The consultation

What repeats

Five findings that hold across the literature.

The guideline sets seven things the surgeon must do and two things the surgeon must not

The clinical practice guideline on nasal form and function after rhinoplasty applies to patients aged 15 years and older. Clinicians should ask about motivations and expectations, say whether those expectations are realistic, and document that conversation. They should assess comorbid conditions that change or rule out surgery, naming obstructive sleep apnoea, body dysmorphic disorder, bleeding disorders and long-term use of decongestant nasal sprays. They should evaluate the airway, educate the patient about the recovery and about the possible need for later nasal surgery, counsel patients with sleep apnoea, explain how discomfort will be managed, and record satisfaction with appearance and with breathing at a minimum of 12 months. The guideline recommends against antibiotics past 24 hours and against routine nasal packing. Three societies then turned the guideline into a measure set: one outcome measure, patient satisfaction, and three process measures covering motivations and expectations, airway assessment, and shared decision making on non-narcotic pain control.

Rests on: the clinical practice guideline · the plain language summary · Manahan et al., rhinoplasty performance measures.

The complaint that brings a patient in differs between a first nose and a revision

Four hundred consecutive consultations were coded for what the patient said. People coming for a first operation named a nose that was too large and a dorsal hump. People coming after an earlier rhinoplasty named a crooked nose, tip asymmetry, wide nostrils, a dorsal scoop and columellar show, and raised alar retraction, a pointy tip and scarring, which the first group almost never mentioned.

Rests on: Chauhan et al., primary versus revision complaints · and revision rhinoplasty.

Screening for body dysmorphic disorder is part of the appointment

The weighted prevalence across every setting that has been surveyed is 20.1% in rhinoplasty surgery and 13.2% in general cosmetic surgery, against 1.9% in the adult community. Pooled across fifteen studies of 1,977 Asian rhinoplasty seekers, prevalence was 30.0%, running at 36% when a questionnaire was used and 18% when the diagnostic criteria were applied by interview. In a Brazilian series of 50 candidates selected for excessive preoccupation with appearance, 48% had symptoms of the disorder and 54% had moderate to severe obsessive-compulsive symptoms about appearance. Six questionnaires have been validated in a cosmetic setting, the shortest of them a seven-item form that most patients finish in one to two minutes. Among patients screened before and after surgery in one practice, 83% who screened positive before the operation screened negative afterwards, while a positive screen at either point tracked with worse satisfaction with appearance.

Rests on: Veale et al., weighted prevalence by setting · Chua et al., pooled prevalence · Ramos et al., candidate screening · Thomson et al., validated screening tools · Losorelli et al., outcomes after a positive screen · and the psychology of rhinoplasty.

Aesthetic expectation runs higher than aesthetic satisfaction ever does

Patients rated what they expected before surgery and what they got after it on the same scale. Mean aesthetic expectation before a cosmetic rhinoplasty was 89.69. Mean aesthetic satisfaction was 79.09 in the first two months and 75 beyond a year, both lower than the expectation that preceded them. Functional expectation behaved the other way, with satisfaction scoring above it. In 183 septorhinoplasty patients scored the same way, expectation before a cosmetic operation was 86.15 against 79.24 before a functional one, the highest expectation of all, 92.17, was recorded in the cosmetic patients who ended up dissatisfied, and how far expectation was covered correlated with satisfaction at 0.907.

Rests on: Kandathil et al., expectation against satisfaction · Avcu and Metin, expectation coverage.

Shopping many surgeons predicts a worse reported result

Patients who had seen three surgeons were compared with patients who had seen four or more. Mean outcome scores after surgery were 82% in the three-surgeon group and 68.92% in the group that had consulted more widely, with 50 patients in each arm. The authors read the pattern as a signal to examine those patients more carefully before agreeing to operate.

Rests on: Erkan and Erkan, multiple consultations.

By what the appointment produces

Four records come out of the visit, and each one is used later.

A written note of motivation and expectation

This is the guideline's first action statement and it is the record that a later dispute turns on. Of 23 United States rhinoplasty malpractice decisions handed down between 1960 and 2018, technical error was alleged in 69.6% and a fault in the consent process in 21.7%, and the main contributing factor was dissatisfaction with appearance in 60.7%. Twenty of the 23 were decided for the surgeon.

Rests on: the clinical practice guideline · Ong et al., malpractice litigation.

A physical examination and a baseline score

The examination covers medical and nasal history, the outside of the nose in each standard view, and the airway, which the guideline makes a separate action statement because appearance surgery can change breathing. The Standardized Cosmesis and Health Nasal Outcomes Survey is a ten-item patient questionnaire with an obstruction domain and a cosmesis domain, validated for rhinoplasty. Recording it before surgery is what makes the guideline's twelve-month documentation comparable to anything.

Rests on: Clappier and Tanna, preoperative evaluation · Moubayed et al., SCHNOS · the clinical practice guideline · and nasal anatomy · and nasal airway obstruction.

A simulated image, where the surgeon uses one

Consecutive patients were imaged at consultation, and 13.2% were turned down because surgeon and patient never agreed on a simulated result. Of the 290 who were accepted, 178 went ahead and 38 cancelled. Dissatisfaction with the simulation ran at 42% in the group that postponed and 16% in the group that was operated on.

Rests on: Lekakis et al., morphing as a selection tool · and rhinoplasty photography.

What to ask about the consultation

Questions the evidence supports asking.

What did you write down about what I want

The guideline requires the discussion of motivations and expectations, and the surgeon's feedback on whether they are realistic, to be documented. Ask to see that note.

Rests on: the clinical practice guideline · the plain language summary.

How will you check my breathing today

Airway evaluation before surgery is a guideline action statement, and the surgeon may delegate it. Ask what was examined, and ask what the plan is if the operation narrows the airway.

Rests on: the clinical practice guideline · and nasal airway obstruction.

Which questionnaire will I fill in, and when will I fill it in again

Ask for the Standardized Cosmesis and Health Nasal Outcomes Survey or a comparable instrument before surgery and again at a year. Without a baseline, the twelve-month record has nothing to compare against.

Rests on: Moubayed et al. · the clinical practice guideline.

How do you screen for body dysmorphic disorder

Ask which tool is used and who reads it. Prevalence in rhinoplasty candidates is high enough that a practice with no screening step is choosing not to look.

Rests on: Chua et al. · Ramos et al. · and the psychology of rhinoplasty.

What am I consenting to, and can I take it home

Adding a filmed explanation to the standard consent conversation was tested on 40 prospective patients. The video ran 25 minutes and answered 65 questions collected across 30 real consultations. Patients scored 4.00 out of five on recall of the risks afterwards. The European Rhinoplasty Course faculty has published a consensus consent form for rhinoplasty and septorhinoplasty, checked for legal validity. Patients informed 14 days before surgery were less anxious the day before it than patients informed 3 days before, with 25 in each arm.

Rests on: Hakimi et al., video-assisted consent · Hellings et al., EUFOREA consensus consent · Aysel et al., consent timing and anxiety.

The terms, defined

The words used at a first rhinoplasty appointment.

• Action statement: a numbered recommendation in a clinical practice guideline, each one graded by the strength of the evidence behind it. [28145823]
• Body dysmorphic disorder: a psychiatric condition of preoccupation with a perceived defect in appearance, screened for with a short questionnaire in cosmetic practice. [40907540]
• Comorbid condition: an illness the patient already has that changes or rules out the operation, such as obstructive sleep apnoea or a bleeding disorder. [28145823]
• Morphing: editing a photograph of the patient's nose to show a proposed result. [32092769]
• NOSE score: Nasal Obstruction Symptom Evaluation, the patient questionnaire for blocked breathing. [28880988]
• SCHNOS: Standardized Cosmesis and Health Nasal Outcomes Survey, ten items split between an obstruction domain and a cosmesis domain. [28880988]
• Primary rhinoplasty: a first operation on an unoperated nose. [21908809]
• Revision rhinoplasty: an operation on a nose that has been operated on before. [21908809]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology publishes the guideline and a plain language summary written for patients, both free to read from the academy's own page. The summary is the shortest way for a patient to see what a surgeon is supposed to do before operating.

• The guideline landing page

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries two chapters on this appointment. They are written for surgeons and go further into examination technique than a patient page should.

• The Rhinoplasty Consult: Patient Evaluation
• Psychiatric Screening of the Rhinoplasty Patient

The reference summary

Body Dysmorphic Disorder in StatPearls, on the National Library of Medicine's Bookshelf, gives the diagnostic criteria, the screening tools and the treatment options in full text at no charge.

The societies

• American Society of Plastic Surgeons, patient information on what a consultation covers. See associations.

The trials in progress

Screening at the consultation is under test.

• AI Screening for BDD in Aesthetic Surgery, completed, 3722 participants.

What is not settled

• No trial shows that documenting motivations and expectations changes the outcome. The guideline recommendation rests on the panel's judgement of harms avoided, not on a randomised comparison. [28145823]
• Reported prevalence of body dysmorphic disorder swings with the instrument used, from 36% by questionnaire to 18% by diagnostic interview in the same pooled dataset. Of the six screening tools reviewed for a cosmetic surgery setting, two had been validated there, and the one tested against outcome did not predict the subjective result. [40907540] [22109751]
• Whether a positive screen should stop an operation is unresolved. One series reports that most positive screens resolve after surgery, while a positive screen still tracks with lower satisfaction. Litigation data, drawn from published court decisions that exclude settlements, run to 23 cases across almost sixty years, too few to rank causes reliably. [38452148] [33331894]
• The finding that psychological markers predict claims comes from one case-control study of fifty-five litigating patients against 85 who did not litigate, in a single forensic referral stream. [41419223]
• Whether morphing raises expectations or filters them is argued both ways. The selection study reports that patients who disliked the simulation were the ones who did not proceed. [32092769]