Psychiatric Screening Before Plastic Surgery

A record-setting 14.6 million elective surgical and non-surgical cosmetic enhancements were performed last year, thanks to advancements in medical techniques and the advent of less-invasive, cost-effective procedures. But with this increase in popularity, are we opening the floodgates to putting patients at risk for unnecessary operations?

One way to minimize the risk associated with any surgical procedure is to determine its need and then weigh the dangers against the rewards. Another is to find out whether the patient is electing for the right procedure for the right reasons through a psychiatric screening process that has become more important in recent years.

Although boosted self-esteem and increased confidence are added benefits to fixing an embarrassing physical flaw, they can also lead both the patient and surgeon down a slippery slope. Body dimorphic disorder (BDD) — a condition where patients see themselves in negative, unrealistic ways — can result in the patient becoming obsessive over a certain body flaw and may lead to excessive, unneeded surgeries. Pre-screening can help identify this and other issues, and it may direct a patient to a more appropriate course of action.

In 2006, the British Association of Aesthetic Plastic Surgeons (BAAPS) issued a checklist of 8 warning signs to help cosmetic surgeons identify prospective patients with serious body image problems. This checklist includes watching out for:

1. A preoccupation with an imagined defect
2. Excessive concern over a minor blemish or flaw
3. A perceived flaw causing significant distress and impaired social or working life
4. When the preoccupation is not accounted for by another mental disorder
5. Multiple consultations for surgery
6. Multiple surgical procedures
7. Unrealistic expectations about the outcome of the surgery, such as wanting to look like a particular movie star
8. Lack of clarity about the goals for the procedure

While there is no hard-and-fast rule in the US for this screening process, there are certain things that a plastic surgeon is urged to look for. Is the patient's dress provocative and alluring? Does the patient retreat from physical contact or actively avoid eye contact? How is the patient's affect and mood? Is the voice monotone or easily excitable? If any of these questions raise a red flag for a plastic surgeon, it is not unreasonable to send the potential patient for a psychiatric evaluation to help determine his or her driving factors for the surgery.

Although these reasons may be diverse, the underlying catalyst for a patient wanting a plastic surgery procedure should be simple and pure: to make themselves feel better and healthier, both physically and mentally.

I often ask my patients, “Why do you want this procedure and how do you feel it will better your life?” In some cases, the reasons may be purely aesthetic, but in others — as with breast reduction candidates where neck, shoulder, and back pain is often a factor — the reason truly is they are looking for a better quality of life.

By increasing psychological screenings, surgeons can ensure the patient fully understands the procedure they are electing for and the realistic results that can be expected from such a procedure. Though plastic surgery can make great changes to a person’s body, we are not miracle workers and there is only so much a plastic surgeon can do.

While most patients do understand that plastic surgery will change their appearance, sometimes this change can be jarring for those who are not properly prepared for it. Psychological screenings can help identify these potential issues early on so that they can be discussed. Preparation is the key to performing a successful procedure and ensuring that patients are truly happy with their results.

Robert T. Grant, MD, MSc, FACS, is Chief of the combined Divisions of Plastic Surgery at New York-Presbyterian Hospital-Columbia University Medical Center and New York-Presbyterian Hospital-Weill Cornell Medical Center. He is also Associate Clinical Professor of Surgery in the College of Physicians and Surgeons at Columbia University and Adjunct Associate Professor of Clinical Surgery at Weill Cornell Medical College. For more information about Dr. Grant or to contact him, visit his website at www.robertgrantmd.com.