Obsessed with Perfection: Patients Whose Issues Lie Deeper Than the Skin

body dysmorpia

Addressing cosmetic concerns, treating injuries, and recognizing psychological issues that require professional counselling make plastic surgery a tricky line of work. And while no one has the right to question another person’s insecurities, plastic surgeons, like all doctors, bear the responsibility of refusing to work with patients they’ve determined unsuitable candidates for any given procedure.

“A good plastic surgeon is someone who can say ‘no’” says Dr. Renato Calabria, a plastic surgeon based in Beverly Hills.

But what exactly does that mean and how does it come into play? What is an unfit candidate and how might a doctor come to that conclusion? For such a challenging problem, it’s surprisingly common.

“This is a tough situation, and something that most plastic surgeons face on an almost weekly basis,” says Dr. Anthony Taglienti, a plastic surgeon who practices in Smithown, NY.

Dr. Zachary Farris of Dallas, Texas notes that if you know what to look for, you can quickly distinguish those people who simply aren’t fit for plastic surgery. “The first big group of patients to be turned down are the medically unhealthy ones, such as the heavy smokers with coronary stents and uncontrolled diabetes,” says Farris. “I simply explain to them that the risks of surgery outweigh the benefits. Sometimes they’re able to optimize their health by seeing a medical specialist beforehand. At that point they can at least be re-considered for plastic surgery sometime in the future.”

doctors body dysmorphia
Drs. Calabria, Taglienti, Farris, and Burdorf

Unrealistic Expectations and Body Dysmorphic Disorder (BDD)

Another group of people who may find themselves being denied treatment are those who have unrealistic expectations from a procedure.

“It could be a woman entering the office requesting surgery to make her belly button look exactly like Kim Kardashian’s,” says Farris. “Or it could be someone who wants to have a full tummy tuck but insists that they emerge from the procedure with no scars. In these instances I try to reason with patients and explain to them that their expectations are unreasonable – or even impossible to attain – and there’s an excellent likelihood they would be disappointed after surgery anyway. If they persist, I simply tell them that I wouldn’t be comfortable doing their surgery, that I’m not the right doctor to help them achieve their goals.”

It all sounds simple and obvious enough, right? But that doesn’t mean these situations aren’t difficult for doctors to handle. As Farris points out, a great deal of patients who get turned down may be diagnosable with a common condition: Body Dysmorphic Disorder (BDD). Apparently 1 in 50 people live with BDD, a legitimate disorder marked by one’s obsession with, or fixation on, a minor (by medical standards) or non-existent physical flaw. BDD can also manifest as an addiction to physical self-improvement, creating, or at least agitating, eating disorders, social anxiety, and other conditions requiring psychiatric care.

“It is important to be mindful that Body Dysmorphic Disorder is all too common and real,” says Taglienti. “So it always needs to be ruled out when diagnosing patients.”

Plastic surgeons certainly shouldn’t masquerade as psychologists or social workers, nor is it expected they’d have such expertise, but one seldom-touted qualification all plastic surgeons should possess is the training and compassion to recognize BDD traits and/or any other issues that could render a person mentally unfit for a procedure.

Some doctors, like Dr. Calabria, believe this issue of ruling out potential candidates isn’t addressed often enough in the plastic surgery community, noting that regrettably, surgeons will sometimes go ahead with a procedure in spite of these concerns.

“By operating on patients with BDD, plastic surgeons definitely need to shoulder some share of responsibility,” says Dr. Calabria. “There needs to be tougher standards set by the plastic surgery community when it comes to dealing with these patients.”

To better rule out unfit patients, doctors must pay special attention to certain telltale signs during their initial consultations.

“A red flag could be the patient spending many hours a day evaluating themselves in front of the mirror, avoiding social situations or appearing in photos because of some perceived flaw, or constantly comparing their appearance to others,” says Farris. “These individuals shouldn’t be getting plastic surgery as it’s not likely to help much with any of their underlying problems. Instead, they should be guided towards counseling and psychiatric evaluation.”

These individuals shouldn’t be getting plastic surgery. Instead, they should be guided towards counseling and psychiatric evaluation.

Dr. Zachary Farris

But it’s not just those with medical issues and possible BDD that surgeons have to be wary about, it’s also patients who are ambivalent or uncertain about their plastic surgery journeys.

“One other red flag to look out for are patients who don’t know what they want,” says Farris. “The ideal patient should already have a good idea about what they want from plastic surgery, and have reasonable expectations.  They should be able to articulate their goals, whether it’s to reduce a hump on their nose or lift their sagging breasts after having children and breastfeeding them. I often encourage patients to bring in ‘wish pics’ of what they’re trying to look like.”

Yet another type of patient who may present a red flag is the one who is recently recovering from a deep trauma, such as divorce or the death of a loved one. Just think, how many times have you or someone you know changed their hairstyle or started hitting the gym after a messy breakup? Sounds reasonable enough, I know, but plastic surgeons say there are lots of patients who go to irrational extremes when looking to transform or heal after a loss.

“Recent negative life-changing events like divorce or death can prompt some people to look to plastic surgery to fill a void in their lives,” says Nashville-based plastic surgeon Dr. Michael Burgdorf. “Except it’s obviously not the way to deal with the emotions resulting from these events.”

In his experience, Dr. Calabria says he’s found that reasoning with a client from the beginning is key. This means that when you do sign on with a client, you highlight exactly what they can expect from the procedure.

Recognizing the Symptoms of BDD

Dr Calabria has the following advice for his fellow doctors: don’t be shy or waste any time asking questions to vet potential patients for candidacy. On the initial sign-up forms, make sure you’re loaded up with questions that can better help you pinpoint any problems like these. The sooner you find those red flags, the better it is for everyone.

“I think an excellent way to diagnose patients for BDD or similar conditions is simply to ask the right questions,” says Dr. Calabria, who notes the following as key queries for his own patients.

  • Do you excessively worry about your physical appearance? Do you avoid mirrors?
  • Do you wear make-up to camouflage your perceived flaw?
  • Do you scrutinize others appearance for comparison?
  • Do you diet?
  • Do you excessively exercise?
  • Do you avoid having your picture taken?
  • Do you ask for reassurance from others about your appearance? Have you had any previous plastic surgery?
  • Are you unsatisfied with the procedures?
  • Are your perceived flaws interfering with relationships or your job?
  • How many hours do you spend focusing your efforts on your perceived flaws?

Drawing back to the patient who seeks plastic surgery to heal an emotional wound, Dr. Burgdorf suggests asking these people more personal questions.

It’s normal for someone seeking plastic surgery to answer “yes” to a handful of these queries. After all, it’s not like they’re looking to go under the knife for fun, it’s rather because their quality of life has been compromised due to unhappiness based on a physical issue. But someone who answers “yes” to all or most of these questions should prompt concern.

“I always try to ask my patients what’s going on in their lives and what’s in their immediate future. Why are they looking to have this surgery? For a special event? A class reunion?” says Dr. Burgdorf. “I want to get down to their ‘WHY’ of the surgery. Because ultimately that’s pretty important information.”

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