 [ Symptoms ] as a plastic surgeon are there patients you would refuse [ Disease ] body dysmorphic disorder is a very recognized condition where the patient is mind does not 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 is not very hard because you know they come to us and they are 38 years old and they have had 3 face lifts already but sometimes you have 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 does not seem right in other words the patient is worries seem disproportional to how good they look to you that is 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 is one condition that has to be sorted out the other condition is someone who does not 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 is 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 have known for 25 years although i have 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 is 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 was not very good she looked wrong she looked pulled she looked strapped to the 747 look and that you can not disengage that i mean that it is permanent you can not reverse it so sometimes peculiar to our community here particularly the hollywood environment there is a little greater tendency towards that people are struggling very hard to hold on to that youthful appearance but