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Original Article |

Ethical Considerations in Aesthetic Rhinoplasty A Survey, Critical Analysis, and Review FREE

Kian Karimi, MD; Martin F. McKneally, MD, PhD, FRCSC; Peter A. Adamson, MD, FRCSC
[+] Author Affiliations

Author Affiliations: Pacific Eye & Ear Specialists, Los Angeles, California (Dr Karimi); and Departments of Surgery (Dr McKneally) and Otolaryngology–Head and Neck Surgery (Dr Adamson), Joint Centre for Bioethics (Dr McKneally), and Division of Facial Plastic and Reconstructive Surgery (Dr Adamson), University of Toronto, Toronto, Ontario, Canada.


Arch Facial Plast Surg. 2012;14(6):442-450. doi:10.1001/archfacial.2012.132.
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Published online

Although the practice of medicine is built on a foundation of ethics, science, and common sense, the increasing complexity of medical interventions, social interactions, and societal norms of behavior challenges the ethical practice of aesthetic surgeons. We report a survey of the opinions, practices, and attitudes of experienced and novice facial plastic surgeons. The survey consisted of 15 clinical vignettes addressing ethical quandaries in aesthetic rhinoplasty. The vignettes are based on the experience and observations of the senior author (P.A.A.) over nearly 30 years of practice and teaching. Fellowship directors and facial plastic surgery fellows of the American Academy of Facial Plastic and Reconstructive Surgery were surveyed anonymously. Five of the 15 vignettes demonstrated significant differences between the responses of the fellowship directors and the fellows. No single vignette had a unanimous consensus in either group. Aesthetic rhinoplasty surgeons encounter ethical issues that should be reflected on by both experienced and inexperienced facial plastic surgeons, preferably before being faced with them in practice. We present a practical approach to ethical issues in clinical practice. Our survey can also be used as a stimulus for further discussion and teaching.

Figures in this Article

It appears to me that in Ethics, as in all other philosophical studies, the difficulties and disagreements, of which history is full, are mainly due to a very simple cause: namely to the attempt to answer questions, without first discovering precisely what question it is which you desire to answer.

George Edward Moore, Principia Ethica [1903].

Perhaps the question we hope to answer herein is implied in the works of Hippocrates, who is credited with the simple general principle of always acting in the patient's best interests and, first and foremost, doing no harm. In rhinoplasty, the best course of action is often not immediately obvious, and some cases are fraught with ethical quandaries and conflicts. Considered by many to be the father of modern aesthetic surgery, Jacques Joseph, MD, recognized early in his career the psychological, psychosocial, and ethical aspects that were inherent in aesthetic rhinoplasty.13 Since his time, the ethical challenges faced by the modern rhinoplasty surgeon have become more complex. This study examines the decision-making of established and novice facial plastic surgeons by posing 15 clinical scenarios related to aesthetic rhinoplasty.

Ethical analysis in clinical medicine is commonly based on the 4 principles described by Beauchamp and Childress4: respect for autonomy, beneficence, nonmaleficence, and justice. We used these principles as the conceptual framework for our study. Autonomy is the principle that respects the right of patients to make informed decisions about their own bodies. Beneficence obliges us to act in the patient's best interest. Nonmaleficence, based on the Hippocratic Oath, requires physicians to minimize harm. Justice requires fairness in the treatment of patients and colleagues. Although these principles are not mutually exclusive, they provide a framework with which to investigate and explore ethics with respect to rhinoplasty.

Discussion of ethical challenges and principles in plastic surgery literature is underrepresented, as Chung et al5 reported in a recent systematic review; they found only 110 articles that clearly focused on ethical principles in a pool of over 100 000 articles. It is generally agreed that aesthetic plastic surgery is requested not only to satisfy the desires of the patient who seeks such interventions but, more importantly, to address the patient's psychological and psychosocial needs, perceptions, and expectations. The aesthetic plastic surgeon will perform the requested interventions to enhance the patient's life, not “save” it. On the one hand, enhancement of the quality of life of the patient seeking aesthetic plastic surgery is an acceptable indication and is typically the ethical justification given by most aesthetic plastic surgeons.6 On the other hand, Atiyeh et al7(p829) argued that “a closer look from an ethical viewpoint makes clear that the doctor who offers aesthetic interventions faces many serious ethical problems having to do with the identity of the surgeon as a healer.” The premise that aesthetic surgery is primarily a business, guided by a market ethic aimed at material gain and profit and arguably not an integral part of the health care system, undergirds this argument. Modern aesthetic rhinoplasty could be perceived as a tool to fulfill wishes instead of relieving suffering or treating illness. However, most rhinoplasty surgeons feel that aesthetic rhinoplasty is a powerful means by which the patient can be anatomically, emotionally, and psychologically healed.6

The rhinoplasty literature addresses patient selection, avoiding potential problems, and dealing with dissatisfied patients.8,9 Underlying ethical considerations in rhinoplasty are rarely explored. The rhinoplasty surgeon, in general, wishes to recommend treatments that are most appropriate for each specific patient to achieve his or her own unique goals with maximum benefit and least risk. Some of the pitfalls described in the general plastic surgery literature are pertinent to rhinoplasty surgery. Ethical breaches include failure to properly obtain informed consent; failure to perform a standard medical history and physical examination, including appropriate investigation of medical and psychological comorbidities; breaching the standard of care in the technical aspects of the surgical procedure; failure to properly address a complication in a timely manner; misrepresentation as an expert witness; and false or unsubstantiated advertisements.10

We surveyed the views of rhinoplasty teachers and trainees on representative ethical issues. Based on our empirical data, we have formulated a practical approach that may be helpful to inexperienced and experienced surgeons. The survey can also be used as a stimulus for further discussion and teaching of ethics in rhinoplasty surgery.

Approval to conduct this study (No. 10-0707-AE) was obtained from the University Health Network Research Ethics Board at the University of Toronto (Toronto, Ontario, Canada).

Fifteen theoretical vignettes, each based on ethical challenges encountered in the senior author's (P.A.A.) practice, were posed to a total of 103 facial plastic surgeons and facial plastic surgeons-in-training, hereinafter referred to as fellows. The survey website www.askitonline.com was used to conduct the survey. The facial plastic surgeons polled were all fellowship directors in the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) and board-certified by the American Board of Facial Plastic and Reconstructive Surgery, and thus considered mentors and leaders in the specialty. These fellowship directors are expected to set an example in accordance with the AAFPRS Code of Ethics.11 AAFPRS fellows would have all signed the “fellowship agreement,” also binding them to the same guidelines and ethical principles. To minimize bias, the answers were entered anonymously, except for general demographic information (Figure 1).

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Figure 1. Demographic information asked of each survey participant.

Prior to conducting the survey, the questions asked and the choice of answers were reviewed with a statistician and ethicist and modified accordingly. The individual questions and answer choices are presented in Figure 2.

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Figure 2. Ethical vignettes asked of each survey participant.

The response rate to the survey overall was 54% (56 of 103). Fifty-four percent of the fellowship directors (30 of 56) and 55% of the fellows in the AAFPRS (26 of 47) agreed to participate in the study. The survey data were collected from February through April 2011.

DEMOGRAPHICS

Most fellows had performed 10 to 50 rhinoplasties, whereas most fellowship directors had performed more than 100 (Figure 3). As expected, fellows had fewer years of experience than fellowship directors, and a larger percentage of the fellows' practice involved primary rather than revision rhinoplasties compared with the practices of the fellowship directors (Figure 4 and Figure 5). Both groups reported their most common approach to be “open,” followed by “both,” and, least frequently, “endonasal” (Figure 6). Over 85% of participants in this study were affiliated with a university, whereas less than 20% in either group worked exclusively in private practice (Figure 7).

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Figure 3. Number of rhinoplasties performed.

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Figure 4. Surgeons' years in practice.

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Figure 5. Primary vs revision rhinoplasty. Percentages that are primary (A) and revision (B).

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Figure 6. Approaches used in rhinoplasty.

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Figure 7. Affiliations of rhinoplasty surgeons.

RESPONSES TO VIGNETTES

Fisher exact test was used to compare the responses of fellows and fellowship directors. Of the 15 vignettes, responses differed significantly between fellows and fellowship directors for 2 of 15 of cases (13%), including cases 4 and 14 (Figure 8). Differences were not statistically significant for another 3 of 15 (20%) of cases, including cases 1, 2, and 7 (Figure 9). The differences in responses between fellowship directors and fellows are as follows.

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Figure 8. Cases with statistically significant different responses between fellowship directors and fellows. A, Case 4, a patient with good result demanding revision (P = .05); B, case 14, transcultural 18-year-old seeking rhinoplasty with parents opposing (P = .03). See Figure 2 for a description of the cases.

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Figure 9. Cases without statistically significant different responses between fellowship directors and fellows. A, Case 1, colleague with website photographs of another surgeon's work ( = .09); B, case 2, a patient requesting an unnatural result ( = .16); C, Case 7, a patient who has undergone multiple operations seeking perfection ( = .13). See Figure 2 for a description of the cases.

Responses to other cases are reported in the eFigure.

Ethical issues in rhinoplasty have been raised since the inception of the procedure. From the days of Tagliocozzi in the 16th century, there was documentation of negative connotations associated with changing the shape of one's nose, as it was felt to interfere with the will of God.12 The morality of aesthetic plastic surgery was affirmed by Pope Pius XII, who decreed “esthetic surgery, far from opposing the will of God in restoring perfection to the greatest work of His visible creation, seems rather to conform better with it, and renders clear testimony to its wisdom and goodness.”13(p65) The current opinion of most facial plastic surgeons can perhaps best be represented by the dissertation of Jack Anderson, MD,13(p65) which addresses the “morality” of aesthetic rhinoplasty. He concludes that aesthetic rhinoplasty, in the context of appropriate motives, conforms to “ . . . administering to the whole individual” and “is not only ethical and permissible but also a necessity in some cases.”

Rhinoplasty has become an accepted tool to improve both the function and the appearance of the organ that is central to facial aesthetics and to the upper airway. Modern aesthetic rhinoplasty nearly always addresses the functional as well as the aesthetic aspects of the nasal airway (eg, placing a spreader graft to improve symmetry and increase the cross-sectional area of the internal nasal valve, or avoiding overaggressive resection of the cephalic margin of the lower lateral cartilages).

ETHICAL DILEMMAS

The survey conducted in this project focused on ethical dilemmas that are commonly faced by rhinoplasty surgeons, including the following: questionable patient motivations, psychological comorbidities, dissatisfied patients, litigious patients, relationships with surgical colleagues, intraoperative and postoperative decision-making, patients with questionable social support, patients' alternative lifestyles, and surgeon honesty with insurance companies.

An overall response rate of 54% suggests a fairly strong interest in the subject matter even though this was an uncompensated survey. More than half of fellowship directors (54%) and fellows (55%) completed the survey. Analyzing the demographic information, it was interesting to note that 10% of AAFPRS fellows had performed 50 to 100 rhinoplasties, which likely reflects significant experience during residency or spending some years in practice prior to entering the fellowship (Figure 3). When assessing primary vs revision rhinoplasty, most fellowship directors and fellows responded that 51% to 75% of their cases were primary (Figure 5). Fellows were more likely to use an open approach, whereas fellowship directors were split between predominantly “open” or “both” (Figure 6).

Of the 15 vignettes, statistically significant different responses between fellowship directors and fellows were observed in 2 of 15 of cases (13%) (Figure 8). In 1 of the vignettes, a disgruntled malpractice attorney returns 1 year after rhinoplasty with what is described as an acceptable result. Although most (>70% of fellows and 65% of fellowship directors) elected to proceed with revision surgery, waiving surgeon's fees only (while making the patient pay for anesthesia and facility fees), 30% of fellowship directors refused to perform any more surgery, and only 15% of fellows chose this option. The fact that fellowship directors were twice as likely to refuse performing additional surgery may reflect how experience teaches surgeons when not to operate in situations in which the probability of a favorable outcome is low.

In the second vignette that had significantly different responses ( = .05) between fellowship directors and fellows, an 18-year-old woman who lives at home requests aesthetic rhinoplasty but lacks the support of her parents, who are adamantly opposed to her undergoing the operation. She goes to the consultation visit with her boyfriend, and she has the financial means to pay for the operation. Forty-five percent of fellowship directors answered that they would speak to the parents of the patient and proceed only with their consent, whereas 15% of fellows would have done so. Sixty-five percent of fellows would proceed with rhinoplasty if the patient's boyfriend seemed supportive and agreed to help with postoperative recovery, whereas only 37% of fellowship directors answered this way. Not a single fellow answered that they would refuse to do the operation altogether, whereas 10% of fellowship directors selected this theoretical action (Figure 8). Although 18 years is the legal age of consent for surgery in most jurisdictions, the varied responses in this vignette suggest that fellowship directors are more aware of the negative consequences that an unsupportive environment can have, especially pertaining to rhinoplasty. It is well documented that positive and negative feedback from family members can influence patients' overall satisfaction after aesthetic rhinoplasty.9 Negative feelings are easily transferred from the family to the surgeon.

Three cases did not display statistical significance between the answer choices given by fellowship directors and fellows (Figure 9). In response to a colleague posting on a website patient photographs that were of private patients of his fellowship director, most fellows (70%) would call the individual directly and advise him to take the pictures down, whereas only 35% of fellowship directors would do so. Sixty percent of fellowship directors would report this finding directly to the facial plastic surgeon's fellowship director, whereas only 25% of fellows would do this. Interestingly, 5% of fellowship directors and fellows would “do nothing,” and 5% of fellowship directors would report this finding directly to the state licensing board. This may reflect the fellowship directors' greater comfort with contacting their own peers in this situation.

In the second case with quite different responses, a patient presents with a normal-appearing nose but desires aesthetic rhinoplasty with a scooped-out dorsum and a pinched nasal tip. One hundred percent of fellowship directors would refuse to perform the operation; 45% simply would refuse the patient, and 55% would take the extra step of advising the patient that she should never have a rhinoplasty and discussing their aesthetic and anatomic concerns with her. Ninety percent of fellows would refuse to perform the operation, whereas 5% would perform the operation as long as she acknowledged that she would have an “operated” appearance and possibly poor function, whereas the other 5% would try to achieve her aesthetic goals with injectable fillers. Although most responders in both groups would refuse to perform surgery, it is interesting to note that a small percentage of fellows would try to offer this patient surgery—this likely represents optimistic expectations of satisfying this patient while avoiding functional complications.

In the third case that had varied responses, a medical student who sought revision aesthetic rhinoplasty had undergone 3 prior rhinoplasties and exhibited elements of body dysmorphic disorder and a personality disorder. Most fellows (55%) would offer surgery if this theoretical patient had undergone psychiatric evaluation and clearance, whereas only 35% of fellowship directors would do so. Most fellowship directors (55%) would refuse to operate on this patient and advise that he not seek additional surgery, whereas only 35% of fellows would perform this action. This case possibly best represents the evolution of practice for rhinoplasty surgeons, who often serve as the psychologists themselves. Although a psychologist or psychiatrist is an important colleague to involve in the care of patients with psychiatric illnesses, it is more important that the surgeon feel comfortable with the patient's psychiatric condition, expectations, and motivations. It is better to have an unhappy patient who does not undergo an operation than a dissatisfied patient who has had an operation.

Consensus between fellowship directors and fellows was noted in most of the vignettes. Both cohorts would request to see prior operative records prior to embarking on revision surgery for a “botched” nose. Most responders (75% of fellows and 90% of fellowship directors) would offer to perform rhinoplasty on a sister-in-law, whereas only 5% of fellows and 10% of fellowship directors would refuse. Operating on family members is generally discouraged, except in an emergent or urgent situation. In some jurisdictions, it is grounds for a finding of professional misconduct if a complaint is ultimately filed by a dissatisfied family member.

In the case in which the underage patient is bleeding profusely and the parents have asked that she not be given a transfusion because they are Jehovah's Witnesses, 42% of fellowship directors and 45% of fellows would respect the parents' wishes and not transfuse, whereas 35% of fellowship directors and 25% of fellows would give her a transfusion in an effort to save the child's life and prevent possible neurologic sequelae. Although it is more ambiguous in the case of a mature adolescent, the courts are clear when it comes to children. The US Supreme Court has ruled that “Parents may be free to become martyrs themselves, but it does not follow (that) they are free . . . to make martyrs of their children.”14 When parents refuse blood on behalf of their children, based on religious beliefs, consideration should be given to these beliefs and treatment accommodated where possible. However, the child's welfare is always paramount, and blood considered to be essential can be given, although the surgeon assumes a risk of being sued for nonconsented treatment.15

In response to the vignette in which a cross-dressing man desires a feminine nose, 90% of fellowship directors would offer surgery with 55% seeking psychiatric clearance. Seventy-five percent of fellows would offer surgery; 50% would request psychiatric clearance. Approximately 10% of both cohorts would refuse to perform surgery.

When dealing with a patient with multiple medical comorbidities, 75% of fellows would perform the rhinoplasty at an outpatient surgery center. Only 60% of fellowship directors would do this—25% of fellowship directors would recommend the patient go to a tertiary care center, whereas less than 10% of fellows made this recommendation.

When dealing with an intraoperative complication of unlikely long-term negative consequences, such as dislocating the septum at the keystone area, only 45% of fellowship directors and fellows would tell the family of this occurrence immediately after the surgery. Forty percent of fellows and 28% of fellowship directors would tell the patient routinely at the first postoperative visit of this occurrence, whereas 15% of fellowship directors and 8% of fellows would discuss this problem only if there were a functional or aesthetic concern after the surgery. Less than 5% of both groups of surgeons would never discuss this complication with the patient or the family.

Most fellowship directors and fellows would offer a reduced fee when operating on a colleague.

When dealing with a functional complication (eg, internal valve collapse) as a result of rhinoplasty in one's own patient, 45% of fellowship directors and 70% of fellows would not offer any refund but would perform a revision gratis to address the problem. Despite threats of litigation, 35% of fellowship directors and 20% of fellows would recommend that the patient see the other surgeon she had chosen to have her revision surgery without offering a refund.

Finally, when dealing with insurance companies, 20% of fellows would perform a septorhinoplasty with both cosmetic and functional components and dictate the case such that it was covered by insurance, whereas only 6% of fellowship directors would do so. Fifty-five percent of fellowship directors and 40% of fellows would proceed with the functional component alone since the patient is unwilling to pay for the cosmetic component. Eighteen percent of fellowship directors and only 4% of fellows would refuse to perform the case altogether. The 20% rate of fellows who would perform the operation and dictate an ambiguous operative report is disconcerting. When 169 internists were surveyed regarding deception of third-party payers, only 2.5% were willing to deceive the insurance companies with regard to cosmetic rhinoplasty.16

RECOMMENDATIONS

Most of the rhinoplasty surgeons responding to our survey are in accord with the management of these ethical problems despite their different levels of experience. The divergence of opinion on some of the questions suggests the need for guidance for younger rhinoplasty surgeons and a reference standard for the specialty.

The ethical framework of 4 principles4 was applied to surgical complications in an article by Adedeji et al.17 These authors include “undesirable outcomes” as a complication, a category very relevant to rhinoplasty surgery. The principles can serve as heuristics or general rules when constructing a personal code of conduct for rhinoplasty surgeons, but the principles do not provide a specific pathway to right action. In his excellent text Doing Right: A Practical Guide to Ethics for Medical Trainees and Physicians, which is commonly given to many first-year trainees in medical school, Hébert18 proposed an ethics decision-making procedure to assist physicians. Although this will be useful to most physicians, it lacks the specificity and complexity required by rhinoplasty surgeons. To provide a more specific algorithm for use in rhinoplasty surgery, we have adapted his approach. Herein, we propose a classification of ethical issues (Table) and a template for ethical decision-making (Figure 10) related to rhinoplasty. Although every patient and situation is unique, these frameworks may facilitate logical and thoughtful decision making for rhinoplasty surgeons faced with ethical dilemmas. We look forward to comments about their usefulness.

Table Graphic Jump LocationTable. Classification of Ethical Issues in Rhinoplastya
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Figure 10. The rhinoplasty surgeon's template for resolving ethical problems. Do the right thing based on your knowledge, experience, and values. This template was adapted from Hébert.18

Ethical issues will continue to evolve as the complexity of rhinoplasty increases with advances in technology and bioengineering capabilities. In addition, the sophistication of the rhinoplasty consumer is exponentially increasing, as evidenced by patients bringing in their own digitally morphed images. Patients today have increasingly higher expectations for their outcomes. Surgeons will continue to develop their own ethical codes of conduct throughout their career. Personal codes of conduct can differ, modified by personal values, virtues, beliefs, preferences, circumstances, and experience. A logical, consistent, and reasoned approach to the ethical dilemmas encountered in rhinoplasty patients can help conscientious surgeons proceed with confidence.

Correspondence: Kian Karimi, MD, Pacific Eye & Ear Specialists, 11645 Wilshire Blvd, Ste 600, Los Angeles, CA 90025 (kiankarimi@gmail.com).

Accepted for Publication: January 30, 2012.

Published Online: June 18, 2012. doi:10.1001/archfacial.2012.132

Author Contributions:Study concept and design: Karimi, McKneally, and Adamson. Acquisition of data: Karimi. Analysis and interpretation of data: Karimi, McKneally, and Adamson. Drafting of the manuscript: Karimi. Critical revision of the manuscript for important intellectual content: Karimi, McKneally, and Adamson. Administrative, technical, and material support: Karimi and Adamson. Study supervision: Karimi, McKneally, and Adamson. Formulation of the ethical framework: McKneally.

Financial Disclosure: Dr Adamson has been a medical consultant for Allergan Canada.

Behrbohm H, Briedigkeit W, Kaschke O. Jacques Joseph: father of modern facial plastic surgery.  Arch Facial Plast Surg. 2008;10(5):300-303
PubMed   |  Link to Article
Triana R. Jacques Joseph: surgical sculptor.  Arch Facial Plast Surg. 1999;1(4):324-325
PubMed   |  Link to Article
Bhattacharya S. Jacques Joseph: father of modern aesthetic surgery.  Indian J Plast Surg. 2008;41:(suppl)  S3-S8
PubMed
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3rd ed. Oxford, England: Oxford University Press; 1979
Chung KC, Pushman AG, Bellfi LT. A systematic review of ethical principles in the plastic surgery literature.  Plast Reconstr Surg. 2009;124(5):1711-1718
PubMed   |  Link to Article
Litner JA, Rotenberg BW, Dennis M, Adamson PA. Impact of cosmetic facial surgery on satisfaction with appearance and quality of life.  Arch Facial Plast Surg. 2008;10(2):79-83
PubMed   |  Link to Article
Atiyeh BS, Rubeiz MT, Hayek SN. Aesthetic/cosmetic surgery and ethical challenges.  Aesthetic Plast Surg. 2008;32(6):829-839
PubMed   |  Link to Article
Adamson PA, Litner JA. Psychological aspects of revision rhinoplasty.  Facial Plast Surg Clin North Am. 2006;14(4):269-277
Link to Article
Adamson PA, Chen T. The dangerous dozen: avoiding potential problem patients in cosmetic surgery.  Facial Plast Surg Clin North Am. 2008;16(2):195-202
PubMed   |  Link to Article
Shiffman MA. Medical liability issues in cosmetic and plastic surgery.  Med Law. 2005;24(2):211-232
PubMed
American Academy of Facial Plastic and Reconstructive Surgery.  Code of Ethics. http://www.aafprs.org/Code_Of_Ethics.pdf. Accessed November 3, 2010
Bull TR. Rhinoplasty: aesthetics, ethics and airway.  J Laryngol Otol. 1983;97(10):901-916
PubMed   |  Link to Article
Anderson JR. What physicians should know about nasal plastic surgery.  J La State Med Soc. 1963;115:337-341
PubMed
 Prince v Massachusetts 1944 321 US. 158, 170 
Woolley SL, Smith DRK. ENT surgery, blood and Jehovah's Witnesses.  J Laryngol Otol. 2007;121(5):409-414
PubMed   |  Link to Article
Freeman VG, Rathore SS, Weinfurt KP, Schulman KA, Sulmasy DP. Lying for patients: physician deception of third-party payers.  Arch Intern Med. 1999;159(19):2263-2270
PubMed   |  Link to Article
Adedeji S, Sokol DK, Palser T, McKneally M. Ethics of surgical complications.  World J Surg. 2009;33(4):732-737
PubMed   |  Link to Article
Hébert PC. Doing Right: A Practical Guide to Ethics for Medical Trainees and Physicians. 2nd ed. Oxford, England: Oxford University Press; 2009:23

Figures

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Figure 1. Demographic information asked of each survey participant.

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Figure 2. Ethical vignettes asked of each survey participant.

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Figure 3. Number of rhinoplasties performed.

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Figure 4. Surgeons' years in practice.

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Figure 5. Primary vs revision rhinoplasty. Percentages that are primary (A) and revision (B).

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Figure 6. Approaches used in rhinoplasty.

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Figure 7. Affiliations of rhinoplasty surgeons.

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Figure 8. Cases with statistically significant different responses between fellowship directors and fellows. A, Case 4, a patient with good result demanding revision (P = .05); B, case 14, transcultural 18-year-old seeking rhinoplasty with parents opposing (P = .03). See Figure 2 for a description of the cases.

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Figure 9. Cases without statistically significant different responses between fellowship directors and fellows. A, Case 1, colleague with website photographs of another surgeon's work ( = .09); B, case 2, a patient requesting an unnatural result ( = .16); C, Case 7, a patient who has undergone multiple operations seeking perfection ( = .13). See Figure 2 for a description of the cases.

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Figure 10. The rhinoplasty surgeon's template for resolving ethical problems. Do the right thing based on your knowledge, experience, and values. This template was adapted from Hébert.18

References

Behrbohm H, Briedigkeit W, Kaschke O. Jacques Joseph: father of modern facial plastic surgery.  Arch Facial Plast Surg. 2008;10(5):300-303
PubMed   |  Link to Article
Triana R. Jacques Joseph: surgical sculptor.  Arch Facial Plast Surg. 1999;1(4):324-325
PubMed   |  Link to Article
Bhattacharya S. Jacques Joseph: father of modern aesthetic surgery.  Indian J Plast Surg. 2008;41:(suppl)  S3-S8
PubMed
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3rd ed. Oxford, England: Oxford University Press; 1979
Chung KC, Pushman AG, Bellfi LT. A systematic review of ethical principles in the plastic surgery literature.  Plast Reconstr Surg. 2009;124(5):1711-1718
PubMed   |  Link to Article
Litner JA, Rotenberg BW, Dennis M, Adamson PA. Impact of cosmetic facial surgery on satisfaction with appearance and quality of life.  Arch Facial Plast Surg. 2008;10(2):79-83
PubMed   |  Link to Article
Atiyeh BS, Rubeiz MT, Hayek SN. Aesthetic/cosmetic surgery and ethical challenges.  Aesthetic Plast Surg. 2008;32(6):829-839
PubMed   |  Link to Article
Adamson PA, Litner JA. Psychological aspects of revision rhinoplasty.  Facial Plast Surg Clin North Am. 2006;14(4):269-277
Link to Article
Adamson PA, Chen T. The dangerous dozen: avoiding potential problem patients in cosmetic surgery.  Facial Plast Surg Clin North Am. 2008;16(2):195-202
PubMed   |  Link to Article
Shiffman MA. Medical liability issues in cosmetic and plastic surgery.  Med Law. 2005;24(2):211-232
PubMed
American Academy of Facial Plastic and Reconstructive Surgery.  Code of Ethics. http://www.aafprs.org/Code_Of_Ethics.pdf. Accessed November 3, 2010
Bull TR. Rhinoplasty: aesthetics, ethics and airway.  J Laryngol Otol. 1983;97(10):901-916
PubMed   |  Link to Article
Anderson JR. What physicians should know about nasal plastic surgery.  J La State Med Soc. 1963;115:337-341
PubMed
 Prince v Massachusetts 1944 321 US. 158, 170 
Woolley SL, Smith DRK. ENT surgery, blood and Jehovah's Witnesses.  J Laryngol Otol. 2007;121(5):409-414
PubMed   |  Link to Article
Freeman VG, Rathore SS, Weinfurt KP, Schulman KA, Sulmasy DP. Lying for patients: physician deception of third-party payers.  Arch Intern Med. 1999;159(19):2263-2270
PubMed   |  Link to Article
Adedeji S, Sokol DK, Palser T, McKneally M. Ethics of surgical complications.  World J Surg. 2009;33(4):732-737
PubMed   |  Link to Article
Hébert PC. Doing Right: A Practical Guide to Ethics for Medical Trainees and Physicians. 2nd ed. Oxford, England: Oxford University Press; 2009:23

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Ethical considerations in aesthetic rhinoplasty: a survey, critical analysis, and review [published online June 18, 2012]. Arch Facial Plast Surg doi:10.1001/archfacial.2012.132.

eAppendix. Responses to cases.

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