An essential part of the initial evaluation of a potential rhinoplasty patient involves making a judgment about the patient’s motivations for seeking the procedure and about their psychological and psychiatric fitness for a cosmetic procedure.(1) There is little literature regarding psychiatric screening of rhinoplasty patients (2-4).
The reported prevalence of psychiatric illness in patients seeking rhinoplasty varies widely in the literature. Regardless of the specific percentage of patients seeking rhinoplasty who have psychiatric issues, the critical point is that, some will; and it is important that the surgeon be able to identify the patient who needs specific management of these issues. In this chapter, we attempt to identify not only factors that may suggest further evaluation, but also to provide the surgeon with a broad overview of typical psychiatric and psychological conditions and concerns that could predispose patients to less than optimal outcomes.
There have been significant changes in the way rhinoplasty patients have been studied and assessed over the past 50-75 years.(5) Much of the early psychiatric literature on this topic, published in the 1940s-1970s was reported in the form of individual case reports and discussions, and even larger studies were often based on psychodynamic interviews rather than more objective and measurable diagnostic criteria or psychometric testing.(1,4,6-7) This literature appears to be mostly of historical interest. Much of this literature comments on the nose’s status as sexually symbolic. Not surprisingly, predominantly psychodynamic assessments and conceptualizations often estimated very high rates of personality disorders and neurotic or even psychotic thought processes to be behind patient motivations for rhinoplasty. In fact, studies relying on psychodynamic interviews of cosmetic surgery patients in general have yielded estimates of non-specific psychiatric illness ranging anywhere from 20% to as high as 70%.(1,4,6-7)
As the literature has begun to more objectively and reproducibly identify mental health problems and their relationships to psychosocial issues, with a few exceptions, the patient population appears to be markedly less psychiatrically ill than previously reported. In fact, most patients experience outcomes that appear to improve psychosocial functioning in domains such as increased self-esteem, self-confidence, social confidence, and decreased anxiety and hostility.(2-4,8)
When to Seek Formal Mental Health Consultation
As rhinoplasty and other plastic surgical procedures have become increasingly popular over the last 25 years, there remain wide variations in recommendations regarding the extent to which formal psychiatric consultation should be utilized. Some published editorials and studies have recommended the inclusion of an assessment by a psychologist or psychiatrist at the time of the initial surgical consult. Most of the current literature suggests that far less aggressive screening may be sufficient, with only patients of particular concern warranting referral for formal psychiatric or psychological evaluation.(4-5,8,10)
Though there is no clear consensus for the extent of an appropriate screening, there are a number of principles that should be considered, and recommendations that can generally be regarded as prudent. Whether done by a mental health professional or by the surgeon, a brief psychiatric and drug and alcohol use history and assessment of current mental status are part of a full history and physical and should be completed at the time of medical evaluation, as with any medical or surgical evaluation.(4)
One of the few controlled studies comparing non-elective plastic surgery patients to elective plastic surgery patients showed that elective patients had significantly higher rates of both reported history of psychiatric disorders and current psychiatric medication prescriptions . Of patients seeking cosmetic surgery, 19% reported a history of psychiatric diagnosis and 18% reported currently taking psychiatric medications, as opposed to 4% and 5% respectively, in those who were seeking non-elective plastic surgical procedures. (4)
A basic mental status exam as well a drug and alcohol use screen can also be helpful in identifying untreated mental health concerns, which can then can be further assessed and treated by a mental health professional. (4-5,8,9)
Motivations and Expectations
It is widely accepted that an important concern in selecting an appropriate surgical candidate is to identify the patient’s goals of surgery. Responses can be divided into “internal” or “external” motivations.(2,3,9-10) The internally motivated patient will describe a desire to achieve a particular physical appearance, ideally to match one’s own ideal self-image, and is widely believed to be more likely to report a positive outcome. This is opposed to an externally motivated patient who may describe being pressured by another person to pursue surgery, or to solve various conflicts or problems in his or her interpersonal life. The internally motivated patient is generally considered to be at a lower risk for dissatisfaction with cosmetic procedures. (2-3,10)
Closely linked to the patient’s source of motivation for the procedure are their expectations for the procedure. Measurable, concrete, physical characteristics that are concordant with results that the surgeon can reasonably expect to achieve are considered to be healthier responses to this line of questioning than are vague responses. Less healthy responses cited in the literature include comments asking the surgeon to use their judgment to produce whatever they feel would look best, “magical cures” of interpersonal, professional, or sexual problems, or elaborate expectations or desire to take on the appearance of another person. These may indicate expectations that are beyond what a surgeon may reasonably expect to achieve.(1,8) In addition to one’s positive expectations from surgery, an ideal candidate should also be able to demonstrate understanding and acceptance of the possible risks and limitations of the procedure.
Specific Psychiatric Diagnoses
Any psychiatric condition may be present in patients who request rhinoplasty, but there are certain disorders that are more common, and some that may be stronger predictors of poor outcomes or contraindications for surgical interventions.(5) Body dysmorphic disorder (BDD), has been the most widely studied and suggested as a surgical contraindication. Other conditions identified as risks can be stratified into several categories: personality disorders (most frequently those categorized in Cluster B), mood disorders, anxiety disorders including PTSD, and psychotic disorders.
Body Dysmorphic Disorder
Body Dysmorphic Disorder (BDD) is characterized by preoccupation with a defect in appearance that is either imagined or slight, but generates an excessive amount of concern. Excessive concern refers to thinking about the deficit for more than one hour per day, though 40 percent of individuals with BDD report thinking about the body part of concern for 3-8 hours per day.(11) The degree of preoccupation with physical defects in BDD patients is so consuming that it causes significant impairment in social, occupational, or other areas of functioning.
Patients with BDD typically have concerns about a specific part of their body. These concerns generally involve their face, and typically a specific part of their face. One study indicated that the three most common areas of concern were the hair (63 percent), skin (50 percent), and nose (50 percent).(12) Thus, BDD is of particular concern among individuals seeking rhinoplasty, especially those seeking revision rhinoplasty for cosmetic reasons. It is of particular concern that patients with BDD appear to be at a relatively high risk of engaging in self-destructive and aggressive behavior. Approximately 80 percent of patients with BDD report a lifetime history of suicidal ideation and 20 to 25 percent have made an attempt.(11) In addition, 28 percent of individuals with BDD describe a history of violent behavior and about 40 percent of cosmetic surgeons report having been threatened by a person with BDD. (13)
The point prevalence of BDD is estimated to be between 0.7 percent and 2.4 percent of the general population.(11) It is somewhat more common in women, and unmarried individuals.(11) The prevalence of BDD is thought to be substantially higher among individuals seeking cosmetic surgery, with estimates varying widely, ranging from 3 to 53 percent.(11) Today, however, the incidence of BDD amongst cosmetic surgery patients is likely at the lower end of this range, as cosmetic surgery is more mainstream and is available to a wider range of the population than previously.
However, studies in the past 10 years, have shown that BDD may be common among people seeking rhinoplasty. One study of 226 Belgian patients pursuing rhinoplasty indicated that at least 33 percent of the 226 enrolled displayed at least moderate symptoms of BDD. In this Belgian study, patients with aesthetic goals, those pursuing revision rhinoplasty, and those with a psychiatric history generally had more severe symptoms. Those with BDD also had decreased quality of life and appearance related disturbance of daily living.(14) A study of 306 Iranian patients pursuing rhinoplasty, revealed that 41 percent had a psychiatric disorder and 24.5 percent met criteria for BDD.(15) It is important for cosmetic surgeons, particularly those specializing in rhinoplasty, to be vigilant for signs and symptoms of BDD among their patients.
Two screening tools, the BDD Questionnaire Dermatology Version (BDDQ-DV) and the Dysmorphic Concern Questionnaire (DCQ), have been validated in the dermatology setting.(16) A recent study has indicated that the Body Image Concern Inventory (BICI) was a valid and internally consistent measure for assessing the risk of BDD in prospective rhinoplasty patients, when compared to a semi-structured DSM-IV based interview.(17) Tasman et al. suggested using DSM based questions for screening such as: 1) Are you very worried about your appearance in any way? 2) Does this concern preoccupy you? That is, do you think about it a lot and wish you could worry about it less? 3) What effect has this preoccupation with your appearance had on your life? These authors suggest that affirmative answers to all three questions is highly suggestive of BDD, but even one affirmative response is cause for heightened vigilance.(18)
BDD is typically co-morbid with other psychiatric conditions and patients with BDD frequently report a lifetime history of depression (90%), anxiety (70%), and psychosis (30%).(19) Also, nearly half generic viagra of patients with BDD (48.9%) have a comorbid substance use disorder.(20)
Treatment with medical procedures to address the perceived defect is almost invariably unsuccessful. However, studies have suggested that 71-76 percent of people with BDD pursue cosmetic surgery and 64-66 percent receive it.(11) However, very few patients with BDD, (3.6-7 percent), report an improvement in BDD symptoms following surgery.(11) Moreover, those who do not perceive an improvement in appearance often react with anger towards the surgeon or develop a depression.(19) One study retrospectively examined 200 patients with BDD, 42 of whom underwent surgery on the body part of concern and 158 who did not. Ultimately, only 2.3% of those who had surgery displayed an overall decrease in the symptoms of BDD.(21) It is generally thought that the majority of patients with BDD who receive cosmetic surgery such as rhinoplasty are left with unchanged or worsened psychological symptoms.(22)
Mood Disorders and “The patient in Crisis”
Mood disorders are the most common clinical entities both in the general population and among cosmetic surgery patients, with Major Depressive Disorder being self-reported by about 17% of cosmetic surgery patients and an additional 1% reporting Bipolar Disorder, which is about the same as the prevalence in the general population.(4) Depression carries with it an increased risk of poor outcomes, though some studies have conversely shown post-surgical decreases in levels of depression and anxiety. (2, 3)
Several authors specifically make reference to avoiding offering surgery to the “patient in crisis,” referring both to patients with acute mood episodes, as well as people experiencing acute grief, particularly recent loss of a relationship, job, or loved one. (2, 8, 23)
While there is probably little concern for offering surgery to patients with well-controlled mood disorders in active treatment, patients suffering from active mood symptoms, especially those who have indications of impaired judgment or appear to be motivated by expectations of social change or changes in current relationships should be offered a referral for further mental health evaluation.(1,23)
While a variety of current and past personality disorder diagnoses have been suggested as potentially complicating factors in the rhinoplasty patient, Cluster B disorders, especially Narcissistic Personality Disorder, Histrionic Personality Disorder, and Borderline Personality Disorder tend to be most-discussed in the literature. (2,3,8-9,23-24)
This class of disorder has been linked to poor post-surgical outcomes in several studies and is widely considered by surgeons to be linked to increased patient demands and even violence against surgeons and staff in cases of perceived sub-optimal results.(2,3,8-9,23-24) Though these conditions are not necessarily absolute contraindications to cosmetic procedures, it is a general consensus that patients exhibiting overt personality pathology be, at minimum, referred for psychiatric evaluation prior to offering surgery, and offered surgery with some caution.(8-9,23,24)
While there is a great deal of overlap in presentation between these three personality disorders, borderline personality disorder is generally the most concerning, because it is much more frequently associated with suicide threats and attempts, self-mutilating behaviors, and intermittent psychotic symptoms. While not a diagnostic criterion, these patients can often be identified by their prominent use of splitting, which can be seen in the office setting as extreme devaluation of one physician and idealization of another. Other cardinal features include long patterns of unstable, chaotic relationships, impulsivity, and very intense experiences and expressions of anger.(25) Of particular concern to surgeons, stressful events, including surgical recovery can trigger an acute worsening of these patients’ chronic symptoms, leading to some suggestions to avoid operating on patients with this condition.(23)
Narcissistic personality disorder, characterized by unexplained, pervasive grandiosity, entitlement, and demand for admiration according to DSM IV-TR criteria, has been reported in about 1% of the general population, but unexplained grandiosity and need for admiration have been described in up to 25% of patients presenting for rhinoplasty. (24-25) They may be extremely concerned with their physical appearance, and may have unrealistic fantasies regarding potential results and effects of cosmetic surgery.(24) It has been suggested that patients with narcissistic personality disorder are also generally poor surgical candidates, as their extreme expectations are unlikely to be met, which can result in hostility and anger.(23)
Histrionic Personality disorder, characterized by a persistent need for attention, accompanied by dramatic emotional expression, and an overly provocative, sexualized behavior, may be similarly overrepresented in this population, with an estimated prevalence of 10% of cosmetic surgery patients compared to only 2% overall.(24-25) While not a contraindication to surgery, it is recommended that these patients be given frequent reassurance in the office setting, as this will often satisfy their need for attention and improve outcomes.(23-24)
Symptoms of PTSD are especially relevant in patients presenting for reconstruction or repair of facial trauma, as the traumatic event leading to the need for the procedure may well have resulted in symptoms of PTSD.(5) Reconstruction and a return to an appearance closer resembling a patient’s pre-trauma body image can be part of the psychological healing process and can relieve significant distress, but untreated PTSD symptoms may prevent a return to premorbid functioning and could conceivably cause a negative psychosocial outcome if the traumatic event has not been adequately processed prior to surgical intervention. This presents an excellent opportunity to identify and arrange for appropriate treatment of previously unidentified PTSD cases. (5)
Other Findings or Populations of Special Concern
Violence and legal history
A history of patient assaults, threats, or other violent behavior should be assessed and viewed with caution, especially if violence has been directed against a previous treating physician or physicians. This could indicate an inability of the patient to tolerate negative outcomes and should be referred for further evaluation or refused surgery.(23)
Diagnoses of current and past drug and alcohol abuse are generally absent from studies looking at the medical and psychiatric histories of aesthetic surgery patients.(4) Legal history, especially if related to drug charges or alcohol-related charges may provide additional insight into these potential complicating factors. This should also highlight the importance of a screen for current and past and current alcohol and drug use patterns as part of the general medical history.
The cross-cultural patient and Loss of Identity
Loss-of-identity is proposed by many authors as a significant cause of patient dissatisfaction with an otherwise technically and aesthetically successful surgery, and in one study, “intolerable loss of a personal, familial, or ethnic characteristic” accounted for fully 10% of the stated motivations for revision rhinoplasty cases.(26) This represents a significant, and potentially avoidable, cause of patient dissatisfaction. The cases offered in the literature seem to most often refer to those of Middle Eastern descent, though it is reasonable to suspect that this concept can probably be applied to any patient describing a wish to have a nose more consistent with traits expected in an ethnic or cultural group differing from one’s own heritage.(8) There are very positive results described in case reports, though those cases tend to have evidence of family approval of the procedure.(8)
Adolescent patients should be assessed carefully and have been shown to be at risk of poorer psychosocial outcomes after cosmetic surgery by multiple studies.(2) Legal ability to provide consent for an elective procedure is an important issue. Much of the risk inherent in the adolescent population appears to be http://billhobbs.com/ related to an innate tendency to overestimate potential benefits while underestimating potential risks, which has been suggested to be a function of the still-developing adolescent brain. This is complicated by research that has shown that even the general public tends to have a poor understanding of potential risks and benefits of cosmetic procedures.(8) If one plans to operate on even a competent teenaged patient, particular attention should be paid to their ability to accurately describe the range and likelihood of various surgical outcomes, with emphasis on fully understanding the possible risks, ideally with family involvement and support for the procedure.
Revision candidates have historically been considered to be a unique clinical entity and higher-risk population, with the general assumption that as a group, they are difficult to please and overly demanding.(23,26) However, research suggests that revision rhinoplasty candidates , in aggregate, appear to be much more similar to primary rhinoplasty candidates than previously thought. In a single-clinic study of 150 consecutive patients, fewer than 10% of the presenting patients requested improvement of an already acceptable result (by the surgeon’s subjective opinion) and had satisfaction rates similar to those of primary rhinoplasty patients.(26)
In summary, the large majority of revision rhinoplasty patients are individuals who seek reasonable additional improvements after their primary surgery fell short of expectations. However, screening for psychiatric disorders and referring for treatment when there is concern, can help to optimize surgical outcomes in patients.
A Note on Suicide Risk in Cosmetic Surgery
There have been some studies noting a statistically significant correlation between breast augmentation surgery and suicide risk, up to a three-fold increase over the general population. It is important to note that this correlation seems specific to breast augmentation as opposed to other cosmetic surgical procedures such as rhinoplasty.(27) At this time, there does not appear to be any evidence that the performing of cosmetic procedures has any causal link to suicide or suicidal behavior, but this information should serve to reinforce the importance of psychiatric screening of patients who present for cosmetic surgery, as this may provide an excellent opportunity to refer an at-risk patient for potentially life-saving psychiatric treatment regardless of a decision whether to operate or not. (27) Alcohol or drug abuse, prior history of mental health diagnoses or suicide attempts, family history of suicide, access to firearms, borderline personality disorder, social isolation, and eating disorders all confer an increased risk of suicide and can be seen frequently in the cosmetic surgery clinic setting. As with any complete history and physical, assessment of suicidal thoughts or behaviors should be completed, with positive results referred on for an appropriate level of care.
For all patients seeking rhinoplasty, it is advised that the surgeon obtain a general psychiatric and drug and alcohol use history and to assess the patient’s current mental status. If this initial assessment elicits any concerning findings, referral to a mental health professional may be appropriate. Patients who appear to have certain psychiatric diagnoses such as Body Dysmorphic Disorder or various personality disorders (including Borderline, Narcissistic, and Histrionic) are at higher risk for negative outcomes and may benefit from referral to a mental health professional prior to surgery. Patients with well-controlled mood disorders or Post Traumatic Stress Disorder may be appropriate surgical candidates depending on the individual factors.
Patients who are predominantly motivated for surgery by external factors are of concern, as are those with unclear goals for the surgery. Other populations that should be treated with particular caution are those with a history of violent behavior, teenagers, and those at risk for losing cultural identity. While patients considering revision rhinoplasty should be assessed carefully, there is conflicting data regarding whether or not this is a high-risk population. Thoughtful psychiatric screening prior to rhinoplasty is important and can lead to discovery of undiagnosed conditions, referral for optimization of care, and identification of patients at risk for sub-optimal outcomes.
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- Honigman RJ, Phillips KA, Castle DJ. A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004 Apr 1;113(4):1229-37.
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- Sarwer DB, Zanville HA, LaRossa D, Bartlett SP, Chang B, Low DW, Whitaker LA. Mental health histories and psychiatric medication usage among persons who sought cosmetic Surgery. Plast Reconstr Surg. 2004 Dec;114(7):1927-33.
- Sarwer DB, Crerand CE. Psychological issues in patient outcomes. Facial Plast Surg. 2002 May;18(2):125-33.
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- Correa AJ, Sykes JM, Ries WR.Considerations before rhinoplasty. Otolaryngol Clin North Am. 1999 Feb;32(1):7-14.
- Gorney M. Recognition and management of the patient unsuitable for aesthetic surgery. Plast Reconstr Surg. 2010 Dec;126(6):2268-71.
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- Ende KH, Lewis DL, Kabaker SS. Body dysmorphic disorder. Facial Plastic Surgery Clinics of North America 2008; 16: 217-23.
- Picavet V. High prevalence of body dysmorphic disorder symptoms in patients seeking rhinoplasty. Plastic and Reconstructive Surgery 2011; 128: 509-517.
- Alavi M. Body dysmorphic disorder and other psychiatric morbidity in aesthetic rhinoplasty candidates. Journal of plastic, reconstructive and aesthetic surgery 2001; 64: 738-741.
- Picavet V, Lutgardis G, Horissen M, et al. Screening tools for body dysmorphic disorder in a cosmetic surgery setting. Laryngoscope 2011; 121:2535–2541.
- Ghadakzadeh S, Ghazipour A, Khajeddin N, et al. Body image concern inventory for identifying patients with BDD seeking rhinoplasty: using a Persian (Farsi) version. Aesthetic Plastic Surgery 2011; 35: 989-994.
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- Sarwer DB. Discussion: High prevalence of body dysmorphic disorder symptoms in patients seeking rhinoplasty. Plastic Reconstructive Surgery 2011; 128: 518-9.
- Davis RE, Bublik M. Psychological considerations in the revision rhinoplasty patient. Facial Plast Surg. 2012 Aug;28(4):374-9.
- Shridharani SM, Magarakis M, Manson PN, Rodriguez ED. Psychology of plastic and reconstructive surgery: a systematic clinical review. Plast Reconstr Surg. 2010 Dec;126(6):2243-51.
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- Constantian MB. What motivates secondary rhinoplasty? A study of 150 consecutive patients. Plast Reconstr Surg. 2012 Sep;130(3):667-78. doi: 10.1097/PRS.0b013e31825dc301.
- Sarwer DB, Brown GK, Evans DL. Cosmetic breast augmentation and suicide. Am J Psychiatry. 2007 Jul;164(7):1006-13.