Association Between Mental Health Status and Patient Satisfaction With the Functional Outcomes of Rhinoplasty

Key Points

Question

Is preoperative mental well-being associated with patient-reported and objective functional outcomes of rhinoplasty?

Findings

In this case-control study, patients with poor mental well-being had equal or greater improvements in both subjective and objective nasal function compared with controls following rhinoplasty.

Meaning

Rhinoplasty imparts similar benefits to nasal function regardless of mental well-being.

This case-control study compares satisfaction with the functional outcomes of rhinoplasty between patients with normal mental well-being and those with poor mental well-being.

Abstract

Importance

Mental health can have an impact on patient satisfaction with rhinoplasty. However, the association between mental health and patient satisfaction with functional outcomes of rhinoplasty is poorly understood.

Objective

To determine whether preoperative mental health is associated with satisfaction with functional outcomes of rhinoplasty.

Design, Setting, and Participants

This case-control study assessed baseline nasal function and postsurgical functional outcomes for 88 consecutive patients undergoing rhinoplasty with both cosmetic and functional goals at 2 tertiary rhinologic centers in Sydney, Australia.

Exposures

Poor mental well-being was defined preoperatively by the Optum SF-36v2 Health Survey mental component summary.

Main Outcomes and Measures

Nasal function was assessed with patient-reported outcome measures, including visual analog scales, the Nasal Obstruction Symptom Evaluation Scale (NOSE), the 22-item Sinonasal Outcome Test (SNOT-22), and Likert scales. Objective outcomes included nasal peak inspiratory flow, nasal airway resistance, and minimum cross-sectional area. All outcomes were assessed preoperatively and 6 months postoperatively. The 36-item Optum SF-36v2 Health Survey mental component summary was used to assess mental well-being, with a score of less than 40 indicating poor mental well-being and a score 40 or higher indicating normal well-being.

Results

Mean (SD) patient age was 37.6 (12.9) years and 53 of 88 (60.2%) were women. The mental component summary defined impaired well-being in n = 24 (cases) and normal well-being in n = 64 (controls). There were improvements in the total study population across most nasal function outcomes and in both groups. After rhinoplasty, benefit was seen for both groups in visual analog scale (left side mean [SD] change, 18 [30]; P < .001 and right side mean [SD] change, 24 [30]; P < .001); NOSE (mean [SD] change, 1.35 [1.21]; P < .001); and SNOT-22 (mean [SD] change, 0.81 [0.88]; P < .001) scores. Nasal peak inspiratory flow improved for both groups (mean [SD] change, 32 [45] L/min; P < .001), while nasal airway resistance and minimum cross-sectional area remained similar (change in nasal airway resistance, 0.086 Pa/cm³/s; 95% CI, −0.007 Pa/cm³/s to 0.179 Pa/cm³/s and change in minimum cross-sectional area, −0.04 cm²; 95% CI, −0.21 cm² to 0.13 cm²). Patients with poor mental health had similar improvements in nasal function compared with controls.

Conclusions and Relevance

Rhinoplasty imparts similar benefits to nasal function assessed by patient-reported outcome measures and objective airflow measures regardless of preoperative mental health status.

Level of Evidence

3.

Introduction

Rhinoplasty is a surgical operation of the nose whose success is measured by both aesthetic and functional outcomes^1,2 that can be assessed through objective measures and patient reports. This study focuses on the association of mental well-being with functional outcomes of rhinoplasty.

Satisfaction is a subjective evaluation conceptualized as an interplay between cognitive and affective processes.³ While this interplay has been neither acknowledged nor applied in previous rhinoplasty studies, it explains what shapes a patient’s satisfaction, with cognition relating to patient expectations and affect to emotions. Surgeons might assume that an objective, physical improvement from rhinoplasty will lead to better health, social confidence, and self-esteem—facilitating satisfaction. However, while most patients who undergo rhinoplasty are satisfied with their procedure, this is not true for all.^{2,4,5,6,7,8,9,10} This is problematic because success in rhinoplasty relies more on patient satisfaction than on a technically perfect result.^11,12,13,14 This subjectivity makes successful outcomes in rhinoplasty difficult to achieve, as success is less a result of objective surgical input than the product of complex patient expectations and emotions.

Satisfaction with rhinoplasty is the product of multiple factors. First, numerous studies have found that cognitive factors such as patient expectations^1,15,16 and social expectations^{1,10,13,17,18,19} are related. Second, some researchers have posited that satisfaction may be influenced by revision status. Patients undergoing rhinoplasty revision generally have a higher emotional investment in the outcome of their procedure, as they were presumably unsatisfied with the primary operation,²⁰ and the revision rhinoplasty may be complicated by scar tissue from prior operations, making it challenging to improve functional outcome. This has not been substantiated in the literature, with similar satisfaction observed between patients undergoing primary and secondary rhinoplasty.^14,21 Satisfaction may also depend on the extent of the presenting defect,^13,22 with objective changes in nasal function following rhinoplasty documented to be most noticeable in patients with a substantial original defect, such as septal deviation²³ or moderate to severe obstruction.²² Anecdotally, men are less satisfied with cosmetic rhinoplasties than women.²⁴ However, previous studies^{6,7,11,14,18,24,25,26,27,28,29,30,31,32,33} have been unable to confirm whether satisfaction differs between the sexes because women make up the overwhelming majority of patients undergoing rhinoplasty. In this way, the demographic characteristics of populations undergoing rhinoplasty are a barrier to analyzing whether sex may influence patient satisfaction. Hence, satisfaction may be shaped by several complex factors, including expectations, revision status, and sex.

While mental health may be only 1 of the numerous factors affecting satisfaction with rhinoplasty, it is an important issue. There is no consensus about the psychological predisposition of people who undergo rhinoplasty, although some believe that there is a higher prevalence of poor mental health,^{10,11,27,28,33,34,35} especially body dysmorphic disorder, anxiety,^11,27,29,30 and depression.^27,29,30 In contrast, other studies indicate that those who choose rhinoplasty are psychologically stable^6,11,17 and have normal self-esteem but poor body image.^{5,9,12,16,18,35,36} These disputes may be explained by studies using differing diagnostic criteria and being conducted in different cultural settings. The effect of surgical interventions on psychological outcomes for patients who undergo rhinoplasty has been explored, but with conflicting results.^2,35,37,38

This study will explore how differences in mental health status are associated with patient satisfaction with nasal function and compare patient-reported outcome measures (PROMs) with objective measures. In light of the sizable proportion of patients undergoing rhinoplasty who have impairments in mental health, it is crucial to investigate how this may influence satisfaction with their nasal function postoperatively.

Methods

Consecutive patients presenting with a mix of functional and cosmetic indications for rhinoplasty who underwent airflow analysis at 2 tertiary clinics in Australia were included. Airway analysis was performed prior to surgery and at a mean (SD) of 6 (1) months postoperatively. Patients submitted basic demographic information and completed mental health assessments and nasal function questionnaires in a case-control study. All patients underwent rhinoplasty using an open structure approach performed by 1 of 2 tertiary surgeons (G.N.M. and R.J.H.) with attention to both functional and aesthetic aspects. Ethics approval was obtained from the St Vincent’s Hospital Institutional Review Board. Patients gave oral consent to participate in the study.

Defining the Cases (Impaired Mental Well-being) and the Controls

The mental health case definition was performed via the 36-item Optum SF-36v2 Health Survey, which assesses quality of life through physical, social, psychological, and emotional domains.³⁹ The subset of questions assessing emotional quality of life and well-being forms the mental component summary (MCS). The normalized mean score of 50 for the MCS was used as a reference. A difference of 10 points is considered clinically important and thus the cases were those patients who received a score of less than 40, indicating poor mental well-being,³⁹ and those with scores 40 or higher were controls.

Patient-Reported Outcome Measures

Five tools assessed patient-perceived functional benefit from rhinoplasty. A visual analog scale (VAS) asked patients to rate ease of breathing on a linear scale ranging from no nasal obstruction (0 mm) to complete obstruction (100 mm) on the left and right sides. A number was then obtained from 0 to 100 for severity of nasal obstruction. Two validated questionnaires, the Nasal Obstruction Symptom Evaluation Scale (NOSE) and 22-item Sinonasal Outcome Test (SNOT-22), were also used. Additionally, the nasal obstruction symptom was a single item derived from SNOT-22 that used a 6-point Likert scale for nasal obstruction ranging from 0 (no problem) to 5 (very severe problem). A global score of nasal function anchor scores used a 13-point Likert scale from −6 (terrible) to 0 (neither good nor bad) to +6 (excellent) to assess overall nasal function.

Airflow Analysis Outcomes

Objective assessment of nasal function included nasal peak inspiratory flow (NPIF), active anterior rhinomanometry, and acoustic rhinometry, all validated in patients undergoing rhinoplasty.⁴⁰ Measurements were taken with the patient seated for at least 10 minutes in a climate-controlled room, then after 15 minutes of topical application of 0.15 mg of oxymetazoline. Decongested outcomes were used to minimize the effect of mucosal contributions to obstruction and thus provided a better representation of the structural changes following rhinoplasty.⁴¹ Nasal peak inspiratory flow assessed collapsibility using an In-Check Nasal inspiratory flow meter (Clement Clarke International). A tight seal was applied without compressing the external nares. The patient performed a maximal forced inspiratory effort through the nose with the mouth closed. The best of 3 attempts was recorded to accommodate patient learning.^42,43 Nasal airway resistance (NAR) was measured using active anterior rhinomanometry (A6 Rhinomanometer [GM Instruments]) with a fixed reference level of 150 Pa according to international standards.⁴⁴ The patient held an anesthetic mask airtight around the nose, with the nostril contralateral to the testing side sealed with a nasal plug. The patient was instructed to breathe normally through the nose with the mouth closed. The opposite side was then tested using the same method. The entire process was repeated until 2 consistent measurements were produced within 15%. Representative values from each side were combined by NARIS software (GM Instruments) to obtain total NAR. Minimum cross-sectional area (MCA) was measured with an acoustic rhinometer (GM Instruments). The sound tube was applied to the nostril using an appropriately sized nosepiece to create an airtight seal. Patients were instructed to hold their breath during each measurement, which consisted of 4 readings.²³ This process was repeated until 2 consistent MCA results were produced within 15%.

Statistical Analysis

We used SPSS statistical software, version 22 (IBM) for statistical analysis. Continuous data were checked for normality using frequency histograms. To determine functional benefit from rhinoplasty, the absolute differences between PROMs and airflow analysis preoperatively and postoperatively were compared using paired t tests. Groups were compared using absolute change in PROMs and fold changes for airflow analysis outcomes (to assist in normalization of interpatient variability)⁴² using independent t tests. Kendall tau-b was used to analyze differences in Likert scales. To assess the clinical benefit from rhinoplasty, the proportion of patients improving with a minimal clinically important difference (MCID) was compared using a Fisher exact test. Prior literature guided the MCID of VAS scores (8.0),⁴⁵ SNOT-22 scores (0.40),⁴⁶ NOSE scores (0.34),⁴⁵ NPIF (20 L/min),⁴³ and MCA (0.23 cm²).⁴⁷ As no MCID exists for NAR, this was calculated as half a standard deviation of baseline results.⁴³ Bonferroni correction was performed to counteract the 9 independent outcomes, with a 2-sided P value of .005 set as a more stringent significance level.

Results

Baseline Characteristics

Eighty-eight patients were assessed (53 [60.2%] women; mean [SD] age, 37.6 [12.9] years; mean [SD] BMI [calculated as weight in kilograms divided by height in meters squared], 22.7 [3.6]). In this group 37 of 88 (42.0%) were patients having revision procedures. The MCS defined impaired well-being in n = 24 (cases) and normal well-being in n = 64 (controls). Baseline demographic characteristics and airflow analysis outcomes were similar between cases and controls (Table 1). However, cases had significantly worse preoperative PROMs pertaining to nasal function (Table 1).

Table 1. Comparison of Demographic Characteristics and Baseline Nasal Function by Mental Health Status.

Characteristic	Total (N = 88)	Mental Health Status		Difference (95% CI)	P Value
		Normala (n = 64)	Poorb (n = 24)
Demographics
Age, mean (SD), y	37.6 (12.9)	38.4 (13.4)	35.7 (11.8)	2.7 (−3.20 to 8.60)	.40
Women, No. (%)	53 (60.2)	42 (65.6)	11 (45.8)	NA	NA
Revision rhinoplasty, No. (%)	37 (42.0)	23 (35.9)	14 (58.3)	NA	NA
BMI, mean (SD)	22.7 (3.6)	22.5 (3.5)	23.4 (3.8)	0.9 (−0.90 to 2.70)	.33
Patient-reported outcomes, mean (SD)
VAS score for left side	43 (26)	37 (25)	62 (19)	−25 (−34.98 to −15.02)	<.001
VAS score for right side	52 (24)	49 (26)	58 (16)	9 (0.80 to 19.2)	.04
NOSE score	2.32 (1.00)	2.03 (0.93)	3.14 (0.70)	1.11 (0.74 to 1.48)	<.001
SNOT-22 score	1.59 (0.84)	1.33 (0.75)	2.31 (0.62)	0.98 (0.66 to 1.30)	<.001
Nasal obstruction symptom rated moderate or worse, No. (%)	58 (66.0)	29 (45.5)	23 (95.8)	NA	NA
Nasal function anchor score rated poor or worse, No. (%)	65 (74.2)	43 (67.3)	22 (91.6)	NA	NA
Airflow analysis, mean (SD)
NPIF, L/min	125 (52)	124 (53)	131 (48)	7 (−17 to 31)	.59
Total NAR, Pa/cm3/s	0.331 (0.152)	0.309 (0.124)	0.395 (0.210)	0.086 (−0.007 to 0.179)	.07
Total MCA, cm2	1.02 (0.32)	1.03 (0.29)	0.99 (0.38)	−0.04 (−0.21 to 0.13)	.64

Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); MCA, minimum cross-sectional area; NA, not available; NAR, nasal airway resistance; NOSE, Nasal Obstruction Symptom Evaluation Scale; NPIF, nasal peak inspiratory flow; SNOT-22, 22-item Sinonasal Outcome Test; VAS, visual analog scale.

^aCorresponds to a score of 40 or higher on the SF-36v2 Health Survey mental health component.

^bCorresponds to a score of less than 40 on the SF-36v2 Health Survey mental health component.

Postoperative Changes in Nasal Function Outcomes

There were improvements in the total study population across most nasal function outcomes (Table 2) and in both groups (Table 3 and Table 4). Rhinoplasty improved patient perceptions of nasal function with decreased sensation of nasal obstruction assessed by VAS on the left side (mean [SD] change, 18 [30]; P < .001) and VAS on the right side (mean [SD] change, 24 [30]; P < .001) and lower scores in disease-specific quality-of-life measures NOSE (mean [SD] change, 1.35 [1.21]; P < .001) and SNOT-22 (mean [SD] change, 0.81 [0.88]; P < .001). Additionally, there were improved scores in the nasal obstruction symptom for 74 of 88 patients (84.4%) (P < .001) and nasal function anchor score for 80 of 88 patients (90.4 0%) (P < .001) (Table 2). Objectively, nasal function had improvements in airflow with increased NPIF (mean [SD] change, 32 [45] L/min; P < .001), but NAR and MCA did not change with rhinoplasty.

Table 2. Comparison of Change in Nasal Function Outcomes by Mental Health Status.

Outcome	Total Population (N = 88)		Mental Health Status		P Value
	Difference	P Value	Normala (n = 64)	Poorb (n = 24)
Patient-reported outcomes, mean (SD)c
Change in VAS score for left side	−18 (30)	<.001	−12 (26)	−36 (33)	.001
Change in VAS score for right side	−24 (30)	<.001	−22 (30)	−27 (31)	.53
Change in NOSE score	−1.35 (1.21)	<.001	−1.11 (1.15)	−1.98 (1.13)	.002
Change in SNOT-22 score	−0.81 (0.88)	<.001	−0.64 (0.77)	−1.23 (0.99)	.01
Nasal obstruction symptom rated improved, No. (%)	63 (71.7)	<.001	43 (67.3)	20 (83.3)	.02
Nasal function anchor score rated improved, No. (%)	80 (90.9)	<.001	55 (86.6)	24 (100)	.12
Airflow analysis, mean (SD)d
Change in NPIF, L/min	1.22 (0.49)	<.001	1.22 (0.48)	1.22 (0.54)	.96
Change in total NAR, Pa/cm3/s	1.04 (0.56)	.08	1.11 (0.61)	0.85 (0.32)	.05
Change in total MCA, cm2	0.99 (0.35)	.73	0.97 (0.34)	1.04 (0.36)	.39

Abbreviations: MCA, minimum cross-sectional area; NAR, nasal airway resistance; NOSE, Nasal Obstruction Symptom Evaluation Scale; NPIF, nasal peak inspiratory flow; SNOT-22, 22-item Sinonasal Outcome Test; VAS, visual analog scale.

^aCorresponds to a score of 40 or higher on the SF-36v2 Health Survey mental health component.

^bCorresponds to a score of less than 40 on the SF-36v2 Health Survey mental health component.

^cAbsolute change.

^dFold change.

Table 3. Change in Nasal Functional Outcomes for Patients With Normal Mental Well-being .

Outcome	Preoperative	Postoperative	Absolute Change	P Value
Patient-reported outcome, mean (SD)a
VAS score for left side	36 (25)	25 (24)	−12 (26)	.001b
VAS score for right side	49 (26)	27 (23)	−22 (29)	<.001b
NOSE score	2.01 (0.93)	0.90 (1.02)	−1.11 (1.15)	<.001b
SNOT-22 score	1.31 (0.73)	0.66 (0.63)	−0.64 (0.77)	<.001b
Airflow analysis, mean (SD)a
NPIF, L/min	125 (53)	142 (48)	17 (38)	.001b
Total NAR, Pa/cm3/s	0.310 (0.121)	0.321 (0.154)	0.011 (0.160)	.58
Total MCA, cm2	1.02 (0.29)	0.96 (0.33)	−0.07 (0.33)	.11

Abbreviations: MCA, minimum cross-sectional area; NAR, nasal airway resistance; NOSE, Nasal Obstruction Symptom Evaluation Scale; NPIF, nasal peak inspiratory flow; SNOT-22, 22-item Sinonasal Outcome Test; VAS, visual analog scale.

^aAbsolute change.

^bTwo-tailed significance.

Table 4. Change in Nasal Functional Outcomes for Patients With Impaired Mental Well-being .

Outcome	Preoperative	Postoperative	Absolute Change	P Value
Patient-reported outcome, mean (SD)a
VAS score for left side	62 (19)	26 (26)	−36 (33)	<.001b
VAS score for right side	58 (16)	31 (25)	−27 (31)	<.001b
NOSE score	3.14 (0.70)	1.16 (1.05)	−1.98 (1.14)	<.001b
SNOT-22 score	2.31 (0.62)	1.07 (0.86)	−1.24 (1.00)	<.001b
Airflow analysis, mean (SD)a
NPIF, L/min	131 (48)	150 (61)	19 (43)	.02
Total NAR, Pa/cm3/s	0.395 (0.212)	0.288 (0.095)	−0.107 (0.212)	.02
Total MCA, cm2	0.99 (0.38)	0.96 (0.33)	−0.03 (0.35)	.70

Abbreviations: MCA, minimum cross-sectional area; NAR, nasal airway resistance; NOSE, Nasal Obstruction Symptom Evaluation Scale; NPIF, nasal peak inspiratory flow; SNOT-22, 22-item Sinonasal Outcome Test; VAS, visual analog scale.

^aAbsolute change.

^bTwo-tailed significance.

While rhinoplasty conferred improvements for nasal function outcomes overall, some differences emerged with mental well-being (Table 2). Patients with poor mental well-being had a greater improvement in VAS scores for the left side than those with normal well-being (mean [SD] change, 36 [33] vs mean [SD] change, 12 [26]; P = .001); however, the similarity between the groups in change in VAS scores for the right side (P = .53) questions the clinical meaning of this difference. Cases improved more than controls in NOSE score (mean [SD] change, 1.98 [1.13] vs mean [SD] change, 1.11 [1.15]; P = .002) but not in SNOT-22 score (mean [SD] change, 1.23 [0.99] vs mean [SD] change, 0.64 [0.77]; P = .01). The change in nasal obstruction symptom was similar between the groups, improving in 20 of 24 cases (83.3%) compared with 43 of 64 controls (67.3%) (Kendall tau-b = 0.226; P = .02). However, mental well-being did not affect change in nasal function anchor score. Finally, there were no differences in fold change of nasal airflow analysis outcomes between the controls and cases.

Improvements in Nasal Function Outcomes With an MCID

The proportion of patients who had rhinoplasty and experienced improvements with an MCID in both PROMs and objective measures of nasal function was not influenced by mental well-being (Table 3).

Discussion

Rhinoplasty demonstrated a functional benefit, with the majority of patients having significantly improved PROMs and less collapsibility in objective airflow analysis regardless of mental well-being as defined by the MCS. This relationship is unlikely to be artifactual, given the highly conservative level of significance (P = .005). Greater benefit was seen in NOSE scores in those with poor mental well-being, but this may be due to a bias inherent in comparing preoperative and postoperative outcomes. Indeed, preoperatively those with impairments in mental well-being report significantly worse NOSE scores than those with normal mental well-being (mean [SD] score 2.64 [0.95] vs 1.96 [1.04]; P < .001)⁴⁸; hence, patients with a better initial perception of nasal function have less scope for improvement following rhinoplasty. The greater improvements in perceptions of nasal function observed in individuals with poor vs normal mental well-being may thus be a consequence of a lower baseline rather than a different surgical benefit. The findings suggest that impairments in mental health are unlikely to adversely affect patient satisfaction with functional outcomes of rhinoplasty.

These findings contrast to anecdotal beliefs that those with worse mental health are less likely to be satisfied or gain benefit from rhinoplasty.^1,24 Comparing our findings with those in the existing rhinoplasty literature is challenging, as there are multiple methods of gauging satisfaction, each with strengths and limitations, that produce different cohorts of satisfied and unsatisfied patients.^{8,24,32,49,50} For instance, studies allowed satisfaction to be interpreted by the patient to include appearance, function, and general level of care; had limited evaluations of function^32,50; were retrospective or cross-sectional^6,8,50,51 and thus subject to recall bias⁴⁸; or were not validated.²⁴ Clearly, research in rhinoplasty would benefit from a more standardized and rigorous approach to gauging satisfaction. Compared with prior literature, a strength of this study was prospectively and comprehensively assessing rhinoplasty functional outcomes with both subjective and objective parameters. This resolved heterogeneity in patient perception and limited recall bias to accurately assess functional benefit. Satisfaction was assessed through validated PROMs to provide a more rigorous measure of patient perceptions of surgical benefit, especially as this is the major end point for rhinoplasty.^19,35,52 It seems intuitive that subjective PROMs can be complemented with objective outcomes such as airflow analysis; however, previous studies using these measures were limited to particular patient groups, such as those who have undergone certain procedures or those with specific anatomical defects.^41,53,54 Objective outcomes can help surgeons validate the benefit of a surgery, particularly when the clinical picture is unclear, as in instances in which perceptions are influenced by mental health.

Our assessment of satisfaction addressed 2 deficits in the literature: first, through assessing PROMs relating specifically to function,³⁸ and second, through comparing PROMs with objective measures.⁵⁵ Our conclusions agreed with those of previous smaller studies, including 1 that found no significant association between preoperative measures of self-esteem and dysmorphic concerns and 6-month postoperative satisfaction in Australian patients who had cosmetic rhinoplasty⁵⁵ and another that concluded that the majority of female patients with mild to moderate body dysmorphic disorder were satisfied with their results 1 year postoperatively.³² Goh and Lo⁴⁹ had similar findings in their study of Asian patients who underwent rhinoplasty, with those with mild body dysmorphic disorder having a lower score on the Rhinoplasty Outcomes Evaluation (ROE) preoperatively and postoperatively compared with controls; however, the change in ROE scores was similar between the 2 groups, suggesting a similar level of perceived improvement.

Despite a lack of empirical investigation, some studies suggest that prior rhinoplasties, male sex, and younger age are associated with poor mental health and unsatisfactory surgical outcomes,^2,6,56,57 while others disagree.^14,21,58 Revision status and sex had an even distribution across groups in this study. This was surprising, given that patients undergoing rhinoplasty revision generally have a higher emotional investment in the outcome of their procedure, as they were presumably unsatisfied with the primary operation.²⁰ Moreover, the lack of sex difference in perception of nasal function was interesting, given that women tend to report more symptoms than men,⁵⁹ perhaps because of sociocultural influences more than physical differences.⁶⁰ Our study population had a more balanced representation of the sexes compared with previous studies in which women made up the overwhelming majority of patients undergoing rhinoplasty.^{6,7,11,14,18,24,25,26,27,28,29,30,31,32,33} A significant sex difference in mental health status was not reflected in our study, refuting suggestions (based on nonsignificant findings)^7,36 that men undergoing rhinoplasty have a greater prevalence of psychopathology. Sex made no difference for rhinoplasty satisfaction assessed by ROE in 24 men and 34 women.⁵⁸ Thus, 2 potential factors affecting satisfaction and mental health, sex and revision status, had a limited confounding effect.

While society, surgeons, and researchers often dichotomize rhinoplasty as functional or cosmetic, it requires attention to both. As the structure and function of the nose are intimately related, procedures performed with the intent of changing appearance alter structure and thus affect function, making both crucial end points for rhinoplasty.^14,61,62 Furthermore, it has been acknowledged that there is a fine distinction between cosmetic and medical indications for surgery,⁵⁷ with some patients presenting with functional issues and not disclosing cosmetic motives, possibly because of stigma associated with cosmetic surgery.¹⁸ Conversely, patients primarily seeking rhinoplasty for cosmetic reasons may also have underlying functional problems. This was illustrated in a previous study⁶³ showing higher VAS and SNOT-22 scores in cosmetic rhinoplasty candidates compared with population controls; in addition, 62% had at least 1 structural sinonasal pathology on clinical endoscopic examination. There is conflicting evidence regarding differences in satisfaction with rhinoplasty between patients undergoing cosmetic and functional operations. For instance, there are indications that those who have cosmetic rhinoplasty are less satisfied with their operations than their functional counterparts,⁷ perhaps because of fundamental differences in their psychosocial backgrounds.¹¹ This conflicts with reports⁵⁸ that patients undergoing cosmetic and posttraumatic (functional) rhinoplasty did not significantly differ in satisfaction as measured by the change in ROE score, and another study⁵¹ demonstrating that patients undergoing cosmetic rhinoplasty gained a greater benefit than those receiving functional rhinoplasty and assessed through a retrospectively administered Glasgow Benefit Inventory. In our study group, there were 2 patients who had a bilateral VAS score of 0, indicating that the vast majority had functional impairments. A subgroup analysis for the group with bilateral VAS scores of 0 would be inadequately powered for a comparison, and we cannot offer a cosmetic-only subset. Hence, considering that rhinoplasty is an operation addressing both function and appearance and that patients often need to improve both, patients were included regardless of their primary motive for rhinoplasty. These broad inclusion criteria strengthened external validity to the general population undergoing rhinoplasty and minimized selection bias. However, it is important to evaluate how mental well-being may have an impact on cosmetic outcomes of rhinoplasty.

Limitations

Prior to inclusion, patients were deemed psychologically fit for surgery by the surgeon and the mental health assessments were likely to detect subclinical mental health issues. Hence, the study population may have been biased toward people with normal mental well-being or subclinical impairments in mental well-being. Using validated questionnaires was useful, given that surgeons have difficulty in detecting mental health concerns, such as body dysmorphic disorder.⁶⁴ Self-reporting of mental well-being has both benefits and limitations. An accurate case definition was limited by relying on patients to accurately report their own attitudes, values, and feelings, which may have been influenced by intentional or unintentional attempts to present themselves in a certain way to the researcher.⁶⁵ Moreover, the use of a cutoff was simplistic considering the complexity of mental health, which has a spectrum with potentially different effects on patient perceptions of nasal function. However, the strengths of using patient self-assessment with validated cutoffs were considerable—limiting interviewer bias, enabling replication, and demonstrating the utility of these methods as practical clinical screening tools.

One of the biggest challenges of rhinoplasty is predicting outcomes. This study’s findings provide some evidence that patients undergoing rhinoplasty perceive improvement in nasal function postoperatively regardless of mental well-being. Rather, other factors may influence satisfaction, such as patient expectations for appearance and social outcomes. This makes it imperative that surgeons assess patient expectations preoperatively and offer appropriately tailored medical advice regarding realistic outcomes to better inform cognitive processes contributing to satisfaction^1,66 and to assess mental health.

Conclusions

Differences in preoperative mental health status, defined by a practical and acceptable questionnaire, did not appear to influence patient reported nasal function or objective airflow benefit conferred by rhinoplasty. Functional satisfaction following rhinoplasty does not appear to be a product of impaired preoperative mental well-being.