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Dysmorphic Discussions has the FLU.

We will return with a Xmas special as soon as the coughing stops and the virus is killed. 

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This week I had a consultation with a BAAPS surgeon about the possibility of replacing my breast implants. They are McGhan high profile placed sub-pectorally. I have not had any problems with them but recently I have been sensing changes and have some concerns. Quietly in attendance throughout the consultation and invisible to most was my alter-ego  the Body Dysmorphic Disorder Poster Girl

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Cognitive Behaviour Therapy is the current treatment of choice for this often misrepresented disorder. The theory implies that if the ugliness is imagined then the thoughts linked to the imagination or the imagination itself need to be changed to something better for recovery to happen. Some therapists like to use ‘flooding’, a technique which confronts the patient all at once with the maximum fear stimulus. ‘Desensitization’ involves repeated exposure in increasing amounts. It might be over-simplified to suggest that CBT views Body Dysmorphic Disorder patients as suffering from a case of mind over matter. If the mind is dealt with, then the implants won’t matter. For an existentialist psychotherapist, the focus is on the individual and his/her world-view rather than guiding someone’s thinking.  Existential therapy invites the individual to investigate meaning through four different dimensions: physical, social, psychological and spiritual. The individual is encouraged to explore his/her existence with all its isolation and anxiety. Enquiry into these dimensions will reveal and welcome diversity in body image. It does not necessarily negate the ideas behind cognitive behavioural therapy. Dysmorphia Needs A Poster Girl! 

Fourteen years ago, the family health clinic on a routine check-up, noticed a lump in my breast. The tests revealed that the lump was benign and the consultant told me that the lump would never grow to be anything larger than a small pea. Almost immediately that I walked out of that consultation, the lump started growing and became the size of large golf ball which on a 32a breast was horrifying. It was worrying, too, as it was contradicting the information that the consultant had given me. I waited again for another appointment and was told that the lump was still benign but would have to be removed.  I could deal with that.  Ok. So far, so good. Proceed. 

Waiting in a tiny ward for surgery at my local London hospital, I discovered that the young and very beautiful girl in the next bed to me had had the same thing happen to her and was also waiting to have a lump removed. The surgeon came and visited each of us individually in the ward to have a pre-operative chat. I overheard the surgeon telling the girl in the next bed that he would make sure not to leave a scar on her breasts and would try to go in from under and to the side to minimize any scar. The consultant pulled open the curtain and then came and sat next to me to explain the surgery to me. He did not offer me those same assurances. I asked him if he would be kind enough to make the scar as small as possible and he told me that was more than possible and promised me he would. 

As I came round from surgery, I overheard the girl in the next bed talking to someone about the tiny elastoplast she had under her breast.  As I heard this, my hand went to where my bandage was and it was across the front of my breast right in the middle. Uh oh + anger + tears followed by futile attempts to appear as if I was not terrified by all of this. This was not good.  

What happens when the realization of a larger than expected wound is dawning on a patient with Body Dysmorphic Disorder?  Does the imagined ugliness just expand to incorporate the new problem? Is it like being the boy with his finger in the dyke? When the doctor came by, I pulled my courage together to say that I was surprised to see where the wound was made and he replied with ‘we didn’t realize you wanted a scar underneath your breast’. It was not the same surgeon that I spoke to earlier. Horror. I held it together and I was told that I would have to wait for the wound to heal and the scar to form and to come back and re-assess how I felt at that point. They told me I would probably feel happier by then. 

Are you kidding me? I don’t have enough fingers to plug that dyke? 

When I returned for the follow-up appointment in out-patients, I started the complaint procedure. As the complaint escalated with one person after another coming to examine me and explain that the surgeon was unaware that I would have preferred a more discreet scar, I was becoming more and more dumbfounded. Really? They didn’t think I would want a more discreet scar? Seriously? Eventually they sat me down and said those famous words: ‘wait here’. 

After about half an hour a man came into the cubicle where I sat and attempted to reason with me that the scar would not stop me from living. I was about ready to faint with all this rationality when eventually, pleadingly, he asked in what he hoped was a rhetorical way ‘what would you have us do?’ I guess they expected me not to have thought this through and not to have an answer because so far they had not offered me any suggestions as to what to do. They kept me with the feeling that there was no answer to my dilemma even though they acknowledged it was unsightly and could have been avoided.  By this time, half of the hospital had seen my breasts: a deeply unpleasant experience! Some of them said the breast looked ok.  Others responded with ‘oh’ biting back their real response. It is very difficult to be indignant when you are naked from the spare tyre up. The worst part was that it was totally impossible to work out from their dishonest reactions whether this particular ugliness was real or imagined. The answer would have been irrelevant anyway because the fact was that there was no need for me to have had to sport a long and wide scar for life across a tiny breast. Had I been warned ahead of time that a scar would be a non-negotiable part of the removal of this particular lump, then I would have psychologically prepared myself to deal with it. I would not have been happy but I would not have been complaining to whoever it was that I was complaining to. 

After all the powers-that-be had examined my breast, I gathered my courage together and without pause for breath, explained to them that I believed that if they put a set of breast implants in me, this would lift (stretch) the skin and reposition the scar. They were shocked and horrified that anyone would suggest this to them.  It was 1996.  Dear oh dear. Women don’t speak surely?! Where was her consent form for this outbreak of speech? I had friends who had breast implants and they all had shown me their results and I had noticed that the skin was stretched, shiny. The medics huddled together and then turned to me saying that they agreed that I was now a suitable candidate for a consultation in the plastics department. They said it as if it was their idea! Should I mention how shaken I was by all of this? 

It took about two years before I was seen and the surgeon did agree that a pair of breast implants would help to reposition the scar so that it would be less noticeable. By this time I was running a patient support site for cosmetic surgery patients and had received many photos from many women who all talked about the skin stretching in response to the implant.  I brought two or three friends with breast implants to my consultation so that I could specifically point out to the surgeon the type of result I hoped to achieve.  

I will always be grateful to those friends (I met them on my website) that came along with me for morale support and for educational purposes! I’m not suggesting that everyone takes someone along as an example to show a surgeon but sometimes it is helpful if you don’t know how to say something clearly.   Also, I was very worried that the surgeon might change his mind about my surgery and I needed friends there to help pick me up off the floor from the potential disappointment I worried about. It is massively important to have real patients share real experiences (good and bad) with real photos so that other patients can gain better understanding about procedural possibilities or even impossibilities. Supplementing consultation information with other patients’  experience is a joy and a lesson for all. I am proud to have been the first woman online in the UK to voluntarily offer (and benefit from) free cosmetic surgery patient support . Fortunatley, this particular surgeon was happy with the concept. 

I was absolutely delighted that the surgeon I consulted approved me for breast implants to disguise the unsightly scar.  I waited nearly another two years to have the surgery. I was given surgery dates which were cancelled over and over again in those two years. Each time the disappointment sickened me. It was a torturous wait. When I called to see if anything could be done to get me into surgery any sooner, I was always reminded how unimportant my procedure was to them. I did not ask for a scar but I was being asked to live with it for longer than I felt necessary. I empathize with anyone who is waiting for any surgery on the NHS. Time passes s-l-o-w-l-y. 

Four years of misery. I agree that this is not the same type of misery that others with more serious medical conditions suffer from but within the parameters of my universe, this felt like a lifetime. 

I had a pre-op consultation to discuss the surgery and the size and shape of the implants. This is where the nature of the surgery changed slightly.  I was informed that 310cc round, sub-pectoral McGhan implants would be adequate to move the scar. I asked if I could have a larger size of implant arguing that the results might be more aesthetic (to me) with a larger size. I was granted my wish. It was a nice feeling. I was kind of excited. 

When I woke up from surgery, my alter-ego was in a very anxious state. One quick look down ‘neath the sheets told me that I did not look any less ugly! How predictable. So my ugliness had not gone away. Not at all. I was disappointed. I hoped the imagined ugliness would just disappear as soon as I saw my nice new shiny breasts. That isn’t what happened though.  I felt exactly the same about myself as I have always done. I had learned to incorporate being flat chested into my imagined ugliness and now I was resigned to learning how to incorporate being a new size and shape into my imagined ugliness. Same thing different day. No change there then!  I will say though that I was totally delighted that the scar was moved out of sight. Thoroughly and utterly delighted. Oh and I also love wearing bikinis on the beach now. I still imagine I am ugly but I feel that I look better. How weird is that? It’s not an absence of pain but it is a reduction. So far, one plus point! That is a great result for the pro cosmetic surgery within Body Dysmorphic Disorder group! If only I lived on a beach more of the time! 

I think this helps to illustrate how in some cases, plastic surgery for body dysmorphic disorder can be acceptable. Part of my imagined ugliness was about the size of my breasts. Yes, I understand that cosmetic surgery may not change that part of me that refuses to budge from imagined ugliness. That was not the main goal of this surgery anyway. As long as any patient knows before surgery that the results of the surgery may not alter their feelings/thoughts about themselves, then it might be a marriage made in heaven or at least an acceptable proposition. 

Not everyone will be in my boat. In cases of Body Dysmorphic Disorder patients, there are similarities and there are also differences.  There are degrees of suffering. There are different levels of self-awareness. Some patients with Body Dysmorphic Disorder who come from a family of other sufferers may have to find different ways of dealing with the disorder compared to other patients who are unique in their family with this disorder. Different people will have different reasons for presenting themselves for cosmetic surgery. If a patient can see that part of their problem will remain or possibly get worse with the results of plastic surgery but part of their problem may be resolved, then it is a case of appreciating the individual concerned. Partial relief of pain is better than no relief of pain. How can we tell which patients are able to accept what can and can not be changed psychologically from cosmetic surgery? Whether it is cognitive behavioural, existential, integrative or any other type of psychotherapy, a patient must at least be attempting to gain some insight into their condition before they can gain any possibility of benefit from cosmetic surgery. Ultimately, the benefit must outweigh the risk. 

Anyone who undergoes cosmetic surgery takes a risk whether they have Body Dysmorphic Disorder or not. The question is whether or not the possibility of the benefit outweighs all the risks involved. I wish anyone who chooses to undergo cosmetic surgery all the best of luck in the world. Oh and have a look at my sister site: www.cosmeticsupport.com

sister site to Dysmorphic Discussions

First edition of New Blog
http://cosmeticsupport.blogspot.co.uk