Abstract
Background:
Rhinoplasty is conducted to address both cosmetic and functional objectives. It is not merely a cosmetic procedure, as it frequently aims to improve function by enhancing nasal breathing and removing congenital or acquired obstructions. The current study aims to determine the functional, cosmetic, and psychological outcomes of rhinoplasties.
Methods:
This is a descriptive cross-sectional study. The data were collected using an interview and an online Google form. A chi-square test was used to determine the relationship between qualitative variables and quantitative variables using frequency, percentage, and mean for quantitative variables. Each variable’s P value is used to detect statistical significance. The significance level was set at a P value of less than 0.05.
Results:
Of the 234 patients enrolled in this study, 69.2% were women, whereas 30.8% were men, with a mean age of 22.86 ± 4.546 years. In terms of satisfaction, functional satisfaction accounted for about 59% of all satisfaction, cosmetic satisfaction was 63.2%, and psychological satisfaction was 70.9%. The primary reason for surgery was cosmetic (45%).
Conclusion:
The majority of enrolled participants were satisfied with their functional outcomes, whereas their satisfaction with psychological and cosmetic outcomes was moderate.
Takeaways
Question: What are the functional, cosmetic, and psychological outcomes of rhinoplasty surgery, and what factors influence the satisfaction levels of individuals who undergo this procedure?
Findings: A study found that most rhinoplasty participants were satisfied with functional outcomes and moderately satisfied with psychological and cosmetic aspects. Cosmetic improvement was the primary motive, with sex and age influencing surgery purpose. Psychological satisfaction was higher in calm individuals, and postsurgery, social acceptance correlated with self-acceptance.
Meaning: The study revealed that patients who underwent rhinoplasty were satisfied with function but moderately satisfied with psychological and cosmetic outcomes, highlighting the procedure’s multifaceted impact.
INTRODUCTION
The nose is a complex structure and is important in facial aesthetics and respiratory physiology.1 It consists of the external nose and nasal cavity. The external nose is composed of a bony part and a cartilaginous part, both of which are covered by the skin. The nasal cavity is divided into the right and left nasal cavities by the nasal septum, which itself has bony and cartilaginous parts.2 Rhinoplasty (which is commonly known as a nose job) is a plastic surgery procedure to improve the function or change the shape of the nose. There are two types of plastic surgery: reconstructive surgery to restore the function of the nose and cosmetic surgery to change the shape of it.3 Because the face is the most important anatomical structure that determines how a person is perceived, for the harmony of the face, each component of the face is very important, but the nose is the center of the face. The size and shape of the nose greatly affect a person’s appearance, which can play an important role in social life and relationships.4 According to anatomy, the nose is the first passage of the respiratory system, so any problem or deviation of the nose can cause nasal obstruction, uncomfortable breathing, and a decrease in the quality of life (shortness of breath, possible outcomes of insomnia, nasal obstruction, and the way that someone talks).5 This is why the evaluation of rhinoplasty outcomes is important to determine the satisfaction of individuals who underwent this type of surgery. According to statistics from the American Society of Plastic Surgeons, rhinoplasty is one of the most commonly performed cosmetic surgery procedures for both functional and aesthetic purposes.6 One of the primary goals of surgery is to improve the patient’s appearance and ultimately relieve their social anxiety and abusive complexities. The patient’s satisfaction varies by sex, age, education level, culture, ethnicity, and, most importantly, the patient’s expectations.7,8 According to some reports, cosmetic procedures increased by 147% from 1997 to 2009.8 Also, according to the American Society of Plastic Surgeons, 352,555 people will undergo nose reshaping and rhinoplasty in 2020.9 In the United States, rhinoplasty was the third most popular surgical cosmetic procedure in terms of the number of procedures performed with more than 215,000 rhinoplasty procedures carried out in 2017. With this being said, among all the common surgical procedures in Iran, rhinoplasty is the most common, and as claimed by recent reports, the actual rhinoplasty surgery, with a rate of 2.75 (180 per 100,000 of the 100,000 Iranian population), has the seventh rank among the 50 most common invasive procedures.10,11 Due to limited information and studies about the outcomes and impacts of this surgery on people’s lifestyles in Iraq, highlighting the significance of our findings. Therefore, the current study aimed to evaluate satisfaction, determine problems, and find overall outcomes among patients undergoing rhinoplasty surgery.
METHODS
Study Design and Setting
This was an analytical cross-sectional study. Permission was obtained from the family and community medicine department (University of Sulaimani, College of Medicine) after reviewing the questionnaire. The declaration of anonymity and confidentiality was given to the participants before administering the questionnaire shared via Google Forms. Informed consent was obtained from all the participants.
Inclusion and Exclusion Criteria
This study focused on patients between 18 and 45 years of age, including both sexes. Individuals who underwent rhinoplasty and agreed to participate were included. Individuals younger than 18 years of age and older than 50 years of age, individuals with any chronic or allergic condition, and participants who filled out the questionnaire for the pretesting and pilot study were excluded from the study.
Sample and Data Collection
The data collection process used a convenience sampling technique, utilizing a validated questionnaire to assess the outcomes after rhinoplasty surgery. The questionnaire was distributed online through Google Forms and administered through interviews in clinics. The questionnaire comprised five sections covering sociodemographic status, general inquiries, functional aspects, cosmetic considerations, and psychological factors. Self-confidence as the people’s sense of competence and skill, their perceived capability to deal effectively with various situations, was measured among participants based on the Rosenberg Self-Esteem Scale, in which a score less than 15 was considered low/no self-esteem.12,13 Socioeconomic status was categorized into three levels: good (upper class), corresponding to an income of more than US $10 per day; moderate (middle class), corresponding to an income of $6–10 per day; and bad (lower class), corresponding to an income of $2–5 per day.14 Data regarding social acceptance were collected through self-reporting by the patients themselves. Patients assigned a score based on the following criteria: discriminated by all family members and peers, discriminated by people other than first-degree relatives and peers, discrimination happens often by random people, perceived “normal” by first-degree relatives and peers, perceived “normal” and included by all.
A pilot study was conducted on a sample of five to 10 individuals who had undergone rhinoplasty. Convenience and purposive sampling methods were used for the pilot study, and data were gathered through interviews. The primary objectives of this pilot were to assess the time required for completing questionnaires and to evaluate their adequacy.
Aesthetic and Respiratory Evaluation Methods
For aesthetic satisfaction, the first question of the rhinoplasty outcome evaluation was used, which states “How well do you like the appearance of your nose?” with the options being “not at all,” “somewhat,” “moderately,” “very much,” and “completely.” However, due to complexity, the answers were simplified. “Not at all” and “somewhat” were combined to “bad,” “moderately” remained the same, and “very much” and “completely” were combined into “good.”15
Respiratory evaluation in the current study was conducted through several methods: first, patient feedback, in which the evaluation of respiratory function included gathering subjective feedback from patients regarding their nasal breathing experience. Second, the cold spatula test is a method used to assess nasal airflow by placing a cold spatula at the entrance of the nostril and observing the response.16 Third, the cotton test is another objective measure used to evaluate nasal airflow by inserting a small piece of cotton into the nasal cavity and observing its movement.17
Satisfaction Degree
Preoperative and postoperative photographs of patients who underwent rhinoplasty were taken. Different ranges of outcomes, from “poor” to “excellent” satisfaction levels were obtained, for each outcome category (functional, cosmetic, and psychological) (Figs. 1–3).
Fig. 1.
Preoperative and postoperative photographs demonstrating outcomes following rhinoplasty. Preoperative (A and B) and postoperative (C and D), frontal (A and D) and side profile (B and C) photographs of a patient who underwent rhinoplasty. The patient had good cosmetic satisfaction.
Fig. 3.
Preoperative and postoperative photographs demonstrating outcomes following rhinoplasty. Preoperative (A and B) and postoperative (C and D), frontal (A and C) and side profile (B and D) photographs of a patient who underwent rhinoplasty. The patient had good functional satisfaction.
Fig. 2.
Preoperative and postoperative photographs demonstrating outcomes following rhinoplasty. Preoperative (A and B) and postoperative (C and D), frontal (A and C) and side profile (B and D) photographs of a patient who underwent rhinoplasty. The patient had good psychological satisfaction
Statistical Analysis
Collected data were initially recorded using Google Forms, transferred to an Excel sheet, and subsequently analyzed using the Statistical Package for Social Science (IBM SPSS) program, version 24, for statistical analysis. In the analysis of quantitative variables, an independent sample t test and ANOVA were employed, with means and SDs used for presentation, and additionally chi-square test was used for comparison of two or more categorical variables. Frequency and percentages were utilized to present qualitative data. A significance threshold of a P value of less than 0.05 was adopted in this study.
RESULTS
Of the total of 234 patients who participated in this study, 72 (30.8%) were men and 162 (69.2%) were women, with a mean age of 22.86 ± 4.546 years (18–45 years). The majority of the participants (80.3%) were single. In terms of educational level and residency, 84.6% of participants had a bachelor’s or diploma degree, and 62.85% were living in rural areas. Regarding age distribution, 89.7% of participants fell within the 18–27 age group, whereas 70.1% were identified as having a moderate economic status. Regarding the reason for doing surgery, it was observed that aesthetic was the most common reason (45%). The majority of these procedures were conducted in private hospitals or clinics, making up approximately 90% of the total (Table 1).
Table 1.
Sociodemographic Characteristics of Study Participants
| Variables | Frequency | Percentage (%) |
|---|---|---|
| Sex | ||
| Male | 72 | 30.8 |
| Female | 162 | 69.2 |
| Age, y | ||
| 18–27 | 210 | 89.7 |
| 28–36 | 18 | 7.7 |
| 37–45 | 6 | 2.6 |
| Educational level | ||
| Primary-high school | 31 | 13.3 |
| University-institute | 198 | 84.6 |
| Master or higher | 5 | 2.1 |
| Marital status | ||
| Single | 188 | 80.3 |
| Married | 46 | 19.7 |
| Residency | ||
| Outside city | 87 | 37.2 |
| Inside city | 147 | 62.8 |
| Socioeconomic status | ||
| Good | 67 | 28.6 |
| Moderate | 164 | 70.1 |
| Bad | 3 | 1.3 |
| Causes of surgery (male/female) | ||
| Function | 47 (25/22) | 20 (10.68/9.40) |
| Aesthetic | 105 (27/78) | 44.9 (11.54/33.33) |
| Both | 82 (21/61) | 35 (8.97/26.06) |
| Place of doing surgery | ||
| Private hospital | 211 | 90.2 |
| Government hospital | 23 | 9.8 |
| Self-confidentiality | ||
| Yes | 143 | 61 |
| No | 39 | 17 |
| Maybe | 52 | 22 |
In terms of outcomes after rhinoplasty surgery, the primary functional issue that patients experienced postsurgery was breathing difficulties, with snoring following behind, 90%, and 28.6%, respectively. Regarding functional satisfaction, more than 50% of the patients expressed confidence in attaining a favorable functional outcome, whereas around 40% described their satisfaction with functionality as moderate. Although the number of patients with a favorable cosmetic result was twice that of those with an unfavorable outcome, the highest proportion (63.2%) fell under the category of a moderate level of cosmetic satisfaction. Regarding psychological outcomes, a small fraction of participants experienced unfavorable psychological outcomes, whereas approximately two-thirds of the cases reported a moderate level of satisfaction (Table 2).
Table 2.
Surgery Outcome Characteristics
| Outcomes | Frequency | Percentage (%) |
|---|---|---|
| Breathing problems | ||
| Yes | 211 | 90.2 |
| No | 23 | 9.8 |
| Snoring problems | ||
| Yes | 67 | 28.6 |
| No | 167 | 71.4 |
| Sleeping trouble | ||
| Yes | 34 | 14.5 |
| No | 200 | 85.5 |
| Voice change | ||
| Yes | 48 | 20.5 |
| No | 186 | 79.5 |
| Smell problem | ||
| Yes | 42 | 18.4 |
| No | 192 | 81.6 |
| Functional satisfaction | ||
| Good | 138 | 59 |
| Moderate | 87 | 37.2 |
| Bad | 9 | 3.8 |
| Cosmetic satisfaction | ||
| Good | 57 | 24.4 |
| Moderate | 148 | 63.2 |
| Bad | 29 | 12.4 |
| Psychological satisfaction | ||
| Good | 52 | 22.2 |
| Moderate | 166 | 71 |
| Bad | 16 | 6.8 |
Regarding the association between sex and the main cause of doing surgery, a significant difference between sexes regarding whether the cause of surgery was aesthetic, functional, or both (P < 0.05) was found. Men primarily underwent surgery for functional reasons, whereas women generally pursued it for aesthetic purposes. In terms of the association between age group and functional outcome, it was observed that age did not prove to be a determining factor in influencing functional outcomes (P = 0.055). However, a majority of individuals within the 18–27 age group had a good functional outcome (Table 3).
Table 3.
Association between Age Group and Functional Outcome
| Functional Outcome | Age Group (y) | P | ||
|---|---|---|---|---|
| 37–45 | 28–36 | 18–27 | ||
| Bad | 9 (4.3) | 0 (0) | 0 (0) | 0.055 |
| Good | 129 (61.4) | 8 (44.4) | 1 (16.7) | |
| Moderate | 72 (34.3) | 10 (55.6) | 5 (83.3) | |
| Total | 210 (100) | 18 (100) | 6 (100) | |
In examining demographic characteristics across different functional outcome groups, the majority of characteristics showed no significant differences, except for age. Notably, there was a significant difference in age between these groups, with those in the moderate functional outcome category exhibiting a higher mean age (24.20 ± 5.85) compared with individuals with either bad or good outcomes, with a P value of 0.002 (Table 4). Among patients with good functional outcome, age was a significant predictor (B = −0.104, P = 0.001), with older age associated with decreased odds of experiencing a good outcome after rhinoplasty surgery. However, for the bad category, although the coefficient for age suggests a negative association (B = −0.101), the effect did not reach statistical significance (P = 0.295) (Table 5).
Table 4.
Comparison between Demographic Characteristics among Functional Outcome Groups
| Demographic Variable | Functional Outcome | P | ||
|---|---|---|---|---|
| Good | Moderate | Bad | ||
| Sex (N) | 138 | 87 | 9 | 0.111 |
| Male | 38 | 33 | 1 | |
| Female | 100 | 54 | 8 | |
| Age, y (mean ± SD) | 22.07 ± 3.4 | 24.20 ± 5.85 | 22.11 ± 2.26 | 0.002 |
| Educational level (N) | 138 | 87 | 9 | 0.894 |
| Primary-high school | 22 | 8 | 1 | |
| University-institute | 114 | 76 | 8 | |
| Master or higher | 2 | 3 | 0 | |
| Marital status (N) | 138 | 87 | 9 | 0.926 |
| Single | 112 | 69 | 7 | |
| Married | 26 | 18 | 2 | |
| Residency (N) | 138 | 87 | 9 | 0.121 |
| Outside city | 44 | 38 | 5 | |
| Inside city | 94 | 49 | 4 | |
| Socioeconomic status (N) | 138 | 87 | 9 | 0.577 |
| Good | 42 | 23 | 2 | |
| Moderate | 93 | 64 | 7 | |
| Bad | 3 | 0 | 0 | |
Table 5.
Parameter Estimates for Functional Outcome Categories
| Parameter Estimates for Functional Outcome Categories in Logistic Regression Analysis | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Functional Outcome | B | Std. Error | Wald | df | Sig. | Exp(B) | 95% Confidence Interval for Exp(B) | ||
| Lower Bound | Upper Bound | ||||||||
| Bad | Intercept | 0.061 | 2.175 | .001 | 1 | 0.978 | |||
| Age | −0.101 | 0.097 | 1.099 | 1 | 0.295 | 0.904 | 0.748 | 1.092 | |
| Good | Intercept | 2.860 | 0.764 | 14.018 | 1 | 0.000 | |||
| Age | −0.104 | 0.033 | 10.132 | 1 | 0.001 | 0.901 | 0.845 | 0.961 | |
The reference category is moderate.
Concerning the correlation between psychological satisfaction and psychological status, it was observed that calm patients exhibited significantly higher satisfaction levels compared with anxious patients (P < 0.001). Approximately 80% of anxious patients perceived themselves as moderately satisfied psychologically. There was an important relationship between social and self-acceptance; increasing social acceptance leads to an increase in self-acceptance (P < 0.001) (Table 6).
Table 6.
Correlation between Psychological Satisfaction and Psychological Status
| Self-acceptance | Social Acceptance | ||||||
|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | Total | P | |
| 1 | 3 | 2 | 2 | 1 | 2 | 10 | <0.001 |
| 2 | 5 | 5 | 1 | 3 | 1 | 15 | |
| 3 | 1 | 11 | 28 | 14 | 9 | 63 | |
| 4 | 0 | 0 | 17 | 40 | 20 | 77 | |
| 5 | 2 | 0 | 5 | 9 | 53 | 69 | |
| Total | 11 | 18 | 53 | 67 | 85 | 234 | |
DISCUSSION
Rhinoplasty is one of the most popular procedures performed by facial plastic surgeons around the world. This procedure has low patient satisfaction compared with other plastic surgery procedures.7,15 Although surgeons may consider a procedure successful, the patient’s satisfaction plays a crucial role, and the inverse holds as well. The level of success in a procedure is determined by the patient’s satisfaction, as their perspective is the primary measure. However, many surgeons do not employ quantitative questionnaires to assess surgical outcomes. The outcome may be influenced by the potential impact of social, environmental, educational, and life experiences, and varying expectations.18–20
Several studies have been conducted on the outcomes of rhinoplasty surgery. In a study involving 468 participants, the majority of participants who underwent rhinoplasty were women (81.4%).21 In another study by Arima et al, which was conducted on 61 patients, it was observed that women (51.6%) undergo rhinoplasty more frequently than men (49.4%).21 In the current study, the majority of participants undergoing the surgery were women (69.2%). This suggests a greater concern among women about their appearance compared with men.
In this study, most of the patients who underwent rhinoplasty were young (89.7%). This is in line with a study performed on 103 patients in which most of the participants were below the age of 30 (79.6%).22 However, there are other studies in which most participants were older than 35 years.23 Concerning postsurgical outcomes, approximately 96.2% of all surgical cases showed functional satisfaction with a good to moderate outcome. Cosmetic satisfaction among patients accounted for about 87.6% of the total, and psychological satisfaction accounted for about 93.1% of the total. These findings surpass those reported in many studies in the genuine literature.20,21,23,24
Regarding the age, it was not identified as a significant factor affecting satisfaction after rhinoplasty surgery. This finding is consistent with the findings of a study by Biggs et al,25 which included 100 patients and also found no association between age and satisfaction levels after surgery. Also, the current finding is contrary to the finding of a study by Arima et al, which concluded that older individuals exhibited higher satisfaction scores in comparison to their younger counterparts.19 Furthermore, other studies have also identified age as a factor influencing satisfaction.26–28 In our perspective, the variations in age may be attributed to how age groups are categorized, potentially leading to an uneven distribution of the sample or the combination of distinct age groups into one category. Despite that- a majority of individuals younger than 27 years of age had a good functional outcome, bad functional outcome was only reported among young age groups, and the possible explanation is that the majority of participants were young. Also, studies indicate that there is a discrepancy in satisfaction levels after rhinoplasty between younger and older patients. Specifically, individuals younger than 30 years old typically report lower postoperative satisfaction scores compared with those in the 30- to 50-year-old and over 50-year-old age groups. Consequently, younger patients undergoing rhinoplasty require more comprehensive preoperative counseling, including detailed information about the limitations of the procedure, to achieve a satisfactory outcome.26,29
Concerning the primary reasons for undergoing the surgery, aesthetics was the main cause for 45% of individuals, followed by both functional and aesthetic, which accounted for about 35% of total individuals who underwent rhinoplasty. These findings differ from another study conducted in Brazil in 2017, where the aesthetic purpose was 4.7% and a combination of both reasons was 82.2%.19 This variation may be attributed to the significant rise in the demand for aesthetic rhinoplasty in Asia for the past two decades, driven by increased self-interest, heightened media awareness, and advancements in surgical techniques.7 Regarding the association between sex and purpose of surgery, it was observed that 75% of participants who were doing surgery for aesthetic purposes were women and nearly 52% who were doing it for functional purposes were men (P = 0.002). One view for explaining this finding is that women’s greater interest in appearance is socially learned, which is driven purely by social promotion and marketing of feminine image.30
Among the three choices for psychological outcomes, more than 70% achieved a moderate level, whereas 22.2% reported a good outcome, and only 6.8% reported a poor psychological outcome. Determining psychological status before surgery and psychological outcome after it leads to a significant outcome. Individuals who were psychologically calm before surgery were significantly more satisfied than anxious patients, and this is similar to other studies.1,18 The means of social acceptance (3.84) and self-acceptance (3.77) on a five-degree scale were highly significant, indicating that self-acceptance increased with social acceptance. Social acceptance refers to the level of inclusion and acceptance a person feels within their social environment. Likewise, assuming that a patient experiences a positive alteration in their physical appearance, it is believed that this change will contribute to an enhancement in their psychological well-being, encompassing improvements in self-acceptance and self-esteem.
The current study highlights the multifaceted impact of rhinoplasty, shedding light on its functional, cosmetic, and psychological outcomes. It underscores the importance of considering both the aesthetic and functional aspects of the nose in surgical planning. Although most participants were satisfied with their functional outcomes, moderate satisfaction levels were noted for cosmetic and psychological outcomes. Understanding patients’ diverse motivations and expectations is crucial in achieving successful outcomes. Moreover, preoperative psychological assessment and postoperative support may enhance overall satisfaction. This comprehensive approach can guide clinicians in optimizing patient care and ensuring holistic well-being postrhinoplasty.
Regarding the limitations of the current study, although the study’s sample size was adequate, its predominantly young adult participants from a specific region may limit the generalizability of findings globally. Longitudinal follow-up could provide insights into the durability of outcomes. Preoperative psychological assessment’s importance was acknowledged but not extensively explored. Addressing these limitations, including broader age representation, objective assessments, long-term follow-up, and deeper exploration of preoperative psychological factors, can strengthen future research, fostering a more comprehensive understanding of rhinoplasty outcomes and informing improved patient-centered care in aesthetic surgery.
In conclusion, although the majority of enrolled participants were satisfied with their functional outcomes, moderate satisfaction levels were noted for cosmetic and psychological outcomes.
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
PATIENT CONSENT
Patients provided written consent for the use of their images.
Footnotes
Published online 16 August 2024.
Disclosure statements are at the end of this article, following the correspondence information.
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