Should Plastic Surgeons Operate on Patients Diagnosed with Body Dysmorphic Disorders?

Abstract

Sir: We read the Viewpoint entitled “Should Plastic Surgeons Operate on Patients Diagnosed with Body Dysmorphic Disorders?” (Plast Reconstr Surg. 2012;129:406e–407e). The authors pose four important questions. Body dysmorphic disorder, originally dysmorphophobia, is a somatoform disorder marked by a compulsive thought with an imagined or trivial defect in appearance that causes clinically significant distress or impairment in social life. We defined the more comprehensive term “dysmorphopathy” to refer to all conditions of psychological distress related to body image. A classification of dysmorphopathies was created for plastic surgery patients to help surgeons deliver proper treatment (Table 1).Table 1: Classification of the Psychosomatic DysmorphopathiesFirst, the authors ask whether we should operate on patients diagnosed with body dysmorphic disorder. The answer is yes, it is possible to operate on body dysmorphic disorder patients only after a correct assignment of the patient to a dysmorphopathy subtype. For example, in case of a severe subjective dysmorphopathy, the patient must not be operated on and will need only psychotherapy. Other patients need psychological support or psychotherapy before the operation. Second, can patients with mild body dysmorphic disorder benefit from plastic surgery? Plastic surgery may play the role of a dual treatment in selected cases in which treating the external morphologic appearance cures the internal well-being. We define this process eumorphic plastic surgery.1 Third, is there any way to predict the patient’s satisfaction with the results of plastic surgery? In our practice, we adopted methods to predict the patient’s expectations, such as the pgm A questionnaire on motivations and expectations.2 Our questionnaire is easy to complete for the patient and through a quick glance gives the surgeon an objective idea on the severity of the patient’s body image. The assessment of the expectations is the main moment for the inclusion or exclusion of the patient as a candidate for surgery. Fourth, the authors wonder whether it is ethical to operate on body dysmorphic disorder patients. It is not justified to operate on a patient without making a diagnosis of dysmorphopathy subtype. For example, it is not ethical to operate on a dysmorphophobic who corresponds to the severe subjective dysmorphopathy. On the contrary, if a full assessment of the dysmorphopathy subtype is obtained and surgery appears to be appropriate, not only is the operation ethical, but it is also likely to have a psychotherapeutic effect. We can achieve eumorphic plastic surgery3 when the deep needs of the patient are identified and the deformity is related to an internal psychological disturbance such as the Minotaur syndrome,4 a psychological distress resulting from the appearance of the patient’s face. The decision to operate or not is the plastic surgeon’s responsibility.5 They are supposed to identify the deep motivation or the psychological disorder1–3 and, as medical doctors, are not entitled to take refuge in an alleged role of exclusively surgical technicians performing procedures. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No outside funding was received. Paolo Giovanni Morselli, M.D., Ph.D. Filippo Boriani, M.D. Bologna University Bologna, Italy