The Body Dysmorphic Disorder Questionnaire—Aesthetic Surgery: Are We Screening the Troublesome Patients?

Abstract

This study aims to clarify the current concept of performing rhinoplasty in patients with possible body dysmorphic disorder (BDD). The primary objective was to investigate the validity and evolution over time of the Body Dysmorphic Disorder Questionnaire—Aesthetic Surgery (BDDQ-AS) before and after surgery. Together with the BDDQ-AS, also the Nasal Obstruction Symptom Evaluation scale, FACE-Q nose and nostrils, and Utrecht questionnaire (UQ) were used for convergent validation. In this prospective study, 187 patients completed these patient-reported outcome measures at four time points: at the preoperative consultation and postoperatively at 3, 6 and 12 months. The preoperative BDDQ-AS positivity rate was as high as 55.1%. Postoperatively, there was a highly significant decrease in the odds of scoring positive on the BDDQ-AS. At the preoperative consultation, positively screened patients were less satisfied with the esthetics of their noses with worse scores on UQ, FACE-Q nose, and visual analog scale. The preoperative differences in outcome measure ratings disappeared postoperatively, except for the FACE-Q nostrils, which surprisingly showed better values in BDDQ-AS positive patients. Younger age and absence of nasal trauma were statistically significant covariates associated with positive BDDQ-AS screening. Due to the overwhelming decrease in positive BDDQ-AS outcomes after surgery, a positive screening result on the BDDQ-AS should not be interpreted as a formal contraindication for surgery. Collaboration with psychologists or psychiatrists remains crucial to diagnose BDD conclusively.

Keywords

body dysmorphic disorder - rhinoplasty - PROM

Introduction and Aim

Body dysmorphic disorder (BDD) is a psychiatric disorder with intrusive thoughts about one or more perceived flaws in physical appearance and time-consuming, compulsive behavior.[1] BDD is classified under obsessive–compulsive disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).[2] BDD patients are mostly preoccupied with five to seven different body parts, with the nose being one of the three most frequently reported body parts of excessive concern.[3] BDD symptoms reduce the quality of life and can cause significant appearance-related disruption of everyday living.[4] [5]

Its prevalence in the general population is estimated at 0.7 to 7 %.[6] However, the prevalence is known to be higher in a clinical setting and especially in rhinoplasty candidates.[4] [7] [8] [9] [10] [11] [12] [13] [14] According to a meta-analysis from Nabavizadeh et al, the pooled prevalence for BDD was 32.7% in rhinoplasty candidates.[6] AlAwadh et al found a preoperative prevalence of BDD ranging from 22 to 52% in publications between 2016 and 2021.[10] The wide range in prevalence rate in various studies is most likely due to differences in population but also in the interpretation and application of the diagnostic criteria for BDD.[15] The gender ratio is reported as equal, although some studies have found a slight preponderance in women.[16] [17] [18]

BDD is a condition that represents a point of intersection between the surgical area and psychiatry.[7] BDD is chronic but responds favorably to medical treatment.[19] [20] [21] The standard treatment for BDD involves the combination of antidepressants and cognitive behavioral therapy.[22] Although still controversial, there is growing consensus that individuals suffering from BDD have no benefit from dermatologic and surgical treatments, even though they are found to be used in about 50% or more of BDD patients.[23] [24] The fact that these high-risk patients may lead to unnecessary procedures with ethical and medicolegal consequences is not recognized.[25]

The gold standard BDD diagnostic tool is SCID-V, a structured clinical interview based on the diagnostic criteria for BDD as described in the DSM-5 ([Table 1]). This interview with 24 questions is time-consuming and therefore impractical in a clinical esthetic setting. It also requires a trained clinician or mental health professional able to recognize diverse mental health disorders.[1] It is used in a psychiatric environment and is not yet validated in a cosmetic surgery setting.[26]

Table 1 DSM-5 criteria for Body dysmorphic disorder[1]

DSM-5: Body dysmorphic disorder
Disorder class: obsessive-compulsive and related disorders
A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, and reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.
C. The preoccupation causes clinically significant distress or impairment in social, occupational or other areas of functioning.
D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.
Specify if:  • With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case. Specify if:  • Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g., “I look ugly” or “I look deformed”).   ○ With good or fair insight: The individual recognizes that the body dysmorphic disorder beliefs are definitely or probably not true or that they may or may not be true.   ○ With poor insight: The individual thinks that the body dysmorphic beliefs are probably true.   ○ With absent insight/delusional beliefs: The individual is completely convinced that the body dysmorphic beliefs are true.

Consequently, various screening tools were developed with the purpose of screening patients more efficiently in daily practice for esthetic practitioners without training or experience in mental health disorders. In a recent meta-analysis (2023) by Pereira et al on assessment tools for BDD, 16 self-administered questionnaires were identified.[26] According to these authors, only five were considered as validated screening instruments in an esthetic setting, namely BDD Questionnaire (BDDQ), BDDQ Dermatology Version, Dysmorphic Concern Questionnaire (DCQ), Body Dysmorphic Disorder Questionnaire-Aesthetic Surgery (BDDQ-AS), and Cosmetic Procedure Screening Questionnaire (COPS). In the opinion of these authors, the validation process for both BDDQ-AS and COPS had inconsistencies, while there was a lack of consensus for the DCQ score cut-off value.[26]

The BDDQ-AS can be used to identify patients with BDD, with a sensitivity of 100% and specificity of 90%.[27] This self-administered screening tool was validated in a rhinoplasty population by Lekakis et al in 2016. It is a brief 7-item screening tool for BDD symptoms based on the criteria of BDD in the DSM-IV. The questionnaire comprises three “yes/no” questions and four questions with a 5-point Likert scale. As the outcome of the questionnaire is binary (positive or negative for BDD), it is not a severity-measure tool. To assess its concurrent validity, BDDQ-AS was compared to the BDD-YBOCS severity measure tool, whereas the convergent validity was assessed by comparing the BDDQ-AS to the Sheehan Disability Scale and Derriford Appearance Scale-59.[27] Spataro et al also conducted a prospective study to evaluate the convergent validity of BDDQ-AS and SCHNOS for identifying BDD preoperatively.[28] However, according to Pereira et al, the validation process of BDDQ-AS still has some inconsistencies as it was not performed against a validated diagnostic tool for BDD.[26]

The purpose of the present study is to clarify the current concept of performing rhinoplasty in patients with possible BDD, as measured with the BDDQ-AS. The primary goal is to explore sample characteristics associated with positive BDDQ-AS screening. The secondary goal is to investigate the predictive value of the BDDQ-AS on rhinoplasty outcomes as measured by patient-reported outcome measures (PROMs). The associations between the BDDQ-AS and validated rhinoplasty PROMs add to the convergent validity of the BDDQ-AS. The third goal of this study is to examine the evolution of BDDQ-AS outcomes after surgery.

Methods

The study is part of a prospective observational longitudinal outcome cohort study in a single private hospital center. Participants had to be rhinoplasty candidates who master the Dutch language. Other inclusion criteria included age over 18 years and a new patient status. Those eligible and willing to take part signed an informed consent form. These patients were invited to complete the Utrecht questionnaire (UQ), NOSE scale, FACE-Q rhinoplasty module and the BDDQ-AS pre- and postoperatively as part of standard clinical care. It was made clear to the patients that the results of the preoperative questionnaires, including the BDDQ-AS, would be used for scientific purposes only and would not take part in the decision-making to perform surgery. The participants provided data at four time points: at the preoperative consultation and 3, 6, and 12 months postoperatively.

Rhinoplasty Patient-Reported Outcome Measures

The NOSE scale was developed by Stewart et al in 2004 as the first validated questionnaire for assessing subjective nasal obstruction.[29] The questionnaire contains five items evaluating the quality of life related to nasal obstruction. The questions are responded to as 0) not a problem, 1) very mild problem, 2) moderate problem, 3) fairly bad problem, and 4) severe problem. The sum of the answers is multiplied, providing a score ranging from 0 (no nasal obstruction) to 100 (severe nasal obstruction).

The FACE-Q was developed by Klassen et al in 2010 measuring patient satisfaction in facial plastic and reconstructive surgery.[30] Two items of the FACE-Q instrument are used for the evaluation of rhinoplasty and constitute the FACE-Q rhinoplasty module: “Satisfaction of the nose” contains ten questions, and “Satisfaction of the nostrils” contains five questions that are scaled on a four-point Likert scale. Items in both scales are responded to as (1) very dissatisfied, (2) somewhat dissatisfied, (3) somewhat satisfied, and (4) very satisfied. The raw ordinal score is converted into equivalent linear interval data from 0 to 100, generated by a Rasch transformation, with higher scores indicating better outcomes.

The UQ was developed by Lohuis et al[31] in 2013 and focuses on the subjective perception of nasal appearance in esthetic rhinoplasty. The UQ captures the answers to five questions and a visual analog scale (VAS). The questions are responded to as 1) not at all, 2) a little, 3) moderate, 4) much or often, and 5) very much or often. The sum of the answers provides a score ranging between 0 and 25 with higher scores indicating worse outcomes. Two questions were designed as trick questions to help the surgeon screen for signs of BDD. The VAS assessing self-satisfaction with nasal appearance ranges from 0 (very ugly) to 10 (very nice).

Statistical Analysis

Data were analyzed with Statistical Package for the Social Sciences (SPSS) 28.0 for Windows (SPSS Inc., Chicago, IL) and R Statistical Software (v 4.2.2; R Core Team 2022). Continuous variables were described as means and standard deviations and categorical variables as percentages. p-Values less than 0.05 were considered significant. A simple logistic regression was performed to examine whether a covariate had a significant predictive value on the preoperative BDDQ-AS. As covariates, age, gender, previous nasal trauma or surgery, ethnicity, smoking, and respiratory allergy were included. A logistic mixed model was applied to model the changes in the BDDQ-AS outcome over time and to analyze how each covariate predicted the BDDQ-AS outcome at different time points. To check for informative missingness, associations between missing data at each time point and the covariates were investigated using Fisher's exact test for categorical covariates and Mann–Whitney test for the continuous covariate age. Correlation coefficients (Spearman's rho) were calculated between BDDQ-AS and the PROMs employed. A mixed logistic model further investigated the correlation between rhinoplasty outcome (PROMS) and BDDQ-AS status.

Results

Sample Characteristics and Association with Preoperative Body Dysmorphic Disorder Questionnaire—Aesthetic Surgery Outcome

From June 2020 to February 2022, 205 patients presenting for rhinoplasty were sequentially enrolled from the ENT outpatient department of GZA St. Vincentius Hospital in Antwerp, Belgium. In total, 187 (91.2%) patients completed all the questionnaires (BDDQ-AS, FACE-Q, UQ, and NOSE) preoperatively. The mean age was 30.3 years, with a range from 18 to 64 years old, and a higher percentage of females (70.4%) compared to males (29.6%). Twenty-two percent of the included population were smokers. Twenty-seven percent had a history of previous nasal surgery (either septoplasty and/or previous rhinoplasty) and 45.8% had experienced nasal trauma before the surgery. The group who screened positive on the BDDQ-AS had a significantly greater percentage of females and less frequently a history of nasal trauma. In addition, their age was significantly younger. Age, gender, and history of nasal trauma affected the odds of screening positive on the preoperative BDDQ-AS, as shown in [Table 2].

Table 2 Simple logistic regression on covariates at preoperative baseline

	OR	se(OR)	lowlim	uplim	p-Value
Age	0.965517	1.014475	0.938701	0.9931	0.014614
Ethnicity	0.853731	1.367134	0.462521	1.575835	0.613072
Gender	0.452381	1.410111	0.230658	0.887239	0.020992
Respiratory allergies	0.563524	1.350644	0.312646	1.015716	0.056376
Smoking	0.679215	1.413341	0.344765	1.338109	0.26352
History of nasal surgery	0.676638	1.387802	0.355954	1.28623	0.233292
History of nasal trauma	0.353571	1.357014	0.194362	0.643194	0.00066

Note: The odds ratios (OR) are given along with the 95% confidence interval using the preoperative time point as reference level (odds that BDDQ-AS = 1). Significant p-values are set in bold.

Predictive Value of the Body Dysmorphic Disorder Questionnaire—Aesthetic Surgery on Rhinoplasty Outcome

The results of the pre- and postoperative patient-reported outcome measures, classified according to the preoperative BDDQ-AS outcome, are shown in [Table 3]. The patients who screened positive preoperatively on the BDDQ-AS showed significantly worse scores for UQ, VAS, and FACE-Q nose than those who screened negative. After surgery, regardless of their preoperative BDDQ-AS status, VAS, FACE-Q nose and nostrils scores were significantly higher and NOSE and UQ scores were significantly lower for all study participants. These outcome measure differences rated preoperatively between both groups disappeared postoperatively. The NOSE scores were neither pre- nor postoperatively significantly different in both groups. Interestingly, FACE-Q nostrils became postoperatively significant with higher scores in the BDDQ-AS positive group.

Table 3 Pre- and postoperative UQ, VAS, FACE-Q, and NOSE scores according to preoperative BDDQ-AS status

Time point	Questionnaire	BDDQ-AS -		BDDQ-AS +		p-Value[a]
		n	mean ± SD	n	mean ± SD
Preoperative	UQ	83	12.325 ± 4.47	102	17.667 ± 4.56	<0.001
	VAS	82	4.146 ± 1.91	100	2.910 ± 1.70	<0.001
	NOSE	84	63.512 ± 27.44	101	59.683 ± 28.20	0.353
	FACE-Q nose	84	44.440 ± 12.75	103	35.456 ± 10.56	<0.001
	FACE-Q nostrils	84	48.940 ± 24.95	103	49.427 ± 25.21	0.895
3 months	UQ	72	7.569 ± 3.39	97	8.330 ± 4.33	0.218
	VAS	72	7.708 ± 1.46	97	8.103 ± 1.23	0.058
	NOSE	74	24.318 ± 24.05	97	17.357 ± 21.14	0.826
	FACE-Q nose	74	70.027 ± 16.04	98	71.714 ± 15.44	0.486
	FACE-Q nostrils	74	67.703 ± 22.974	98	77.765 ± 22.07	<0.001
6 months	UQ	66	7.212 ± 3.33	70	7.771 ± 4.09	0.385
	VAS	65	7.985 ± 1.32	71	8.183 ± 1.56	0.427
	NOSE	66	26.364 ± 25.29	70	18.22 ± 20.90	0.075
	FACE-Q nose	68	72.618 ± 16.94	72	73.403 ± 17.61	0.789
	FACE-Q nostrils	68	70.588 ± 21.81	72	78.431 ± 21.74	0.035
12 months	UQ	47	7.298 ± 3.73	49	7.163 ± 3.35	0.853
	VAS	48	7.896 ± 1.24	49	8.204 ± 1.46	0.265
	NOSE	49	24.184 ± 26.65	49	16.939 ± 22.05	0.137
	FACE-Q nose	48	69.958 ± 17.80	51	75.020 ± 17.64	0.159
	FACE-Q nostrils	48	70.396 ± 21.84	51	81.039 ± 20.45	0.014

Abbreviation: BDDQ-AS, Body Dysmorphic Disorder Questionnaire—Aesthetic Surgery; NOSE, Nasal Obstruction Symptom Evaluation; SD, standard deviation; UQ, Utrecht questionnaire, VAS, visual analog scale.

Note: Significant p-values are set in bold.

^a Independent sample Student t-test.

Correlations between BDDQ-AS and the rhinoplasty PROMs could be interpreted as very weak to moderate. UQ showed the strongest correlations at all time points, both before and after surgery. At the preoperative time point, Spearman's rank correlation was r_s (183) = 0.513, which was statistically significant (p ≤ 0.001; [Table 4]).

Table 4 Convergent validity between BDDQ-AS and rhinoplasty PROMs at different time points (Spearman's rank correlation ρ)

		UQ	VAS	NOSE	FACE-Q NOSE	FACE-Q NOSTRILS
	n	185	182	185	187	187
BDDQ-AS Preoperative	Spearman's ρ	0.513	-0.325	−0.081	−0.411	0.017
	p-value	< .001	< .001	0.272	< .001	0.821
	n	158	158	158	159	159
BDDQ-AS 3 Months	Spearman's ρ	0.363	−0.221	0.086	−0.241	−0.151
	p-value	< .001	0.005	0.284	0.002	0.057
	n	135	135	135	136	136
BDDQ-AS 6 Months	Spearman's ρ	0.423	−0.173	−0.035	−0.226	−0.184
	p-value	< .001	0.045	0.684	0.008	0.032
	n	93	95	95	94	94
BDDQ-AS 12 Months	Spearman's ρ	0.296	−0.173	0.045	−0.207	−0.228
	p-value	0.004	0.094	0.663	0.045	0.027

Abbreviations: BDDQ-AS, Body Dysmorphic Disorder Questionnaire—Aesthetic Surgery; PROM, patient-reported outcome measures; NOSE, Nasal Obstruction Symptom Evaluation; UQ, Utrecht questionnaire, VAS, visual analog scale.

Note: Significant p-values are set in bold.

Due to incomplete PROM data of certain individuals, which lacked observations at one or more time points, we investigated if there were signs of informative missingness. We tested the association between missing PROM values at any time point and the covariates and between missing values at a given time point and the value of the outcome at the preceding time points. No significant associations were found indicating that the data were missing at random.

A mixed logistic model was fitted with the PROMs as dependent variables, patient ID as random effect, and preoperative BDD outcome, time, and their interaction as fixed effects. This latter term tests whether the change in rhinoplasty outcome over time differs according to the BDDQ-AS outcome and is considered as robust for values missing at random.[32] The evolution of rhinoplasty outcomes over time (with 95% confidence interval) according to the preoperative BDDQ-AS outcome is shown in [Fig. 1].

Fig. 1 Evolution of the PROMS at the different time points depending on their preoperative BDDQ-AS screening.

Evolution of Body Dysmorphic Disorder Questionnaire—Aesthetic Surgery Outcome

As the BDDQ-AS questionnaires were filled out at baseline (pre-operatively) and postoperatively at 3, 6, and 12 months, [Fig. 2] shows the number of patients who were positively and negatively screened for BDDQ-AS at subsequent time points. The odds ratios (odds that BDDQ-AS screening is positive) using the preoperative time point as reference level (along with the upper and lower limit around the odds ratio) are significantly lower at the follow-up time points compared to the preoperative time point ([Table 5]). The raincloud plot in [Fig. 3] visualizes the evolution of BDDQ-AS in patients. At 3 months postoperative, about 2% of the BDDQ-AS negative patients became positive, while from the BDDQ-AS positive patients, about 13% remained positive. However, at 12 months postoperative, the conversion of BDDQ-AS negative into positive patients dropped to 1%. Inversely, about 4% of the initial BDDQ-AS positive patients remained positive. As previously described, age, gender, and previous nasal trauma were statistically significant covariates at the preoperative baseline. However, mixed logistic regression demonstrated that only age and previous nasal trauma were statistically significant in time ([Table 6]).

Fig. 2 Evolution of BDDQ-AS outcome: the number of BDDQ-AS positive (1) and BDDQ-AS negative (0) patients across the four different time points.

Table 5 Prediction of BDDQ-AS status in relation to different time points

	BDDQ-AS = 1	OR	SE (OR)	Lower limit	Upper limit	p-Value
Time 3 months	9.4% (n = 159)	0.024	1.836	0.007	0.077	<0.001
Time 6 months	8.8% (n = 137)	0.024	1.845	0.007	0.078	<0.001
Time 12 months	5,2% (n = 96)	0.019	2.216	0.004	0.090	<0.001

Abbreviation: BDDQ-AS, Body Dysmorphic Disorder Questionnaire—Aesthetic Surgery; OR, odds ratio.

Note: The odds ratios (OR) are given along with the 95% confidence interval using the preoperative time point as reference level (odds that BDDQ-AS = 1). Significant p-values are set in bold.

Fig. 3 Raincloud plot demonstrating the progress of BDDQ-AS positive (1) and negative (0) patients in time.

Table 6 Effect of covariates on BDDQ-AS status

	OR	SE (OR)	Lower limit	Upper limit	p-Value
Age	0.947508	1.022209	0.90758	0.989191	0.014098
Ethnicity	1.114469	1.572619	0.458866	2.706761	0.81081
Gender	0.390667	1.738363	0.13217	1.154734	0.089167
Allergy	0.648811	1.574725	0.266439	1.579936	0.34073
Smoking	0.909895	1.657185	0.338084	2.44883	0.85171
Previous nasal surgery	0.526262	1.624429	0.203343	1.361995	0.185771
Nasal trauma	0.283806	1.657957	0.105356	0.764514	0.012735

Abbreviation: BDDQ-AS, Body Dysmorphic Disorder Questionnaire—Aesthetic Surgery; OR, odds ratio.

Note: Logistic mixed model (including time) with one covariate at a time (odds that BDDQ-AS = 1). The odds ratios (OR) are given along with the 95% confidence interval. Significant p-values are set in bold.

Discussion

Characteristics Associated with Positive Body Dysmorphic Disorder Questionnaire—Aesthetic Surgery Outcome Screen

This research contributes to the increasing body of the literature that characterizes the prevalence and potential risk factors of a positive BDDQ-AS screen. In our population of rhinoplasty patients, the preoperative BDDQ-AS positivity rate was as high as 55.1%. Age, gender, and previous nasal trauma were statistically significant covariates at the preoperative baseline indicating that a younger age, female gender, and an absent history of nasal trauma are associated with an increased likelihood of a positive BDDQ-AS screen. However, mixed logistic regression demonstrated that only age and previous nasal trauma were statistically significant in time. Despite the female preponderance in the preoperative BDDQ-AS group, gender was not significantly associated with a positive BDD screening postoperatively. Research has indicated that BDD occurs in both males and females, but the clinical features of BDD may differ.[1] For BDD symptoms of the nose, no difference in gender was found. In line with our population, Wei et al also found a female predominance of a positive BDDQ-AS screen preoperatively in certain age groups.

Younger age as a predictor for a positive BDDQ-AS screen in rhinoplasty patients is consistent with the study of Wei et al and in agreement with previous studies reporting a link between younger age and positive BDD screens in facial plastic surgery patients.[16] [17] [33] [34] There are likely multiple factors that contribute to this link. The development of psychiatric conditions, such as BDD, can be influenced by low self-esteem.[35] [36] Self-esteem usually increases with age.[36] Bjornsson et al examined the age of BDD's onset and found that individuals who developed BDD early in life had more severe BDD symptoms and a higher risk for other psychiatric conditions including borderline personality disorder, anxiety disorders, suicidal attempts, and psychiatric hospitalization.[37] Wei et al also found a positive interaction between younger age and psychiatric history on the risk of positive BDDQ-AS screening.[16] Additionally, a decline in body image among adolescents and young adults may be a result of increased social media influence and screen time.[38] The increasing trend of “Zoom” mirror gazing may highlight dissatisfaction with perceived flaws in appearance.[39]

When it comes to nasal trauma, we suggest that patients with posttraumatic anomalies have a more realistic mindset compared to patients with predominantly aesthetic wishes. In the preoperative population studied by Wei et al, those who had aesthetic/cosmetic motivations and those seeking revision rhinoplasty had higher rates of positive BDD screening.[16] The latter was not confirmed in our cohort.

Predictive Value of the Body Dysmorphic Disorder Questionnaire—Aesthetic Surgery Outcome on Rhinoplasty Outcome

Preoperatively, UQ, FACE-Q nose, and VAS score were significantly worse in BDDQ-AS-positive patients. These findings agree with what was expected and contributes to the convergent validity of the BDDQ-AS. However, postoperatively, BDDQ-AS-positive patients did not differ significantly anymore from BDDQ-AS-negative patients concerning the outcome of UQ, FACE-Q, nose and VAS score. The NOSE scale measuring the functional outcome was neither pre- nor postoperative significantly different. Surprisingly, in our population, the FACE-Q nostrils demonstrated significantly higher scores postoperatively in the BDDQ-AS-positive group.

This contrasts with the findings of Lekakis et al, where BDDQ-AS-positive patients scored postoperatively significantly worse on the VAS and ROE. The initial assumption that the surgical outcome would be worse in BDDQ-AS-positive patients must be questioned based on our results. Although we acknowledge the inherent risk of bias, the inclusion criteria were not of such a nature that only patients with mild-to-moderate BDD would have been admitted for rhinoplasty. Assuming that only mild-to-moderate patients with BDD would have been operated in the present cohort and that this would be the explanation for the lack in outcome difference, it is expected that there would be no difference in the preoperative phase either. In our cohort BDDQ-AS positive patients were less satisfied with their nose preoperatively but had comparable surgical outcomes as negatively screened patients. Another explanation could be that the BDDQ-AS measures another construct which can be influenced with surgery.

The literature also shows conflicting results on rhinoplasty outcome in patients with possible BDD. There is a broad consensus that BDD should be a contraindication for aesthetic rhinoplasty, as a favorable outcome is unlike. A prospective study in 2013, which determined the influence of preoperative BDD symptoms on patients' postoperative satisfaction and quality of life with the modified Yale-Brown Obsessive Compulsive Scale, concluded that patients with more severe BDD symptoms are significantly less satisfied after surgery in comparison with patients with low-to-moderate scores.[40] Some studies also found a negative influence of BDD on the patients' self-assessment regarding their nasal function.[7] Contrarily, Rabaoli et al, reported considerable improvement after rhinoplasty irrespective of the presence or intensity of BDD symptoms even in severe cases, as measured with the body dysmorphic disorder examination (BDDE). In another study on female rhinoplasty patients with mild-to-moderate BDD, Felix et al discovered with the aid of the same BDDE, a remission rate of 81% and a postoperative satisfaction of 90% after 1 year.[41] These contradictory findings may be attributed to the use of different screening or diagnostic tools and potential issues with the content validity of some of these tools.

Evolution of Body Dysmorphic Disorder Questionnaire—Aesthetic Surgery Outcome after Surgery

An interesting finding in our study is that the proportion of patients scoring positive on the BDDQ-AS decreased significantly after rhinoplasty. The initial hypothesis that the BDDQ-AS outcome remains unchanged regardless of surgical intervention, must therefore be rejected. The hypothesis that BDD can be partially cured with surgical intervention seems highly unlikely as it goes against the current beliefs of this disorder. Based on the positive correlation between BDDQ-AS and UQ, we assume screening tools might measure psychosocial well-being and self-esteem rather than BDD itself. UQ is indeed a validated and standardized questionnaire with emphasis on the psychosocial aspects of rhinoplasty.[31] In a more general population of cosmetic patients, Von Soest et al[42] showed an improvement in self-esteem after surgery, whereas the level of psychological problems did not change postoperatively. Moss and Harris evaluated the long-term effects of cosmetic surgery and concluded that surgical intervention can improve depression, self-esteem, and anxiety.[43] In addition, Sarwer et al have shown that depression and anxiety improved following aesthetic surgery.[44]

In conclusion, younger age, female gender, and absence of nasal trauma are patient characteristics associated with positive BDDQ-AS screen. BDDQ-AS-positive patients were less satisfied with their nose preoperatively but had comparable surgical outcomes after rhinoplasty as negatively screened patients. In our population, BDDQ-AS outcome could be influenced by surgery and there was a highly significant decrease in the odds of scoring positive on the BDDQ-AS after surgery.

This study adds to the existing literature on risk factors for a positive BDDQ-AS screen and the effect of the BDDQ-AS on rhinoplasty outcome. To the best of our knowledge, this is the first study investigating the evolution over time of a BDD screening tool after surgery. Our study has certain limitations. The study was conducted in a single center for rhinoplasty, and the results may not be transferable to other settings. The clinical ENT setting made it impossible to use the gold standard BDD diagnostic tool, SCID-V, to assess concurrent validity. Further research on the evolution of other validated BDD screening tools after surgery would be useful to better understand the validity and interpretability of these screening tools.

Based on our findings, we suggest that a positive screening result on the BDDQ-AS should not be interpreted as a formal contra-indication for rhinoplasty. As described by Lekakis et al, the BDDQ-AS cannot diagnose BDD; it can only suggest possible BDD. At present, collaboration with psychologists or psychiatrists seems imperative to diagnose BDD conclusively. We hope this study provides further insight into the psychological complexity of rhinoplasty patients.

Conflict of Interest

None declared.

^* Laura Pingnet and Frank Declau are shared first authors.

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Publication History

Accepted Manuscript online:
10 January 2024

Article published online:
15 February 2024