Dear Editor,

We read with interest a recent letter by Morselli and collaborators entitled “Body dysmorphic disorder: There is an ‘ideal’ strategy?” [1] on surveys for the psychological evaluation of patient expectations and satisfaction in cosmetic surgery [1, 2] that may provide complementary information to that obtained from instruments with well-validated psychometric properties, such as the Body Dysmorphic Symptoms Scale (BDSS) [3] and Yale–Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS) [4].

Body dysmorphic disorder (BDD) has been considered the most relevant neuropsychiatric condition to appearance-enhancing medical treatments in a sociocultural context that values physical attractiveness. Plastic surgeons and patients with BDD may perceive beauty in different ways. Surgeons have realistic expectations of the surgical results based on experience and training, whereas BDD patients have ideal expectations. These patients seek normality and to meet a beauty standard but with unrealistic expectations, believing that the plastic surgeon has an ethical obligation to fulfill their goals and not understanding treatment limitations.

It is therefore fundamental to detect BDD symptoms during screening and risk assessment of cosmetic surgery. About 80% of surgeons identify BDD only after surgery [5] because many BDD patients are functional and have an appropriate discourse adapted to the reality they seek to modify. The chronicity of BDD is associated with fluctuations in symptom intensity and body parts of concern. The symptoms are exacerbated by the condition itself and not by the surgical procedure. Concerns about different parts of the body may be aggravated if they already existed prior to the cosmetic procedure. There are often the main concern and a secondary concern with physical appearance. This very subtle detail may be one of the most important parameters to be detected by the plastic surgeon during patient assessment, as it may interfere with overall patient satisfaction following treatment. In the age of selfies and postings on the Internet, the demand for body perfection combined with body image distortions brings new complicating factors, affecting the dynamics of the doctor–patient relationship. Patients’ ideal expectations that “erase” defects and imperfections, and obsession with the treatment results often exceed what plastic surgeons expect to be achieved in reality by cosmetic surgery, signaling the presence of BDD.

BDD reveals itself as a stigma when compared to other mental disorders. It has been trivialized by being confused with vanity and futility, or underestimated and mistaken for other mental disorders by mental health professionals. Most patients feel shame and prefer not to talk about their symptoms. Thus, a good doctor–patient relationship is essential for detecting this psychopathology in plastic surgery.

The presence of mild-to-moderate BDD is not an exclusion criterion for aesthetics or cosmetic surgery [6, 7], but the treatment requires specific planning and a multidisciplinary approach. Recent studies have presented preliminary evidence for the effectiveness of cosmetic procedures in reducing BDD symptoms and providing patient satisfaction with treatment results [7, 8], with plastic surgery being indicated as a possible adjuvant treatment for this population [7,8,9,10]. The high prevalence of BDD among cosmetic surgery [3, 11] and dermatology [12] patients indicates that these individuals have to be properly identified, treated, and monitored and that prospective studies are necessary to evaluate the efficacy of cosmetic treatments for BDD [10].

The systematic administration of validated instruments in the pre- and postoperative periods of cosmetic surgical procedures to assess the patients’ level of psychological distress related to their physical appearance and satisfaction with treatment results will provide relevant information in the medium and long term for the development of more sensitive validated instruments for detection of severe levels of BDD symptoms to help plastic surgeons in the selection of patients in a more effective and practical manner [3].