Social Perception of the Nasal Dorsal Contour in Male Rhinoplasty

Key Points

Question

What are the social perception consequences of male rhinoplasty when specific modifications of the male nasal dorsal contour are carried out?

Findings

In this web-based survey study of 503 participants featuring 12 computer-simulated nasal dorsal contours of a male volunteer, the man in the photograph featuring the nose with the ski slope dorsal shape, nasofrontal angle of 130°, and nasolabial angle of 97° was deemed most attractive; this profile was also among the most frequently selected for other positive characteristics. Subset analyses also revealed statistically significant dorsal contour preferences by observers’ gender and age.

Meaning

This study’s results may potentially better inform rhinoplasty surgeons and their male patients on how changes to the nasal dorsal contour may not only affect the overall perception of a man’s social attributes, but also perception by observers’ sociodemographics.

Abstract

Importance

The social perception of nasal dorsal modification for male rhinoplasty is poorly understood.

Objective

To investigate the association of modifying the male nasal dorsum with the perception of such social attributes as youth, approachability, healthiness, masculinity/femininity, intelligence, successfulness, and leadership.

Design, Setting, and Participants

Using computer simulation software, 12 images with varied combinations of the nasal dorsal shape, nasofrontal angle (NFA), and nasolabial angle (NLA) were generated from a photograph of a male volunteer’s face in profile. These photographs were then sent to participants at a university clinic who were English-speaking adult internet users who were masked to the purpose of the study, which asked them to value different social attributes regarding the face in the photograph in a 16-question survey. The study was conducted in September 2018 and the data were analyzed thereafter until March 2019.

Exposures

Twelve photographs embedded in a 16-question survey.

Main Outcomes and Measures

Population proportions of responses and χ² test and graphical analysis based on 95% confidence intervals.

Results

Of 503 respondents (survey provision rate, 100%), 412 (81.9%) were women, 386 (76.7%) were white, 32 (6.4%) were Hispanic or Latinx, 63 (12.5%) were black/African American, 10 (2.0%) were Asian/Pacific Islander, and the median age was 46 years (interquartile range, 32-61 years). The man with ski slope–shaped nose with an NFA of 130° and NLA of 97° was often associated with frequently perceived positive characteristics; specifically, he was judged to be the most attractive (95% CI, 18%-26%; P < .001). Participants also often associated superlative youth (95% CI, 15%-24%; P < .001), approachability (95% CI, 13%-20%; P = .002), and femininity (95% CI, 14%-22%; P < .001) with dorsal contours that did not feature a dorsal hump. The man with a dorsal hump–shaped nose with an NFA of 140° and NLA of 105° was associated by the highest proportion of participants with being the oldest (95% CI, 35%-44%; P < .001), least approachable (95% CI, 27%-35%; P < .001), least attractive (95% CI, 37%-42%; P < .001), and least healthy (95% CI, 26%-34%; P < .001). Subset analyses also revealed statistically significant dorsal contour preferences by observers’ age, gender, and race/ethnicity.

Conclusions and Relevance

A reduced dorsal slope combined with more acute NFAs and NLAs was associated with positively perceived social attributes. The results may be of interest to rhinoplasty surgeons and their male patients when planning changes to the nasal dorsal contour.

Level of Evidence

NA.

This study examines the association between changes to the male nasal dorsum on profile view and 503 survey respondents’ social perceptions.

Introduction

The specific role of nasal dorsal modification and its association with gender-specific rhinoplasty has been widely discussed,^1,2 especially for female and feminizing rhinoplasty.^2,3 Existing guidance for nasal dorsal modification in male rhinoplasty is often shared from the cumulative descriptive experience of senior rhinoplasty surgeons with a lifetime of career expertise.^4,5 Naini et al^6,7,8 have published a series of quantitative studies on manipulating various cephalometric angles in 2-dimensional silhouettes, including the nasofacial, nasofrontal, and mentolabial angles and their association with perceived attractiveness. However, the interaction of the dorsal hump with these cephalometric angles and its association with not just perceived attractiveness, but also other perceived social attributes like masculinity, age, health, success, leadership ability, and intelligence has not, to our knowledge, been studied in photographed men.

There are several articles besides Naini et al^6,7,8 that set precedents for using third-party perception to measure outcomes for facial plastic and reconstructive surgeries; specifically, web-based methods to capture public perception have been previously validated. A study using a web-based survey of casual observers evaluating unique patient faces before and after rhinoplasty found that patients postoperatively appeared more attractive, healthier, and more successful.⁹ A prior study from our research group¹⁰ using similar methods specifically examined the comparative contributory association of tip rotation and dorsal reduction with perception for patients in general with dorsal hump and tip ptosis. However, to our knowledge, there have been no prior studies that apply web-based public perception as a tool to measure the association of nasal dorsal modification of male faces with masculinity and other social attribute outcomes. The objective of this study was to investigate the association of modifying male nasal dorsum with the perception of such social attributes as youth, approachability, healthiness, masculinity/femininity, intelligence, successfulness, and leadership ability.

Methods

Four male patient volunteers provided written informed consent for their preoperative photographs on lateral view to be used for research and publication purposes. The lateral view was chosen as it has previously been described as one of the most informative views for visual, personality, and gender expression perception for men.^1,10,11 Using the Delphi method, 3 authors (S.P.M, B.N., and C.K.) selected 1 male volunteer’s photograph of the 4.

Using the 2017 version of Adobe Photoshop (Adobe Systems Inc), 4 combinations of the nasofrontal angle (NFA) and nasolabial angle (NLA) of the man’s face were generated, with 130° vs 140° for the NFA and 97° vs 105° for the NLA. The NFAs were chosen as part of prior research’s findings of an ideal vs approximately an upper limit of what was considered “attractive.”^7,12 These findings by prior third-party perception studies are largely backed by prior cephalometric, anthropometric, and expert opinion studies.^4,13 The NLAs were chosen as part of prior study’s findings of an ideal vs approximately an upper limit of what was considered “aesthetic.”^14,15,16

Three nasal dorsal contour modifications were then generated and applied to each of the 4 combinations of the NLAs and NFAs. The 3 modifications were as follows: (1) dorsal hump, (2) linearization of the nasal dorsum, and (3) gentle ski slope of the nasal dorsum. This resulted in 12 computer-generated combinations of the NFA, NLA, and nasal dorsal shape with the base features of 1 man on lateral view (Figure 1).

Figure 1. Twelve Computer-generated Combinations of the Nasofrontal Angle (NFA), Nasolabial Angle (NLA), and Nasal Dorsal Shape Used in the Qualtrics Survey.

Utilizing the Qualtrics survey software (Qualtrics LLC) platform, a survey consisting of 16 questions was created. All 12 generated patient images were inserted in a random pattern into each question. The questions asked for the “most” and “least” representation of age, approachability, attractiveness, healthiness, masculinity/femininity, intelligence, success, and perceived leadership ability (eTable 1 in the Supplement). Participants in the survey were asked to choose the image that they perceived best represented the superlative posed in each question. The survey was then distributed to a requested sample size of 500 participants from within the Qualtrics survey corporation’s participant database (≥18 years) who were masked to the purpose of the study. The participants were unaware of the purpose of the study and were reimbursed for responses.

The study was approved by the Stanford University institutional review board. The age groups were defined as 4 age groups were formed: younger than 33 years, 33 to 46 years, 47 to 61 years, and older than 61 years. The racial/ethnic groups were defined as white, black/African American, Hispanic/Latinx, Asian/Pacific-Islander, and Other.

Statistical Analysis

The differences in the distribution of categorical data were assessed by a χ² Pearson square test, with the level of significance of 2-tailed P value at ≤.05. The population proportions of responses were also assessed graphically to detect statistically significant differences between proportions by comparing their 95% confidence intervals, calculated as 95% CI = p̂ ± 1.96 × √ (p̂ × (1 − p̂) / n), in which p̂ represented the sample proportion. When there were more than 2 subgroups used in the analysis, the differences between groups were assessed using a Bonferroni post hoc test. All analyses were conducted using Stata/IC, version 15 (StataCorp).

Results

Table 1 describes 503 surveys that were completed (100% completed survey return rate by Qualtrics LLC, with 3 additional surveys provided by Qualtrics LLC). Respondents’ median age was 46 years (interquartile range, 32-61 years). Most were women (412 [82%]), white (386 [77%]), and straight/heterosexual (455 [90%]). Additionally, most had not had a personal or family history of plastic surgery (440 [87%]) and had at least a high school education (488 [97%]).

Table 1. Demographic Characteristics of the Sample.

Variable	Frequency, No. (%)
Age group, y
<33	131 (26)
33-46	123 (24)
47-61	131 (26)
>61	118 (23)
Gender
Men	89 (18)
Women	412 (82)
Other	2 (0)
Racial/ethnic group
White	386 (77)
Hispanic/Latinx	32 (6)
Black/African American	63 (13)
Asian/Pacific Islander	12 (2)
Other	10 (2)
Sexual orientation
Straight/heterosexual	455 (90)
Lesbian/gay	9 (2)
Bisexual	30 (6)
Declined to state	9 (2)
Personal history of plastic surgery or in family or friends
No	440 (87)
Yes	63 (13)
Educational level
No high school	15 (3)
High school	488 (97)
Total	503 (100)

Eleven of 16 questions (69%) demonstrated significant differences in the proportions of the chosen images (Table 2). The most visible pattern regarding the perception of a person’s age, approachability, attractiveness, healthiness, and successfulness was the association of more positive social attributes with linear or ski slope dorsal shapes (Figure 2). No clear preferences in nasal shape were observed when judging masculinity. Instead, perceived femininity was associated with linear or ski slope dorsal shapes. Perceived intelligence and leadership ability were not associated with any particular image. Instead, “least intelligence” and “least leadership ability” were connected to the dorsal hump. Overall, the man with the nose with a dorsal hump with an NFA of 140° and an NLA of 105° (Figure 1D) was the highest-proportion pick for “oldest” (95% CI, 35%-44%; P < .001), “least approachable” (95% CI, 2%-35%; P < .001), “least attractive” (95% CI, 37%-42%; P < .001), “least healthy” (95% CI, 26%-34%; P < .001), and “least successful” (Figure 2).

Table 2. Distribution of Total Responses.

Questions	Images, % of Responses													P Value
	1a	2b	3c	4d	5e	6f	7g	8h	9i	10j	11k	12l	Total
Youngest	3	2	1	3	6	9	10	11	19	10	8	18	100	<.001
Oldest	12	14	16	40	2	3	2	2	3	3	3	2	100	<.001
Most approachable	3	2	3	4	7	12	15	7	17	12	9	9	100	.0017
Least approachable	16	13	14	31	3	3	2	2	5	4	3	4	100	<.001
Most attractive	2	2	2	2	6	10	14	11	21	12	8	11	100	<.001
Least attractive	14	15	19	39	1	2	2	2	1	1	2	2	100	<.001
Most healthy	4	2	3	2	7	12	14	9	17	10	9	12	100	.001
Least healthy	11	17	13	30	2	4	2	6	3	4	6	3	100	<.001
Most masculine	8	9	10	6	10	8	11	7	9	9	7	7	100	.99
Most feminine	2	2	1	2	5	11	9	7	18	16	13	15	100	<.001
Most intelligent	9	6	9	6	7	13	12	8	12	7	7	5	100	.56
Least intelligent	11	13	12	18	5	4	6	8	6	5	5	6	100	.01
Most successful	9	7	6	6	8	9	11	6	16	8	6	9	100	.49
Least successful	12	16	12	20	3	5	4	6	7	5	5	7	100	<.001
Most leaderlike	8	10	8	5	7	9	12	7	13	9	7	7	100	.86
Least leaderlike	10	12	11	14	4	7	4	6	8	8	7	9	100	.37

Abbreviations: NFA, nasofrontal angle; NLA, nasolabial angle.

^aDorsal hump; NFA, 130°; NLA, 97°.

^bDorsal hump; NFA, 130°; NLA, 105°.

^cDorsal hump; NFA, 140°; NLA, 97°.

^dDorsal hump; NFA, 140°; NLA, 105°.

^eLinear; NFA, 130°; NLA, 97°.

^fLinear; NFA, 130°; NLA, 105°.

^gLinear; NFA, 140°; NLA, 97°.

^hLinear; NFA, 140°; NLA, 105°.

ⁱSki slope; NFA, 130°; NLA, 97°.

^jSki slope; NFA, 130°; NLA, 105°.

^kSki slope; NFA, 140°; NLA, 97°.

^lSki slope; NFA, 140°; NLA, 105°.

Figure 2. Response Distribution in Total for Queries.

The x-axis image numbers correspond to the following: (1) dorsal hump; nasofrontal angle (NFA), 130°; nasolabial angle (NLA), 97°; (2) dorsal hump; NFA, 130°; NLA, 105°; (3) dorsal hump; NFA, 140°; NLA, 97°; (4) dorsal hump; NFA, 140°; NLA, 105°; (5) linear; NFA, 130°; NLA, 97°; (6) linear; NFA, 130°; NLA, 105°; (7) linear; NFA, 140°; NLA, 97°; (8) linear; NFA, 140°; NLA, 105°; (9) ski slope; NFA, 130°; NLA, 97°; (10) ski slope; NFA, 130°; NLA, 105°; (11) ski slope; NFA, 140°; NLA, 97°; and (12) ski slope; NFA, 140°; NLA, 105°. The error bars represent 95% confidence intervals.

A subset analysis by gender was also performed (see data in eTable 2 in the Supplement). For “least approachable” and “least attractive,” the photograph of the man with a dorsal hump, an NFA of 140°, and an NLA of 105° (Figure 1D) had the highest proportion of votes by men and women, but the percentage of women who ranked that aforementioned profile as “least approachable” (34%) and “least attractive” (41%) appeared much higher than that of the men (21% and 30%, respectively).

Where there were more than 2 observer characteristics used in the analysis, the differences between groups were assessed using a Bonferroni post hoc test. The only statistically significance differences were found between responses given by different age groups. The differences were detected regarding the query “the oldest” between respondents ages 47 to 61 years vs younger than 33 years (P = .001) and 47 to 61 years vs 33 to 46 years (P = .047). However, the highest-proportion choice in these groups was the same image with a dorsal hump, an NFA of 140°, and an NLA of 105° (31% vs 53% and 31% vs 38%, respectively) (Figure 1D). For the same question concerning the oldest appearance, there was also a significant difference between respondents older than 61 years vs younger than 33 years (P = .01), with the highest-proportion choice being the same image (36% vs 53%) (Figure 1D). When picking the “most successful” image, another post hoc difference was observed between people ages 47 to 61 years vs younger than 33 years (P = .03) with the highest-proportion choice being the face with the dorsal hump, an NFA of 130°, and an NLA of 105° (13%) (Figure 1B) vs image with the ski slope dorsal contour, an NFA of 130°, and an NLA of 97° (18%) (Figure 1I), respectively.

Discussion

To our knowledge, this web-based survey is the first to draw cross-sectional associations between changes to the male nasal dorsum on profile view and various superlative third-party social perceptions. The man with ski slope–shaped nose with an NFA of 130° and NLA of 97° was often associated with frequently perceived positive characteristics; specifically, he was judged to be the most attractive. Participants also often associated superlative youth, approachability, and femininity with dorsal contours that did not feature a dorsal hump. The man with a dorsal hump, an NFA of 140°, and an NLA of 105° was associated for most participants with frequently perceived negative characteristics, such as being the oldest, least approachable, least attractive, and least healthy. Further, participants least frequently associated linear and ski slope shapes with not just those negative characteristics but also “least intelligent” and “least successful.” There were inconsistent preferences for the most or least leaderlike profile or most masculine. These patterns were largely consistent among participant age–based subset analyses after post hoc corrections, which was the only subset post hoc analysis with significant results. There was often an association of a ski slope shape and linear contours with more positively associated characteristics and a dorsal hump with more negatively associated characteristics.

This study agrees with prior findings with the rhinoplasty literature and adds complex implications for rhinoplasty surgeons and their male patients. The ideal NFA and NLA for attractiveness found by other third-party social perception studies examining nasal features, as well as other expert opinion articles,^{6,7,8,10,11,12,13,14,15,16} were supported. This study adds several significant statements on other social attributes that appear to link the same NFA and NLA preferred for attractiveness with the other positive social attributes. Moreover, while this study confirms prior expert opinions on the traditional association between the ski slope dorsum and femininity,⁴ the ski slope dorsum was also consistently associated with the frequently perceived positive social attributes in our cohort. This finding adds complexity to our current understanding of the interaction between femininity and such desired positive characteristics as attractiveness, healthiness, youth, approachability for the male face. Finally, there was a marked rejection of the dorsal hump for many participants in total and in the subset analysis, as confirmed by other studies.^10,17

While femininity and these previously mentioned desired positive characteristics were strongly clustered in the sample, masculinity and perceived leadership ability were particularly interesting constructs that the cohort could never uniformly agree were associated with particular dorsal contours. Masculinity, and other interassociated attributes, such as aggression, trustworthiness, and leadership ability, has been among the most well-studied variables in the facial perception research of the male face, particularly through investigations into facial height¹⁸ and a man’s facial width-to-height ratio.¹⁹ To our knowledge, little prior research has been performed on the male profile view, and this study sought to add to the conversation on this particular view’s association with socially perceived attributes.

Notably, subset analyses revealed certain social perception preferences for the male dorsal contour by observer sociodemographics, such as age and gender, that have had scant prior examination. While all other age brackets agreed, the younger participants in the sample most often found the dorsal hump to be oldest-appearing, a generational preference that facial plastic surgeons should potentially mark. Additionally, while men and women found the man with a dorsal hump, an NFA of 140°, and an NLA of 105° to be “least attractive” and “least approachable,” women more frequently than men held that association in the study. Race/ethnicity subset analyses from this study were not significant after post hoc correction; future studies incorporating larger samples of varied racial/ethnic observer participants may find potential attribute preferences.

Strengths and Limitations

The strengths of this study include the large sample size of the participants surveyed, which was among the largest of prior facial analysis and social perception studies focused on the male face. Using a web-based platform facilitated the accruement of statistical power, which has been historically harnessed in other studies.^9,10 Additionally, the sample was large enough to produce relatively narrow confidence intervals for the estimates, leading to a more precise interpretation of results. Further, using computer simulation software may have provided a methodological advantage to using multiple male volunteer faces for this study. It is well documented that several factors interact to affect social perceptions drawn from the face, including the association of the facial subunits with each other, as well as skin colorations, skin texture, lighting, grooming, and facial expressions.^20,21,22 Using computer simulation software of a gray-scale photograph to isolate the changes to the queried variables associated with the nasal dorsum while keeping the base features of the man’s face constant allowed for more controlled results.

The limitations of this study are inherent to the study design and population. Our predominant survey participant profile was a heterosexual/straight-identified white woman. While some of our subset analyses were statistically significant for participant demographics beyond that predominant profile, additional and/or stronger conclusions may have been drawn had the study population been more diverse. Additionally, the conclusions drawn may only be generalizable to men who have similar countenances as the photographed man of our study (ie, same race/ethnicity, age, and grooming habits). Further studies involving facial analyses of men of more diverse base features and of other races/ethnicities are needed. Moreover, as a cross-sectional survey, we captured a snapshot of contemporary attitudes to draw these results; social attributes preferred by the participants in total as well as by participant subsets are known to be malleable constructs that are prone to variable societal influences, such as fashion, media, and politics.

Conclusions

Particular combinations of the NFA, NLA, and dorsal shape on profile view appear to generate significant statements on a man’s perceived age, approachability, attractiveness, health, gender expression, intelligence, and success. This study’s results may potentially better inform rhinoplasty surgeons and their male patients on how changes to the nasal dorsal contour may change the perception of a man’s social attributes.

Supplement.

eTable 1. Qualtrics survey questionnaire

eTable 2. Response distribution based on gender