Patient-Reported Dissatisfaction After Lip Lift: Insights From a Thematic Analysis of RealSelf Reviews

Abstract

Lip lift surgery has grown in popularity because of changing aesthetic ideals and social media influence. Despite high reported satisfaction rates, patient dissatisfaction, especially regarding aesthetic outcomes and emotional impact, remains underexplored in the literature. The authors of this study aim to identify common causes of patient dissatisfaction after lip lift surgery and evaluate the psychosocial impact of these experiences using publicly available online reviews. Twenty-five publicly available patient narratives from RealSelf (New York, NY) describing dissatisfaction following lip lift surgery were analyzed in this qualitative descriptive study. No exclusions were made based on geography or demographics. A hybrid thematic analysis was conducted using Braun and Clarke's 6-phase framework, coded with NVivo 15 (Lumivero, Denver, CO). Coding combined inductive (data-driven) and deductive (theory-driven) approaches, referencing the FACE-Q and PHQ-9 validated domains. Emotional distress was scored from 0 to 3 based on language intensity. Among 25 patient reviews following lip lift surgery, most procedures were performed in the United States (n = 21). Scar-related concerns were the most common (n = 15, 60%). Other common sources of dissatisfaction were nasal/alar distortion (n = 6) and lip asymmetry (n = 5). PHQ-9 scoring revealed high emotional impact, with 59.3% in severe and 25.9% in moderate distress. Based on FACE-Q domains, 54.8% experienced appearance-related distress, 35.7% psychological, and 9.5% social distress. Although lip lift surgery is generally well tolerated with favorable outcomes, a notable minority report aesthetic dissatisfaction and psychological distress. Recognizing these concerns aids counseling, whereas future studies should integrate dissatisfaction rates with quantitive assessments of aesthetic improvement.

Level of Evidence: 4 (Therapeutic)

Lip lift surgery has witnessed a marked increase in popularity in recent years, fueled by evolving beauty standards, the influence of social media, and a growing interest in facial aesthetic enhancements.¹ Although generally safe with high satisfaction rates when performed for appropriate candidates, some patients remain dissatisfied, often because of unmet expectations or a limited understanding of risks and outcomes.² Although qualitative studies have examined dissatisfaction in procedures like rhinoplasty and facelift, lip lift surgery remains underexplored in this regard. This lack of literature limits the ability to prepare patients adequately during preoperative counseling.

The authors of this study aim to fill that gap by exploring patient dissatisfaction through thematic analysis. Our primary objective is to identify common concerns following lip lift surgery; our secondary aim is to evaluate the psychosocial impact, such as regret, embarrassment, or lowered self-esteem.

METHODS

Ethics Statement

The publicly available de-identified data from an open online platform were utilized in this study. According to Kuwait University IRB policy, this did not constitute human participant research and was exempt from review.

Study Design and Data Source

The publicly available patient reviews from RealSelf (New York, NY), which is a widely utilized online platform where patients voluntarily post experiences and reviews of cosmetic procedures, were analyzed in this qualitative descriptive study. The aim was to analyze reported dissatisfaction narratives following lip lift surgery through thematic analysis of patient responses.

We included 25 patient narratives that explicitly described dissatisfaction following lip lift. Reviews were selected based on depth of narrative and relevance to the study's objective. The reviews spanned from the website's inception through April 2025.

Data Extraction

From each included narrative, we extracted the following variables: the review ID, date, the country where surgery was performed, the reported cost of the procedure, the patient's immediate postoperative satisfaction, specific concerns or sources of dissatisfaction, the timing and reason for any revision surgery, the emotional impacts described (such as regret, anxiety, or embarrassment), the number of expert opinions sought postoperatively, and any expert or surgeon commentary that was mentioned. These variables were organized using Microsoft Excel, Version 16.0 (Microsoft Corporation, Redmond, WA).

Thematic Analysis

A qualitative thematic analysis was conducted to explore patients' experiences of dissatisfaction following lip lift procedures. Patient narratives were imported into NVivo 15 software (Lumivero, Denver, CO) for coding and analysis. The analysis followed Braun and Clarke's 6-phase framework: familiarization, coding, generating themes, reviewing themes, defining/naming themes, and writing up results. We used a hybrid coding approach—inductive (data-driven) to capture unexpected patterns, and deductive (theory-driven) to structure coding using predefined domains from validated instruments.

Themes and subthemes were then conceptually mapped to established outcome domains using the FACE-Q and PHQ-9 frameworks (see Appendices A–C). A flowchart outlining this process is presented in Figure 1.

Figure 1.

Flowchart summarizing the 6-phase thematic analysis process used to explore patient-reported dissatisfaction after lip lift surgery, following Braun and Clarke's framework and guided by FACE-Q domains and PHQ-9 inspired distress scoring.

Frameworks for Coding: FACE-Q and PHQ-9

To guide interpretation of the themes, we used 2 validated frameworks: FACE-Q and PHQ-9. FACE-Q is a patient-reported outcome measure used in facial aesthetic surgery. In this study, we did not administer the questionnaire or calculate numeric scores. Instead, themes were mapped conceptually to FACE-Q domains—Appearance Distress, Psychological Function, and Social Function. For example, scar complaints were assigned to Appearance Distress; feelings of hopelessness or regret were mapped to Psychological Function; and embarrassment or social avoidance were categorized under Social Function. This helped us organize concerns into meaningful, validated outcome categories.

PHQ-9 is a 9-item questionnaire used to assess depression severity, where each item is scored from 0 to 3, and total scores range from 0 to 27. Because patient narratives were unstructured, we could not calculate formal PHQ-9 scores. Instead, we used its severity scale as a guide to assign a researcher-coded emotional distress score from 0 to 3 for each narrative. This score was based on the intensity of emotional language in the patient's comments (eg, “mildly disappointed” = 1; “destroyed me psychologically” = 3). This was an adapted proxy score—not a formal PHQ-9 result.

Reliability

Two independent coders analyzed all narratives. An audit trail was maintained throughout the coding process, and discrepancies were resolved through joint review. This dual coding ensured consistency and enhanced thematic reliability.

RESULTS

Demographics

In this study, a total of 25 patient reviews of lip lift surgeries performed across various locations were included. The majority of surgeries were performed in the United States (n = 21). Two cases were reported from Turkey. A single case was reported in each of Canada and Poland. Surgery costs were reported in approximately half of the cases, with prices ranging from $2000 to $10,000. The average cost was ∼$5136 USD. None of the included reviews provided sufficient detail regarding the timing of review postings relative to surgery or whether revision procedures were performed.

Outcome Dissatisfaction

Out of 25 patients, 15 (60%) expressed scar-related concerns. Of these, 8 described their scar as simply noticeable or large, and 7 specifically referred to it as hypertrophic. Eleven patients expressed other aesthetic concerns, such as lip asymmetry (n = 5) or lack of noticeable improvement (n = 3). Ten patients encountered structural complications, such as nasal or alar distortion (n = 6). Three patients encountered functional complications such as nasal flaring (n = 2) and difficulty with mouth closure/speech difficulties (n = 1).

Figure 2 demonstrates a mind map showing common patients concerns following lip lift surgery.

Figure 2.

Mind map showing common patients' concerns after lip lift surgery.

Thematic Analysis

After applying PHQ-9 distress scores to patients' comments, the majority were in severe distress (59%) and moderate distress (25.9%) as shown in Figure 3.

Figure 3.

Pie chart showing distribution of Emotional Distress Scores among patients.

When patients’ narratives were categorized according to the FACE-Q domains, more than half (54.8%) had appearance-related distress, whereas 35.7% had psychological function deficits, and 9.5% had social function deficits, as seen in Figure 4. Table 1 demonstrates the PHQ-9 emotional distress scores and FACE-Q domains among patients’ narratives.

Figure 4.

Pie chart showing distribution of FACE-Q domains among patient narratives.

Table 1.

PHQ-9 Emotional Distress Score and FACE-Q Domain of Patients' Narratives

No. of responses	Narrative	Emotional distress score	FACE-Q domain—theme
1	I feel so f-ing ugly all the time	3	Psychological function—hopelessness/depression
2	I look like I belong on an episode of botched	3	Psychological function—hopelessness/depression
3	This has destroyed me psychologically	3	Psychological function—hopelessness/depression
4	I do not think I can ever recover	3	Psychological function—Hopelessness/depression
5	My face is ruined	3	Psychological function—disfigurement
6	This is the biggest mistake I’ve ever made	3	Psychological function—regret
7	My nose is now looking unnatural and odd	2	Appearance distress—asymmetry
8	Don’t waste your money	1	Psychological function—regret
9	Scarred for life	3	Psychological function—disfigurement
10	I live with regret every day	3	Psychological function—regret
11	Very disappointed	2	Psychological function—hopelessness/depression
12	I am sad and very disappointed with how it turned out	2	Psychological function—hopelessness/depression
13	Feeling hopeless and cheated	3	Psychological function—hopelessness/depression
14	Small setback	1	Psychological function—regret
15	Emotionally devastated	3	Psychological function—hopelessness/depression
16	So heartbreaking	3	Psychological function—trauma and distress
17	Scary and traumatic experience	3	Psychological function—trauma and distress
18	The emotional distress doesn't end	3	Psychological function—trauma and distress
19	I feel so disfigured and irrevocably changed	3	Psychological function—disfigurement
20	This is mutilation	3	Psychological function—disfigurement
21	I feel gaslit	2	Social function—embarrassment
22	I'm embarrassed	2	Social function—embarrassment
23	Embarrassment	2	Social function—embarrassment
24	The toll on my client facing work, my modeling work, and my identity is unquantifiable	3	Social function—work identity impact
25	I am looking into legal counsel	2	Social function—legal response

DISCUSSION

Lip lift procedures are widely regarded as highly successful, offering excellent aesthetic enhancement when performed on appropriately selected patients by experienced surgeons.³ The procedure's brief duration and minimal intraoperative discomfort make it especially suitable for office-based settings, eliminating the need for general anesthesia or sedation, with the procedure regularly being done under local anesthesia.⁴ This approach not only lowers overall procedural costs but also facilitates faster recovery, contributing to the lip lift's increasing popularity among individuals seeking subtle yet effective facial rejuvenation.⁵ Being able to perform this surgery in such a convenient manner has broadened access and appeal among both genders and age demographics, with each respective group having their own ideal appearance profiles.⁶

Despite these advantages and generally high satisfaction rates, the authors of this study highlight that complications such as visible scarring, and asymmetry can arise, potentially leading to significant emotional distress in a subset of cases. These findings express the importance of comprehensive preoperative counseling to manage expectations and mitigate postoperative regret.

Trends in facial plastic surgery, where even technically successful procedures, such as rhinoplasty or facelift, can yield inconclusive outcomes in areas like body image, mental health, quality of life, and social functioning.⁷ Aesthetic rhinoplasty patients, for instance, often present with higher baseline depression scores compared with those undergoing functional procedures, and postoperative depression has been observed even in cases with satisfactory surgical outcomes.^8,9 Among lip lift patients, dissatisfaction with scarring has occasionally been shown to negatively influence perceptions of surgical success.²

Variations in surgical techniques may contribute to variability in patient-reported outcomes. Innovations such as the “Tri Lift” deep-plane method and nasal sill flap modifications aim to enhance patient satisfaction and reduce visible scarring compared with traditional bullhorn approaches, with the choice of technique often guided by the surgeon's experience, training, and aesthetic judgment.^10-12

Preoperative counseling remains a critical determinant of postoperative satisfaction. Poor patient–provider communication and inadequate informed consent are widely recognized as key contributors to dissatisfaction in cosmetic procedures.¹³ Surgeons should address realistic expectations, potential risks such as scarring or asymmetry, the emotional impact of suboptimal outcomes, and the possibility of revision surgery. The use of visual aids, standardized assessment tools, and expectation-alignment strategies may further support informed decision making and reduce regret.¹⁴

Postoperative care also plays a significant role in shaping patient satisfaction. Early scar interventions, such as silicone gel, silicone sheeting, and topical corticosteroids, have demonstrated efficacy in reducing hypertrophic or pigmented scars.^15,16 Additionally, laser therapy and microneedling may enhance scar appearance following facial cosmetic surgery.^17,18 Based on our findings, regular follow-up and proactive scar management protocols may help address early signs of dissatisfaction, prevent emotional distress, and improve long-term outcomes.

Limitations

In this exploratory study, we included a limited sample of 25 publicly posted narratives, restricting the generalizability of findings. Some demographic data (such as age, gender, and socioeconomic background) of reviewers were unavailable, which restricts interpretation. In addition, the temporal relationship between surgery and review could not be reliably assessed, which impacts interpretation of whether dissatisfaction reflected short-term healing issues or long-term outcomes. Moreover, RealSelf is not a scientific or validated data source, and the findings are subject to selection bias and reporting bias, because patients with negative experiences may be more inclined to post reviews online. Finally, the qualitative nature of the study does not allow quantitative inference. Nonetheless, the analysis highlights important emotional and aesthetic dissatisfaction patterns in lip lift outcomes, an area currently underrepresented in the literature. Future studies should incorporate larger, more diverse datasets to validate these findings and allow broader generalization.

CONCLUSIONS

Although lip lift surgery is generally associated with high satisfaction and favorable aesthetic outcomes, our analysis highlights a significant subset of patients who experience dissatisfaction, particularly related to aesthetic and emotional distress. Showcasing common postoperative aesthetic concerns and their psychosocial impact in the literature formulates an important framework during counseling encounters with patients. Future research should incorporate dissatisfaction rates while quantitatively measuring aesthetic changes.

Supplemental Material

This article contains supplemental material located online at https://doi.org/10.1093/asjof/ojaf129.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article, including payment of the article processing charge.