Aesth Plast Surg
https://doi.org/10.1007/s00266-021-02344-x
SURVEY
BDD Knowledge, Attitude and Practice Among Aesthetic Plastic
Surgeons Worldwide
Nada Raafat Khattab1 • Dan Mills2
Received: 10 February 2021 / Accepted: 4 May 2021
 Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2021
Abstract
Background Body dysmorphic disorder (BDD) is a con-
troversial topic in the field of plastic surgery.
Objective Our aim was to determine whether BDD
knowledge, attitude and practice (KAP) are affected by the
experience of the surgeon in the field, sex of the surgeon,
country of practice, and the number of patients the surgeon
sees annually. We were particularly interested in uncov-
ering any significant relations in KAP of BDD between
plastic surgeons practicing in developed versus developing
countries.
Methods We created a two-page survey of 24 questions
about the KAP of BDD. The survey was sent to aesthetic
plastic surgeons worldwide via ISAPS global email list.
The data were collected over a period of 20 days at the end
of 2020.
Results A total of 464 plastic surgeons completed the
survey. The only factor that determines the awareness of
BDD is the experience of the surgeon. The more experi-
enced the surgeon is, the more likely he/she is to be
familiar with the clinical picture of BDD. Although aware,
the more experienced surgeons tend to dismiss the impor-
tance of referring BDD patients to psychiatrists/psycholo-
gists. Male surgeons tend to diagnose more patients with
BDD than female surgeons. Surgeons who estimated the
& Nada Raafat Khattab
nadarkhattab@gmail.com
Dan Mills
dcm2@danmillsmd.com
1
Plastic Surgery Unit, Kasr Al Ainy Hospital, Faculty of
Medicine, Cairo University, Al Manial, Cairo 11562, Egypt
2
Aesthetic Plastic Surgical Institute, 3185 Pacific Coast Hwy,
Suite 201, Laguna Beach, CA 92651, USA
SPECIAL TOPIC
correct prevalence of BDD among patients seeking surgery
acquired knowledge of BDD from scientific journals. The
KAP is relatively similar between surgeons practicing in
developed and developing countries, and the main statis-
tically significant difference was in the questions used
during the course of the interviews to diagnose BDD.
Conclusion We can deduce from the results that most
aesthetic surgeons worldwide have got knowledge of the
presentation of BDD and are keen to diagnose the disorder
in their practice. It is worth noting that surgeons usually
have their unique approach in the management of BDD.
Our study highlights the importance of not only raising
awareness of the best management of BDD, but also of
establishing a consensus that BDD is a contraindication to
aesthetic treatment. The best methods to raise awareness
are through journals and plastic surgery residency.
Level of Evidence V This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors https://www.springer.com/00266.
Keywords BDD
Body dysmorphic disorder
Aesthetic
plastic surgeons
The French poet, Voltaire, said ‘if you were to ask a peacock where
his soul were situated, he would say ‘‘In the tip of my magnificent
tail.’’ [1].
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Introduction
Body image is a person’s perception of their body with
either a positive or negative valence [2]. Excessive and
persistent preoccupation with perceived flaws in appear-
ance is known as body dysmorphic disorder (BDD).
Although the perceived flaws are unobservable or appear
only slight to others, they give rise to significant distress in
the sufferer. Patients diagnosed with BDD usually engage
in compulsive behaviors such as frequent mirror checking,
excessive makeup, skin picking and other symptoms of
anxiety. [3].
According to a systematic review, the prevalence of
BDD in the general population is estimated to be 1.9%. The
frequency of the disorder in psychiatric settings ranges
from 5.8 to 7.4% [4]. In cosmetic setting, a meta-analysis
concluded that 15.04% (range 2.21–56.67%) of plastic
surgery patients and 12.65% (range 4.52–35.16%) of der-
matology patients have BDD, most of which were women
[5]. Another paper reported that the disorder occurs equally
in males and females [6]. Studies have concluded that there
are certain populations who are more susceptible to
developing BDD than others. For example, patients seeking
rhinoplasty have the highest prevalence of BDD, 20.1%.
Furthermore, adolescents are at an increased risk of being
diagnosed with the disorder compared to adults [6]. A
paper concluded that more than 70% of BDD patients are
diagnosed before 18 years of age [7]. BDD could impede
the normal development of the adolescent and may pave
the way to many other psychiatric disorders [8].
Sociocultural factors can be condemned guilty for con-
tributing to the birth of BDD. The beauty standards set by
the society and culture influence the perception of body
image. For example, for centuries people from different
cultures viewed facial symmetry a symbol of facial har-
mony and attractiveness. Contrary to the popular belief, a
study concluded that a beautiful face does not necessarily
have to be a symmetrical one. Some degree of asymmetry
makes one’s facial beauty peculiar rather than disfigured
[9]. Insecurities due to internalization of beauty standards
result in body image dissatisfaction which can make them
go to great lengths as seeking aesthetic surgery in pursuit of
a beautiful body. The ever-increasing availability, acces-
sibility and affordability of such procedures can also be
attributed to the rising demand for them [10].
The diagnosis of the disease is mainly dependent on
questionnaires and the interview with the patient. Only two
questionnaires were evaluated in the cosmetic setting: the
‘Body dysmorphic disorder Questionnaire Dermatology
version’ and the ‘dysmorphic concern questionnaire’ [11].
It is of upmost importance to determine whether the
patient’s interest in the aesthetic procedure is labile or not.
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Aesth Plast Surg
If they are motivated by secondary gains or temporary
reasons, this should raise a red flag. Performing an aes-
thetic procedure without prior psychological assessment
can result in grave consequences for the surgeon [12].
Therefore, BDD should not be missed in the aesthetic
setting and cosmetic professionals should be fully aware of
the disease.
Our study aims to survey aesthetic plastic surgeons
worldwide on BDD. After the approval of the current
ISAPS president, Dr. Nazim Cerkes, we sent the survey via
ISAPS global email list. Given the limited availability of
validated screening, the question arises as to whether aes-
thetic surgeons rely on their clinical sense to identify
patients with BDD. For that reason, in this study we sought
to investigate the methods and skills used by aesthetic
plastic surgeons to screen patients that do not need or are
not indicated for aesthetic treatment. Furthermore, we
wanted to determine the attitude of aesthetic plastic sur-
geons with different backgrounds toward BDD and the
necessity of raising awareness on this topic in 2021. In the
literature, we have found five studies that are relevant to
our paper [13–17].
Methodology
We have created a two-page survey of 24 questions about
the KAP (knowledge, attitude and practice) of BDD. Many
of the questions were inspired from previous studies
[13–17]. The survey was sent to aesthetic plastic surgeons
worldwide via ISAPS global email list. The data were
collected for a period of 20 days at the end of 2020, from
October 18 to November 6. A pdf was attached to the email
that provided information about the clinical picture of BDD
and the purpose of the study.
Statistics
Power analysis was conducted to calculate the optimal
sample size. According to ISAPS international survey in
2017 and the previous related research [13–17]. we
assumed the following: population size is 50,000, propor-
tion of sample with the expected outcome = 0.80, margin of
error = ? / - 5.0%. confidence level= 95.0%, and response
rate = 80.0 %. Svysampsi 50,000, prop (0.8) moe (5.0), lev
(95), resp (0.8). Therefore, the estimated sample size nee-
ded to survey is 245. The estimated required sample size
adjusted for 80.0 % response rate is 306. Hence, we found
that a sample size of 464 is satisfactory.
Data were entered and statistically analyzed on the
Statistical Package of Social Science Software program,
version 25 (IBM SPSS Statistics for Windows, Version
25.0. Armonk, NY: IBM Corp.). Data were presented using
Aesth Plast Surg
mean and standard deviation for quantitative variables and
frequency and percentage for qualitative ones. Comparison
between groups for qualitative variables was performed
using Chi-square or Fisher’s exact tests, while for quanti-
tative variables the comparison was conducted using
independent t test. P values less than or equal to 0.05 were
considered statistically significant.
Results
Twenty-four questions were asked to assess the demo-
graphics, knowledge, attitude and practice of aesthetic
plastic surgeons. We further analyzed the data to determine
whether there is a significant difference in the KAP within
the demographics: years of experience in the field, sex of
the surgeon, country of practice, and the number of patients
the surgeon sees per year. We focused on the countries the
surgeons practice in, categorized into developed and
developing countries according to the Human Develop-
ment Index (HDI) rated by the United Nations Develop-
ment Program 2020. A total of 538 surgeons have
registered a response, and 464 surgeons have agreed to
participate in the survey. This makes a response rate of
86.3%
Demographics
Four questions were related to the participants’ demo-
graphic characteristics, presented in Fig. 1. A total of 242
out of 464 surgeons (52.2%) who completed the survey
have practiced aesthetic plastic surgery for at least 20
years. Thirty-four percent of participants see more than 500
patients per year. Most of the surgeons were males, 77.2%.
Figure 1 Demographics of Aesthetic plastic surgeons worldwide
More surgeons, 56%, practice in developed countries
compared to developing countries, 44%. Surgeons from the
USA represented 15% of surgeons worldwide, which is the
greatest population in the study.
Knowledge
As illustrated in Fig. 2, four questions were asked to assess
the knowledge of participants regarding BDD. Surgeons
familiar with the clinical picture of BDD, who answered
question 5 with ‘yes’ rather than ‘slightly’ or ‘no,’ were
considered aware of the disorder. Surgeons aware of BDD
represent 84% of the population. Journals followed by
residency are the most common sources of knowledge of
BDD. Only 2% of surgeons were learning about BDD for
the first time. The most commonly reported estimate of the
prevalence of BDD in the plastic surgery setting whether in
Medspa or Surgery is 5–10%. Medspa refers to the non-
invasive aesthetic services offered in plastic surgery
clinics.
Attitude
Three questions were related to the attitude toward BDD,
demonstrated in Fig. 3. Most of the participants, 62%, think
BDD is always a contraindication to aesthetic treatment.
However, a significant portion, 32%, believe that the
treatment of BDD patients by cosmetic professionals is
contraindicated only occasionally. Two-thirds, 60%, of
surgeons believe that BDD patients could possibly benefit
from an aesthetic treatment, endorsing the answer ‘Both’ as
in ‘medspa and surgery’ when asked which procedure
would be effective.
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Figure 2 Knowledge of aesthetic plastic surgeons worldwide
Figure 3 Attitude of Aesthetic plastic surgeons worldwide
Practice
Thirteen questions were related to the practice of BDD
(Table 1). About 90% of surgeons have seen a patient with
BDD before, most of them see less than 5 per year. The
BDD behaviors most commonly observed are unrealistic
expectations, and excessive concerns and requests. Partic-
ipants also gave examples of other behaviors they have
encountered which includes crying, comparison with
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Aesth Plast Surg
others, and not looking into the surgeon’s eyes. More than
70% of aesthetic plastic surgeons have discovered that the
patient suffers from BDD after performing the procedure.
An incidence that has occurred with less than five patients
for most of the surgeons. About 80% put in the effort to
diagnose BDD during the interview asking an average of
six questions from Q15 in Table 1. The most commonly
asked questions are concerning the patient’s motives,
expectations and history of past cosmetic procedures and
Aesth Plast Surg

Table 1 Practice of aesthetic plastic surgeons worldwide

Q12. Have you performed an aesthetic procedure on a patient and discovered afterwards that he/she probably has BDD?
No 105 (22.6%)
Yes 359 (77.4%)
Q13. If yes, approximately how many?
\5 212 (59.1%)
5–10 88 (24.5%)
11–20 26 (7.2%)
[20 33 (9.2%)
Q14. Do you put in the effort to elicit BDD during the interview with the patient?
No 101 (21.8%)
Yes 363 (78.2%)
Q15. What do you particularly ask about that aids you in the diagnosis of BDD? (more than one answer could be given)
The reason behind choosing to undergo the procedure 369 (79.5%)
How they cope with the body part they dislike 217 (46.8%)
How much time they spend thinking about the body part they dislike 294 (63.4%)
If there are other body areas they dislike in themselves 205 (44.2%)
How their lifestyle and activities are affected by the body part they dislike 290 (62.5%)
History of abuse/harassment 114 (24.6%)
History of a psychiatric disorder 267 (57.5%)
History of past cosmetic procedures and their satisfaction with them 385 (83.0%)
What they expect from the procedure they are currently seeking 361 (77.8%)
Their reaction to past failures 236 (50.9%)
None of the above 0 (0.0%)
Other 28 (6.0%)
Total number of responses
Range 0–11
Mean ± SD 5.9 ± 2.5
Median (IQR) 6 (4–8)
Q16. How do you diagnose a patient with BDD?
Written questionnaire 12 (2.6%)
Interview 364 (78.4%)
Both 61 (13.1%)
Neither 27 (5.8%)
Q17. Do you discuss with the patient the possibility of BDD?
No 103 (22.2%)
Yes 171 (36.9%)
Sometimes 190 (40.9%)
Q18. .Have you ever seen a patient with BDD?
No 54 (11.6%)
Yes 410 (88.4%)
Q19. If yes, how many patients with BDD do you see per year?*
Less than 5 256 (62.4%)
5–10 95 (23.2%)
more than 10 59 (14.4%)
Q20. What are the behaviors you encounter in patients with BDD? (more than one answer could be given)
Excessive concern/ distress 333 (71.8%)
Excessive camouflaging 122 (26.3%)
Unrealistic expectations from other surgeries and/or other surgeons 361 (77.8%)
Unusual or excessive requests for cosmetic surgery 326 (70.3%)
Reference to others taking special note of the perceived flaw 150 (32.3%)

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Table 1 continued
Belief that the procedure will transform patient’s life or solve all problems 304 (65.5%)
Skin picking 39 (8.4%)
Other 16 (3.4%)
Total number of responses:
Range 0–8
Mean ± SD 3.6 ± 1.8
Median(IQR) 4 (3–5)
Q21. Do you refer patients with BDD to a psychologist/ psychiatrist?
No 59 (14.4%)
Yes Always 139 (33.9%)
Sometimes 212 (51.7%)
Q22. Do you perform aesthetic procedures on patients with BDD?
Never 120 (29.3%)
Yes 11 (2.7%)
Sometimes 164 (40%)
only if accompanied by psychological care 115 (28%)
Q23. Have you ever been threatened by a patient with BDD?
No 261 (63.7%)
Yes 149 (36.3%)
Q24. What is/are the most encountered outcome(s) in the majority of patients with BDD on whom you operate? (more than one answer could be
given)
Never operated on a patient with BDD 78 (16.8%)
Majority were satisfied 107 (23.1%)
Majority were NOT satisfied 155 (33.4%)
Patient became preoccupied with another body area 140 (30.2%)
*Beginning of the second page that will only appear if the surgeon has chosen ‘yes’ for question 18.

their satisfaction with them. The respondents who endorsed
the answer ‘others’ for this question gave very interesting
answers including:
• ‘‘Difficulty taking responsibility of made decisions,
blames others, history of eating disorders, excessive
sports/ Instagram/ FB/ selfies.’’
• ‘‘The number of times a day they look at the body part
they dislike in the mirror.’’
• ‘‘I give 5 pictures of different body types including that
of the patient, and I ask which one she looks like’’
• ‘‘How they are affected by others’’
• ‘‘What their family/ friends think about it’’
• ‘‘The patients themselves show multiple pictures in
their phone galleries where they have spent hours
clicking themselves from different angles.’’
Most of the participants claim they use interviews as
their main method of diagnosis, while relatively a few,
15%, use questionnaires paired with interviews or not.
Following a positive finding, the actions of the participants
varied significantly. The possible actions encompass dis-
cussing the diagnosis with the patient, referring the patient
to a psychologists/ psychiatrist, and eventually performing
the procedure. Approximately 40% of respondents always
discuss the possibility of BDD with the patient. One third
always refer a BDD patient to a psychologist/ psychiatrist.
Thirty percent of aesthetic plastic surgeons never treat a
BDD patient, 40% sometimes/ always do, and 30% only
treat a BDD patient if accompanied by psychological care.
The most encountered outcome in the majority of BDD
patients the surgeons operated on is negative; patients were
either not satisfied or became preoccupied with another
body area. Moreover, about 40% of participants have been
threatened by a patient suffering from BDD.
Significant Relations
The only factor that significantly determines the awareness
of BDD among aesthetic surgeons is the years of experi-
ence, P value = 0.004. Surgeons are definitely aware of
BDD, 84%, are more likely to know the correct prevalence
of BDD, 11–20%, in the plastic surgery practice (P value
of 0.003), and to put in the effort to elicit BDD during the
interview with the patient (P value of 0.001). Moreover,
they are more likely to ask the questions with P value
\0.05 illustrated in Table 2. Surgeons who estimated the

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Table 2 Questions asked by surgeons in relation to familiarity with the clinical picture of BDD
Are you familiar with the clinical picture of BDD?
No (N = 12) Yes (N = 391) Slightly (N = 61) P value

What do you particularly ask about that aids you in the diagnosis of BDD?
The reason behind choosing to undergo the procedure 5 (41.7%) 322 (82.4%) 42 (68.9%) 0.000*
How they cope with the body part they dislike 4 (33.3%) 186 (47.6%) 27 (44.3%) 0.57
How much time they spend thinking about the body part they dislike 3 (25.0%) 262 (67.0%) 29 (47.5%) 0.000*
If there are other body areas they dislike in themselves 3 (25.0%) 176 (45.0%) 26 (42.6%) 0.375
How their lifestyle and activities are affected by the body part they dislike 3 (25.0%) 256 (65.5%) 31 (50.8%) 0.003*
History of abuse/harassment 5 (41.7%) 96 (24.6%) 13 (21.3%) 0.36
History of a psychiatric disorder 8 (66.7%) 224 (57.3%) 35 (57.4%) 0.811
History of past cosmetic procedures and their satisfaction with them 6 (50.0%) 334 (85.4%) 45 (73.8%) 0.003*
What they expect from the procedure they are currently seeking 7 (58.3%) 314 (80.3%) 40 (65.6%) 0.014*
Their reaction to past failures 6 (50.0%) 206 (52.7%) 24 (39.3%) 0.152
Other 1 (8.3%) 24 (6.1%) 3 (4.9%) 0.882
*Indicates P value \0.05.

prevalence of BDD among patients seeking surgery cor-
rectly, 11–20%, acquired knowledge of BDD from scien-
tific journals (Table 3). There is a greater percentage of
female surgeons who have never operated on BDD patients
compared to male surgeons, P value = 0.003. Surgeons
who have less than five years of experience showed the
greatest likelihood of referring patients diagnosed with
BDD to a psychologist/ psychiatrist, P value = 0.033.
Meanwhile, surgeons with more experience ask more
questions to patients to diagnose BDD, P value = 0.044.
Surgeons who had the experience of diagnosing BDD
postoperatively fail to routinely ask preoperatively about
the patients’ expectations (P value = 0.04), history of past
cosmetic procedures (P value = 0.00) and psychiatric dis-
orders (P value = 0.027). There is a significant difference
across all subgroups regarding the practice of performing
aesthetic procedures on patients only to discover afterward
that they suffer from BDD. This incident is more likely to
have happened with the more experienced male surgeons
practicing in developed countries who see more patients
per year as demonstrated in Table 4.
Surgeons Practicing in Developed Versus
Developing Countries
Table 5 depicts the demographics of surgeons in developed
versus developing countries. The years of practice and the
number of patients seen per year showed a significant
difference between the two groups. Participating surgeons
from developed countries are more experienced and see
more patients per year. However, there was no difference
in the ratio of males to female surgeons between the two
groups.
As illustrated by Table 6, there is no difference in the
awareness of BDD between the two groups. Surgeons in
both groups acquired knowledge of BDD mostly from
journals and residency. However, more surgeons in
developed countries were aware of BDD from journals and
colleagues compared to surgeons in developing countries,
P value = \0.05. In contrast, surgeons in developed
countries were more likely to be learning about BDD for
the first time from the survey, P value = 0.033.

Table 3 Surgeons who

How did you acquire knowledge of BDD? Surgery Country v2 df P value
estimated the prevalence of
BDD among patients seeking Developed Developing
surgery correctly, 11–20%,
acquired knowledge of BDD 11-20%
from scientific journals Internet 16 (40%) 11 (26.8%) 1.58 1 0.209
Journals 28 (70%) 17 (41.7%) 6.68 1 0.01*
Residency 20 (50%) 20 (48.8%) 0.012 1 0.913
Colleagues 12 (30%) 11 (26.8%) 0.1 1 0.752
Learn about it for the first time 0 2 (4.9%) 2 1 0.157
*Indicates P value \0.05.

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Table 4 Surgeons who performed an aesthetic procedure on a patient and discovered afterward that he/she probably has BDD
Country Sex Approximately how many patients do you see per How many years have you been in practice?
year?
Developed Developing Male (n Female (n less than 200 200–350 (n 350–500 (n [500 (n less than5 5to 10 (n 11 to20 (n 21 to 30 (n more than
(n = 259) (n = 205) = 358) = 106) (n = 97) = 102) = 106) = 159) (n = 47) = 58) = 117) = 141) 30 (101)

Have you performed an aesthetic procedure on a patient and discovered afterwards that he/she probably has BDD?
No 45 60 66 39 38 27 20 20 22 20 25 24 14
(17.4%) (29.3%) (18.4%) (36.8%) (39.2%) (26.5%) (18.9%) (12.6%) (46.8%) (34.5%) (21.4%) (17%) (13.9%)
Yes 214 145 292 67 59 75 86 139 25 38 92 117 87
(82.6%) (70.7%) (81.6%) (63.2%) (60.8%) (73.5%) (81.1%) (87.4%) (53.2%) (65.5%) (78.6%) (83%) (86.1%)
P value 0.002* 0.00* 0.00* 0.00*
*Indicates P value \ 0.05.
Aesth Plast Surg
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Table 5 Difference in
Country
demographic characteristics
between surgeons in developed Developed (No=259) Developing (No=205) v2 df P value
and developing countries
How many years have you been in practice?
Less than5 13 (5.0%) 34 (16.6%) 17.77 4 0.001*
5–10 36 (13.9%) 22 (10.7%)
11–20 69 (26.6%) 48 (23.4%)
21–30 79 (30.5%) 62 (30.2%)
More than 30 62 (23.9%) 39 (19.0%)
Approximately how many patients do you see per year?
Less than 200 35 (13.5%) 62 (30.2%) 19.58 3 0.00*
200–350 62 (23.9%) 40 (19.5%)
350–500 63 (24.3%) 43 (21.0%)
[500 99 (38.2%) 60 (29.3%)
Sex
Male 201 (77.6%) 157 (76.6%) 0.068 1 0.785
Female 58 (22.4%) 48 (23.4%)
*Indicates P value \0.05.

Table 6 Knowledge of surgeons practicing in developed versus developing countries

Country Test of significance df P value
Developed (n = 259) Developing (n = 205)

Knowledge
Are you familiar with the clinical picture of BDD?
No 4 (1.5%) 8 (3.9%) v2 = 4.14 2 0.126
Yes 216 (83.4%) 175 (85.4%)
Slightly 39 (15.1%) 22 (10.7%)
How did you acquire knowledge of BDD? (choose all that apply)
Internet 79 (30.5%) 50 (24.4%) v2 = 2.12 1 0.144
Journals 152 (58.7%) 83 (40.5%) v2 = 15.16 1 0.00*
Residency 121 (46.7%) 96 (46.8%) v2 = 0.001 1 0.981
Colleagues 96 (37.1%) 57 (27.8%) v2 = 4.44 1 0.035*
Learning about it now for the first time 1 (0.4%) 7 (3.4%) v2 = 4.53 1 0.033*
*Indicates P value \0.05.

There was no statistically significant difference between Discussion

the two groups regarding the surgeons’ attitude toward
BDD. As for their practice, surgeons in developed coun-
tries are more likely to perform aesthetic procedures on a
patient only to discover afterward that the patient has BDD,
P value = 0.002. Surgeons in developed countries asked
more questions to diagnose BDD, P value = 0.014. There
was also a significant difference in the questions asked by
the two groups as illustrated by Table 7. Nothing else in the
BDD practice showed statistically significant difference
between the two groups.
This study examined the KAP of aesthetic plastic surgeons
worldwide. In this discussion, a comparison is made
between our population of plastic surgeons with other
cosmetic doctors including dermatologists [13–17].
Awareness of cosmetic doctors of BDD is relatively
high in all studies [13–17]. approximately 80%, with a
significantly higher awareness rate among dermatologic
surgeons, reaching 92% [14]. Although aware, aesthetic
plastic surgeons in the current study failed to diagnose
BDD consistently since 77% realized only after treatment
that the patient likely suffers from BDD. Dermatologic

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Table 7 Questions asked by surgeon in developed and developing countries to diagnose BDD
Country Test of df P value
significance
Developed (n = Developing (n =
259) 205)

What do you particularly ask about that aids you in the diagnosis of BDD?
The reason behind choosing to undergo the procedure 214 (82.6%) 155 (75.6%) v2 = 3.46 1 0.063
How they cope with the body part they dislike 134 (51.7%) 83 (40.5%) v2 = 5.82 1 0.016*
How much time they spend thinking about the body part they 169 (65.3%) 125 (61.0%) v2 = 0.901 1 0.343
dislike
If there are other body areas they dislike in themselves 116 (44.8%) 89 (43.4%) v2 = 0.087 1 0.767
How their lifestyle and activities are affected by the body part 174 (67.2%) 116 (56.6%) v2 = 5.48 1 0.019*
they dislike
History of abuse/harassment 61 (23.6%) 53 (25.9%) v2 = 0.327 1 0.567
History of a psychiatric disorder 158 (61.0%) 109 (53.2%) v2 = 2.87 1 0.09
History of past cosmetic procedures and their satisfaction with 225 (86.9%) 160 (78.0%) v2 = 6.31 1 0.012*
them
What they expect from the procedure they are currently seeking 213 (82.2%) 148 (72.2%) v2 = 6.68 1 0.01*
Their reaction to past failures 127 (49.0%) 109 (53.2%) v2 = 0.783 1 0.376
None of the above 0 0
Other 17 (6.6%) 11 (5.4%) v2 = 0.29 1 0.591
Total number of Answers (mean ± SD) 6.21 ± 2.373 5.65 ± 2.521 t = 2.45 462 0.014*
*Indicates P value \0.05.

surgeons have experienced that to a lesser extent, 70%
[14]. These percentages are lower than that reported 19
years ago, 84% [15].
The prevalence of BDD in the aesthetic practice is
debatable although all studies agree that is rather small. In
our study, participants believed that the prevalence of BDD
among patients seeking noninvasive procedures (medspa)
and surgery was the same, 5-10%. Although optimally the
prevalence of BDD ranges from 11 to 20%, their estimate
is still within the accepted range. In a study conducted in
2001, surgeons believed that the prevalence of BDD was as
small as 2% [15]. This highlights the increased awareness
of aesthetic plastic surgeons in our study compared to
aesthetic plastic surgeons 19 years ago.
Our results demonstrate that 60% of participants con-
sidered BDD an absolute contraindication to aesthetic
treatment. That is similar to the findings of the American
study conducted in 2013 [14], the Dutch study conducted in
2015 [13], and the Saudi study conducted in 2020 [16].
However, it is twice the percentage reported 19 years ago
[15]. Based on our study, this could be explained by the
increased awareness of plastic surgeons, the fact that 40%
of surgeons received threats from BDD patients and that
the majority of BDD patients are not satisfied
postoperatively.
Surprisingly, 60% of respondents in our study believed
an aesthetic procedure could possibly alleviate the symp-
toms of BDD indicating that this is equally true for Medspa
and surgery. These findings could be the result of the
surgeons’ experience in operating on patients with mild to
moderate BDD, which was proven to be successful in
previous studies [18, 19].
Most of the surgeons in our population, 80%, regardless
of the country they practice in, explore BDD during the
interview. This is equal to the percentage reported by the
Dutch study [13]. But less than that reported by the Saudi
study, 91% [16]. In comparison with the 60% of aesthetic
plastic surgeons in our study who enquire about the psy-
chiatric history of their patients, 80% of dermatologic
surgeons do [14].
With regard to the management of a BDD patient, there
are three possible actions: Discussing the finding with the
patient, referring the patient to a psychologist/ psychiatrist,
and finally operating on the patient. Although it is bad
practice, one-fifth of respondents in the current study do
not discuss the possibility of BDD with the patient. This is
opposed to 7% in the study conducted in 2015 on derma-
tologic surgeons [13]. In our study, 40% of surgeons
always refer BDD patients to a psychologists/ psychiatrists.
This is approximately equal to the studies performed in
2015 [13]. and 2020 [16], but less than those performed in
2001 [15], 2008 [17], and 2013 [14]. Indicating that
recently aesthetic surgeons dismiss the importance of
psychologists/ psychiatrists in the treatment of BDD
patients. In our sample, 60% adopt good strategies when it
comes to performing the procedure on a BDD patient, 30%

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Aesth Plast Surg
perform the procedure only if it is accompanied by psy-
chological care and 30% never perform the procedure.
The BDD behaviors most commonly encountered by
aesthetic surgeons in this study agree with the two other
studies examining the same aspect [15, 16]. BDD patients
most commonly present with unrealistic expectation form
past cosmetic treatments and excessive concern and
requests. Based on the results of our study and Kattan
et al.’s study [16], we can conclude that in 2020 cosmetic
professionals observe less of the BDD behaviors that were
commonly observed in 2001. This can be possibly
explained by the increased awareness of BDD patients that
they may not be offered treatment if they manifest these
symptoms; therefore, they are secretive about them.
This study has several strengths due to the information
collected about the demographics of participants allowing
for comparisons between various subgroups. However, it is
not without limitations. To avoid sending out a lengthy
survey, we did not gather data about the knowledge of
surgeons regarding the prevalence of BDD among patients
seeking different aesthetic treatments. In addition, it is
worth mentioning that respondents depend on their mem-
ory to answer the questions which may lead to some bias.
Taking everything into account, dermatologic surgeons
are more aware of BDD compared to aesthetic plastic
surgeons. They are more likely to estimate the prevalence
of BDD correctly and adopt good practice in the manage-
ment of BDD, therefore less likely to diagnose BDD
postoperatively. Furthermore, aesthetic plastic surgeons in
2020 are more aware of BDD compared to 2001. Aesthetic
plastic surgeons nowadays are more likely to estimate the
correct prevalence of BDD. Although they are more likely
to consider BDD a contraindication to treatment, they are
more liable to treat BDD patients compared to aesthetic
surgeons 19 years ago. Surprisingly, patients treated by
aesthetic plastic surgeons in 2020 are less likely to be
unsatisfied postoperatively. The most probable explanation
is that aesthetic surgeons nowadays can identify when
BDD is mild enough to allow treatment with high success
rates.
Acknowledgements I wish to record my gratitude and profound
thanks to Ms. Catherine Foss, past executive director of ISAPS, for
her suggestions and tremendous help in sending out the questionnaire.
Funding No funding was received for this study.
Declarations
Conflict of interest The authors declare that they have no conflicts of
interest to disclose.
Human or Animal Rights This article does not contain any studies
with animals performed by any of the authors. No ethical committee
approval was required.
Informed Consent Participants knowingly and willingly participated
in the research.
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