REVIEW PAPER

Factitious Disorder (Munchausen Syndrome) in Plastic Surgery

A Systematic Review of 42 Cases
Rhian Louise Evans, LLB, MA, MBE,a Jennifer Catherine Tew, BSc,a
Downloaded from http://journals.lww.com/annalsplasticsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsI
Ho4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/19/2024

Gregory Peter Yates, BA, MA,a and Marc Feldman, MDb

Personal accounts from patients with FD are illustrative of the profound

Introduction: Patients with factitious disorder (FD) or “Munchausen syndrome”
distress caused by living with this mental disorder2 (Fig. 1).
intentionally fabricate or induce medical problems for psychological gratifica-
Although FD is seen in a wide range of specialties, it is consid-
tion. They may deceive plastic surgeons into performing multiple unnecessary
ered to be particularly high risk in plastic surgery where surgeons
procedures. We undertook the first systematic review of FD case reports in plastic
may be manipulated into performing unnecessary and invasive proce-
surgery. Our aims were 2-fold: (1) describe the adverse outcomes associated with
dures. Plastic surgeons are frequently asked to operate on wounds that
these cases and (2) identify strategies for their prevention by surgeons.
do not resolve with conservative care.3 Where these wounds are facti-
Methods: MEDLINE, EMBASE, and SCOPUS databases were searched. We in-
tious in nature, surgical management has the potential to cause “serious
cluded cases in which an adult with FD presented to a plastic surgeon. Our search
and irreversible disability to the patient [and] possible medicolegal
returned a total of 42 eligible cases reported from North America (43%), Europe
claims from the patient's family.”3,4 It is, therefore, vital that plastic sur-
(37%), and Asia (20%).
geons are able to recognize, confront, and manage patients with FD—
Results: Seventy-six percent of patients were women, and 62% worked in health
with referral to a mental health professional if warranted.
care. Sixty percent had a comorbid psychiatric disorder, the most common (50%)
Unfortunately, little empirical research has been published to
being depression. Ninety-three percent of our sample presented with self-induced
guide plastic surgeons in assessing or reducing risk in cases of FD.3 It
lesions. The average delay in diagnosis of FD was 54 months, with 46% of pa-
is not a common disorder. Retrospective studies suggest that FD is diag-
tients receiving multiple surgical procedures in this time, including debridement
nosed in less than 1% of patients attending specialist clinics, and 0.6%
(36%) and skin grafts (39%). Surgical wounds were frequently exploited by pa-
to 3% of referrals to psychiatry from hospitals.5 Furthermore, patients
tients to remain in, or return to, hospital: 50% contaminated or manipulated their
with FD are notoriously secretive: once discovered, they are rarely will-
wounds to prevent healing. Thirty-six percent of cases resulted in significant
ing to talk to health care professionals—let alone volunteer for research.
long-term disability (24%) or disfigurement (12%). Ten percent of patients received
Individual case studies have, therefore, been the mainstay of research
an amputation. Outcomes were improved when patients were confronted by surgeons,
into FD, and many such cases have been published in plastic surgery
however, and 62% were willing to see a psychiatrist. Surgeons were able to support
journals in recent years.
recovery in 33% of cases—for example, by using occlusive wound dressings.
The objective of our study was to undertake the first systematic
Conclusions: Patients with FD who present to plastic surgeons are high risk: the
review of FD case reports in plastic surgery. This methodology has been
majority require surgical intervention for severe self-injury, and many engage in
recognized as an effective way to study uncommon presentations and
harmful behaviors, such as “doctor-shopping.” Early recognition of FD in plastic
complications in both psychiatry and surgery.6–8 In aggregate, case re-
surgery is, therefore, crucial and may be achieved via careful examination of le-
ports offer larger samples than would be possible with empirical re-
sions for unusual morphology. Medical records may reveal extensive health care
search methods. We aimed to identify the following in our sample: (1)
service use and negative investigations. Finally, plastic surgeons may play an im-
adverse outcomes associated with FD in plastic surgery and (2) strate-
portant role in managing such patients. Management strategies include direct ob-
gies for their prevention by surgeons.
servation by nursing staff in the postoperative period and use of strict occlusive
dressings to prevent access to surgical wounds.
METHOD
Key Words: factitious disorder, Munchausen syndrome, plastic surgery,
fabrication, self-induced
Study Eligibility
(Ann Plast Surg 2021;86: e1–e6) A systematic search was conducted for case studies of adult patients
meeting the Diagnostic and Statistical Manual of Mental Disorders-5
atients with factitious disorder (FD) or “Munchausen syndrome” in-
P tentionally fabricate medical problems for psychological gratifica-
tion.1 They are typically motivated by a desire for attention and
criteria for FD1 (Table 1). We aimed to include cases in which patients
were assessed and/or treated by a plastic surgeon.
Cases were included if the DSM-5 criteria for FD were met but
sympathy from health care professionals, family members, and others. the patient was described using other terms, such as “self-injury” and
“self-mutilation.” Conversely, cases were excluded if the authors re-
Received April 30, 2020, and accepted for publication, after revision June 26, 2020. ferred to “factitious disorder” or “Munchausen syndrome” but their pa-
From the aBart's and The London School of Medicine and Dentistry, London, tient did not meet the DSM-5 criteria. The decision to exclude cases on
England; and bDepartment of Psychiatry and Behavioral Medicine, University these grounds was made following discussion with a senior psychiatrist
of Alabama, Tuscaloosa, AL.
Conflicts of interest and sources of funding: none declared. (M.D.F.) with significant experience in FD. For example, cases were ex-
R.L.E. and J.C.T. are co-first authors. cluded if they met DSM-5 criteria for malingering—which is defined as
Reprints: Gregory Peter Yates, BA, MA, Barts and The London School of Medicine the intentional fabrication of a medical or surgical problem that is pri-
and Dentistry, Garrod Building, Turner Street, Whitechapel, London, E1 2AD. marily motivated by external incentives, such as financial gain or
E-mail: [email protected].
Supplemental digital content is available for this article. Direct URL citations appear in avoiding military service.1
the printed text and are provided in the HTML and PDF versions of this article on
the journal’s Web site (www.annalsplasticsurgery.com). Search Strategy
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/21/8604–00e1 A keyword search of literature published in English before
DOI: 10.1097/SAP.0000000000002526 August 2019 was conducted. MEDLINE, EMBASE, and SCOPUS

Annals of Plastic Surgery • Volume 86, Number 4, April 2021 www.annalsplasticsurgery.com e1

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

 Evans et al Annals of Plastic Surgery • Volume 86, Number 4, April 2021
Downloaded from http://journals.lww.com/annalsplasticsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsI
Ho4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/19/2024

FIGURE 1. Patient perspectives about living with FD, used with permission from Gregory Yates and Marc Feldman, who collected these
insights from patients for use in their book—Dying to be Ill: True Stories of Medical Deception.2
databases were searched using combinations of the following two sets Data Collection
of terms: (1) factit*, munchausen*, self-injur*, self-mutilat*, self-inflict*, Single cases were extracted from 23 studies, whereas the remain-
and (2) plastic*, reconstruct*, wound*, ulcer*, burn*, abscess*, graft*, ing 7 contributed multiple cases. Data were entered into a Microsoft Ex-
flap*. The formula used for our MEDLINE search is provided in the cel (2016) database and the categories listed below. For each variable,
Supplementary Material, http://links.lww.com/SAP/A541. The search the percentage of cases in which relevant information was found is in-
protocol was constructed through discussion between 3 authors (G.P.Y., dicated in parentheses:
R.L.E., J.C.T.) then executed by one (G.P.Y.). 1. Demographic characteristics: We recorded the age (93%), sex
A total of 3034 records were returned by our search ranging from (100%), marital status (26%), and occupation (50%) of the patient
July 1948 to August 2019. A supplementary Google Scholar search, 2. Medical history: We recorded any psychiatric comorbidity described
and a survey of the bibliographies of key review articles added a further by the authors after psychiatric assessment or review of notes (71%)
12 records to this sample. Two thousand one hundred and thirty-five re- as well as any history of malingering (14%). Additionally, we re-
cords remained after duplicates were excluded—of which 1106 were viewed the patient's ongoing psychosocial stressors (71%) and their
determined to be irrelevant to our study aims on the basis of their title. prior health care service use (83%).
Abstracts were obtained for 792 of the 1029 titles remaining. Five hun- 3. Fabrication methods: We recorded whether the patient falsely re-
dred and sixty-four abstracts were determined to be irrelevant to our ported, simulated, and/or self-induced their signs and symptoms
study aims. From the remaining 228 abstracts, 193 full texts were ob- (100%). We also noted whether the patient presented with one lesion
tained. Three authors (G.P.Y., R.L.E., J.C.T.) completed the title and ab- or multiple lesions (100%).
stract review stage with each author independently responsible for one 4. Case outcomes: We recorded the number of procedures received by
third of the records reviewed. the patient (100%) and how many plastic surgery teams were in-
Thirty full texts were excluded because they did not include a volved in their care (100%). We then recorded the length of the inter-
case report. Ninety-nine were excluded because the case reported did val in months between the initial presentation of the patient and their
not involve assessment or treatment by a plastic surgeon. Thirty-four eventual diagnosis with FD (100%). Finally, we recorded whether
were then excluded because the patient assessed or treated by the plastic the patient sustained permanent injury or disfigurement as a result
surgeon did not meet the DSM-5 criteria for FD. In total, 30 full texts of their deception (80%) and whether they accepted referral to a psy-
proceeded to data extraction.4,9–36 All full text inclusions and exclu- chiatrist (62%).
sions were reviewed and, where necessary, discussed, by at least 2 au-
thors (G.P.Y., R.L.E., J.C.T.).
The Preferred Reporting Items for Systematic Reviews and RESULTS
Meta-Analyses (PRISMA) flow chart for the search process is provided A total sample of 42 patients was extracted from individual case
in Figure 2. reports (n = 23) and case series (n = 7). The date of publication for in-
cluded studies ranged from 1972 to 2018, and cases were reported from
America (43%), Europe (37%), and Asia (20%).
A breakdown of results for demographic characteristics may be
TABLE 1. DSM-5 Criteria for FD Imposed on Self1 found in Table 2, and medical history in Table 3. A summary of fabri-
cation methods and clinical outcomes may be found in Table 4.
FD Imposed on Self The sample size for the findings presented in this study varied
(A) Falsification of physical or psychological signs or symptoms, or according to the data available in individual cases. The sample size is
induction of injury or disease, associated with identified deception indicated in parentheses.
(B) The individual presents himself or herself to others as ill, impaired, or
injured.
Demographic Characteristics
(C) The deceptive behavior is evident even in the absence of obvious
external reward. The mean age of patients at presentation was 33 (range = 41) and
(D) The behavior is not better explained by another mental disorder, such as
76% (n = 32/42) were female. Patients were unmarried in 55% of cases
delusional disorder or another psychotic disorder. (n = 6/11), married in 27% (n = 3/11), and divorced in 18% (n = 2/11).
A health care–related occupation was reported by 66% of patients

e2 www.annalsplasticsurgery.com © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

 Annals of Plastic Surgery • Volume 86, Number 4, April 2021 Factitious Disorder in Plastic Surgery
Downloaded from http://journals.lww.com/annalsplasticsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsI
Ho4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/19/2024

FIGURE 2. PRISMA flow diagram, showing each stage of our systematic review.

(n = 14/21) and the most common profession mentioned was nursing surgical complaints, and 49% (n = 17/35) had engaged multiple clini-
(n = 10/21). cians for a single complaint.
Twenty-seven percent of patients (n = 8/30) faced known ongo-
ing life stressors at the time of their presentation to plastic surgery.
These stressors included a difficult family environment (n = 5) and
Medical History
Comorbid psychopathology was reported in 60% of cases
(n = 18/30)—notably not only depressive (n = 8) and personality
(n = 5) disorders but also psychosomatic symptoms (N = 3), anxiety TABLE 3. Relevant Medical History of Patient Sample
(n = 2), and bipolar disorder (n = 1). Authors discovered a history of
malingering in 14% of cases (n = 6/42)—including 2 instances of med- Variables n %
icolegal action taken against a surgeon and 2 false claims for disability Psychiatric history
benefits. Extensive health care use was common in our sample: 88% No comorbid psychiatric disorder 12/30 40%
(n = 15/17) were under the care of multiple specialists for medical or
Any psychiatric disorder 18/30 60%
Depression 8/18 44%
TABLE 2. Demographic Characteristics of Patient Sample Personality disorder 5/18 28%
Other 11/18 61%
Variables n %
History of malingering
Sex Reported malingering 6/42 14%
Female 32/42 76% Medicolegal 2/6 33%
Male 10/42 24% Work-related 2/6 33%
Occupation Other 2/6 33%
Health care–related 14/21 66% Life stressors
Other employment 5/21 24% Any stressor 8/30 27%
Unemployed 2/21 10% Family 5/8 63%
Marital status Other relationship 3/8 38%
Married 3/11 27% Health care service use
Unmarried 6/11 55% Engaged in “doctor shopping” 17/35 49%
Divorced 2/11 18% Presented to multiple specialties 15/17 88%

© 2020 Wolters Kluwer Health, Inc. All rights reserved. www.annalsplasticsurgery.com e3

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

 Evans et al Annals of Plastic Surgery • Volume 86, Number 4, April 2021

recognized. Plastic surgeons facilitated recovery in 14 cases. They did

TABLE 4. Summary of Fabrication Method(s) Associated With so by restricting patient access to wounds (eg, through occlusive dress-
the Index Presentation and Consequent Clinical Outcomes ings and casts) or placing the patient under direct supervision
postsurgery.
Variables n % Mean [Range]
Fabrication method(s)
DISCUSSION
Downloaded from http://journals.lww.com/annalsplasticsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsI

—
Ho4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/19/2024

Falsely reported signs/symptoms 20/42 48%

Simulated signs/symptoms 4/42 10% —
Self-induced signs/symptoms 39/42 93% — Evaluation of Risk
Single lesion 27/42 64% — Our results show that patients with FD who present to plastic sur-
Multiple lesions 15/42 36% — geons are inherently risky. The lesions seen in our sample were over-
Outcomes whelmingly (93%) the product of self-mutilation and were usually
(81%) severe enough to require surgical intervention. Indeed, many re-
Multiple plastic surgery teams 7/39 18% —
involved quired multiple operations. The methods used by patients typically in-
volved injection of a foreign material (eg, urine), application of a
Number of plastic surgeries received — — 4 [33]
corrosive agent (eg, paint stripper), or mechanical self-injury (eg, exco-
Time between initial presentation and — — 14 [144] riation). Self-induced disease of this severity is rarely seen in other spe-
diagnosis of FD (months)
cialties where FD is commonly encountered, such as cardiology.37 It is,
Patient sustained permanent 9/34 26% — however, seen in other surgical specialties, such as obstetrics and
disfigurement/injury
gynecology38
Patient accepted referral to psychiatry 11/26 42% — The cases we reviewed also featured classic behaviors associated
with FD, such as “doctor-shopping.” Often used in relation to
relationship problems (n = 3), such as divorce, child custody dispute, drug-seeking behaviors, “doctor-shopping” describes patients who visit
and marriage preparations. several doctors for a single health problem.39 Roughly half of the pa-
tients in our sample engaged with multiple surgeons for their fabricated
lesions. In doing so, they exposed themselves to considerable risk:
Fabrication Methods “multiple consultations and overlapping prescriptions are associated
The majority of our sample presented with lesions that were with drug misuse, polypharmacy, and increased medical expenses.”39
self-induced (n = 39/42). A breakdown of methods used by patients Poor communication between hospitals prevented surgeons who
to self-injure is provided in Table 5. Multiple lesions were noted in had been “doctor-shopped” from accessing information about past pre-
36% (n = 15/42) of cases. scriptions, admissions, and surgeries. They were forced instead to rely
Two patients simulated their lesions: one by dousing their skin on the information provided by the patient—which was typically false
with liquid to simulate serous exudate, and the other by pretending to or misleading. Behaviors such as “doctor-shopping” help to explain
be unable to unclench their fist. Other patients simulated signs and the poor outcomes seen in our results: an average of four operations
symptoms to make their presentation more convincing: one withheld were performed per case, with one quarter resulting in permanent injury
urine to simulate retention, and another tampered with their thermome- or disfigurement—including four amputations.
ter to convince clinicians they had a fever.
Thirty-six percent (n = 15/42) of patients lied to surgeons about
the cause of their lesion—claiming, for instance, that they had been in- TABLE 5. Methods Used by Patient Sample to Inflict Self-Induced
jured in an accident, or that surgical wounds had reopened “spontane- Lesions
ously.” Twelve percent (N = 5/42) of patients lied to clinicians about
their need for surgical intervention: multiple patients lied about a family Variables n
history of malignancy to persuade their surgeon to undertake a radical Injection of foreign material 11
mastectomy. The majority of patients presented to surgeons with Urine 2
self-induced lesions and misled them verbally, but many relied on their Toothpaste 2
lesions alone to guarantee they would be operated on.
Feces 1
Cigarette ash 1
Outcomes Shaving cream 1
The patients in our sample received extensive surgical care: the Menstrual blood 1
mean number of operations received by patients was 4 (range = 33), Sodium hypochlorite 1
and in 18% of cases (n = 7/39), these operations were undertaken by Mascara 1
multiple plastic surgery teams. Half of our sample (n = 21/42) exploited Unknown 2
their surgical wounds to garner further attention and care from health Application of corrosive substance 3
care professionals—for example, by deliberately contaminating, burn-
Paint stripper 1
ing, or tearing open skin grafts and reconstructive flaps. Twenty-six per-
cent of patients (n = 9/34) sustained permanent injury or disfigurement Soda lye 1
either as a result of their self-mutilation or complications of surgery. Pa- Unknown 1
tients in our sample underwent unnecessary amputations, mastecto- Mechanical self-injury 12
mies, and hand surgeries resulting in nerve damage. Excoriation with nails 7
The average delay between initial presentation and a diagnosis of Excoriation with pin 1
FD was 14 months (range = 144). In 57% of cases (n = 24/42) patients Incision with surgical instruments 1
were confronted by their plastic surgeon—and, in several cases, a Self-inflicted blunt trauma 1
psychiatrist—with their suspicions of FD. Eleven patients accepted re- Unknown 2
ferral to a psychiatrist once their deceptive behavior had been

e4 www.annalsplasticsurgery.com © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

 Annals of Plastic Surgery • Volume 86, Number 4, April 2021 Factitious Disorder in Plastic Surgery

Recognition of FD wounds. Particular efforts should be made to ensure the patient is not
The findings of this study indicate several factors that should left alone when the wound is exposed—for instance, during dressing
raise suspicion of FD in plastic surgery. Foremost among these factors changes.33 Similar strategies have been employed in other specialties.
is the morphology of the lesions themselves, which may appear peculiar For example, Kubota et al44 resolved a case of factitious levothyroxine
to surgeons when compared with naturally occurring wounds.32 Sur- malabsorption by persuading their patient to take levothyroxine at reg-
geons should be wary of isolated, well circumscribed ulcers surrounded ular outpatient appointments under direct observation by nursing staff.
Downloaded from http://journals.lww.com/annalsplasticsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsI

by healthy tissue.4 Deeper examination may reveal necrosis arising

Ho4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/19/2024

from the surface of the wound, as opposed to the wound bed. Given Strengths
the self-inflicted nature of FD, body sites easily accessible to the patient Factitious disorder is considered to be a rare disorder. However,
are commonly implicated—notably, the dorsum of the nondominant most plastic surgeons will encounter one or more of these patients dur-
hand.9 ing their career. Our study is the first to explore outcomes for these pa-
Methods of wound tampering involved excoriation with nails or tients, who are known to be high-risk. By collating a relatively large
manipulation with instruments, such as scalpels and tweezers. Given sample of case reports, we have shed light on strategies that have been
the deceptive nature of patients with FD, it is unlikely that any such im- used by plastic surgeons to recognize, confront, and manage patients
plements would be seen at the bedside. Nevertheless, a high index of with FD. Furthermore, our findings have helped to dispel two pervasive
suspicion should exist when the patient is a health care professional— myths about treating this disorder: that its sufferers are unwilling to en-
as in 66% of our cases—due to their ease of access to surgical tools. gage with psychiatrists, and that there is nothing any other kind of clini-
Patients with FD are extremely inventive in their methods and cian can do for them. The rich level of detail provided by the case study
surgeons should emulate this creativity to aid diagnosis. In 1 case format facilitated this.
we reviewed, the use of a dressing soaked in tetracycline solution ex-
posed the ruse: Ultraviolet light revealed tetracycline on the patient's Limitations
fingernails—proving definitively that they had tampered with the When taking into account the findings of this review, a number
dressing and sabotaged their treatment. Similar techniques have been of limitations should be considered. First, although case reports consti-
used in other specialties. Endocrinologists, for example, have measured tute almost all knowledge concerning FD, they are vulnerable to publi-
C-peptide and thyroglobulin levels to gather evidence for surreptitious cation bias. Obscure, novel, or severe cases tend to be submitted for
use of insulin and thyroxine, respectively.40 publication, with little consideration for the more common manifesta-
Patient records may also provide clues to the FD diagnosis and tions of the disease. The preponderance of cases involving health care
should not be undervalued. Recurrent negative laboratory investiga- professionals may also be attributed to this bias37
tions are not uncommon in these cases26 and many of the patients in Second, it is possible that case reports were missed by our key-
our sample had an extensive, documented history of negative wound word search due to variability in the primary surgical team providing
swabs and biopsies. Several authors noted a contradiction between their care. For example, breast surgery lies under the remit of both plastic
patient's enthusiasm for painful or high-risk surgery and the hospital re- and general surgery and as such, cases presenting to a general surgeon
cords, which showed multiple failed attempts at surgical treatment. may have been overlooked. Similarly, cases involving the hands and
Health care service use was generally extensive in our sample, with feet may have been omitted due to cross-over between plastic surgery
most patients positive for the “thick-file sign” seen in chronic FD2 and orthopedics.
Finally, our sample size was insufficient for statistical testing.
Managing FD Nevertheless, this study provides an insight into a rarely studied but im-
It is frequently claimed that patients with FD are unwilling to en- portant aspect of plastic surgical practice.
gage with psychiatrists.41 Our results suggest that this is not always the
case. The majority of surgeons were willing to confront patients with
CONCLUSIONS
their suspicions, and the offer of psychiatric treatment was accepted in
42%. It may be more accurate to state that patients with FD are amena- Within plastic surgery, patients with FD patients are undoubtedly
ble to psychiatric intervention if confronted nonpunitively. Where possi- high-risk. They self-mutilate, seek out multiple operations, and sabo-
ble, the conversation should take place with a mental health tage their surgical wounds. Our review of 42 patients shows how this
professional present. The best outcomes may be achieved with patience. self-destructive cycle often leads to permanent injury or disfigurement.
In dermatology, clinicians are encouraged to avoid confrontation upon To interrupt the cycle, surgeons should ensure they are aware of factors
first meeting patients with self-inflicted lesions—and to instead focus that point to a diagnosis of FD. We encourage surgeons to be suspicious
on providing support and empathy, with a view to maximizing the like- of morphologically unusual lesions with repeat negative swabs and
lihood of successful confrontation at follow-up.42 Additionally, in clin- biopsies—especially when patient records show a “thick file” of past
ical practice, dermatologists tend not to explicitly use terms such as hospital attendances. Comanagement of these patients with the mental
dermatitis artefacta with these patients. Avoidance of labels such as health team is preferable. Surgeons should consider confronting pa-
“Munchausen” may be similarly beneficial for plastic surgeons. tients in a nonpunitive manner to encourage them to engage with a psy-
Our review highlighted numerous methods that can be employed chiatrist. Surgeons should also treat FD directly by using strict occlusive
by plastic surgeons to achieve “surgical control” of self-destructive pa- dressings and close monitoring by nursing staff.
tients. These interventions are of particular importance when psychiat-
ric treatment is delayed or rejected. Strict occlusive dressings such as REFERENCES
multi-layer bandaging and vacuum-assisted closure should be used
wherever possible, as in some cases of FD they may lead to complete 1. American Psychiatric Association. Diagnostic and statistical manual of mental
disorders (DSM-5®). American Psychiatric Pub; 2013 May 22.
healing.29,43 Despite the ever-evolving nature of plastic surgery, the
2. Feldman MD, Yates GP. Dying to be ill: true stories of medical deception.
number of donor sites for grafts and flaps is not infinite, and the choice Routledge; 2018 May 11.
is dependent on several factors. However, where possible, donor sites 3. Eisendrath SJ, Telischak KS. Factitious disorders: potential litigation risks for
that are minimally accessible to the patient may be of benefit. plastic surgeons. Ann Plast Surg. 2008;60:64–69.
Meticulous monitoring by nursing staff in the postoperative pe- 4. Zibis AH, Dailiana ZH, Papaliaga MN, et al. Munchausen syndrome: a differen-
riod is time-intensive but may deter patients from sabotaging their tial diagnostic trap for hand surgeons. J Plast Surg Hand Surg. 2010;44:222–224.

© 2020 Wolters Kluwer Health, Inc. All rights reserved. www.annalsplasticsurgery.com e5

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

 Evans et al Annals of Plastic Surgery • Volume 86, Number 4, April 2021

5. Yates GP, Mulla MM, Hamilton JC, et al. Factitious disorders in medical and psy- 25. Inui K, Hanafusa T, Namiki T, et al. Intractable postoperative wounds caused by
chiatric practices. In: Rogers R, Bender SD, eds. Clinical Assessment of Malinger- self-inflicted trauma in a patient with cutaneous Munchausen syndrome present-
ing and Deception. New York: The Guilford Press; 2018:212–235. ing as a pyoderma gangrenosum-like lesion. Case Rep Dermatol. 2016;8:97–101.
6. Yates G, Bass C. The perpetrators of medical child abuse (Munchausen syndrome 26. Lazzeri D, Romeo G, De Rosa M, et al. Plastic surgery and Munchausen's syn-
by proxy)—a systematic review of 796 cases. Child Abuse Negl. 2017;72:45–53. drome: ‘surgeon, beware!’. J Plast Reconstr Aesthet Surg. 2010;63:e319–e320.
7. Abdul Jabbar A, Patel A, Marzlin N, et al. Internal mammary artery-to-pulmonary 27. Little A, Curtis H, Kellogg B, et al. Munchausen syndrome disguised as
vasculature fistula: systematic review of case reports. Vasc Med. 2017;22: gossypiboma: an interesting case. Eplasty. 2016;16:ic39.
Downloaded from http://journals.lww.com/annalsplasticsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsI

426–431.
Ho4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/19/2024

28. Méndez-Fernández MA. The factitious wound: plastic surgeon beware. Ann Plast
8. Chavez P, Messerli FH, Casso Dominguez A, et al. Atrioesophageal fistula fol- Surg. 1995;34:187–190.
lowing ablation procedures for atrial fibrillation: systematic review of case reports.
Open Heart. 2015;2:e000257. 29. Nardella D, Sohawon MS, Heymans O. Munchausen' s syndrome in plastic sur-
gery practice: a bewildering situation! Indian J Plast Surg. 2007;40:194–198.
9. Acartürk TO, Abdel-Motleb M, Acar F. How to kill a flap: Munchausen
syndrome—a silent trap for plastic surgeons. J Hand Microsurg. 2014;6:42–44. 30. Paraskeva PA, Ridgway M. An unusual surgical presentation of Munchausen's
syndrome. Int J Surg (London, England). 2004;2:123–124.
10. Agris J, Simmons CW Jr. Factitious (self-inflicted) skin wounds. Plast Reconstr
Surg. 1978;62:686–692. 31. Park AJ, Scerri GV. Munchausen's syndrome—masquerading as necrotizing fasci-
11. Al-Qattan MM. Factitious disorders of the upper limb in Saudi Arabia. J Hand itis. J R Soc Med. 1996;89:170P–171P.
Surg (Br). 2001;26:414–421. 32. Pavan C, Scarpa C, Bassetto F, et al. Munchausen's syndrome in plastic surgery:
12. Anderson LG. Munchausen syndrome: hospital hobo of the 1990s. Plast Surg an interdisciplinary challenge. Plast Reconstr Surg Glob Open. 2015;3:e428.
Nurs. 1994;14:220–224. 33. Phelps DB, Buchler U, Boswick JA Jr. The diagnosis of factitious ulcer of the
13. Basaran K, Datli A, Kurt M. An important diagnosis for the hand surgeon: “the hand: a case report. J Hand Surg [Am]. 1977;2:105–108.
clenched fist syndrome”. J Plast Reconstr Aesthet Surg. 2014;67:1304–1306. 34. Seoighe DM, Dempsey M, Lawlor C, et al. Factitious disorder as a differential di-
14. Carlson MJ, Linscheid RL, Lucas AR. Recognition of factitial hand injuries. Clin agnosis for recurrent skin graft failure. J Plast Reconstr Aesthet Surg. 2011;64:
Orthop Relat Res. 1977;222–227. e89–e91.
15. Castor B, Ursing J, Aberg M, et al. Infected wounds and repeated septicemia in a 35. Siim E, Medgyesi S. Ulcus cruris recidivans caused by auto-mutilations. Case re-
case of factitious illness. Scand J Infect Dis. 1990;22:227–232. port. Scand J Plast Reconstr Surg. 1979;13:355–357.
16. de Fontaine S, Van Geertruyden J, Preud'homme X, et al. Munchausen syndrome. 36. Tollefson TT, Kriet JD, Wang TD, et al. Self-induced nasal ulceration. Arch Facial
Ann Plast Surg. 2001;46:153–158. Plast Surg. 2004;6:162–166.
17. Drinker H, Knorr NJ, Edgerton MT Jr. Factitious wounds. A psychiatric and sur- 37. Yates GP, Feldman MD. Factitious disorder: a systematic review of 455 cases in
gical dilemma. Plast Reconstr Surg. 1972;50:458–461. the professional literature. Gen Hosp Psychiatry. 2016;41:20–28.
18. Feldman MD, Hamilton JC. Mastectomy resulting from factitious disorder. Psy- 38. Edi-Osagie EC, Hopkins RE, Edi-Osagie NE. Munchausen's syndrome in obstet-
chosomatics. 2007;48:361. rics and gynecology: a review. Obstet Gynecol Surv. 1998;53:45–49.
19. Feldman MD. Prophylactic bilateral radical mastectomy resulting from factitious
39. Biernikiewicz M, Taieb V, Toumi M. Characteristics of doctor-shoppers: a system-
disorder. Psychosomatics. 2001;42:519–521.
atic literature review. J Mark Access Health Policy. 2019;7:1595953.
20. Friedman B, Yaffe B, Blankstein A, et al. Self-inflicted hand injuries: diagnostic
challenge and treatment. Ann Plast Surg. 1988;20:345–350. 40. Kinns H, Housley D, Freedman DB. Munchausen syndrome and factitious disor-
der: the role of the laboratory in its detection and diagnosis. Ann Clin Biochem.
21. Fujiwara T, Kubo T, Yano K, et al. A case of intractable recurrent abdominal cu- 2013;50:194–203.
taneous ulceration caused by self-injection of menstrual blood. Eur J Plast Surg.
2008;30:303–304. 41. Bass C, Halligan P. Factitious disorders and malingering: challenges for clinical
assessment and management. Lancet. 2014;383:1422–1432.
22. Ghilli M, Mariniello MD, Colizzi L, et al. Breast surgeons dealing with
Munchausen syndrome: a self-induced necrotic phlegmon of the breast treated 42. Wojewoda K, Brenner J, Kąkol M, et al. A cry for help, do not omit the signs. Der-
with surgery, negative pressure and epidermal fractional skin grafting. Breast J. matitis artefacta—psychiatric problems in dermatological diseases (a review of 5
2019;25:526–527. cases). Med Sci Monit. 2012;18:Cs85–Cs89.
23. Grenga TE, Dowden RV. Munchausen's syndrome and prophylactic mastectomy. 43. El-Sabbagh AH. Negative pressure wound therapy: an update. Chin J Traumatol.
Plast Reconstr Surg. 1987;80:119–120. 2017;20:103–107.
24. Hallock GG. Futility of muscle flaps for self-inflicted wounds. Ann Plast Surg. 44. Kubota S, Fukata S, Matsuzuka F, et al. Successful management of a patient with
1993;30:131–135. pseudomalabsorption of levothyroxine. Int J Psychiatry Med. 2003;33:183–188.

e6 www.annalsplasticsurgery.com © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.