Body Dysmorphic Disorder (BDD) is a well recognized psychological classification that is not a rare sighting in a plastic surgeon’s office or surgery center. Most of the time BDD patients are ‘discovered’ after a surgical encounter due to either good camouflage by the patient or lack or recognition during the presurgical discussion(s). While outsiders can be quick to question how such an oversight can happen, truly insightful time spent in most plastic surgery consultations is quite limited. Nor is it practical to require every patient for cosmetic surgery to undergo some form of psychological testing or a questionnaire, even if we accept the premise they would have a high rate of identifying those patients who will be dissatisfied with their plastic surgery
An interesting study on the BDD patient was published in the July issue of the Annals of plastic surgery. Researchers evaluated retrospectively 200 BDD patients who received such cosmetic treatments (n = 42) compared to those who did not (n = 158). Receivers of either surgical or non-surgical cosmetic treatments reported less severe BDD symptoms and delusions than those subjects that did not receive such treatments. While getting the treatment lessened one’s preoccupation with the treated body part, overall BDD severity improved in only just a few of the patients. In those patients who wanted cosmetic treatments but did not get them was primarily due to cost and physician refusal.
What does this study really tell us? Perhaps to no surprise, someone who suffers from BDD is not cured or usually even improved by physically altering what they think bothers them. When you don’t have an insightful perspective on how your physical traits appear (do any of us really?) then it would be hard to see how changing a target that you don’t see clearly would be helpful. At best it is a psychologically risky gamble. Which is why most plastic surgeons, if they knew the patient had true BDD, would refuse surgery.
However, BDD can be very hard to spot and its actual definition may have shifted over the past decade. This is recognized today by extreme plastic surgery. Extreme has two meanings in the plastic surgery context. One version of extreme is for the unnatural or out of body proportion surgery. The woman who now wants 1000cc saline breast implants or the patient who wants his nose built up (overprojected) to look like an almost cartoon character appearance. While these changes are not ‘normal’, these patients have very well defined targets and they know exactly what they want. Getting there will make them satisfied (for now) but is it appropriate to create these potential ‘deformities’ even if they can technically be done and do not place the patient at any medical risk for doing so?
The second type of extreme plastic surgery is more common and television shows have even been done about it. It is when perfectly normal and appropriate plastic surgery procedures are done but a large number of them are combined and done at the same time. An example would be a ten hour surgery consisting of a facelift, rhinoplasty, breast augmentation, tummy tuck and liposuction. While all of it can be done, is it appropriate to expose the patient to increased medical risks for the sake of recovery efficiency and cosmetic expediency?
Is extreme plastic surgery just an extension or variation of BDD? Most psychologists would probably say not but I would submit that the risk of creating some equally unhappy patients exists just as well. These more obvious forms of BDD are easier to spot and control before surgery is ever done.
Dr. Barry Eppley
Indianapolis, Indiana