Picavet et al.1 conclude that “the severity of preoperative body dysmorphic disorder symptoms has a negative effect on patient satisfaction and quality of life, regardless of the objective nasal deformity.” The definition of body dysmorphic disorder includes a preoccupation with a slight or imagined defect in appearance causing clinically significant distress.2 Despite the (inaccurate) title of their study, the authors concede that only 2 percent of their patients fit this definition,1 similar to the prevalence of this disorder in the general population3 and even among secondary rhinoplasty patients.4
The authors believe that the definition of body dysmorphic disorder should be expanded, forgoing the requirement for only a slight physical defect, and effectively raising the prevalence of this disorder among rhinoplasty patients to 35 percent—the proportion of patients with at least moderate obsessive-compulsive scores. The authors believe that a “disturbed body perception” in rhinoplasty patients adversely influences their perception of nasal shape. However, their data support the reverse argument. The prevalence of moderate obsessive-compulsive symptoms among their control patients was only 5 percent,1 suggesting a connection between the presence of a nasal deformity and obsessive symptoms in all except the 2 percent of patients who were symptomatic despite a minimal nasal deformity. Patients with lower nasal appearance scores tended to have more obsessive-compulsive symptoms. In other words, the deformity comes first and the psychological effects are secondary in all patients except those with true body dysmorphic disorder. This finding is not surprising. The nose is vital to one’s appearance, analogous to a woman with underdeveloped breasts. It would be interesting to compare psychological test scores before and after surgery to determine whether a rhinoplasty can improve symptoms of self-consciousness and low self-esteem, just as a breast augmentation is known to do.5
To support a conclusion that body dysmorphic disorder symptoms (or more accurately, obsessive-compulsive symptoms related to appearance) impair postoperative patient satisfaction, the investigators would need to compare nasal shape and rhinoplasty outcome scores before and after surgery. Surprisingly, despite the fact that these tests were administered before and at 3- and 12-month intervals after surgery, no such longitudinal comparison is provided. Only postoperative nasal shape and outcome scores are compared; there is no comparison with preoperative baseline scores. Such a before-and-after comparison might also reveal whether a successful rhinoplasty affects psychological testing (also administered postoperatively) and determine whether the patient’s obsessive symptoms are truly intrinsic as the authors suggest or reactive (indeed, an overreaction), as discussed above.
Coincidentally, most of these cosmetic rhinoplasty patients were included in another recent study by these authors,6 enabling some before-and-after comparisons. The data points in the authors’ Figure 1 from their previous study (that also included noncosmetic rhinoplasties) reveal that the mean preoperative nasal shape score rated by patients with obsessive-compulsive scores of 15 or less was approximately 4.0. Patients with higher obsessive-compulsive scores graded their preoperative nasal appearance 2.7 on average. Analysis of postoperative data illustrated in Figure 2 from the more recent study1 reveals mean scores of 7.5 for less-obsessed patients and 5.9 for more-obsessed patients. The improvements were similar, measuring 3.5 and 3.2 points (on a scale of 0 to 10), respectively. Patients with more obsessive-compulsive traits tended to have lower nasal appearance scores after surgery, just as they did before surgery. Contrary to the authors’ conclusion that obsessive-compulsive traits negatively influence the perceived outcomes, there was no impairment of subjective surgical improvement in these patients. Obsessive patients just started with a lower rating. In fact, the more-obsessed patients are arguably even better candidates for surgery because their preoperative condition is so poor (2.7) and at least they can be improved to an intermediate level of appearance (5.9), as opposed to less-obsessed patients who start with mediocre scores (4.0) and end with moderately high scores (7.5).
Patients with body dysmorphic disorder may not be merely dissatisfied; they have been known to blame their surgeon and seek revenge legally and even physically.3 This disturbing hostility separates them from obsessive patients who do not become enraged at their surgeon. They frequently suffer from comorbid psychiatric abnormality.3 Can these troubled patients be reliably identified before surgery? The authors’ findings suggest that if our patients are submitted to psychological evaluations to detect at least moderate obsessive-compulsive tendencies, we can expect to turn down between 35 and 43 percent of cosmetic rhinoplasty candidates, almost all of whom do not have body dysmorphic disorder.1,6 As a practical matter, some patients will decline psychological tests, finding them intrusive or demeaning (it is clear that they are tests of psychiatric abnormality). Contrary to conventional wisdom, cosmetic surgery patients are not more dissatisfied, critical, or preoccupied with their overall appearance than the general population.7
The severity of the deformity is not irrelevant; it is a vital part of the risk-to-benefit analysis. The surgeon needs to see the deformity and be confident that he or she can correct it.4 If a patient seems excessively detail-oriented, the risk-to-benefit ratio must be heavily weighted toward a benefit if he or she is to be considered for surgery, and the patient must grasp the surgical limitations. This is not the time to offer a repeated rhinoplasty with a view to an incremental difference. The magnitude of the deformity, the reasonableness of the patient’s request, and his or her tolerance for imperfection4 are important considerations. Clinical judgment cannot be avoided or replaced with a questionnaire that is likely to needlessly exclude patients from surgery that may improve their quality of life.
The author has no conflicts of interest to disclose. There was no outside funding for this study.
Eric Swanson, M.D.
11413 Ash Street
Leawood, Kan. 66211
1. Picavet VA, Gabriëls L, Grietens J, Jorissen M, Prokopakis EP, Hellings PW. Preoperative symptoms of body dysmorphic disorder determine postoperative satisfaction and quality of life in aesthetic rhinoplasty. Plast Reconstr Surg. 2013;131:861–868
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. 2000 Washington, DC American Psychiatric Publishing
3. Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg. 2006;118:167e–180e
4. Constantian MB. What motivates secondary rhinoplasty? A study of 150 consecutive patients. Plast Reconstr Surg. 2012;130:667–678
5. Swanson E. Prospective outcome study of 225 cases of breast augmentation. Plast Reconstr Surg. 2013;131:1158–1166; discussion 1167–1168
6. Picavet VA, Prokopakis EP, Gabriëls L, Jorissen M, Hellings PW. High prevalence of body dysmorphic disorder symptoms in patients seeking rhinoplasty. Plast Reconstr Surg. 2011;128:509–517
7. Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg. 1998;101:1644–1649
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