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Page 2 of 14 Zhang et al. Plast Aesthet Res 2024;11:23 https://dx.doi.org/10.20517/2347-9264.2023.111

INTRODUCTION
Rhinoplasty is one of the most commonly performed facial cosmetic procedures, and it is generally
[1,2]
considered a technically challenging and intricate operation . A diverse spectrum of patients across ages
and ethnicities pursue rhinoplasty for purely aesthetic concerns, purely functional, or a combination of
[1]
both . From a cosmetic standpoint, patients might seek to correct a crooked nose, a nose with a bump on it,
a nose that is “too large” or “too small,” and various other concerns. The goals of rhinoplasty are commonly
understood to restore or establish normal symmetry, structure, and function to maximize aesthetic balance
[3]
and proportions of the face . Several studies have reported how impactful rhinoplasty can be in improving
one’s self-esteem, self-confidence, and quality of life . No matter the objective outcome achieved, the
[4,5]
rhinoplasty surgeon will undoubtedly encounter a cosmetic patient who is persistently dissatisfied with their
results. Understanding common risk factors for postoperative dissatisfaction, practicing proper patient
selection, and performing effective preoperative counseling are essential. With revision rhinoplasty rates
reported to range from 5%-15% in the literature [3,6-8] , and with a number of those instances related to
non-objective patient concerns, it is imperative to understand the interplay of psychosocial factors,
personality characteristics, chief complaints, proper communication, and motivations for seeking revision
rhinoplasty in the management of “difficult patients.”

[9]
Patient satisfaction is critical for a rhinoplasty to be considered successful . Patient satisfaction ratings after
rhinoplasty are relatively low compared to other cosmetic surgeries, reported to be 72%-89% [3,10,11] . Multiple
studies comparing surgeon and patient ratings of rhinoplasty results show that their determinations of a
good aesthetic outcome are not always the same , indicating that perhaps there are patient factors that
[12]
cause them to “see” themselves differently, recalling the old adage that beauty may truly be “in the eye of the
beholder”. What concerns are present in the beholder’s mind? How do they perceive themselves and these
deformities? What do they hope rhinoplasty can accomplish? With this in mind, during the rhinoplasty
consultation, the surgeon makes an assessment of both the patient’s physical condition and psychological
condition, motivations, hopes, and expectations from the procedure [1,13] .

Complications occur despite the best efforts of experienced surgeons, and a certain percentage of patients
will be dissatisfied. As reflected in the assigned title of this chapter, the persistently dissatisfied patient is
commonly called the “difficult” patient, and it is important to understand what this term means. The simple
goal of aesthetic rhinoplasty is to make a patient happy about their nasal appearance. Some patients are
more easily satisfied for technical reasons, for psychological reasons, or both. Some patients require more
effort, either in or outside of the operating room, and the surgeon commits to doing what they can to try to
help the patient achieve this goal. Nothing works all the time, and from time to time, a surgeon will fall
short of this task. Nevertheless, the surgeon strives to make all of their patients happy to the extent that it is
feasible.

With that in mind, this article reviews the current literature regarding factors related to persistent cosmetic
dissatisfaction after rhinoplasty and approaches to management. Furthermore, an examination of patients’
motivations for pursuing revision surgery may provide insights into the management of this patient
population.

LITERATURE SCREENING
A literature search was performed using Medline (PubMed) and Embase databases during September and
October of 2023. Keywords included “rhinoplasty”, “dissatisfaction”, “complaints”, “perception”, “body
dysmorphic disorder”, “narcissistic personality disorder”, “malpractice or negligence”, and “revision
rhinoplasty”. Results were not limited by geographical region or date of publication. Non-English language