Key Points
Questions
What are the differences in social perception of people who undergo cosmetic rhinoplasty for dorsal hump reduction, tip rotation, or both?
Finding
From a web-based survey of 840 respondents, a significant association was found for age, approachability, attractiveness, and health for hump reduction, and attractiveness and health for combined dorsum and tip rotation. No significant association was found for any of the responses when the tip alone was rotated with or without manipulation of the dorsum.
Meaning
Rhinoplasty procedures for nasal cosmesis involving dorsal reduction with or without tip manipulation were perceived to make a person more attractive and healthier, and dorsal reduction had a greater effect than tip manipulation in adding value to social perception of the facial profile.
This survey study examines social perceptions of age, approachability, perceived success, overall health, intelligence, and attractiveness of people who have undergone cosmetic rhinoplasty for dorsal hump reduction, tip rotation, or both in combination.
Abstract
Importance
Social perception by laypersons of people who have undergone rhinoplasty primarily for cosmetic purposes has not been fully described.
Objective
To evaluate the social perception of patients who have undergone cosmetic rhinoplasty.
Design, Setting, and Participants
Preoperative images of 4 patients with dorsal hump and tip ptosis were selected using the Delphi method. Computer simulations of dorsal hump reduction and tip rotation, alone or in combination, were performed. Using the Qualtrics internet-based survey platform, laypersons blinded to the purpose of the study viewed randomized original and simulated images and estimated the age, approachability, perceived success, overall health, intelligence, and rated their attractiveness on a visual analog scale from 0 to 100.
Main Outcomes and Measures
Comparison of responses (mean [SD] score) for each of the 3 types of simulated image against the original image employing a pairwise comparison of means (Dunnett test).
Results
After excluding 27 (4%) invalid responses, a total of 813 respondents (593 women and 220 men) were included in the study. The mean (SD) age was 44.6 (16.2) years. A total of 628 (77%) respondents were white and the observed highest level of education was a bachelor’s degree (193 [24%]) or having attended college but without a diploma (194 [24%]). A significant age reduction (31 [10] years; 95% CI, −2.5 to 0; P = .04) and an increase in approachability (64 [22]; 95% CI, 0.7-5.8; P = .009), attractiveness (60 [22]; 95% CI, 4.0-9.4; P < .001), and health (70 [19]; 95% CI, 0.7-5.2; P = .006) for the simulation involving hump reduction was observed. When combined simulation of dorsum and tip rotation were tested, only significant increases in attractiveness (60 [23]; 95% CI, 3.6-9.0; P < .001) and health (69 [19]; 95% CI, 0.1-4.6; P = .03) were seen. No significant association was found for any of the responses when the tip alone was rotated. The Wilks λ varied slightly below 1.0 showing significant P values (P < .05) for all variance and covariance (respondent particulars).
Conclusions and Relevance
Though rhinoplasty procedures for nasal cosmesis involving both the nasal dorsum and tip were perceived to make a person more attractive and healthier, these results suggest that manipulation of the dorsum is more strongly associated with perception of the nose.
Level of Evidence
Introduction
The psychosocial aspects of facial plastic surgery have gained much importance. With approaches based on social principles1 and psychological theories,2,3 we have come a long way from the traditional perspective of questioning the emotional and mental status of people requesting cosmetic surgery. With the advent of social media and the gaining popularity of selfies, there is an increased focus on facial form. The human brain processes information about facial symmetry based on the central position of the nose.4 The centrality of its location is known to draw unconscious attention to an individual’s nose.5 A profile with a nose that is not straight receives more attention6,7 and this potential to attract such negative attention alters the perception of an individual.6,8,9 The associated stigma places such individuals at a disadvantage and affects their interaction with society.10 In supporting evidence for this stigma, a recent study by Nellis et al,9 the first to quantify the effect of rhinoplasty on social perceptions, showed that people undergoing rhinoplasty derive a multifaceted benefit in their social interaction.
In cosmetic rhinoplasty, changes are made to the outward appearance of the nose11 to improve facial aesthetics by modifying nasal dimensions to attain symmetry.12 Modifications typically involve altering the size of the nose, the shape of the bridge or the tip, and reducing the nostril span.13 Some of the most common rhinoplasty procedures for nasal cosmesis involve dorsal hump reduction, tip reduction, tip rotation, and straightening a crooked nose.11 Cosmetic rhinoplasty is the sixth most commonly performed cosmetic procedure in the United States,14 and the second most common among males.14 Among all the cosmetic procedures performed in the United States, aesthetic rhinoplasty was found to be the second most common procedure for those aged 18 years or younger and the third most common for those younger than 34 years.14 It also has the eighth-highest national average cost per procedure.14
Considering the importance of nasal symmetry in preserving or improving facial aesthetics, there is very little evidence available in the literature that looks at how social interactions vary after rhinoplasty. This study attempts to build on the study by Nellis et al9 by analyzing the social perceptions among the general population of patients whose profiles were altered by computer simulation for 2 of the commonly performed aesthetic rhinoplasty procedures: dorsal hump reduction and tip rotation.
Methods
The study was approved by the Stanford University institutional review board, including waiver of written informed consent owing to the deidentification of survey data, and the survey was undertaken in September 2017.
Preoperative images of 4 patients (2 women and 2 men) who presented to the Facial Plastic & Reconstructive Surgery clinic with dorsal hump and tip ptosis were selected by 3 authors (S.P.M., S.P.M., C.K.K.) using the Delphi method. To simulate a surgical outcome, the senior author (S.P.M.), using Adobe Photoshop (version CC 2017, Adobe Systems Inc) for computer simulations, created a side profile view of dorsal hump reduction and tip rotation, alone or in combination for each of the 4 patients from their original image (Figure) (eFigure 1 in the Supplement). The side profile view of the original preoperative image of the patient was designated as image 0.
Figure. Example of Images Used in the Survey.
A, Original image. B, Simulation of dorsum only. C, Simulation of dorsum and tip combined. D, Simulation of tip.
Using the Qualtrics platform, we created 4 surveys. Each survey consisted of a total of 4 images, including randomized original and simulated images, making sure each survey consisted of all 4 different patient images and their types. This was done to ensure that each respondent does not view 2 images of the same patient in a survey. The Qualtrics survey respondent’s distribution system was used to send the surveys to a general population of 840 respondents with the requirements that each respondent be older than 18 years and be able to read and write English. Respondent details of age, gender, ethnicity, educational status, and prior exposure to facial rejuvenation surgery by self or by a family member were collected. Each respondent, blinded to the purpose of the study viewed these randomized original and simulated images and estimated the age, perceived success, overall health, and intelligence and rated their attractiveness on a visual analog scale from 0 to 100.
Statistical Analysis
Multivariable analysis of variance (1-way MANOVA) was used including analysis of covariances for the respondents’ characteristics. The analysis was interpreted based on the level of significance assessed as a 2-tailed P value of Wilks λ. The cut-off for the level of statistical significance was set at P ≤ .05. To compare simulated images against the original image (image 0), Dunnett pairwise comparisons of means was employed. The results were accompanied by standard errors (SEs) and 95% confidence intervals (CIs). To clarify the graphic presentation of the changes in the responses’ means, the responses were transformed into their lognormal form. The overall responses given on patients’ age, approachability, attractiveness, healthiness, intelligence, and successfulness across the different image types were reported as means and standard deviations (SDs). The responses were also presented as medians, interquartile ranges and ranges. All the analyses were carried out using Stata/IC statistical software (version 14, StataCorp).
Results
A total of 840 respondents participated in the survey. In all, 27 (4%) respondents were excluded owing to invalid responses. Responses from 813 respondents were used for statistical analyses. The demographic details of survey respondents are shown in Table 1.
Table 1. Demographic Details of Survey Respondents.
| Respondent | No. (%) |
|---|---|
| Age, mean (SD), y | 44.6 (16.2) |
| Gender | |
| Male | 220 (27) |
| Female | 593 (73) |
| Ethinicity | |
| White | 628 (77) |
| Hispanic/Latino | 51 (6) |
| Black/African American | 85 (10) |
| Asian | 37 (5) |
| Hawaiian/Pacific Islander | 4 (0) |
| Other | 8 (1) |
| Education | |
| High school/no diploma | 22 (3) |
| High school | 163 (20) |
| College/no diploma | 194 (24) |
| Trade/technical/vocational degree | 44 (5) |
| Associate degree | 97 (12) |
| Bachelor's degree | 193 (24) |
| Master's degree | 76 (9) |
| Professional degree | 8 (1) |
| Doctorate | 16 (2) |
The Wilks λ varied slightly below 1.0 showing significant P values for all variance and covariance (Table 2). Using gender, race, education level, exposure to facial rejuvenation surgery by self or by an immediate family member as covariates, further models were rebuilt including 1 covariate at a time (Table 2). Of the covariates, only previous surgery in the family was found to be significant across all models.
Table 2. Statistical Significance of Models With Different Sets of Dependent Variables and All Covariates Included.
| Model | P Values of Wilks λ | |||||
|---|---|---|---|---|---|---|
| All Image Types | Covariates | |||||
| Sex | Race | Educational Level | Previous Surgery | Previous Surgery in Family | ||
| All dependent variables | <.001 | .01 | <.001 | <.001 | .02 | <.001 |
| Guessed age | .04 | .94 | .09 | .76 | .06 | .01 |
| Approachability | .01 | <.001 | .004 | <.001 | .12 | <.001 |
| Attractiveness | <.001 | .06 | <.001 | <.001 | .70 | <.001 |
| Health | .01 | .68 | .69 | <.001 | .03 | .002 |
| Intelligence | .95 | .79 | .02 | <.001 | .38 | <.001 |
| Success | >.99 | .85 | .04 | .06 | .53 | <.001 |
Dunnett tests of the 3 simulated images against image 0 showed a significant reduction in age (31 [10] years; 95% CI, −2.5 to 0; P = .04) and an increase in approachability (64 [22]: 95% CI, 0.7-5.8; P = .009), attractiveness (60 [22]; 95% CI, 4.0-9.4; P < .001), and health (70 [19]; 95% CI, 0.7-5.2; P = .006) for the simulation involving hump reduction alone. For the combined simulation of dorsum and tip rotation, a significant increases in only attractiveness (60 [23]; 95% CI, 3.6-9.0; P < .001) and health (69 [19]; 95% CI, 0.1-4.6; P = .03) were seen. No significant effects were found when the nose tip alone was rotated (Table 3 and Table 4). No differences were found between responses when comparing simulated hump reduction alone with combined simulation of dorsum and tip rotation. A significant decrease in attractiveness was found when simulation of tip alone (55 [23]) was compared with the combined simulation of dorsum and tip rotation (60 [23]; 95% CI, −7.3 to −2.0; P < .001), but none of the other responses showed any significant effects. The respondent responses for all the 4 different images of the nose are presented in eFigure 2 in the Supplement as medians, interquartile ranges, and ranges. The mean differences in average responses for each of the 4 different image types of the nose are shown graphically in eFigure 2 in the Supplement.
Table 3. Average Response for Age, Perceived Success, Overall Health, Intelligence, and Attractiveness on a Visual Analog Scale of 0 to 100.
| Characteristic | Mean (SD) | |||
|---|---|---|---|---|
| Original Image | Dorsal Hump Reduction | Hump Reduction and Tip Rotation | Tip Rotation | |
| Age, y | 31.9 (11.0) | 30.7 (10.4) | 31.2 (11.0) | 31.9 (10.6) |
| Approachability | 60.9 (22.4) | 64.2 (21.5) | 63.4 (20.1) | 61.9 (21.9) |
| Attractiveness | 53.7 (23.6) | 60.4 (22.1) | 60.0 (22.6) | 55.3 (23.3) |
| Health | 67.0 (19.6) | 69.9 (18.9) | 69.3 (19.0) | 68.1 (19.7) |
| Intelligence | 66.9 (18.6) | 66.8 (18.8) | 66.5 (18.4) | 67.0 (18.1) |
| Success | 64.3 (18.9) | 64.2 (19.0) | 64.2 (18.8) | 64.3 (18.7) |
Table 4. Pairwise Comparisons of Means With Base Set at Preoperative Image (Dunnett Test).
| Covariate | Image Typea | Contrast (SE) | 95% CI | P Value |
|---|---|---|---|---|
| Guessed age | 1 vs 0 | −1.3 (0.5) | −2.5 to 0 | .04 |
| 2 vs 0 | −0.8 (0.5) | −2.1 to 0.5 | .31 | |
| 3 vs 0 | 0.0 (0.5) | −1.3 to 1.3 | >.99 | |
| Approachability | 1 vs 0 | 3.2 (1.1) | 0.7 to 5.8 | <.001 |
| 2 vs 0 | 2.4 (1.1) | −0.2 to 5 | .07 | |
| 3 vs 0 | 0.9 (1.1) | −1.6 to 3.5 | .71 | |
| Attractiveness | 1 vs 0 | 6.7 (1.1) | 4.0 to 9.4 | <.001 |
| 2 vs 0 | 6.3 (1.1) | 3.6 to 9 | <.001 | |
| 3 vs 0 | 1.6 (1.1) | −1.0 to 4.3 | .33 | |
| Healthiness | 1 vs 0 | 2.9 (1.0) | 0.7 to 5.2 | <.001 |
| 2 vs 0 | 2.4 (1.0) | 0.1 to 4.6 | .03 | |
| 3 vs 0 | 1.1 (1.0) | −1.2 to 3.3 | .54 | |
| Intelligence | 1 vs 0 | −0.1 (0.9) | −2.3 to 2 | .99 |
| 2 vs 0 | −0.4 (0.9) | −2.5 to 1.8 | .95 | |
| 3 vs 0 | 0.2 (0.9) | −2.0 to 2.3 | .99 | |
| Successfulness | 1 vs 0 | −0.1 (0.9) | −2.3 to 2.1 | .99 |
| 2 vs 0 | −0.1 (0.9) | −2.3 to 2.1 | .99 | |
| 3 vs 0 | 0.0 (0.9) | −2.2 to 2.2 | >.99 |
Abbreviation: SE, standard error.
Image type 0, 1, 2, and 3 indicate original image, simulation of dorsum only, simulation of dorsum and tip, combined, and simulation of tip, respectively.
Discussion
Rhinoplasty is a complex operation, with multiple iterations of interventions possible for any given patient. Thus, it is difficult to define what aspects of the change in nasal form are most important in achieving a satisfactory result. Patient-reported outcome measures for measuring aesthetic results in rhinoplasty are an important tool.15,16 Although these patient-reported outcome measures, particularly the Standardized Cosmesis and Health Nasal Outcomes Survey, do separate individual aspects of nasal form, to our knowledge no study to date has examined the social perception of individual aspects of nasal form.
Dorsal reduction and tip rotation are 2 of the most commonly performed procedures in rhinoplasty and are often done in combination. Herein we have specifically analyzed the effects of tip rotation and dorsal reduction in perception of the nose by a large group of laypersons across various social variables such as age, approachability, attractiveness, health, intelligence, and success. Using simulations of patients’ profile images for 2 of the commonly performed cosmetic rhinoplasty procedures, we found simulations of dorsal hump reduction alone were perceived to be younger, more approachable, more attractive, and healthier. When both hump reduction and tip rotation simulations were used, the person was found to be more attractive and healthier. When we controlled for tip manipulation, we found the image simulation of tip alone to be less attractive than the combined simulation of dorsum and tip rotation. With the exception of perceived success, our results are similar to Nellis et al,9 wherein it was shown that people who have undergone rhinoplasty are perceived to be more attractive, healthier, and more successful compared with their preoperative image.
Most of the available evidence in the literature on psychosocial assessment of rhinoplasty patients was based on the attractiveness of a person.8,17,18,19 Studies by Cash et al1 and Nellis et al9 stand out in having truly evaluated social perception in people who have undergone rhinoplasty.
Several factors in this study add to its strength. The large sample size used for this survey ensured that a broader spectrum of respondent demographics was included. By using computer simulations instead of actual postoperative images of patients and looking at specific cosmetic rhinoplasty outcomes, we were able to minimize the variability that may arise from the surgical techniques involved, surgeon expertise, and surgical outcomes. Clearly, other variables can affect the perception of ideal nasal form: gender, race, and facial form are some examples. Furthermore, for any given patient, an infinite number of variations in nasal form can be simulated. In the current study, we chose to examine specific effects of profile changes as a first step in understanding the contributions of various aspects of rhinoplasty in the perception of the patient. Simulations allowed us to have control over specifics of nasal profile changes.
Our study limited investigation to the profile view only. Our intention was to limit the variables studied. Further studies that evaluate modifications on the 3-dimensional aspect of the nose could be performed but may run into difficulty with regard to accurate representation of tip volume changes, for example, on a 2-dimensional image.
Limitations
The study herein represents a pilot study insofar as it raises several questions regarding social perception of different aspects of nasal form. First, what is the threshold of change in form that results in perceptual change? Is the change in perception graded? Are these results generalizable? The changes to the nasal form used herein were created using simulation, but were unlikely to be detected as such by the observers. However, we cannot rule this out as a bias of some observers despite the changes created being well within achievable results. As mentioned above, the use of simulation allowed us to individually manipulate tip and dorsal contour variables while controlling for all other visual variables one might encounter in delayed before/after result photography. Furthermore, as pointed out by Ahmed et al,20 tip rotation and projection are intimately related, and this has not been explored in the current study. The answers to the above questions would come from a much larger study of multiple varying degrees of reduction and tip rotation in patients whose facial features are otherwise similar.
Given that reduction of the dorsum carries with it a risk of airway compromise, measuring the perceived changes in attractiveness and health created by simply reducing dorsal height provides some validation for the maneuver. Of course, reduction in dorsal height should be performed in conjunction with some form of midvault reconstruction.21 We were somewhat surprised to find that tip rotation alone had little affect on the social perception parameters measured when an ideal dorsum was created. Furthermore, tip rotation in the setting of a high dorsum created a less attractive nose. Taken together, these data suggest that one of the most powerful maneuvers in rhinoplasty is indeed dorsal reduction.
Conclusions
Respondent-rated responses from laypersons show that specific maneuvers in rhinoplasty for nasal cosmesis can have differential effects on perception of health and attractiveness. Specifically, reduction of dorsal height has a greater positive effect on social perception than tip position. Further studies on other maneuvers in rhinoplasty may be useful.
eFigure 1. Example of Images Used in the Survey
eFigure 2. Respondent Responses for the Different Image Types
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eFigure 1. Example of Images Used in the Survey
eFigure 2. Respondent Responses for the Different Image Types