Surgeon perspectives on surgical options for early-stage breast cancer

To evaluate the practice patterns of general and plastic surgeons regarding patients with early-stage breast cancer, all general and plastic surgeons in Quebec and Maryland were mailed self-administered questionnaires evaluating surgeon demographics, practice patterns, treatment preferences, and satisfaction with the results of lumpectomy and radiation therapy or breast reconstruction. Response rates of 38.3 percent and 26.7 percent were obtained for general surgeons in Quebec and Maryland, respectively. The ratio of reported mastectomies to lumpectomies was 1:2 in Maryland and 1:5 in Quebec. All general surgeons considered lumpectomy an important option. Ninety percent of Maryland surgeons versus 44 percent of Quebec surgeons considered mastectomy important. A total of 53.6 percent versus 24.9 percent of general surgeons in Maryland and Quebec, respectively, considered delayed reconstruction an important option. Additionally, 81.3 percent of Maryland surgeons considered immediate reconstruction important, and 79.6 percent discussed it with all stage I or II patients. More than 75 percent of Quebec general surgeons reported discussing immediate or delayed reconstruction with < or =50 percent of these women. Response rates of 53.6 percent and 48.8 percent were obtained for plastic surgeons in Quebec and Maryland, respectively. In one year Quebec plastic surgeons reported that they performed less than half the number of reconstructions performed by Maryland plastic surgeons (7.2 versus 17.3). In Quebec, 82.3 percent of surgeons reported that they frequently discuss delayed reconstruction, 25.1 percent immediate, 62.5 percent pedicled TRAM, and 51.7 percent nonautogenous options. In Maryland, 74.3 percent of plastic surgeons frequently discuss delayed reconstruction, 95.7 percent immediate, 89.9 percent pedicled TRAM, and 85.9 percent nonautogenous options. For women with early-stage breast cancer, regional variations exist in the surgical options discussed and provided.     

Body image concerns of breast augmentation patients

This study investigated the body image concerns of women who sought cosmetic breast augmentation. Thirty breast augmentation candidates completed several measures of body image before their initial surgical consultation. Thirty physically similar women who were not interested in breast augmentation were recruited from the medical center and university community and also completed the measures. Breast augmentation candidates, as compared with women not seeking augmentation, reported greater dissatisfaction with their breasts. Augmentation candidates rated their ideal breast size, as well as the breast size preferred by women, as significantly larger than did controls. In addition, women interested in breast augmentation reported greater investment in their appearance, greater distress about their appearance in a variety of situations, and more frequent teasing about their appearance. Finally, breast augmentation candidates also reported more frequent use of psychotherapy in the year before the operation as compared with women not seeking augmentation. These results replicate and extend previous studies of body image in cosmetic surgery patients.     

Capsular contracture after breast reconstruction with silicone-gel and saline-filled implants: a 6-year follow-up

A major problem after breast reconstruction with augmentation mammaplasty is contracture of the fibrous capsule around the prosthesis. In a series of 72 breasts in 65 women, silicone-gel and saline-filled implants were randomly selected prior to breast reconstruction. The results were judged with respect to consistency, tenderness, wrinkles, and sounds by two independent plastic surgeons according to the breast augmentation classification (BAC) and by the patients themselves. Capsular contracture was found by the surgeons in 50 percent of the gel implant group and in 16 percent of the saline implant group, which is in conformity with the results of the follow-up 5 years earlier. The incidence of deflation was 16 percent in the saline group and occurred in different sizes of both overinflated and underinflated prostheses. The degree of slow leakage from saline implants will be discussed. Despite the high rate of contractures in the gel group, 85 percent of all patients were satisfied with the result of the reconstruction.     

Aesthetic outcomes in patients undergoing breast conservation therapy for the treatment of localized breast cancer

Localized breast cancer can be treated with lumpectomy and postoperative radiation therapy, also called breast conservation therapy, with an efficacy equivalent to that of mastectomy. Reports evaluating the effects of radiotherapy suggested that breast conservation therapy had "acceptable" cosmetic outcomes; thus, posttreatment evaluation for aesthetic impact has not been instituted as a standard of care. More recent reports have suggested that the effect of breast conservation therapy on aesthetic outcome is not minimal and that patients may benefit from reconstructive consultation. The purpose of this study was to measure objectively the aesthetic change in women who undergo breast conservation therapy and whether the extent of change is significant enough (objectively and subjectively) to warrant plastic surgery consultation. The authors evaluated 21 patients who had undergone breast conservation therapy. Eleven non-breast cancer patients seeking plastic surgery consultation were used as controls. Standardized five-view photographs (frontal, left and right lateral, and left and right lateral oblique views) were obtained. Patient photograph sets were compiled and evaluated independently by eight reviewers (four surgeons, two nurses, and two medical students). Reviewers evaluated the photographs using the breast asymmetry score (score range, 0 to 9) assessing breast size, ptosis, nipple-areola position, shape, scar appearance, contour deformity, and skin changes. The authors considered 2 SD above the control mean as significant. Breast conservation therapy patients also completed a 15-item questionnaire targeting objective and subjective data about treatment-related breast change. Breast conservation therapy patients had an average treatment-related asymmetry score of 1.93, with 35 percent demonstrating significant change as compared with controls. Although most patients (86 percent) were satisfied with the cancer treatment outcome, all patients noted asymmetry. The authors' data indicate that breast conservation therapy can cause significant asymmetry; thus, an option for plastic surgery consultation as part of the treatment protocol is warranted.     

Current practices of plastic surgeons at King Abdulaziz University Hospital in requesting breast imaging studies prior to non-oncological breast surgeries

BackgroundIn the context of the high incidence of breast cancer and the high frequency of breast cosmetic surgeries, malignant and/or premalignant lesions are frequently detected incidentally in postoperative histopathology specimens. The current literature does not provide clear practice guidelines for the use of preoperative imaging prior to non-oncological breast surgeries.ObjectivesIn this study, we aimed to determine the current practices of plastic surgeons at King Abdulaziz University Hospital (KAUH) and their use of preoperative breast imaging before non-oncological breast surgeries.DesignNon-intervention/ retrospective record review.SettingsDepartment of Radiology at King Abdulaziz University Hospital (KAUH).MethodsIn 08/06/2017 at King Abdulaziz University Hospital, we conducted a single-center, retrospective chart review of the medical files of candidates for non-oncological breast surgery in order to examine preoperative imaging requests by plastic surgeons in the period 01/01/2013 to 08/06/2017.Main outcome measuresThe practice of plastic surgeons at KAUH in requesting preoperative imaging prior non-oncological breast surgeries.Sample size104 patients.ResultsWe found that, in the period 2013 to 2017, 104 women who underwent non-oncological breast surgeries were evaluated for recent preoperative breast imaging. Only 37 patients (35.6%) were found to have had preoperative imaging, and only less than one fifth (19.4%) of those 37 patients had abnormal preoperative imaging results, all of which were negative for malignancy.ConclusionsAlthough the yield of malignancy on preoperative breast imaging was zero in women seeking non-oncological breast surgeries at KAUH, we recommend the establishment of unified practice guidelines to be followed by plastic surgeons for better postoperative screening in different risk groups.LimitationsLack of follow up of patients postoperatively for any development of malignancy.     

Reconstruction after conservative treatment for breast cancer: cosmetic sequelae classification revisited

Patients with suboptimal results following breast conservative therapy are presenting more frequently to plastic surgeons as a difficult management problem. A three-type "cosmetic sequelae classification" is proposed to evaluate and manage these patients. From February of 1991 to November of 2001, 85 patients were treated for cosmetic sequelae of breast conservative therapy at the Institut Curie. The patients were followed up prospectively for 6 to 132 months (median, 33 months). They were assessed with regard to age, site and stage of tumor, type of initial breast conservative therapy undertaken, corrective operative procedures performed, complications, and cosmetic results. Forty-eight patients (56.5 percent) had type 1 cosmetic sequelae, 33 patients (38.8 percent) had type 2, and four patients (4.7 percent) had type 3. Type 1 was managed by contralateral symmetrizing procedures. Type 2 was the most difficult to manage by means of various procedures. Type 3 required mastectomy and immediate breast reconstruction. Type 1 had 97.6 percent good results compared with 82.7 percent for type 2. Three of the four type 3 patients had good results. This article reaffirms the validity of the cosmetic sequelae classification as a simple, practical guide for breast reconstructive surgeons. It discusses the various choices of reconstructive procedures available, the importance of preventing these cosmetic sequelae, and the role of the plastic surgeon in the planning of conservative treatment of breast cancers.     

Clinical applications of three-dimensional photography in breast surgery

Three-dimensional imaging in breast surgery has several uses clinically. The most practical applications are for the evaluation of breast asymmetries, both congenital and acquired, and for the evaluation of factors affecting breast shape in augmentation mammaplasty. Other uses of three-dimensional imaging that we have found clinically helpful are for evaluation of patients desiring reduction mammaplasty and for evaluation of patients undergoing unilateral breast reconstruction to determine the expander and permanent implant size that gives the best symmetry with the contralateral breast. We present five cases in which we investigate the use of three-dimensional imaging clinically by using the images to determine quantitative information about the breast, such as volume or projection. Overall, three-dimensional imaging is very helpful in providing objective information about the breast for use in preoperative planning. In addition, by analyzing clinical cases, it can provide objective data about the breast and surgical mammaplasty (especially augmentation mammaplasty) that may help surgeons better understand those factors that contribute to breast shape and influence surgical outcomes. There are currently some limitations of this system, influenced by patients with significant ptosis or obesity, which may introduce errors into the three-dimensional data, making them unreliable. However, we believe three-dimensional imaging has great clinical potential in surgical mammaplasty.     

Reconstructive breast surgery: referring physician knowledge and learning needs

Despite the positive impact that reconstructive breast surgery can have on a woman's quality of life, the percentage of eligible candidates that have this procedure remains surprisingly low. The authors hypothesized that this may be attributable to inadequate knowledge, inadequate information, and/or misinformation available to physicians caring for these patients. A needs assessment of primary care physicians, general surgeons, oncologists, and plastic surgeons was conducted to determine referring physicians' current level of knowledge of reconstructive breast surgery and to discover potential learning needs. This comprised a survey, focus groups, and individual interviews. Referring physicians rated their own knowledge of reconstructive breast surgery as low. Plastic surgeons rated their referring physicians' knowledge as even lower. Specific learning needs were identified, as large discrepancies between referring physicians' self-reported knowledge of individual breast reconstruction topics and their own opinion of their relevance were revealed. In addition, despite evidence to the contrary, more than one-third of referring physicians indicated a belief that a breast reconstruction delayed the detection of local cancer recurrence and adversely interfered with adjuvant oncologic therapy. This lack of knowledge and misinformation may be negatively affecting patient referrals to plastic surgeons, as more than one-third of referring physicians and 90 percent of plastic surgeons believed that eligible candidates were not being offered referrals because of inadequate referring physician knowledge of this topic. Furthermore, patients older than 49 years were not being referred despite the fact that plastic surgeons would consider these patients as potential surgical candidates. Referring physician gender affected both referral patterns and perceived importance of reconstructive breast surgery. Finally, personal beliefs and past experiences played a role both in physicians' decisions to refer patients and in patients' decisions to have breast reconstructions. These deficiencies in information, knowledge, and learning needs should be addressed by educational interventions during residency training and through continuing education endeavors.     

Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of breast types

In breast augmentation, surgeons usually choose a pocket location for the implant behind breast parenchyma (retromammary), partially behind the pectoralis major muscle (partial retropectoral), or totally behind pectoralis major and serratus (total submuscular). Each of these implant pocket locations has specific indications, but each also has a unique set of tradeoffs. When applied to a wide range of breast types, each pocket location has limitations. Glandular ptotic and constricted lower pole breasts offer unique challenges that often are not solved without tradeoffs when using a strictly retromammary, partial retropectoral, or total submuscular pocket. This article describes specific indications and techniques for a dual plane approach to breast augmentation in several different breast types, introducing techniques that combine retromammary and partial retropectoral pocket locations in a single patient to optimize the benefits of each pocket location while limiting the tradeoffs and risks of a single pocket location. A total of 468 patients had dual plane augmentation between January of 1992 and March of 1998 using the specific techniques of dual plane augmentation described in this article. All patients were treated as outpatients and received general anesthesia. Indications, operative techniques, results, and complications for this series of patients are presented. Dual plane augmentation mammaplasty adjusts implant and tissue relationships to ensure adequate soft-tissue coverage while optimizing implant-soft-tissue dynamics to offer increased benefits and fewer tradeoffs compared with a single pocket location in a wide range of breast types.     

Variation in management of small invasive breast cancers detected on screening in the former south east Thames region: observational study.

OBJECTIVE: To examine the variation in surgical and adjuvant treatment of breast cancer of known histology and detected on screening in a large cohort of patients treated by the surgeons of a health region. DESIGN: Part prospective, part retrospective observational study using the databases of a region''s breast screening programme and of the cancer registry. SETTING: The former South East Thames region. SUBJECTS: 600 women aged 49-79 who presented during 1991-2 with invasive breast cancer up to 20 mm in diameter that had been detected on screening. These patients were treated by 35 surgeons. MAIN OUTCOME MEASURES: Mastectomy rate by surgeon and the use of adjuvant treatment (radiotherapy, tamoxifen, and chemotherapy) were compared with risk factors, tumour grade, resection margins, and axillary node status. RESULTS: The mastectomy rate varied between nil and 80%, although the numbers at these extremes were small (0/13 v 8/10). Surgeons operating on more than 20 such cases had a lower mastectomy rate (15%) than surgeons treating fewer cases (23%), but this difference was confounded by variation in casemix. There were also wide variations in mastectomy rates and in axillary sampling rates that were independent of casemix or caseload. There was broad agreement on the use of adjuvant tamoxifen (94%), but few patients received chemotherapy (2.5%). 78 patients (19%) did not receive radiotherapy, including 51 out of 317 patients with unfavourable tumours, and 26 patients did not receive tamoxifen. Whether the patient received adjuvant treatment was more dependent on referral by the surgeon than the risk factors for local recurrence and was independent of caseload. CONCLUSION: Mastectomy rates for similar tumours vary widely by surgeon independently of casemix or caseload, but surgeons with a higher caseload tend to have a lower mastectomy rate. Omission of postoperative radiotherapy or tamoxifen after conservative treatment is not related to risk factors for local recurrence or caseload. Confidential feedback of treatment profiles to individual surgeons has been used, but when benefit has been established treatment should be guided by evidence based protocol.     

Implications of axillary sentinel lymph node biopsy in immediate autologous breast reconstruction

For patients with invasive breast cancer, if the results of an axillary sentinel node biopsy are determined to be positive after permanent pathologic examination, the current recommendation is to perform a complete axillary node dissection. Subsequent axillary surgery may compromise the blood supply to an immediate autologous breast reconstruction. The purpose of this study was to determine which clinicopathologic factors in clinically node-negative breast cancer patients may be associated with an increased risk of positive axillary nodes. Identification of these factors will allow surgeons to modify their approach to immediate autologous breast reconstruction in these high-risk patients. The relationship between presenting clinicopathologic characteristics and the incidence of axillary metastases was analyzed by chi-square test and multivariate analysis in 167 patients with invasive breast cancer and a clinically negative axilla who underwent modified radical mastectomy with an immediate free transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. Axillary nodal metastases were found in 35 percent of clinically node-negative breast cancer patients. Multivariate analysis showed that patient age of 50 years or younger (p = 0.019), T2 tumor stage or greater (p = 0.031), and presence of lymphovascular invasion on the initial biopsy specimen (p < 0.001) were independent predictors of axillary metastases in clinically node-negative patients. Based on these results, the authors propose an algorithm for decision making in clinically node-negative breast cancer patients who desire autologous breast reconstruction and sentinel lymph node biopsy. Options for immediate autologous breast reconstruction in patients undergoing mastectomy and axillary sentinel lymph node biopsy that may minimize the risk of vascular damage on reoperation include the use of the internal mammary artery and vein as recipient vessels for a free TRAM flap or a pedicled TRAM flap. If an axillary-based blood supply is used, the authors are considering the use of cadaveric dermis to isolate the pedicle of the flap away from the remaining axillary contents. New developments in breast cancer diagnosis and treatment necessitate a team approach, with increased communication between the breast surgeon and the plastic surgeon in planning surgery for these patients.     

Self-reported symptoms among women after cosmetic breast implant and breast reduction surgery

A retrospective cohort study was performed in Sweden to evaluate the possibility that an individual symptom or constellation of illness symptoms related to silicone occurs in women after breast implant surgery. A random sample (n = 2500) of all women in the Swedish national implant registry who underwent breast augmentation surgery with alloplastic breast implants during the years 1965 through 1993 was compared with a sample (n = 3500) of women who underwent breast reduction surgery during the same period, frequency matched to the implant patients for age and calendar year at the time of surgery. In total, 65 percent of the breast implant patients (n = 1546) and 72 percent of the breast reduction patients (n = 2496) completed a self-administered questionnaire covering 28 rheumatologic and other symptoms and lifestyle and demographic factors. Practically all of the 28 symptoms inquired about were reported more often by women in the breast implant cohort, with 16 (57 percent) significantly more common in breast implant recipients. In contrast, few significant differences or consistent patterns were observed in the length of time since the implant and in the type (silicone or saline) or volume of the implant. Although women with breast implants report a multitude of symptoms more often than women who have breast reduction surgery, the lack of specificity and absence of dose-response relationships suggest that the excess of reported symptoms is not causally related to cosmetic implants.     

An approach that integrates patient education and informed consent in breast augmentation

Informed consent requires surgeons to provide information about all available alternatives and their associated risks and tradeoffs to every prospective breast augmentation patient. The informed patient and surgeon then make decisions based on the information the patient has received, clinical parameters that may affect those decisions, and the patient's willingness to accept specific risks and tradeoffs. During the authors' 22 years of clinical practice, substantial changes have occurred in the requirements for adequate informed consent and the methods of ensuring that patients receive it.The numbers of alternatives for augmentation and the relative benefits and risks of each method have changed substantially over the past two decades. Four specific areas of postoperative issues stimulated major changes in the authors' approach to patient education and informed consent: 1) questions or dissatisfaction with implant size postoperatively, 2) questions about financial responsibility for costs associated with untoward events requiring reoperation postoperatively including capsular contracture or other problems, 3) spouses or other concerned parties rendering opinions postoperatively when they had not been involved in the informed consent process, and 4) criteria for whether reoperations were indicated, how many were indicated, and when implant removal without replacement might be most logical.This paper describes an approach that integrates patient education and informed consent in stages by 1) providing detailed, highly specific written and verbal information, 2) utilizing a staged approach to education and informed consent that provides information and requires simultaneous, informed consent in stages, 3) repeating each critical topic at least two or three times during the process, requiring repetitive written documentation by the patient on at least three different occasions, 4) emphasizing patient accountability for choices selected, and 5) organizing the education and informed consent process so that it is clinically practical and also increases thoroughness and documentation while conserving surgeon time.This staged, integrated system of patient education and informed consent uses a comprehensive set of informed consent documents that are available for downloading from the Plastic and Reconstructive Surgery Web site (www.plasreconsurg.org).Before incorporating any of the informed consent documents or statements reported in this paper, each surgeon should seek review by the surgeon's malpractice insurance carrier and by appropriate legal counsel to ensure compliance with state and federal laws applicable to the surgeon's practice. These documents have evolved to prospectively address patient management issues that have occurred over the authors' 22-year experience in augmentation. The documents are not endorsed by ASPS and do not necessarily represent the views of ASPS.     

Surgical treatment of breast cancer in previously augmented patients

The incidence of breast cancer is increasing each year. Concomitantly, cosmetic breast augmentation has become the second most often performed cosmetic surgical procedure. As the augmented patient population ages, an increasing number of breast cancer cases among previously augmented women can be anticipated. The surgical treatment of these patients is controversial, with several questions remaining unanswered. Is breast conservation therapy feasible in this patient population and can these patients retain their implants? A retrospective review of all breast cancer patients with a history of previous augmentation mammaplasty who were treated at the Revlon/UCLA Breast Center between 1991 and 2001 was performed. During the study period, 58 patients were treated. Thirty patients (52 percent) were treated with a modified radical mastectomy with implant removal. Twenty-eight patients (48 percent) underwent breast conservation therapy, which consisted of lumpectomy, axillary lymph node dissection, and radiotherapy. Twenty-two of the patients who underwent breast conservation therapy initially retained their implants. Eleven of those 22 patients (50 percent) ultimately required completion mastectomies with implant removal because of implant complications (two patients), local recurrences (five patients), or the inability to obtain negative margins (four patients). Nine additional patients experienced complications resulting from their implants, including contracture, erosion, pain, and rupture. The data illustrate that breast conservation therapy with maintenance of the implant is not ideal for the majority of augmented patients. Breast conservation therapy with explantation and mastopexy might be appropriate for rare patients with large volumes of native breast tissue. Mastectomy with immediate reconstruction might be a more suitable choice for these patients.     

Investigating the link between television viewing and men's preferences for female body size and shape in rural Nicaragua

The different levels of media access in otherwise very similar villages in rural Nicaragua provided a natural laboratory to explore the effect of television (TV) access on men's preferences for female body size and shape. In study 1 we compared the female body ideals of men from three discrete villages who experienced different levels of TV but otherwise inhabited a similar ecological and sociocultural environment. 3D modelling software enabled participants to create their ideal female body with more precision than simply choosing a figure from a limited range of 2D images. In study 2 we further explored local men's perceptions of female physical attractiveness and attitudes towards television using focus group discussions. Results from study 1 showed that men in the high TV villages preferred significantly slimmer bodies compared to those in the low TV village. Regression analyses showed TV access to be a significant predictor of ideal body size and upper body shape, but not of ideal lower body shape. The central theme to emerge from study 2 was the importance of the relationship between lower body shape, movement, and sex in the men's judgments of female attractiveness: the curvaceous body was perceived by the men to be a reliable cue to potential sexual promise, rather than valued simply for its visual aesthetic. Overall, findings suggest that TV access is linked to rural Nicaraguan men's perceptions of ideal female body weight and breast size, but preferences for a curvaceous lower body shape may be driven primarily by judgments of female sexual promise.     

Evaluation and comparison of aesthetic results and patient satisfaction with bilateral breast reduction using the inferior pedicle and McKissock's vertical bipedicle dermal flap techniques

In the last two decades, McKissock's technique for reduction mammaplasty was largely replaced by Robbins's inferior pedicle technique. However, a substantial number of plastic surgeons still perform McKissock's technique in the belief that it is superior to the inferior pedicle technique in terms of aesthetic results and complication rate. In this study, the authors compared the aesthetic results, complication rates, and patient satisfaction with the two techniques. Numerous studies in the past few years have shown an improvement in physical symptoms in addition to excellent patient satisfaction after breast reduction. However, almost all of these studies have used questionnaires that were mailed to the patients for evaluation. In the present study, aesthetic evaluations by the surgeon and an objective observer were performed in addition to evaluations by the patients themselves, thereby increasing the objectivity and the significance of the patients' evaluations. Two groups of 24 and 27 patients were compared. The groups were almost identical in terms of demographic data and the amount of breast tissue removed. The aesthetic results were good to excellent in both groups, and the groups had similar complication rates. When the patients' evaluations were compared with those of the surgeon and the objective observer, no significant difference was found between the observer and the patients. In one of the groups, the surgeon's evaluations were significantly higher than those of the patients, although they were not significantly higher than the observer's. In terms of aesthetic results, complication rates, and patient satisfaction, no differences existed between the groups. In addition, the patients' evaluations were determined to be a reliable index of aesthetic results and, in these cases, they were often identical to objective evaluations.     

Munchausen's syndrome and prophylactic mastectomy

A patient sought bilateral prophylactic mastectomies because of a strongly positive family history of breast cancer. Fortunately, prior to operation, this family history was discovered to be a fabrication by the patient. Few ablative plastic surgical procedures are done without objective criteria. Plastic surgeons relying on a positive family history as sufficient indication for bilateral prophylactic mastectomy need to be aware that such a history may be the contrivance of a patient with Munchausen's syndrome. A high index of suspicion may enable the plastic surgeon to recognize Munchausen's syndrome and thus avoid both contributing to the patient's illness and performing an unwarranted operation.     

Body dysmorphic disorder: diagnosis and approach

Body dysmorphic disorder is a psychiatric disease that can be frequently encountered in an aesthetic practice. Body dysmorphic disorder is characterized by a preoccupation with a minimal or nonexistent appearance defect and causes significant distress and interferes with the social life of the patient. The perceived physical anomaly may involve the shape and size of the whole body or may be centered around single units. Body dysmorphic disorder patients are known to request multiple aesthetic procedures that leave them unsatisfied. Only a timely diagnosis will enable the surgeon and staff to adequately address the patient's needs. Body dysmorphic disorder patients cannot be cured with surgery. Diagnostic techniques such as patient interview and observation are presented in this article. With this, the plastic surgeon should be able to diagnose body dysmorphic disorder preoperatively. Using the presented algorithm to approach body dysmorphic disorder patients will avoid disappointment for patients and surgeons alike.