Sir: We would like to thank you for the possibility of further discussing our article published in the February issue of Plastic and Reconstructive Surgery.1 Pavlidis et al. refer to “high resistance” to perform facial feminization procedures, reserving these procedures for selected cases to respect human nature. According to this principle, all cosmetic procedures would be affected because they influence patients lifelong; this “working” principle cannot guide surgeons to indicate surgical procedures to avoid possible reoperative surgery. Psychological imbalance affects all patients undergoing cosmetic surgery, not only transgender patients. On this principle, we fully agree that there is a possible increase of bias that could be corrected by proper preoperative evaluation by specialized medical or paramedical staff, but certainly not by the same surgeon who will perform surgery (conflict of interest). Rules to engage patients undergoing transgender surgery have been widely discussed and accepted, but guidelines to identify diseases such as body dysmorphic disorder have not been developed.1,2 Body dysmorphic disorder, in particular, is a well-established psychiatric disorder characterized by an excessive concern with a nonexisting or slight defect in physical appearance, and diagnosing it during a preoperative consultation remains challenging. Body dysmorphic disorder is usually associated with poor quality of life, extremely high rates of suicide and, following cosmetic surgery, high rates of dissatisfaction, occasionally manifesting as aggressiveness.3,4 As further proof of an emerging point of discussion, it is notable how four epidemiologic studies have examined mortality among women with cosmetic silicone gel–filled breast implants and have found that risk of death from suicide is twofold to threefold higher in this group than among women of comparable age in the general population.5–7 The same authors, pending further investigations, suggest supporting patients undergoing cosmetic surgery by psychiatric consultation, which is the only means, in this difficult field, of making the proper diagnosis.4 Furthermore, de Brito et al. analyzed the level of body dissatisfaction and prevalence of body dysmorphic disorder in patients seeking abdominoplasty (n = 90), rhinoplasty (n = 151), and rhytidectomy (n = 59), based on the Body Dysmorphic Disorder Examination, which was administered preoperatively. The authors conclude that abdominoplasty candidates showed the highest prevalence; rhytidectomy candidates exhibited the highest percentage of severe cases, and rhinoplasty candidates had the lowest percentage of severe cases.6 On these considerations, transgender patients should receive proper psychiatric and psychological support with respect to the other patients undergoing cosmetic procedures because they are involved in proper referral centers. As further support, we would like to emphasize that our patients met specific criteria for facial feminization surgery (we did not record any suicides), 16 (48.4 percent) had undergone previous breast augmentation, and six (18.1 percent) had undergone surgery of the genitalia.1 DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Mirco Raffaini, M.D., D.D.S.Department of Maxillofacial SurgeryUniversity of FlorenceFlorence, ItalyFace Surgery CenterParma, Italy Alice Sara Magri, M.D.Face Surgery CenterParma, Italy Tommaso Agostini, M.D.Department of Maxillofacial SurgeryUniversity of FlorenceFlorence, Italy