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Page 8 of 14 Zhang et al. Plast Aesthet Res 2024;11:23 https://dx.doi.org/10.20517/2347-9264.2023.111

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which the surgeon declined to perform a revision, and what advice was given to patients as a result .
Multiple reasons for rejection were present in 76% of cases, and the majority of reasons were patient-related
factors including unrealistic expectations (37.6%), unreliable for pre-, peri- or postoperative care (24.2%),
dissatisfaction with 2D/3D morphed imaging (19.4%), financial reasons (18.3%), unhealthy motivations
including poor self-esteem or body shame (14.5%), and comorbid psychiatric conditions including
depression or anxiety (14%) with severe BDD identified in 11.3% of cases. Additionally, 30.6% of patients
were turned away due to limited or no options for surgical improvement of cosmesis or function, and 18.3%
had what the surgeon deemed to be a minimal deformity with too much surgical risk. If patients were
declined a revision rhinoplasty at that visit, 41.1% of patients were advised to follow-up at the outpatient
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clinic after some time passed, and 32.8% were referred to a colleague for a second opinion .

ARE THERE WAYS WE CAN OBJECTIVELY MEASURE SATISFACTION?
Of the studies identified, 10 used previously validated patient-reported outcome and quality of life
questionnaires to measure satisfaction more objectively after rhinoplasty, including rhinoplasty outcome
evaluation (ROE) (n = 5 studies) and FACE-Q (n = 5 studies).

Alsarraf et al. first developed the Rhinoplasty Outcome Evaluation (ROE), a brief and easy-to-complete
questionnaire, which asks six questions covering three quality of life domains: physical, mental/emotional,
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and social . Responses are scored 0 (least satisfaction) to 4 (maximum satisfaction) and include items such
as “How well do you like the appearance of your nose?” and “Would you like to surgically alter the
appearance or function of your nose?” [Table 3]. The ROE has since been shown to have high validity and
reliability [24,43] . Scored out of 100 points, Arima et al. reported a mean increase in patient satisfaction of
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50.2 . In five studies, Arima et al., Khan et al., Haddady et al., AlHarethy et al., and Hellings & Trenite
used ROE as a tool to measure satisfaction in their patients postoperatively by comparing mean differences
between pre- and post-op scores, and all found it easy to use and effective for assessing rhinoplasty
outcomes, with average improvements ranging from 30 to 50 points [9,17,19,24,25] .

The FACE-Q rhinoplasty scale was developed by Klassen et al. . The first part of the questionnaire,
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“Satisfaction with Nose”, consists of 10 questions regarding the patient’s satisfaction with the size, shape,
and overall nasal appearance. Patients rate their level of satisfaction on a scale of 1 to 4 (1 = very dissatisfied,
4 = very satisfied). The second part, “Adverse Effects”, asks patients to rate the extent of how much they
were bothered by postoperative problems such as thickness or swollen appearance of skin or tenderness
over the nose on a scale of 1 to 4 (1 = not at all, 4 = extremely) [Table 4]. Five studies by Schwitzer et al,
East et al., Maassarani et al., Citron et al., and Wang et al. used FACE-Q to assess factors related to patient
dissatisfaction [15,16,23,45,46] .

During a consultation, rhinoplasty surgeons have the opportunity to evaluate a patient’s goals and
motivations and assess the likelihood of a successful outcome. While the surgeon makes a subjective
assessment during the course of the consultation, the outcome questionnaires described here warrant
consideration as part of the surgeon’s armamentarium. Additionally, a novel preoperative assessment
classification system for evaluating case complexity proposed by Jiang et al. could also potentially assist in
decision making in revision rhinoplasty. Implementation of such a system could assist providers in
screening patients in a systematic way. Jiang et al. suggest that such a system could also inform pricing and
even support a conversation with a patient if the surgeon decides that this person is not a surgical candidate
in their hands .
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