217
FACIAL PLASTIC
Body Dysmorphic Disorder
Kevin H. Ende, MDa,b,c, David L. Lewis,
Sheldon S. Kabaker, MDc,*
- Recognizing body dysmorphic disorder in
a cosmetic surgery practice
- The decision to treat patients who have
body dysmorphic disorder
- Medical legal risks with patients who have
body dysmorphic disorder
Body dysmorphic disorder (BDD) is a recognized
psychiatric disorder in the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-
IV) [1]. Increased awareness of BDD has led to
a considerable amount of literature on this condi-
tion. BDD patients often seek consultation with
a cosmetic surgeon, and it has become exceedingly
important to identify the condition during the ini-
tial patient visit. The Broken Mirror, by Dr. Katherine
Phillips [2], is the authoritative text on BDD, and is
referenced throughout this article.
BDD can be defined as an obsession with an as-
pect of one’s appearance far beyond what is con-
sidered normal. This perceived flaw becomes an
obsession, which torments patients for years. In
extreme cases, it may culminate in suicide with
an increased rate 45 times that found in the gen-
eral population [3]. It is normal to care about
how one looks. In fact, 95% of the population
makes an effort to improve their appearance in
some fashion. The spectrum ranges from simply
a
Department of Otolaryngology, Head and Neck Surgery, University of California San Francisco, San Francisco,
CA, USA
b
Facial Plastic and Reconstructive Surgery, San Francisco, CA, USA
c
Aesthetic Facial Plastic Surgery Medical Clinic, 3324 Webster Street, Oakland, CA 94609, USA
* Corresponding author.
E-mail address: nunoz@aol.com (S.S. Kabaker).
1064-7406/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
SURGERY CLINICS
OF NORTH AMERICA
Facial Plast Surg Clin N Am 16 (2008) 217–223
MD
b,c
,
- Case studies
- Example of operative success for a patient
with body dysmorphic disorder
- Summary
- References
nice clothing, hairstyling, color treatments,
makeup, and skin care products to plastic surgery.
Patients who have BDD may present to a cosmetic
surgeon with complaints of their nose being too
large or of thinning hair, although they can focus
on any body part. It is easy to discount their con-
cerns, because they may not make sense. BDD is
not uncommon, however, occurring in 1% of
the general population. The percentage is 6 to
16 times higher in patients presenting to plastic
surgery clinics. Some patients who have BDD
function in society better than others. Some may
not attend social functions because of their obses-
sion with their appearance, spending evenings
staring in a mirror. Patients who have BDD often
seek the assistance of a cosmetic surgeon, some-
times several, in search of a physical cure for their
psychiatric disorder. The degree to which they suf-
fer varies, and the diagnosis often is missed. Cos-
metic surgery has gained increasing popularity
throughout the world over the years. There is
doi:10.1016/j.fsc.2007.11.012
218 Ende et al
increased awareness of the benefits of plastic sur-
gery for the effects of aging, skin problems, nasal
deformities, variations from the ideal, hair loss,
and posttraumatic disfigurement problems. For
the most part, plastic surgery patients are reason-
able and can be handled in a standard manner.
BDD is diagnosed by three criteria as listed in the
DSM-IV. First, patients must have a preoccupation
with some imagined or slight defect in their appear-
ance and have a markedly excessive level of con-
cern. Patients who have BDD spend, on average, 3
to 8 hours each day thinking and acting out about
their obsession. Second, the obsession and concern
interferes with normal life functions, such as em-
ployment, schooling, and social and marital rela-
tionships. Third, other psychiatric diagnoses do
not apply, such as obsessive-compulsive disorder
(OCD) or bulimia. BDD and depression often coex-
ist, with 94% of patients reporting depression at
some point during their treatment of BDD. There
are some diagnoses that fall in-between. For in-
stance, trichotillomania can be a form of OCD or
BDD depending on the specific context. In BDD,
pulling out the hair is not a form of stress relief,
and patients must seek alternative means to allevi-
ate their anxiety. When the act of pulling out the
hair is a form of stress relief, these patients are diag-
nosed more accurately with OCD. In either dis-
order, treatment can be instituted and often is
effective.
Although some body parts may be underreported
secondary to embarrassment, the most common
areas of concern to patients who have BDD are
the skin, hair, and nose. On average, most patients
focus on five body parts over the course of the dis-
order (Table 1). The obsession is not necessarily
constant. For example, patients who have BDD
and who have minor acne may lose their obsession
when the skin periodically is clear. Patients may be
specific and discuss symmetry, size, color, or con-
tour when describing the nature of the perceived ir-
regularity. Patients most often are concerned with
specific body areas, but some patients may define
their overall appearance as ‘‘ugly.’’
Recognizing body dysmorphic disorder in
a cosmetic surgery practice
Patients who have BDD can present with different
levels of this disorder. Patients often present with
a depressed mood (as clinical depression often co-
exists), spend a long time describing their con-
cerns, and go into great detail. Alternatively,
patients may address a physical concern casually
and ask a cosmetic surgeon to make them look
Table 1: Location of 10 most perceived facial
defects in patients who have body dysmorphic
disorder
Percentage of
patients who
Body part have concerna
Skin 73
Hair 56
Nose 37
Eyes 20
Teeth 20
Ugly face 14
Lips 12
Chin 11
Eyebrows 11
Ears 9
a
Percentages add up to more than 100% because people
generally are concerned with more than one aspect of
their appearance.
Data from Phillips KA. The broken mirror: understanding
and treating body dysmorphic disorder. New York:
Oxford University Press; 2005.
‘‘normal.’’ In many cases, patients who have minor
flaws already look normal, and surgery would have
minimal demonstrable effect. If a physician takes
a more detailed history at this point, the patient’s
obsession with appearance may become more ob-
vious. Patients often say things such as, ‘‘I think
about it a lot,’’ ‘‘It’s always on my mind,’’ or ‘‘I’m
obsessed.’’ Instead of wanting to look better, youn-
ger, or less tired, a patient may say, ‘‘I keep trying to
make myself look ok.’’ Patients often seek reassur-
ance from friends and family members only to
have their concerns trivialized. Doctor shopping
also should raise a red flag, as patients learn to cir-
cumvent the screening process after rejection by
several surgeons. Physicians should address pa-
tients’ concerns over dissatisfaction with prior cos-
metic procedures and ask if other surgeons have
refused to perform revision or ‘‘unnecessary’’ sur-
gery. Attention should be paid to gratuitous flattery
(‘‘you are the absolute best plastic surgeon’’), his-
tory of reclusion, and overall psychiatric and sub-
stance abuse history. One nonconfrontational
question to address a history of BDD is, ‘‘Have
you ever received any kind of counseling related
to feelings about your appearance?’’ Patients who
have BDD often describe long-term camouflage,
such as headbands on patients who have self-per-
ceived high hairlines, posturing away from the pa-
tient’s ‘‘bad side,’’ and drastic measures to cover up
slight imperfections, such as wearing turtleneck
sweaters in the summer (Table 2). Frequent mirror
checking with touching and measuring is
 Body Dysmorphic Disorder 219

Table 2: Common behaviors of patients who The decision to treat patients who have body
have body dysmorphic disorder dysmorphic disorder
Percentage It can be difficult to convince, in a tactful and non-
of people confrontational manner, patients who have BDD
with
that they should seek treatment of a psychiatric
Behavior behavior
disorder. Surgeons should explain that patients
Camouflaging 91 are not crazy and that they may have a treatable ill-
With posture 65 ness. Despite surgeons’ best efforts, patients may
With clothing 63 become severely agitated with this suggestion. Al-
With hand 49 though 30% of surgeons believe that patients
With hair 49
who have BDD should not have any surgery, it is
With hat 29
Comparing body 88
not suggested that cosmetic surgeons immediately
part with others dismiss the patients from their practice and refuse
Checking 87 to perform any procedures. Rather, counseling
appearance in (cognitive behavioral therapy) and pharmacother-
mirrors and other apy (usually a selective serotonin reuptake inhibi-
reflecting surfaces tor) by a psychiatrist who has expertise in this
Seeking surgery, 72 area should be suggested before revisiting the
dermatologist idea of plastic surgery. These treatments can be ef-
Excessive grooming 59 fective in allowing patients to function better in so-
Seeking reassurance, 54
ciety and become less obsessed with their
attempt to convince
appearance. In some cases, patients still may bene-
others that defect is
unattractive fit from plastic surgery after treatment of BDD. Sur-
Touching defect 53 gery should be performed, however, only with
Clothes changing 46 a treating psychiatrist’s approval. Approval for sur-
Dieting 39 gery, however, may be the result of a psychiatrist’s
Skin picking 38 severe frustration with a patient who is difficult to
Mirror avoidance 24 treat. Ultimately, a surgeon must make a decision
Excessive tanning 22 whether or not to operate on a patient. Operating
Excessive exercise 21 on a patient who has BDD may even trigger new
Excessive weight 18
obsessions, leading to further surgery. Although
lifting
studies show that 12% of patients report improve-
Data from Phillips KA. The broken mirror: understanding ment in their long-term symptoms of BDD after
and treating body dysmorphic disorder. New York: surgery, no studies have provided insight as to
Oxford University Press; 2005. which patients who have BDD fall into this cate-
gory. In addition, patients must be deemed in a sta-
ble psychiatric stage and agree to continue
supportive care with a psychiatrist long after the
proposed surgery.

prototypic of patients who have BDD as is mirror

avoidance. Computer imaging may be useful in
helping surgeons identify BDD. When computer-
generated postoperative results are presented, pa-
tients who have BDD may be inappropriately en-
thusiastic about the change or become persistent
with their demands for further alteration. Further
attempts at image manipulation usually do not sat-
isfy patients or surgeons. Eighty-four percent of
a surveyed group of plastic surgeons reported oper-
ating on a patient that they deemed appropriate
for surgery and, to their dismay, realizing during
the postoperative period that the patient had
BDD. Despite a surgeon’s best efforts, diagnosis be-
fore treatment is not always possible.
Medical legal risks with patients who have
body dysmorphic disorder
Although most cosmetic surgery patients are satis-
fied postoperatively, patients who have BDD often
are unhappy with the results of cosmetic surgery
no matter what the outcome. Surgeons may feel
that they have hit a ‘‘homerun’’ with near-perfect
results, yet a patient is devastated. A minor flaw
may lead a patient who has BDD to blame the sur-
geon for an imagined serious mistake. Studies
show that despite a flawless job, more than 90%
of patients who have BDD continue to suffer
from the disorder to some degree and profess
220 Ende et al
unhappiness with results. Statistics related to in-
creased liability are difficult to obtain, but sur-
geons should consider this possibility before
operating on any patient suspected of having
BDD. Extraordinary amounts of time may be in-
vested into postoperative patient counseling and
revision surgeries in an attempt to achieve unob-
tainable results and patient satisfaction. Despite ex-
cellent cosmetic results judged by the treating
surgeon and other experts in the field, malpractice
attorneys may attempt to exploit the diagnosis of
BDD. Juries in the past may have had little sympa-
thy for wealthy men seeking surgical alteration of
their appearance who were unhappy with the re-
sults. As BDD now is a recognized psychiatric diag-
nosis, however, the attorney may attempt to argue
that a patient’s BDD was treated incorrectly. Male
patients who have rhinoplasties and who have
BDD seem to represent the largest number of pa-
tients in this category.
Case studies
A middle-aged man who had a rhinoplasty and
at least seven revision surgeries over an 11-year
period originally presented to the senior author
after four rhinoplasties. These four procedures
were performed by two other surgeons, both of
whom he had threatened with legal action. Be-
cause of additional verbal threats of violence to
the previous surgeons, it became necessary for
each surgeon eventually to file restraining orders
against him. He subsequently had further rhino-
plastic procedures by a fourth surgeon who was
unaware of the majority of his previous history
(Fig. 1).
As cartilage grafts were placed, revised, and re-
moved over a 2-year period, this patient had sev-
eral psychiatric decompensations requiring
hospitalization. All of our surgeries were per-
formed in consultation with psychiatrists. The pa-
tient even required emergency transportation to
the psychiatric hospital directly from the recovery
room after one of our operations! During his
time under our care, the patient was seen periodi-
cally by psychiatrists who had apparent limited
BDD experience. Each time, a different psycho-
therapist believed that the patient had realistic ex-
pectations and was prepared for a realistic result.
Perhaps they hoped that revision surgery might
lessen the issue of nasal appearance in his overall
therapy for depression and BDD or alleviate the
need for them to participate any further in his
care.
The patient seemed quite pleased and some-
what relieved by the results of each revision sur-
gery but only for a short period of time. Several
years later, having never been cured of his BDD
through surgery or by his psychiatrist, the patient
threatened to sue us and a restraining order be-
came necessary. Over a period of 6 years, the pa-
tient regularly left messages with his three
surgeons, such as ‘‘thanks for screwing up my
nose,’’ and requested copies of his records yearly.
Although no legal action ever was filed, the patient
stated, ‘‘I want you punished’’ and ‘‘I will not relax
until justice is served,’’ in reference to his dissatis-
faction with what most surgeons would consider
a satisfactory result. These results, although not
the esthetic ideal, conformed to this patient’s com-
puter-generated image alteration agreed on during
a preoperative consultation.
A recent study supported the need for caution by
treating physicians, with 28% of patients who had
BDD reporting having ever been violent and 40%
of surgeons reporting threatened violence by a pa-
tient who had BDD. Several attempted and suc-
cessful murders of plastic surgeons by patients
who had BDD are documented, with a dispropor-
tionate number of cases related to male
rhinoplasty.
With more examples like this being reported,
surgeons need to exercise careful judgment
when deciding to operate on patients who have
BDD, accept the risks of patient dissatisfaction
and threatened violence or legal action, prepare
patients properly through consent forms and sur-
gical counseling, and work closely with treating
psychiatrists who can help prepare patients to ac-
cept the results.
Example of operative success for a patient
with body dysmorphic disorder
A young man (age 23 when first seen by the senior
author) who was diagnosed with BDD after a sep-
torhinoplasty, represents a surgical success story
over many years under our care. Although the out-
come of his first surgery was less than perfect
(mild polly beak deformity and tip asymmetry),
the patient was obsessed with having his nose re-
operated to achieve a near-perfect form. Before
presentation in our office, he had seen 11 plastic
surgeons, dropped out of school, was not working,
lived at home with his parents, and socially was
withdrawn. Although his major complaints were
that the nose looked ‘‘rounded and snubby’’ and
he wanted it to look more like it did before his
rhinoplasty, he presented an exhaustive two-page
list of specific nasal issues. Improvement was def-
initely possible, but his expectations and obses-
sions with the outcome seemed to exceed any
surgeon’s ability. Before his consultation with
our practice, he had started psychiatric therapy.
He was diagnosed, counseled, and treated
 Body Dysmorphic Disorder 221

Fig. 1. (top left) Patient with BDD after 4 rhinoplasties by 2 other surgeons. (top middle) Patient after dorsal
graft modification. (top right) Larger dorsal cartilage graft placed to defeminize the patient’s dorsum. (bottom
left) Frontal view of top left. (bottom left of center) Frontal view of top middle. (bottom right of center) Frontal
view of top right picture. (bottom right) Patient after final dorsal graft removal.

Fig. 2. (left) Patient with BDD prior to rhinoplasty. (middle) Same patient 1 month after rhinoplasty. (right) Same
patient after augmentation mentoplasty and submental liposuction.
222 Ende et al
Fig. 3. (left) Patient with BDD prior to rhinoplasty. (middle) Same patient 1 month after rhinoplasty. (right) Same
patient after augmentation mentoplasty and submental liposuction.
pharmacologically and through cognitive behav-
ioral therapy for BDD. He underwent revision rhi-
noplasty 1.5 years later only after being given
a ‘‘green light’’ by his psychiatrist. This psychiatrist
had prepared him for a less than perfect result and
had arranged for frequent follow-up postopera-
tively. Since this procedure, the patient has contin-
ued treatment of BDD; started a new career as an
electrician; is more involved with his hobbies, in-
cluding music; and is developing a more active so-
cial life.
Three years later, this patient presented for treat-
ment of his microgenia. He had worn a goatee to
camouflage it for many years. We asked him to
shave it for evaluation purposes. He presented,
clean-shaven, for his next preoperative visit with
a jacket held over his lower face. With the psychi-
atrist’s approval, augmentation mentoplasty and
submental liposuction were performed success-
fully (Figs. 2–4). His preoperative mentoplasty be-
havior seemed to indicate that he still suffered
from BDD but it was controlled. He continues to
do well and feels he is progressing positively in
life.
Summary
In summary, BDD is common among patients seek-
ing cosmetic surgery. There is nothing wrong with-
wanting to look better, younger, or more attractive.
The therapeutic benefits of plastic surgery and abil-
ity to boost self-esteem have long been recognized.
When this becomes an obsession and patients offer
certain clues during an initial consultation, how-
ever, plastic surgeons should have a high index of
suspicion for BDD. Although it can be difficult for
young plastic surgeons to deny patients who have
BDD the cosmetic surgery they desperately are seek-
ing, psychiatric referral and treatment always should
occur first. The authors suggest looking up the
website of Dr. Phillips [4], which frequently has up-
dated information on BDD and ongoing related re-
search and lists several psychiatrists who have an
interest in treating BDD.
Although standard preoperative counseling by
a plastic surgeon may begin to prepare patients
who have BDD for surgery, collaboration with
 Body Dysmorphic Disorder 223

Fig. 4. (left) Patient with BDD prior to rhinoplasty. (middle) Same patient 1 month after rhinoplasty. (right) Same
patient after augmentation mentoplasty and submental liposuction.

a psychiatrist is necessary to achieve successful sur-
gical and psychiatric outcomes.
References
[1] American Psychiatric Association. Diagnostic and
statistical manual of mental disorders, 4th edition
(DSM-IV). Washington (DC): American Psychiat-
ric Association; 1994.
[2] Phillips KA. The broken mirror: understanding
and treating body dysmorphic disorder. New
York: Oxford University Press; 2005.
[3] Gorden A. Early recognition of troubled patients
avoids a litany of future problems. Plastic Surgery
News 2007;18:1–50.
[4] Phillips KA. Available at: www.bodyimageprogram.
com. Accessed January 2, 2008.