The secret of personal attraction is locked up in our unique imperfections, flaws, and frailties.

By Alexander Zuriarrain, MD, FACS

The quote, from social researcher and author Hugh MacKay, underscores the message we as cosmetic and plastic surgeons must deliver to our patients in the presence of a growing prevalence of body dysmorphic disorder (BDD). 

BDD is a psychiatric disease that causes a preoccupation with illusory flaws in one’s features or body shape and affects both men and women, especially adolescents and younger adults. Experts contend the increased incidence of the disorder is being driven, in part, by social media and society’s fascination with “selfies.” 

In fact, a 2018 article published in JAMA Facial Plastic Surgery indicates that more than half of plastic and cosmetic surgeons report having conversations with patients who want to undergo aesthetic procedures, particularly facial fillers, rhinoplasty, and liposuction, to improve the way they look in “selfies.”

Moreover, authors of a 2020 study in Dermatology Reports find BDD to be “significantly associated with longer duration spent on Snapchat and Instagram.” These same investigators describe manifestations of BDD as “excessive mirror checking or mirror avoidance, camouflaging certain body parts, seeking reassurance, and excessive evaluation. Patients with BDD are frequently seen seeking correction at plastic surgery and dermatology clinics.”

Importance of BDD Pre-Procedure Screening

The physician authors of a 2021 Psychology Today article contend the “unattainable desire” for appearance perfection “can lead to plastic surgery addiction…, a compulsion to continuously alter one’s appearance with cosmetic surgery.” And they call on plastic and cosmetic surgeons to use questionnaires or other screening tools for signs of BDD, such as a patient’s overconcern about appearance or attempts to hide aspects of it, belief facial flaws or body shape is impacting quality of life and relationships with other people, an impaired self-image, and the desire to obtain aesthetic procedures on multiple occasions and in rapid succession. 

“The ability to help patients with BDD get treatment for their condition [by referring them to psychiatrists or therapists] is as important to the plastic surgeon’s repertoire as their surgical skills are,” these physicians write.

Further, a survey involving more than 170 respondents from Dutch associations in aesthetic plastic surgery, dermatology, and cosmetic medicine indicates “most cosmetic professionals have some degree of awareness of body dysmorphic disorder, although the number [of BDD patients] they report encountering in clinical practice departs from prevalence figures,” say the questionnaire’s authors. Their study appears in an issue of Plastic and Reconstructive Surgery.

However, scientists writing in a 2020 edition of the Journal of Cosmetic Dermatology state, “The incidence of body dysmorphic disorderis high. Even though treating patients with this disorder may worsen symptoms and is fraught with potential complications, [surgeon] screening is low, due in part to a lack of knowledge of the disorder, as well as inadequate screening tools.” These same investigators indicate respondents to a survey “sent to nearly 3,000 practicing dermatologists and members of the American Society for Dermatologic Surgery (ASDS), estimated that 13% of all new patients likely had BDD. [But] only 60% [of responding surgeons] routinely asked new patients about psychiatric history, and 37% did not consider BDD to be a contraindication to cosmetic treatment, despite the acknowledgement…that patients with BDD who received treatment became more focused on the defect or found new defects to focus on after the procedure.”

Cosmetic Procedures Most Desired by BDD Patients

Cosmetic rhinoplasty, facial fillers, abdominoplasty, and liposuction are procedures commonly sought by patients with BDD. In a 2019 report in Aesthetic Plastic Surgeryscientists note finding a “high prevalence of BDD and moderate to severe appearance-related obsessive-compulsive symptoms…among aesthetic rhinoplasty candidates.”

Another study, this one in Laryngorhinootologieindicates “the central position of the nose in the face makes the nose one of the most common areas of concern in patients with BDD. Thus, aesthetic rhinoplasty is suspected [of being] one of the most frequently requested and performed surgical procedures in this population.” 

The authors of this study go on to say that “BDD should be considered a contraindication for aesthetic rhinoplasty, as favorable outcome is unlikely. In order to prevent patients from undergoing unsatisfying surgery, and in the context of the increasing importance of medico-legal arguments, the rhinoplasty surgeon should be familiar with BDD.”

Additional research has found links between BDD and requests for liposuction (Dermatologic Surgery) and abdominoplasty (Aesthetic Surgery Journal). In fact, the authors of the Aesthetic Surgery Journal article say, “Body contouring surgery is most frequently sought by patients with BDD and those with eating disorders.” Other researchers find eating disorders and BDD to be interrelated and prevalent in plastic surgery patients and suggest both disorders are “contraindications to surgery.”

Moreover, in an online article in Cosmetic Treatments and Body Dysmorphic Disorderexperts suggest as many as 40% of BDD patients pursue cosmetic treatments. In one study, as many as 14% of patients in cosmetic dermatology clinics “met the criteria” for having BDD, the authors write, adding that these patients were more likely to be dissatisfied with their treatment outcomes and seek additional procedures.

Key Takeaways

So, what is the key takeaway? As aesthetic and plastic surgeons, we must do a better job of recognizing patients who suffer from symptoms of BDD. That means learning as much as possible about the disorder and finding appropriate screening tools. Scientists, writing in Tijdschrift Voor Psychiatrie, conclude: “Preoperative screening of BDD patients is vital so that efficient psychiatric treatment can be initiated, and patients not subjected to surgical interventions which may be ineffective or even harmful.”

Cosmetic surgery is not a first-order treatment protocol for BDD and can expose a patient to unnecessary surgical risks. In fact, one study showed that only 2% of BDD patients who had undergone cosmetic surgery were satisfied with the end results.

Historically, experts in our field have advised that BDD be treated first as a psychiatric disorder before any surgery is performed. Of course, as we better understand the disorder, we might consider what some experts call “more nuanced decision-making” concerning suitability of specific patients for cosmetic procedures.

According to authors of an article in the International Journal of Womens Dermatology“some studies report…those [patients] with mild-to-moderate BDD, [who have] no significant impairment in overall functioning, [are without] localized appearance concerns, and [maintain] realistic psychosocial expectations may benefit” from appearance-enhancing surgery. Indeed, cosmetic surgery could improve their overall mental perspective and health.

And research published in the Journal of Plastic, Reconstructive & Aesthetic Surgery suggests just that: A majority of the studied rhinoplasty patients diagnosed with mild to moderate BDD experienced remission of their BDD symptoms and expressed satisfaction with the results of their cosmetic procedure one year postoperatively.

Perhaps, our message to patients, especially those suspected of having BDD, should be what the author of an online article titled “Body Dysmorphia and Cosmetic Surgery” wrote. Beauty, balance, harmony of the face and body “work in concert with other perceived elements, making us like and even feel attracted to someone. Alongside…good looks, authenticity and vulnerability are two very underrated elements of attraction. Visible flaws are there to offer this sense of vulnerability and authenticity. They make you a certified human.”

Or, as author Norhafsah Hamid one said: Do not have expectations. We humans are created imperfect…we have flaws.

Alexander Zuriarrain, MD, FACS, is a board-certified plastic surgeon and owner of Zuri Plastic Surgery in Miami. Listen to a podcast PSP did with him here.