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


In health care, the aspects that contribute to postoperative satisfaction are complex. Surgeons currently lack tools to help predict postoperative satisfaction. However, the results of this study support that the maximizer/satisficer survey, which is traditionally used in the product consumer setting, may be a valuable tool in predicting postoperative satisfaction. This is the first study to describe the application of product consumerism theory and how it may be applied in the health care setting to begin to understand satisfaction. This study identified a significant association between those who displayed maximizer decision-making characteristics to lesser satisfaction. The results did not identify any associations between maximizer/satisficer decision-making styles and measures of depression, anxiety, or illness anxiety. There was only a modest correlation between maximizer/satisficer scores and agreeableness, indicating that patients with a satisficer style were more likely to be warmer, more considerate, and more cooperative in interpersonal interactions than others. There were no other significant relationships between decision-making style and personality traits. These data support that satisfaction may be rooted in consumer-like decision-making characteristics—something not previously described. Therefore, the maximizer/satisficer survey measures an aspect of the patient experience not traditionally captured by the five personality traits of the NEO Personality Inventory-Revised or psychological states of depression, anxiety, or illness anxiety measured in standard clinical surveys. Our results show that the maximizer/satisficer survey offers a metric for predicting those at risk for lesser patient satisfaction.

Interestingly, in this study cohort, the indication for surgery did not correlate with satisfaction, as patients in the aesthetic, functional, and reconstructive groups did not vary significantly in their satisfaction or maximizer/satisficer survey decision-making styles. Within the aesthetic (elective) population, these data did not demonstrate a skewing toward the maximizer population, indicating that these results do not support the idea that those seeking aesthetic surgery are at a higher risk for dissatisfaction. Using the maximizer/satisficer decision-making characteristics, the only significant link to decreased satisfaction was having maximizer decision-making characteristics regardless of the indication for surgery. A limitation of this study design, however, is the imprecision of designating different operations as aesthetic, functional, or reconstructive. In reality, there is a significant amount of overlap between these categories, and a single type of surgery may be appropriately placed in more than one category. For example, is a collapsed alar rim after cancer excision functional or reconstructive? What about a scar revision in a face-lift patient? Because the distribution of both maximizer/satisficer and psychiatric parameters was normal, however, it is unlikely that the categorization of the operations had a meaningful impact on the outcome. Clinically, this study suggests that this tool could be used in consultation with patients undergoing all facial plastic surgery procedures.

This study did note a small drift downward in mean patient satisfaction scores and the number of patients rating themselves as extremely satisfied from 3 to 12 months after surgery. Although interesting, these changes were not statistically significant. These data suggest that regardless of indication for seeking facial plastic surgery (aesthetic, functional, or reconstructive) those patients who demonstrated a shift in satisfaction scores only did so after a period of waiting. This may be attributable to postsurgical optimism bias and willingness to accept some amount of dissatisfaction in the immediate postoperative period.[47] This phenomenon should not be interpreted as a downward drift in outcomes by clinical and administrative leaders who focus on "top box" performance. These findings do raise the question, however, of how patients should be counseled in the postoperative period regarding improvement of perceived outcomes over the near term versus long term, which is beyond the scope of this article but an interesting observation nonetheless.

The goal of this study was to learn more about the patient characteristics during the preoperative visit that may affect postoperative satisfaction. The results should not be interpreted as an indication to turn patients away from surgery based on their tendency to be maximizers, as most patients were at least very satisfied with their surgical results. Rather, this information could be used to facilitate a transparent discussion of patient expectations. This type of conversation could be helpful, especially for patients characterized as maximizers, who may be at an increased risk for lesser satisfaction compared to satisficers. Researching use of this tool in the medical setting was not intended to identify who is "a good patient" or "a bad patient," but rather to enhance surgeons' abilities to counsel the diversity of patients seen in practice and learn how to better manage their expected satisfaction.

This study provides new insight into a better understanding of different types of patients' motivations for surgery and their expectations afterward. Historically, plastic surgeons operating on the face have tried to make sense of these from a medical perspective, which is understandable, because these are medical interventions. However, a lack of correlation between personality traits or psychological states and satisfaction has shown this approach to be incomplete. Incorporating measures of consumer behavior profiling may be a helpful indicator of postoperative satisfaction. For the first time, plastic surgeons can better assess which patients are likely to be less satisfied after surgery and may have a different preoperative conversation with them to better manage their expectations.

Our retrospective review of relationships among maximizer/satisficer survey scores, patient satisfaction, patients' comments about surgical results, and surgeons' notations about minor deficits raises the possibility that patients with satisficer decision-making styles can be satisfied with outcomes of facial plastic procedures even if they notice minor problems. However, this finding must be interpreted with caution, as it was the result of a post hoc analysis.

The strengths of this study include its prospective design and careful analysis of a range of psychological variables, including depression, anxiety, illness anxiety, and personality traits, which allowed the evaluation of potential relationships between patient satisfaction, decision-making style, and clinical psychological metrics. The main weakness is the number of patients that were lost to follow-up in the year after surgery. Although our response rate of 70 to 75 percent was acceptable for survey studies of this type, it may have limited our power to detect relevant relationships. There also were only a few patients with clinically significant depression, anxiety, or illness anxiety in this cohort. They were distributed across patient satisfaction categories in proportions roughly equal to the remainder of the cohort (i.e., two-thirds were extremely or very satisfied). However, their small number may have produced false-negative results because of a limited range effect. Larger prospective cohorts or a multi-institutional review would be helpful to corroborate these data.