Rhinoplasty: Are we selecting

the right patients?

CONFLICT OF INTEREST.

MEDICAL ASSOCIATE DIRECTOR MERCK SHARP & DOHME, MEXICO.

OUTCOMES RESEARCH LEAD

AGENDA

WHAT ARE WE DOING TO SELECT PATIENTS FOR AESTHETIC

RHINOPLASTY?
KEY POINTS IN FACIAL ANALYSIS
BEHIND THE SCENES OF RHINOPLASTY: PSHYCHOLOGY OF RHINOPLASTY.

AESTHETIC RHINOPLASTY
RHINOPLASTY CONTINUES TO RANK AMONG THE MOST POPULAR SURGICAL
COSMETIC TREATMENTS. IN 2014, NOSE RESHAPING WAS THE SECOND MOST
COMMON SURGICAL PROCEDURE PERFORMED IN THE UNITED STATES.
SUCCESS OF RHINOPLASTY MAY VARY ACCORDING TO THE AESTHETIC
PERCEPTION OF THE PATIENT AS WELL AS THE PREOPERATIVE STATUS OF THE
NOSE.
NASAL BREATHING AND PSYCHOLOGY OF THE PATIENT CONTRIBUTE TO THE
SUCCESSFUL OUTCOME.

WHAT ARE WE DOING TO SELECT PATIENTS

FOR AESTHETIC RHINOPLASTY?

SURVEY OF 41 OTOLARYNGOLOGIST AND PLASTIC SURGEONS THAT

PERFORM AESTHETIC RHINOPLASTY.
QUESTIONS REGARDING THEIR PRACTICE AND EXPERIENCE WITH
AESTHETIC RHINOPLASTY.
DESCRIPTIVE ANALYSIS OF THE RESULTS.

RESULTS.
YEARS OF PRACTICE:
39.02% HAVE BETWEEN 5 TO 10 YEARS AND MORE THAN 10 YEARS
PRACTICING (78.04%)
21.95% HAVE LESS THAN 5 YEARS OF PRACTICE

PHOTOGRAPHS
100% USE TO TAKE PREOPERATORY PHOTOGRAPHS, 93.75% BY
THEMSELVES.
84.3% USE THE SAME BACKGROUND, 75% USE THE SAME DISTANCE,
34.3% SPECIAL FLASH (AVOIDING SHADOW IN THE BACKGROUND),
15.6% OTHER (SAME POSITIONS, LIGHT IN FRONT OF PATIENT, ETC.)

RESULTS.
FACIAL ANALYSIS.
POWELL & HUMPHREY 34.48%, THIRDS AND FIFTHS 79.31%, DIVINE
PROPORTION 27.59%, OTHER 13.79% (GONZALEZ ULLOA, DIGITAL
PROGRAM, VIEW)

RESULTS.

PSYCHOLOGICAL ANALYSIS
25% PERFORM AN ANALYSIS BY THEMSELVES
6.25% REFER TO PSYCHOLOGIST
68.75% DO NOT PERFORM ANY ANALYSIS.

82.14% KNOW WHAT BODY DYSMORPHIC DISORDER IS.

RESULTS

57.14% DOES NOT DOCUMENT THEIR SURGICAL PLAN

FACIAL ANALYSIS AND PHOTOGRAPHS WERE CONSIDERED THE MOST
IMPORTANT ASPECTS OF PREOP ANALYSIS (57.14% AND 78.57%
RESPECTIVELY ON A 5 POINT LIKERT SCALE)
PSHYCHOLOGICAL ANALYSIS SCORED THE LESS IMPORTANT IN 25% OF
THE CASES.

FACIAL ANALYSIS

AESTHETIC ANALYSIS BEGINS WITH UNIVERSALLY ACCEPTED STANDARDS

FOR IDEAL PROPORTIONS, KEEPING IN MIND INDIVIDUAL UNIQUENESS
AND HOW THOSE STANDARDS APPLY TO THE PATIENTS OVERALL FACIAL
STRUCTURE.
THE GOALS OF ANALYSIS ARE TO DEFINE EXTERNAL NASAL DEFORMITIES,
PREDICT THE UNDERLYING ANATOMIC VARIATIONS, AND DETERMINE THE
APPROPRIATE SURGICAL INTERVENTION
IT DOESNT MATTER WHICH TYPE OF ANALYSIS YOU USE, WHAT IS
IMPORTANT THAT YOU DOCUMENT YOUR PLAN.

PSYCHOLOGY OF RHINOPLASTY: HISTORY

THE
FACE
HAS
ALWAYS
BEEN
CONSIDERED THE PERSONIFICATION OF
ONES SOUL. IT IS THE REPRESENTATION
OF THE PERSONS IDENTITY FROM THE
SOCIAL POINT OF VIEW.
FACIAL APPEARANCE IS CLOSELY TIED TO
THE SELF-IMAGE, SELF-CONFIDENCE,
AND SELF-WORTH OF THE INDIVIDUAL.
THE FACE IS THE PART THAT FIRST
ENTERS IN CONTACT AND REMAINS THE
LONGEST
IN
INTERPERSONAL
RELATIONS.

PSYCHOLOGY OF RHINOPLASTY: HISTORY

ELEMENTS OF APPEARANCE THAT HAVE THE
GREATEST INFLUENCE IN INTERPERSONAL
RELATIONS ARE ATTRACTIVENESS, BEAUTY AND
SEXUAL ATTRACTION.
A PERSON IS CONSIDERED PHYSICALLY
ATTRACTIVE IF VARIOUS GROUPS OF JUDGES
FIND HIM SO.
THIS JUDGEMENT IS NOT CONSTANT, IT VARIES
IN TIME, DIFFERS FORM ONE CULTURE TO
ANOTHER AND IS INFLUENCED BY MASS MEDIA,
ART, LITERATURE, FILMS, PUBLICITY, ETC.
WITH THE INTRODUCTION OF CAMERAS
EMBEDDED IN CELL PHONES AND WIDELY
ACCEPTANCE OF SOCIAL MEDIA, FACIAL
AESTHETICS HAS BEEN MORE IMPORTANT THAN
EVER BEFORE IN THE HUMAN HISTORY

PSYCHOLOGY OF RHINOPLASTY: HISTORY

THE NOSES ASPECT IS CRITICAL NOT ONLY FOR THE ANATOMY OF THE
FACE, BUT ALSO BECAUSE THIS ORGAN FREQUENTLY IS ONE OF THE
FACTORS THAT CAN DISTURB, CONSCIOUSLY OR SUBCONSCIOUSLY, OUR
IMAGE OF OUR BODY AND OUR PERSONALITY DEVELOPMENT
IT HAS CULTURAL, ETHNIC, SYMBOLIC, AND PSYCHOLOGICAL
SIGNIFICANCE

 BUT DOES EVERY PATIENT ASKING FOR SURGERY IS A GOOD

CANDIDATE?
HOW CAN WE DIFFERENCIATE BETWEEN PATIENTS THAT WILL
BENEFIT FROM SURGERY FROM THOSE WHO DONT?

PSYCHOLOGY OF RHINOPLASTY: HISTORY

SURGICAL ADVANCES FOLLOWING WORLD WAR I WERE ACCOMPANIED BY
ENTHUSIASTIC REPORTS OF THE EMOTIONAL RELIEF EXPERIENCED BY
DISFIGURED
INDIVIDUALS
WHO
UNDERWENT
RECONSTRUCTIVE
SURGERY.
IN THE 40S AND 50S THE FIRST PSYCHIATRIC EVALUATIONS OF PEOPLE
SEEKING ELECTIVE COSMETIC SURGERY. WARNING
SURGEONS WERE CAUTIONED OF THE PSYCHOPATHOLOGY OF THE
MALE PATIENT, AS WELL AS OF THE INSATIABLE SURGERY PATIENT
WHO SOUGHT OUT NUMEROUS COSMETIC PROCEDURES IN PURSUIT
OF THE PERFECT FACE.
EARLY INVESTIGATIONS BASED MAINLY ON CLINICAL INTERVIEW,
SHOWED A 70% PATIENTS WITH PSYCHIATRIC DISTURBANCES (NEUROTIC
DEPRESSION AND PASSIVE DEPENDENT PERSONALITY)

 Clinical interview not described

Diagnostic criteria?

Marked psychological disturbance

deviating from the normal picture
in need of therapy

PSYCHOLOGICAL ASSESSMENTS

CLINICAL INTERVIEW

ARE THE PATIENTS SOUGHTING FOR THE SAME COSMETIC PROCEDURE, AFFECTED BY THE SAME
PSYCHOLOGICAL PROBLEM?

IS IT DIFFERENT FROM A PATIENT SEARCHING FOR A TYPE-CHANGING SURGERY (RESHAPING

RHINOPLASTY) TO A RESTORATIVE SURGERY (FACELIFT)?

THE MAJORITY OF COSMETIC SURGERY PATIENTS WERE PSYCHOLOGICALLY DISTURBED.

PSYCHOMETRIC ASSESSMENTS

MANY TESTS (MINNESOTA MULTIPHASIC PERSONALITY INVENTORY, BRIEF SYMPTOM INVENTORY, EYSENCK
PERSONALITY INVENTORY, ETC)

THE MEASURES USED ARE NOT DESIGNED TO TAP THE TYPES OF PSYCHOPATOLOGY SPECIFIC TO THESE
PATIENTS.

 Less psychopathology
No clear relationship
between given cosmetic
procedures and specific
forms of psychopathology

SATISFACTION
PATIENTS SATISFACTION HAS BEEN DEFINED AS THE PATIENTS
PERCEIVED IMPROVEMENT IN WELL-BEING FOLLOWING THE
INTERVENTION.
APROXIMATELY 10 TO 15% OF PATIENTS ARE NOT SATISFIED BY RESULTS
OF COSMETIC NASAL SURGERY.
A CASE SERIES OF RHINOPLASTY REVISION SHOWED THAT 41% OF THE
CASES, ASKED FOR THE REVISION BECAUSE THEY NOTED ASYMMETRIES
OR IRREGULARITIES IN THE NASAL DORSUM, 33% ASKED FOR REVISION
BECAUSE THEY NOTED NOT ENOUGH CORRECTION OF NASAL
DEFORMITY.

PATIENT SATISFACTION?
A UK DEPARTMENT OF HEALTH
SYSTEMATIC REVIEW IDENTIFIED
ONLY 9 SPECIFIC INSTRUMENTS THAT
DEMOSTRATED ADEQUATE
PSYCHOMETRIC PROPERTIES AND
WERE DEVELOPED WITH PATIENT
INPUT.
PATIENT SATISFACTION WITH THEIR
APPEARANCE IS AN OFTEN
OVERLOOKED OUTCOME, AND ABLE
TO BE MEASURED IN FACIAL
AESTHETICS USING THE FACE-Q
SCALES.

PATIENT REPORTED OUTCOMES

PATIENT-REPORTED OUTCOMES ARE THE PATIENTS FEEDBACK, ELICITED

DIRECTLY FROM THEM WITHOUT INTERPRETATION BY THE PHYSICIAN OR
OTHERS, ON HOW THEY PERCEIVE THE PHYSICAL, MENTAL, OR SOCIAL
CONDITION RELATED TO THEIR CONDITION OR TREATMENT.
SYSTEMATIC USE OF PRO TOOLS IMPROVES COMMUNICATION AND DECISION
MAKING BETWEEN PHYSICIANS AND PATIENTS AND ENHANCES PATIENT
SATISFACTION WITH CARE.

BODY DYSMORPHIC DISORDER (BDD)

IS ONE OF THE MOST COMMON PSYCHIATRIC CONDITIONS FOUND IN
PATIENTS SEEKING COSMETIC SURGERY. ABOUT 5% AND UP TO 16.6% IS
THE REPORTED GLOBAL PREVALENCE
A STUDY IN IRAN SHOWED A 31.5% PREVALENCE AMONG RHINOPLASTY
CANDIDATES AND 70.7% OF THEM HAD MODERATE TO SEVERE FORMS
OF BDD.
80% OF PLASTIC SURGEONS IN THE USA REPORT THEY WOULD NOT
OPERATE A PATIENT WITH BDD, BUT 84% HAS UNWILLINGLY OPERATED
AT LEAST ONE.

BDD

DEFINED AS APREOCCUPATION WITH AN IMAGINED DEFECT IN ONES

APPEARANCE.
ALTERNATIVELY, IF A SLIGHT PHYSICAL ANOMALY IS PRESENT, THE
PERSONS CONCERN IS MARKEDLY EXCESSIVE.
DSM-IV, THE PREOCCUPATION SHOULD LAST FOR AT LEAST AN HOUR A
DAY1 AND CAUSE CLINICALLY SIGNIFICANT DISTRESS OR IMPAIRMENT IN
SOCIAL, OCCUPATIONAL OR OTHER IMPORTANT AREAS OF FUNCTIONING.
ANXIETY AND DEPRESSION HAS A PREVALENCE OF 26.8% TO 40% IN
BDD PATIENTS.

 BDDQ
(SENSITIVITY OF 100 % AND A SPECIFICITY
BDD
ASSESSMENT
OF 8993 %)

ARE YOU VERY WORRIED ABOUT YOUR APPEARANCE IN

ANY WAY?
DOES THIS CONCERN PREOCCUPY YOU? THAT IS, DO YOU
THINK ABOUT IT A LOT AND WISH YOU COULD WORRY
ABOUT IT LESS? HOW MUCH TIME DO YOU SPEND
THINKING ABOUT IT? (MORE THAN 1 H PER DAY IS
SUGGESTIVE AND MORE THAN 3 HR IS HIGHLY SPECIFIC
FOR BDD).
WHAT EFFECT HAS THIS PREOCCUPATION HAD ON YOUR
LIFE?
HAS IT: SIGNIFICANTLY INTERFERED WITH YOUR SOCIAL LIFE,
SCHOOL WORK, JOB, OTHER ACTIVITIES, OR OTHER ASPECTS OF
YOUR LIFE? CAUSED YOU A LOT OF DISTRESS? AFFECTED YOUR
FAMILY OR FRIENDS?

BDD ASSESSMENT

DYSMORPHIC CONCERN QUESTIONNAIRE (DCQ) 7 ITEMS.

YALE BROWN OBSESSIVE COMPULSIVE SCALE

CONCLUSION

COMPLETE SURGICAL PLAN NEED TO BE DOCUMENTED BEFORE

SURGERY.
PATIENT SELECTION SHOULD NOT ONLY HAVE A PREOPERATORY
ASSESSMENT PURELY FROM THE RHINOLOGICAL STANDPOINT;
PSYCHOLOGICAL ASPECTS SHOULD BE CONSIDERED AS WELL.
STANDARIZATION OF ASSESSMENT.