Body dysmorphia, self-mutilation and the reconstructive surgeon.

Body dysmorphic disorder (BDD) is a disabling preoccupation with a slight or an imagined defect in appearance. It is recognised in some patients who present to the plastic surgeon requesting multiple cosmetic procedures. Very rarely, BDD patients may wish for amputation of a healthy limb and may even mutilate themselves deliberately in order to necessitate amputation. These patients pose a diagnostic challenge as BDD is uncommon and they are often uncooperative whilst appearing mentally sound. Furthermore, they raise difficult ethical and legal issues for the surgeon. Although there is some guidance for the management of BDD patients seeking elective amputation, there is currently none for the management of those who present in the emergency setting. Illustrated by the case of a man who, having failed to find a complicit surgeon, attempted self-amputation of the hand, we review the relevant ethical, legal and management issues with advice by the British Medical Association and General Medical Council.