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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 20  |  Issue : 1  |  Page : 1-12

Long-term cosmetic and functional outcomes of rhinoplasty: A cross sectional study of patients’ satisfaction


1 House-officer, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
2 Consultant Otolaryngiologist and Facial Plastic Surgeon, King Abdulaziz University, Jeddah, Saudi Arabia
3 Resident Department of Otorhinolaryngology-Head & Neck Surgery, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Web Publication23-Dec-2019

Correspondence Address:
Sara Howldar
Faculty of Medicine, King Abdulaziz University, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.273913

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  Abstract 


Objective: To assess patients’ satisfaction about cosmetic and functional outcomes of uncomplicated rhinoplasty and the consequent psychological impact
Materials and Methods: A cross-sectional study was carried in adult patients (≥20 years), who underwent primary, functional/cosmetic rhinoplastic surgery at Al Mashfa hospital, Jeddah, before January 2015 (1 year of postoperative follow-up). Patients were contacted for an anonymous telephonic interview using a validated [1], semi-structured questionnaire investigating 7 postoperative satisfaction parameters.
Results: Two hundred patients who underwent functional (13.5%), cosmetic (20.5%) or both functional and cosmetic (66.0%) rhinoplasty were included. Satisfaction analysis showed 48.0% satisfied rate. Female and divorced participants had lower satisfaction compared to their counterparts; and divorced women had lowest satisfaction score 28.33/100. Pre- to post-rhinoplasty assessments showed remarkable improvement in nose function (mean±SD=53.72±27.10 to 95.71±8.86; p<0.001), appearance (41.70±26.29 to 95.49±9.18; p<0.001) and patient’s mood (51.34±29.83 to 95.84±11.47; p<0.001), respectively. Change in mood was correlated with both change in function (r=0.412; OR [95%CI]=1.61 [1.39; 1.86]; p<0.001) and appearance (r=0.748; OR [95%CI]=2.30 [2.07; 2.55]; [p<0.001).
Conclusion: Patients who underwent primary uncomplicated rhinoplasty have fair satisfaction about functional long-term outcomes but remain relatively dissatisfied esthetically; especially female, divorced and unemployed patients. The functional and cosmetic improvements have positive impact on the patient’s psychological wellbeing.

Keywords: Rhinoplasty, long-term, satisfaction, impact, cosmetic, functional, psychological impact


How to cite this article:
Howldar S, Fida A, Allinjawi O, Zaqzoog F, Qurban G. Long-term cosmetic and functional outcomes of rhinoplasty: A cross sectional study of patients’ satisfaction. Saudi J Otorhinolaryngol Head Neck Surg 2018;20:1-12

How to cite this URL:
Howldar S, Fida A, Allinjawi O, Zaqzoog F, Qurban G. Long-term cosmetic and functional outcomes of rhinoplasty: A cross sectional study of patients’ satisfaction. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2018 [cited 2021 Apr 21];20:1-12. Available from: https://www.sjohns.org/text.asp?2018/20/1/1/273913




  Introduction Top


Growing demand for rhinoplasty surgery with a parallel increase in the performance requirements is challenging surgeons to be in constant improvement [2]. Consequently, new techniques are being developed continuously to improve patients’ satisfaction and quality of life (QoL), whether by simple closed reduction or by strong framework of grafts [3],[4]. Other techniques have developed to improve assessment of patient’s expectations, such as computer imaging planning ([4]. However, low satisfaction rates remain frequent in rhinoplasty due to the difficulty of the procedure in addition to unrealistic patient expectation [6].

A high degree of subjectivity interferes in the assessment of rhinoplasty outcomes. Patient dissatisfaction may be in relation with esthetic or functional concerns, which may or may not be confirmed by objective quantitative measures. In either case, patient’s assessment remains the ultimate determinant of a rhinoplasty success, as dissatisfaction often leads to multiple revisions [7],[8]. Furthermore, continuous progress in surgeons’ skills and improvement in rhinoplasty outcomes are paralleled by a change in the pattern of patients’ concerns that give rise to dissatisfaction and revision requests [9]. On the other hand, revision rhinoplasty is associated with a high risk of poor functional outcomes, such as airway occlusion, often compromised by the focus on cosmetic concerns [8],[9],[10].

Several teams studied satisfaction in patients after primary rhinoplasty. A study in Brazil showed a high level of patient’s satisfaction after rhinoplasty, with approximately 85% totally satisfied with a total mean of 73.25/100 [12]. Other authors have carried out pre- and postoperative assessments to highlight improvement in satisfaction regarding various functional and esthetic aspects [12],[13],[14].

Recently, assessment of QoL among the patients undergoing rhinoplasty has gained interest, providing comprehensive view on the impact of the health condition and the benefits of treatment. Several authors demonstrated significant improvement in QoL among patients, including psychological, physical, and social dimensions [15],[16].

Aim

This study aimed to assess patients’ satisfaction about cosmetic and functional outcomes of uncomplicated, primary rhinoplasty, and the consequent psychological impact. It also investigated demographic factors associated with satisfaction.

Study objectives:

  • To assess long-term (≥1 year) post-rhinoplasty satisfaction level regarding various functional and esthetic aspects
  • To analyze the statistical association of long-term post-rhinoplasty satisfaction with demographic factors such as age, gender, and marital status, etc.
  • To assess pre-to-post-rhinoplasty improvement in nose function, appearance and in patient’s mood; and to analyze the correlation of improvement in patient’s mood with that in function and appearance.



  Methods Top


A cross-sectional study was carried out between Jan 2016-June 2016, at the ENT department of Al Mashfa hospital, Jeddah, Saudi Arabia. Adult patients aged >20 years, who underwent primary, uncomplicated, functional or cosmetic rhinoplasty surgery before January 2015 (at least 1 year of postoperative follow-up), were included in the study. Participants aged <20, those who underwent revision rhinoplasty or simultaneously additional nasal surgery, those with facial trauma, psychiatric disorders were excluded; as well as patients who had post-rhinoplasty infectious complications.

Two hundred patients were randomly selected from the hospital database and contacted for an anonymous telephonic interview using a valid, disease-specific questionnaire investigating 7 postoperative satisfaction parameters related to function, cosmetic and social aspects [17]. Each of the previous parameters is a 5-point likert-type scale item scored as 0 to 4 (peritem score), where greater scores correspond to higher satisfaction in the given item. A total satisfaction score was calculated as the sum of scores from the 7 items and expressed on a 0-100 scale. Three additional questions analyzed overall patient’s assessment of function (4) and appearance of the nose [14] as well as his/her mood [18], pre- and post-rhinoplasty. Function and appearance were rated from 0=extremely bad to 100=extremely good; while mood was rated from 0=depressed to 100=joyful. The questionnaire was translated in Arabic and administered in the language in which the participant was most comfortable.


  Statistical Methods Top


Statistical analysis was performed with the Statistical Package for Social Sciences version 21.0 for Windows (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to present participants’ characteristics and distribution (frequency/percentage) in different satisfaction levels, for all 7 studied parameters; and mean scores were calculated for each parameter and presented in bar chart. Chi-square test was used to analyze association of demographic factors with different satisfaction levels. Per-item satisfaction scores (0-4) were compared between different categories of demographic factors using nonparametric tests including Mann-Whitney U test for binomial variables and Kruskal-Wallis test for multinomial variables; significant results are presented in bar charts. Total satisfaction scores (0-100) were compared using parametric tests, including independent t-test for binomial variables and One-way Analysis Of Variance (ANOVA) for multinomial variables; results are presented as mean±SD. Pre-to-post-rhinoplasty improvement in function, appearance and mood was analyzed using paired t-test; results are presented as means±SD in bar graphs. Linear regression was carried out to analyze psychological impact of functional and cosmetic outcomes by correlating the change in mood score (post – pre-rhinoplasty rating) with change in function and change in appearance, respectively; results are presented as scatter plot with fitting curve and correlation coefficient. A p-value of <0.05 was considered to reject the null hypothesis.


  Results Top


Participants’ characteristics

Majority of the participants were married (57.0%) and females (76.0%), with a mean±SD [range] age=33.78±7.41 [20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51] and high educational level (university+; 72.5%). Rhinoplasty was functional in 13.5% and cosmetic in 20.5%; while majority (66.0%) had both functional and cosmetic [Table 1].
Table 1: Participants' characteristics

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Satisfaction about rhinoplasty outcomes

Results of the satisfaction questionnaire (7 items) are presented in [Table 2]. Relatively higher percentages of satisfaction in items related to functional outcomes was observed when compared to those related to cosmesis. For example, satisfaction rate was 53.5% in the category very satisfied or completely satisfied regarding nose breathing (Q2), while it was only 35.5% regarding nose appearance (Q1). Further, 67.0% expressed the likelihood or intention to attempt a new surgery to improve current appearance (Q6), versus 53.0% to improve function (Q7). Mean (SD) total satisfaction score was 50.68 (29.55)/100. Mean peritem satisfaction score was highest for nose breathing (2.5/4), followed by friends’ and family satisfaction about nose appearance (2.4/4); while lowest score was for likelihood to attempt revision rhinoplasty to improve current appearance (1.5/4) [Figure 1].p<0.001), from pre- to post-rhinoplasty assessment. The notable decrease in SD, in all three parameters, further demonstrates the impact of rhinoplasty on patient’s satisfaction [Figure 2].
Table 2: Satisfaction about cosmetic and functional outcomes ≥1 year post rhinoplasty

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Figure 1: Mean satisfaction scores by parameter Caption: bars represent mean satisfaction score by parameter (range=0-4).

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Figure 2: Patient-reported pre-to-post-rhinoplasty improvement in nose function and appearance and patient's mood

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Demographic factors associated with satisfaction

Analysis of satisfaction by gender showed lower total satisfaction score (46.50±28.78 versus 63.91±28.28; p<0.001) and lower per-item scores in 6 out of 7 parameters, as compared to males, respectively. The most significant per-item difference was for likelihood of revision rhinoplasty for cosmetic concern (mean score=1.16 in females, versus 2.44 in males; Mann-Whitney U test: p<0.01) [Figure 3].
Figure 3: Rhinoplasty outcome satisfaction by gender Caption: comparison of rhinoplasty outcomes between males and females using nonparametric tests (Mann-Whitney U test) showed lower satisfaction scores among females regarding 6 out of 7 parameters. Bar represent mean scores.

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Satisfaction by marital status showed lower total satisfaction score among divorced participants (33.13±29.15) as compared to other categories including single (57.99±29.67), married (52.41±27.40) and widowed (66.52±32.62); using OneWay ANOVA with post hoc analysis using Tukey’s test (p<0.001). In addition, per-item scores were lower among divorced participants in all 7 parameters and the differences were statistically significant [Figure 4].
Figure 4: Rhinoplasty outcome satisfaction by marital status Caption: comparison of rhinoplasty outcomes between different marital status categories using nonparametric tests (Kruskal-Wallis test) showed lower satisfaction scores among divorced patients regarding all investigated parameters. Bar represent mean scores

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Satisfaction by occupation showed that unemployed category of participants had the lowest total satisfaction score (40.48±28.27; p=0.023, OneWay ANOVA) as compared to students (66.92±29.88), public (52.26±28.14) and private (48.57±28.63) sector employees, businessmen (50.50±31.02) and retired participants (78.57±21.43). In post-hoc analysis, only difference between unemployed participants and students was statistically significant (p=0.021). Peritem analysis showed that unemployed participants had the lowest score regarding nose appearance (p=0.008) and appearance limiting social and professional activities (p=0.007), confidence that nose appearance nose was the best possible (p=0.016), and likelihood to attempt revision rhinoplasty to improve appearance (p=0.016).

No significant difference in total or per-item satisfaction scores was observed by indication (p=0.193), age category (p=0.120), nationality (p=0.299) or educational level (p=0.881).

Psychological impact of cosmetic and functional outcomes

Linear regression showed positive correlation of the pre-to-post-rhinoplasty change in mood with both the change in function and appearance; however, correlation was stronger with appearance (r=0.748; p<0.001) than with function (r=0.412; p<0.001) [Figure 5].
Figure 5: Psychological impact of rhinoplasty cosmetic and functional outcomes

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  Discussion Top


For several reasons, long-term patient’s satisfaction after rhinoplasty is unpredictable, even after early postoperative satisfaction or good procedural outcomes [19]. Therefore, studying long-term satisfaction is essential and often shows discrepancy between surgeons’ assessment and patients’ subjective concerns, which may evolve or change over time.

The present study highlighted relatively low long- term patient’s satisfaction about rhinoplasty outcomes, showing a mean (SD) total satisfaction score=50.68 (29.55) and up to 56.5% satisfaction rate, depending on the item. Further, lower satisfaction rates were observed in parameters related to cosmetic aspects, ranging from 33.0% to 35.5%, depending on the item. On the other hand, this study showed a considerable improvement in pre-to-post-rhinoplasty nose function and appearance and patient’s mood with >40 increase in overall assessment on a 0-100 scale. This in contrast indicates that although rhinoplasty helps in restoring a good part of the patient’s self-image, patient’s expectations often remain elusive. In some cases, several personality factors are associated with low level of satisfaction, such as obsessive personality trait that are often observed among rhinoplasty candidates [20]. Surgeons should be aware of patients’ concerns and remain receptive to details of their complaints, as lack of receptiveness is one of the cause where the patients are not preferring to revisit the same surgeon in case of revision [7].

Compared to our findings, a range of satisfaction rates were reported by other authors. Faidiga et al. reported 85.0% of total satisfaction in Brazil [12]. In another Brazilian study, Arima et al., reported 68.4% excellent satisfaction and 21.1% good satisfaction post 1 to 8 years of rhinoplasty [14]. In a social media study, Khansa et al. reported 83.6% of satisfaction rate, [6]. Comparably, Bagheri et al. assessed 1-year post-rhinoplasty outcomes and found 84% of satisfaction rate [21]. Higher satisfaction rates were reported in an Egyptian study by Foda, who assessed 1 year post-rhinoplasty satisfaction regarding columellar scar problems among 600 Arabian patients after external rhinoplasty and found 93% satisfaction score, with dissatisfaction mainly related to scar size or hyperpigmentation [22]. Several factors may explain the discrepancy in satisfaction rates between different studies, such as differences in the methods and tools used in the assessment as well as in the manner results were interpreted; in addition to population-related factors such as societal and cultural aspects [8],[23]. Another factor that may interfere with satisfaction rate is the type of nose deformity; for example, deviated nose deformity is associated with less satisfaction rate compared to other deformities [24]. Unfortunately, no data are available in Saudi Arabia about the patterns of nose deformities among candidates of rhinoplasty; and it may be interesting to assess the prevalence of each nose deformity in the local ethnic groups and study whether rhinoplasty satisfaction is predicted by the type of deformity.

In pre-to-post-rhinoplasty assessment, the present study showed +42.0, +53.8 and +44.5 increase in overall nose function, appearance and patient’s mood, respectively. Comparably, Schwitzer et al. reported smaller extent of improvement including +26.5 and + 15.7 increase in satisfaction about facial appearance and psychological well-being, respectively [25]. Arima et al. used Alsarraf’s questionnaire in pre- and post-rhinoplasty assessments and reported +51.5 increase in total satisfaction score [14].

Demographic characteristics showed female preponderance (76.0%) and relatively young age (mean=33.78) among candidates of rhinoplasty which is in agreement with the available literature, such as 71.2% of female and 30.1 mean age reported by Schwitzer et al. [26]. However, generally men of different ages are increasingly involved in cosmetic surgery [19].

87.6% (females); and authors reported that dissatisfied females expressed more explicitly the reasons of their dissatisfaction, while men were too elusive [6]. Similarly, Schwitzer et al. demonstrated that women experienced significant improvement in all parameters including facial appearance, social function, psychological well-being, and all aesthetic aspects of the nose including size, shape, profile, in the mirror and in photos; whereas men perceived significant improvement only in facial appearance ([26]. Herruer et al., in a systematic review (including 27 articles), concluded that male gender was among the predictors of dissatisfaction after rhinoplasty [27]. In an attempt to explain this obvious dichotomy in findings between the previous studies and our study regarding women versus men satisfaction, we analyzed total satisfaction scores by gender and marital status subcategory. Results showed that divorced women had the lowest total satisfaction score (mean±SD=28.33±26.18); which is far lower than all other sub-categories, where mean±SD scores ranged from 48.85±26.16 in married females to 66.07 in widowed females (p<0.001; OneWay ANOVA). This finding clearly indicates the existence of specific factors that interfere with satisfaction and that are particularly associated with divorced women. In the conservative Saudi society, this sub-category of the population is highly exposed to negative social stressors, the impact of which may be exacerbated by further psychological and social impact of the nose deformity; especially if divorce is the consequence of this deformity. In some cases, divorce may be a major motivation for rhinoplasty [28.] In such cases, it is relevant to investigate whether dissatisfaction is related to the particular psychosocial context [27]; in which case it would be judicious to provide psychological support to these patients to improve self-image and avoid compulsive and obsessive revision rhinoplasty. These observations also open the prospect to study the correlation between the psychosocial impact of nose deformity pre- and post-rhinoplasty satisfaction; with the hypothesis that a psychological intervention pre-rhinoplasty may be efficient to improve post-rhinoplasty satisfaction and self-image in some categories of patients.

This study evidenced the strong correlation of positive psychological impact of rhinoplasty with improvement and introversion in 8 months after rhinoplasty, with greater improvement among patients who underwent rhinoplasty for cosmetic motivation [30]. Gunel et al. demonstrated that patients with cosmetic concerns had high psychological distress before and in the early period after rhinoplasty; and that psychological distress decreased significantly in 3 months after rhinoplasty [15]. Other authors highlighted significant improvement in patient’s quality of life following rhinoplasty [4],[31]. Generally, cosmetic surgery is reported to be associated with good psychological impact on patients, including in appearance, and to a lesser extent with improvement in function. This demonstrates the importance of esthetic aspects and body-image concerns in psychological well-being [29]. Ercolani et al. reported significant reduction in anxiety, negative emotions, restored self-esteem and body image and improved mood and quality of life [19]. However, negative psychological disorders, such as loss of identity, have been reported in case of poor rhinoplasty outcomes. Such severe outcomes seem to be occurring in patients with prior psychological or personality disorders [32]. Prior personality or psychological disorders were also demonstrated to be significant predictors of dissatisfaction[27].

Limitations

The main limitation of this study is the cross-sectional design requiring from patients to recall preoperative assessments. Other parameters such as type of nose deformity and pre-rhinoplasty psychosocial well-being were not investigated, although these would provide more accurate information on satisfaction factors. However, as the study was conducted by telephonic interview, only important items were included for practical reasons.

Recommendations

Findings and gaps from this study recommend carrying out further studies on patterns of nose deformities among candidates of rhinoplasty in Saudi Arabia, and to analyze the correlation of the identified types of deformities with patient’s expectation, procedure outcomes and satisfaction. Psychosocial impact of nose deformity should be included in pre-rhinoplasty assessment as it constitutes an important factor of satisfaction; and, in some categories of patients, a psychological intervention before rhinoplasty may be efficient to improve post-rhinoplasty satisfaction and self-image.


  Conclusion Top


The preset study a relatively low long-term satisfaction after primary rhinoplasty; showing 48.0% of satisfied patients with a mean total satisfaction score of 50.68/100, with lower satisfaction rates and scores regarding cosmetic aspects.

On the other hand, pre-to-post-rhinoplasty showed a considerable improvement in psychological well- being, which was strongly correlated with the improvement in nose function and to a larger extent, with appearance. The offset between improvement in psychological well-being and satisfaction level appears to be aConclusion

The preset study a relatively low long-term satisfaction after primary rhinoplasty; showing 48.0% of satisfied patients with a mean total satisfaction score of 50.68/100, with lower satisfaction rates and scores regarding cosmetic aspects.

On the other hand, pre-to-post-rhinoplasty showed a considerable improvement in psychological well-being, which was strongly correlated with the improvement in nose function and to a larger extent, with appearance. The offset between improvement in psychological well- being and satisfaction level appears to be a difficult issue to resolve, where complex personal, psychosocial and cultural factors may be involved.

Satisfaction was even lower among females and divorced participants; divorced women had the lowest satisfaction score; indicating the particular influence of some specific psychosocial contexts on patient’s satisfaction, beyond the cosmetic outcome. In such cases where psychosocial factors are suspected to have significant contribution in dissatisfaction, psychological interventions may be efficient to improve satisfaction and restore self-image, as well as to prevent excessive re-surgery.

Disclaimer

This paper was presented on the 23rd Saudi ORL Annual Conference, on April 20th - 21st, 2017 held in Albaha Province, Saudi Arabia



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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