Commentary on: Rhinoplasty Outcomes in Patients With Symptoms of Body Dysmorphia

See the Original Article here.

These were statements from my own patients, ironic because the results that they hated were ultimately included in my textbook.¹ Why did they say such things? And why had I operated on them? What didn’t I see?

Those questions have bothered me since 1995, when I operated on 3 such individuals who had good results but were devastated postoperatively. One gave up her job as a university professor and moved to a distant town. She thought her nose pointed toward the ceiling. One was a radiologist's wife who stayed in her bedroom because of a small graft irregularity in her left alar wall. The third was a man who tried to amputate his nose with a razor because he thought his dorsum was too high.

These are extreme examples of patients that surgeons wish to avoid and that sparked the research by Losorelli et al.² The authors reviewed a series of 115 rhinoplasty patients (30% revision rhinoplasties) who had been screened for body dysmorphic disorder (BDD) by the Body Dysmorphic Disorder–Aesthetic Surgery Questionnaire (BDDQ-AS), the Standardized Cosmesis and Health Nasal Outcomes Survey–Obstruction and Cosmesis (SCHNOS), and the Visual Analog Scale (VAS).²

Preoperatively, 30% of the patients screened BDDQ-AS–positive and 69% screened negative. Postoperatively, however, only 8% of patients screened positive and 92% screened negative; therefore 74% of BDD-positive were converted to negative by successful surgery. The authors conclude that most BDD patients, as screened by these metrics, can be happy after rhinoplasty. They caution, however, that they could not predict which preoperative BDDQ-AS–positive patients would be satisfied postoperatively.

The BDDQ-AS screen is a 7-question survey asking whether respondents were concerned about their appearances and preoccupied enough with these concerns that they impaired daily life. What none of the paper's metrics appears to evaluate is the size of the deformity, which is surprising because the cardinal criteria of body dysmorphic disorder in the DSM-5 are “perceived defects or flaws in physical appearance that are not observable or appear slight to others.”³ Marked concern that disrupts a patient's life, especially in conjunction with a minimal deformity, is what prompts many surgeons to refuse to operate.

My first question about the current paper, therefore is, did the patients actually have BDD as defined by the DSM-5? We do not know. Presumably all patients in the current paper had obvious deformities or they would not have qualified for surgery. If so, how can they be body dysmorphic? Do we conclude that these surgeons’ success rate must prompt us to revise the literature cautioning surgery on BDD patients?^4-13

There is already evidence that surgery can be successfully performed on severely psychologically troubled individuals. Sixty-four years ago, Edgerton, Jacobson, and Meyer documented their study of 98 aesthetic surgery patients with “minimal deformity.”¹⁴ Of the group that underwent surgery, 73% demonstrated psychopathology, depression, obsessive–compulsive disorder, troubled family relationships, or marital difficulties. Fifty-five percent had turbulent postoperative courses, some requesting additional surgery.

A 1967 survey of 692 plastic surgeons by Knorr, Edgerton, and Hoopes had defined the characteristics of the “insatiable plastic surgery patient”: often unmarried with impressively low self-esteem, either grandiose or passive and obsequious, obsessive about appearance, potentially aggressive or highly anxious, vague about surgical goals, and having “minimal deformities” that nevertheless distressed them intensely.¹⁵ Their surgeons believed that only 7% of the patients were satisfied postoperatively. “A review of the literature,” the paper concluded, “indicates that this syndrome has not been described previously.” Indeed, it would be another 20 years before body dysmorphic disorder would be formally defined in the DSM-III-R.¹⁶

But in 1975 Dr Edgerton, my mentor at the University of Virginia, wrote an editorial in which he asked, “What is the plastic surgeon's obligation to the emotionally disturbed patient?”¹⁷ He concluded that well-screened and in consultation with a mental health team, many of these patients can be satisfied with surgery; the deformity will no longer dominate their lives.

Edgerton's follow-up paper reported 87 severely psychologically disturbed patients, each considered to be so distressed that surgery would have been contraindicated: those with severe neuroses, personality disorders, psychoses, extreme anxiety, self-consciousness, or depression.¹⁸ Seventeen percent of the patients had personality disorders and 13% were psychotic. The responses to their deformities were exaggerated, and most had been unable to find surgeons who would operate. Many patients had undergone repeated inpatient psychiatric treatment. Any of these patients would today be defined as troublesome, and it is safe to say that very few plastic surgeons would operate on them. Interestingly, the authors determined that the patients’ perceptions of their deformities should take precedence over the surgeon's own aesthetic judgment.

Edgerton, Langman, and Pruzinski also noted that there was little correlation between the magnitude of the anatomical deformity and the degree of preoperative distress or the significance of the postoperative improvement. Even patients with modest deformities (in the surgeon's opinion) benefited significantly. This lack of correlation between the magnitude of the preoperative deformity and the distress that it provokes is frequently cited as an unexplained phenomenon in the body image literature and was a focus of our own research. It again contradicts the first criterion of BDD.³

Forty percent of patients were requesting their first cosmetic surgeries; however, even primary patients can be body dysmorphic: in my review of 1000 consecutive rhinoplasty patients 24 years ago, 11.5% of the body dysmorphic patients had never undergone nasal surgery (unpublished data).

Eighty-seven of Edgerton's patients had a total of 318 operations performed by the same surgeon; 32% were rhinoplasties. Eighty-two percent improved. All patients said that they would undergo the surgery again. Only 13.8% had no improvement; however, none sought further surgery elsewhere. Most importantly, no patients exhibited the types of negative outcomes predicted when significantly psychologically disturbed patients undergo surgery: no suicides, no psychotic decompensations, no litigation. Given this cohort, the outcomes are rather extraordinary.

If the DSM-5 criteria accurately describe surgical patients, the individual with a straight, symmetrical nose without airway obstruction who nevertheless wants surgery for nontraditional indications (eg, to be prettier than a sister or to win a father's approval), thereby satisfying all BDD criteria, should be much more likely to be unhappy.

But in our 218-patient survey, deformity severity did not predict satisfaction. Patients with significant deformities were as likely to be perennially dissatisfied as those with symmetrical, unobstructed noses.¹⁹

Patients tested for body shame provided the answer.²⁰ Body shame, not deformity size, predicted postoperative dissatisfaction. Body-shamed patients were nearly 5 times more likely to request revisions than patients without body shame. For surgical patient populations, deformity size is less important than its meaning to the patient.

The other question is, if some preoperative patients were BDDQ-AS positive, why did the surgeon operate on them?

I can answer that. It is because they look the same as all other patients preoperatively. These patients are sophisticated and compensated during the interview. It is postoperatively that they realize that surgery has not eradicated feelings of being defective, make up that they have been victimized, and become angry at the surgeon, saying what would have been appropriately said to abusers when they were children, but not to their surgeons.²¹

The current authors were not able to predict which BDDQ-AS–positive patients would be satisfied. Here we can offer our own observations.^{19, 21} Surgeons must watch and listen for those characteristics that we observed most often in our unhappy patients: unmarried individuals who had multiple cosmetic operations beginning early; a high rate of previous postoperative dissatisfaction; self-described perfectionism, antidepressant use, and other health problems, particularly a history of excessive pain or drug use.¹⁹ Look also for guarded, untrusting, indecisive, or boundaryless patients who argue or interrupt, or uncontrolled parents or spouses who try to manipulate or dismiss the patient's wishes. We have previously tabulated these behaviors.^{22, 23} Current DSM-5 criteria do not accurately define the most troublesome patients that plastic surgeons see: BDD should be a 2-specialty diagnosis.²⁴

The data in the Losorelli et al paper may not be applicable for surgeons less experienced than its senior author. But it serves 2 important purposes: it encourages experienced sturgeons who can select patients wisely and deliver good results that they can still satisfy many worried or obsessed individuals.

The paper is also an in terrorem for those surgeons who feel financial pressure to schedule cases or who ignore “gut feelings” that a patient should be turned away.

Not every patient has had a perfect life. The seeds of self-worth are planted early by caregivers and childhood experiences, so that body shame and unhappiness precede surgery, not follow it. Anger and discontent in such patients may not therefore reflect postoperative phenomena, but rather preoperative personal demons unrelated to the operation, which is why even our most successful surgeries can fail.

Disclosures

The author has no disclosures or conflicts of interest to declare.

Funding

The author received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes