Psychosocial Factors Surrounding Aesthetic Rhinoplasty: A Systematic Review

Abstract

Background:

Rhinoplasty, widely known to improve form and function, is growing in popularity for both cosmetic and functional purposes. The preexisting psychosocial state of a patient significantly affects the perceived outcome of aesthetic rhinoplasty, even when surgery is technically successful. Given the elevated rates of distress, depression, social dysfunction, and body dysmorphic disorder among candidates, psychosocial optimization is essential.

Methods:

A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies published from January 2000 to August 2024 examining associations between aesthetic rhinoplasty outcomes and psychological factors were identified through PubMed, Cochrane Library, and Embase. Eligible studies evaluated psychosocial characteristics, preoperative mental health status, and postoperative satisfaction.

Results:

Patients with preexisting mental health conditions, including body dysmorphic disorder, anxiety, and depression, consistently reported lower postoperative satisfaction despite technically successful results. Patient-reported outcome measures demonstrated that psychological readiness, social context, and expectation setting significantly influenced perceived outcomes. Individuals with diminished psychosocial functioning were more likely to experience reduced postoperative satisfaction, underscoring the interplay between psychological pathology and subjective assessment of surgical success.

Conclusions:

Evaluating patient motivations, expectations, and psychosocial readiness allows physicians to better predict satisfaction and improve expectation management. Incorporating a thorough preoperative mental health assessment can help identify modifiable psychosocial factors and optimize outcomes for patients pursuing aesthetic rhinoplasty.

Takeaways

Question: How do psychosocial factors such as anxiety, depression, and body dysmorphic disorder influence patient satisfaction and outcomes following aesthetic rhinoplasty?

Findings: Preoperative mental health conditions, particularly body dysmorphic disorder, anxiety, and depression, are strongly associated with reduced postoperative satisfaction, even when rhinoplasty is technically successful. Across included studies, patient-reported outcome measures consistently demonstrated that psychological readiness, expectations, and social context meaningfully shaped perceived surgical results.

Meaning: Aesthetic rhinoplasty outcomes are significantly influenced by the patient’s psychological profile, underscoring the importance of preoperative mental health screening and expectation management.

INTRODUCTION

Rhinoplasty is a widely performed surgery by plastic surgeons and otolaryngologists, often sought after to address both aesthetic concerns and functional needs.¹ Although functional rhinoplasty can often be objectively assessed based on measurable outcomes, the necessity for aesthetic rhinoplasty is completely subjective, shaped largely by a patient’s perception. Although objective measurements and facial proportions have been thoroughly investigated, rhinoplasty outcomes are better measured based on a patient’s satisfaction. This can be influenced by sex; age; education; culture; ethnicity; and, most importantly, their preoperative psychological state and expectations.²

Numerous studies describe the role of mental health in the outcomes of aesthetic rhinoplasty. Piromchai et al³ report that individuals seeking cosmetic rhinoplasty exhibit significantly higher rates of psychological distress compared with the general population, with anxiety and social dysfunction being the most prominent concerns. Suboptimal psychological functioning at baseline compounded with unrealistic expectations can profoundly influence a patient’s postoperative satisfaction and, consequently, the perceived success of the surgical outcome.⁴

Given the subjective nature of the perceived rhinoplasty outcome, this further begs recognition of the importance of addressing all psychological factors before aesthetic rhinoplasty.^5–7 As such, the mental health status of aesthetic rhinoplasty candidates must be thoroughly evaluated to optimize outcomes and minimize postoperative dissatisfaction, which may often persist despite technical success.³ Patient-reported outcome measurements (PROMs) remain the gold standard of assessing the success of aesthetic rhinoplasty. This review synthesized existing data on the relationship between aesthetic rhinoplasty outcomes and the psychosocial status of a patient.

MATERIALS AND METHODS

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.⁸ Studies published between January 2000 and August 2024 were searched in PubMed, Cochrane Library, and Embase databases using the search terms “(rhinoplasty) AND (psychosocial).” This search initially yielded 62 studies. After 3 duplicate studies were removed, 59 articles remained for further screening.

Three independent reviewers (K.K.N., C.J.C., and M.S.) conducted the initial screening based on the titles and abstracts of the 59 studies. Eligible designs included observational and randomized controlled studies. Meta-analyses, systematic reviews, case reports, and case series were excluded. Inclusion criteria were studies evaluating psychological or psychosocial factors related to aesthetic rhinoplasty and studies reporting pre- and/or postoperative outcomes or patient satisfaction. Exclusion criteria were studies unrelated to aesthetic rhinoplasty, studies not reporting psychosocial or psychological data, and commentaries, editorials, or letters without original data.

Following this process, 16 articles were deemed potentially relevant and selected for full-text review (Fig. 1). These full texts were further evaluated by 2 authors (K.K.N. and C.J.C.) for their relevance to the relationship between rhinoplasty outcomes and psychosocial status. Any discrepancies in the selection process were resolved through discussions with 2 senior authors (J.C.D. and B.J.M.).

Fig. 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

The studies were reviewed according to key criteria, including author, year of publication, country, study design, population, psychological evaluation tools used, and the type of rhinoplasty (cosmetic or functional). They were then categorized by their main findings and further analyzed with a focus on postoperative satisfaction, psychological distress, the prevalence of body dysmorphic disorder (BDD), and associations with mental health disorders.

RESULTS

A total of 11 studies met the inclusion and exclusion criteria (Table 1). The studies reviewed span various countries, reflecting diverse cultural and clinical contexts. Participant demographics show an average age ranging from the early 20s to the early 30s, with men and women represented in varying proportions across studies. The terminology used to describe psychosocial factors in aesthetic rhinoplasty varied, with “BDD” being the most frequently referenced condition, followed by “psychological distress” and “patient satisfaction.” Moreover, American and European studies both used the term “BDD” consistently, whereas unique terms such as “appearance-driven motivations” appeared predominantly in European articles. The studies differed in treatment roles and angle of approach, with specialists being represented in varying degrees.

Table 1.

Summary of Included Studies Examining Psychosocial Factors in Aesthetic Rhinoplasty

Study, Year	Country of Origin	Sample Size (Men/Women)	Age (Mean or Median, y)	Study Design	Focus Area/Diagnosis	Tool/Methodology	Key Findings	Follow-up Period
Günel and Omurlu, 20155	Turkey	79 (49 male, 30 female)	24.14 ± 4.997 (mean)	Prospective clinical study	Psychosocial distress and QoL in rhinoplasty patients	DAS-24, NOSE scale, ROE scale	Rhinoplasty significantly improved QoL and nasal obstruction; emotional distress normalized after 12 wk	6 mo
Kütük and Arikan, 20199	Turkey	90 (32 men, 58 women)	27.4 ± 6.5 (mean)	Prospective randomized controlled study	Functional and aesthetic outcomes in rhinoplasty	NOSE scale, ROE scale, DAS-24	Rhinoplasty significantly improved functional and aesthetic outcomes and reduced psychosocial distress; closed rhinoplasty showed less distress than open rhinoplasty	6 mo
Javo and Sørlie, 20106	Norway	1862 (women)	27 ± 5.0 (mean)	Cross-sectional survey	Interest in cosmetic procedures, including rhinoplasty	Questionnaires assessing body image, personality traits, BDD symptoms, and social factors	Low education level, BDD-like symptoms, appearance orientation, and a history of teasing are significant predictors of interest in rhinoplasty. Women interested in rhinoplasty often express interest in multiple procedures	N/A
Homsy et al, 202110	Finland	83 (29 men, 54 women)	Median:33 (range: 18–86)	Cross-sectional survey	Patient-reported outcomes for nasal reconstruction and rhinoplasty	Translated Finnish FACE-Q rhinoplasty scales and 15D health-related QoL questionnaire	Finnish FACE-Q scales demonstrated high reliability and validity for assessing rhinoplasty and nasal reconstruction outcomes. High internal consistency with minimal adverse effect reporting	3 y (median from surgery)
Shauly et al, 202011	United States	298 (172 women, 126 men)	Mean: 26 (range: 18–55)	Cross-sectional survey	Psychological factors in rhinoplasty candidates	PRIME-MD questionnaire, SCHNOS scale	57.84% of rhinoplasty-seeking patients reported a psychological disorder. Younger age, female sex, and moderate income were significant predictors for rhinoplasty interest. Screening is critical for optimal outcomes	N/A
Brucoli et al, 201912	Italy	56 (15 men, 41 women)	Mean age = 28 (range 18–57)	Prospective study	Assessment and comparison of personality traits and psychosocial status of patients undergoing orthognathic surgery or rhinoseptoplasty	Minnesota Multiphasic Personality Inventory, Myers-Briggs Type Indicator, Tree Drawing Test (Baum Test), Body Cathexis Scale	Patients undergoing rhinoseptoplasty exhibited higher levels of anxiety, irrational fears, and concerns about their body and health, with 54.55% dissatisfied with their body image, compared with 51.85% in the orthognathic surgery group. Orthognathic surgery patients showed greater tendencies for social introversion and insecurity, whereas both groups shared traits of emotional distress, though with notable differences in personality and psychosocial characteristics	N/A
Saeed et al, 202113	Pakistan	110 women	Majority aged 24–28, no specific mean/median provided	Prospective, questionnaire-based, qualitative study	Evaluation of BDD in women seeking rhinoplasty, introduction of the term “SIFON” (single, immature, female, overexpectant, narcissistic)	Dysmorphic Concerns Questionnaire, demographic data collection and statistical analysis (SPSS v25), univariate analysis of BDD across demographic variables	A significant proportion (41.8%) of women seeking rhinoplasty were diagnosed with BDD, with the majority being single, educated, and aged 24–28 y, highlighting the need for preoperative psychiatric evaluations to identify high-risk patients. The study introduces the term “SIFON” (single, immature, female, overexpectant, narcissistic) to describe women with specific psychosocial traits similar to the previously established “SIMON” term for men	N/A
Kucur et al, 201614	Turkey	41 patients (27 men, 14 women) versus 34 controls (19 men, 15 women)	Patients: 26.5 ± 5.6; controls: 24.5 ± 4.8	Prospective observational study	Psychological characteristics and QoL in rhinoplasty candidates	LSAS, HADS, Rosenberg Self-Esteem Scale, SF-36 QoL questionnaire	Patients seeking rhinoplasty showed elevated social anxiety and avoidance,. Significant QoL impairments were identified in rhinoplasty candidates. SF-36 can be useful for preoperative psychological screening	N/A
Soni et al, 202015	India	65 patients (52 men, 13 women)	Mean age = 20.2 (range 14–44)	Prospective observational study	Evaluation of postrhinoplasty outcomes using patient-reported satisfaction and QoL metrics	FACE-Q appraisal scales to measure satisfaction with facial and nose appearance, social function, psychological well-being, and psychosocial distress, alongside demographic profiling and statistical analysis with SPSS v21	Postrhinoplasty, patients reported significant improvements in facial and nose appearance satisfaction, social function, psychological well-being, and reduced psychosocial distress, with more than 79% achieving satisfaction and a median cumulative score of 87. However, 4 patients showed dissatisfaction, linked to high preoperative psychosocial distress and unrealistic expectations, highlighting the importance of preoperative counseling	6 mo
Bodnar et al, 20217	Ukraine	99 patients (group I: 7 men, 23 women; group II: 30 men, 39 women)	Group I: 19–30; group II: 19–50	Observational comparative study	BDD and nonpsychotic mental disorders in cosmetic rhinoplasty candidates	Clinical, psychodiagnostic, and sociodemographic evaluations using MADRS, STAI, Rogers-Diamond SPA, and Leonhard-Shmishek questionnaire	Group I (no visible defects) exhibited moderate depression, high personal anxiety, low adaptability, and high emotional discomfort, with cosmetic surgery failing to improve psychological outcomes. Group II (visible defects) had milder symptoms and better adaptability	N/A
Patnaik et al, 201916	India	51 patients (44 men, 7 women)	Mean age: 22.94 ± 6.18 (men: 23.45 ± 5.93, women: 19.71 ± 7.20)	Prospective study	Psychological assessment in cosmetic rhinoplasty	DAS-59; Likert-scale scoring; preoperative and 3-mo postoperative assessment	DAS-59 is effective in assessing psychosocial distress in cosmetic rhinoplasty patients. High preoperative scores for negative self-concept and facial self-consciousness predict lower satisfaction. Better preoperative counseling is recommended for these subsets of patients	3 mo

DAS-24, Derriford Appearance Scale 24; DAS-59, Derriford Appearance Scale 59; MADRS, Montgomery–Åsberg depression rating scale; N/A, NA, not available; NOSE, nasal obstruction symptom evaluation; SF-36, 36-item short form health survey; SIMON, structured interview for mental disorders; SPA, social physique anxiety scale; STAI, state-trait anxiety inventory; QoL, quality of life.

There may be several sources of potential bias across the included studies. PROMs introduce potential for measurement bias due to subjectivity. Selection and reporting biases may also be present, as studies were restricted to English-language publications and often favored positive psychosocial findings. Additionally, few studies controlled for psychiatric comorbidities or social factors, limiting the ability to draw definitive causal conclusions.

The Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) is used to determine the preoperative functional and aesthetic need for rhinoplasty. In a crowdsourcing survey done by Shauly et al,¹¹ 33.62% of patients who were satisfied with the appearance of their nose reported a SCHNOS score that indicated a need for aesthetic or functional rhinoplasty. Of those who were unsatisfied with the appearance of their nose, only 44.93% reported a SCHNOS score that indicated a need for rhinoplasty.

The Rhinoplasty Outcome Evaluation (ROE) is used to assess patient satisfaction following rhinoplasty. The questionnaire gives a score based on patient-reported physical, emotional, and social factors. Gökçe Kütük and Arikan⁹ reported an average increase of 62.5 points between the preoperative and 6-month postoperative assessments in the cosmetic rhinoplasty group. They measured the functional rhinoplasty group and recorded a substantially smaller average increase of 35.6 points in that same period.⁹ Günel and Omurlu⁵ assessed ROE scores in primary, secondary, functional, and cosmetic rhinoplasty candidates and found that all patients were significantly improved by surgery, and there was no significant difference between their postoperative scores.

The FACE-Q aesthetic patient-reported outcome instrument rhinoplasty module is regarded by many as the most accurate instrument for assessing patients undergoing aesthetic rhinoplasty.^15,17 The questionnaire contains 2 items: “satisfaction of the nose” and “satisfaction of the nostrils.” Both items are scored on a 4-point Likert scale and classified as very dissatisfied, somewhat dissatisfied, somewhat satisfied, or very satisfied.¹⁷ Homsy et al¹⁰ used the FACE-Q as a postsurgical questionnaire for patients who had undergone nasal resection, reconstruction, or rhinoplasty. The patients also filled out a 15-dimensional general health-related quality of life instrument (15D) and ranked their self-perceived normality of the nose. They found that appearance-related psychosocial distress was weakly correlated with depression, distress, and vitality on the 15D instrument, and moderately correlated with self-perceived normality of the nose. Satisfaction had no significant correlation with any 15D items but correlated moderately with self-perceived normality of the nose. Satisfaction demonstrated high correlation with self-perceived normality but no correlation with any of the 15D items. The study found a strong correlation between lower satisfaction with appearance and a higher likelihood of postoperative depression.¹⁰

Soni et al¹⁵ found significant improvements in patient perceived facial appearance, appearance of the nose, social confidence, and psychological well-being after rhinoplasty in an Indian population seeking functional and cosmetic rhinoplasty based on the FACE-Q. In those with scores that did not show expected improvements and demonstrated dissatisfaction, psychosocial dysfunction and unrealistic expectations were found to be more likely.¹⁵

The Derriford Appearance Scale 24 measures the psychological distress of a patient as it relates to the perception of their physical appearance.⁵ Gökçe Kütük and Arikan⁹ found an average decrease of 40 points between the preoperative and postoperative survey following cosmetic rhinoplasty and a 10-point average decrease after functional rhinoplasty. Though individuals pursuing aesthetic rhinoplasty experienced a greater drop in distress level, both groups recorded an average of 20 points in their 6-month postoperative assessment.⁹ Günel and Omurlu⁵ congruently found that preoperative Derriford Appearance Scale 24 scores were substantially higher in those seeking secondary or cosmetic rhinoplasty when compared with those seeking primary or functional rhinoplasty, whereas postoperative scores were nearly identical.

The Derriford Appearance Scale 59 calculates factorial scores based on general self-consciousness of appearance, social self-consciousness of appearance, sexual and bodily consciousness of appearance, negative self-concept, facial self-consciousness of appearance, and physical distress and dysfunction. Patnaik et al¹⁶ assessed patients seeking aesthetic rhinoplasty and found (+) 29.17, (+) 21.68, (+) 11.54, (+) 5.11, (+) 3.10, (+) 6.36, (+) 3.79 changes in those categories following surgery, respectively, with the former 3 having a P value of less than 0.05. Overall, a significant reduction in psychosocial distress was observed following aesthetic rhinoplasty.¹⁶

Javo and Sørlie⁶ assessed the likelihood of interest in aesthetic augmentation in Norwegian women through a questionnaire where respondents ranked themselves on a numeric scale. Of the measured variables, low education level, recommendation of cosmetic surgery, and low appearance evaluation were the most significant predictors for pursuing cosmetic surgery in general. Rhinoplasty differed from other aesthetic procedures in that the presence of emotional distress, eating disorder, and knowing someone who had cosmetic surgery were the strongest predictors for pursuing surgery. Qualities of BDD, across all questioned categories and variables, were the strongest predictor for pursuing aesthetic rhinoplasty.⁶

Saeed et al¹³ evaluated BDD in female rhinoplasty candidates using the Dysmorphic Concerns Questionnaire. The Dysmorphic Concerns Questionnaire consists of 7 questions that are ranked on a 4-point scale (0–3). The study used a sum score greater than 11 as the cutoff for association with BDD. Of the 110 female individuals who completed the questionnaire, 41.8% had a score (>11) that indicated BDD. All individuals with BDD were either single (48.2%) or divorced (71.4%), with no married women having BDD. BDD was found in 47% of patients with education above a diploma, 59.4% of students, 15.4% of unemployed individuals, and 6.7% of employed individuals. Women aged 24–28 years had the highest prevalence of BDD compared with other age groups. The study found that an increasing number of educated women expressed a desire for aesthetic rhinoplasty, not driven by concern about their nose, but rather, driven by an underlying psychological disposition. The study proposed the term SIFON: single, immature, female, overexpectant, and narcissistic as predictive qualities of those seeking aesthetic rhinoplasty.¹³

Bodnar et al⁷ evaluated the mental health of patients seeking aesthetic rhinoplasty and divided them into 2 groups: group I (those without visible nasal defects) and group II (those with visible defects). Patients in group I asked the surgeon to make their nose “just beautiful” and showed excessive anxiety, claiming social limitations due to their appearance. In this group, 100% of patients demonstrated traits associated with BDD, with most also having a background congruent with depressive mood disorder. The study found that patients in group II sought rhinoplasty to improve social functioning, with 60.9% being primary candidates. This group also demonstrated anxious and depressive symptoms, with 26.1% demonstrating qualities of depressive syndrome. Only 10% of patients in group II demonstrated traits associated with BDD.⁷

Kucur et al¹⁴ conducted a psychological evaluation assessing anxiety and depression in aesthetic rhinoplasty patients using the hospital anxiety and depression scale (HADS). Results showed that the HADS/anxiety and HADS/depression combined (HADS/total) scale demonstrated a score of 11.73 ± 6.39 for those seeking aesthetic rhinoplasty and 9.5 ± 4.78 for the control group (P = 0.092). The same study assessed anxiety (Liebowitz Social Anxiety Scale [LSAS]/anxiety) and avoidance (LSAS/avoidance) using the LSAS and found that the aesthetic rhinoplasty group scored an average LSAS/total of 91.12 ± 21.31, and the control group scored an LSAS/total of 77.03 ± 17.36 (P = 0.003). Results suggested that those seeking aesthetic rhinoplasty demonstrate reduced social functioning and emotional difficulties, with significantly increased anxiety and avoidance.¹⁴

The primary care evaluation of mental disorders (PRIME-MD) is a self-reported questionnaire for mental health information and is used to assess somatoform disease, irritable bowel syndrome, binge eating disorder, major depressive disorder, generalized anxiety disorder, and alcohol use disorder. In a crowdsourcing-based study, Shauly et al¹¹ found that 57.94% of patients expressing interest in aesthetic rhinoplasty had a psychological disorder, as identified through the PRIME-MD. In the same study, 38% of women and 27% of men showed willingness for aesthetic rhinoplasty. Not only did more women complete the survey, but they also showed measurably higher interest in the subject. A significantly larger portion of young adults aged 18–24 years (52.92%) showed willingness for aesthetic rhinoplasty when compared with those aged 25–34 (~35%), 35–44 (~30%), and 45–54 years (~20%).¹¹

Brucoli et al¹² examined personality traits of individuals seeking orthognathic surgery and rhinoseptoplasty based on the Myers-Briggs Type Indicator and Minnesota Multiphasic Personality Inventory questionnaires. The study concluded that evidence of narcissistic, dependent, and obsessive-compulsive disorders has a high prevalence in patients seeking rhinoseptoplasty.

DISCUSSION

The nose plays a central role in shaping our facial appearance, influencing body image and self-esteem, while greatly contributing to personality development.¹⁶ As a result, rhinoplasty remains one of the most performed aesthetic procedures worldwide, with a steadily increasing number of aesthetic rhinoplasties performed each year.⁵ Though aesthetic rhinoplasty can significantly improve quality of life and deliver major improvements in patient-reported outcomes, satisfaction following rhinoplasty is multifactorial. It is a combination of technical surgical success, a patient’s preoperative expectations, and a patient’s experience through the postoperative course.^17,18

A patient’s psychological suitability for cosmetic surgery can be evaluated by examining motivations, expectations, goals of surgery, self-perceived body image, psychiatric history, and current psychological state.⁶ Inclination toward cosmetic surgery often stems from an individual’s psychological perception of their features, with substantial evidence linking personality traits, attitude, and self-concept to how one views their physical appearance.^6,11 Their self-image can also be profoundly shaped by opinions of others, such as family and friends.¹¹

Thus, a patient’s subjective measure of aesthetic rhinoplasty can be important in determining its success, and procedural technical success may not accurately predict the patient’s postoperative outlook. It is therefore imperative to set realistic expectations preoperatively to ensure that the patient’s and surgeon’s goals align. The physician must therefore consider psychological and social circumstances during the consultation to determine if the results will line up with the patient’s definition of success.⁵

If a patient has unrealistic expectations or undiagnosed BDD, dissatisfaction after aesthetic rhinoplasty will persist despite technical achievement.^11,15 Patients with depression, anxiety, BDD, and poor psychological functioning represent a large portion of those pursuing rhinoplasty.^7,11,14 Depressed patients are more likely to have postoperative dissatisfaction and show smaller improvements in satisfaction with postoperative appearance compared with individuals without any psychiatric comorbidities.¹⁵ These patients may fail to disassociate perceived inadequacies with physical appearance and do not recognize the psychological root of their distress.^7,11

Comparing the PROMs of aesthetic and functional rhinoplasty candidates demonstrates the benefit of aesthetic rhinoplasty in mitigating distress and improving quality of life. However, the psychological emphasis on perfection and excessive attention given to minor or nonexistent defects in highly anxious, self-conscious, and obsessive individuals distorts expected outcomes.⁵ Various studies have shown that patients without symptoms of anxiety experience higher levels of satisfaction after aesthetic rhinoplasty and show greater decreases in appearance-related distress as opposed to those with anxiety-related disorders.²

Javo and Sørlie⁶ defined body dysmorphia as “preoccupation with an imagined defect in one’s appearance.” The prevalence of BDD may be as high as 57.8% among aesthetic rhinoplasty candidates, which may be explained by the nose’s central placement on the face, leaving it vulnerable to scrutiny.^6,13 Patients with BDD are more likely to experience aesthetic concern after rhinoplasty and report lower ROE scores compared with those without BDD, regardless of confounding variables such as age, sex, and marital status.¹⁹

SCHNOS-reported outcomes demonstrate that a considerable portion of those dissatisfied with their appearance after surgery do not meet the preoperative criteria for aesthetic rhinoplasty.^11,19 Individuals seeking cosmetic rhinoplasty are more likely to be secondary rhinoplasty candidates, whereas those seeking functional rhinoplasty are more often primary surgical candidates. In other words, patients predisposed to or experiencing psychiatric disorders may seek cosmetic surgery to correct a mental health disorder they do not recognize. It subsequently follows that an increasing number of physicians consider the presence of a psychological disorder a contraindication for aesthetic rhinoplasty.⁷

Adults younger than the age of 25 years are more inclined to undergo aesthetic rhinoplasty, which may be due to heightened sensitivity to appearance and a desire to conform to social standards.^5,13 Additionally, women are more likely to seek and undergo aesthetic rhinoplasty, with research indicating that they tend to pay greater attention to their appearance than men.^5,11

Appearance and anthropometric facial features differ across ethnicities due to a mix of genetic and cultural influences. A physician should account for variability in the ideal anthropometric measurements across ethnicities rather than solely relying on objective surgeon-measured assessments.¹⁵ Culture and ethnicity both influence the psychosocial state of a patient and significantly influence patient satisfaction. This should be considered alongside traditional aspects of psychological suitability. Many PROMs have been successfully translated, adapted, and validated into different languages and are effective in evaluating preoperative indications and postoperative satisfaction rates across various cultures.^20–22

The physician should consider psychological improvement alongside surgical success and should be aware of any psychopathology and psychiatric comorbidities in patients seeking rhinoplasty for cosmetic revision.²³ Preoperative counseling may be required, and the determination by the surgeon could be crucial to the success of rhinoplasty.¹⁵ Preoperative discussions with patients regarding their cosmetic concerns and the surgical aspects that may address these allow for an early glimpse into the patient’s preoperative psyche. This allows the surgeon to investigate whether concerns align with structural deficiencies or if they are fabricated from a nonexistent deficit. If the physician, with the context of psychosocial factors surrounding a patient, deems an individual unsuited for cosmetic rhinoplasty, they should strongly advise them against pursuing surgery.¹²

Rhinoplasty should be deferred in patients with signs of suboptimal psychological readiness, unrealistic expectations, a history of multiple cosmetic procedures, pressure from external sources, and underlying psychopathology such as depression, anxiety, BDD, bipolar disorder, borderline personality disorder, or suicidality. These patients may be at a higher risk of postoperative dissatisfaction, repeat procedures, or even psychological decompensation following aesthetic surgery.^5–7,13,23 In such individuals, surgery may not only fail to resolve psychological distress but can further damage psychological health, resulting in worsened psychiatric symptoms or pursuit of unnecessary revision surgery.^13,23

Studies have yet to assess aesthetic rhinoplasty patients on a longitudinal basis. Gaining insight into the distress, satisfaction, and mental health of patients years after surgery might provide information on the true utility of cosmetic rhinoplasty in helping patients overcome deep-rooted feelings of inadequacy. Investigating the number of aesthetic rhinoplasty candidates who are undergoing treatment for a mental health disorder may also provide further insight into the psychosocial risk factors associated with the procedure.¹¹

CONCLUSIONS

Psychological improvement alongside surgical success is critical in cosmetic rhinoplasty. Aesthetic rhinoplasty can have dramatically positive effects on self-perception, emotional distress, and quality of life. The overall success of surgery may be overshadowed by a patient’s psychological disposition or mental health status if undiagnosed preoperatively. Psychosocial considerations for aesthetic rhinoplasty are traditionally based around the diagnosis of BDD, but anxiety, depression, and other mood and personality disorders also influence a patient’s self-perception. It is important to consider any factor that might predispose a patient to dissatisfaction following cosmetic rhinoplasty and to ensure the adequate and appropriate diagnosis of such factors preoperatively.

DISCLOSURES

Dr. MacKay discloses consulting fees from Axogen, Integra LifeSciences, Trimed, and Tissum. Evan J. Hernandez discloses consulting fees from Axogen and Checkpoint Surgical. The other authors have no financial interest to declare in relation to the content of this article.