body dysmorphic disorder is a very recognized condition where the patient’s mind doesn’t really reflect what their appearance is. they always thing that they are not as good looking not as young they are unhappy with their appearance and despite having often very nice and appropriate procedures they want more they want something different. well frankly in our training for example we were trained by psychiatrists in interviewing you know how to interview how to ask the question how to get to it. now sometimes it’s not very hard because you know they come to us and they are 38 years old and they’ve had 3 face lifts already. but sometimes you’ve got to do a little more work. but generally you kind of get at the issues because you look at them and you listen and you get a sense and it just doesn’t seem right. in other words the patient’s worries seem disproportional to how good they look to you. that’s how you sort it out and the sorting is important because that patient generally presents i think a much bigger challenge than one might want to take on because they often are not satisfied regardless of the high quality of the work delivered. that’s one condition that has to be sorted out. the other condition is someone who doesn’t necessarily have the wrong view of their appearance they just feel like they have to be up to the minute and every year they just have to have something done to keep up with the joneses almost. it’s like a badge of honor or courage oh yes i just had a face lift this year. but the problem with that is with each successive operation becomes more difficult more fraught with hazard and runs the risk of going over the edge of looking natural. we had a very high profile patient come in here who i’ve known for 25 years. although i’ve not operated on her she was operated on by one of my teachers and when i first met her and she came in and asked me about having the chemical peel the chemical wrinkle removal process. well i know that my teacher did that procedure on her many many years ago and again it’s a long lasting procedure. she certainly did not need it so i advised against it and respectfully declined to take on the case. well i saw her later and somehow she had something else done and i have to say it wasn’t very good. she looked wrong she looked pulled she looked strapped to the 747 look. and that you can’t disengage that i mean that it’s permanent you can’t reverse it. so sometimes peculiar to our community here particularly the hollywood environment there’s a little greater tendency towards that. people are struggling very hard to hold on to that youthful appearance. but as you know from some of the very high profile celebrities who have had too much nose job work done etcetera etcetera you can pass the point of no return and that’s not very good. bad decision bad decision by the patient and by the way bad decision by the doctor. i can tell you in our practice here 20% of the people that come in are told either that it’s not appropriate to do or what they have is so unusual complex or whatever that they would best be served at least by a consultation with another specialist. for example someone who has had two or three eyelid operations and they’ve had some problems with it i’m not sure they should have another one. but i will defer to my colleague in the ophthalmic plastic surgery world to help make that decision. there is always the risk of taking an imperfection and making it worse and that is never a happy scene. no surgeon wants to preside over either a complication or a failure. you want the right operation for the right patient and that gives you a happy patient and that’s what drives us in this work. it’s about making people happy and having a waiting room of people on the post-operative visit days who are all sitting there saying wow this is really great i’m glad i did this.
as a plastic surgeon are there patients you would refuse?