DUBAI // Plastic surgeons are concerned patients are not receiving enough pre-surgery consultations. As the market becomes more competitive, some doctors are reluctant to reject patients. "If you work in a centre that has a large volume and doesn't depend on money, it's fine," said Dr Ioannis Michael Salivaras, medical director of the American Academy of Cosmetic Surgery Hospital. "But some doctors don't have so many cases so it's difficult for them to turn patients away, and this is wrong. "The patient could be suffering from neurosis, or even something more serious, such as body dysmorphic disorder." Body dysmorphic disorder is marked by an imagined physical defect or a minor defect that others cannot see. "The doctor has to be sensitive about this … make a diagnosis and see if he can treat it by referring the patient to a psychologist," Dr Salivaras said. "Otherwise the implications can be more severe. The condition will become worse and the patient will come back to you." Worldwide, one in 13 patients is rejected for surgery after consultation and the rate here is similar, said Dr Mazen Max Sawaf, medical director of CosmeSurge. "All decent cosmetic surgeons have to know a little bit of psychology," he said. "If there is any doubt, the patient must be referred to a psychologist." A patient's reasons for wanting surgery or a history of previous surgery are good indicators of an underlying problem. "Some people just want to do it for their self-esteem, and that's fine," said Dr Saliha Afridi. "But if they identify themselves with the surgery, that's not a healthy place to start. It can almost become addictive." Therapy is also important after surgery, she said. "I had one patient who started gaining weight after liposuction, and because of the procedure, she wasn't gaining it naturally. "These patients need to be followed up with a dietitian or therapist to make sure they maintain their weight." There are no regulations requiring consultations, said Dr Allen Rezai, founder of Elite Cosmetic Surgery. It is incumbent on the doctor. According to international best practice, the first consultation with a patient should last between 45 minutes and an hour. Then, repeat consultations are often necessary to allow a patient time to weigh up the information and options. "A good surgeon knows when to use the knife and when to reject the patient,"said Dr Rezai.