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Abstract

Sir: We sincerely thank Dr. Swanson for his vivid interest in our recent large-scale prospective study on the impact of preoperative symptom severity of body dysmorphic disorder on subjective outcomes in aesthetic rhinoplasty. This study highlights for the first time the inverse correlation between the severity of preoperative body dysmorphic disorder symptoms and the postoperative satisfaction of rhinoplasty patients. First, we clearly state that we agree fully with Dr. Swanson’s opinion about the importance of clinical judgment on the risk-to-benefit ratio in the preoperative evaluation of aesthetic rhinoplasty patients, as is the case in any surgical setting. In aesthetic rhinoplasty, the identification of the severe body dysmorphic disorder patient, presenting with delusional thoughts and a perfect nasal shape, is not a challenge. We here deal with the true preoperative challenge, which is the identification of those patients with a “surgically correctable” nasal deformity and discrete body dysmorphic disorder traits, that are at risk of not being satisfied with the postoperative results. In the latter case, clinical judgment is only considered a weak base for evaluating the degree of severity of body dysmorphic disorder symptoms, and objective tools are warranted for research purposes. Most rhinoplasty surgeons agree that the recognition of body dysmorphic disorder symptoms can be challenging, and underdiagnosis of the latter may be a reason for postoperative dissatisfaction. In a previous study by our group, we highlighted the high prevalence of body dysmorphic disorder symptoms in an aesthetic rhinoplasty population using validated questionnaires and confirmed the low prevalence of true body dysmorphic disorder. We want to explicitly point out that some colleagues may draw false conclusions from our results, such as the statement of body dysmorphic disorder symptoms being the result of the nasal deformity. As our data clearly demonstrate the lack of correlation between the objective evaluation of the nasal shape by the surgeon and the body dysmorphic disorder symptom severity, they do not support the argument of body dysmorphic disorder being the consequence of a nasal deformity. Of note, many other authors have already demonstrated that the subjective evaluation of the nasal deformity does not correspond to the objective scoring of the deformity by the surgeon. Furthermore, the discrepancy between the low percentage of rhinoplasty patients meeting the criteria for full body dysmorphic disorder and the high percentage of patients with significant body dysmorphic disorder symptoms highlights the difficulties of applying the current diagnostic criteria for body dysmorphic disorder in an aesthetic surgery setting. We recognize that not all patients with moderate to severe obsessive-compulsive symptoms concerning their appearance have body dysmorphic disorder, as explicitly stated in the article. Finally, we would like to comment on the remark concerning the lack of comparison between postoperative results and preoperative baseline scores. Taking into account the wide variety of baseline scoring of the nasal deformity and the variable degree of percentage of improvement of scoring of the nasal deformity by the patient, the authors felt the most interesting approach was to study the correlations between the preoperative body dysmorphic disorder symptom severity and the final appreciation of the nasal shape by the patient. Considered together, we are convinced that our large-scale prospective study on the impact of body dysmorphic disorder symptom severity on the subjective outcomes of rhinoplasty contributes significantly to the field of facial plastic surgery, as it demonstrates for the first time the importance of non–surgery-related reasons for (dis)satisfaction in aesthetic rhinoplasty patients. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Valerie A. Picavet, M.D. Peter W. Hellings, M.D., Ph.D. Department of Otorhinolaryngology, Head and Neck Surgery University Hospitals Leuven Leuven, Belgium