Psychological Red Flags in Rhinoplasty: Predictors of Malpractice Claims.

[BACKGROUND] Rhinoplasty is among the most frequently performed aesthetic procedures worldwide but also carries the highest litigation risk. Malpractice claims often arise less from surgical error than from poor patient selection and overlooked psychological comorbidities.

[OBJECTIVES] This study aimed to identify clinical and psychological predictors of malpractice litigation after rhinoplasty, highlighting the importance of patient selection. We hypothesized that litigating patients would exhibit higher rates of BDD traits, somatization, and dissatisfaction with body image and self-esteem.

[METHODS] A case-control design was applied. 55 patients referred for forensic evaluation after malpractice claims were compared with 85 rhinoplasty patients without litigation. Structured forensic assessments included functional endoscopy and standardized photographic analysis. Psychometric evaluation was performed using the Symptom Checklist-90-Revised (SCL-90-R), Body Image Quality of Life Inventory (BIQLI), Rosenberg Self-Esteem Scale (RSES), and Satisfaction with Appearance Scale (SWAS).

[RESULTS] Litigation patients were significantly older (p = 0.002), had lower educational attainment (p < 0.05), and were more often operated on by specialists rather than professors (p < 0.001). They were also more frequently operated in private hospitals (p = 0.010). Psychologically, litigation patients showed higher somatization prevalence (p = 0.019) and significantly lower BIQLI, SWAS, and RSES scores (all p < 0.05). Logistic regression identified low BIQLI scores and specialist-level surgery as independent predictors of litigation.

[CONCLUSIONS] Failure to recognize BDD traits, somatization, or unrealistic expectations strongly increases malpractice risk. Effective prevention requires rigorous preoperative screening, transparent communication, and multidisciplinary evaluation. Correct patient selection remains the surgeon's strongest safeguard-enhancing outcomes, protecting professional credibility, and minimizing litigation.