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Know the signs: Body Dysmorphic Disorder in aesthetics


Dr. Wever discusses the prevalence of BDD in the aesthetic practice and how to identify the psychological disorder.

Capi Wever, M.D., PhD

Dr. Wever

This year, the American Society of Plastic Surgeons (ASPS) reported that “nearly a quarter million more cosmetic procedures [were] performed in 2018 than the previous year. According to the ASPS annual plastic surgery statistics report, there were more than 17.7 million surgical and minimally invasive cosmetic procedures performed in the United States in 2018, a number that has risen steadily over the past five years.”

But it’s not all good news. Along with this increase is the likelihood that more patients with psychological disorders are also walking through the practice door.

In his presentation, “Body Dysmorphic Disorder in Cosmetic Surgery: A Practical Review,” at the recent Global Aesthetics conference in Miami, Florida, Capi Wever, M.D., Ph.D, a facial plastic surgeon practicing in the Netherlands, outlined the prevalence of body dysmorphic disorder (BDD) in the profession and how to best manage it.

“I think many surgeons are not aware about [the] details and how to diagnose and treat people that have body dysmorphic disorder,” he says.

Related to obsessive-compulsive disorder, BDD is a psychiatric disorder “characterized by preoccupation with an imagined defect in physical appearance or a distorted perception of one’s body image,” according to a study published in the International Journal of Women’s Dermatology (IJWD).1

Characterized in the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5, personality disorders are put into A, B and C clusters.2

“Cluster A types are unlikely to visit us in our practices, cluster B includes borderline personality disorder and cluster C includes [BDD],” Dr. Wever explains.

While the general population has a 2% prevalence of BDD, that increases to more than 10% in aesthetic medicine.

Dr. Wever believes 80% of surgeons know in hindsight they’ve operated on patients with BDD and that underscores the need to identify signs of the disorder.

“So, you might say that John is a very social guy, but when it comes to work, he can be rather neurotic and precise about what he does,” he says. “As long as it doesn’t inhibit him to function normally, psychosocially and in his work domain, that’s perfectly ok. But when those same characteristics become blown up and abnormal in their magnitude that’s when we start thinking about a personality disorder rather than a trait.”

When trying to tell whether a patient is exhibiting symptoms of BDD, “You should look for the people that have a minor aesthetic concern but attribute a whole lot of emotional value to it,” Dr. Wever says. “[BDD] has obsessive components. Ask ‘how often do you look at yourself in the mirror?’ Mirror gazing and grooming for more than two or three hours a day are typical hallmarks of [BDD].”


Though generic questionnaires may be of help, he explains that these can be easily manipulated, especially in milder BDD cases.

“[Patients are] pretty aware that they should mark or check certain red flags because they want us to do the surgery for them,” Dr. Wever says.

The study, “Cosmetic Professionals' Awareness of Body Dysmorphic Disorder”, published in Plastic and Reconstructive Surgery in 2017, surveyed 173 members of Dutch professional associations for aesthetic plastic surgery, dermatology and cosmetic medicine and reported that two-thirds considered BDD as a contraindication.3

Dr. Wever says the treatment for these patients is not to operate but instead recommend phycological treatment.

“If you suspect it and catch them ahead of time, don’t offer them surgery,” he says. “The standard of care is [selective serotonin reuptake inhibitors] like antidepressants.”

If those patients are not identified before surgery, there is a risk of dangerous consequences.

“A lot of people with [BDD] do something called splitting,” he says. “They categorize the world as the bad parts and the good parts. Surgery can actually trigger them from moving from a positive self-image to a negative self-image, which can lead to self-damage.”

Along with an internal split that can occur with a patient, external splitting directed towards the medical team can also happen.

“You can go from being the good guy to the bad guy just by operating on them, and they can start harming you,” Dr. Wever says.

This can manifest in lawsuits, threats of physical harm and even murder. Since 1991, three plastic surgeons have been murdered by dissatisfied patients with BDD, according to a study published in Aesthetic Plastic Surgery.4

Dr. Wever explains that BDD is a topic that everyone in the aesthetic industry should be aware of and educated about so patients can receive the correct treatment, which may be phycological treatment or cognitive behavioral therapy.

“The standard treatment for these people is definitely not to operate,” Dr. Wever says. “You will not make them happy.”


1. Higgins S, Wysong A. Cosmetic Surgery and Body Dysmorphic Disorder - An Update. Int J Womens Dermatol. 2018;4(1):43-48.

2. Association AP. Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). American Psychiatric Pub; 2013.

3. Bouman TK, Mulkens S, Van der lei B. Cosmetic Professionals' Awareness of Body Dysmorphic Disorder. Plast Reconstr Surg. 2017;139(2):336-342.

4. Sweis IE, Spitz J, Barry DR, Cohen M. A Review of Body Dysmorphic Disorder in Aesthetic Surgery Patients and the Legal Implications. Aesthetic Plast Surg. 2017;41(4):949-954.

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