Avoid dysmorphic patients, senior surgeon cautions

New Orleans — The reason cosmetic surgeons should avoid dysmorphic patients is very simple, Mark Gorney, M.D., says.

Dr. Gorney

"It's because the patient's dissatisfaction is not their nose, or their breast or their ears — their problem is between their ears," he says.

Dr. Gorney should know. He started practicing plastic surgery in 1957 and is currently a senior consultant for a national liability carrier that insures a great number of esthetic surgeons. Dr. Gorney also teaches a course on identifying the dysmorphic patient, in conjunction with a psychiatrist. Body dysmorphia disorder is not easy to recognize, he says.

"It comes in all shades of gray — from minimal but repairable to really extreme, where it interferes with the patient's function in society."

Dr. Gorney spoke at the American Society for Aesthetic Plastic Surgery's (ASAPS) Aesthetic Meeting 2005 here.

He says it takes time and effort to identify the dysmorphic patient. He offers a few tips for distinguishing them:

• Ask potential patients a lot of very probing questions.
• Visit two or three times before committing to surgery.
• Watch the language; watch the body language.
• Analyze what is bothering the patient and why.

Dr. Gorney says he learned the hard way. When he was young and inexperienced, a handsome young actor ready to start his career in earnest came for treatment, saying his agent wanted him to have his nose fixed in order to get bigger and better roles. Dr. Gorney didn't think the nose was too bad, but the patient was an actor, so he went along with the request.

"He had a barely perceptible bump and a little thickish skin that made the nose a bit bulky. He had diagrams, photographs of handsome men and knew exactly what he wanted, but he didn't want the change to be noticed.

"The surgery went well and the result was absolutely beautiful, but the young man took one look and immediately objected, 'My nose — what have you done to me?'

"It wasn't until later I learned from the patient's girlfriend that the man wasn't a very good actor and I had taken away his one excuse for not becoming a success — I had pulled his rug out from under him."

That was when Dr. Gorney started to realize that dysmorphic patients are more often men than women.

Stay alert Dr. Gorney says the surgeon should answer three questions before making the decision to operate:

• Physical deformity: Is there a real deformity?
• Emotional stability: Is the patient emotionally stable?
• Rapport: Can you be totally open with the patient, and do they trust you and have confidence in you?

If the answer to all three questions is "yes," that's when the surgeon should consider going ahead, Dr. Gorney says.

On the other hand, if the patient complains about a minor physical flaw, or one that the surgeon can barely see, that's the first reason the surgeon should run in the opposite direction as fast as possible.