Persistent cosmetic dissatisfaction in rhinoplasty & management of the difficult patient

Abstract

The rhinoplasty surgeon will undoubtedly encounter a cosmetic patient who is persistently dissatisfied with their results, no matter the objective outcome achieved. This article seeks to describe risk factors for postoperative dissatisfaction and highlight effective management strategies for the “difficult patient.” A literature search was performed using PubMed and Embase databases during September and October of 2023 to identify articles that analyzed factors related to dissatisfaction in rhinoplasty. Forty unique references were identified. The majority of structural aesthetic complaints related to dissatisfaction after rhinoplasty were residual dorsal hump (20%) or persistent tip dissatisfaction (19%-37%). Demographic factors including younger age, male sex, self-referral, history of body dysmorphic disorder or abuse/neglect were risk factors for postoperative dissatisfaction. Ineffective patient-provider communication, litigation due to inadequate informed consent, and surgeon inattentiveness were contributing factors to postoperative dissatisfaction. Revision rhinoplasty rates ranged from 5%-15%, where most patients sought revision surgery due to the development of a new deformity or failure to correct the original deformity, with the greatest complaints at the nasal bridge and nasal tip. Validated patient-reported outcome measures including Rhinoplasty Outcome Evaluation (ROE) and FACE-Q can be effective questionnaires to assess satisfaction. Appropriate patient selection, adequate preoperative counseling and consent, effective communication, and reaching a consensus about surgical goals are all effective strategies in the management of a dissatisfied patient.