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Page 4 of 14 Zhang et al. Plast Aesthet Res 2024;11:23 https://dx.doi.org/10.20517/2347-9264.2023.111

Table 1. Structural aesthetic factors associated with patient dissatisfaction
Structural aesthetic factors associated with increased patient dissatisfaction Structural reasons for pursuing revision
after rhinoplasty rhinoplasty
Residual dorsal hump Elevated nasal bridge
Insufficient size reduction Crooked nose
Persistently bulbous tip Tip asymmetry
Tip irregularity Broad nasal base; wide or large nostrils
Scarring Dropped nasal tip

ANALYSIS OF DEMOGRAPHIC VARIABLES COMPARED TO RATES OF
DISSATISFACTION
Several demographic characteristics have been explored to identify risk factors for dissatisfaction after
rhinoplasty. In general, younger patients complain more about aesthetics, while older patients complain
more about nasal function or obstruction [14,19] . A retrospective review of 117 patients by Ghorbani et al.
found that adults aged 25-34 most frequently reported dissatisfaction with the general shape of their nose
[14]
whereas those older than 35 reported dissatisfaction mainly due to breathing problems [Table 2].
Similarly, Arima et al. administered the ROE questionnaire to 61 patients and they found that patients < 30
years had significantly lower satisfaction ratings of their appearance compared to patients in the 30-50 year
old group .
[19]

Male gender is frequently labeled as a risk factor for dissatisfaction after cosmetic surgery [2,13,20,21] .
Consequently, the SIMON (single, immature, male, obsessive, and narcissistic) characteristics have been
correlated with higher revision rates [6,22] and some have suggested that cosmetic operations should be
[22]
avoided in patients who have these risk factors [Table 2]. A survey-based study involving 468 patients
asked them to rate their appearance and whether they felt surgery was worthwhile . They found that males
[21]
were three times more dissatisfied than females (12.8% vs. 4.6% dissatisfaction). Dissatisfied males were
younger (mean age 29.4) compared to dissatisfied females (age 43.3 years) . Additionally, when analyzing
[21]
whether gender influenced the appreciation of aesthetic improvements after surgery, they found that a
[21]
larger number of males failed to appreciate such improvements compared to females . Other studies have
also reported greater dissatisfaction ratings by male patients based on FACE-Q outcomes ; however, these
[23]
trends were not reproduced in other cohorts who found no difference in satisfaction between males and
females [19,24,25] .

Other demographic factors have also been explored. McKinney et al. performed a retrospective review of
200 patients undergoing rhinoplasty, and found that patients who were self-referred were more than twice
[26]
as likely to be dissatisfied compared to those referred by a physician . Ghorbani et al. additionally stratified
patients by level of education, including high school and university education. A higher level of education
(specifically university education) was associated with greater dissatisfaction with overall nasal shape,
whereas patients who had up to a high school education or less had the highest rate of dissatisfaction with
respect to breathing [Table 2].
[14]

PATIENT PSYCHOSOCIAL & PSYCHIATRIC FACTORS
Several elements of the patient’s psychosocial and psychiatric profiles have been shown to affect both
[13]
motivation for seeking rhinoplasty as well as postoperative satisfaction . Many patients simply have
unrealistic or unachievable expectations, which may reflect a lack of understanding or even self-deception in
some cases. Minor red flags can include if the patient cannot understand that the goal is improvement, not
perfection, and that a specific result cannot be guaranteed. A patient might be unrealistic, such as expecting
"no scar" or requesting changes that would result in an altered appearance contrary to the patient's race or