Psychological Characteristics of Revision Rhinoplasty Patients

4 Psychological Characteristics of Revision Rhinoplasty Patients
Canice E. Crerand, Lauren M. Gibbons, and David B. Sarwer

Rhinoplasty is one of the most popular cosmetic procedures performed in the United States.1 In 2006, 141,912 were performed, making it the sixth most commonly performed cosmetic surgical procedure.¹ Although the majority of these operations were likely primary procedures, a significant percentage were secondary or revision procedures. In 1997, the last year that revision rhinoplasties were reported by the American Society of Plastic Surgeons, 22% were revisions.² In a retrospective analysis of 218 consecutive rhinoplasties performed in the early 1990s, the revision rate was 10%.³

Understanding the psychological characteristics of patients who desire and undergo primary or revision rhinoplasty is important for several reasons. First, cosmetic procedures such as rhinoplasty are often seen as analogous to psychological interventions; when successful, both result in psychosocial benefits to the patient.⁴ Second, there may be a subset of patients, particularly those with certain psychiatric disorders, for whom rhinoplasty or its revision may not be beneficial. Because of these issues, an understanding of the psychological characteristics of rhinoplasty patients may have implications for both patient selection and treatment outcome.

The psychological characteristics of rhinoplasty patients have received substantial attention in the literature, owing in part to the enduring popularity of this procedure. Far less attention, however, has been paid to the psychological characteristics of patients presenting for revision rhinoplasty. This chapter will review studies of the psychological characteristics of rhinoplasty patients in general. We will provide an overview of one psychiatric disorder, body dysmorphic disorder (BDD), which may be more common among patients presenting for primary and revision rhinoplasty. Strategies for assessing the preoperative psychological functioning of prospective rhinoplasty patients are also offered.

Studies of the Psychological Characteristics of Rhinoplasty Patients

Early Studies

Plastic surgeons and mental health professionals have long been interested in the psychological characteristics of rhinoplasty patients. The first investigations were conducted in the 1940s and 1950s.^5,6 These and subsequent studies in the 1960s primarily relied on unstructured, psychodynamically oriented clinical interviews. From this theoretical orientation, the nose frequently was considered to be a symbolic representation of the penis. The desire for rhinoplasty was interpreted as the individual’s unconscious displacement of gender or sexuality conflicts onto his or her nose.^7–9

Not surprisingly, results from these studies suggested that the majority of rhinoplasty patients were psychologically disturbed.^5,6 One group of researchers assumed that all patients desiring rhinoplasty were, in fact, suffering from psychiatric disoders.⁵ Other studies noted high rates of personality disorders.¹⁰ Postoperative exacerbations of these conditions also were described.¹⁰

During the 1970s and 1980s, investigators began to use reliable and valid self-report psychometric measures in their studies.^11,12 Several also used control groups and preoperative and postoperative assessments, both of which were often absent from previous studies. Results suggested that patients had far less preoperative psychopathology than previously reported.^13–16 Other studies documented improvements in psychosocial functioning after surgery.^14,15,17,18

For example, a study that used the Minnesota Multiphasic Personality Inventory found essentially normal preoperative personality profiles in a sample of 90 patients.¹⁵ Postoperatively, no changes in personality profiles occurred, and patients reported that surgery had positive effects on their self-concept.¹⁵

Recent Studies

More recent studies, for the most part, have continued to use improved methodologies. Collectively, these studies have found little evidence of preoperative psychopathology and have noted improvements in psychosocial well-being postoperatively. For example, Goin and Rees¹⁹ administered the Brief Symptom Inventory, a measure of psychological symptoms, to a sample of 121 rhinoplasty patients. Preoperatively, patient responses fell within the normal range. Postoperatively, patients reported reductions in anxiety, depression, and obsessive behavior. Another prospective study found improvements in self-esteem both 1 week and 4 months after surgery.²⁰

Other studies have compared the psychological characteristics of rhinoplasty patients with patients seeking septorhinoplasty or septoplasty.^21,22 Rhinoplasty patients reported more problems with life functioning on a measure of well-being, symptoms or problems, and life and social functioning.21 No differences in well-being or psychological symptoms were found between the groups. Similarly, rhinoplasty and septoplasty patients did not differ with respect to self-reported interpersonal problems.²² A study of 25 septorhinoplasty patients that used psychiatric interviews and self-report measures (e.g., Beck Depression Inventory, Symptom Checklist-90) found no evidence of psychopathology preoperatively, with the exception of a few patients with mild adjustment disorders.²³ Postoperatively, patients noted improvements in social desirability and satisfaction with surgical outcome. Half of the patients with adjustment disorders reported improvements in their symptoms.²³

Ercolani and colleagues assessed the personality characteristics of 72 rhinoplasty patients preoperatively and postoperatively using the Extroversion and Neuroticism scales, the Maudsley Personality Inventory, and the Anxiety scale of the Inventory for Personality and Anxiety Testing.²⁴ Increases in extroversion and reductions in neuroticism and anxiety were noted postoperatively. In a subsequent study, 79 rhinoplasty patients were assessed preoperatively and postoperatively using these same measures.²⁵ At 6 months postoperatively, patients reported decreases in neuroticism and anxiety and increases in extroversion. At 5 years postoperatively, patients continued to report decreases in neuroticism and anxiety, however, increases in extroversion were no longer apparent. According to unspecified preoperative psychological evaluations, 34% of this sample displayed symptoms of mild to moderate psychiatric disorders, including BDD (discussed in the next section), other somatization disorders, social phobia, and personality disorders.²⁵ These patients also had elevated preoperative Inventory for Personality and Anxiety Testing and Maudsley Personality Inventory scores that were still apparent for most at both follow-up assessments. Thus, it appears that patients with more significant psychopathology did not experience postoperative symptom improvement.

Several studies have found that cosmetic surgery patients report increased body image dissatisfaction before surgery.^26–30 They also report heightened dissatisfaction with the specific physical feature considered for surgery.^28–31 These findings also hold true for rhinoplasty patients, with female rhinoplasty patients reporting increased dissatisfaction with their nose compared with the degree of dissatisfaction with overall facial appearance reported by aging face patients.²⁸

Conclusions

It is difficult to reconcile the findings from the studies over the past several decades, largely because of methodological differences between the investigations. Early studies relied heavily on psychodynamically oriented interviews, which conceptualized the desire for rhinoplasty as the patient’s unconscious displacement of sexual conflicts onto the nose.⁷ Not surprisingly, these studies suggested that the majority of rhinoplasty patients were psychologically disturbed and that surgery might exacerbate psychopathology. As studies began to incorporate standardized psychometric assessments, less psychopathology was found, and several studies suggested that rhinoplasty could produce improvements in psychological symptoms. However, many of these studies suffered from methodological problems, such as small sample sizes and the lack of appropriate control groups, which limited the validity of the findings.

Recent studies, which have addressed many of the methodological weaknesses of earlier studies, have found relatively modest differences between rhinoplasty patients and other people. These studies also provided preliminary evidence that among patients with more severe psychological symptoms, surgery may not result in psychological benefits.²⁵ However, many of these studies have investigated symptoms of psychopathology as opposed to the prevalence of formal psychiatric diagnoses in this population. Nonetheless, recent studies suggest that in most cases, people seek rhinoplasty to improve the appearance of their noses, not because they are psychologically disturbed. Although the findings reviewed are based on studies of primary rhinoplasty patients, they may apply to patients desiring revision rhinoplasty as well.

Rhinoplasty and Body Dysmorphic Disorder

The rate of psychiatric disorders among cosmetic surgery patients is largely unknown. Two clinical interview studies in the 1990s assessed rates of psychiatric disorders among patients who sought a range of cosmetic surgical procedures. These studies reported that 20 to 48% had a formal psychiatric diagnosis.^32,33 However, both studies suffered from methodological problems that call into question the validity of the findings. To date, no large studies using structured clinical interviews and standardized diagnostic criteria have been conducted.

Regardless, it is likely that all of the major psychiatric disorders exist among patients who desire cosmetic procedures. One psychiatric disorder, BDD, appears to occur with increased frequency among cosmetic surgery patients and particularly among those who seek rhinoplasty.

Diagnostic Criteria

According to the Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR), BDD is defined as a preoccupation with an imagined or slight defect in appearance that results in significant emotional distress or impairment in daily functioning.³⁴ BDD was first recognized in the United States as a psychiatric disorder in 1987.35 However, descriptions of “minimal deformity” and “insatiable” patients, which are consistent with the features of BDD, appeared in the literature much earlier.^36,37

Clinical Characteristics

BDD tends to be a chronic disorder that typically begins during late adolescence.^38,39 It is thought to occur equally among men and women.^38,40 Persons with BDD typically report preoccupation with their noses, skin, or hair.^38,41 However, any body part can become a source of concern, and it is common for persons with BDD to be preoccupied with more than one physical feature.⁴¹ Areas of concern and symptom severity vary over the course of the disorder.^38,39 Insight also varies; some patients acknowledge that their concerns are excessive, whereas others may hold their beliefs about their appearance with delusional intensity.^42,43

Persons with BDD typically experience intrusive thoughts about their appearance. They frequently engage in repetitive, compulsive behaviors such as camouflaging their perceived flaw or checking their appearance in the mirror. Some seek reassurance from others about their “defect,” often to the point of causing strain in their social and romantic relationships.⁴⁴ Skin picking is common.^45,46 Performing such compulsive behaviors for more than 1 hour per day is considered to be a diagnostic indicator of BDD.^47,48

The intrusive thoughts and compulsive behaviors frequently cause emotional suffering. Many persons with BDD experience significant impairment in social and occupational functioning as well as decreased quality of life.^48,49 Descriptions of persons with BDD who have performed their own cosmetic surgeries have appeared in the literature.⁵⁰ Persons with severe forms of the disorder may become housebound or may engage in self-harming or suicidal behaviors.^38,39,51

Prevalence

BDD is thought to occur in 1 to 2% of the general population, although this rate has yet to be confirmed with epidemiological studies.³⁴ Community studies have reported prevalence rates of 0.7%,^52,53 whereas rates of 2.5 to 5% have been reported in university samples.^54–57 Higher rates of the disorder have been found among U.S. samples of patients presenting for cosmetic (7 to 8%)^29,58 or reconstructive (7 to 16%) surgery.^58,59 Rates of 9 to 53% have been reported among international samples of cosmetic surgery patients. The use of different assessment methodologies likely accounts for the variance in rates among these studies.^32,60–62 Among patients seeking dermatological treatment, studies suggest that 9 to 15% have BDD.^63–65 Persons with BDD also present to other treatment providers, including dentists, maxillofacial surgeons, and medical aestheticians, although the rate of the disorder in these populations is unknown.^41,66–68

Few studies have examined in particular the rate of BDD among persons specifically seeking rhinoplasty or revision rhinoplasty. Veale and colleagues⁶⁹ compared the psychological characteristics of a group of 29 patients who sought rhinoplasty to a group of patients with BDD with nose concerns who were in psychiatric treatment. In the first part of the study, patients presenting for rhinoplasty completed self-report measures of BDD symptoms, anxiety, and depression. Nearly 21% (n = 6) of primary rhinoplasty patients had positive screens for BDD. However, after surgery, none of these patients had positive screens for BDD, and all reported satisfaction with their surgical results. The authors suggest that the patients who screened positive for BDD before surgery did not, in fact, have the disorder, particularly because they did not report the expected levels of anxiety and depression typically associated with BDD.

In the second part of the study, Veale and colleagues⁶⁹ identified important differences between patients presenting for rhinoplasty and patients with BDD. Those with BDD were significantly younger, more depressed and anxious, more preoccupied with their noses, and had greater functional impairment compared with rhinoplasty patients. Persons with BDD were also more likely to engage in compulsive behaviors and to have been discouraged from having cosmetic surgery by family and friends.

To date, no published studies have examined the rate of BDD in revision rhinoplasty patients. One unpublished report (MB Constantian, M.D., oral communication, March 2005) suggested that 7 of 200 consecutive revision rhinoplasty patients were thought to have BDD. Additional studies are needed to further assess the rate of BDD among patients seeking both primary and secondary rhinoplasty. The following case describes a woman with BDD who presented for revision rhinoplasty:

Julie was a 28-year-old, European American woman who presented to a plastic surgeon with concerns about a “bump” on her nose. She was married, had no children, and was not employed. She came to her initial appointment very well dressed and well groomed, suggesting significant affluence. She reported that she underwent her first rhinoplasty at the age of 16 and had undergone two other revisions with her initial surgeon since that time. She indicated that the initial surgeon said there was nothing else to be done to address her concerns. She also said that she heard that the surgeon she is consulting with today was “the best rhinoplasty surgeon in town.”

At first glance, the surgeon is unable to see the “bump” on her nose. When he gives Julie a mirror and asks her to show him the bump, she holds onto the mirror for several minutes and points to an area on the bridge of her nose where no bump is apparent to the surgeon. Julie reported that her nose makes her “ugly” and that she thinks about it every day. When she feels particularly bad, she is unable to leave the house. This has become a point of contention in her marriage. Her husband would like to go out on the weekends, but Julie frequently refuses. When Julie does go out, she prefers to go to the movies or restaurants far away from her home and where she is unlikely to run into people she knows.

Comorbid Disorders

Depression is the most common comorbid condition found with BDD, with up to 90% of patients reporting a lifetime history of the disorder.70 Substance use, anxiety, and eating and personality disorders also commonly co-occur.^{38,39,51,70–73} The high comorbidity rate, in combination with the secrecy associated with the disorder, may compromise accurate diagnosis and treatment.^48,51

Nonpsychiatric Treatment

People with BDD frequently seek cosmetic and dermatological treatments to fix their perceived appearance flaws.^{38,41,50,51,68} Often, they will “doctor shop” until they find a surgeon who will provide their desired procedure.^41,74 The largest study of nonpsychiatric treatment among BDD patients (n = 250) found that 76% sought and 66% received treatment, most commonly dermatological and surgical procedures.⁴¹ In a subsequent study of 200 persons, nonpsychiatric treatment was sought by 71% and received by 64%.⁶⁸ Topical acne agents, collagen injections, electrolysis, and tooth whitening were the most commonly received treatments.⁶⁸ Rhinoplasty is the most commonly received surgical procedure.^41,50,68 This finding is not surprising, considering that the nose is a common area of concern.