Body dysmorphic disorder and surgical outcomes

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Patient-reported outcome measures (Proms), in the form of pre- and post-surgery questionnaires, are used to evaluate the outcome of a surgical procedure, from a patient’s point of view, as regards health-related quality of life (HRQoL) and psychosocial burden.

If you are a surgeon in a high-risk category, about to undertake surgery to correct something health-related (removal of a cancerous mass, correction of a deviated septum caused by a rugby injury, breast reduction to prevent back pain, orthopaedic correction of a limb post-car accident), you should discuss with the patient the option of bringing in a plastic surgeon to take care of the aesthetic aspect. The functional and aesthetic are inextricably linked, because both contribute towards the patient’s ultimate satisfaction with the outcome of the procedure and their resultant quality of life.

However, an alarm bell should go off if the patient has had numerous past procedures, performed by a list of different practitioners, which they refer to as “inadequate”. A paper, published in the Medical Journal of Australia cautions against taking on patients with a history of legal proceedings, threats, or overt violence towards a previous surgeon (cosmetic or otherwise).

It suggests that a patient’s psychiatric history and state of mind be assessed before cosmetic procedures are performed. This is because certain psychiatric disorders – such as body dysmorphic disorder (BDD), depression or a psychotic diagnosis – can present with heightened concern about the way in which the patient looks.

Body dysmorphic disorder

BDD presents with “a preoccupation with an objectively absent or minimal deformity that causes clinically significant distress or impairment in social, occupational, or other areas of functioning”. Those diagnosed with this neurosis may become obsessive about their perceived defect and are unlikely to find any cosmetic procedure beneficial.

If a surgeon picks this up and refers the patient on for psychiatric evaluation and treatment, this is likely to be successful in up to two-thirds of BDD patients, potentially averting the need for surgery altogether.

A surgeon should always advise their patients that surgery performed under general anaesthetic has its risks and side effects, and is only carried out when necessary. The surgeon should clearly outline what is realistic, and what the risks and complications might be. Wound complications can have devastating consequences. A psychiatric evaluation may serve to prevent instances of unrealistic expectation and unnecessary litigation.