Body Dysmorphic Disorder Often Goes Undetected in Cosmetic Surgery Work-up

December 15, 2016

By Marilynn Larkin

NEW YORK—Routine implementation of validated screening instruments such as the Body Dysmorphic Disorder Questionnaire (BDDQ) prior to cosmetic surgery "may improve patient care," researchers suggest.

"Patients with BDD have an obsessive preoccupation with perceived defects of their appearance that are minuscule or nonexistent and commonly involve the nose, eyes, skin, or hair," write Dr. Lisa Ishii of Johns Hopkins University School of Medicine in Baltimore, Maryland and colleagues in JAMA Facial and Plastic Surgery, online December 8.

"Numerous studies have shown that patients (with BDD) tend to have poor satisfaction following surgery and show a higher rate of aggression and litigation toward surgeons," they note.

To investigate BDD prevalence in facial plastic surgery and assess surgeons' ability to identify the disorder, the team recruited 597 patients (about two-thirds had an average age of 45 and one-third, 56) in three facial cosmetic surgical sites from 2015 to 2016.

All patients completed the BDDQ. After each clinical session, surgeons independently determined the likelihood that a patient had BDD.

Depending on the type of surgery to be performed, patients also completed other facial-satisfaction screening tests preoperatively, including the FACE-Q, Blepharoplasty Outcomes Evaluation (BOE), Facelift Outcomes Evaluation (FOE), Rhinoplasty Outcomes Evaluation (ROE) and Skin Rejuvenation Outcomes Evaluation (SROE).

Overall, 58 of the 597 patients (9.7%) screened positive for BDD by the BDDQ, whereas 16 of 402 patients (4.0%) were suspected of BDD by surgeons screening clinically.

A higher percentage of patients presenting for cosmetic surgery (37 of 283 patients, or 13.1%) screened positive on the BDDQ compared with those who were to undergo reconstructive surgery (21 of 314 patients, or 6.7%; odds ratio, 2.10).

Gender was not significantly associated with BDDQ status (OR, 1.8).

Those who screened positive on the BDDQ had lower baseline (preoperative) satisfaction with their appearance as assessed by the FACE-Q (OR, 0.93), ROE (OR, 0.95), BOE (OR, 0.94), FOE (OR, 0.89) and SROE (OR, 0.92).

Surgeons correctly identified only two of 43 patients (4.7%) who screened positive for BDD on the BDDQ. Nevertheless, most (89%) were certain they could accurately screen for BDD.

Dr. Ishii told Reuters Health, "Most surgeons do not routinely administer the BDDQ to prospective cosmetic procedure patients."

"Given the prevalence of body dysmorphic disorder in patients seeking cosmetic surgery and the high proportion of patients with body dysmorphic disorder missed by the surgeons in their typical intake," she said by email, "we believe that the BDDQ should be routinely administered to prospective cosmetic patients."

"The BDDQ is easy to incorporate into a busy clinical flow, so the return on investment is high," she concluded.

Dr. Gregory Greco, chairman of the Division of Plastic Surgery at Monmouth Medical Center in Long Branch, New Jersey, called the study "interesting" and said "the overall findings are likely consistent with the populations seeking facial plastic surgery."

Nevertheless, he told Reuters Health by email, "The study specifically looks at the surgeon's ability to predict body dysmorphic disorder preoperatively, but does not state whether any patient with a positive score actually underwent surgery and if so, whether they in fact (were) satisfied or dissatisfied with their results."

Dr. Greco also pointed to "the very positive finding that 90-plus percent of patients seeking cosmetic surgery and 96-plus percent of patients seeking reconstruction are doing so for the appropriate reasons."

"I do not use the actual BDDQ, but I do ask similar questions of my patients," he observed. "The most important part of plastic surgery is the management of expectations. Very honest, real discussions must occur prior to any surgery. I always ask my patients 'why now?' and 'what is the impetus for surgery?' Major life events, divorce, deaths, breakups, job loss etc. can cloud judgment."


JAMA Facial Plast Surg 2016.

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