How Patient Decision-Making Characteristics Affect Satisfaction in Facial Plastic Surgery

A Prospective Pilot Study

Jeremie D. Oliver, B.S., B.A.; Deanna C. Menapace, M.D.; Jeffrey P. Staab, M.D., M.S.; Oren Friedman, M.D.; Chelsey Recker, P.A.-C.; Grant S. Hamilton, M.D.


Plast Reconstr Surg. 2019;144(6):1487-1497. 

In This Article

Abstract and Introduction


Background: The main objective of this study was to prospectively analyze which personality traits, clinical psychiatric states, and patient decision-making characteristics predict who will be less satisfied after facial plastic surgery.

Methods: This prospective study enrolled 60 adult subjects into one of three groups: aesthetic, functional, and reconstructive facial plastic surgery procedures (n = 20 in each group) from November of 2011 to February of 2016. Self-report surveys of personality traits (i.e., NEO Personality Inventory-Revised), psychiatric state (i.e., Patient Health Questionnaire, Generalized Anxiety Disorder, Health Anxiety Inventory–Short Form), and decision-making characteristics (maximizer/satisficer survey) were given during the preoperative clinic visits. In postoperative follow-up, satisfaction questionnaires at 3, 6, and 12 months were administered. Data analysis examined associations between patient satisfaction, decision-making characteristics, and psychiatric variables.

Results: Bivariate analyses showed that maximizer/satisficer decision-making style was significantly related to patient satisfaction scores in the year following surgery. This difference reached statistical significance at 6 months and remained a strong trend at 12 months. Patients who were less than extremely satisfied at both postoperative time points were more likely to portray the maximizer decision-making style. No other variables were associated with patient satisfaction at any time point. Maximizer/satisficer survey scores were not associated with self-reports of depression, anxiety, or illness anxiety. Mean scores on the maximizer/satisficer survey did not differ among the aesthetic, functional, and reconstructive groups.

Conclusions: The maximizer/satisficer survey captures an aspect of patient care not traditionally measured by standard clinical psychometric screening tools to help predict satisfaction. A short questionnaire targeting consumer decision-making may be a helpful tool for preoperative counseling.


A primary measurement of success in facial plastic surgery is patient satisfaction.[1–10] As plastic surgeons operating on the face are rarely curing disease, it could be argued that patient satisfaction is the most important outcome. A mismatch between the surgeon's and the patient's expectations can result in dissatisfaction despite the outcome meeting a technical standard of excellence.[6,7] Another challenge is that objective medical or surgical measures may not correlate with report of symptom relief.[11,12] Opinions also differ with regard to varying patient factors that may be associated with greater or lesser postoperative satisfaction.[13–15] With aesthetic procedures, psychiatric illnesses such as depression or body dysmorphic disorder are considered to be predictors of lesser patient satisfaction, but empirical data do not universally support this contention.[16–24] Surgical experience suggests that patients with significant obsessive compulsive personality traits may be more difficult to satisfy than those with histrionic traits, despite traditional psychological theories to the contrary.[25,26] Interestingly, psychosomatic research also suggests that patients with high levels of body vigilance, health anxiety, or introverted temperaments may be predisposed to persistent physical complaints and excessive functional impairment when afflicted by medical illnesses.[27–44] Despite these notions persisting in the literature and practice, there are no objective tools to help identify patients who may be at a higher risk of being less satisfied following surgery. In the book The Paradox of Choice by Barry Schwartz, Ph.D., a consumer-based approach to analyzing satisfaction is described.[45] He identifies two types of decision-makers—maximizers and satisficers—based on their approaches to making decisions and the ease with which each experiences satisfaction after making a choice. Maximizers tend to be perfectionistic in their approach to decision-making and often experience regret after making the decision. Satisficers, in contrast, set acceptable criteria for themselves and will choose the option that meets their standard adequately. A maximizer/satisficer survey was then derived from this theory. However, this concept has not yet been tested as it applies to health care but may provide a gateway to better understanding patients' satisfaction with medical and surgical treatment. The aim of this study was to identify psychological variables associated with decreased patient satisfaction after aesthetic, functional, or reconstructive facial plastic surgery using several validated psychiatric inventories and to explore the usefulness of the maximizer/satisficer survey and what role these factors may play in satisfaction outcomes. The hypotheses were as follows:

  1. Unfavorable psychosomatic variables and/or maximizer tendencies will be associated with decreased satisfaction following aesthetic, functional, or reconstructive facial surgery.

  2. Unfavorable psychosomatic variables and maximizer tendencies will have less influence on dissatisfaction in the functional and reconstructive groups.