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Kant et al. Plast Aesthet Res. 2026;13:4 Page 9 of 20

Most genital surgeries, regardless of the gender modality, require patients to focus a significant amount of
time and energy on parts of their body that have already been a source of distress, albeit due to incongruence
between natal sex and gender rather than dysmorphia. Regardless of a history of BDD, patients should be
coached on how to balance the desire to monitor their healing progress and report back to their surgical
team with the potential difficulties that may arise from compulsive or ritualized checking. Patients should be
reminded in advance that it is not unusual for individuals who frequently check areas of concern in an
attempt to reassure themselves to experience a paradoxical effect - where the checking exacerbates anxiety,
thus intensifying the perception of common and generally safe complications, such as granulation tissue or
mild wound dehiscence.

Body-focused repetitive disorders
BFRBs are conditions that lead patients to engage in behaviors such as hair pulling and excoriation (skin
picking or scratching) [63,64] . During recovery, these behaviors can compromise the integrity of surgical sites by
either tugging at necessary sutures or introducing harmful bacteria onto recent wounds. While they may
provide stress relief and be engaged in consciously but compulsively, BFRBs can also include what are known
as “automatic” behaviors, which are done without intention and may catch people by surprise only after the
behavior has been engaged in for a substantial period of time [64,65] .

While the exact cause of BFRBs is not fully understood, conditions that disrupt the texture of the skin, such
as acne or psoriasis, can lead to an increased number of tactile cues . Patients who engage in BFRBs report a
[65]
sensation of itching, tingling, or “tension” in the affected area, which can only be ameliorated by engaging in
the BFRB itself . This can pose challenges for patients with exposed stitches or newly formed scars - both of
[65]
which can trigger automatic picking behavior. Additionally, opioids commonly used in pain management
routines are known to cause itchiness, and the dry air of hospital environments may draw moisture out of
the skin, having the same effect. Proactive engagement with Habit Replacement Therapy can provide
competing responses that keep the hands busy , and keeping the area covered with a sheet or light surgical
[66]
dressing may reduce the risk of automatic picking. Pharmaceutical interventions such as N-acetyl cysteine have
been shown to decrease skin picking [67,68] , while naloxone has been used to manage itchiness caused by
opioids .
[69]

Obsessive-compulsive disorder and related conditions
Obsessive-compulsive disorder (OCD) is a highly heterogeneous condition characterized by persistent
ruminative thoughts alongside compulsive behaviors designed to mitigate the anxiety caused by these
thoughts. Many presentations of OCD elicit substantial health anxiety, either regarding the health of the
patient or people around them. Patients with contamination-based OCD will often wash to excess, and the
inability to shower for as long as a week while inpatient may be an unexpected but highly distressing
experience for patients.

Validated measures such as The Yale-Brown Obsessive Compulsive Scale can be helpful for getting a picture
of the role OCD plays in an individual’s life by breaking down the condition into subdomains such as level of
distress, frequency of ritualized behavior and ability to resist performing anxiety-reducing behaviors (e.g.,
compulsions) . Exposure and response prevention therapy (EXRP), which builds a person’s natural ability
[70]
to resist compulsive behavior through a process called fear-extinction, may be indicated prior to surgery .
[71]

The predisposition to ruminative thoughts can also make it more difficult to tolerate the anxiety of the
unknown and exacerbate the distress associated with common complications such as hematoma or wound
dehiscence. People with OCD may also attempt to seek reassurance from providers in excess of what is
feasible on an outpatient basis during the immediate postoperative period. Communication between the