Prospective Evaluation of an Automated Rule-based Screening Tool for Body Dysmorphic Disorder in Aesthetic Surgery

Body dysmorphic disorder (BDD) is underdiagnosed in aesthetic surgery and poses significant risks for postoperative dissatisfaction and complications. Structured screening tools are required to improve early detection and guide surgical decision-making. This study evaluated the effectiveness of an automated, rule-based screening system incorporating the Body Dysmorphic Disorder Questionnaire (BDDQ) in a large cohort of patients undergoing cosmetic surgery.

This prospective study enrolled 3722 adult patients who underwent elective cosmetic procedures between January 2021 and July 2024 in a solo plastic surgery practice. The patients completed an online dynamic questionnaire, including the BDDQ. A rule-based algorithm integrates BDDQ scores with clinical variables to flag BDD risk. Patients with positive screening results underwent psychological assessments before surgical eligibility was determined. Postoperative outcomes were assessed using a multidimensional satisfaction questionnaire that included a visual analog scale. Inter-rater reliability was calculated for the exclusion and satisfaction ratings.

Among the 3722 patients, 1080 (29.02%) tested positive for BDD. Only 8 BDD-positive patients underwent surgery after psychological evaluation, of whom 75% reported high satisfaction at follow-up (mean: 15.7 mo). Cohen κ indicated strong inter-rater agreement for BDD classification (κ = 0.86), exclusion decisions (κ = 0.81), and satisfaction (κ = 0.79). The prevalence aligns with the upper estimates in aesthetic surgery populations and reflects enhanced detection via structured screening.

Automated rule-based BDD screening improves psychological risk detection and planning in aesthetic surgery. This approach supports early referral and may enhance patient safety and satisfaction. Therefore, multicenter validation is recommended.