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Zhang et al. Plast Aesthet Res 2024;11:23 https://dx.doi.org/10.20517/2347-9264.2023.111 Page 5 of 14

Table 2. Demographic factors associated with increased patient dissatisfaction after rhinoplasty

Younger age

Male sex

Self-referral

Higher levels of education

SIMON characteristics (single, immature, male, obsessive, narcissistic)

sex . Additionally, some patients might believe that undergoing rhinoplasty can alter their external life
[13]
circumstances. One study reported that patients who believe that rhinoplasty will solve problems related to
their social, domestic, or occupational life are more likely to be dissatisfied . However, in a study analyzing
[13]
Realself.com reviews, they found no significant difference in the proportion of patients who were
dissatisfied because they expected their life circumstances (i.e., their professional or romantic situation) to
improve after rhinoplasty (29.5% vs. 23.3%) .
[10]

Patients with psychopathology ranging from personality disorders, including narcissistic personality
disorder (NPD), to posttraumatic stress conditions, to obsessive-compulsive type disorders, such as body
dysmorphic disorder (BDD), have been shown to potentially have a lower rate of satisfaction after
surgery [11,27,28] . According to a study by Constantian and Lin, a history of psychological trauma including
abuse or neglect was the most significant factor influencing patient satisfaction and a number of operations,
and the most prominent factor driving surgery in patients with milder deformities . In fact, some authors
[29]
have suggested that potentially causative links exist between trauma (abuse/neglect), body image disorders,
and obsessive plastic surgery . Body dysmorphic disorder may be a model of the disordered adaptation to
[29]
abuse or neglect, a variant of posttraumatic stress disorder.

BDD might present with the preoccupation of an imagined or minor defect in appearance, but one that
results in significant distress and impairment in social and occupational functioning. In the DSM-5, BDD is
classified under “obsessive-compulsive and related disorders”, and has been shown to predict a poor
psychological outcome, produce a high risk of dissatisfaction with the result, and lead to requests for
recurrent surgical interventions . A recent systematic review and meta-analysis of 2,132 patients estimated
[20]
[30]
the prevalence of BDD in patients seeking rhinoplasty to be 32.7% , leading to the suggestion of routine
implementation of screening tools available to assist in preoperative determination of BDD . In a
[31]
prospective study with 166 adults undergoing cosmetic rhinoplasty, the authors assessed the presence of
BDD symptoms using the Yale-Brown Obsessive-Compulsive Scale, and postoperative satisfaction was
evaluated using a visual analog scale to rate their overall nasal shape and by using the Rhinoplasty Outcome
Evaluation (ROE) questionnaire. They found that preoperative body dysmorphic disorder symptom scores
[28]
inversely correlated with postoperative satisfaction at 3 months using both VAS and ROE .

Finally, Neaman et al. found that on an analysis of the number of preoperative visits, patients who required
more frequent preoperative visits reported higher levels of postoperative dissatisfaction compared to those
[6]
who had fewer appointments with the surgeon prior to undergoing surgery . Perhaps patients with anxious
or obsessive-compulsive tendencies are more likely to schedule frequent preoperative visits and are thus
more likely to be fastidious with their postoperative self-assessment or self-image. Taking these things