Prevalence of body dysmorphic disorder in patients who are candidates and/or are submitted to aesthetic procedures in the specialty of plastic surgery: a systematic review with meta-analysis

This study aimed at showing the prevalence of body dysmorphic disorder (BDD) in patients who are candidates and/or are submitted to aesthetic procedures in the specialty of plastic surgery via a systematic review of the literature and a meta-analysis. To comply with the proposed objective, we analyzed the most relevant studies originally published in any language that were available in the National Library of Medicine (MEDLINE), Cochrane, and SciELO databases. Searches were performed using keywords associated with the theme and inclusion and exclusion criteria. Thus, the final sample of this study was composed of 15 publications, which were submitted to a meta-analysis. It can be confirmed that 12.5% of the patients who were candidates/submitted to aesthetic procedures in the specialty of plastic surgery had BDD. Of these, the majority were women (75.7%) with a mean age of 30 (± 10.5) years. Given the high number of patients with BDD attended to in the specialty, it is important that plastic surgeons focus on providing patients with adequate care to identify individuals who potentially have BDD and consequently conduct an interdisciplinary followup with the participation of psychologists and psychiatrists. ■ ABSTRACT

Prevalence of body dysmorphic disorder in patients who are candidates and/or are submitted to aesthetic procedures in the specialty of plastic surgery: a systematic review with meta-analysis

INTRODUCTION
Aesthetic procedures have become considerably popular over the last two decades 1 .In 2000, more than 1.3 million aesthetic surgeries were performed in the United States alone, showing an increase of 198% in relation to that in 1992 2 .In 2013, 1,452,356 aesthetic surgeries were performed in the United States, placing Brazil, where 1,491,721 surgeries were performed, in first place in the ranking of this type of procedure 3 .
Owing to the increased demand for aesthetic plastic surgery procedures, there is an increased interest in aspects related to this specialty and its patients.As an example, we can cite studies that seek to characterize the psychiatric disorders that these patients experience [4][5][6][7][8] , i.e., body dysmorphic disorder (BDD).
In general, individuals who feel that their physical characteristics do not conform to ideal standards of beauty have an increased risk of body dissatisfaction 9 ; however, this dissatisfaction is extremely high in patients with BDD 10 .

OBJECTIVE
Considering that the relationship between BDD and the specialty of plastic surgery is still poorly understood and researched, this study aimed at verifying the prevalence of BDD in patients who are candidates and/or are submitted to aesthetic procedures in plastic surgery via a systematic review of the literature and a meta-analysis.

Search Strategy
To comply with the proposed objective, we analyzed the most relevant studies published originally in any language until January 2016 (when the search was performed), which were indexed to the United States National Library of Medicine (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), and SciELO databases, where the searches were performed.
Aiming at selecting quality scientific evidence studies, we sought publications related to meta-analyses and randomized controlled clinical trials (RCTs).The period of public publication was not initially established owing to the lack of knowledge on the number of publications on the subject available in the scientific literature.
Inclusion and exclusion criteria are applied as shown in Chart 1.

RESULTS
Although we initially searched for RCTs or metaanalyses, no meta-analyses on the subject were found in the databases during the search.Therefore, only RCTs were analyzed in this study.
In addition, it is important to state that no study published in Brazil was found on the topic during the searches.However, although published in an international journal, it was possible to verify the performance of a national survey 10 , which is a part of the sample used in this meta-analysis.
In total, 17 publications were found that would initially be used as the basis for the data collection of this study; however, two had to be eliminated after further analysis of their methodologies owing to noncompliance with the adopted inclusion criteria.The first study that was eliminated was that of Javo and Sorlie 17 ; despite investigating the prevalence of BDD in patients who were candidates for aesthetic procedures, they did so by sending questionnaires by e-mail to the patients, which invalidated the diagnostic method used by the authors for this study.The second excluded study was that of Metcalfe et al. 18  To investigate the presence of psychiatric symptoms and to evaluate perceptual, cognitive, and behavioral aspects related to body image in plastic surgery patients.
Vindigni et al. 21002 The importance of recognizing body dysmorphic disorder in cosmetic surgery patients: do our patients need a preoperative psychiatric evaluation?

English
To assist in the recognition of BDD in patients who are candidates for aesthetic procedures, besides analyzing the psychopathological comorbidities of these patients.
Aouizerate et al. 22 2003 Body dysmorphic disorder in a sample of cosmetic surgery applicants English To prepare the first European report on the prevalence and clinical and functional characteristics of patients with BDD in the field of plastic surgery.

English
To stipulate the prevalence of BDD among patients seeking cosmetic procedures.

English
To investigate the relationship between personality disorders and dysmorphic symptoms in patients who are candidates for plastic surgery.

Dutch
To determine, comparatively, the prevalence of BDD in a university medical center in the specialties of dermatology and plastic surgery.
Hayashi et al. 5 2007 Importance of a psychiatric approach in Cosmetic Surgery English To evaluate the importance of a psychiatric approach in plastic surgery patients.It should be noted that of those studies that made comparisons between the prevalence of BDD in patients of plastic surgery and dermatology or other specialties, only the data related to the patients who were candidates and/or were submitted to procedures of plastic surgery were collected to comply with the objective proposed in this research.
To identify the prevalence of BDD, the data regarding the number of patients included in the samples and the number of patients diagnosed with BDD were collected.In addition, we sought data regarding sex and age group, as well as the number of aesthetic procedures that the patients affected by BDD in the field of plastic surgery underwent to draw their profiles accordingly.
However, it can be reported that the data collected from the study by Felix et al. 10 refer to those presented in the methodology used by the authors, considering that at a certain point, they excluded patients with severe BDD, who were included in the analysis performed in this study.
Table 1 shows the data obtained in the publications included in this meta-analysis.
As previously mentioned, this study aimed at verifying the prevalence and establishing a profile of patients with BDD in the field of plastic surgery; however, it was not possible to estimate the number of aesthetic procedures to which the patients were submitted owing to the fact that the publications did not provide these data.In addition, two studies 5,25 did not present the standard deviation despite presenting the mean age of the patients with BDD, which led to the elimination of their data in the quantification of the patients' age group (as shown in Table 1).
Based on the meta-analysis performed in the 15 publications that met the inclusion and exclusion criteria established in this study, it was verified that 12.5% of the patients who were candidates and/or submitted to aesthetic procedures in the specialty of plastic surgery had BDD.Of these, the majority were women (75.7%) with a mean age of 30 (± 10.5) years.

DISCUSSION
After conducting a systematic review of the literature, it was possible to observe the lack of research conducted worldwide on the involvement of BDD in patients who were candidates for/submitted to aesthetic procedures in the specialty of plastic surgery.More specifically, it should be noted that there is no national publication on the subject, and there is only one study in Brazil that measured the prevalence of BDD in these patients 10 .
In the literature, a study verified the prevalence of BDD in patients who were candidates and/or were submitted to aesthetic procedures, comparing those associated with the specialty of plastic surgery with those who sought the specialty of dermatology; such a study reported that the prevalence of BDD is higher in dermatology patients (8.5%) than in plastic surgery patients (3.16%) 24 .However, the percentage of 3.16% found by the authors is considerably lower than the 12.5% found in this study when the meta-analysis was composed of 15 studies.It is possible to state that the prevalence of 12.5% of the patients affected by BDD who were submitted to aesthetic procedures in plastic surgery can be considered quite high when compared with the findings of studies that analyzed the prevalence in the general population (between 0.7% and 2.4%) [13][14][15][16] .Even when analyzing the data of the 15 publications that were used in this metaanalysis separately, none presented a percentage within the margin found for the general population.The study that found the lowest percentage of BDD in the plastic surgery patients was that of Vulink et al. 24 , with a value of 3.16%, while the highest percentage was reported in the study by Vindigni et al. 21(53.57%).
It is very important for professionals to be aware of the possibility that plastic surgery patients may have BDD, not only owing to the high prevalence found in this study and the comparison of this rate with that of the general population, but also because of the findings of Biraben-Gotzamanis et al. 8 , which showed that six of the seven patients with BDD who underwent aesthetic plastic surgery continued to present the disorder, even 5 years after the procedure.Although the patients reported satisfaction with the results of the surgeries, their performance was not effective in reducing the symptoms of BDD, thus requiring psychological and psychiatric treatment.
Therefore, it is believed that the correct diagnosis and treatment of BDD can improve patients' selfesteem and quality of life more effectively than aesthetic procedures of plastic surgery that were not efficient based on the survey findings by Biraben-Gotzamanis et al. 8 .A multidisciplinary follow-up of patients who are candidates for aesthetic procedures of plastic surgery is necessary to assist them better and obtain excellent results both for the patients and professionals involved.
In addition, we emphasize that further research studies with different methodologies are required to explain better the prevalence of BDD in plastic surgery patients, mainly in Brazil, where the subject is still poorly studied.

CONCLUSION
Based on the meta-analysis, it was concluded that 12.5% of the patients who were candidates and/or submitted to exclusively aesthetic procedures of plastic surgery had BDD, with a dominance of women with a mean age of 30 years.
Considering the high number of patients with BDD attended to in the specialty, it is important that plastic surgeons focus on providing patients with adequate care to identify individuals who potentially have BDD and consequently conduct an interdisciplinary follow-up with the participation of psychologists and psychiatrists.

COLLABORATIONS
RVER Analysis and/or interpretation of data; final approval of the manuscript; conception and design of the study; completion of surgeries and/or experiments; writing the manuscript or critical review of its contents.

GBS
Final approval of the manuscript; writing the manuscript or critical review of its contents.

FVA
Final approval of the manuscript.

Chart 1 .
Inclusion and exclusion criteria and main results.explained/incomprehensible methodology • Diagnosis performed in a non-standardized/recommended way Patients • Candidates of/submitted to functional surgery • Not related to the specialization of plastic surgery Type of Publication • Only abstract Main results • Prevalence of BDD in patients from the specialty of plastic surgery RCT: Randomized controlled clinical trial; BDD: Body dysmorphic disorder.
, which analyzed 188 patients (32 of whom had BDD [17.02%]), but only analyzed women who underwent breast reconstruction after mastectomy due to breast cancer; the objective of this research was related to purely aesthetic procedures.Thus, the final sample of this study was composed of 15 publications (Chart 2).Publications included in the meta-analysis.

Table 1 .
Data obtained in the publications used in this meta-analysis.
* Data removed from the meta-analysis.BDD: Body dysmorphic disorder.