally high potential rates of revision, a patient who wants or undergoes multiple procedures does not necessarily throw up a red flag. Many patients after a plastic surgery procedure are very critical of the result in the understandable interest of getting the best result and return on their investment. This makes it difficult sometimes to tell someone that this is as good as you can do and they should live with their current level of improvement. I have learned over the years that the best way to control the ‘perfectionist’ is to not do revisional surgery for free. This helps the patient place a ‘value’ on their pointsd of critique. In the case of Michael Jackson, where money was no object, there is virtually no stop sign in this regard.
While it is true that an ‘ethical’ plastic surgeon should stop operating at some point and refer a patient for psychological counseling, that approach becomes very difficult when the patient is a celebrity. (it is difficult even when the person is not a celevrity for that matter) And even if the BDD patient is turned down by one plastic surgeon, there is always other plastic surgeons who will perform ‘revisional’ cosmetic surgery an unlimited number of times. As long as the patient has money, they can always find their next cosmetic surgery fix.
But BDD appears to have two different variations. Some BDD patients (Type 1) keep operating on the same things in search of perfection, often until they develop a deformity or problem. Other BDD patients (Type 2) seek to literally change their appearance, undergoing operations on different areas with the objective of creating a new look or to be a different person. Type 1 BDD patients are more common and I have seen several in my Indianapolis plastic surgery practice over the years. Type 2 BDD patients, such as Michael Jackson, are extremely rare even though they seem more common due to the media attention that they garner.
Body Dysmorphic Disorder (BDD) is a well recognized finding in a very small number of plastic surgery patients. People suffering from BDD perceive themselves as unattractive, focusing on a small physical defect or an imaginary cosmetic flaw. They frequently seek repeated plastic surgery operations, never being satisfied and always thinking that the physical problem persists. While they are at some significant risk for suicide, my observation is that they are focused on more surgery rather than taking their own lives.
What is the underlying cause of BDD? There has been some speculation that the cause of BDD is, at least partly, driven by society’s high emphasis on appearance. Since BDD is a more recent diagnosis and the upsurge in cosmetic surgery is also fairly new, the potential cause and effect relationship between the two seems obvious. However, recent research published in the December 2007 issue of the Archives of General Psychiatry suggests that it may be more than just an environmental influence. Scientists at the University of California have found that there may be a visual brain glitch that makes BDD patients see the world differently. They outfitted 12 patients with goggles that showed digital images of faces that were either unretouched photographs, line drawings of faces, or images that had facial details blurred out. MRI imaging of their brains revealed that BDD patients used the left side of their brain more often than normal. As the left side of the brain is very sensitive to complex details, people with BDD may have an inaccurate visual assessment of what they see….perhaps seeing details that aren’t really there. In short, they may see faces inaccurately, not as they really are.
This study certainly makes sense in that there is really an internal ‘wiring’ problem in what they see, not that they are just plain crazy. They may be literally seeing things that aren’t there. This may perfect sense if you have ever worked with someone with BDD. They literally are showing things on their face, even with a mirror in hand, that you have a very difficult time seeing. Whether that lends them to successful psychiatric therapy, I do not know. But perhaps their brains may be capable of being retrained rather than relying on medications.
Dr. Barry Eppley
Body Dysmorphic Disorder and Plastic Surgery Addiction
Many patients ask or assume that I frequently see so called ‘plastic surgery addicts’ as they phrase it. Their perception of the plastic surgery addict is the patient who just can’t stop having plastic surgery and comes back over and over. In reality, there is some truth to their assumption but also a lot of misconceptions.
The misconception part is that the vast majority of plastic surgery patients are normal, have one or two procedures, are immensely happy, and are cetainly not addicts by any stretch of the imagination. Probably most plastic surgery practices have about 1/3 of their patients who come back at some point after one surgery to have another. I call this ‘accomplishment feedback’. They have had a very positive experience from their initial plastic surgery procedure and, as a result, are motivated to seek out other procedures in the future. This type of patient is hardly an addict. It is this happiness that accounts for much of the increase in people having plastic surgery procedures over the past five years. (TV shows, the internet, and widely available financing programs make significant contributions as well)
The true plastic surgery addict really falls under the psychiatric diagnosis of Body Dysmorphic Disorder. (BDD) They obsess over perceived problems or have greatly exaggerated concerns over small imperfections. They frequently have seen numerous plastic surgeons, have had multiple operations, and will travel great distances to be seen. Often they do have some real physical problems and they can be quite charming and convincing. Often they are not easy to spot and the heroic and egotistical mentality that goes with being a surgeon can make one easily overlook such a patient. They often do not appear crazy……until after surgery.
I have had personal experience with five true BDD patients and have mistakenly operated on several of them earlier in my practice. The pain that I have endured in taking care of them have taught me several valuable lessons that influence how I practice today. As an unaltered rule, I will not even consider performing surgery on someone that comes in with complaints or concerns about a prior plastic surgery procedure by another surgeon…..until I have spoken to that surgeon and received copies of their medical records. This simple step is the surest method to diagnose a BDD patient, the most dangerous form of a plastic surgery addict.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.