- Email: [email protected]
Complex Orthognathic Surgery: Assessment of Patient Satisfaction
J Oral Maxillofac Surg 66:934-942, 2008
Complex Orthognathic Surgery: Assessment of Patient Satisfaction Jeffrey C. Posnick, DMD, MD,* and John Wallace, DDS, MD† Purpose: The purpose of our survey study was to determine if bimaxillary orthognathic surgery with
simultaneous intranasal surgery and other procedures carried out primarily for the correction of a developmental dentofacial deformity can be completed with a high level of patient satisfaction and minimal complications. Patients and Methods: A consecutive series of 42 patients entered in the study from senior surgeon’s (J.P.) patients at a single institution who underwent the minimum designated simultaneous procedures (Le Fort I, sagittal osteotomies of the mandible, septoplasty, inferior turbinate reduction) during a 1-year period. Patient satisfaction was assessed through analysis of data gathered from a postsurgical patient satisfaction questionnaire. The questionnaire is used to assess overall postsurgical/orthodontic patient satisfaction and patient assessment of head and neck function. The questionnaire was independently completed by each subject at least 6 months after surgery and only after removal of all orthodontic appliances and planned dental rehabilitation. Results: The results of our study clarify that bimaxillary orthognathic surgery including simultaneous intranasal (septoplasty and turbinate reduction) and other procedures (genioplasty, liposuction, and removal of third molars) can be carried out with a high level of patient satisfaction (89% of our study patients). Nevertheless, 2 of 42 patients (5%) in our study group were dissatisfied despite the absence of surgical or orthodontic complications and the clinicians’ feelings that the results achieved were an improvement. Conclusions: The results of our study clarify that complex bimaxillary orthognathic surgery including simultaneous intranasal and other procedures can be carried out with a high level of patient satisfaction. © 2008 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 66:934-942, 2008 success.2 While patients do consider occlusion as an important aspect of success, there are other motives/ objectives that cannot be overlooked if overall favorable results are to be achieved.1,3-8 It is not uncommon for a post orthognathic surgical result to be labeled as unsatisfactory by the surgeon, orthodontist, or restorative dentist (ie, imperfect occlusion) while the patients’ rating is more favorable.9 It is just as likely that the treating clinicians may feel that a successful outcome has been achieved (ie, satisfactory occlusion, favorable skeletal morphology) while the patient feels their esthetic objectives have not been met.5,9-11 Surveys and questionnaires are tools available to clinicians that may more objectively explain a subjective assessment of patient satisfaction.1,5,12 In the study by Bennett and Phillips,13 emphasis was placed on the importance of understanding discrepancies between patients’ and doctors’ rating of outcome after specific therapies. The point is made that healthrelated quality of life instruments (questionnaires/surveys) should be self-reporting to provide an accurate assessment of the patient’s perception of the surgical results, rather than relying on the clinician’s percep-
Orthognathic surgery is a commonly performed maxillofacial procedure with a documented safety record. Interestingly, there are few reports in the literature discussing patient satisfaction after bimaxillary orthognathic surgery. Clinicians have few tools to objectively measure the success of the orthognathic procedures carried out.1 Frequently, the postoperative occlusion and cephalometric parameters are considered the “gold standards” to determine surgical *Director, Posnick Center for Facial Plastic Surgery, Chevy Chase, MD; Clinical Professor of Surgery and Pediatrics, Georgetown University, Washington, DC; Adjunct Professor of Orthodontics, University of Maryland, Baltimore College of Dental Surgery, Baltimore, MD. †Past Fellow, Cranio-Maxillofacial Surgery, Posnick Center for Facial Plastic Surgery, Chevy Chase, MD; Fellowship sponsored by the Foundation of Oral and Maxillofacial Surgery; Currently in Private Practice, Dallas, TX. Address correspondence and reprint requests to Dr Posnick: 5530 Wisconsin Ave, Suite 1250, Chevy Chase, MD 20815; e-mail: [email protected] © 2008 American Association of Oral and Maxillofacial Surgeons
0278-2391/08/6605-0016$34.00/0 doi:10.1016/j.joms.2008.01.014
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tion of the postoperative outcome. Survey anonymity has the advantage of allowing the respondent to answer questions in a forthright manner, but prevents the correlation of the patient’s preoperative, intraoperative, and postoperative data when assessing the outcome of surgery. To date, no report has examined patient satisfaction and acceptance of results after bimaxillary orthognathic surgery when combined with intranasal and other procedures carried out in conjunction with orthodontic treatment and dental rehabilitation. We now report on data from a health-related quality of life survey (questionnaire) completed postoperatively by a consecutive series of the senior author’s (J.P.) patients after completion of orthodontic therapy and dental rehabilitation.
Patients and Methods A self-assessment survey was mailed to a consecutive series of the senior surgeon’s patients who underwent bimaxillary orthognathic surgery (Le Fort I osteotomy and sagittal split osteotomies of the mandible) combined with intranasal (septoplasty and inferior turbinate reduction) and other procedures (ie, chin osteotomy, cervical/submental liposuction, removal of third molars) at a single institution during a 12-month timeframe. Exclusion criteria were as follows: age less than 15 years; those who previously underwent orthognathic or temporomandibular joint (TMJ) surgery; those with a cleft-craniofacial syndrome; those who had previously undergone resection of a head and neck malignancy; had history of radiation treatment; or had sustained facial fractures requiring open reduction/internal fixation. Actual patient exclusions included: prior orthognathic surgery (N ⫽ 3); prior septoplasty (N ⫽ 4); and a cleftcraniofacial syndrome (N ⫽ 7). Forty-two patients met inclusion criteria for the completion of the selfassessment survey. The survey was sent to each subject at least 6 months after surgery and after completion of orthodontic treatment and restorative dental procedures. The post surgical patient satisfaction questionnaire (PSPSQ)14 was designed by the authors to assess each patient’s overall satisfaction with the procedure(s), functional improvements, and recognized or perceived negative affects of the procedures. The questionnaire was self-administered anonymously, but coded to identify the responder for later correlation to known demographic data and to allow association with documented postoperative complications/events. The PSPSQ used a 7-point Likert scale for the respondents to rate their level of satisfaction/acceptance of each question asked (Fig 1). A designated administra-
tive assistant coordinated the logistics of survey mailing and retrieval. Each patient’s presenting developmental jaw (dentofacial) deformity was classified as follows: ● ● ● ● ● ●
Mandibular deficiency with or without maxillary deformity Mandibular excess with or without maxillary deficiency Maxillary excess with or without mandibular deformity Asymmetric mandibular prognathism with or without maxillary deformity Combined maxillomandibular deficiency Idiopathic condylar resorption
The primary surgical procedures performed included a maxillary Le Fort I osteotomy, sagittal osteotomies of the mandible, and intranasal surgery (septoplasty and reduction of inferior turbinates). Adjunctive procedures varied with the functional and esthetic needs for each patient and included: segmental maxillary surgery, genioplasty, cervical/submental liposuction, and removal of impacted third molars. Additionally, patients were also evaluated for complications specific to the orthognathic and intranasal procedures. Complications specific to the orthognathic procedures included: infection requiring extended use of antibiotics or drainage procedures; dental injury; fibrous union; aseptic necrosis; bleeding requiring secondary treatment; oroantral fistula; and oronasal fistula. Complications specific to the intranasal procedures included: postoperative nasal bleeding requiring packing or cauterization; the need for postoperative blood transfusion specific to nasal bleeding; the presence of septal perforation; and postoperative nasal obstruction requiring additional procedures within 6 months after orthognathic surgery. Perioperative airway compromise was also reviewed, including the need for delayed extubation, re-intubation, or tracheotomy. Forty-two survey forms were mailed with a selfaddressed, postage-paid, return envelope. With a second mailing and the use of fax and/or e-mail delivery of the surveys, 42 patients responded to the survey, resulting in a 100% return rate that was achieved within 90 days of the last patient’s inclusion in the study.
Data Analysis All questions within each survey were answered by each responder (Table 1). For the purposes of data analysis, a patient response of 1, 2, or 3 on the Likert scale was considered unfavorable or not accepting of the surgical/orthodontic results. A patient response of
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FIGURE 1. The PSPSQ used in our study is shown. The PSPSQ uses a 7-point Likert scale for the respondents to rate their level of satisfaction/ acceptance of each question asked. Posnick and Wallace. Complex Orthognathic Surgery. J Oral Maxillofac Surg 2008.
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Table 1. TABULATION OF THE LIKERT SCORE (1-7) TO EACH OF THE 9 SURVEY QUESTIONS
Score
Q1
Q2
Q3
Q4
Q5
Q6
Q7
Q8
Q9
1 2 3 4 5 6 7
2 0 0 5 0 12 19
1 0 1 1 9 11 19
1 1 2 1 6 13 18
2 3 0 1 4 10 22
1 0 3 4 8 8 18
2 1 2 1 4 15 17
1 0 1 2 4 12 22
2 1 0 2 4 6 27
2 2 5 10 6 12 5
Posnick and Wallace. Complex Orthognathic Surgery. J Oral Maxillofac Surg 2008.
5, 6, or 7, was considered favorable or accepting of the treatment rendered. A patient response of 4 was considered neutral. We estimated the average satisfaction score and computed a 95% confidence interval for each question. Confidence interval calculation relied on a t-distribution, although this assumes that the sample mean is normally distributed. The results are displayed in Figure 2. We also calculated the proportion of subjects that gave a favorable response (score of 5 or above) on each question, along with 95% confidence intervals. Confidence intervals for these proportions used the Wilson formula, as recommended by Agresti and Coull.15 Results are presented in Figure 3. Finally, Pearson correlation coefficients were calculated for responses to each pair of questions (Table 2).
Results DEMOGRAPHICS, DIAGNOSIS, AND OTHER PROCEDURES
years. Median age was 22 years. Seven of the 42 patients were under 18 years of age (4 ⫽ 15 years; 1 ⫽ 16 years; 2 ⫽ 17 years). All patients were treated with a combined orthodontic and surgical approach that included: Le Fort I osteotomy, sagittal osteotomies of the mandible, septoplasty, and inferior turbinate reduction. The most frequent pattern of jaw deformity identified for the study group was vertical maxillary excess (hyperplasia) (17 of 42; 40%) followed by mandibular deficiency (hypoplasia) (9 of 42; 21%). Simultaneous maxillofacial procedures completed in addition to those listed above varied. Thirty-eight percent of the patients (16 of 42) underwent simultaneous removal of wisdom teeth. Seventeen percent (7 of 42) also underwent suction-assisted lipectomy of the neck. Eighty-six percent of the patients (36 of 42) underwent osseous genioplasty. COMPLICATIONS
The study group included 15 males and 27 females. Mean age was 25 years and ranged from 15 to 55
In our study group, all patients were either extubated in the operating room or within 2 hours after surgery in the recovery area. None of the study group required overnight intubation, re-intubation, or tra-
FIGURE 2. Plot of the estimated mean satisfaction Likert scale scores and 95% confidence intervals corresponding to each of the 9 survey questions.
FIGURE 3. Plot of the estimated proportion of subjects that gave a favorable rating, along with 95% confidence intervals, corresponding to each of the 9 questions asked in the survey.
Posnick and Wallace. Complex Orthognathic Surgery. J Oral Maxillofac Surg 2008.
Posnick and Wallace. Complex Orthognathic Surgery. J Oral Maxillofac Surg 2008.
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Table 2. TABULATION OF PEARSON CORRELATION COEFFICIENTS BETWEEN RESPONSES TO EACH OF THE 9 SURVEY QUESTIONS
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
Q2
Q3
Q4
Q5
Q6
Q7
Q8
Q9
0.72 1 — — — — — — —
0.72 0.62 1 — — — — — —
0.55 0.55 0.78 1 — — — — —
0.62 0.44 0.59 0.58 1 — — — —
0.75 0.45 0.8 0.65 0.75 1 — — —
0.54 0.59 0.7 0.56 0.55 0.55 1 — —
0.71 0.58 0.65 0.73 0.65 0.69 0.61 1 —
0.3 0.35 0.45 0.26 0.37 0.35 0.64 0.31 1
Posnick and Wallace. Complex Orthognathic Surgery. J Oral Maxillofac Surg 2008.
cheotomy. No patients required nasal packing, posthospital discharge blood transfusion, or additional nasal procedures on their septum, turbinates, or sinus within the initial 6 months after surgery. None were found to have perforations of the nasal septum. The study patients were evaluated for complications specifically associated with Le Fort I and sagittal osteotomies of the mandible. All maxilla and mandibles healed without infection, recurrent sinusitis, fibrous union, aseptic necrosis, or dental injury. One patient experienced post surgical idiopathic condylar resorption with resulting malocclusion. No patient required return to the operating room for control of bleeding or airway management. Sixty-nine percent (29 of 42) of the Le Fort I osteotomies also underwent segmental maxillary surgery (2 or 3 segments); however, no complications associated with segmental surgery (ie, periodontal complications, root resorption, oroantral/ nasal fistulae) were noted. OVERALL PATIENT SATISFACTION
To assess overall patient satisfaction, 3 questions were asked: First, “If you had to make the decision again, how likely would you be to undergo this same surgery?” Eighty-three percent (35 of 42) responded positively to this question. Twelve percent (5 of 42) were neutral and 5% (2 of 42) reported that they would not have undergone orthognathic surgery if they had to do it all over again. When asked the second question, “How likely would you be to recommend the same surgery to others?” 2 individuals (5%) stated they would not recommend the same surgery to others. One of the 42 patients (2%) was neutral, while 93% (39 of 42) would recommend the same surgery to others. Asked the question “Considering everything, how satisfied are you now with the results of surgery?” 88% (37 of 42) were satisfied, while 1 patient (2%) was neutral, and 4 (10%) had at least some degree of dissatisfaction. The average score for each question was approximately 6 (5.5 to 6.5, 95% confidence interval) (see Fig
2). Our results suggest that more than 70% of subjects would give a positive response to each (all 3) global satisfaction question (Fig 3). According to the survey, 2 of the 42 consecutive patients treated were dissatisfied (answered in the negative to all 3 satisfaction questions). Interestingly, 1 of the 2 dissatisfied patients was judged by the 3 treating clinicians (surgeon, orthodontist, restorative dentist) to have a satisfactory result (acceptable occlusion and improved facial esthetics). The second dissatisfied patient developed idiopathic condylar resorption approximately 3 to 6 months after surgery with a resulting residual malocclusion. The Pearson correlation coefficients highlight several points in our study group. The global satisfaction questions within the survey (questions 1-3) all correlate highly with each other. Of the 3 global satisfaction questions asked, question no. 3 correlates closest with the specific head and neck “function” questions (nos. 4-9). Of the specific “function” questions (nos. 4-9), perceived lip/chin region “numbness” (no. 9) has the weakest correlation with overall patient satisfaction. SATISFACTION WITH OCCLUSION
We asked the question “Overall, how satisfied are you with your current bite?” At completion of treatment, 5 of 42 (12%) were not entirely satisfied with their occlusion, while 2% (1 of 42) gave a neutral response to this question. The majority of patients (36 of 42; 86%) expressed satisfaction with their occlusal result after completion of orthodontic therapy. SATISFACTION WITH SPEECH
Speech articulation issues are not generally considered a major factor in a patient’s decision to undergo jaw surgery. We asked the question “Overall, how satisfied are you with your current speech articulation?” Our data suggests that 34 of 42 (80%) of patients were satisfied with their postoperative speech articulation. Ten percent (4 of 42) had no strong
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feeling, while 4 of 42 (10%) were not completely satisfied with their speech at the completion of treatment. SATISFACTION WITH LIP CLOSURE
Patients in our study group were asked “Overall, how satisfied are you with your current lip posture and lip closure?” Thirty-six of 42 (86%) of the patients were satisfied with static lip posture and their ability to actively close their lips, while 12% (5 of 42) were not satisfied, apparently feeling that their ability to control their lips was not completely normal. SATISFACTION WITH BREATHING
When asked the question “Overall, how satisfied are you with your current breathing?” 90% (38 of 42) of patients were overall satisfied with their post-treatment breathing. Five percent (2 of 42) were neutral in their assessment, while 2 of 42 (5%) were dissatisfied with at least some aspect of their breathing. ACCEPTANCE OF CURRENT TMJ FUNCTION/FACIAL PAIN
Each patient was asked the question “Overall, how accepting are you with your current level of TMJ function/facial pain?” Eighty-eight percent (37 of 42) were accepting of their current TMJ function and any degree of facial pain that they may have. Five percent (2 of 42) were neutral about this issue, while 3 of 42 (7%) were not completely accepting of their posttreatment level of TMJ dysfunction and/or facial pain. ACCEPTANCE OF CURRENT LOWER LIP/CHIN REGION SENSIBILITY
Patients were asked to respond to the question “Overall, how accepting are you with your current level of lower lip/chin sensation?” This question registered the highest level of patient dissatisfaction. Twenty-one percent (9 of 42) of patients were dissatisfied with their postsurgical sensory loss. Twentyfour percent (10 of 42) were neutral on this issue, while 23 of 42 (55%) were accepting of their post treatment level of lower lip-chin region sensory return.
Discussion Scott et al14 studied psychosocial predictors of satisfaction among orthognathic surgery patients in their multisite randomized trial comparing rigid and wire fixation in patients undergoing sagittal split osteotomies of the mandible for the management of mandibular retrusion. They found the postsurgical oral health status questionnaire esthetics subscale and the post surgical patient questionnaire significantly correlated. Hatch et al16 completed a randomized controlled trial
939 in patients undergoing sagittal split osteotomies of the mandible with advancement for correction of Class II malocclusions. Quality of life was measured using the Sickness Impact Profile. This was used as a generic measure of health-related quality of life. They also used the Oral Health Status Questionnaire, a specific measure of oral health and function designed for use with orthognathic surgery patients. They found that the health-related disability associated with Class II malocclusion was only modest compared with many other medical conditions (ie, diabetes), for which the rating system was developed. Nonetheless, orthognathic surgery patients did exhibit progressive and statistically significant improvement in health-related quality of life across a wide variety of functional domains. Interestingly, while 5 of 42 (12%) of our studied patients were not completely satisfied with their occlusion, only 2 of 42 (5%) of the patients treated were dissatisfied with the overall experience of having undergone the orthognathic procedures and orthodontic treatment. Therefore, it is apparent that the occlusion achieved is not the only important factor when a patient is judging surgical success or failure. These data also show that in our study group, despite the fact that 21% (9 of 42) of the patients were dissatisfied with the degree of sensory return (lower lip/chin) only 5% (2 of 42) were dissatisfied with the postoperative surgical results overall. Kiyak et al17 reported that women undergoing orthognathic surgery were more frequently motivated by a hope of esthetic improvements while men were more likely expecting improvement in their occlusion and mastication. They also indicated that neuroticism was a significant predictor of unfavorable orthognathic surgery outcomes, but it did not in itself predict long-term patient dissatisfaction. Peterson and Topazian18 found that presurgical communication between the surgeon and the patient and presurgical patient attitudes (expectations) were important predictors of post surgical levels of satisfaction. Kayak et al11,19,20 confirmed the findings of Peterson and Topazian18 and also believed presurgical anxiety, patient pessimism, and poor social support systems to be additional risk factors for postsurgical dissatisfaction in conjunction with occurrences of complications and neurosensory loss. Holman et al21 completed research indicating that regardless of the patient’s reasons for undergoing orthognathic surgery (ie, functional improvements or esthetic enhancement), optimistic patients generally reported higher rates of postsurgical satisfaction and improvements in function and social life when compared with pessimists. They also concluded that “anxious” patients, regardless of their motives for undergoing orthognathic surgery, are at greater risk for post surgical
940 complications. While the occurrence of a post surgical complication is a concrete risk factor for patient dissatisfaction, the clinician’s ability to select out those patients likely to harbor unrealistic expectations remains an important aspect of surgical judgment.22 Ideally, reliable psychometric tests would be used to screen patients at risk for dissatisfaction. Individuals found at risk for setting unrealistic expectations would be counseled against initiating treatment until they are “psychologically” ready. The Eysensk Personality Inventory (EPI),14,18,21,23,24 the revised symptom check list–90 (SCL-90-R),14,25,26 the Sickness Impact Profile (SIP),25,27,28 the 5 scales from the Oral Health Status Questionnaire (OHSQ),14,25,26 Oral Health Impact Profile 49 (OHIP),5,29,30 and the Orthognathic Quality of Life Questionnaire (OQLQ)2,31 have all been used as orthognathic surgery assessment tools in the past. In our view, the orthognathic surgery patients’ selfverification needs (the need to feel accepted) are an important factor that should not be overlooked if a favorable result is to be achieved. For example, patients who undergo orthognathic procedures may expect to draw attention to their “new” appearance. If orthodontic treatment and orthognathic surgery results in positive and praising feedback from those in their social circles, self-verification is fulfilled and they are likely to be satisfied.19 Some orthognathic patients may have realistic expectations but do not have a supportive social network of family and friends to fulfill their self-verification needs. Negative appearance-related commentary (ie, teasing or more subtle forms of negative feedback) has been shown to significantly affect body image and psychosocial functioning.8 If the comments (of others) are not good or do not meet personal expectations (which can be unrealistically too high), self-verification needs are not fulfilled and they are likely to be “dissatisfied.”5 One typical post orthognathic surgery self verification need is a “normal” occlusion. The feedback that an individual receives from their treating clinicians (eg, orthodontist, restorative dentist, and surgeon) about occlusion would be expected to influence their level of satisfaction. A patient’s varied social setting may also effect their perception of appearance and ultimately personal satisfaction. Haimovitz et al32 have brought to our attention an additional factor, which is the “changing opinion of a persons appearance” based on the environment. In their study, 144 women had very different body satisfaction scores depending on the social situation such as: walking in front of a group of men; walking at the beach while wearing a swimsuit; having lunch with a close female friend; getting dressed for school (work) in private; or trying on swimsuits in a department store dressing room. A
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female patient may be completely satisfied with her surgical results in a case of body liposuction when she wears a dress to work, but she may have wanted (expected) the surgery to allow her to proudly wear a bikini on the beach and be admired by observers. If wearing a bikini and receiving positive feedback is a paramount goal, then no matter how much praise she receives in the office, her self-verification needs will be unfulfilled and she will be dissatisfied. Body dysmorphic disorder (BDD) is a medical condition that can be difficult for the orthognathic surgeon to recognize prior to surgery. It is characterized by extreme dissatisfaction and preoccupation with a perceived appearance defect that often leads to significant functional impairment. It is estimated that 7% to 15% of individuals presenting for cosmetic surgery suffer with BDD. Cunningham et al33,34 described how an individual presenting for orthognathic surgery may have an underlying BDD. A surgical procedure to improve facial esthetics typically does not change the “appearance concerns” of the individual with BDD. Orthognathic procedures may even exacerbate the symptoms despite the clinician’s assessment of a favorable morphologic result.33 No matter how skilled the surgeon and how perfect the end results, a dissatisfied patient should be expected when treating BDD, and therefore surgery should be avoided unless extensive counseling is performed before the proposed procedure. The development of an effective psychosocial screening interview method or use of a self-reporting assessment survey to help identify individuals with BDD is needed in clinical practice.34-37 We can better care for our orthognathic surgery patient if we understand: their expectations, those of their immediate social network, and the expectations of the collaborating treating clinicians. If an appropriate questionnaire/inventory could be given preoperatively to identify potential future miscommunications by exposing unrealistic or hidden expectations, we would all do so. Broughton et al38 suggest the pretreatment use of the 25-item “Cooper Smith” selfesteem inventory questionnaire as a template that can be taken, graded, and interpreted quickly in a clinical setting. In their opinion, the “Cooper Smith” inventory may identify individuals with low self-esteem, which is a known risk factor for patient dissatisfaction. The study by Broughton et al38 reviewed patient satisfaction after body liposuction. While a great majority of their patients were satisfied with the procedures carried out and the results achieved (despite postoperative pain, fat return, or weight gain), a consistent minority of patients were dissatisfied with a low (postoperative) opinion of their personal appearance. This reinforces the need for careful preoperative patient selection, clear communication of realis-
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tic expectations, and the importance of including the family or significant companion and collaborating clinicians in the process. Despite our best efforts, there is no failsafe method of preventing a dissatisfied patient from blaming a third party (ie, surgeon, orthodontist, or hospital). This reinforces the need for all clinicians to maintain a thorough medical record and open lines of communication to limit the inevitable percentage of dissatisfied patients from successfully “blaming the clinician” for any personal unhappiness they perceive after treatment. The results of our study clarify that bimaxillary orthognathic surgery (Le Fort I and sagittal osteotomies of the mandible) including simultaneous intranasal (septoplasty and turbinate reduction) coupled with adjunctive procedures (genioplasty, liposuction, and removal of third molars) can be carried out with a high level of patient satisfaction (89% of our study patients). Nevertheless, a small percentage of patients (5%) were found to be dissatisfied despite the clinician’s perception that the results achieved were an improvement and that no specific surgical complications occurred. Until the science of patient selection parallels clinical reality, anticipating a consistent minority of dissatisfied patients remains the norm. The meticulous documentation of the patient-doctor relationship and maintaining open lines of communication and collaboration between the patient and treating clinicians remains an essential component of patient management when performing surgical procedures. Acknowledgment The authors would like to acknowledge Sandra DeLauder for her administrative assistance in the collection of the data and Jason Roy, PhD (Biostatistics), of Danville, PA for his statistical analysis of the data collected.
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941 8. Zhou Y, Hagg U, Rabie AB: Severity of dentofacial deformity, the motivations and the outcome of surgery in skeletal Class III patients. Chin Med J (Engl) 115:1031, 2002 9. Burke L, Croucher R: Criteria of good dental practice generated by general dental practitioners and patients. Int Dent J 46:3, 1996 10. Newton JT, Minhas G: Exposure to “ideal” facial images reduces facial satisfaction: An experimental study. Community Dent Oral Epidemiol 33:410, 2005 11. Kiyak HA, McNeill RW, West RA, et al: Predicting psychologic responses to orthognathic surgery. J Oral Maxillofac Surg 40: 150, 1982 12. Herbelein TA, Baumgartner R: Factors affecting response rates to mailed questionnaires: A quantitative analysis of the published literature. Am Sociol Rev 43:447, 1998 13. Bennett ME, Phillips CL: Assessment of health-related quality of life for patients with severe skeletal disharmony: A review of the issues. Int J Adult Orthodon Orthognath Surg 14:65, 1999 14. Scott AA, Hatch JP, Rugh JD, et al: Psychosocial predictors of satisfaction among orthognathic surgery patients. Int J Adult Orthodon Orthognath Surg 15:7, 2000 15. Agresti A, Coull BA: Approximate is better than “exact” for interval estimation of binomial proportions. Am Statistician 52:119, 1998 16. Hatch JP, Rugh JD, Clark GM, et al: Health-related quality of life following orthognathic surgery. Int J Adult Orthodon Orthognath Surg 13:67, 1998 17. Kiyak HA, McNeill RW, West RA: The emotional impact of orthognathic surgery and conventional orthodontics. Am J Orthod 88:224, 1985 18. Peterson LJ, Topazian RG: The preoperative interview and psychological evaluation of the orthognathic surgery patient. J Oral Surg 32:583, 1974 19. Kiyak HA, West RA, Hohl T, et al: The psychological impact of orthognathic surgery: A 9-month follow-up. Am J Orthod 81: 404, 1982 20. Kiyak HA, Hohl T, West RA, et al: Psychologic changes in orthognathic surgery patients: A 24-month follow. J Oral Maxillofac Surg 42:506, 1984 21. Holman AR, Brumer S, Ware WH, et al: The impact of interpersonal support on patient satisfaction with orthognathic surgery. J Oral Maxillofac Surg 53:1289, 1995 22. Pavone I, Rispoli A, Acocella A, et al: Psychological impact of self-image dissatisfaction after orthognathic surgery: A case report. World J Orthod 6:141, 2005 23. Finlay PM, Atkinson JM, Moos KF: Orthognathic surgery: Patient expectations; psychological profile and satisfaction with outcome. Br J Oral Maxillofac Surg 33:9, 1995 24. Hatch JP, Rugh JD, Bays RA, et al: Psychological function in orthognathic surgical patients before and after bilateral sagittal split osteotomy with rigid and wire fixation. Am J Orthod Dentofacial Orthop 115:536, 1999 25. Motegi E, Hatch JP, Rugh JD, et al: Health-related quality of life and psychosocial function 5 years after orthognathic surgery. Am J Orthod Dentofacial Orthop 124:138, 2003 26. Hatch JP, Rugh JD, Clark GM, et al: Health-related quality of life following orthognathic surgery. Int J Adult Orthodon Orthognath Surg 13:67, 1998 27. Phillips C, Kiyak HA, Bloomquist D, et al: Perceptions of recovery and satisfaction in the short term after orthognathic surgery. J Oral Maxillofac Surg 62:535, 2004 28. Motegi E, Hatch JP, Rugh JD, et al: Health-related quality of life and psychosocial function 5 years after orthognathic surgery. Am J Orthod Dentofacial Orthop 124:138, 2003 29. Slade GD, Spencer AJ: Developing and evaluation of the Oral Health Impact Profile. Community Dent Health 11:3, 1994 30. Slade GD: Assessing change in quality of life using the Oral Health Impact Profile. Community Dent Oral Epidemiol 26:52, 1998 31. Cunningham SJ, Garratt AM, Hunt NP: Development of a condition-specific quality of life measure for patients with dentofacial deformity: I. Reliability of the instrument. Community Dent Oral Epidemiol 28:195, 2000
942 32. Haimovitz D, Lansky LM, O’Reilly P: Fluctuations in body satisfaction across situations. Int J Eat Disord 13:77, 1993 33. Cunningham SJ, Bryant CJ, Manisali M, et al: Dysmorphophobia: Recent developments of interest to the maxillofacial surgeon. Br J Oral Maxillofac Surg 34:368, 1996 34. Cunningham SJ, Feinmann C: Psychological assessment of patients requesting orthognathic surgery and the relevance of body dysmorphic disorder. Br J Orthod 25:293, 1998 35. Rispoli C, Acocella A, Pavone I, et al. Psychoemotional assessment changes in patients treated with orthognathic sur-
COMPLEX ORTHOGNATHIC SURGERY gery: Pre and postsurgery report. World J Orthod 5:48, 2004 36. Crerand C, Franklin M, Sarwer D: Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg 118:167, 2006 37. Sarwer DB, Crerand CE, Gibbons LM: The Art of Aesthetic Surgery. St. Louis, MO, Quality Medical Publishing, 2005, pp 33-57 38. Broughton G III, Horton B, Lipschitz A, et al: Life outcomes, satisfaction, and attitudes of patients after liposuction: A Dallas experience. J Plastic Reconstr Surg 117:1738, 2006
Complex Orthognathic Surgery: Assessment of Patient Satisfaction Jeffrey C. Posnick, DMD, MD,* and John Wallace, DDS, MD† Purpose: The purpose of our survey study was to determine if bimaxillary orthognathic surgery with
simultaneous intranasal surgery and other procedures carried out primarily for the correction of a developmental dentofacial deformity can be completed with a high level of patient satisfaction and minimal complications. Patients and Methods: A consecutive series of 42 patients entered in the study from senior surgeon’s (J.P.) patients at a single institution who underwent the minimum designated simultaneous procedures (Le Fort I, sagittal osteotomies of the mandible, septoplasty, inferior turbinate reduction) during a 1-year period. Patient satisfaction was assessed through analysis of data gathered from a postsurgical patient satisfaction questionnaire. The questionnaire is used to assess overall postsurgical/orthodontic patient satisfaction and patient assessment of head and neck function. The questionnaire was independently completed by each subject at least 6 months after surgery and only after removal of all orthodontic appliances and planned dental rehabilitation. Results: The results of our study clarify that bimaxillary orthognathic surgery including simultaneous intranasal (septoplasty and turbinate reduction) and other procedures (genioplasty, liposuction, and removal of third molars) can be carried out with a high level of patient satisfaction (89% of our study patients). Nevertheless, 2 of 42 patients (5%) in our study group were dissatisfied despite the absence of surgical or orthodontic complications and the clinicians’ feelings that the results achieved were an improvement. Conclusions: The results of our study clarify that complex bimaxillary orthognathic surgery including simultaneous intranasal and other procedures can be carried out with a high level of patient satisfaction. © 2008 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 66:934-942, 2008 success.2 While patients do consider occlusion as an important aspect of success, there are other motives/ objectives that cannot be overlooked if overall favorable results are to be achieved.1,3-8 It is not uncommon for a post orthognathic surgical result to be labeled as unsatisfactory by the surgeon, orthodontist, or restorative dentist (ie, imperfect occlusion) while the patients’ rating is more favorable.9 It is just as likely that the treating clinicians may feel that a successful outcome has been achieved (ie, satisfactory occlusion, favorable skeletal morphology) while the patient feels their esthetic objectives have not been met.5,9-11 Surveys and questionnaires are tools available to clinicians that may more objectively explain a subjective assessment of patient satisfaction.1,5,12 In the study by Bennett and Phillips,13 emphasis was placed on the importance of understanding discrepancies between patients’ and doctors’ rating of outcome after specific therapies. The point is made that healthrelated quality of life instruments (questionnaires/surveys) should be self-reporting to provide an accurate assessment of the patient’s perception of the surgical results, rather than relying on the clinician’s percep-
Orthognathic surgery is a commonly performed maxillofacial procedure with a documented safety record. Interestingly, there are few reports in the literature discussing patient satisfaction after bimaxillary orthognathic surgery. Clinicians have few tools to objectively measure the success of the orthognathic procedures carried out.1 Frequently, the postoperative occlusion and cephalometric parameters are considered the “gold standards” to determine surgical *Director, Posnick Center for Facial Plastic Surgery, Chevy Chase, MD; Clinical Professor of Surgery and Pediatrics, Georgetown University, Washington, DC; Adjunct Professor of Orthodontics, University of Maryland, Baltimore College of Dental Surgery, Baltimore, MD. †Past Fellow, Cranio-Maxillofacial Surgery, Posnick Center for Facial Plastic Surgery, Chevy Chase, MD; Fellowship sponsored by the Foundation of Oral and Maxillofacial Surgery; Currently in Private Practice, Dallas, TX. Address correspondence and reprint requests to Dr Posnick: 5530 Wisconsin Ave, Suite 1250, Chevy Chase, MD 20815; e-mail: [email protected] © 2008 American Association of Oral and Maxillofacial Surgeons
0278-2391/08/6605-0016$34.00/0 doi:10.1016/j.joms.2008.01.014
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tion of the postoperative outcome. Survey anonymity has the advantage of allowing the respondent to answer questions in a forthright manner, but prevents the correlation of the patient’s preoperative, intraoperative, and postoperative data when assessing the outcome of surgery. To date, no report has examined patient satisfaction and acceptance of results after bimaxillary orthognathic surgery when combined with intranasal and other procedures carried out in conjunction with orthodontic treatment and dental rehabilitation. We now report on data from a health-related quality of life survey (questionnaire) completed postoperatively by a consecutive series of the senior author’s (J.P.) patients after completion of orthodontic therapy and dental rehabilitation.
Patients and Methods A self-assessment survey was mailed to a consecutive series of the senior surgeon’s patients who underwent bimaxillary orthognathic surgery (Le Fort I osteotomy and sagittal split osteotomies of the mandible) combined with intranasal (septoplasty and inferior turbinate reduction) and other procedures (ie, chin osteotomy, cervical/submental liposuction, removal of third molars) at a single institution during a 12-month timeframe. Exclusion criteria were as follows: age less than 15 years; those who previously underwent orthognathic or temporomandibular joint (TMJ) surgery; those with a cleft-craniofacial syndrome; those who had previously undergone resection of a head and neck malignancy; had history of radiation treatment; or had sustained facial fractures requiring open reduction/internal fixation. Actual patient exclusions included: prior orthognathic surgery (N ⫽ 3); prior septoplasty (N ⫽ 4); and a cleftcraniofacial syndrome (N ⫽ 7). Forty-two patients met inclusion criteria for the completion of the selfassessment survey. The survey was sent to each subject at least 6 months after surgery and after completion of orthodontic treatment and restorative dental procedures. The post surgical patient satisfaction questionnaire (PSPSQ)14 was designed by the authors to assess each patient’s overall satisfaction with the procedure(s), functional improvements, and recognized or perceived negative affects of the procedures. The questionnaire was self-administered anonymously, but coded to identify the responder for later correlation to known demographic data and to allow association with documented postoperative complications/events. The PSPSQ used a 7-point Likert scale for the respondents to rate their level of satisfaction/acceptance of each question asked (Fig 1). A designated administra-
tive assistant coordinated the logistics of survey mailing and retrieval. Each patient’s presenting developmental jaw (dentofacial) deformity was classified as follows: ● ● ● ● ● ●
Mandibular deficiency with or without maxillary deformity Mandibular excess with or without maxillary deficiency Maxillary excess with or without mandibular deformity Asymmetric mandibular prognathism with or without maxillary deformity Combined maxillomandibular deficiency Idiopathic condylar resorption
The primary surgical procedures performed included a maxillary Le Fort I osteotomy, sagittal osteotomies of the mandible, and intranasal surgery (septoplasty and reduction of inferior turbinates). Adjunctive procedures varied with the functional and esthetic needs for each patient and included: segmental maxillary surgery, genioplasty, cervical/submental liposuction, and removal of impacted third molars. Additionally, patients were also evaluated for complications specific to the orthognathic and intranasal procedures. Complications specific to the orthognathic procedures included: infection requiring extended use of antibiotics or drainage procedures; dental injury; fibrous union; aseptic necrosis; bleeding requiring secondary treatment; oroantral fistula; and oronasal fistula. Complications specific to the intranasal procedures included: postoperative nasal bleeding requiring packing or cauterization; the need for postoperative blood transfusion specific to nasal bleeding; the presence of septal perforation; and postoperative nasal obstruction requiring additional procedures within 6 months after orthognathic surgery. Perioperative airway compromise was also reviewed, including the need for delayed extubation, re-intubation, or tracheotomy. Forty-two survey forms were mailed with a selfaddressed, postage-paid, return envelope. With a second mailing and the use of fax and/or e-mail delivery of the surveys, 42 patients responded to the survey, resulting in a 100% return rate that was achieved within 90 days of the last patient’s inclusion in the study.
Data Analysis All questions within each survey were answered by each responder (Table 1). For the purposes of data analysis, a patient response of 1, 2, or 3 on the Likert scale was considered unfavorable or not accepting of the surgical/orthodontic results. A patient response of
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FIGURE 1. The PSPSQ used in our study is shown. The PSPSQ uses a 7-point Likert scale for the respondents to rate their level of satisfaction/ acceptance of each question asked. Posnick and Wallace. Complex Orthognathic Surgery. J Oral Maxillofac Surg 2008.
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Table 1. TABULATION OF THE LIKERT SCORE (1-7) TO EACH OF THE 9 SURVEY QUESTIONS
Score
Q1
Q2
Q3
Q4
Q5
Q6
Q7
Q8
Q9
1 2 3 4 5 6 7
2 0 0 5 0 12 19
1 0 1 1 9 11 19
1 1 2 1 6 13 18
2 3 0 1 4 10 22
1 0 3 4 8 8 18
2 1 2 1 4 15 17
1 0 1 2 4 12 22
2 1 0 2 4 6 27
2 2 5 10 6 12 5
Posnick and Wallace. Complex Orthognathic Surgery. J Oral Maxillofac Surg 2008.
5, 6, or 7, was considered favorable or accepting of the treatment rendered. A patient response of 4 was considered neutral. We estimated the average satisfaction score and computed a 95% confidence interval for each question. Confidence interval calculation relied on a t-distribution, although this assumes that the sample mean is normally distributed. The results are displayed in Figure 2. We also calculated the proportion of subjects that gave a favorable response (score of 5 or above) on each question, along with 95% confidence intervals. Confidence intervals for these proportions used the Wilson formula, as recommended by Agresti and Coull.15 Results are presented in Figure 3. Finally, Pearson correlation coefficients were calculated for responses to each pair of questions (Table 2).
Results DEMOGRAPHICS, DIAGNOSIS, AND OTHER PROCEDURES
years. Median age was 22 years. Seven of the 42 patients were under 18 years of age (4 ⫽ 15 years; 1 ⫽ 16 years; 2 ⫽ 17 years). All patients were treated with a combined orthodontic and surgical approach that included: Le Fort I osteotomy, sagittal osteotomies of the mandible, septoplasty, and inferior turbinate reduction. The most frequent pattern of jaw deformity identified for the study group was vertical maxillary excess (hyperplasia) (17 of 42; 40%) followed by mandibular deficiency (hypoplasia) (9 of 42; 21%). Simultaneous maxillofacial procedures completed in addition to those listed above varied. Thirty-eight percent of the patients (16 of 42) underwent simultaneous removal of wisdom teeth. Seventeen percent (7 of 42) also underwent suction-assisted lipectomy of the neck. Eighty-six percent of the patients (36 of 42) underwent osseous genioplasty. COMPLICATIONS
The study group included 15 males and 27 females. Mean age was 25 years and ranged from 15 to 55
In our study group, all patients were either extubated in the operating room or within 2 hours after surgery in the recovery area. None of the study group required overnight intubation, re-intubation, or tra-
FIGURE 2. Plot of the estimated mean satisfaction Likert scale scores and 95% confidence intervals corresponding to each of the 9 survey questions.
FIGURE 3. Plot of the estimated proportion of subjects that gave a favorable rating, along with 95% confidence intervals, corresponding to each of the 9 questions asked in the survey.
Posnick and Wallace. Complex Orthognathic Surgery. J Oral Maxillofac Surg 2008.
Posnick and Wallace. Complex Orthognathic Surgery. J Oral Maxillofac Surg 2008.
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Table 2. TABULATION OF PEARSON CORRELATION COEFFICIENTS BETWEEN RESPONSES TO EACH OF THE 9 SURVEY QUESTIONS
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
Q2
Q3
Q4
Q5
Q6
Q7
Q8
Q9
0.72 1 — — — — — — —
0.72 0.62 1 — — — — — —
0.55 0.55 0.78 1 — — — — —
0.62 0.44 0.59 0.58 1 — — — —
0.75 0.45 0.8 0.65 0.75 1 — — —
0.54 0.59 0.7 0.56 0.55 0.55 1 — —
0.71 0.58 0.65 0.73 0.65 0.69 0.61 1 —
0.3 0.35 0.45 0.26 0.37 0.35 0.64 0.31 1
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cheotomy. No patients required nasal packing, posthospital discharge blood transfusion, or additional nasal procedures on their septum, turbinates, or sinus within the initial 6 months after surgery. None were found to have perforations of the nasal septum. The study patients were evaluated for complications specifically associated with Le Fort I and sagittal osteotomies of the mandible. All maxilla and mandibles healed without infection, recurrent sinusitis, fibrous union, aseptic necrosis, or dental injury. One patient experienced post surgical idiopathic condylar resorption with resulting malocclusion. No patient required return to the operating room for control of bleeding or airway management. Sixty-nine percent (29 of 42) of the Le Fort I osteotomies also underwent segmental maxillary surgery (2 or 3 segments); however, no complications associated with segmental surgery (ie, periodontal complications, root resorption, oroantral/ nasal fistulae) were noted. OVERALL PATIENT SATISFACTION
To assess overall patient satisfaction, 3 questions were asked: First, “If you had to make the decision again, how likely would you be to undergo this same surgery?” Eighty-three percent (35 of 42) responded positively to this question. Twelve percent (5 of 42) were neutral and 5% (2 of 42) reported that they would not have undergone orthognathic surgery if they had to do it all over again. When asked the second question, “How likely would you be to recommend the same surgery to others?” 2 individuals (5%) stated they would not recommend the same surgery to others. One of the 42 patients (2%) was neutral, while 93% (39 of 42) would recommend the same surgery to others. Asked the question “Considering everything, how satisfied are you now with the results of surgery?” 88% (37 of 42) were satisfied, while 1 patient (2%) was neutral, and 4 (10%) had at least some degree of dissatisfaction. The average score for each question was approximately 6 (5.5 to 6.5, 95% confidence interval) (see Fig
2). Our results suggest that more than 70% of subjects would give a positive response to each (all 3) global satisfaction question (Fig 3). According to the survey, 2 of the 42 consecutive patients treated were dissatisfied (answered in the negative to all 3 satisfaction questions). Interestingly, 1 of the 2 dissatisfied patients was judged by the 3 treating clinicians (surgeon, orthodontist, restorative dentist) to have a satisfactory result (acceptable occlusion and improved facial esthetics). The second dissatisfied patient developed idiopathic condylar resorption approximately 3 to 6 months after surgery with a resulting residual malocclusion. The Pearson correlation coefficients highlight several points in our study group. The global satisfaction questions within the survey (questions 1-3) all correlate highly with each other. Of the 3 global satisfaction questions asked, question no. 3 correlates closest with the specific head and neck “function” questions (nos. 4-9). Of the specific “function” questions (nos. 4-9), perceived lip/chin region “numbness” (no. 9) has the weakest correlation with overall patient satisfaction. SATISFACTION WITH OCCLUSION
We asked the question “Overall, how satisfied are you with your current bite?” At completion of treatment, 5 of 42 (12%) were not entirely satisfied with their occlusion, while 2% (1 of 42) gave a neutral response to this question. The majority of patients (36 of 42; 86%) expressed satisfaction with their occlusal result after completion of orthodontic therapy. SATISFACTION WITH SPEECH
Speech articulation issues are not generally considered a major factor in a patient’s decision to undergo jaw surgery. We asked the question “Overall, how satisfied are you with your current speech articulation?” Our data suggests that 34 of 42 (80%) of patients were satisfied with their postoperative speech articulation. Ten percent (4 of 42) had no strong
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feeling, while 4 of 42 (10%) were not completely satisfied with their speech at the completion of treatment. SATISFACTION WITH LIP CLOSURE
Patients in our study group were asked “Overall, how satisfied are you with your current lip posture and lip closure?” Thirty-six of 42 (86%) of the patients were satisfied with static lip posture and their ability to actively close their lips, while 12% (5 of 42) were not satisfied, apparently feeling that their ability to control their lips was not completely normal. SATISFACTION WITH BREATHING
When asked the question “Overall, how satisfied are you with your current breathing?” 90% (38 of 42) of patients were overall satisfied with their post-treatment breathing. Five percent (2 of 42) were neutral in their assessment, while 2 of 42 (5%) were dissatisfied with at least some aspect of their breathing. ACCEPTANCE OF CURRENT TMJ FUNCTION/FACIAL PAIN
Each patient was asked the question “Overall, how accepting are you with your current level of TMJ function/facial pain?” Eighty-eight percent (37 of 42) were accepting of their current TMJ function and any degree of facial pain that they may have. Five percent (2 of 42) were neutral about this issue, while 3 of 42 (7%) were not completely accepting of their posttreatment level of TMJ dysfunction and/or facial pain. ACCEPTANCE OF CURRENT LOWER LIP/CHIN REGION SENSIBILITY
Patients were asked to respond to the question “Overall, how accepting are you with your current level of lower lip/chin sensation?” This question registered the highest level of patient dissatisfaction. Twenty-one percent (9 of 42) of patients were dissatisfied with their postsurgical sensory loss. Twentyfour percent (10 of 42) were neutral on this issue, while 23 of 42 (55%) were accepting of their post treatment level of lower lip-chin region sensory return.
Discussion Scott et al14 studied psychosocial predictors of satisfaction among orthognathic surgery patients in their multisite randomized trial comparing rigid and wire fixation in patients undergoing sagittal split osteotomies of the mandible for the management of mandibular retrusion. They found the postsurgical oral health status questionnaire esthetics subscale and the post surgical patient questionnaire significantly correlated. Hatch et al16 completed a randomized controlled trial
939 in patients undergoing sagittal split osteotomies of the mandible with advancement for correction of Class II malocclusions. Quality of life was measured using the Sickness Impact Profile. This was used as a generic measure of health-related quality of life. They also used the Oral Health Status Questionnaire, a specific measure of oral health and function designed for use with orthognathic surgery patients. They found that the health-related disability associated with Class II malocclusion was only modest compared with many other medical conditions (ie, diabetes), for which the rating system was developed. Nonetheless, orthognathic surgery patients did exhibit progressive and statistically significant improvement in health-related quality of life across a wide variety of functional domains. Interestingly, while 5 of 42 (12%) of our studied patients were not completely satisfied with their occlusion, only 2 of 42 (5%) of the patients treated were dissatisfied with the overall experience of having undergone the orthognathic procedures and orthodontic treatment. Therefore, it is apparent that the occlusion achieved is not the only important factor when a patient is judging surgical success or failure. These data also show that in our study group, despite the fact that 21% (9 of 42) of the patients were dissatisfied with the degree of sensory return (lower lip/chin) only 5% (2 of 42) were dissatisfied with the postoperative surgical results overall. Kiyak et al17 reported that women undergoing orthognathic surgery were more frequently motivated by a hope of esthetic improvements while men were more likely expecting improvement in their occlusion and mastication. They also indicated that neuroticism was a significant predictor of unfavorable orthognathic surgery outcomes, but it did not in itself predict long-term patient dissatisfaction. Peterson and Topazian18 found that presurgical communication between the surgeon and the patient and presurgical patient attitudes (expectations) were important predictors of post surgical levels of satisfaction. Kayak et al11,19,20 confirmed the findings of Peterson and Topazian18 and also believed presurgical anxiety, patient pessimism, and poor social support systems to be additional risk factors for postsurgical dissatisfaction in conjunction with occurrences of complications and neurosensory loss. Holman et al21 completed research indicating that regardless of the patient’s reasons for undergoing orthognathic surgery (ie, functional improvements or esthetic enhancement), optimistic patients generally reported higher rates of postsurgical satisfaction and improvements in function and social life when compared with pessimists. They also concluded that “anxious” patients, regardless of their motives for undergoing orthognathic surgery, are at greater risk for post surgical
940 complications. While the occurrence of a post surgical complication is a concrete risk factor for patient dissatisfaction, the clinician’s ability to select out those patients likely to harbor unrealistic expectations remains an important aspect of surgical judgment.22 Ideally, reliable psychometric tests would be used to screen patients at risk for dissatisfaction. Individuals found at risk for setting unrealistic expectations would be counseled against initiating treatment until they are “psychologically” ready. The Eysensk Personality Inventory (EPI),14,18,21,23,24 the revised symptom check list–90 (SCL-90-R),14,25,26 the Sickness Impact Profile (SIP),25,27,28 the 5 scales from the Oral Health Status Questionnaire (OHSQ),14,25,26 Oral Health Impact Profile 49 (OHIP),5,29,30 and the Orthognathic Quality of Life Questionnaire (OQLQ)2,31 have all been used as orthognathic surgery assessment tools in the past. In our view, the orthognathic surgery patients’ selfverification needs (the need to feel accepted) are an important factor that should not be overlooked if a favorable result is to be achieved. For example, patients who undergo orthognathic procedures may expect to draw attention to their “new” appearance. If orthodontic treatment and orthognathic surgery results in positive and praising feedback from those in their social circles, self-verification is fulfilled and they are likely to be satisfied.19 Some orthognathic patients may have realistic expectations but do not have a supportive social network of family and friends to fulfill their self-verification needs. Negative appearance-related commentary (ie, teasing or more subtle forms of negative feedback) has been shown to significantly affect body image and psychosocial functioning.8 If the comments (of others) are not good or do not meet personal expectations (which can be unrealistically too high), self-verification needs are not fulfilled and they are likely to be “dissatisfied.”5 One typical post orthognathic surgery self verification need is a “normal” occlusion. The feedback that an individual receives from their treating clinicians (eg, orthodontist, restorative dentist, and surgeon) about occlusion would be expected to influence their level of satisfaction. A patient’s varied social setting may also effect their perception of appearance and ultimately personal satisfaction. Haimovitz et al32 have brought to our attention an additional factor, which is the “changing opinion of a persons appearance” based on the environment. In their study, 144 women had very different body satisfaction scores depending on the social situation such as: walking in front of a group of men; walking at the beach while wearing a swimsuit; having lunch with a close female friend; getting dressed for school (work) in private; or trying on swimsuits in a department store dressing room. A
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female patient may be completely satisfied with her surgical results in a case of body liposuction when she wears a dress to work, but she may have wanted (expected) the surgery to allow her to proudly wear a bikini on the beach and be admired by observers. If wearing a bikini and receiving positive feedback is a paramount goal, then no matter how much praise she receives in the office, her self-verification needs will be unfulfilled and she will be dissatisfied. Body dysmorphic disorder (BDD) is a medical condition that can be difficult for the orthognathic surgeon to recognize prior to surgery. It is characterized by extreme dissatisfaction and preoccupation with a perceived appearance defect that often leads to significant functional impairment. It is estimated that 7% to 15% of individuals presenting for cosmetic surgery suffer with BDD. Cunningham et al33,34 described how an individual presenting for orthognathic surgery may have an underlying BDD. A surgical procedure to improve facial esthetics typically does not change the “appearance concerns” of the individual with BDD. Orthognathic procedures may even exacerbate the symptoms despite the clinician’s assessment of a favorable morphologic result.33 No matter how skilled the surgeon and how perfect the end results, a dissatisfied patient should be expected when treating BDD, and therefore surgery should be avoided unless extensive counseling is performed before the proposed procedure. The development of an effective psychosocial screening interview method or use of a self-reporting assessment survey to help identify individuals with BDD is needed in clinical practice.34-37 We can better care for our orthognathic surgery patient if we understand: their expectations, those of their immediate social network, and the expectations of the collaborating treating clinicians. If an appropriate questionnaire/inventory could be given preoperatively to identify potential future miscommunications by exposing unrealistic or hidden expectations, we would all do so. Broughton et al38 suggest the pretreatment use of the 25-item “Cooper Smith” selfesteem inventory questionnaire as a template that can be taken, graded, and interpreted quickly in a clinical setting. In their opinion, the “Cooper Smith” inventory may identify individuals with low self-esteem, which is a known risk factor for patient dissatisfaction. The study by Broughton et al38 reviewed patient satisfaction after body liposuction. While a great majority of their patients were satisfied with the procedures carried out and the results achieved (despite postoperative pain, fat return, or weight gain), a consistent minority of patients were dissatisfied with a low (postoperative) opinion of their personal appearance. This reinforces the need for careful preoperative patient selection, clear communication of realis-
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tic expectations, and the importance of including the family or significant companion and collaborating clinicians in the process. Despite our best efforts, there is no failsafe method of preventing a dissatisfied patient from blaming a third party (ie, surgeon, orthodontist, or hospital). This reinforces the need for all clinicians to maintain a thorough medical record and open lines of communication to limit the inevitable percentage of dissatisfied patients from successfully “blaming the clinician” for any personal unhappiness they perceive after treatment. The results of our study clarify that bimaxillary orthognathic surgery (Le Fort I and sagittal osteotomies of the mandible) including simultaneous intranasal (septoplasty and turbinate reduction) coupled with adjunctive procedures (genioplasty, liposuction, and removal of third molars) can be carried out with a high level of patient satisfaction (89% of our study patients). Nevertheless, a small percentage of patients (5%) were found to be dissatisfied despite the clinician’s perception that the results achieved were an improvement and that no specific surgical complications occurred. Until the science of patient selection parallels clinical reality, anticipating a consistent minority of dissatisfied patients remains the norm. The meticulous documentation of the patient-doctor relationship and maintaining open lines of communication and collaboration between the patient and treating clinicians remains an essential component of patient management when performing surgical procedures. Acknowledgment The authors would like to acknowledge Sandra DeLauder for her administrative assistance in the collection of the data and Jason Roy, PhD (Biostatistics), of Danville, PA for his statistical analysis of the data collected.
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