Figure 1. Neelam A. Vashi, MD, discusses body dysmorphia and aesthetic surgery.
It is no surprise that smartphones, and the ability to take self-portraits with them, has been one of the biggest influences on trends in aesthetics in recent years. In 2017, 55% of facial plastic surgeons reported patients requesting procedures for the primary purpose of wanting to look better in selfies, a 13% increase from the previous year.1
One unfortunate side effect of this technology and the use of social media to share such images has been a negative impact on individuals’ body image, self-esteem, and mental health. The prevalence of high-quality cameras and software that allow users to edit, filter, and alter their image have made unattainable beauty standards even more ubiquitous, and despite efforts to counteract those messages, such as the #nomakeup and #nofilter campaigns, heavily edited images remain pervasive.
The Dermatologist spoke with Neelam A. Vashi, MD, who, with Susruthi Rajanala and Mayra B. C. Maymone, MD, DSc, at the department of dermatology at Boston University School of Medicine, coauthored a commentary in JAMA Facial Plastic Surgery that highlighted concerning trends in patients seeking cosmetic surgery to look more like their filtered selves.2 In particular, she discussed the importance of recognizing patients with body dysmorphic disorder (BDD) in cosmetic clinics.
Selfies in Aesthetics
“The mass appeal of selfies comes from how fast and easy they are to create and subsequently share on social media networks,” said Dr Vashi. “People now want to look more flattering in these photographs that they share among their followers, which can range from mere acquaintances to family, old friends, and work colleagues.”
Dr Vashi has noticed an increasing scrutiny of selfies by those who take them. Many physicians are now seeing patients seeking cosmetic procedures to not only improve their appearance in traditionally taken photographs, but also “to look more like filtered and altered versions of themselves, with unblemished skin, bigger eyes, smaller noses, and fuller lips.”
Identifying BDD Patients
While not every patient seeking to look better in a selfie has a mental health condition, it is important for physicians to consider the possibility that a patient may need more than fillers or rhinoplasty to address their problems with their appearance. BDD is estimated to affect 0.7% to 2.4% of the general population.3 Identifying patients with BDD is important because surgery rarely addresses, and could even worsen, the underlying condition.
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“While there is not a particular procedure that could be a red flag for BDD, there are certain behaviors you can look for,” explained Dr Vashi. Highly invasive procedures can be detrimental to those with BDD because there is no way to reverse them, she added. Some behaviors patients with BDD exhibit include:
- Doctor shopping with dissatisfaction of results
- Excessively checking appearance in mirrors
- Seeking reassurance from the physician or any family members in the room
- Using makeup or clothing to cover up perceived defects
- Making statements that indicate impairment in work, school, or social realms
- Spending substantial amounts of time thinking about or trying to camouflage the defect
In addition to red flags, there are several easy ways physicians can screen patients for BDD or other related mental health conditions that should be considered before discussing or initiating cosmetic procedures. Dr Vashi recommends physicians ask patients:
- Do you think about your appearance a lot and wish you could think about it less?
- Does your appearance upset you a lot?
- Has it caused you any problems with work, school, or relationships?
- Are there things you avoid because of your appearance?
“Due to the difficulty of diagnosis, multiple self-questionnaires have been developed, and 3 of the current surveys have been authenticated by psychiatric evaluation when used in dermatology and plastic surgery settings,” said Dr Vashi. These include the Dysmorphic Concern Questionnaire, Body Image Concern Inventory, and Body Dysmorphic Disorder Questionnaire—Dermatology Version (BDDQ-DV). “BDDQ-DV is a 1-page, self-reported questionnaire that has a high sensitivity and specificity for correctly diagnosing BDD,” said Dr Vashi.
Figure 2. Neelam A. Vashi, MD, examining a patient in her clinic.
Caring for Patients with BDD
“BDD is a very isolating disorder with high rates of suicide attempts and completion. It should be taken very seriously,” said Dr Vashi. If a patient screens positive for BDD, Dr Vashi advises avoiding commenting on the perceived defect or offering cosmetic solutions for it. Instead, she recommends the following:
- Empathize with the patient
- Act in a nonjudgmental way
- Ask about suicidal thoughts
- Decide one’s comfort level with starting treatment (ie, selective serotonin reuptake inhibitors)
- Refer the patient to an appropriate mental health expert (while recognizing that the patient may not accept the referral)
- Familiarize oneself with resources and offer patients information regarding the disorder, such as https://bdd.iocdf.org/professionals/
Given their popularity, selfies and image-based social media platforms will most likely continue to dominate trends in cosmetic treatment, and unfortunately continue to harm those with mental health conditions such as BDD. “It is important for clinicians to understand the implications of social media on body image and self-esteem to better treat and counsel their patients,” wrote Dr Vashi and her colleagues.2
1. American Academy of Facial Plastic and Reconstructive Surgery. 2018 Annual Survey Statistics. https://www.aafprs.org/media/stats_polls/m_stats.html. Published January 29, 2018. Accessed November 13, 2018.
2. Rajanala S, Maymone MBC, Vashi NA. Selfies—Living in the era of filtered photographs. JAMA Facial Plast Surg. 2018;20(6):443-444.
3. Vashi NA. Obsession with perfection: Body dysmorphia. Clin Dermatol. 2016;34(6):788-791.