Current Predictors of Revision at Time of Primary Rhinoplasty

Garbaccio NC, Smith JE, Schonebaum DI, Foster L, Mehdizadeh M, Cordero JJ, Lin SJ.

PubMed 41286173 Publisher (DOI)Free full text (PMC)

What this paper says

In 101,562 primary rhinoplasty patients, social exclusion, personality disorders, prior filler injections and sedative dependence were the strongest predictors of later revision surgery, and the authors propose replacing the 1999 SIMON mnemonic with BLAKE.

Overview

Surgeons have long used SIMON (single, immature, male, overly expectant, narcissistic) to flag patients likely to be dissatisfied. The authors queried the TriNetX records database for patients aged 15 or older who had primary rhinoplasty at least three years earlier, and used a Cox proportional hazards model across 115 patient variables to see which predicted revision.

Sections of note

Revision risk 16.8 times higher with social exclusion or rejection; 5.36 times with personality disorders; 3.45 times with a history of subcutaneous filler; 2.64 times with anxiolytic or sedative dependence; 1.38 times with male sex; 1.16 times with anxiolytic use.
Being married, BMI over 30, older age at surgery and a diagnosed deviated septum were associated with lower revision risk.
More women than men had revisions, but the difference was not significant (p = 0.062).
Proposed mnemonic BLAKE: Borderline/personality disorders, Lonely/social exclusion, Anxiolytics/sedatives, Kosmetik focus, previous Enhancement with fillers.
Level of Evidence III.

What it means for a patient

Social isolation and psychiatric diagnoses were far stronger predictors of revision than sex or age in this dataset.
Patients who had nasal filler before surgery were about three times more likely to have revision.
A functional (breathing) indication was linked to fewer revisions, suggesting expectations differ for cosmetic-only cases.

Why this paper matters

It is the largest data-driven update of a widely taught patient-selection rule. Limits: database coding cannot capture motivation or surgeon skill; revision is an imperfect proxy for dissatisfaction.

Terms

Revision rhinoplasty: a second operation to correct the result of the first.
Cox proportional hazards model: a statistical method for time-to-event risk.
Anxiolytic: an anti-anxiety medication such as a benzodiazepine.
SIMON: a 1999 mnemonic for patients thought likely to be unhappy with cosmetic surgery.
Body dysmorphic disorder is not named here, but personality disorders in the model overlap with psychiatric screening concerns.

Summary written by rhinoplasty.cc from the abstract, 2026-09-08; not medical advice. The authors' own abstract follows.

Abstract

Background: Before primary rhinoplasty, it is crucial to identify patients whose concerns may not be adequately addressed by surgery. In 1999, Gorney and Martello introduced SIMON to describe patients who may be unsatisfied: single, immature, male, overly expectant, and narcissistic. This paper advocates for an evidence-based mnemonic to enhance patient selection.

Methods: TriNetX database medical records were queried for patients who underwent primary rhinoplasty at least three years ago at ≥ 15 years old. A Cox proportional hazards model quantified relationships between 115 patient variables, including SIMON-like characteristics, and risk of revision rhinoplasty.

Results: Of 101,562 patients, more female patients underwent revision rhinoplasty than male patients (p = 0.062). Revision risk was 16.8× higher with social exclusion/rejection; 5.36× higher with personality disorders; 3.45× higher with history of subcutaneous filler injections; 2.64× higher with anxiolytic or sedative dependence; 1.38× higher with male sex; and 1.16× higher with anxiolytic use. "Married" relationship status, BMI > 30, older age at surgery, and diagnosed deviated septum were negative associations with revision rhinoplasty.

Conclusion: In the current day, additional nuance in social relationships, surgical history, psychiatric diagnosis, and surgical indication may be required to predict revision rhinoplasty. We propose an acronym, BLAKE: Borderline/personality disorders, Lonely/social exclusion, Anxiolytics/sedatives, Kosmetik focus, and previous Enhancement with fillers. BLAKE captures the most salient predictors of revision at the time of primary rhinoplasty, updating the SIMON acronym to be non-gendered and nonreligious.

Level Of Evidence Iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Abstract as indexed by PubMed; the article is open access (PubMed Central).