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Zhang et al. Plast Aesthet Res 2024;11:23 https://dx.doi.org/10.20517/2347-9264.2023.111 Page 3 of 14

studies were excluded.

Articles were included if they analyzed patient and/or surgical outcome factors related to dissatisfaction in
rhinoplasty, discussed objective measures of satisfaction in rhinoplasty, or described general strategies for
managing the dissatisfied patient after rhinoplasty. The reference lists of included articles were reviewed to
identify additional articles for inclusion. Articles were excluded if they focused on primarily functional
rhinoplasty, non-surgical rhinoplasty, rhinoplasty in cleft lip or palate patients, or did not examine factors
or management as pertains to the cosmetically dissatisfied patient. The evidence was organized into themes
that emerged during the review.

A total of 40 unique references were identified for inclusion in this review. Several factors that may affect
patient satisfaction following cosmetic rhinoplasty were identified, with the following themes emerging
from the literature: anatomic and structural concerns, demographic factors, history of psychopathology
(e.g., body dysmorphic disorder), and psychosocial factors, personality traits, and satisfaction with
healthcare.

STRUCTURAL AESTHETIC COMPLAINTS
The most obvious explanation for patient dissatisfaction after rhinoplasty is the case where objective
cosmetic irregularity or deformity exists. In a retrospective review of 369 patients who underwent cosmetic
rhinoplasty, Neaman et al. found that the most common reasons for dissatisfaction were residual dorsal
hump (20% of patients) and persistent tip fullness or wideness (17% of patients) . They saw that revision
[6]
rates were closely related to preoperative findings of tip fullness, asymmetry, and increased width.
Consequently, they found that persistent tip deformities were significantly associated with dissatisfaction
[6]
and correlated with obtaining a revision rhinoplasty in their cohort .
Other cohort studies have demonstrated similar common aesthetic complaints. Ghorbani et al. reported
data on 117 patients, where the most common aesthetic complaints included gross nasal deviation (17.9%),
dissatisfaction with overall nasal shape (34.2%), nostril asymmetry (29%), nasal tip irregularity (23.9%), and
skin deformity due to scarring (23%) . Citron et al. administered the FACE-Q rhinoplasty satisfaction
[14]
questionnaire to 165 patients, and found that the nasal tip had the lowest postoperative satisfaction rates,
with 19% of patients reporting dissatisfaction with the tip , similar to findings by Wang et al. with 707
[15]
patients assessed using FACE-Q . Haddady et al. administered the rhinoplasty outcome evaluation (ROE)
[16]
questionnaire to 60 patients and found that “bulbous tip” and “nose too wide” were the most common
[17]
factors related to dissatisfaction (25%, 25%) . Similarly, De Souza et al. analyzed 19 patients with low
satisfaction scores (ROE ≤ 50) and found that a history of previous rhinoplasty and a “crooked nose” had a
significant risk of presenting with a lower postoperative ROE score . These findings were corroborated by
[18]
Khansa et al., who analyzed over 2,000 real-patient reviews for common complaints after rhinoplasty on a
website called Realself.com . Realself.com is a free website with thousands of patient reviews of their
[10]
cosmetic procedures, including approximately 18,000 ratings listed under rhinoplasty. Overall, 89% of
patients rated undergoing rhinoplasty as “worth it”. Based on these reviews, overall shape was cited as a
common reason for dissatisfaction after rhinoplasty (“too large”, “too small”, “too wide”, or “too deviated”).
Once again, the most common complaints were residual dorsal hump (69% females, 46% males), excessive
scarring (34.9% females, 17.8% males), and tip dissatisfaction (too bulbous [46%, 21%], too pinched [37.7%,
[10]
20.2%], too under-rotated [56.4%, 29.5%]) [Table 1]. Finally, among dissatisfied patients, significantly
more females than males complained that they now looked like a different person . This study also
[10]
revealed that male patients’ reviews were less likely to articulate specifically which deformities bothered
them .
[10]