A Practical Guide to Managing Body Dysmorphic Disorder in the Cosmetic Surgery Setting

Abstract

A recent article by Rajanala and colleagues 1 has shone light on current trends to "enhance" selfies with the simple use of Instagram or Snapchat filters. The authors describe increasing rates of patients presenting to cosmetic surgery practices requesting treatment to make them look like these enhanced, often unrealistic, versions of themselves. While some appearance dissatisfaction is nearly ubiquitous in the general population-so common that it has been termed "normative discontent"-at the extreme end of this spectrum are patients with a psychiatric illness called body dysmorphic disorder (BDD). In general, patients with BDD make poor candidates for cosmetic surgery. Prevalence studies show that 7.7% to 9.7% of patients who present to facial plastic and reconstructive surgery settings screen positive for BDD. 2,3 Specifically, 13.1% seeking cosmetic surgery 2,3 and 1.8% 3 to 6.7% 2 seeking reconstructive surgery likely have BDD. However, surgeons only correctly recognize BDD in 4.7% of cases. 2 Plastic and reconstructive surgery practices both would likely benefit from enhanced BDD screening, management, and referral procedures. Herein, we provide a brief, practical guide to (1) understanding BDD, (2) identifying patients with BDD in a cosmetic surgery practice, (3) understanding the risks of performing cosmetic surgery on patients with BDD, and (4) referring patients with BDD to appropriate care. These recommendations may also be relevant for other medical professionals, such as dermatologists and dentists. For further resources, see the comprehensive guide by Sarwer and colleagues. 4

Treatment utilization and treatment barriers in individuals with body dysmorphic disorder

“…On the other hand, individuals with prior surgery still reported an increased preference for cosmetic procedures and reported to be more certain with their way of help seeking. Therefore, medical professionals should be aware of the fact that they treat a considerable number of patients who could suffer from BDD [9] and thus should use available guidelines for the identification and management of these clients [51,52]. Third, our data directly reflect that individuals with poorer insight favored cosmetic or medical treatments over mental health treatment.…”

Perceived impact of COVID‐19 pandemic on body dysmorphic disorder and anxiety among population seeking cosmetic procedures

“…Theoretically, up to 10% of BDD patients search for esthetic procedures, whereas 2% of individuals with eating disorders seek cosmetic procedures 5 . Physicians usually underestimate the diagnosis of BDD in patients seeking cosmetic procedures leading to numerous unnecessary treatment modalities for changing patients’ appearance and dissatisfaction 11 . Potentially, halt of esthetic procedures could aggravate concern of BDD patients regarding thinking of imperfection physical beauty and appearance 5 …”

“…5 Physicians usually underestimate the diagnosis of BDD in patients seeking cosmetic procedures leading to numerous unnecessary treatment modalities for changing patients' appearance and dissatisfaction. 11 Potentially, halt of esthetic procedures could aggravate concern of BDD patients regarding thinking of imperfection physical beauty and appearance. 5 In another study, 15.2% of individuals reported symptoms of anxiety and body dissatisfaction, which were indicative of BDD during the COVID-19 pandemic.…”

An Evidence-based Pathway for Body Dysmorphic Disorder in Facial Aesthetics

“…In the event of suspected BDD, the aesthetic procedure should not be performed, 13,14,16,19,20,22,45 rather the patient should be referred to mental health services for mental health and social assessment, patient education as well as potential mental health treatment. 13,14,17,21,22,26,27,31,33,34,36,38,39,46,49 Following mental health assessment and potential treatment, a multidisciplinary approach should be adopted between the aesthetic clinician and mental health professional to assess whether or not the benefits of the aesthetic procedure outweigh the risks. 13,20,22,28,31,36,41,44…”

“…The articles advocated a multidisciplinary pathway consisting of aesthetic clinicians and mental health professionals, working closely with patients. 17,22,27,28,33,44 Articles discussed that in all patients, assessment for BDD should take place before performing any facial aesthetic treatment. [13][14][15][16][17][18][19][20]22,32,37,40,43,45,[48][49][50] This assessment could be carried out by a mental health professional.…”