Dear Dr Bermant
I would like to contribute my own personal blog to the site in case it helps anyone with Body Dysmorphic Disorder. I do not believe that all patients with Body Dysmorphic Disorder should be denied cosmetic surgery. I think there are varying levels of this disorder. I also believe that it is very much misunderstood.
I have personal experience with this disorder as well as being professionally qualified as a psychotherapist. I have also had good and bad experiences of cosmetic surgery. I'm always available to talk to about any of my experiences and - as you know - offer both non-profit and private counselling services.
The Blog in question is: www.dysmorphicconfessions.blogspot.co.uk
This should not be construed as medical advice. I am a retired Board Certified Plastic Surgeon.
Body Dysmorphic Disorder is one of many factors influencing if surgery should or should not be performed. It is an element of the equation about the problem to be solved and needs to be factored into any sugeon's decision to operate just as if there was an infection, the injury being a dog bite, or morbid obesity. Surgeon Judgment
Better surgeons are all trained to be aware of Body Image Disorders and impact on expectations and realistic results. Like many conditions, dysmorphia comes in different degrees and any one individual can differ in how this expresses over time. The issue can focus on a single body part, component of body part, or defect or be more global in nature. Whether something should be operated on is Surgical judgement. Some surgeons are born with consummate surgical judgement skills. No matter what level it starts, there is always room to learn. Surgical safety and satisfaction are part of the risks, benefits, and alternate care decision making each surgeon must make then educate the patient about these options. There are many tales of horror taught at surgical meetings about the risks of this condition and the need to be so careful in patient selection to achieve a happy outcome. Mark Gorney, M.D., F.A.C.S. teachings were the best learning experience on this topic. Here is one of his papers Recognition and management of the patient unsuitable for aesthetic surgery.
. This is one of the areas that is dangerous to push a surgeon beyond their comfort level of safe surgery. Disaster strikes when the surgery does not achieve unrealistic expectations or worse leave the patient with a now noticeable deformity when none existed before.
Unfortunately I have seen many such complications from other surgeons' misadventures in this difficult situation.
Body Dysmorphic Disorder can push expectations beyond the range of what realistic can offer. Real surgery has its limits. There is range of accuracy that for say the fickle nature of cartilage will permit a surgeon to deliver for a pinback Otoplasty
ear cosmetic surgery. For each ear problem, I tried to estimate within what range my sculpture could yield for closeness to the head. When someone says "but doc, I just want this back a little bit more" but that request is beyond the accuracy skills of the surgery, offering the operation, in my opinion, would be a grave error. I saw many such individuals traveling around the country on their xth operation, 6th, 12th and so forth. Yet for a fee, some surgeon had done just one more revision, one more this or that.
Extent and stability of Body Dysmorphia must be factored into the complexity of the operation, degree of deformity to be changed (subtle vs major change), distance to return to surgeon for validation of reality of result, other medical conditions, experience of the surgeon, prior operations, what has been achieved, and so many other factors all can come into play. Assurance from a therapist that the patient is a candidate sometime is an option, and at other times mandatory as in some body changing surgery like Transgender
Here is a parallel topic: Plastic Surgery Forum- Self Esteem Body Image See Shrink Trainer Before Surgeon?
Hope this helps,
Michael Bermant, MD
Retired Plastic SurgeonLearn More About Plastic Surgery