Cosmetic Surgery and Body Dysmorphic Disorder - An Update

Caring for Patients With Body Dysmorphic Disorder Seeking to Undergo Plastic Surgery and/or Aesthetic Interventions

In the field of medical aesthetics and plastic surgery, it is not uncommon to interact with clients who never seem to be satisfied, regardless of the success of an intervention. Medical professionals may attribute this to the patient having an overly critical nature; however, this continual dissatisfaction could also be the result of a mental health disorder known as body dysmorphic disorder (BDD) that is significantly underdiagnosed and prevalent within the plastic surgery and aesthetic patient population. According to the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5; American Psychiatric Association, 2013), BDD is defined as, "a preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others" (Substance Abuse and Mental Health Services Administration, 2016, Table 23). Having the ability to identify the signs of BDD, utilize appropriate communication skills with individuals who may have BDD, and understand the implications of providing additional aesthetic treatments for patients who present with BDD allows aesthetic practitioners to prioritize and promote patient safety, well-being, and satisfaction.

The Dysmorphic Concern Questionnaire: Is It Possible to Predict a Satisfactory Result After Cosmetic Eyelid Surgery?

PURPOSE

As oculofacial surgeons performing esthetic surgery, the most valuable result is a satisfied patient. It can be extremely frustrating to have an unhappy patient with, what we believe is, a satisfactory result. Therefore, the ability to predict satisfaction is of extreme importance. We studied our cosmetic eyelid surgery patients to try to find factors that can predict satisfaction.

METHODS

We retrospectively studied 454 consecutive patients, who underwent any combination of 7 cosmetic surgical procedures. Patients answered the Dysmorphic Concern Questionnaire (DCQ) before surgery. We studied age, gender, type and number of procedures performed, DCQ score, presence of complications, and history of previous fillers. At the 3-month follow-up visit, patients were given an outcome report survey to graduate their surgical results on a scale from 1 to 5. Results were evaluated using a model of binary logistic regression in which the outcome variable was divided into 2 groups.

RESULTS

Three hundred eighty-six patients (85%) were female and the median age was 54.8 years old. The median for the number of procedures was 2 (range, 1-5). Two hundred two of the 454 patients (44.5%) had a history of fillers. Twenty-five patients had complications. DCQ score was significantly lower in the satisfied group (median score, 3) versus the unsatisfied group (median, 6), p = 0.007. In the multiple binary logistical model, the variables age, male gender, DCQ, presence of complications, and upper eyelid blepharoplasty resulted as significant.

CONCLUSIONS

We found a significant positive association with upper lid blepharoplasty and a negative association with increasing age, male gender, occurrence of complications, and DCQ score, as predictors of patient satisfaction. We routinely administer the DCQ to all cosmetic patients: It is a brief, sensitive, and specific screening instrument for body dysmorphic disorder.

The association between use of social media and the development of body dysmorphic disorder and attitudes toward cosmetic surgeries: a national survey

Introduction

Body dysmorphic disorder (BDD) causes distress due to one's negative appraisal of their body image. The development of BDD has been linked to the passive use of social media and photo-editing apps. People with BDD typically pursue cosmetic surgeries to remedy their perceived flaws. The dramatic increase in the use of photo-editing apps and their well-established effects on mental health is a public health concern.

Purpose

To study the association between use of social media and the development of BDD and acceptance toward cosmetic surgeries (ACSS) among Saudis.

Methods

An online, cross-sectional, validated survey conducted among Saudis 18 and older. Descriptive analyses were utilized for demographics and prevalence rates of main study variables. ANOVA was used to compare mean scores in BDD and ACSS among different demographic groups. Tukeys post-hoc test was done to identify the categories that were different when the ANOVA test showed a statistically significance. A p-value of <0.05 was considered statistically significant.

Results

A total of 1,483 Saudi adults completed the questionnaire. Key results showed that BDD was found in 24.4 % of the sample. The percentage of participants with BDD who spent 4-7 h per day on Instagram and Snapchat (29%) was significantly higher than those who spent only less than an hour per day on these platforms (19%) (p < 0.001). Individuals with BDD had a significantly higher risk of accepting cosmetic surgery compared to those without BDD (p < 0.001).

Conclusion

A growing body of evidence suggests that social media may impact mental health in different ways. This study reveals that heavy use of these platforms is associated with negative appraisals about one's physical appearance, and it fosters one's tendency toward cosmetic surgery, especially among females.

Long-Term Safety and Reliability of Using Tutoplast-Processed Fascia Lata to Refine the Nasal Dorsum in Primary and Revision Rhinoplasty

BACKGROUND

Tutoplast-processed fascia lata (TPFL) is an allograft substance employed alongside cartilaginous materials to achieve optimal augmentation in rhinoplasty. Alternatively, it can be utilized to conceal and smooth irregularities of the nasal dorsum during the procedure. Despite its application, there is limited available data on the extended safety of TPFL. Consequently, our objective was to assess the enduring long-term safety and reliability of TPFL in both primary and revision rhinoplasty.

METHODS

A retrospective cohort study was conducted on 300 patients who underwent primary and revision rhinoplasty with TPFL grafts. Baseline characteristics, types of surgical techniques, and surgical outcomes were evaluated. The surgical success and satisfaction rates were assessed as primary outcomes. The Statistical Package for Social Sciences (SPSS), version 27 for Windows, was used to conduct the statistical analysis.

RESULTS

TPFL was used in both primary and revision rhinoplasty, with septal cartilage being the most common conjunction graft material. The overall surgical success rate was 97.3%, with only 2.7% of patients experiencing complications. The satisfaction rate was 92.7%, with no significant difference between primary and revision cases. The highest satisfaction rate was found in patients who underwent the crushed cartilage in fascia technique (96.3%).

CONCLUSIONS

TPFL in conjunction with cartilaginous materials; is a safe and reliable option for dorsal augmentation and camouflage material in primary and revision rhinoplasty, with low complication and high patient satisfaction rates.

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 .

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

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.

Surgical Written Consent in Aesthetic Plastic Surgery: A Plastic Center Audit of Surgical Consent Standards

Background Informed consent is a fundamental aspect of modern medical practice that requires effective communication and an ample understanding of medical ethics, patient autonomy, and the legal obligations of healthcare professionals. Maintaining high-quality surgical informed consent is a crucial step in the healthcare process. Thus, we aimed to obtain surgical written consent on abdominoplasty, suction-assisted abdominal dermo lipectomy, and lower body lifting from our hospital database over three months (January to March, 2023) to assess our level across the American Society of Plastic Surgeons (ASPS) system. Results A total of 45 surgical written consents were obtained and 37 consents remained after exclusion. Bleeding, infection, and hematoma were mentioned in more than 80% of our consents. However, important complications such as ileus and umbilical malposition were never mentioned. Overall, the completion rate of written complications ranged from 14% to 56% in comparison to data from the ASPS. Conclusions Our results show a measurable inconsistency in surgical written consents at our center. Thus, establishing a comprehensive and accurate surgical written consent will aid in protecting our center against deficient surgical written consent accusations, improve the experience of patients, and enhance the quality of service provided by our center.

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 Dysmorphic Disorder (BDD) among the Lebanese University students: associated risk factors and repercussion on mental health

Introduction

Body Dysmorphic Disorder (BDD) is a psychological illness characterized by persistent and intrusive preoccupation with an imagined or slight defect in appearance. This study aimed to determine the prevalence of BDD and investigate its association with mental health status (depression and anxiety), religiosity, eating disorder risk, and self-esteem among Lebanese University students.

Methods

A cross-sectional study was conducted in March 2020, involving students from the Lebanese University. Data were collected using the dysmorphic concern questionnaire (DCQ), Rosenberg self-esteem scale (RSE), religiosity scale, patient health questionnaire (PHQ-9), generalized anxiety disorder assessment (GAD-7), Eating Attitude test-26 scale (EAT-26).

Results

A total of 6,448 participants were enrolled in our study. The overall prevalence of BDD among university students was (6.4%).Our results showed that Lebanese students with BDD were more likely to have anxiety ORadj 1.3 (95% CI: 1.2-1.7) p-value 0.001, depression ORadj 1.2 (95% CI: 1.15-1.5) p-value 0.007, and eating disorder (Bulimia & Food preoccupation ORadj 1.06 (95% CI: 1.03-1.2) p-value 0.0, and oral control ORadj 1.09 (95% CI: 1.05-1.1) p-value < 0.001) compared to those with no BDD. We also found that students with BDD had Lower Self-esteem ORadj 0.88 (95% CI: 0.78-0.9) p-value < 0.001), and less likely to be religious ORadj 0.88 (95% CI: 0.82-0.9) p-value 0.02) compared to those with no BDD.

Conclusions

This pioneering study sheds light on the prevalence of BDD among Lebanese university students and its associated factors. Our findings underscore the importance of early detection of BDD during adolescence and young adulthood, necessitating timely psychological intervention to prevent chronicity and complications.

Prevalence and Characteristics Associated with Positive Body Dysmorphic Disorder Screening Among Patients Presenting for Cosmetic Facial Plastic Surgery

Background: Many patients with body dysmorphic disorder (BDD) seek out cosmetic surgery to alleviate their symptoms of distress related to a perceived defect in their appearance; however, the prevalence and risk factors for BDD among patients with cosmetic concerns have not been well characterized. Methods: We screened adult patients presenting to the clinic from June 2021 through September 2022 for BDD using the BDD Questionnaire-Aesthetic Surgery (BDDQ-AS) who were seen in consultation for rhinoplasty, aging face, and injectables. Results: Among 488 patients, the prevalence of screening positive for BDD was 41.0%. The prevalence of a positive BDD screen was highest among patients who were younger (p = 0.02), and those who had a positive self-reported psychiatric history (p = 0.02). Among rhinoplasty patients, those with aesthetic/cosmetic motivations, and those seeking revision rhinoplasty had higher rates of positive BDD screen. Higher scores on the Standardized Cosmesis and Health Nasal Outcomes Survey-Nasal Obstruction Score (SCHNOS-O) (p = 0.01) and Standardized Cosmesis and Health Nasal Outcomes Survey-Nasal Obstruction Score-Nasal Cosmesis Score (SCHNOS-C) (p < 0.0001) were predictive of a positive BDD screen, while question 5 of the SCHNOS was highly predictive of positive BDD screening (p < 0.0001). Conclusions: Our study characterizes relationships between positive BDD screening and age, gender, self-reported psychiatric history, and motivations for consultation, among patients seen for cosmetic surgery evaluation in a facial plastic and reconstructive surgery setting.

Accuracy of computer-aided design trial restorations fabricated with different digital workflows

STATEMENT OF PROBLEM

Trial restorations are a versatile tool for visualizing the esthetic treatment plan and should be an accurate replica of the planned smile design. The accuracy of conventionally fabricated trial restorations has been investigated; however, studies on the accuracy of different digital workflows for trial restoration fabrication are lacking.

PURPOSE

The purpose of this in vitro study was to evaluate the accuracy of computer-aided design (CAD) trial restorations fabricated with different digital workflows.

MATERIAL AND METHODS

A patient in need of additive esthetic treatment was examined, and intraoral and extraoral photographs and intraoral digital scans were made, followed by 3D digital smile design using the exocad software program. The reference virtual design was converted into trial restorations (N=40) by using different digital workflows: subtractive manufacturing, additive manufacturing, additive manufacturing of 3D designed index, and silicone index on an additively manufactured cast. Fabricated trial restorations of all groups were scanned with a desktop scanner, providing a standard tessellation language (STL) file serving as the test data for each trial restoration. All the STL files of the test and reference data were imported into a reverse engineering software program to evaluate the 3D trueness of each workflow. Also, analog and digital 2D linear measurements (maxillary left central incisor height, maxillary left central incisor width, and intercanine width) were made to assess any dimensional alterations between the fabricated trial restorations and the reference digital smile design. A 1-way analysis of variance (ANOVA) was used to analyze the data followed by the Tukey post hoc test (α=.05).

RESULTS

For 3D trueness measurements, root mean square (RMS) values representing the deviations between the fabricated trial restorations and the reference digital smile design varied significantly among the different groups (P<.001), with the highest mean deviation found in the group of additive manufacturing of 3D designed index (0.21 ±0.01 mm), while the lowest mean value of deviation was found in the group of subtractive manufacturing (0.11 ±0.02 mm). For both the digital and analog 2D linear measurements, post hoc pairwise comparisons showed the group of additive manufacturing of 3D designed index to have significantly higher values of deviation than the other groups in all assigned measurements (P<.001).

CONCLUSIONS

The accuracy of CAD trial restorations was affected by the fabrication technique, and implementing conventional steps in the digital workflows of trial restoration fabrication may result in discrepancies that affect accuracy when compared with the reference design.

Prevalence of Psychiatric Disorders in Aesthetic Surgery

PURPOSE

Our study aimed to characterize and objectify the prevalence of psychiatric disorders and the use of psychotropic drugs in patients interested in undergoing aesthetic surgery. The psychiatric profile of this population is particularly interesting and is related to self-perception and the general concept of beauty.

METHODS

We conducted an observational, retrospective, and bicenter study of 2092 patients seen in plastic surgery departments. Data on general characteristics, pathology, psychiatric history (PH), use of psychotropic drugs, addictions, surgical requests, and surgical complications were recorded and analyzed.

RESULTS

Based on our inclusion criteria, we selected 524 patients. The prevalence of psychiatric disorders was 32.25%. The prevalence of depressive disorders (19.27%), anxiety disorders (8.21%), and sleep-wake cycle disorders (7.06%) should be noted. Comparing the population with psychiatric history (PH+) and without psychiatric history (PH-), significant differences were found in patient ethnicity, addictions (tobacco, 37.50% vs 15.00%; drugs, 3.26% vs 0.59%), and comorbidities. In the 66.86% (n = 113) of PH+ patients, the plastic surgeon did not record the presence of psychiatric disorders in the medical record.

DISCUSSION

This study offers a broad view of the prevalence and characteristics of psychiatric disorders and the use of psychotropic drugs among patients who want to undergo aesthetic surgery. The prevalence of psychiatric problems in the study population is higher than in the general population (32.25% vs 15.02%).

CONCLUSIONS

Our results suggest that plastic surgeons should be properly trained to manage these patients. A multidisciplinary approach involving plastic surgeons, psychiatrists, and psychologists is advocated.

Body Dysmorphic Disorder and Self-esteem in Adolescents and Young Adults with Acne Vulgaris

Body dysmorphic disorder is a mental health disorder characterized by a preoccupation with a perceived flaw, which is commonly seen among dermatology patients. The objective of this study was to determine the frequency of body dysmorphic disorder and assess self-esteem among a clinical sample of adolescents and young adults being managed for acne vulgaris. A total of 105 patients, age range 13-24 years, receiving acne treatment at 1 of 2 dermatology outpatient clinic were included. A self-report questionnaire was used, which included a body dysmorphic disorder screening tool (based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria) and the Rosenberg Self-Esteem Scale (RSES). Acne was graded with the Cook's acne grading scale. Out of 105 adolescents and young adults visiting a dermatologist due to acne, 13 (12.4%) screened positive for body dysmorphic disorder (95% confidence interval (95% CI) 6.8-20.2%). Patients with body dysmorphic disorder were more likely to have female gender (p = 0.020) and had lower self-esteem (RSES 15.8 vs 20.5, respectively, p = 0.013) compared with patients without body dysmorphic disorder. No differences were found in the frequency of body dysmorphic disorder with DSM-IV or DSM-5 criteria. This is the first study to report on the frequency of body dysmorphic disorder and self-esteem in adolescents and young adults with acne. Ultimately, more awareness of body dysmorphic disorder among adolescents and young adults presenting with dermatological disorders could lead to more rapid recognition and referral to psychiatric units.

Mental health screening in facial cosmetic surgery: a narrative review of the literature

The popularity of cosmetic surgery is on the increase with the face being one of the most common anatomical areas operated on. Pre-existing mental health conditions can be associated with adverse patient outcomes after cosmetic surgery and can result in deterioration of postoperative mental health and lack of patient satisfaction. Therefore, identifying the presence of psychiatric disorders through preoperative screening should be considered during consultation for facial cosmetic surgery. In this study, we reviewed the types of preoperative mental health screening tools used in cosmetic facial surgery and the prevalence of mental health conditions among patients undergoing cosmetic facial surgery. A literature search was conducted on Pubmed, Prospero, Dynamed, DARE, EMBASE, and COCHRANE databases. A total of 12 articles fulfilled the inclusion criteria. A total of 2194 participants were included in this review. Rhinoplasty (n=1154), blepharoplasty (n=138) and rhytidectomy (n=83) were the most performed facial cosmetic procedures, respectively. A total of 758 (34.1%) had a diagnosis of a potential mental health problem following the preoperative screening. With body dysmorphic disorder (BDD) being the most common (20.0%). The BDD questionnaire was the most used screening tool (n=4). Mental health diagnoses were more common in patients in low-income countries (48.4%) compared to patients from non-low-income countries (25.7%). Given our findings, we propose the routine use of mental health screening tools in all patients undergoing facial cosmetic surgery. This will improve satisfaction rates post-facial cosmetic surgery and may reduce the number of unnecessary procedures.

Evidence-based review: Screening body dysmorphic disorder in aesthetic clinical settings

BACKGROUND

Body dysmorphic disorder (BDD) is a psychiatric disturbance with high incidence in aesthetic clinical settings. Early recognition may avoid unnecessary elective procedures with ethical and medicolegal consequences.

AIMS

To identify validated BDD screening tools and critically appraise current literature regarding its implementation and efficacy in aesthetic medicine and surgery scenarios, with the purpose of transposing the findings to the broad clinical settings in the field.

METHODS

Data was collected using advanced search from PubMed (MEDLINE). Having satisfied the search parameters, 12 studies referring BDD definition according to Diagnostic and Statistical Manual of Mental Disorder (DSM-5) criteria and including a BDD screening tool in clinical aesthetic settings were selected.

RESULTS

While BDD screening enables the recognition of at-risk individuals, further work is required to uncover the best screening tool for general aesthetic clinical practice. Level III evidence favored BDD Questionnaire (BDDQ)/BDDQ-Dermatology Version (DV), and The Dysmorphic Concern Questionnaire (DCQ) among the limited available validated screening instruments to be used outside the psychiatric environment. Based on level II self-classification, one study selected BDDQ-Aesthetic Surgery (AS) version for rhinoplasty patients. The validation process of both BDDQ-AS and Cosmetic Procedure Screening Questionnaire (COPS) had limitations. For BDD screening potential in avoiding postoperative complications, the limited studies found evaluating the outcomes following aesthetic treatments using validated BDD screening measures showed a trend toward less satisfaction with aesthetic treatment outcome among positive screening population against non-BDD counterparts.

CONCLUSION

Further research is necessary to establish more effective methods to identify BDD and evaluate the impact of positive findings on aesthetic intervention outcomes. Future studies may elucidate which BDD characteristics best predict a favorable outcome and provide high-quality evidence for standardized protocols in research and clinical practice.

Factors Associated with Likelihood to Undergo Cosmetic Surgical Procedures Among Young Adults in the United States: A Narrative Review

Introduction/Goals

Over the past decade, cosmetic surgical procedures have become increasingly popular. This trend has been driven by procedural innovations as well as access to Internet and social media. Consequently, patients have been seeking cosmetic surgical procedures at younger ages. In this narrative review, studies assessing attitudes towards cosmetic surgical procedures among college-aged young adults were evaluated.

Methods

A search identified 20 studies published from 2002 to 2021 that focused on cosmetic surgical procedures among young adults. Each study used survey-based data to determine attitudes, acceptance, interests, perceptions, and beliefs about cosmetic surgical procedures among college-aged students in the United States.

Results

The proportion of college-aged participants who had undergone cosmetic surgical procedures ranged from 1.3% to 6.4% with surveys reporting that between 21 and 43% were interested in procedures in the future. In general, young women were more likely to express interest in cosmetic surgical procedures than young men. Studies consistently demonstrated an inverse relationship between body satisfaction and use of aesthetic procedures among this patient population. Other factors associated with acceptance and approval of cosmetic surgical procedures included importance of appearance to self-worth, concern with social standing and attractiveness, investment in appearance, media influence on body image, and positive attitudes towards celebrities. Exposure to cosmetic surgery advertising was correlated with increased approval of cosmetic surgical procedures, especially the perception that advertising influences “others” more than survey respondents themselves.

Conclusion

Interest in cosmetic surgical procedures continues to grow among young adults in the United States. In the future, this cohort is likely to become an increasingly important demographic to target for education, advertising, and research regarding cosmetic surgical procedures.

Body Dysmorphic and Narcissistic Personality Disorder in Cosmetic Rhinoplasty Candidates

BACKGROUND

Body dysmorphic disorder (BDD) and other psychological problems are more common in cosmetic surgery applicants.

OBJECTIVE

The aim of this study was to investigate the frequency of the symptoms of BDD and narcissistic personality disorder in rhinoplasty candidates.

MATERIALS AND METHODS

This descriptive cross-sectional study was performed on rhinoplasty applicants. All subjects were evaluated by BDD and narcissistic personality questionnaires (NPI-16).

RESULTS

A total of 380 patients were studied. Our findings showed that the prevalence of mild, moderate, and severe BDD symptoms was 31.6%, 43.4% and 25%, respectively. The mean BDD scores were not significantly different in variables such as gender, age, marital status, history of cosmetic surgery, education, place of residence, and income. 29.5% of the subjects had symptoms of narcissism. There was no significant relationship between the symptoms of narcissism and variables such as gender, age, marital status, history of cosmetic surgery, place of residence, and income. Higher education was associated with higher rates of narcissistic personality disorder (p-value = 0.021).

CONCLUSIONS

According to the results of the study, there was no statistically significant relationship between BDD score and demographic parameters. Also, association between narcissistic personality disorder and demographic characteristics was not significant except for education.

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 .

Implementing the Medical Model in Aesthetic Consultation

Throughout the process of building a new medical spa, it is important to standardize and implement safe, evidenced-based practice standards. As medical spas and aesthetic services become more prevalent and popular, it is more important than ever for providers to ensure that patient safety is a top priority. Integrating a structured medical model into the aesthetic consultation and treatment ensures that a mutual decision-making process is shared between the provider and the patient. Together, the provider and the patient can determine whether the treatment will improve the patient's overall health and well-being. The patient is given the opportunity to fully understand and choose which procedure will best address their overall psychological health, aesthetic concern, and anatomical diagnosis. In establishing agreement with the patient on a common goal, the provider can first assess the risks and benefits, and then determine which intervention or treatment will provide the patient with the greatest benefit. When providers establish and adhere to an easy-to-use, decision-making algorithm, patients are empowered in the decision-making process. This helps build a working, trusting relationship between the patient and the provider, which leads to greater patient satisfaction and patient loyalty. Sharing this medical model algorithm will greatly benefit other aesthetic providers by helping to create a standardized evaluation process in a medically based aesthetic practice.

Is the needle as risky as the knife? The prevalence and risks of body dysmorphic disorder in women undertaking minor cosmetic procedures

OBJECTIVES

Body dysmorphic disorder is commonly considered a contraindication for major cosmetic surgery, but whether body dysmorphic disorder relates to poorer outcomes from minor cosmetic treatment remains unknown. This study aimed to explore the prevalence of body dysmorphic disorder in clients seeking non-surgical cosmetic procedures and to examine whether body dysmorphic disorder clients are vulnerable in minor cosmetic settings. Vulnerability was explored in terms of psychological distress, unrealistic expectations and motivations for treatment outcome, and reduced satisfaction with past cosmetic procedures.

METHOD

A cross-sectional online survey was completed by 154 women seeking minor cosmetic procedures which included the Body Dysmorphic Disorder Questionnaire - Dermatology Version to screen for body dysmorphic disorder, and measures of cosmetic treatment motivation, expectations and satisfaction.

RESULTS

Roughly 25% of women in the current sample screened positive for a potential body dysmorphic disorder diagnosis. Participants with suspected body dysmorphic disorder demonstrated higher levels of psychological distress and more unrealistic expectations and motivations for cosmetic treatment, such as improving social or romantic relationships. However, body dysmorphic disorder participants reported similar levels of satisfaction with past minor cosmetic treatments to the non-body dysmorphic disorder group.

CONCLUSION

While the relationship between body dysmorphic disorder and treatment outcome warrants further investigation in prospective research tracking satisfaction and adverse reactions over time, this preliminary evidence suggests clients with suspected body dysmorphic disorder display several vulnerabilities in non-surgical cosmetic settings. Given the rapidly increasing accessibility of minor cosmetic procedures, further research is needed to determine their safety for clients with body dysmorphic disorder. Detection of body dysmorphic disorder in non-surgical cosmetic settings could facilitate earlier psychological intervention, promoting superior long-term outcomes.

Validation of the Cosmetic Procedure Screening (COPS) Questionnaire in the Greek language

Practitioners in cosmetic and aesthetic treatment practices are likely to unknowingly work with patients with Body Dysmorphic Disorder (BDD). Screening questionnaires to identify the disorder in Greece are lacking. The purpose of this study was to validate a Greek version of the Cosmetic Procedure Screening (COPS) questionnaire, a self-report measure of how the respondents feel about their appearance, before an aesthetic intervention. The COPS was translated into Greek and was completed by 216 adult females from several areas of Attica (four private beauty centers, three dermatology clinics, five plastic surgery clinics, and Thriasio General Hospital of Elefsina) who pursued a cosmetic procedure. Participants also completed the Perceived Stress Scale (PSS-14). The Greek version of the COPS questionnaire demonstrated high internal consistency (Cronbach's α of 0.856) with corrected item's total range 0.468 to 0.687. Two of the factors explained 58.98% of total variance. Twenty (9.26%) women had a possible diagnosis of BDD (80% were unmarried, 95% had no children, 80% had university education). An increase in perceived stress levels was associated with an increase in the likelihood of being diagnosed with BDD (Pearson's r=0.726). The Greek version of the COPS questionnaire is a valid instrument that can be used by professionals to screen adult women for BDD.

The cosmetic surgery paradox: Toward a contemporary understanding of cosmetic surgery popularisation and attitudes

Modern women feel compelled to meet near-impossible standards of beauty. For many, this pursuit ultimately culminates in cosmetic surgery - a radical form of beautification that is rapidly becoming popular worldwide. Paradoxically, while prevalent, artificial beauty remains widely unaccepted in contemporary society. This narrative review synthesizes feminist dialogue, recent research, and real-world case studies to argue that female beauty standards account for both the growing popularity of cosmetic surgery and its lack of mainstream acceptance. First, we implicate unrealistic beauty standards and the medicalization of appearance in popularizing cosmetic surgery. Second, we analyze how negative attitudes toward cosmetic surgery are also motivated by unrealistic beauty standards. Finally, we generate a synthesized model of the processes outlined in this review and provide testable predictions for future studies based on this model. Our review is the first to integrate theoretical and empirical evidence into a cohesive narrative that explains the cosmetic surgery paradox; that is, how cosmetic surgery remains secretive, stigmatized, and moralized despite its surging popularity.

Suicidality in patients with obsessive-compulsive and related disorders (OCRDs): A meta-analysis

INTRODUCTION

Previous meta-analyses showed that OCD is associated with a substantial risk of suicidal behaviours. Conclusive rates of suicidal ideation (current and lifetime) and suicide attempts based on pooled prevalence rates have not so far been calculated using meta-analysis for the other DSM-5 Obsessive-Compulsive and Related Disorders (OCRDs).

OBJECTIVES

This meta-analysis aims to separately calculate the pooled prevalence rates of lifetime suicide attempts and current or lifetime suicidal ideation in BDD, Hoarding Disorder (HD), Skin Picking Disorder (SPD) and Trichotillomania (TTM) and to identify factors associated with increased suicide rates.

METHODS

Our protocol was pre-registered with PROSPERO (CRD42020164395). A systematic review and meta-analysis following PRISMA reporting guidelines was performed by searching in PubMed/Medline, PsycINFO, Web of Science and CINAHL databases from the date of the first available article to April 20th, 2020. Stata version 15 was used for the statistical analysis. Given the small number of studies in TTM and SPD, the two grooming disorders were grouped together. Meta-analyses of proportions based on random effects (Der-Simonian and Laird method) were used to derive the pooled estimates.

RESULTS

Thirty-eigth studies (N = 4559 participants) were included: 23 for BDD, 8 for HD, 7 for Grooming Disorders. For BDD, the pooled prevalence of lifetime suicide attempts, current and lifetime suicidal ideation was, respectively 35.2% (CI:23.4-47.8), 37.2% (CI:23.8-51.6) and 66.1% (CI:53.5-77.7). For HD, the pooled prevalence of lifetime suicide attempts, current and lifetime suicidal ideation was 24.1% (CI:12.8-37.6), 18.4% (CI:10.2-28.3) and 38.3% (CI:35.0-41.6), respectively. For Grooming Disorders, the pooled prevalence of lifetime suicide attempts and current suicidal ideation were 13.3% (CI:5.9-22.8) and 40.4% (CI:35.7-45.3), respectively (no data available for lifetime suicidal ideation).

CONCLUSIONS

The OCRDs as a group are associated with relatively high rates of suicidal behaviour. Through indirect comparisons, we infer that BDD has the greatest risk. Comorbid substance abuse, possibly reflecting poor underlying impulse control, is associated with higher rates of suicidal behaviour in BDD. Our data emphasize the need for clinicians to consider the risk of suicidal behaviour in the management of patients presenting with all forms of OCRDs.

The relationship between obsessive-compulsive spectrum disorders and DSM-5 dysfunctional personality domains in a nonclinical sample of Italian women

To evaluate the usefulness of the DSM-5 maladaptive personality domains in explaining the similarities and differences among four disorders included in the obsessive-compulsive spectrum, 428 Italian community-dwelling women (mean age = 31.96 years, SD = 12.30 years) were administered the Obsessive-Compulsive Spectrum Disorder Scales and the Personality Inventory for DSM-5-Short Form as part of an ongoing online survey on women's health. Multiple Indicators Multiple Causes (MIMIC) confirmatory bifactor analysis results showed that the OCSD general factor (i.e., obsessive-compulsive spectrum factor) was positively associated with Negative Affectivity, whereas Body Dysmorphic Disorder (BDD), Hoarding Disorder (HD), and Skin-Picking Disorder (SPD) specific factors showed significant and substantial differential relationships with dysfunctional personality domains. Specifically, BDD was positively associated with Negative Affectivity, Detachment and Psychoticism domains; HD was associated with high Negative Affectivity and Psychoticism; and SPD was associated with Detachment. © 2020 John Wiley & Sons, Ltd.

Body dysmorphic disorder in children and young people

The incidence of body dysmorphic disorder (BDD) in young people is increasing. Causes of BDD are related to the prevalence of social media and adolescent development, especially the role that brain neuroplasticity has on influencing perception. There are long-term impacts of BDD, including depression and suicide. Prevention and promotion of positive body image are part of the nurse's role; treatment can prevent unnecessary aesthetic surgical interventions.

Psychiatric Assessment and Management of Clients Undergoing Cosmetic Surgery: Overview and Need for an Integrated Approach

Background  Psychiatric disorders are more common among people undergoing cosmetic procedures than the general population and evaluating mental health can be cumbersome for plastic surgeons. We aim to summarize the available literature in this regard and propose an integrated approach to psychiatric assessment and management of mental health issues among this group. Methods  Electronic search of MEDLINE, Google Scholar, and PsycINFO databases was done to identify relevant peer-reviewed English language articles from inception till April 2020. Generated abstracts were screened for their eligibility. Included articles were grouped according to their thematic focus under the following headings; prevalence of psychiatric morbidity among clients posted for cosmetic surgery, assessment tools, and management of psychiatric morbidity in relation to undergoing cosmetic surgery. Results  A total of 120 articles were reviewed. The prevalence of psychiatric disorder in patients undergoing cosmetic surgery was 4 to 57% for body dysmorphic disorder (BDD); the corresponding figures for depression, anxiety, and personality disorder were 4.8 to 25.8, 10.8 to 22, and 0 to 53%, respectively. A range of tools have been used to assess these disorders and specific measures are also available to assess clinical outcomes following surgery. Screening for these disorders is essential to prevent unnecessary surgical procedures, as well as to ensure timely management of the psychiatric comorbidity. Conclusion  Psychiatric morbidity is a common concomitant in cosmetic surgery. A structured and integrated approach to evaluation and management of psychiatric morbidity will help to optimize postsurgical outcomes.

Development of a multiphasic, cryptic screening protocol for body dysmorphic disorder in cosmetic dermatology

Background

The incidence of body dysmorphic disorder in cosmetic dermatology is high. Even though treating patients with this disorder may worsen symptoms and is fraught with potential complications, screening is low, due in part to lack of knowledge of the disorder, as well as inadequate screening tools.

Objectives

To verify the probability of body dysmorphic disorder in a nonsurgical esthetic setting and determine the effect of a multiphasic screening protocol on mitigating poor outcomes in high‐risk patients.

Methods

A multiphasic screening protocol for body dysmorphic disorder was distributed to a total of eight esthetic clinics in the United States. Practitioners administered an anonymous, cryptic prescreening form to all new, incoming patients aged ≥ 18 to ≤ 65 years from June 1, 2019, through September 1, 2019, followed by a second, more extensive screening questionnaire. Patients with suspected or subclinical body dysmorphic disorder could be refused treatment.

Results

A total of 734 initial screenings were recorded over 16 weeks. Of these, 4.2% (31/734) proceeded to the secondary screening phase; 29% (9/31) subsequently screened positive for body dysmorphic disorder. Practitioners refused to treat 77.8% (7/9) of positive screenings. Two patients out of seven who tested positive underwent a third screening and were subsequently treated with positive outcomes.

Conclusions

Use of a cryptic screening protocol enables identification of individuals at risk for BDD and encourages open and continuous communication between patient and provider.

Body Dysmorphic Disorder in the Perspective of the Alternative DSM-5 Model for Personality Disorder: A Study on Italian Community-Dwelling Women

To evaluate the relationships between body dysmorphic disorder (BDD) and Alternative DSM-5 Model for Personality Disorder (AMPD) criterion A and dysfunctional personality trait (i.e., criterion B) measures, 420 Italian community-dwelling women were administered three measures of BDD (i.e., the Body Dysmorphic Disorder Questionnaire, the Body Dysmorphic Disorder-Dimensional Scale, and the Appearance Anxiety Inventory), as well as the Level of Personality Functioning Scale-Brief Form (LPFS-BF) and the Personality Inventory for DSM-5-Short Form (PID-5-SF). The three BDD measures showed substantial convergent validity correlations and could be reliably cumulated to obtain the BDD Cumulative Index (BDDCI). Several significant, nonnegligible correlations were observed between the BDDCI as well as the LPFS-BF scale scores and PID-5-SF personality trait scale scores. Relative importance weight analysis results showed that LPFS-BF scale scores and PID-5-SF trait scale scores were substantial predictors of the BDDCI scores (R = 0.42, f = 0.72). In particular, AMPD criterion A impairment in self-functioning and AMPD criterion B depressivity, anhedonia, perseveration, separation insecurity, and cognitive and perceptual dysregulation were core components of the dysfunctional personality profile associated with BDD.

Body dysmorphic disorder in patients with telangiectasias

BACKGROUND

Chronic venous disease (CVD) patients can present with a spectrum of clinical manifestations ranging from severe ulcerations, thrombosis, and varicose vein hemorrhage to milder ones such as telangiectasias. Some CVD patients have a minimal degree of telangiectasias that are almost invisible to the physician. In spite of successful treatment of these telangiectasias, there are patients that might insist on continuing treatment, focusing excessive attention on what they perceive to be persistent telangiectasias that, in their opinion, must be removed. In these cases, one might be facing a possible body dysmorphic disorder (BDD) diagnosis.

METHODS

This is a multicentric study performed in 223 patients with telangiectasias (C1s) seeking treatment; the Body Dysmorphic Disorder Questionnaire (BDDQ) was answered in private by all the patients. Furthermore, each questionnaire was evaluated in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria for BDD.

RESULTS

From a consecutive sample of 223 patients, 38 patients had criteria for BDD according to the DSM-V; indicating that the prevalence of BDD in patients with telangiectasias is 17%.

CONCLUSIONS

Telangiectasias can be a stress trigger that changes the way patients perceive their own appearance. BDD patients tend to focus their attention excessively upon these types of veins and demand unnecessary treatment for minimal telangiectasias in order to diminish their discomfort with their physical appearance. Body dysmorphic disorder occurs in patients with limbs with C1s disease in considerable proportion and, upon evaluation, these patients should be referred to a psychiatrist. The initiation of any treatment for telangiectasias prior to the psychiatric assessment should be avoided.

Artificial Intelligence in plastic surgery: What is it? Where are we now? What is on the horizon?

INTRODUCTION

An increasing quantity of data is required to guide precision medicine and advance future healthcare practices, but current analytical methods often become overwhelmed. Artificial intelligence (AI) provides a promising solution. Plastic surgery is an innovative surgical specialty expected to implement AI into current and future practices. It is important for all plastic surgeons to understand how AI may affect current and future practice, and to recognise its potential limitations.

METHODS

Peer-reviewed published literature and online content were comprehensively reviewed. We report current applications of AI in plastic surgery and possible future applications based on published literature and continuing scientific studies, and detail its potential limitations and ethical considerations.

FINDINGS

Current machine learning models using convolutional neural networks can evaluate breast mammography and differentiate benign and malignant tumours as accurately as specialist doctors, and motion sensor surgical instruments can collate real-time data to advise intraoperative technical adjustments. Centralised big data portals are expected to collate large datasets to accelerate understanding of disease pathogeneses and best practices. Information obtained using computer vision could guide intraoperative surgical decisions in unprecedented detail and semi-autonomous surgical systems guided by AI algorithms may enable improved surgical outcomes in low- and middle-income countries. Surgeons must collaborate with computer scientists to ensure that AI algorithms inform clinically relevant health objectives and are interpretable. Ethical concerns such as systematic biases causing non-representative conclusions for under-represented patient groups, patient confidentiality and the limitations of AI based on the quality of data input suggests that AI will accompany the plastic surgeon, rather than replace them.

Etiological factors and treatment challenges in an adolescent male with body dysmorphic disorder: A case report

There are very few existing reports in adolescents about the clinical presentation and treatment challenges associated with body dysmorphic disorder coexisting with suicidal behaviour. This case report describes a 13-year old male with body dysmorphic disorder, who was completely convinced that his belief related to the disorder is true (delusional belief) and therefore had no insight into his condition. His preoccupation with the shape of his nose progressed significantly over a 2-year period to the extent that he wore a surgical mask on a daily basis to camouflage the perceived defect. The distress due to the persistent preoccupation and intrusive thinking became so severe that he started to experience suicidal ideation and attempted suicide twice with no harm sustained. This case report focuses on three treatment challenges faced by the treating team: the need of continued treatment with pharmacotherapy and psychotherapy following a cosmetic procedure, the impact of the mother’s preoccupation with her physical appearance on the recovery of the young person, and the management of suicidality. We have also highlighted the probable causative factors of the development of the illness in this patient which are consistent with the established aetiology of body dysmorphic disorder.

Psychiatric Disorders in Facial Plastic Surgery

Body dysmorphic disorder and borderline personality disorder are common in esthetic practices and occur in up to 15% of patients. Operating on these patients may not only lead to dissatisfaction but may also worsen their premorbid condition and can induce negative behavior toward the practice. Preventing surgery and referring patients for cognitive therapy is essential. An adequate understanding of these conditions and the available screening tools is indispensable for all esthetic practitioners. Unrealistic emotional attribution to a facial shape, multiple procedures, a near-normal nose at the outset, childhood trauma, multiple comorbid mental conditions, and social dysfunction are red-flags to consider.

Assessing Unrealistic Expectations in Clients Undertaking Minor Cosmetic Procedures: The Development of the Aesthetic Procedure Expectations Scale

Objective: To develop and validate a novel patient-reported measure to assess internally and externally driven expectations for change after a cosmetic procedure, termed the aesthetic procedure expectations (ASPECT) scale. Method: In total, 186 adults recruited from nonsurgical cosmetic clinics in Melbourne, Australia, accessed an online survey (150 completed; 81% response rate) including the novel ASPECT questionnaire, demographics, and measures of psychological distress. Results: The final sample included 141 women and 5 men with a mean age of 44.78 years (standard deviation = 11.68) with <10% missing data. Results supported a two-factor ASPECT scale measuring intrinsic and extrinsic expectations, with high internal consistency and convergent validity. Heightened extrinsic and intrinsic expectations were both associated with individuals who were emotionally distressed, younger, and had previously undertaken more cosmetic procedures. Cutoff scores for the ASPECT subscales are proposed to aid cosmetic practitioners in identifying clients requiring further assessment. Conclusions: The ASPECT scale may provide a reliable and useful clinical tool for cosmetic practitioners to assess unrealistic expectations and determine which clients may require more in-depth consultation before undergoing surgical or nonsurgical cosmetic treatment.

Exploring the Ethics of Stature Lengthening as Treatment for Height Dysphoria

AIM

To promote a discussion on the ethics and justifications of stature lengthening in patients without skeletal deformity.

BACKGROUND

Stature lengthening for height gain in patients without skeletal deformity has stirred controversy within the orthopedic community. However, current literature does not delineate the ethical issues surrounding this procedure. Improvements in the techniques, technology, and safety profile of stature lengthening warrant an ethical discussion to challenge, justify, and guide the use of this surgical procedure.

REVIEW RESULTS

Examination of ethical issues leads to the distinction between the dual roles of stature lengthening as a treatment vs an enhancement. The primary focus on stature lengthening as treatment allows for exploration of "height dysphoria"-a psychological burden caused by a dissatisfaction with one's height-as the primary pathology that may justify surgical intervention.

CONCLUSION

In our opinion, additional work is required to establish "height dysphoria" as a true pathology in order to ethically justify stature lengthening as a legitimate form of treatment. Further discussion is needed to address the ethics of stature lengthening as an enhancement.

CLINICAL SIGNIFICANCE

This paper addresses salient ethical issues of stature lengthening in patients without skeletal deformity by exploring historical, contemporary, and comparative contexts.

HOW TO CITE THIS ARTICLE

Lee RC, Aulisio M, Liu RW. Exploring the Ethics of Stature Lengthening as Treatment for Height Dysphoria. Strategies Trauma Limb Reconstr 2020;15(3):163-168.

The effectiveness of counseling based on acceptance and commitment therapy on body image and self-esteem in polycystic ovary syndrome: An RCT

Background

Polycystic ovary syndrome (PCOS) is one of the most common endocrine and metabolic disorders known with irregular menstruation, hirsutism, alopecia, obesity, infertility, and acne. These symptoms cause a negative effect on the satisfaction of body image, self-esteem, and quality of life in such patients. Recent studies emphasize the need to consider the psychological problems in these women and also the need for appropriate interventions.

Objective

The aim of this study was to determine the effectiveness of group counseling based on acceptance and commitment therapy (ACT) on body image and self-esteem in patients with PCOS.

Materials and Methods

In this randomized controlled trial, 52 women with PCOS were randomly allocated to intervention and control groups (n = 26/each) using the table of random numbers. Group counseling based on the ACT was held in eight sessions of 90 min once a week for the intervention group. The demographic questionnaire, Littleton development of the body image concern inventory and Rosenberg self-esteem scale were completed in both groups before, immediately after, and one month after the intervention.

Results

The mean scores of body image concern (p = 0.001) and self-esteem (p ≤ 0.001) in the intervention group after the intervention and follow-up were significantly different from the control group.

Conclusion

Based on the findings of this study, use of cognitive-behavioral therapies in health care centers is recommended as a complementary method.

Prevalence and characteristics of body dysmorphic disorder in Arab dermatology patients

OBJECTIVES

  To explore how prevalent body dysmorphic disorder (BDD) is among Arab dermatology patients and what characteristics of  patients are associated with it.

METHODS

  A total of 497 patients from the dermatology outpatient clinic at King Khalid University Hospital, Riyadh, Saudi Arabia, participated in this cross-sectional study conducted between October and December 2018. We asked the patients about their demographic and clinical characteristics, and then asked them to complete a dermatology-based self-report BDD questionnaire. Following this, we appointed 2 independent researchers to evaluate the dermatological flaws highlighted in the patient questionnaires and rate them using a severity scale.

RESULTS

Body dysmorphic disorder was found in 14.1% of Arab dermatology patients. There were significant links between female with BDD (odds ration [OR]: 2.93;  95% CI 1.24, 6.9]), having 2 or more skin conditions with BDD (OR: 4.67; 95% CI 1.33, 16.49) and having a certain skin condition such as hyperpigmentation with BDD (OR: 5.86; 95% CI 1.46, 23.61). The biggest BDD concerns were hyperpigmentation, acne, and hair loss. Conclusion: Body dysmorphic disorder was common among Arab dermatology patients, especially among women and those who have hyperpigmentation or more than one skin condition.

Vaginal Rejuvenation: A Review of Female Genital Cosmetic Surgery

Importance

Female genital cosmetic surgery (FGCS) is a growing area within the field of gynecology with an increasing number of patients asking providers about these services.

Objective

This review aims to increase the knowledge surrounding the types of FGCS performed, the outcomes and complications of these procedures, and the controversy surrounding FCGS.

Evidence Acquisition

This study is a review of the most recent peer-reviewed articles and review articles as well as guidelines and recommendations of the American College of Obstetrics and Gynecology.

Results

Female genital cosmetic surgery is a broad term that encompasses multiple procedures including labiaplasty, vaginoplasty, clitoral hoodectomy, hymenectomy, labia majora augmentation, and G-spot amplification. Minimal data exist regarding the long-term outcomes and complications associated with these procedures. There is also a paucity of literature comparing FGCS to less invasive alternatives. Significant controversy exists regarding FGCS, given the known variation in female genitalia, lack of safety data, and concern for proprietary conflict with these procedures.

Conclusions and Relevance

Cosmetic gynecology surgery has become more popular in recent years, with few studies assessing the long-term benefits and harms of these treatments. Gynecologists should be aware of the lack of evidence supporting the effectiveness of FGCS in light of the growing marketing efforts and patient demand for these procedures.