How the evidence was selected: Criteria for PubMed meta-analyses

A targeted PubMed search was conducted to identify meta-analyses and systematic reviews with meta-analysis on the relationship between body dysmorphic disorder, cosmetic surgery, plastic surgery, aesthetic dermatology and rhinoplasty. Only PubMed-indexed studies with meta-analysis methodology or systematic review with quantitative analysis were included, provided they were relevant to BDD prevalence in aesthetic patients or to its relevance in preoperative selection. The most recent available period was considered, prioritizing studies published between 2022 and 2025.

The final set includes five PubMed-indexed studies: a 2025 meta-analysis of overall and patient prevalence of plastic surgery, a 2025 meta-analysis on Asian rhinoplasty candidates, a 2024 meta-analysis on BDD in aesthetic and reconstructive plastic surgery, a 2023 meta-analysis on rhinoplasty candidates and a 2022 meta-analysis on individuals requesting cosmetic surgery.

Prevalence of body dysmorphic disorder in aesthetic patients

Meta-analyses consistently show that body dysmorphic disorder is more frequent in patients seeking cosmetic surgery than in the general population.

– A 2025 meta-analysis estimated an overall BDD prevalence of 17% in the general population studied.

– In the same analysis, prevalence rose to 24% in plastic surgery patients, making this context particularly relevant for preoperative screening.

– A 2022 meta-analysis included 48 articles and 14,913 individuals requesting cosmetic surgery.

– In this population, the estimated prevalence of BDD was 19.2%, with a 95% CI of 15.8–23%.

– The studies conclude that prevalence is high and that preoperative screening for body image disorders should be part of the assessment pathway.

In patients requesting aesthetic procedures, BDD screening should be considered an integral part of preoperative selection.

Cosmetic surgery and psychological risk: Why BDD changes preoperative assessment

BDD is not simply intense aesthetic dissatisfaction, but a psychiatric condition characterized by persistent concern about perceived defects in physical appearance, often disproportionate to the clinically observable defect.

– In the context of cosmetic surgery, BDD can directly influence expectations, satisfaction and postoperative behavior.

– The patient may request repeated corrections, focus on minimal details or remain dissatisfied even after a technically correct procedure.

– A 2024 meta-analysis included 65 studies and 17,107 patients, estimating an overall BDD prevalence of 18.6% in aesthetic and reconstructive plastic surgery settings.

– The evidence highlights the importance of proactive screening and a multidisciplinary approach when signs compatible with BDD are present.

– Preoperative assessment should therefore not be limited to anatomy or technical feasibility of the procedure, but should include expectations, motivation, degree of distress, realism of the goal and the possible presence of dysmorphic symptoms.

Clinical implication: A patient may be technically operable, but not necessarily a good candidate for cosmetic surgery if psychological distress and expectations are unrealistic.

Aesthetic rhinoplasty: A high-risk population for BDD

Rhinoplasty is one of the most relevant procedures in the relationship between cosmetic surgery and BDD, because the nose has a strong impact on facial perception. A 2023 meta-analysis analyzed 18 studies and 2,132 rhinoplasty candidates, estimating a pooled BDD prevalence of 32.7%, with a 95% CI of 23.6–41.7. This finding makes preoperative screening particularly important in patients seeking aesthetic rhinoplasty.

A 2025 meta-analysis on Asian rhinoplasty candidates confirmed that BDD can influence satisfaction and postoperative outcomes, with possible variations related to cultural context, type of procedure and diagnostic tools used. In rhinoplasty candidates, assessing BDD before surgery may reduce the risk of unnecessary procedures, unrealistic expectations and postoperative dissatisfaction.

Preoperative screening: The main risk-reduction tool

The most consistent message from the meta-analyses is clear: BDD screening before cosmetic surgery is a clinical safety measure, not an accessory detail.

Screening should help identify:

– excessive concern about minimal or non-obvious defects;

– unrealistic expectations about the procedure;

– requests for multiple or repeated corrections;

– psychological distress disproportionate to the anatomical defect;

– strong emotional dependence on the aesthetic outcome;

– difficulty accepting technical limits or realistic results.

This does not mean that every patient with aesthetic dissatisfaction has BDD. It does mean, however, that when clinical suspicion is present, cosmetic surgery should be postponed or reconsidered until an appropriate psychological or psychiatric assessment has been performed.

BDD and postoperative satisfaction: Risk of a result perceived as insufficient

One of the most important implications concerns postoperative satisfaction. In patients with BDD, the problem is not always the technical quality of the result, but the way the result is perceived. Even when the surgical correction is objectively adequate, the patient may continue to focus on details, minimal asymmetries or new body areas. This makes BDD a risk factor for dissatisfaction, requests for revision and difficulties in the doctor-patient relationship. The meta-analysis by Kaleeny and Janis emphasizes that patients with BDD may experience dissatisfaction regardless of the technical quality of the procedure and may request unnecessary procedures that do not resolve the underlying psychological distress.

Implications for informed consent and patient selection

In the context of cosmetic surgery, informed consent should include not only surgical risks, recovery times and technical limits, but also the possibility that the result may not satisfy unrealistic expectations. Meta-analytic evidence supports a more rigorous approach to patient selection. When BDD is suspected, the surgeon should avoid rapid decisions based only on the aesthetic request and consider specialist assessment before proceeding. From a practical standpoint, appropriate patient selection becomes a measure for preventing clinical, psychological and medicolegal risk.

Populations and procedures requiring greater clinical attention

From the five meta-analyses considered, several contexts emerge in which BDD assessment is particularly important:

– patients requesting cosmetic surgery in general;

– patients in aesthetic and reconstructive plastic surgery;

– rhinoplasty candidates;

– patients requesting repeated procedures;

– patients with rigid expectations or expectations that are difficult to realign;

– patients who describe minimal defects as highly disabling.

Rhinoplasty deserves particular attention because the available meta-analyses report a high prevalence of BDD among candidates, higher than that observed in many other aesthetic populations.

Clinical risk-reduction strategies

The evidence supports several practical strategies to reduce the risk associated with BDD and cosmetic surgery:

– use validated preoperative screening tools when available;

– assess expectations, motivations and degree of distress;

– distinguish a correctable anatomical defect from disproportionate concern;

– avoid absolute aesthetic promises;

– document limits, alternatives and possible outcomes;

– involve mental health specialists when suspicion of BDD is significant;

– postpone or avoid indicating surgery when the request appears driven by unrealistic expectations.

These strategies are not intended to automatically “exclude” patients, but to protect both the patient and the surgeon from procedures that may not address the real problem.

Main findings: What the PubMed meta-analyses show

The selected PubMed meta-analyses indicate that:

– BDD is more frequent in aesthetic patients than in the general population.

– In plastic surgery patients, the estimated prevalence may reach approximately one quarter of cases.

– In candidates for cosmetic surgery, the pooled prevalence is around 19%.

– In rhinoplasty candidates, the pooled prevalence may be even higher.

– The presence of BDD may increase the risk of postoperative dissatisfaction and requests for unnecessary procedures.

– Preoperative screening should be considered a central clinical safety measure in cosmetic surgery.

Clinical implications: What this means for aesthetic practice

– The relationship between body dysmorphic disorder and cosmetic surgery requires a broader assessment than anatomical or technical indication alone.

– A patient may be technically operable, but not psychologically ready or not truly suitable for the procedure at that time.

– Cosmetic surgery is safer when the indication is based on a correctable defect, realistic expectations, complete informed consent and adequate psychological stability.

– When distress is disproportionate, rigid or not modifiable through clinical dialogue, the risk of dissatisfaction remains high even after a technically correct procedure.

– Preoperative assessment should therefore include motivation, expectations, degree of perceived distress and possible signs compatible with BDD.

– When BDD is suspected, it may be appropriate to postpone the procedure and consider specialist mental health assessment.