Surgical Rhinoplasty in Mild Forms of Body Dysmorphic Disorder: Safety, Protocols, and Long-Term Outcomes.

Body dysmorphic disorder (BDD) is an obsessive-compulsive disorder concerning body image which negatively distorts the patient's perception of their appearance. In rhinoplasty, surgery on patients with severe BDD is considered contraindicated as patients are often dissatisfied and their BDD symptoms rarely improve. For patients with borderline to mild BDD, however, there has been some preliminary evidence to show that they can benefit from surgical rhinoplasty. In our first article on this series of BDD in rhinoplasty, we presented our two-specialist protocol using mandatory psychiatric evaluation (MPE) to assess patient's suitability. In this present article, we used this protocol to identify a group of borderline to mild BDD patients, performed surgical rhinoplasty on this group, and evaluated the outcome using a visual analog scale (VAS) and a five-point Likert scale. From 2010 to 2023, 1,602 patients attended our practice seeking cosmetic rhinoplasty, out of which, 892 were sent for MPE to the same psychiatrist. The MPE identified 2.5% (22/892) patients as having mild BDD, out of which, 15 were considered suitable for surgical intervention and underwent successful rhinoplasty (follow-up 6-95 months, M = 54.13 months). Five of 15 patients scored 10/10 on the VAS and were very happy, 8 of 15 patients scored 7 to 9/10 on the VAS and were happy, and 2 of 15 patients scored 6/10 on the VAS but were still happy. Although all patients were happier, 3 of 15 patients requested revision rhinoplasty which was not offered as was planned and discussed before the initial intervention. This study shows that in the presence of safe protocols, including a two-specialist model, safe outcomes can be expected even in the long term. Further, the request for revision surgery appears to be common in borderline to mild BDD cases, and we like to warn the patients against it before surgery.

Prevalence of Body Dysmorphic Disorder in Orbital Plastic Surgery and Its Relationship with the Use of Social Media.

BACKGROUND: The prevalence of body dysmorphic disorder (BDD) in the general population ranges from 0.7 to 2.4%; however, higher rates are seen among aesthetic patients. Given the recent rise in popularity of cosmetic surgery, particularly in the post-COVID pandemic setting, the authors hypothesize the prevalence has increased. The purpose of the study is to examine the prevalence of BDD in patients presenting to an oculoplastic surgery clinic at an academic center and determine correlation with social media use. METHODS: This is a survey of patients presenting to the oculoplastic surgery clinic. Participants completed the Dysmorphic Concern Questionnaire (DCQ), in addition to survey questions about social media use. Main outcomes included a positive screen and social media use. RESULTS: A total of 175 patients that presented to the oculoplastic and reconstructive surgery clinic were surveyed. All patients, including cosmetic, functional, and non-surgical, were offered participation in the survey. 9.13% of all patients screened positive for BDD. Patients that screened positive were more commonly female (71.43%). The distribution of patients with BDD was even between Hispanics (52.38%) and non-Hispanics, and 85.71% of patients with BDD were Caucasian. Of patients that screened positive, 71.43% use social media. CONCLUSIONS: The prevalence of BDD may have increased in the past seven years and is seen most in females and Caucasians. There is a positive correlation with social media, which has increased in popularity since the COVID-19 pandemic. It is important to maintain a high clinical suspicion for BDD and consider screening if there is concern. LEVEL OF EVIDENCE IV: 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 www.springer.com/00266 .

Prevalence of Body Somatic Deformities in Plastic Surgery Patients: A Systematic Review with Meta-analysis.

BACKGROUND: Plastic surgery is a surgical specialty that focuses on restoring, reconstructing, or changing the human body. Somatic deformities (SD) are defined by a distorted impression of one's own body image and are rather frequent. The majority of people with SD have some level of social and vocational impairment, with obsessive concerns about appearance leading to compulsive behaviors and, in more severe situations, suicidal thoughts. OBJECTIVE: The current study aims to confirm the prevalence of SD in plastic surgery patients using a systematic review of the literature and a meta-analysis. METHODOLOGY: We have searched for electronic databases with MeSH terms, and the studies for analysis were selected based on inclusion and exclusion criteria and quality assessment. The study was conducted as per the PRISMA guidelines. The pooled prevalence was calculated using fixed and random effect model. The publication bias was assessed qualitatively (funnel plot) as well as quantitatively (Begg, Egger and Harbord tests). All analysis was done using Stats Direct (version 3). RESULTS: The pooled prevalence of somatic deformities in plastic surgery with 95% confidence interval using random effect model was found to be 0.19 [0.12, 0.27] which indicates a significant association of somatic deformities in plastic surgery. The heterogeneity among studies was found to be high as indicated by Cochran Q (P < 0.0001) and I2 tests (98.6%). The qualitative and quantitative analysis has also shown significant involvement of publication bias. CONCLUSION: Based on available evidence, there is a significant association of somatic deformities in plastic surgery. LEVEL OF EVIDENCE III: 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 www.springer.com/00266 .

PREVALENCE OF BODY DYSMORPHIC DISORDER AMONG ATTENDANCES SEEKING FACIAL COSMETIC PROCEDURES IN BAGHDAD.

OBJECTIVE: Aim: To find out the prevalence of body dysmorphic disorder among patients seeking facial cosmetic procedures, find out association of social demographic (age, gender, occupation, marital status, friends relationship, and dating status) ampatientsient with body dysmorphic disorder. PATIENTS AND METHODS: Materials and Methods: A cross-sectional study was done on a sample of 100 patients from Al-waste Hospital and Ghazy Al-Hariri Hospital for surgical specialties in Baghdad by using a body dysmorphic disorder questionnaire to diagnose a probable case and then a semi-structured questionnaire based on DSM5 criteria to diagnose body dysmorphic disorder during the period extended from beginning of January 2019 to the end of April 2019. RESULTS: Results: The chi-square test proved the association between female gender and body dysmorphic disorder is significant P=0.026. Significant associations were also noticed between single patients and body dysmorphic disorder 76.8% in comparison with married 37.8, and divorced or widowed 42.9% (P=0.001). It was found that 68.6% of unemployed patients think that they need to correct their body dysmorphic disorder so they attended the hospital while only 40% of employed persons did so P=0.008. The mean age of patients exposed to a second operation was significantly higher than the mean age of other patients P=0.022. CONCLUSION: Conclusions: High prevalence of body dysmorphic disorder among patients seeking plastic surgery which is about 60%. Body dysmorphic disorder is more common among single and unemployment and among young adults and gender female. There is no significant association between the mean age of male and female patients of body dysmorphic disorder group.

Conflicting Cultural and Religious Views on Cosmesis: The Modern Women's Dilemma.

BACKGROUND: Women from countries with conflicting views on cosmesis may avoid these procedures for the fear of being rejected by the community. Understanding the motives that drive patients from these countries to seek cosmetic procedures helps discern possible causes of postoperative dissatisfaction, which can be prevented by careful selection of patients and individualizing their management protocols. OBJECTIVES: This study helps identify the factors that affect Egyptian Muslim women's attitude toward cosmetic procedures. The main factors tested were female gender role stress (FGRS), body dysmorphic disorder (BDD), and religious attitude. The secondary factors investigated were health evaluation, life satisfaction, self-satisfaction, social media use, TV exposure, spouse/friends/family influence, and internalization of beauty standards. METHODS: Women willing to undergo cosmetic procedures were compared with those who were not. A survey exploring demographics and the different motives were posted for the public online. RESULTS: Among 502 participants, 288 were willing to undergo cosmetic procedures and 214 were not. Our findings showed a statistically significant difference for the degree of BDD, FGRS, and religiousness between willing and unwilling groups. Moreover, greater pressure from partner to change appearance, influence of friends and family on opinion regarding beauty of oneself, internalization of beauty standards, and lower ratings of life and self-satisfaction showed statistically significant association with willingness to undergo cosmetic treatment. CONCLUSION: BDD, FGRS, and religious attitude are among the highest predictors of the willingness of women to undergo cosmetic procedures together with many other factors. This study is the first of its kind to evaluate several unexplored motives and opens the door for future research. 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 www.springer.com/00266 .

Reliability and Validity of the Self-Report Chinese Version of the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS) in Patients Undergoing Plastic Surgery.

BACKGROUND: To develop a self-report Chinese version of the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS) and determine its validity and reliability in patients seeking a consultation with a plastic surgeon or undergoing plastic surgery in China. METHODS: Forward and backward translation and cultural adaptation of the BDD-YBOCS were performed according to recommended guidelines. The self-report Chinese version of the BDD-YBOCS was psychometrically tested using data collected from a cross-sectional validation study, which included 240 patients seeking a consultation with a plastic surgeon or undergoing plastic surgery at the Department of Plastic Surgery, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China, between May and September 2020. Item analysis used the independent sample t test and bivariate Pearson test. Content validity was established through expert interviews. Construct validity was measured with exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Convergent validity and discriminant validity were analyzed using Pearson's correlation to evaluate the association between the self-report Chinese version of the BDD-YBOCS and the Body Dysmorphic Disorder Questionnaire (BDDQ). Internal reliability was assessed using Cronbach's α. RESULTS: No items were removed from the original English version of the BDD-YBOCS based on expert interviews and factor analysis. A total of 220 patients completed the study survey (91.7%). EFA extracted 3 factors, which accounted for 64.50% of the variance. CFA supported a 3-factor structure (χ2/df = 1.322, RMSEA = 0.054, GFI = 0.904, NFI = 0.902, CFI = 0.974 and TLI = 0.966). The scale had good convergent and discriminant validity. Cronbach's α for the scale was 0.871 (P < 0.001) and ranged from 0.852 to 0.873 when individual items were removed. CONCLUSION: The self-report Chinese version of the BDD-YBOCS shows good validity and reliability for use in patients seeking a consultation with a plastic surgeon or undergoing plastic surgery in China. LEVEL OF EVIDENCE IV: 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 www.springer.com/00266 .

Body Dysmorphic Disorder in Rhinoplasty Candidates: Prevalence and Functional Correlations.

BACKGROUND: Rhinoplasty is one of the most commonly performed aesthetic/functional procedures worldwide. Among those who seek rhinoplasty are those whose aesthetic defect is interpreted by themselves disproportionately, leading to significant suffering. These are given the diagnosis of body dysmorphic disorder (BDD). They commonly have high expectations regarding the surgical outcome and are often not satisfied postoperatively. The present study aimed to correlate BDD with the patient's self-assessment of nasal function, analysing whether BDD would have any influence on it. In addition, we verified the prevalence of the disorder in our population. METHODS: Cross-sectional, comparative and analytical study. Eighty-eight patients participated in the trial, 57 of them being candidates for rhinoplasty, rhinoplasty group (RG), and 31 from a random population, control group (CG). Through self-assessment, the BDSS, The Utrecht, SNOT-22 and NOSE questionnaires were applied. Patients with BDSS score ≥ 6 were considered as positive for BDD. Comparisons were made between the groups and among the candidates for rhinoplasty with positive or negative BDD. RESULTS: The prevalence of the disorder was 35.1% in the RG and 3.2% in the CG. Significantly, higher NOSE and SNOT-22 scores, reflecting worse nasal function, were obtained by the RG, especially in those with positive screening for BDD, when compared to those with negative screening (p < 0.05). CONCLUSIONS: BDD affects about one-third of the rhinoplasty candidate population. Their presence seems to exert a negative influence on the patients' self-assessment regarding their nasal function. LEVEL OF EVIDENCE III: 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 www.springer.com/00266 .

[Mental disorders in the dental practice. Patients with body dysmorphic disorder]. / Serie: Psychische stoornissen in de mondzorgpraktijk. Patiënten met een morfodysfore stoornis.

Oral healthcare professionals are frequently consulted by patients who are dissatisfied with their teeth and/or facial looks. Sometimes, this dissatisfaction takes a pathological form. When someone is preoccupied with a (supposed) abnormality barely or not visible to others, performs certain actions in response to the concerns about their appearance and experiences significant suffering, this may be a case of body dysmorphic disorder. Its prevalence is 0.7-2.4% in the general population, but significantly higher in clinics where cosmetic or orthognathic procedures are performed (10-15%). Procedures aimed at improving the abnormality experienced by the patient rarely lead to a reduction of the symptoms, but more often result in more dissatisfaction and complaints towards the practitioner. It is difficult for practitioners to recognise this condition. An overview of characteristics, co-morbidity and consequences of body dysmorphic disorder for oral health and treatment will result in increased awareness of this condition among oral care providers.

Plastic surgery in gynaecology: Factors affecting women's decision to undergo labiaplasty. Mind the risk of body dysmorphic disorder: A review.

Aesthetic surgery of the female genitalia is on the rise. Many procedures are performed. Body dysmorphic disorder (BDD) is a psychiatric disorder and often goes unrecognized in plastic surgery. This review examines actual knowledge of plastic surgery in gynecology, knowledge of motivational factors of women, and BDD. We carried out a systematic electronic search. We used a combination of relevant keywords to construct the search strategy. Included studies were systematic reviews or primary studies published 1990-2017 and containing information about BDD. Reviewers independently assessed study eligibility, extracted data, and assessed quality, undertaking narrative synthesis. The research revealed a variety of plastic procedures available and why women consider undergoing labia reduction surgery.

Invited Response on: Body Dysmorphic Disorder: There is an "Ideal" Strategy?

Body dysmorphic disorder (BDD) has been considered the most relevant neuropsychiatric condition to cosmetic treatments. Patients' ideal expectations often exceed what is expected to be achieved in reality by plastic surgery, signaling the presence of BDD. It is fundamental to detect BDD symptoms during screening for cosmetic surgery. A secondary concern with physical appearance may be one of the most important parameters to be detected during patient assessment, as it may interfere with overall patient satisfaction following treatment. A good doctor-patient relationship is essential for detecting this psychopathology. Mild-to-moderate BDD is not an exclusion criterion for cosmetic surgery, but specific treatment planning and a multidisciplinary approach are required. Recent studies have presented preliminary evidence for the effectiveness of cosmetic procedures in reducing BDD symptoms and providing patient satisfaction with treatment results. The use of validated instruments at pre- and postoperative assessments to systematically evaluate the patient's level of distress with the physical appearance and patient satisfaction with treatment results will provide important information for the development of more sensitive validated tools for detection of severe levels of BDD symptoms to help plastic surgeons in the selection of patients in a more effective and practical manner.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 www.springer.com/00266 .

The Dysmorphic Concern Questionnaire in the German General Population: Psychometric Properties and Normative Data.

BACKGROUND: The Dysmorphic Concern Questionnaire (DCQ) is a widely used screening instrument assessing dysmorphic concerns ranging from a mild to an excessive level. It is often used in the setting of plastic and aesthetic surgery. The present study aimed at examining the psychometric properties of the DCQ in a random general population sample. METHODS: A representative sample of the German general population (N = 2053, aged between 18 and 65 years, 54% females) completed the DCQ as well as questionnaires on depression and appearance concerns. RESULTS: The DCQ showed a good internal consistency with Cronbach's α = 0.81. Its one-factor model structure was confirmed. Normative data were stratified according to gender and age. Women reported more dysmorphic concerns than men, but also within females the DCQ scores differed between age classes. Overall, 4.0% of the sample reported excessive dysmorphic concerns based on a previously defined cutoff sum score ≥ 11. CONCLUSION: The DCQ is a valid and reliable screening tool to identify individuals with excessive dysmorphic concerns. Excessive concerns may indicate also the presence of body dysmorphic disorder, but for verifying a final diagnosis the use of a structured clinical interview is necessary. LEVEL OF EVIDENCE IV: 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 www.springer.com/00266 .

A Review of Body Dysmorphic Disorder in Aesthetic Surgery Patients and the Legal Implications.

BACKGROUND: Body dysmorphic disorder (BDD) is an often under-recognized yet severe psychiatric illness. There is limited guidance for plastic surgeons in the USA in how to recognize and manage patients with BDD and protect themselves from potential litigation and harm. Therefore, in collaboration with legal counsel, we remind our profession of the serious nature of patients with BDD, provide warning signs for recognizing BDD, and critically evaluate the validity of informed consent and the legal ramifications of operating on such patients in the USA. METHODS: A literature review was performed to clearly define the psychopathology of BDD and identify cases of patients with BDD who underwent cosmetic surgery resulting in potential threats to the surgeon. An additional search of the legal literature was performed in collaboration with legal counsel to identify key cases of patients with BDD attempting litigation following cosmetic surgery procedures. RESULTS: The diagnostic criteria and psychopathology of BDD are presented. Warning signs are highlighted to alert the plastic surgeon to patients at high risk for BDD. Strategies for legal protection include a pre-procedure checklist for patients that are suspected of having a BDD diagnosis. CONCLUSION: Body dysmorphic disorder is prevalent in the cosmetic surgery population. Patients with BDD often have a poor outcome following aesthetic surgery, which can result in a dangerous or even deadly situation for the surgeon. We aim to remind aesthetic plastic surgeons of the psychopathology, severity, and specific risks associated with operating on patients with BDD while suggesting specific protective strategies. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Psychological and Psychiatric Traits in Post-bariatric Patients Asking for Body-Contouring Surgery.

BACKGROUNDS: Obese patients, mainly females, feel uncomfortable and unsatisfied with their physical appearance; they have a wrong perception of their image and consequently diminish their self-esteem, sometimes showing difficulties in functional areas such as work, relationship, social activity. Beside health concerns, improving their appearance and body image are often common motives for weight loss in obese individuals and after weight loss about 30% of bariatric surgery patients undergo plastic surgical correction of excessive skin. The authors investigated psychological and psychiatric traits in post-bariatric patients undergoing body-contouring surgery to underline the strong correlation between psychiatry and obesity and avoid unsatisfactory results in post-bariatric patients. METHODS: The Mini International Neuropsychiatric Interview, Beck Depression Inventory II, Yale-Brown Obsessive Compulsive Scale modified for Body Dysmorphic Disorder Tridimensional Personality Questionnaire, Body Uneasiness Test, Barratt Impulsiveness Scale 11, and Binge Eating Scale were performed in 36 post-bariatric patients looking for plastic surgery and 21 controls, similar for clinical features, not seeking shape remodelling. RESULTS: Much different psychiatric pathology characterizes cases, including current body dysmorphic disorder and previous major depression and anxiety disorders, impulsivity, binging and body uneasiness are other common traits. CONCLUSIONS: In post-obesity rehabilitation, a strong collaboration between the plastic surgeon and psychiatrist is recommended to reduce the number of non-compliant patients. Preoperative psychological assessment of the body-contouring patient should be a central part of the initial plastic surgery consultation, as it should be for all plastic surgery patients. LEVEL OF EVIDENCE II: 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 http://www.springer.com/00266 .

Elective amputation of a "healthy limb".

Patients with body integrity identity disorder (BIID) experience a strong desire for amputation from very early on. BIID patients are often dismissed when they share their wish for amputation with surgeons. Consequently, patients resort to self-amputation, including complications and sometimes death. BIID patients are not psychotic and are mentally competent to oversee the consequences of an elective amputation. The authors offer arguments in favor of elective amputation.

Eumorphic Plastic Surgery: Expectation Versus Satisfaction in Body Dysmorphic Disorder.

BACKGROUND: Eumorphic Plastic Surgery aims at improving the severe psychosocial pain caused by a deformity. Dysmorphopathology is an increasingly relevant problem facing the plastic surgeon. OBJECTIVE: The aim of this study is to describe the perioperative questionnaires created by the senior author and to present a cohort of plastic surgery patients suffering from dysmorphopathies. These patients were prospectively followed and evaluated with the proposed questionnaires through their surgical pathway to explore the degree of satisfaction or disappointment compared to expectations. METHODS: All candidates for plastic surgery procedures between April 2011 and June 2013 were included in the study. Preoperatively, all patients completed the Patient Expectation Questionnaire (E-pgm). Twelve months postoperatively, they completed the Patient Satisfaction Questionnaire (S-pgm). The E-pgm and S-pgm were compared to evaluate the consistency between the patient's preoperative expectations and postoperative evaluations. RESULTS: A total of 158 patients were included in the study. Out of them, 79 % experienced an improvement or no variation between preoperative expectations and postoperative satisfaction. With regard to the motivation for undergoing surgery, 91 % showed that the surgical procedure met the motivation. An overall positive perioperative change in life was experienced by 93 % of patients. CONCLUSIONS: The E-pgm questionnaire proved to be a valid and reliable tool for the selection of suitable candidates for surgery and for identification of dysmorphophobic patients. Enhancing the doctor-patient relationship and communication can reduce ambiguity and avoid troublesome misunderstandings, litigation and other legal implications. LEVEL OF EVIDENCE IV: 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 www.springer.com/00266 .

Avoiding Psychological Pitfalls in Aesthetic Medical Procedures.

OBJECTIVE: To assess the prevalence of body dysmorphic disorder (BDD) in an aesthetic surgery setting in the region of Southwest China, and to ascertain the differences in terms of body images between patients in the aesthetic setting and general Chinese population. This study tracked patient satisfaction with their body image changes while undergoing aesthetic medical procedures to identify whether the condition of patients who were presenting with BDD symptoms or their psychological symptoms could be improved by enhancing their appearance. Additionally, this study explored whether there was improvement in quality of life (QoL) and self-esteem after aesthetic medical procedures. METHODS: A total of 106 female patients who were undergoing aesthetic medical procedures for the first time (plastic surgery, n = 26; minimally invasive aesthetic treatment, n = 42; and aesthetic dermatological treatment, n = 38) were classified as having body dysmorphic disorder symptoms or not having body dysmorphic disorder symptoms, based on the body dysmorphic disorder examination (BDDE), which was administered preoperatively. These patients were followed up for 1 month after the aesthetic procedures. The multidimensional body self-relations questionnaire-appearance scales (MBSRQ-AS) and rosenberg self-esteem scale (RSE-S) were used to assess patients' preoccupation with appearance and self-esteem pre-procedure and 1 month post-procedure. Additionally, 100 female healthy control participants were recruited as a comparative group into this study and they were also assessed using BDDE, MBSRQ-AS, and RSE-S. RESULTS: A total of 14.2 % of 106 aesthetic patients and 1 % of 100 healthy controls were diagnosed with BDD to varying extents. BDDE scores were 72.83 (SD ± 30.7) and 68.18 (SD ± 31.82), respectively, before and after the procedure for the aesthetic patient group and 43.44 (SD ± 15.65) for the healthy control group (F = 34.28; p < 0.001). There was a significant difference between the groups in subscales of MBSRQ-AS, i.e. appearance evaluation (F = 31.31; p < 0.001), appearance orientation (F = 31.65; p < 0.001), body areas satisfaction (F = 27.40; p < 0.001), and RSE-S scores (F = 20.81; p < 0.001). There was no significant difference, however, in subscales of MBSRQ-AS, i.e. overweight preoccupation (F = 1.685; p = 0.187), self-classified weight (F = 0.908; p = 0.404) between groups. All the subscales of MBSRQ-AS showed significant differences between the aesthetic patients (pre-procedure) and female adult norms from Dr. Cash's result given in Table 4 (p < 0.001). The study also showed that there were no significant differences in the scores of BDDE, MBSRQ-AS, and RSE-S of those fifteen aesthetic patients diagnosed with BDD after aesthetic procedures lasting one month. CONCLUSION: There was a high prevalence rate (14.2 %) of body dysmorphic disorder in aesthetic procedure seekers, and it seemed that those patients suffering from BDD were more likely to be dissatisfied with the results of the aesthetic medical procedures. However, general aesthetic patients showed improvement in most assessments which indicated that aesthetic medical procedures could not only enhance patient appearance, but also patient low self-esteem and QoL. Self-satisfaction could also be promoted. A screening procedure for BDD including suitable screening questionnaires might be considered for routine use in aesthetic clinical settings to minimize dissatisfaction and complaints. LEVEL OF EVIDENCE IV: This journal requires that the 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. www.springer.com/00266 .

Applying extender devices in patients with penile dysmorphophobia: assessment of tolerability, efficacy, and impact on erectile function.

INTRODUCTION: Most men seeking penile enhancement techniques have a normal penile size. They are either misinformed or suffer from penile dysmorphophobia and should be discouraged from undergoing invasive procedures. Less invasive techniques including penile extenders are not associated with major complications and may be beneficial from a psychological perspective. AIM: We conducted this study to assess the efficacy and safety of AndroPenis (Andromedical, Madrid, Spain) penile extender. METHODS: Between December 2010 and December 2013, 163 men presented to our institution complaining of small penile length and/or girth. All patients received structured psychosexual counseling. Fifty-four patients were willing to use the AndroPenis penile extender after counseling. Patients with major psychiatric disorders were excluded from enrollment. The patients were instructed to wear the device between 4 and 6 hours per day for 6 months. Penile dimensions including flaccid stretched and erected lengths were measured at baseline and after 1, 3, 6, and 9 months. Erectile function was assessed at baseline and 9 months after treatment using the simplified International Index of Erectile Function (IIEF-5). An institutional nonstandardized questionnaire was used to evaluate patient satisfaction at the end of study. MAIN OUTCOME MEASURES: Penile length and girth enhancement as well as satisfaction rate and improvement in erectile function were assessed during follow-up. RESULTS: At 6-month follow-up, a mean gain of 1.7 ± 0.8, 1.3 ± 0.4, and 1.2 ± 0.4 cm was noted for the flaccid, stretched, and erected penile lengths, respectively (all P values < 0.001). During the off treatment period, there were no significant changes in penile lengths. No effect on penile girth was observed. Patient satisfaction survey revealed modest satisfaction. From 13 patients with mild baseline erectile dysfunction, nine patients reported normal erectile function after 9 months. CONCLUSION: Penile extender as a minimally invasive technique is safe and provides modest benefits and patient satisfaction.

Beauty is in the eye of the beholder: body dysmorphic disorder in ophthalmic plastic and reconstructive surgery.

Despite the fact that up to 15% of patients in an aesthetic surgery practice have body dysmorphic disorder (BDD), little has been written about the condition in the oculoplastic literature. The authors describe 3 patients with suspected BDD who presented with perceived periocular defects. To appear "Asian," a 39-year-old Hispanic woman underwent over 30 surgeries. She developed disfiguring scars and lagophthalmos with corneal scarring, remained unsatisfied, and tragically committed suicide. A 52-year-old woman with moderate dermatochalasis underwent a blepharoplasty to improve her vision and appearance and help her gain employment. Despite a good outcome, she remained dissatisfied and blamed the surgeon for her unemployment. Finally, a 73-year-old woman presented demanding treatment for brow rhytids causing severe emotional distress. She was denied intervention due to unrealistic expectations. These patients are suspected to be suffering from BDD. Increased awareness is critical as BDD patients often remain unsatisfied after surgical intervention and are in need of psychiatric care.