Simon Says... Blake Wants a Revision: Predictors of Revision at Time of Primary Rhinoplasty
The psychosocial motives for seeking cosmetic surgery, particularly rhinoplasty, play a significant role in shaping patient-reported outcomes. Discerning surgeons will consider a patient’s psychosocial history at the time of consultation to determine if the patient’s concerns can be adequately addressed by surgery. To guide patient selection, surgeons may recall SIMON, an acronym proposed in 1999 by Gorney and Martello, which characterizes patients deemed unsuitable for cosmetic surgery: single, immature, male, overly expectant, and narcissistic. Twenty-five years later, SIMON has undergone several iterations - SIFON for female patients, Slap-SIMON for patients who “still live at parent’s [house]” - but the core characteristics persist. However, there is limited evidence that SIMON accurately predicts patient dissatisfaction. This paper provides an update to SIMON as the prevailing acronym and advocates for a new evidence-based mnemonic to enhance patient selection.
Methods/Technique
:This study utilized TriNetX, a global health research platform that compiles data from electronic medical records in real time. We queried 134,328,422 records to identify patients who underwent primary rhinoplasty at ≥ 15 years of age at least three years ago. The time limitation was implemented to allow time for surgical revision. Patients were excluded if they had any incidence of cleft lip/palate, congenital malformations of the nose, neoplasm of the nose, or facial trauma occurring within one year before any nose surgery. Patients were split into male and female cohorts. We analyzed cohorts for surgical revision rates, use of other cosmetic procedures, and SIMON-like characteristics, including but not limited to demographic variables, psychiatric diagnoses, psychiatric medications, documented emotional state, and social factors. A Cox proportional hazards model studied the individual relationships between one hundred fifteen patient variables and risk of ≥ 1 revision rhinoplasty.
Results/Complications
:The Cox proportional hazards regression model identified key independent predictors of revision rhinoplasty at the time of primary rhinoplasty. Revision risk was 16.8 times higher with social exclusion/rejection (HR=16.8, p<0.0001); 5.36 times higher with personality disorders (p<0.0001); 3.45 times higher with history of subcutaneous filler injections (p=0.0002); 2.64 times higher with anxiolytic or sedative dependence (p=0.0071); 1.38 times higher with male sex (p<0.0001); and 1.16 times higher with anxiolytic use (HR=1.157, p=0.03). Significant protective factors included “married” relationship status, body mass index > 30, older age at surgery, and diagnosed deviated septum. Major depressive disorder, oral antidepressants, cannabis use, eating disorders, gender identity, emotional lability, and “never married” relationship status were notably not significant predictors of revision rhinoplasty.
Conclusion
:An international database query of patients who underwent primary rhinoplasty partially supported the SIMON criteria. Marriage was protective against revision. Immaturity was weakly supported by a slight decrease in risk for every year of age. Male sex independently predicted revision, but more female patients overall underwent subsequent nose surgeries. The latter observation is explained by a higher prevalence of psychiatric diagnoses and filler use in women, which were both identified as significant independent risk factors for revision. Filler use may align with the “overly expectant” SIMON criterion. Finally, personality disorders, particularly borderline personality disorder, were highly predictive, which captures the narcissism in SIMON.
SIMON ultimately lacks significant nuance in social relationships, surgical history, psychiatric diagnosis, patient age, and clinical indication for surgery. The authors, therefore, present a new acronym, BLAKE: Borderline/personality disorders (2.6x), Lonely/social exclusion (16.8x), Anxiolytics/sedatives (2.637x), Kosmetik (cosmetic) focus (3.45x), and previous Enhancement with fillers (3.45x). BLAKE captures the most salient predictors of revision at the time of primary rhinoplasty, updating the SIMON acronym to be non-binary and non-religious while maintaining the convenience and simplicity of a single-word mnemonic. We encourage surgeons performing rhinoplasty and interested groups to consider BLAKE in their patient selection process.