"Everything has beauty, but not everyone sees it." (1)
Cosmetic surgery performed on patients with body dysmorphic disorder ("BDD")--a mental disorder where individuals are preoccupied with imagined or exaggerated physical flaws-raises issues of concern to medical, legal, and mental health professionals. There is considerable disagreement regarding when a plastic surgeon can appropriately perform an elective procedure on an individual with BDD, whether and when legal liability should attach to this surgery, and what sanctions should be available if legal liability is appropriate. This Article proposes guidelines for this surgery that respect the autonomy of these patients while protecting them from unscrupulous doctors preying on their disorder.
II. BDD and Cosmetic Surgery
A. Body Dysmorphic Disorder
BDD has been classified as a somatoform disorder characterized by an obsessive preoccupation with an imagined or exaggerated defect in one's physical appearance. (2) This preoccupation, the manifestations of which typically first appear during adolescence or early adulthood, causes significant distress and interferes with day-to-day functioning. (3) For a BDD diagnosis, the preoccupation must not be attributable to another psychiatric disorder (such as an eating disorder). (4) Approximately one to two percent of Americans are diagnosed with BDD, with women and men equally likely to experience the disorder. (5)
Any body part can become the subject of obsession, but skin, hair, and nose are the most frequent areas of focus. (6) Men are more likely to become preoccupied with their genitals, height, hair, and body build, while women tend to be concerned with their weight, hips, legs, and breasts. (7) Individuals with BDD will report on average concerns about five to seven different aspects of their appearance during their lifetime. (8) The vast majority seek some form of treatment to fix their perceived flaws. (9) An estimated 30% to 40% of them undergo at least one surgical procedure, 50% to 60% obtain dermatological services, and 10% receive cosmetic dental treatment. (10) This Article's focus is individuals with BDD who pursue major elective cosmetic surgery.
B. Cosmetic Surgery in General
In recent years, the stigma and cost once associated with undergoing plastic surgery has dissipated, and a wide array of procedures--formerly available to only a small, wealthy segment of society--has become relatively mainstream. Many of the medical professionals performing these procedures credit reality television shows and positive media coverage as driving the heightened demand for cosmetic work. (11)
Further, technological improvements have reduced (although not eliminated) scarring and recovery time, while the prospect of receiving significant fees and immediate payment rather than waiting for insurance claims to be processed has greatly expanded the number of physicians who make cosmetic surgery the focus of their practice. (12) Nearly two million cosmetic surgeries were performed in 2008, (13) with over ten million total cosmetic treatments performed when minimally invasive procedures like Botox injections and chemical peels are included. (14) Breast augmentation, liposuction, eyelid surgery, abdominoplasty (a "tummy tuck"), and breast reduction were the most popular surgeries for women, (15) while men, who now constitute approximately one fifth of the patient base, (16) favored liposuction, rhinoplasty (a "nose job"), eyelid surgery, liposuction, male breast reduction, and hair transplantation. (17)
Notwithstanding the increasing normalization of cosmetic surgery in popular culture, concerns have been raised that cosmetic surgery may be performed excessively or unnecessarily, (18) and recent studies have identified heretofore unrecognized long-term psychological hazards associated with the procedures. This research reaffirms the seriousness of undergoing these elective operations and suggests that mental health issues may be associated with the seeking of cosmetic surgery. …