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


Preoperative survey results from the Patient Health Questionnaire, Generalized Anxiety Disorder, Health Anxiety Inventory–Short Form, and maximizer/satisficer survey scores were collected between November of 2011 and February of 2016 from all 60 subjects. Aesthetic cases included eyelid rejuvenation (n = 3), scar revision (n = 2), dorsal hump reduction (n = 5), otoplasty (n = 2), facial aging procedures (n = 6), and chin augmentation (n = 2). Functional procedures included open septorhinoplasty (n = 13) and endonasal septorhinoplasty (n = 7). Reconstructive procedures included hardware revision (n = 5), septal perforation repair (n = 3), cancer reconstruction/reanimation (n = 7), congenital anomalies (n = 3), and granulomatosis with polyangiitis nasal reconstructions (n = 2). The NEO Personality Inventory-Revised was completed by a total of 45 patients (aesthetic, n = 17; functional, n = 18; and reconstructive, n = 10). Postoperative Satisfaction Questionnaires were sent to all subjects at 3-, 6-, and 12- month intervals following their respective procedures. A total of 43 subjects (71.7 percent) completed the requested surveys and returned them to our clinic at the 3-month timeline, 45 subjects (75.0 percent) completed and returned the survey at the 6-month timeline, and 42 subjects (70.0 percent) completed the assigned surveys and returned them at the 1-year timeline.

The psychological profiles of participants in each group are shown in Table 1. Mean self-report scores for depression, anxiety, and illness anxiety did not differ among groups. Self-reported scores for depression, anxiety, and illness anxiety were strongly skewed toward negative (unaffected) scores. One or two people in each group had clinically significant psychiatric symptoms. In addition, the NEO Personality Inventory-Revised personality profiles of the three groups largely fell within the normative range of 45 to 55. All three groups had mean scores for extraversion and conscientiousness in the upper range of normal to slightly above normal, which is not a clinically meaningful deviation from the general populace. Mean neuroticism scores for the functional group were mildly but significantly lower than the population norm (<45) and lower than both of the other groups. Analysis of the subscales (facets) of neuroticism showed that patients in the functional group were on average less angry, demoralized, self-conscious, and impulsive than in other groups. The mean agreeableness score in the reconstructive group was lower than the population norm (<45) and trended lower than in the other two groups. Analysis of the subscales (facets) of agreeableness showed that the patients in the reconstructive group were on average less modest and less likely to profess adherence to rules and regulations.

The mean score on the maximizer/satisficer survey for all patients was 41.5. There are no standard cutoffs at this time to define a maximizer from a satisficer, as the scale is considered to be more a fluid spectrum (score range, 13 to 91), with extremes occurring rarely. However, scores for individual patients ranged from 17 to 61, indicating that the study included individuals with decision-making styles varying from strong satisficer to modestly strong maximizers. Mean scores on the maximizer/satisficer survey did not differ between the aesthetic, functional, and reconstructive groups (Table 1). For the study cohort as a whole, maximizer/satisficer survey scores were not associated with self-reports of depression, anxiety, or illness anxiety. However, the maximizer/satisficer survey scores were correlated moderately and inversely with agreeableness (Pearson r = −0.34; p < 0.022), meaning that patients who were more agreeable were more likely to be satisficers. Maximizer/satisficer survey scores did not correlate significantly with any other personality traits or psychiatric states.

With regard to satisfaction, patient satisfaction scores were strongly skewed toward positive responses, as is typical of the variable. Patients in all three groups (aesthetic, functional, and reconstructive) were, on average, very satisfied with outcomes of surgery at 1 year (Figure 2). Bivariate analyses showed that maximizer/satisficer decision-making style was significantly related to patient satisfaction scores in the year following surgery (Table 2). 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.

Figure 2.

Mean postoperative satisfaction questionnaire scores for functional, aesthetic, and reconstructive groups at 12 months. On average, patients were very satisfied.

Looking at the change in satisfaction over the 1-year postoperative interval, there was a small decrease in the number of patients rating themselves as extremely satisfied and a small increase in the number rating themselves as less than satisfied (Figure 3). These shifts were confined to the functional and reconstructive groups and were not statistically significant.

Figure 3.

Patient satisfaction scores at 3 and 12 months for the functional, aesthetic, and reconstructive groups. The small downward drift in satisfaction scores over time was not significant.

A descriptive representation of complications, complaints, and objective findings is as follows: 19 patients on the maximizer end of the spectrum had satisfaction results that were anything less than extremely satisfied (<37.5), 14 of whom had no complaints. Of the other five patients, four had complaints with identifiable findings. Of those on the maximizer end of the spectrum, there were two complications, including a self-limited pneumothorax and a self-limited hematoma. In contrast, there were 15 patients on the satisficer end of the spectrum with less than extremely satisfied (<37.5) results, seven of whom had no complaints. The eight others had complaints with identifiable correlates. In the satisficer group, there were no reported surgical complications. This is interesting to note, as many of those less than extremely satisfied in the maximizer group did not actually have any complaints [14 of 19 (73 percent)] compared to the satisficer group [seven of 14 (46 percent)].

Overall, in the satisficer group, more complaints were reported in follow-up, but the group gave more favorable satisfaction ratings. There were three patients who were less than satisfied (<27) in the entire cohort—one in the maximizer group and two in the satisficer group. The maximizer had no surgical outcomes identifiable for dissatisfaction, whereas the satisficers both had callus formation at the osteotomy sites.

After completing the statistical analyses of our a priori study hypotheses, we performed a focused post hoc evaluation of possible relationships among maximizer/satisficer survey scores, patient complaints, and surgeons' observations of outcomes. We retrospectively reviewed patients' records for any critical comments that they made about their surgical outcomes and surgeons' notations of any less than desirable results regardless of how minor and regardless of whether or not they related to patients' comments. There were no instances of serious adverse outcomes. Furthermore, there were no statistically significant relationships between patient satisfaction scores at 3, 6, or 12 months and the presence or absence of critical comments from patients for identification of minor deficits by surgeons. Curiously, maximizer/satisficer survey scores were significantly lower (greater tendency toward satisficer decision-making style) in cases where patients' critical comments or surgeons' notations about minor deficits were identified in the medical record (Mann-Whitney test, p < 0.05 for both comparisons) (Table 3).