PSYCHOLOGICAL EVALUATION

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Preoperative screening of the rhinoplasty patient (especially the man) should not stop with a complete medical work-up and careful facial analysis; a thorough psychological evaluation is equally important. Rhinoplasty is an elective operation in which relative or absolute contraindications to surgery are not limited to medical conditions that may cause postoperative morbidity or physical characteristics that limit the degree of surgical change. Psychological and attitudinal characteristics that significantly hinder the patient’s acceptance and satisfaction with the cosmetic outcome may also serve as a potential contraindication to surgery. During the initial interview it is important to ask specific and open-ended questions to gain an understanding of the patient’s motivation and to expose any psychoses. Gathering as much information as possible is critical to ensure that both the patient and the surgeon have the same goals in mind. Questionnaires and personality inventories may provide additional insight into the psyche of the prospective patient. Anderson and Johnson3 have developed a comprehensive questionnaire designed specifically for the facial plastic surgery candidate.

The interview may begin with: “How may I help you today?” or “What brings you to our office?” Then one proceeds to other useful questions, such as²:

1. What features do you dislike about your nose?
2. How long have you disliked your nose?
3. What is your conception of the ideal nose for you?
4. How long have you been thinking about having nose surgery?
5. What made you decide to seek consultation at this time?
6. Has anyone you know ever had cosmetic surgery?
7. Is having surgery your idea, or did someone else encourage you?
8. Have there been any recent changes in your life?
9. How close to your ideal appearance do you expect to be after surgery?
10. What do you think this operation will do for you?

The surgeon should be suspicious of the patient who is vague about his goals, who has seen numerous other physicians, or who has had multiple other cosmetic procedures and is still dissatisfied with his appearance. Manipulative patients, and especially those who are hostile during the interview, are most likely to be unhappy with their results and sue their physician postoperatively.¹⁰ Wright²⁷ observed that four characteristics are consistently evident when observing rhinoplasty patients and reviewing the literature in the psychology of rhinoplasty: (1) psychological disturbance is more prevalent among rhinoplasty patients, especially men; (2) these disturbances tend to be long-term and usually reflect an identity conflict or a somatic conversion of a conflict; (3) the severity of deformity does not correlate with postsurgical satisfaction; and (4) the patient’s repressed hostility is often directed toward the physician.

If during the course of initial evaluation one gets “bad vibes” from the patient, then this is symptomatic of a potentially high-risk patient. These patients, however, should not be rejected at once. Because cosmetic patients can be reserved and may require more time to be open, a follow-up appointment should be arranged. If on the subsequent evaluation the physician continues to feel intuitively uncomfortable, then surgery should be avoided and the patient referred to another physician. Additionally, a rhinoplasty patient should be rejected if he has paranoid thoughts, is delusional, has symptoms of surgical addiction, or is malingering.²⁷ The psychotic patient must be identified and surgery avoided because one does not want to become incorporated in the patient's paranoid delusional system. These patients must be referred to a psychiatrist, especially because these are patients who may harm their physicians.

Although broad generalizations can be made about male rhinoplasty patients, several psychosocial subtypes of patients can be identified who differ in their response to cosmetic surgery. Overtly effeminate homosexual men are usually happy with their results and have fewer psychological disturbances postoperatively. This is in contrast to the “closet” homosexual who is most likely to be dissatisfied with his surgical outcome. It is hypothesized that the effeminate man has made a solid decision about his sexuality and is more likely to know what he wants and thus behave more like a female patient. The man who is in conflict with his sexual identity is not sure what he wants and is more likely to be displeased.³

In general, psychological difficulties in both men and women increase with age, and as patients age they become more intolerant of dramatic changes in their facial features (with the exception of face-lift and blepharoplasty operations). The adolescent body undergoes sudden dramatic changes that are rapidly incorporated into the body image. Consequently, Goin and Goin⁸ believe that adolescent boys, when compared with older men, are more tolerant of their new nose after rhinoplasty. Postadolescent men are more risky as patients because changes in appearance can readily cause body image disturbances.

This is especially true if the dislike for their nose is newly found. “When an adult suddenly develops preoccupations with the appearance of his nose, one should look for changes in the patient’s psychiatric state since mechanisms of projection may be at work.”³

Patients in midlife (fourth to sixth decades) usually have a well-imprinted body image and a clear conception of an ideal appearance. These patients respond best to conservative and subtle changes that maintain a natural look that does not draw undue attention to the nose. Midlife patients who “always wanted something done” find motivation to have rhinoplasty in a variety of circumstances including newly acquired economic independence; nasal trauma; unsatisfactory long-term results with previous surgery; successful surgery of a friend or family member; or recent separation, divorce, or death of a spouse.23 The older male patient suffers from the effects of aging on the nose and requires an even more conservative approach designed to return the nose to its preaged appearance. This type of change is better tolerated and does not carry with it the usual psychological sequela.

Although there are thousands of happy rhinoplasty patients, some with quite bad looking noses, there are many unhappy ones, most with a good result. This point demonstrates the complexity of issues and attitudes that are inherent in these patients, making male rhinoplasty the operation for which patient evaluation and selection must proceed with utmost caution.