ORIGINAL ARTICLE

Identification of Body Dysmorphic Disorder in Patients

Seeking Corrective Procedures From Oral and
Maxillofacial Surgeons
David L. Kashan, MD, Michael P. Horan, DDS, MD, Eric Wenzinger, MD,y
Rachel S. Kashan, MA,§ Dale A. Baur, DDS,z James E. Zins, MD, FACS,
and Faisal A. Quereshy, DDS, MDz

Results: Among the 3 groups, patients seeking dentoalveolar

Introduction: Body dysmorphic disorder (BDD) is an obsessive-
surgery were the most represented (67%) in this sample,
compulsive related disorder characterized by an individual’s pre-
followed by cosmetic surgery (27%) and orthognathic surgery
occupation with the appearance of at least 1 perceived physical
(6%). Twenty-six female participants and 20 male participants
flaw. The bodily concerns held by individuals with BDD are largely
were included, with an overall mean age of 38 years. Two
unnoticeable, if at all, to other individuals. Those living with BDD
percent of participants carried a previous psychiatric diagnosis
are compelled to engage in repetitive behaviors or cognitive acts
and 10.8% of the sample were classified as high-risk for BDD.
that interfere with daily function and activities. Despite the high
The group containing the highest proportion of patients at high-risk
prevalence of BDD in patients who seek cosmetic procedures (ie, as
for BDD were those seeking facial cosmetic procedures (16.7%),
high as 1 in 5 such patients) and the availability of validated
followed by those seeking dentoalveolar procedures (10%); none of
screening tools for this disorder, implementing a protocol of
the patients seeking orthognathic procedures were found to be at
regularly screening for BDD is only rarely practiced by surgeons.
high-risk for BDD (0%).
Few studies have investigated its prevalence in the setting of
Conclusions: The BDDQ is an efficient way to screen for BDD in
elective dentoalveolar and orthognathic procedures. With the scope
patients who are seeking orthognathic or facial cosmetic surgery. In
of practice of maxillofacial surgeons expanding in recent years to
our sample, patients presenting to maxillofacial surgeons for facial
include facial cosmetic procedures, it is becoming increasingly
cosmetic surgery were found to score significantly higher on the
important to screen for such disorders so that patients and physi-
BDDQ than those presenting for dentoalveolar surgery. In contrast
cians can appropriately weigh the risks and benefits of surgical
to results of previous literature, patients seeking orthognathic
intervention.
surgery in our sample demonstrated no elevated risk for BDD, a
Methods: We conducted a cross-sectional cohort study (n ¼ 46)
finding which may be attributable to our small sample size.
consisting of 3 groups of patients, who were seeking either
Ultimately, the data obtained from this study can aid surgeons in
facial cosmetic, orthognathic, or dentoalveolar procedures. All
identifying patients with BDD in their own surgical practice, so that
patients in the study were screened for BDD using the Body
they may appropriately triage patients who may, or may not, benefit
Dysmorphic Disorder Questionnaire (BDDQ) and assessed for
from surgical intervention.
severity of disorder using the BDDQ severity scale. Additional
patient variables included age, sex, history of psychiatric
diagnosis, primary diagnosis, and type of operation/procedure Key Words: Body dysmorphic disorder, cosmetic surgery,
being sought. dentoalveola, facial surgery, orthognathic surgery, plastic surgery

(J Craniofac Surg 2021;32: 970–973)

From the Dermatology and Plastic Surgery Institute, Cleveland Clinic

Foundation, Cleveland, OH; yHarvard Combined Plastic Surgery Resi-
dency Program, Harvard Medical School, Boston, MA; zDepartment of
T raditionally, maxillofacial surgeons have collaborated with
orthodontists to correct dentofacial deformities. Studies indi-
cate that 10% to 15% of individuals who undergo orthognathic
Oral and Maxillofacial Surgery, Case Western Reserve University, surgery are dissatisfied, regardless of outcomes.8 These patients
Cleveland, OH; and §Yeshiva University Ferkauf Graduate School of have typically been viewed as ‘‘high-maintenance’’ without being
Psychology, Bronx, NY. given further consideration. It is possible that a significant number
Received June 24, 2020.
Accepted for publication November 18, 2020.
of these individuals have BDD. The literature has shown an
Address correspondence and reprint requests to David L. Kashan, MD, estimated prevalence of BDD of 11.2% in orthognathic patients
Cleveland Clinic, 9500 Euclid Avenue, Crile Building, A60, Cleveland, and 5.2% of cosmetic dentistry patients.7 As maxillofacial surgeons
OH 44195; E-mail: Dkashan1@yahoo.com expand the scope of practice to include cosmetic facial surgery, it is
The authors report no conflicts of interest. becoming increasingly important for these providers to screen their
Supplemental digital contents are available for this article. Direct URL patients for BDD. Such individuals may then be appropriately
citations appear in the printed text and are provided in the HTML and triaged, counseled against undergoing surgery, and referred to a
PDF versions of this article on the journal’s Web site (www.jcraniofa- mental health provider. The aim of this cross-sectional cohort study
cialsurgery.com). was to identify the epidemiologic differences of BDD in patients
Copyright # 2020 by Mutaz B. Habal, MD
ISSN: 1049-2275 presenting to maxillofacial surgeons for orthognathic, dentoalveo-
DOI: 10.1097/SCS.0000000000007370 lar, and facial cosmetic procedures.

970 The Journal of Craniofacial Surgery  Volume 32, Number 3, May 2021
Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery  Volume 32, Number 3, May 2021 Body Dysmorphic Disorder

METHODS

Study Design
This research was approved by the local review board at Case
Western University School of Medicine. We performed a cross-
sectional cohort study consisting of 3 groups:
1. new patients seeking orthognathic surgery,
2. new patients seeking facial cosmetic surgery, and
3. patients seeking dentoalveolar surgery.

Forty-six patients were enrolled in the study. Fifteen patients

FIGURE 1. Distribution of patients participating in study.
were selected for each group. A set of inclusion criteria determined
the subset of patients who constituted the research study sample.
The inclusion criteria were as follows: male (M ¼ 37.1 years) and female (M ¼ 38.1 years) participants
1. age 18 years or older, and (P > 0.05). Age of participants was stratified according to gender
2. patients interested in orthognathic, facial cosmetic, or and to the type of surgical procedure (orthognathic, facial cosmetic,
dentoalveolar surgery in the Case Western Reserve University or dentoalveolar), which can be seen in Supplementary Digital
School of Dental Medicine. Content, Table 2, http://links.lww.com/SCS/C227. The mean age
Each potential participant received an information sheet from was higher for participants seeking facial cosmetic surgery
either the principal investigator (PI) or co-investigator and was (M ¼ 42.9 years) than for those seeking either dentoalveloar surgery
given the opportunity to ask questions. For individuals interested in (M ¼ 36.9 years) or orthognathic surgery (M ¼ 27 years). Based on
participating, informed consent was obtained. Following the con- the BDDQ, 16.7% of patients seeking facial cosmetic surgery and
sent process, a brief chart review was performed in which data were 10% of patients seeking dentoalveolar surgery were categorized as
collected on demographics, history of psychiatric diagnosis, pri- high-risk for BDD. None of the patients seeking orthognathic
mary diagnosis, and type of operation/procedure sought. surgery was classified as high-risk for BDD. Patients who sought
facial cosmetic surgery were found to have a significantly higher
score (M ¼ 1.83) on the BDDQ severity scale. Those seeking
Body Dysmorphic Disorder Questionnaire orthognathic procedures were found to have an average severity
(BDDQ) score of 1.25 and those seeking dentoalveolar procedures had an
Upon completion of the BDDQ, the PI or co-investigator tallied average score of 1.16.
each patient’s score. Based on the patient’s score, he or she was
stratified as high-risk (ie, those with ‘‘preoccupation’’ and a ranking
of 3 on Items 5 and 6 on the BDDQ) or low-risk (ie, those who DISCUSSION
responded ‘‘no’’ to item 1, or patients without ‘‘preoccupation’’ and Body dysmorphic disorder (BDD) is an obsessive-compulsive
a ranking of <3 on Items 5 and 6). Each patient was immediately related disorder characterized by an individual’s preoccupation
informed of his or her score. It is important to note that the authors with the appearance of at least one perceived physical flaw. The
did not validate the BDDQ with further input from a psychiatrist. Its body imaging of patients with BDD is out of proportion to the
validity, however, has been the center of several other studies. Cash degree of deformity. Such affected individuals demonstrate a wide
et al were able to make several correlations with high BDDQ variety of aberrant behavior. There is a wide range of repetitive
scores.17 These included a higher predilection towards Caucasians, behaviors in which they engage, including excessive grooming,
female gender, elevated BMI, depression, and eating disorders. mirror-checking, and wardrobe changing, among others. Those with
These factors coincided with our findings as discussed in BDD may also engage in mental acts such as comparing their
the analysis. physical concern to that of other individuals. To meet diagnostic
criteria, the concerns must cause significant distress and/or func-
Statistical Analysis tional impairment in the individual’s social life or workplace.1
The mean BDDQ severity index was calculated for each group Impairment ranges from mild to severe. Mild patients may be
and data were presented as mean  standard error. Intergroup represented by the plastic surgery ‘‘junkie’’ that may seek one
differences were analyzed using analysis of variance (ANOVA) surgery after another to improve their physical appearance. 40% of
and Tukey-Kramer posthoc analysis. Data analysis was performed patients with BDD experience suicidal ideation. In severe cases,
on NCSS/PASS ’04 for Windows XP. suicide is attempted in as high as 13% to 33% patients.2–5
According to a recent systematic review by Veale et al, BDD
affects approximately 1.9% of the general population in the United
RESULTS States. Certain populations have been shown to be at increased risk,
The frequencies of new patients (n ¼ 46) seeking either orthog- including college students and patients with a pre-existing psychi-
nathic, facial cosmetic, or dentoalveolar surgeries were recorded atric diagnosis. Studies have also shown an overrepresentation in
over a period. Twenty (43%) of the participants were male, and 26 patients seeking cosmetic and dermatological surgery. Approxi-
participants (57%) were female. Gender differences between types mately 13.2% of patients seeking general cosmetic procedures have
of surgical procedure can be seen in Supplementary Digital Content, a clinical diagnosis of BDD. However, the frequencies reported in
Table 1, http://links.lww.com/SCS/C226. Patients seeking dentoal- the literature lack consensus. This may represent a gross underrep-
veolar surgery were the most represented (67%) in this sample, resentation or over-reporting due to the dearth of uniform screening
followed by cosmetic surgery (27%) and orthognathic surgery (6%) protocols, despite the presence of validated screening tools.6,7 In
(Fig. 1). The mean age of participants in the sample was 37.68 years. many cases, patients with BDD do not seek the help of a clinical
There was no statistically significant difference in age between psychologist or psychiatrist. Many patients are not cognizant of

# 2021 Mutaz B. Habal, MD 971

Copyright © 2021 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Kashan et al The Journal of Craniofacial Surgery  Volume 32, Number 3, May 2021

their disorder or aware of its impact on their daily functioning. and management protocols based on disorder severity, to determine
Consequently, a plastic surgeon, maxillofacial surgeon, dentist, the precise role of surgery in the management of BDD.
dermatologist, or gynecologist may constitute the first healthcare Implementation of regular screening in certain vulnerable
professional to encounter these patients. patient populations may prove beneficial for routine clinical prac-
The concept of BDD, or dysmorphia, was first introduced by tice. Previous studies have shown a significantly increased preva-
Herodotus in 440 BC and was later formally described by Morselli lence of BDD in both inpatient and outpatient psychiatric patients,
in 1886 as ‘‘dysmorphophobia.’’ However, it was only recently with a 4-fold increase in risk compared to that of the general
recognized as a distinct psychiatric disorder in the Diagnostic and population. Only 1 (2%) of the 46 participants in this study carried
Statistical Manual of Mental Disorders, 4th Edition (DSM-IV; a comorbid psychiatric diagnosis. Depression has been shown to
1997). Despite such early acknowledgment, the epidemiology have a lifetime prevalence of 82%, whereas OCD, social phobia,
and natural progression of the disease is poorly understood. Before and substance use disorder have lifetime prevalence rates of 78%,
its incorporation into the DSM-IV, BDD was categorized as a sub- 38%, and 47%, respectively.12 Due to the high rates of comorbidity,
type of obsessive compulsive disorder (OCD). Like OCD, BDD is a patients exhibiting signs or symptoms of the aforementioned dis-
chronic disease that often responds to cognitive behavioral therapy orders should be routinely screened during their initial
(CBT) and pharmacotherapy.8 The role of surgical intervention in surgical consultation.
the treatment of these patients remains controversial in the literature This study is unique in that it investigated epidemiologic
and has been suggested for the management of mild to moderate differences of BDD between orthognathic, dentoalveolar, and facial
disorder presentations. As of yet, few prospective studies and no cosmetic patient populations in the setting of maxillofacial surgery
controlled trials have been conducted to compare surgical interven- practices. The main limitation of this study is the small sample size
tion to the combination of cognitive behavioral therapy and high- (n ¼ 46). Due to the limited number of patients within the orthog-
dose selective serotonin reuptake inhibitors, which remains the nathic surgery group, we cannot comment on the estimated risk in
gold standard. these patients or the potential differences from previous studies.
Like many other psychiatric diagnoses, BDD represents a Additionally, patients who were determined to be high-risk for
spectrum, which can make it difficult to distinguish from normal BDD based on the BDDQ were not secondarily validated to meet
dissatisfaction with physical appearance. Garner et al found that criteria for clinical diagnosis by a mental health professional. As a
more than 50% of women and slightly less than 50% of men were result, the estimated frequencies reported in this study are subject to
dissatisfied with their physical appearance, yet most of these the test indices of the BDDQ. However, the accuracy of the BDDQ
individuals can remain at a high level of functioning and do not for use as a screening tool has been well-documented.13– 15
meet criteria for clinical diagnosis.9 Individuals with BDD are most The BDDQ is an efficient way to screen for BDD in patients
commonly concerned with facial aesthetics, including the appear- seeking orthognathic, dentoalveolar, or facial cosmetic surgery.
ance of their nose, eyes, hair, or skin.10 They can be difficult to Given the potential life-altering consequences of this disorder when
identify in the office and may keep their perceived defects to left untreated, early diagnosis are critical. The role of surgical
themselves. Patients with BDD often seek cosmetic facial surgery intervention in less severe cases remains unstudied and provides an
in attempts to correct their perceived defect but are frequently, if not area for future research. Perhaps the most important is the docu-
always, dissatisfied with the surgical results. Sarwer et al suggested mentation of the relatively high incidence of this problem in the
that operating on patients with BDD can either worsen their patient population studied. Identifying these preoperatively and
symptoms or result in new fixations with other physical features.16 avoiding surgery in those with severe BDDQ scores will serve
In a recent study, Hepburn et al reported that 7.5% of adult patients both patient and surgeons well. How milder forms of this disease
seeking orthodontic alignment of teeth were identified as having would fair with surgical intervention remains unclear.
BDD, as compared to 2.9% of the general population in London,
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The Journal of Craniofacial Surgery  Volume 32, Number 3, May 2021 Body Dysmorphic Disorder

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# 2021 Mutaz B. Habal, MD 973

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