3 Psychological Evaluation
Patient selection is essential for a successful revision rhinoplasty. The physician will determine whether the patient′s desire for surgery is justified and must decide whether a revision will actually solve the patient′s problems. More than in any other specialty, the decision to perform or withhold revision surgery in cases with an aesthetic indication will depend on the emotional, conscious, and unconscious motives of the patient ( Fig. 3.1 ). 1 – 3 The task of the physician, then, is to determine the psychosocial context of the desire for surgery independently of the patient′s self-will. The mental disorders listed below play an important role.
3.1 Reactive and Adjustment Disorders
Facial deformities that are objectively disfiguring are often associated with reactive mental disorders. They may take the form of an acute stress reaction or may develop later as a post-traumatic stress disorder. Patients with high vulnerability may develop an adjustment disorder in their attempt to process or overcome disease or disfigurement. Given the severity of the underlying organic problem, plastic reconstructive or cosmetic surgery is appropriate for these patients (see Case 32, Chapter 25) and may lead to a resolution or improvement of psychological symptoms. 4 But if the mental disorder itself is the dominant finding, even a successful operation may cause psychological disturbance in patients who were projecting their emotional distress onto their physical defect and using it as an excuse for that distress. 5
3.2 Depressive Disorder
Approximately 20% of patients who seek cosmetic surgery have a depressive disorder. The main symptoms are a depressed mood, loss of interest or pleasure in daily activities, apathy, and heightened fatigability. 6 Other symptoms such as body dysmorphic disorder with low self-esteem should be given particular attention in cosmetic surgery because they may create a motive for the operation. The interviewer should ask specifically about suicidal thoughts, which must be excluded. Any evidence in that direction would contraindicate the surgery and prompt an immediate referral for psychotherapy.
3.3 Comorbidity
“Comorbidity” refers to physical symptoms that coexist with a mental disorder. Comorbidities may significantly affect the motivation for and course of aesthetic surgery. Psychological disturbances such as affective disorders (6.3%), anxiety disorders (9%), and somatoform disorders (7.5%) have a high prevalence in the general population. International studies have shown that mental disorders are significantly more prevalent in patients who seek aesthetic surgery. 4 , 6 , 7
3.4 Social Phobias
Anxiety reactions are centered on the fear of being watched and judged by others. Affected individuals tend to avoid social situations, which interferes with relationships, resulting in psychosocial isolation. Primary social phobias in the absence of physical abnormalities are usually associated with a feeling of low self-worth and may cause the patient to seek cosmetic surgery. Eleven percent of patients with social phobia were found to have a body dysmorphic disorder. 8 Cosmetic surgery is not advised in this subset of patients.
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