Preoperative Symptoms of Body Dysmorphic Disorder Determine Postoperative Satisfaction and Quality of Life in Aesthetic Rhinoplasty

Abstract

Sir: We read with great interest the publication entitled “Preoperative Symptoms of Body Dysmorphic Disorder Determine Postoperative Satisfaction and Quality of Life in Aesthetic Rhinoplasty” by Picavet et al. (Plast Reconstr Surg. 2013;131:861–868). We agree with the authors that being able to diagnose dysmorphic disorder preoperatively is important to prevent the failure of cosmetic procedures. The plastic surgeon has to resolve not only an anatomical problem but also a discomfort of personality of the patients. Body dysmorphic disorder is a psychiatric disease characterized by worry with a minimal or nonexistent appearance defect and causes significant distress and interferes with the social life of the patient. The perceived physical anomaly may involve the shape and size of the whole body or may be centered around single units.1 Patients with body dysmorphic disorder are known to request multiple aesthetic procedures that never leave them satisfied. Whenever we are faced with a patient, we must decide whether the patient may have a therapeutic indication for cosmetic surgery. First, we have to evaluate the patient’s motivation for the procedure.2 For example, a question that we could ask our patient is, “Why do you want to undergo to this cosmetic procedure?” We could receive the following two answers: (1) “to please my partner” (this is not an adequate response to submit a patient to a surgical procedure); or, for example, (2) “my nose makes me feel uncomfortable to be with others and with myself” (this is an appropriate response). The physiognomy of mental suffering has changed and continues to evolve over time. In fact, until the 1980s, the most frequent psychiatric disorders were agoraphobia and claustrophobia, whereas now the most common ones are diseases that affect the patient’s perception of himself or herself and his or her own body, such as dysmorphic disorder, anorexia, and bulimia.3 In our experience, we know that rhinoplasty is the most requested procedure by patients with body dysmorphic disorder and therefore this type of surgery requires a greater sensitivity to investigate the patient’s history; we noticed that a large number of secondary surgical revisions that we have to perform were on patients affected by psychological disorders. A confirmation of our experience was given in a study by Picavet et al.4 in which the prevalence of moderate to severe body dysmorphic disorder symptoms in a cosmetic rhinoplasty population was high. Body dysmorphic disorder symptoms significantly reduce the quality of life and cause significant appearance-related disruption of everyday living. Obviously, a patient with this type of disorder can never be satisfied after surgery. How could we answer the patient’s request? In our experience, we believe it is necessary to integrate the look and the listening, because the look can make a survey on the presence or absence of an objective problem, whereas the listening caters to the subjective side of a person. In this way, we can understand the person’s relationship with their body. We use the algorithm presented in Figure 1 to identify which patients are good candidates for cosmetic surgery, and we are working on another algorithm that can outline an objective indication for cosmetic surgery.Fig. 1: Therapeutic algorithm for cosmetic surgery.DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Mauro Barone, M.D. Annalisa Cogliandro, M.D. Paolo Persichetti, M.D., Ph.D. Plastic, Reconstructive, and Aesthetic Surgery Unit Campus Bio-Medico University of Rome Rome, Italy