Risk versus Reward in Rhinoplasty

Economists look at the world through the lens of cost-benefit.  What can you gain and what can you lose with each action you take?  To me this is sensible approach to thinking about whether or not rhinoplasty is for you.  Here’s how I look at it.

What is the benefit?  On surface this seems like an easy question.  For many, the answer is “to have a better nose, of course!”.  An economist would want to measure or quantify this in order to determine the relative value.  An economist might look at the “amount” of improvement and say that the people who start out with the ugliest noses and receive the best outcomes gain the most value.  But that approach ignores the deeply personal aspect of rhinoplasty in which the meaningfulness of the improvement varies so much person to person and is impacted by different individual factors.  While I do think there is some correlation between level of satisfaction and degree of pre-surgery nasal imperfection, I have treated hundreds of patients who have been incredibly happy following rhinoplasty which created subtle changes.  Whatever the degree of imperfection of the nose, I do believe it is critical that each patient feel certain that an outcome in line with the goals created by them and their surgeon feels significant and positive.  This requires that you find a surgeon who is honest / communicative (to set realistic expectations) and skilled / experienced (to be capable of creating the goal).

What are the costs?  The monetary cost is the easiest to grasp as this is a simple number.  Like with any goods or services in a free market, there tends to be a supply-demand relationship that governs price point.  Higher quality is generally associated with higher cost (although this relationship is far from absolute).   Other costs are less directly monetary but fairly easy to conceptualize and include things such as time away from work, post-operative pain, and duration of swelling.  The costs which may be the most difficult to grasp are risks.  Risk implies some uncertainty in outcome which makes them hard to measure against benefit or even compare to other more concrete costs.  It is therefore helpful to analyze risks in different categories.

Risk of death.  Fortunately, the risk of the most catastrophic complication—anesthesia related death—is extremely low and less than 1 in 100,000 for a healthy individual.  This is a common fear, especially for those who have never had surgery, but the risk is very low when compared to other things we take for granted.  For example, 1 in 114 is the average life-time risk of an American dying from a motor vehicle accident and 1 in 9,821 from flying.  https://fortune.com/2017/07/20/are-airplanes-safer-than-cars/

Risk of severe surgical or post-operative complication.  Severe bleeding or infection are the most common “medical” rhinoplasty complications.  In my practice, bleeding requiring urgent attention and intervention occurs in less than 1 in 500 cases.  Post-operative infections happen about 1% of the time.  Of these, in 9 cases out of 10, appropriate antibiotic treatments cure the infection.  In 1 of 10, a procedure (such as incision and drainage of fluid) plus antibiotics cures the infection.  I have never had either a bleed or infection in any rhinoplasty case which has led to any long-term problem or compromise of the outcome.

Risk of deformity.  This is the most common worry I see in prospective patients.  I think that part of the reason for this fear is how rhinoplasty is portrayed in media and on the internet.  When you do a web search on rhinoplasty, you are flooded with images of “botched noses” and “bad celebrity nose jobs.” To many, rhinoplasty is synonymous with Michael Jackson, the poster child of the rhinoplasty disaster.  In my opinion, deformities at the level of Michael Jackson are exceedingly rare, even when performed by less experienced surgeons.  And the numbers get way more favorable with rhinoplasty specialists who have a broader experience base and skill set.  So, the risk of severe deformity is very small.  However, the risk of small imperfection is very high.  No nose can be made perfect no matter how skilled the surgeon.  In the best of cases, these small asymmetries or contour irregularities are minimal and either not visible or barely perceptible.  As such, they are generally not considered to be a complication, but rather normal outcomes.

Risk of dissatisfaction.  This may be the trickiest risk to anticipate for some.  In my experience, more than 95% of the time if the surgery results in an outcome close to the pre-operative goals, the patient is happy and glad they did surgery.  About 2-3% of the time even when we have reached an outcome that I would consider excellent, a patient isn’t completely happy.  The reasons for this are many and complicated and variable person to person.  Sometimes it’s related to expectations, sometimes a patient is highly self-critical, and sometimes to certain personality traits.  Of course, it’s best to avoid getting oneself into this situation through self-screening before committing to surgery.  An ethical surgeon will also try to steer someone away if they feel it is very unlikely that person will be happy even with a good outcome.  I have always tried my best to do this in my practice.

Take-aways: Rhinoplasty has tremendous potential benefit for an individual.  Ultimately, the value of the surgery is deeply personal and should be considered with some honest introspection before going forward.   Understanding the costs and risks should be done carefully and methodically.  Working with an experienced and communicative rhinoplasty specialist is key in both sides of this assessment.  On the benefit side, the surgeon should be clear in their ability to accurately outline goals and skillful enough to surgically create them.  On the risk side, working with an expert physician will greatly mitigate risk, especially as they relate to surgical outcome.  Once you understand these benefits and risks and can apply them to yourself and your surgeon, you will be best equipped to make the decision on whether or not to go forward!