Join Plastic Surgery Practice Co-Chief Editors Alison Werner and Keri Stephens as they talk to Alexander Zuriarrain, MD, FACS—a board-certified plastic surgeon and owner of Zuri Plastic Surgery in Miami—about the prevalence of body dysmorphic disorder (BDD) among plastic surgery patients. The podcast, which follows Zuriarrain’s PSP article about the subject, reveals what’s contributing to the surge of BDD and what red flags surgeons should look out for when encountering possible BDD patients. Hint: The mnemonic “SIMON” comes into play.
Zuriarrain also divulges the role eating disorders play in BDD and what cosmetic procedures BDD patients commonly request. Finally, he shares how plastic surgeons should respond to patients who exhibit signs of BDD.
Hello and welcome to the Plastic Surgery Practice Podcast on the MEDQOR Podcast Network. I’m Keri Stephens and I’m joined by my co-host Alison Warner. We are the co-chief editors of Plastic Surgery Practice. Today we are excited to have Dr. Alex Dr. Zuriarrain back with us to discuss body dysmorphic disorder or BDD among plastic surgery patients. It’s a subject he recently wrote an article about for PSP. Dr. Dr. Zuriarrain is the founder of Zuri Plastic Surgery in Miami, where he specializes in aesthetic procedures of the face and body, including facelift, eyelid surgery, rhinoplasty, breast augmentation and reduction, abdominalplasty, liposuction and the Brazilian butt lift. Dr. Dr. Zuriarrain, thank you for joining us today.
Thank you so much. Appreciate you guys having me on as always, and great to talk to you.
We love it too. So to start in your plastic surgery practice, have you seen a rise of patients suffering from BDD and what do you think has contributed to this surge?
Yeah, I see a lot more body dysmorphic disorder and I think the problem is, is that as physicians we are not being very keen on screening these patients. I think a lot of us don’t really spend a lot of time trying to make this diagnosis. We typically know when somebody is acting in a way that is out of the norm, but we’re not really going anywhere beyond that to really pin down if they really do have the disorder or not. I have a background in psychology, that’s my undergraduate degree and I’m very keen on figuring out whether or not some of my patients are exhibiting these symptoms because it’s a red flag if they are. And you have to be very careful how you treat them.
Okay. So what are some of the top cosmetic procedures BDD patients request and why do you think that is?
So a lot of it has to do with facial surgery. A lot of them are looking at themselves in the mirror and what they have is a minimal disfigurement, but they’re really internalizing it as something much greater than what it really is for the rest of us. They have a delusional distortion of their body image. A lot of them have identity problems, some of them have sexual ambivalence. So it happens a lot. Rhinoplasty is the classic surgery that if you are going to pin down one operation that you really got to be careful with when it comes to body dysmorphic disorder, it’s going to be rhinoplasty. And with rhinoplasty in particular, you’re looking for a mnemonic. And we as surgeons and doctors, we love mnemonics, I mean, that’s the way that we memorize a lot of the amount of information that we have to cram in our heads in medical school.
So there’s a mnemonic called SIMON, and SIMON stands for single immature male, overly narcissistic. And that’s the classic person that if walking into your surgical practice asking for a rhinoplasty or any other surgical procedure, if they fit those categories, you really got to screen them. And if you really are worried about them, for those physicians that are listening to our podcast, you really have to send them to psychiatry. You cannot have any shame in that game, to be honest with you. You got to get them to see a professional. And I think a lot of us shy away from recommending psychiatry because the patient’s going to get totally offended or, “How could you send me to psychiatry? I’m not crazy.” But if you don’t do that, you’re going to hate your life as a surgeon because they’re going to keep coming back to you and they’re going to keep seeing something that is not real in the mirror and there’s no way to help that person through surgery. So you really got to be careful with that.
I wanted to ask a question that goes back to when you were discussing what is body dysmorphia and have you seen the rise in patients? Where does eating disorders fit into that? Because I read in your article you mentioned the fact that eating disorders is seen with patients who are seeking body contouring.
Yes, yes, absolutely. I think it’s that negative relationship with food and unfortunately how a lot of patients, they yo-yo in their weight and they get into these bulimia episodes or anorexia episodes sometimes, sometimes they’re even mixed from a psychological standpoint. And I think these people, again, it all kind of ties into the idea of body image, what they’re seeing in the mirror versus what is the reality. And this is an illness, this is a psychiatric illness, and just like an eating disorder is an illness, body dysmorphia is an illness.
And there are a lot of patients in this subcategory that are also bipolar disorder. They have a lot of anxiety as well as some paranoia peppered into the whole scenario. And so they also can have other attributes. They could be a little bit hostile towards authority sometimes, they may see multiple physicians and then talk very poorly about your colleagues, about the other surgeons that they’ve seen along the way, saying things like, “Well, he doesn’t know what he’s doing, he didn’t want to offer me surgery, but I know that you’re the expert, Dr. Z. I know that you’re going to be the one to get me the rhinoplasty that is going to change my life. So would you do that?”
Yes, a lot of manipulation, total manipulation. And then it’s interesting because if you dig deeper, they don’t really have great social or emotional relationships with a lot of people. You can ask them who, “Well, who’s your closest friend? Or what’s your relationship with your mother or your father like or maybe your siblings?” A lot of them are strange, they live alone, they don’t have a lot of friends. So they’re in a very specific category of person. And they’re also sometimes very confused and sometimes vague about what their motives are. “Oh, why do you want to have surgery?” Well, they’re vague, they’re all over the place. It’s not because, “Well, listen, I have this hump that I really don’t like.”
And then when you’re examining them like, “Yeah, you definitely have a hump. There’s no question. I can fix that hump.” And they’re like, “That’s all I want. All I you to do is fix that hump. I’ve had it since I was 10 years old.” And then you’re like, “Okay, this is a reasonable person.” But when they start getting into this minutiae like, “Oh, I want to lift my tip one centimeter and I want my nostrils to be at this angle and I want this and that .” I mean, then you start to really start to question, what’s the motive here? What do you trying and accomplish?
Well, on that front, you mentioned some that in essence that’s somewhat about screening, but what are some of the ways plastic surgeons can screen patients for BDD and how should they approach patients that show signs of it? You talked a little bit about there, but could you go a little further?
Yeah. So I do think that you’re going to have to take some time as a plastic surgeon reading up on BDD, you have to educate yourself first of all, we don’t expect that when patients walk in the door and you suspect that they have BDD that you’re going to have take a personality test in your office, that’s going to be really awkward in my opinion. I think your job is to have a predetermined set of questions that you know that based on those answers is going to lead you towards that type of diagnosis. And it’s very simple. We talked about a few of them, for example, what does your social relationships look like? What do you do for a living? How long have you been at that job? What’s your relationship with your family like? Some of them have had an unresolved episode of grief or a crisis in their life and they just haven’t gotten over that.
So they do, what we would say is they translate that into their physicality, into the way that they look. And they’re seeing things that are not really there, but they’re misdirecting their grief and they’re misdirecting their anger and their frustration and their sadness onto themselves physically. And the mind body connection is real. I mean, this is true and I live it every day, and I can give you plenty of examples of how the mind is very connected to the body and manifests itself physically a lot. So yeah, you got to read up on BDD a little bit more. There are criteria for diagnosing it and you have to be up to date on that. And as surgeons, we’re obligated to stay up to date on all of these findings, whether it’s a surgical technique or an actual psychiatric diagnosis. You may not be a psychiatrist, but we are dealing a lot with human emotion in plastic surgery.
We’re dealing it with a lot of grief, with a lot of sadness, with a lot of altered sense of self. And even when you do beautiful surgeries, let’s say for example, yesterday I did a breast reduction on a 16 year old girl and she came today for her first post-op visit, looked at herself in the mirror. And it’s a shock. It’s a real shock when you go from an F cup breast to a C cup breast or a D Cup breast. And that happens a lot.
And initially it could be so shocking that they just want to go back to what they looked like before because that’s their comfort zone and they really wanted the surgery and they really wanted the change. But your mind takes some time to adapt and to recognize that this is the new you, it happens a ton in facelift surgery. My God. I mean, facelift surgery is partly the number one where people just look at themselves in the mirror and they’re like, “I like what I’m seeing, but it’s going to take me some time to adjust to this. It’s not going to be immediate.” So yeah, it’s a serious thing to consider.
No, that makes a lot of sense. And you touched on this a little bit earlier, but can you talk about how the BDD patients react after they have had plastic surgery? Are they typically satisfied? Are they dissatisfied?
Yeah, luckily I’ve been really keen on not operating on those patients. So I can’t tell you I have a strong experience or a lot of stories I can tell you about them. I mean, I’ve had what I would consider borderline BDD patients. They may have not had the full-blown diagnosis, but it’s miserable as a surgeon, to be quite honest with you, it’s very frustrating. You have to humble yourself tremendously. And you can’t take anything personally because this is our art. As plastic surgeons, we’re manifesting our destiny to change lives and to create bodies that we find to be beautiful. But not only us, all of society or the majority of the society would find attractive. And so those are the standards that we live by every day. But when somebody comes in and you know you nailed it, you hit it out of the park, you take 10 people off the street and nine of them would agree that they look great when they look at their before and after photos and they’re telling you they look the same, nothing’s changed.
I look terrible, or this was a terrible investment, I should have never had surgery. It’s brutal. It’s hard to absorb that as a surgeon. So as I mature as a plastic surgeon, I become more and more and more selective on who I operate on. And it’s funny because when I was a resident and I was training at the Cleveland Clinic, I had a couple of mentors that used to tell me that, they used to say, “Listen, the patient is choosing you, but you need to choose the patient. It has to be a two-way street. And if you don’t feel like you’re going to be able to operate on somebody and achieve what they’re looking to achieve, then it’s going to set you up for a lot of heartache and a lot of uncomfortable situations.” So I would say that be careful who you’re operating on.
Don’t be so eager to offer somebody surgery so quickly after meeting them. And I would tell especially the younger surgeons that are just coming out, you can have somebody come back two or three times for a consultation. You don’t have to have a one and done [inaudible 00:13:53] consult. If you’re not sure, if you got a sixth sense, if the hairs on your back are standing up or on your neck and somebody’s giving you a weird emotional vibration, just say, “Hey, nice meeting you, but I’d really like to see you back here in a couple weeks or in a month to talk this over. I think this deserves more time.” And then you can really figure out who this person is and if they’re serious about surgery or not.
Well, thank you so much Dr. Dr. Zuriarrain. This was so informative and I’m sure helpful For all of our listeners and to our listeners, be sure to check back soon on the MEDQOR Podcast Network for the next episode of the Plastic Surgery Practice Podcast. And in the meantime, to catch up on the latest industry news, please check out plasticsurgerypractice.com. Until next time, take care.