Picture this: You've just performed a perfect procedure. And then, even though everything went right, one thing after another begins to go wrong.
"Your patient hates the result, and the patient hates you," says plastic surgeon Mark B. Constantian, M.D., FACS. "You show her the preoperative photos and calmly explain what you did. She still hates you and thinks you're a liar and a crook, and she gets on the Internet and tells everyone."
This scenario may sound familiar; you may be thinking body dysmorphic disorder (BDD).
Dr. Constantian, who practices in Nashua, N.H., offers a deeper take. According to his new research, extreme dissatisfaction with plastic surgery procedures may have roots in an extraordinarily high rate of childhood trauma among cosmetic patients in general.
"I've added a big piece about why some patients are obsessed with physical perfection or trying to fix problems that other people don't even see," Dr. Constantian tells Cosmetic Surgery Times. "It's not an unrecognized genetic abnormality or a neurotransmitter problem. They started off in an abusive situation."
Dr. Constantian's research expands on existing knowledge about the close connection between BDD and plastic surgery. He discussed it this year at The Aesthetic Meeting of the American Society for Aesthetic Plastic Surgery.
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BDD causes sufferers to become preoccupied by perceived body flaws to the extent that they can't function properly. 'The flaw they perceive may be non-existent or very minor. They think it really looks terrible, and they want to have it fixed,' says Katharine Phillips, M.D., a professor at Warren Alpert Medical School of Brown University who runs a BDD clinic. 'The problem is with their tendency to focus on tiny details, to obsess and worry about how they look with an inability to see the big picture."
It's difficult to measure BDD, so estimates of the percentage of plastic surgery patients with the condition have varied widely. A study of 234 patients in JAMA Plastic Surgery last year put the numbers at 13% (cosmetic surgery patients) and 2% (reconstructive surgery patients).
Dr. Phillips tells Cosmetic Surgery Times that surgery is rarely a fix for these patients. Another 2010 study found that "overall BDD severity improved with only 2.3% of treatments."
Even worse, surgery can be risky for the patient, who may become suicidal, and the physician, who may be severely criticized, sued or even physically threatened by the patient, Dr. Phillips says.
In a previous study (part 1 and part 2) published in 2014, Dr. Constantian and a colleague studied 100 patients seeking a second rhinoplasty. The rate of childhood abuse was over 90% among those who'd had more than three previous procedures, had a normal nose shape before the first surgery and showed signs of depression and/or were demanding.
"Trauma (abuse/neglect) history was the most significant mediator between patient satisfaction and number of operations and the most prominent factor driving surgery in patients with milder deformities," the researchers wrote.
Is BDD Linked to Childhood Trauma?
For the new study, Dr. Constantian and colleagues sought to better understand the role of childhood trauma. "I wanted to be able to put my findings in context," he says.
The researchers studied 100 consecutive patients post-operatively: mean age 51 (21-77), 77% women, 92% Caucasian and 76% college or graduate school degree. Of the patients, 87% were undergoing aesthetic surgery while the other 13% underwent reconstructive surgery.
The patients answered questions from a 1995-1997 Kaiser Permanente/CDC survey into childhood trauma.
The Kaiser/CDC study found that 67% of 17,433 general medical patients in Southern California gave at least one positive answer on the survey; the number was 81% in the plastic surgery survey. The number of patients who answered yes to more than 4 of 10 questions was also higher in the plastic surgery group at 54% compared to 16% in the Kaiser/CDC group.
In the plastic surgery group, the levels of reports of emotional abuse (49%), emotional neglect (43%) and experience living with drug/alcohol abuse (40%) were double those in the Kaiser/CDC group.
Dr. Phillips says other research links BDD to childhood trauma and also to childhood teasing. But it's difficult to know if they were actually teased more. They may be predisposed to be more sensitive to teasing and more likely to remember it when surveyed, she says.
According to Dr. Constantian, childhood trauma can produce people who are perfectionists, obese, obsessive, untrusting, needy and dependent.
"If they end up in a plastic surgeon's office, it's because that's how they're trying to get self-esteem," he says. "When their wildest dreams aren’t realized — and they never are — they have a flashback to childhood, and their feelings of worthlessness have been reawakened. That's why they get so irrational. You can't reason with them, you can't calm them down."
Body Dissatisfaction vs. Body Shame
So could questions about childhood trauma be a screening tool for BDD? Dr. Constantian doesn't think so. "The patients you love to see didn't necessary have easy childhoods,” he says. “They just overcame them. Trauma doesn't do the same thing to everybody."
So what can plastic surgeons do to help — and avoid — patients with BDD?
"The good patient has body dissatisfaction, and the bad patient has body shame," Dr. Constantian says. He cautions colleagues to keep an eye out for patients who want to fix body parts like noses that are normal because they "aren't perfect enough."
"That's a danger sign," he says. "The patient needs to understand there’s no such thing as perfect."
Dr. Phillips suggests using a survey designed to detect BDD. You can find examples here: www.rhodeislandhospital.org/services/body-dysmorphic-disorder-program/questionnaires.html.
If patients do show signs of deep-seated problems, Dr. Constantian says, trauma treatment is where they belong. The good news, Dr. Phillips says, is that BDD is a "very treatable condition" via medications and therapy.