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Page 10 of 14 Zhang et al. Plast Aesthet Res 2024;11:23 https://dx.doi.org/10.20517/2347-9264.2023.111

tool to create a launching point of discussion for patients who might not otherwise know how to articulate
their concerns. Additionally, there are many other PROMs that assess both aesthetic and functional
outcomes for rhinoplasty that are beyond the scope of this review, including the Functional Rhinoplasty
Outcome Inventory 17, Nasal Obstruction Symptom Evaluation (NOSE), and Standardized Cosmesis and
Health Nasal Outcomes Survey (SCHNOS) [48,49] , each of which measures different dimensions of rhinoplasty
[50]
satisfaction . Additionally, numerical data from such ratings have enabled standardized measures of
success based on patient satisfaction amenable to systematic review and meta-analysis [51,52] .

DISCUSSION AND CONCLUSION
The concept of the “decision for surgery” involves the decision by the patient to undergo the procedure and
the decision by the surgeon that they are willing to perform an operation. The surgeon should carefully
consider the technical, psychological and any other relevant factors as they weigh the decision. If there are
factors that limit the chances of success, those should be discussed with the patient in a forthright manner.
For example, a patient with multiple prior rhinoplasties may have surgical limitations due to scar tissue,
vascular supply, complexity of the deformity, or other technical factors. Additionally, if the surgeon believes
that improvement is possible but that the amount of improvement is likely to be far less than the patient
seems to be expecting, the surgeon should tell the patient directly. In these circumstances, it is sometimes
wise to ask the patient’s permission to discuss their case with colleagues to seek other opinions, as colleagues
may have different experiences and perspectives. The patient will generally appreciate the surgeon who goes
the extra mile in this circumstance.

Similarly, if the patient expresses dissatisfaction greater than the objective findings, this should be discussed
in a kind but forthright manner. A conversation in which the surgeon expresses to the patient the factors
that might limit the chance for success can lead to an agreement about reasonable expectations, or it might
lead to a decision against surgery. In this context, both are reasonable and acceptable outcomes. Whether it
is due to anatomic, technical, psychological or other causes, a dissatisfied patient by definition represents a
more complex situation that requires additional care, time, and attention. As has been pointed out in this
article, a strong doctor-patient relationship creates the best opportunity to provide these patients with the
care they need. The goal of the interaction with any patient is for them to be as happy as possible. For this to
occur, when the persistently dissatisfied patient presents for evaluation, it is advised that the surgeon take
extra time to listen carefully as the patient expresses their concerns or frustrations. The surgeon can then
examine the patient’s nose for any structural, anatomic findings that could be addressed to mitigate and
improve the areas of aesthetic concern and can then provide the patient with options to address their chief
complaints.

Especially due to the prevalence of patients with BDD, we believe the above principles undoubtedly still
apply. However, while associated with a greater risk of dissatisfaction, this diagnosis can be difficult to
make. We believe that awareness of the condition, as well as knowledge of potential symptoms and
common patterns or concerns brought on by the affected individual, can be powerful in the surgeon’s
armamentarium of tools. In cases where severe BDD might be identified, we recommend that psychiatric
consultation be offered in the least judgmental way possible. An in-office screening questionnaire adapted
from the Yale-Brown Obsessive-Compulsive Scale can be offered within routine pre-appointment
[28]
paperwork . For those patients who have an objective issue with their nose (e.g., dorsal hump) and a
diagnosis of BDD, we emphasize the importance of being ever-vigilant and thorough during preoperative
counseling, perhaps scheduling more than one visit prior to proceeding with surgery, taking into account
that if the deformity can reasonably be corrected under the surgeon’s expertise, there is still the presence of
a strong risk factor for dissatisfaction.