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Body Dysmorphic Disorder – Is cosmetic surgery ever the answer?

Body Dysmorphic Disorder – Is cosmetic surgery ever the answer?

Mr Hiroshi Nishikawa, Consultant Plastic, Reconstructive and Aesthetics Surgeon, gives us his thoughts

Body Dysmorphic Disorder (BDD) is a condition where a person has an obsessive preoccupation with their appearance and can go to extreme measures either to hide the problem or to fix it. BDD is a surprisingly common psychological disorder and it is believed that 2.4% of the population suffers from this. It comes under the psychiatric umbrella of the obsessive-compulsive spectrum but undoubtedly it is incorrect to pigeonhole this complex psychological illness and there is a range of severity. BDD can be a very debilitating condition and probably under diagnosed. It can seriously interfere with the quality of life.

It is not unusual for patients with body dysmorphic disorder (BDD) to present to cosmetic surgeons for treatment. In my experience the perceived flaws in people suffering from BDD are more often delusional and there is often total denial or disbelief of anybody that tries to reassure or persuade them that their appearance or problem is in fact normal.

The most difficult patient to help, from a surgeon’s perspective, are those where there is a flaw but in his or her mind it is amplified to be a severe deformity or blemish. The perceived flaw becomes all pervasive and can occupy the patient for much of the day. This variant of BDD, where there is a clinical aspect that could potentially be altered surgically, is difficult to manage. I believe that often it is a mistake to try and help these patients with an operation. Surgery may uncover other psychological problems and often makes the patient feel worse. The surgeon’s benchmark of success is usually not the same as the patient. They often do not want a cosmetic improvement but are desperate to look normal in their own eyes. One of the great challenges in an aesthetic practice is to understand and diagnose patients with this disorder before surgery takes place. 

For the vast majority of patients who have cosmetic concerns, the aims are usually different from that of patients with BDD.  Cosmetic patients want improvement of real flaws of shape, size, position and form relating to areas of the face and body that can be perceived and appreciated by the clinician, partners, confidants and friends.  If a cosmetic patient has anxiety about a small or tiny flaw this does not does not mean that he or she has BDD. It is when there is a delusional element about a problem that no one else can see or the when there is an extreme and unhealthy reaction to a flaw beyond all normal reactions.

I do recall one patient who came to see me for asymmetry of the ears. One ear was sticking out very slightly more the other and they were genuinely concerned about the shape of their earlobes. The patient was articulate and seemed pragmatic about his expectations, so after two consultations, I was convinced I could help them and I thought that I understood their concerns. There was notable improvement after surgery, but it was not perfect enough and I had made the patient even unhappier.  I advised them that another operation was not in their interests, as I could not guarantee that further refinement was possible.

The patient decided to seek a second opinion elsewhere and underwent further surgery. Eventually they returned to my practice, and the shape of the ears had changed considerably. They had been made to stick out less and were now quite flat now against the head. The patient was even more unhappy; the depression and anxiety had a noticeable effect on their appearance. They asked for further surgery to return the ears back to their original state as they felt this would make them less miserable. They claimed their ears were ruining their life. The penny dropped, and I belatedly realised that they had BDD. Much to my frustration, and the patient’s, there was nothing more I could do to help this person, other than instigate a referral for psychological help, which was declined.

During my long surgical career I have often wondered why surgeons still make errors with patient selection; I think there are a number of reasons for this. One is that we miss the obvious because we are convinced by the patient that we can do some good and then surgical instincts take over; changing something because we can. We should not forget the political adage that having nuclear weapons does not mean we have to use them!

Diagnosis and judgement are the cornerstones of all medicine and surgery, and it is the responsibility of the clinician to get this right before embarking upon treatment. Patients with BDD need psychological or psychiatric help, not surgery.

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