ORIGINAL ARTICLE AESTHETIC

Influence of Age on Rhinoplasty Outcomes Evaluation:A Preliminary Study

Lisandra Megumi Arima • Leandro Castro Velasco •

Romualdo Suzano Louzeiro Tiago

Received: 22 December 2010 / Accepted: 24 July 2011 / Published online: 20 August 2011

� Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2011

Abstract

Background The aim of this study was to evaluate the

satisfaction of patients who underwent rhinoplasty by using

the Rhinoplasty outcomes evaluation (ROE) questionnaire

and determine the influence of patient age on the outcomes.

Methods We conducted a longitudinal study to assess

patients’ pre- and postoperative degrees of satisfaction with

their results. The study was done at a tertiary-care medical

center. The ROE questionnaire was applied twice in the

same visit and aimed at measuring the patient’s satisfaction

in both pre- and postoperative moments.

Results The initial sample of this study was composed of

112 patients, 61 of whom have answered the ROE ques-

tionnaire. A mean difference of 50.5 (P \ 0.0001) was

observed between the pre- and postoperative satisfaction

scores. No statistically significant difference was observed

on the mean difference between pre- and postoperative sat-

isfaction scores (CHANGE) according to sex (P = 0.673),

the follow-up time period (P = 0.629), or the kind of sur-

gical procedure (P = 0.904). The mean postoperative score

of the\30-year-old group was lower than the mean of 30 to

\50-year-old (P \ 0.003) and C50-year-old groups

(P \ 0.009).

Conclusion The ROE questionnaire is a tool for evalu-

ating the outcomes of different surgical indications for

correcting nasal deformities. The kind of surgical proce-

dure had no influence on the mean difference between

pre- and postoperative satisfaction scores. By using this

tool we found that the younger age group reported lower

postoperative satisfaction scores than older patients.

Keywords Outcome assessment � Patient satisfaction �Rhinoplasty � Quality of life

Evaluation of surgery outcome was the subject of few

studies from the patient’s point of view, but such analysis is

very important since patient satisfaction is a critical factor

in the success of surgery [1–5]. Several surveys were

performed aimed at validating a reliable questionnaire to be

answered by patients who underwent cosmetic surgery with

the purpose of measuring patient satisfaction postopera-

tively [5–10]. Questionnaires that evaluate quality of life

and self-image became the gold standard and eventually

replaced the simplistic form by which patients were asked

whether they had noticed any improvement after rhino-

plasty [11, 12].

Adopting a generally accepted questionnaire is very

convenient since it standardizes the evaluation and allows

the professionals involved to compare different techniques,

to measure positive and negative effects, and to identify

potential patients who may not benefit from a surgical

procedure [1].

Alsarraf et al. [6, 7, 13] were the first to offer and test an

evaluation tool for several facial plastic surgeries, includ-

ing rhinoplasty, with reliability, internal consistency, and

method validity. Such a validated questionnaire is a tool

available to surgeons so that they can objectively analyze

certain qualitative variables involved in cosmetic surgery,

such as psychological, social, and emotional aspects. The

aim of this study was to evaluate the satisfaction of patients

who underwent rhinoplasty by using the Rhinoplasty

L. M. Arima � L. C. Velasco � R. S. L. Tiago

Department of Otolaryngology—Head and Neck Surgery,

Municipal Public Server Hospital of Sao Paulo, Rua Castro

Alves, 60, Aclimacao District, Sao Paulo, SP, Brazil

R. S. L. Tiago (&)

Rua Pio XII, 439, apt. 122, Sao Paulo 01322-030, Brazil

e-mail: romualdotiago@uol.com.br

123

Aesth Plast Surg (2012) 36:248–253

DOI 10.1007/s00266-011-9805-x

outcomes evaluation (ROE) questionnaire and determine

the influence of patient age on satisfaction.

Materials and Methods

The project was approved by the Research Ethics Com-

mittee prior to initiation of the study. One hundred twelve

consecutive patients who underwent primary rhinoplasty

with a closed approach were identified. Their surgeries

were performed at a tertiary-care hospital. Rhinoplasty

surgeries were either performed or supervised by the third

author.

All patients who underwent rhinoplasty from January

2000 to 2010 took part in this survey. They had a post-

operative follow-up time ranging from 6 months to

10 years, ages starting at 16 years old for female patients

and 17 years old for male patients, and signed an informed

consent form when they appeared at the Institute after

receiving a telephone call. Table 1 shows the reasons why

certain patients did not answer the ROE questionnaire and

were omitted from the study.

A longitudinal study with retrospective chart review and

prospective follow-up to assess patients’ pre- and postop-

erative satisfaction with their results was carried out.

Patients were invited by telephone call to appear at the

Institute and answer the ROE questionnaire (Table 2)

[6, 7]. The ROE questionnaire was presented twice during

the same visit so that patient satisfaction could be measured

in both pre- and postoperative settings. Preoperative

answers were based on viewing photographs recorded in a

standardized way before surgery. Postoperative answers

were based on each patient’s actual outcome [10, 13].

Each ROE question was answered using the grade range

of 0–4, where 0 is the most negative answer and 4 the most

positive one. The answers to each question were added up

and the total was divided by 24 and multiplied by 100 to

obtain a result that ranged from 0 to 100 (0 = minimum

satisfaction, 100 = maximum satisfaction) [7]. The final

result was divided into groups according to their quartile: 0

to \25 and 25 to \50 (no success), 50 to \75 (good), and

C75 (excellent).

After gathering the data, three variables were obtained:

score of patient satisfaction with self-image before surgery,

score of patient satisfaction with current appearance, and

the difference between scores assigned before and after

surgery (increase or decrease in patient satisfaction).

Information on age, sex, postoperative follow-up time

period, and kind of surgical procedure was gathered. Data

were entered into a Microsoft Excel spreadsheet (Microsoft

Corp., Redmond, WA, USA).

To analyze data statistically, the following tests were

used: paired t-test; independent t-test; Mann–Whitney

nonparametric test; and Kruskal–Wallis test. A P \ 0.05

was considered statistically significant.

Results

The initial sample of this study was composed of 112

patients who underwent primary rhinoplasty with a closed

approach, 61 of whom answered the ROE questionnaire.

Patient characteristics are given in Table 3.

It was observed that before surgery 60 patients (98.4%)

scored their satisfaction as \50, with only one patient

(1.6%) scoring satisfaction between 50 and \75. After

surgery, it was observed that 91.8% of patients migrated

from the\50 group to the 50 to\75 group, the outcome of

which was considered good, and those with a score C75

considered their outcome as excellent. In spite of the fact

that 4.9% (3.3 ? 1.6%) of patients remained in the same

Table 1 Number of patients lost to follow-up

Reason N

Incorrect number 28

Unwilling to participate in study 16

No answer despite repeated calls 5

No telephone number in hospital register 1

Reoperated by another team 1

Total 51

Table 2 Rhinoplasty outcomes evaluation (ROE) questionnaire

(1) How well do you like the appearance of your nose?

(2) How well are you able to breathe through your nose?

(3) How much do you feel your friends and loved one like your

nose?

(4) Do you think you current nasal appearance limits your social or

professional activities?

(5) How confident are you that your nasal appearance is the best

that it can be?

(6) Would you like to surgically alter the appearance or function of

your nose?

Table 3 Patient characteristics

Mean age ± SD (years) 33 ± 13.8

Males/females [total no. (%)] 29 (47.5)/32 (52.5)

Surgical procedure [total no. (%)]

Reduction 28 (45.9)

Crooked nose 19 (31.1)

Augmentation 9 (14.8)

African–American 5 (8.2)

Mean follow-up (months) 55.9

Aesth Plast Surg (2012) 36:248–253 249

123

group, the initial condition did not become worse (Table 4).

After surgery it was noticed that 100% of patients’ scores

increased from pre- to postoperative stages, that is, none of

the patients scored lower after surgery than he/she had

scored before surgery (Fig. 1).

The mean preoperative satisfaction score of patients

who underwent rhinoplasty was 27.2 ± 10.8, and postop-

eratively the mean increased to 77.7 ± 17.2 (Table 5). A

mean difference (mean increase in patient satisfaction) of

50.5 was observed between the pre- and postoperative

satisfaction scores, with a statistically significant difference

(P \ 0.0001).

The sample was composed of 29 male (47.5%) and 32

female patients (52.5%). The mean difference between pre-

and postoperative satisfaction scores for male patients was

49.4 while for female patients it was 51.6, without any

statistically significant difference (P = 0.673), as can be

seen in Table 5.

The mean age of the patients was 33 years old (range =

16–65 years) (Table 3). The sample was divided into three

groups: \30 years old (28 patients), 30 to \50 years old

(28 patients), and C50 years old (5 patients). The mean

satisfaction scores before and after surgery in the age

groups is given in Table 5. There was no difference

between mean preoperative satisfaction scores between the

age groups. However, after surgery the mean satisfaction

score of the \30-year-old group was lower than the mean

of the 30 to \50-year-old (P \ 0.003) and C50-year-old

groups (P \ 0.009). The age groups 30 to \50 years old

and C50 years old did not have any difference in mean

postoperative satisfaction scores (P = 0.326), as can be

seen in Fig. 2.

The mean follow-up time after rhinoplasty was of

55.9 months (range = 6 months–10 years) (Table 3). The

sample was divided into two groups according to the fol-

low-up period: 6 to \60 months (31 patients) and C60

months (30 patients). No statistically significant difference

(P = 0.629) was observed in mean figures between

Table 5 Mean pre- (PRE) and postoperative (POST) scores of

patients who underwent rhinoplasty and the difference between the

pre- and postoperative mean scores (CHANGE)

n PRE POST CHANGE P

Mean scores 61 27.2 77.7 50.5 \0.0001

Sex 0.673

Male 29 49.4

Female 32 51.6

Age \0.0001

\30-year-old 28 28.9 71.4

30 to \50-year-old 28 25.2 82.1

C50-year-old 5 23.3 88.3

Follow-up 0.629

6 to \60 months 31 51.8

C60 months 30 49.3

Surgical procedure 0.904

Reduction 28 48.4

Crooked nose 19 51.5

Augmentation 9 53.2

African–American 5 54.2

n number of patients

Table 4 Number of patients who underwent a rhinoplasty according to satisfaction on pre- (PRE) and postoperative (POST) periods

PRE Total

\25 25 to \50 50 to \75

POST

25 to \50 (unsuccessful) 2 (3.3%) 2 (3.3%) 0 (0) 4 (6.6%)

50 to \75 (good) 8 (13.1%) 5 (8.2%) 1 (1.6%) 14 (22.9%)

C75 (excellent) 16 (26.2%) 27 (44.3%) 0 (0) 43 (70.5%)

Total 26 (42.6%) 34 (55.8%) 1 (1.6%) 61 (100%)

Values are number of patients (percentage of total)

Fig. 1 The pre- and postoperative satisfaction scores of patients who

underwent rhinoplasty, according to the follow-up

250 Aesth Plast Surg (2012) 36:248–253

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pre- and postoperative satisfaction scores according to the

follow-up time period (Table 5).

The patients were divided into four groups according

to the kind of surgical procedure: reduction rhinoplasty

(28 patients); rhinoplasty to correct crooked nose (19

patients); augmentation rhinoplasty (9 patients), and African-

American rhinoplasty (5 patients). No statistically significant

difference (P = 0.904) was observed in mean figures between

pre- and postoperative satisfaction scores according to the

kind of surgical procedure (Table 5, Fig. 3).

Discussion

Although, many times surgery is deemed successful by the

surgeon, the patient’s judgment about it may not agree;

sometimes the opposite happens. Certain factors can

influence patient satisfaction, like his/her culture, life

experience, and chiefly his/her level of expectations about

the outcome, which may or may not be realistic [10, 12].

Therefore, it is important for the surgeon to understand the

patient’s complaints and then to analyze the proportions

and ratios between the nose and face through a physical

examination. Help from standardized photographic docu-

mentation is fundamental so that physician and patient, by

mutual agreement, can carry out preoperative planning

taking into account the patient’s anatomical features [14].

Recently, several studies and reviews have been per-

formed to create a tool that is able to measure and analyze

patient satisfaction after surgery [1–10]. This study used

the questionnaire created and validated by Alsarraf et al.

[7], which is an easy and quick and useful in evaluating

different kinds of patients and surgical techniques [5, 10].

The method that we used, that is, a retrospective eval-

uation of preoperative satisfaction and prospective evalu-

ation of postoperative satisfaction, was similar to the one

published by other authors [10]. In this survey, preopera-

tive satisfaction scores were based on both the patient’s

Fig. 2 The mean pre- and

postoperative satisfaction scores

of patients who underwent

rhinoplasty, according to age

group

Fig. 3 The mean pre- and

postoperative satisfaction scores

of patients who underwent

rhinoplasty, according to

indication

Aesth Plast Surg (2012) 36:248–253 251

123

memory and standard preoperative photographs. The

patients had the support of the photographs taken before

surgery at the moment they answered the questionnaire.

Sixty-one patients were evaluated, a number comparable

to that used in the study of Meningaud et al. [5] (58

patients) and higher than that used in the survey with

preliminary results by Alsarraf et al. (26 patients) [7]. The

loss of 51 patients in this study (45.5%) was higher than in

the study by McKiernan et al. (38.3%) [9] and lower than

in the survey by Hellings et al. (48%) [10]. The main

reason for the observed loss was incorrect contact infor-

mation registered in the hospital system (Table 1). All 34

patients who did not take part in the survey because they

were not reached (no or wrong telephone number in the

hospital system) were considered a random loss. However,

the 16 patients (14.3%) who were called and who did not

attend the survey could have made a difference in the

average scores due to a higher or lower degree of satis-

faction. Their absence may be connected to satisfied or

dissatisfied patients who are not interested in returning or

being evaluated further. The loss to follow-up of patients

who do not want to continue their own treatment is a factor

beyond the researchers’ control, and it is difficult to

determine the influence of such individuals on the final

results. It is possible that a future prospective study will

confirm the results and conclusions presented here.

This study found that all patients noticed an improve-

ment after the surgical procedure, since their postoperative

scores were higher than their preoperative scores (Fig. 1).

The mean difference between pre- and postoperative sat-

isfaction scores was 50.5 (27.2 before surgery and 77.7

after surgery), which is higher than the 44.5 outcome

achieved by Alsarraf et al. (38.8 before surgery and 83.3

after surgery) [7]. The biggest difference between the

before and after surgery scores in this study was due to the

lower mean preoperative score resulting from the high

number of patients with functional complaints (88.5%).

According to Hellings et al. [10], for patients who required

two or more rhinoplasties, the mean difference between

pre- and postoperative satisfaction scores was 16 (42.8

before surgery and 58.8 after surgery), which shows the

difficulty in achieving excellent results in patients who

undergo several surgery procedures.

The classification in quartiles helps the surgeon define

which patients can benefit more by undergoing rhinoplasty.

Patients in the first and second quartiles preoperatively are

those who report being more unsatisfied with their

appearance and with nasal function; therefore, they may

experience a great benefit from surgery. Patients in the

third or fourth quartile preoperatively do not have signifi-

cant aesthetic and/or functional changes and may not have

a significant improvement after surgery; in addition, there

is the risk of making their condition worse. This survey

sought to find whether the result in patients in the first and

second quartiles was unsatisfactory or unsuccessful, since

all such patients were unsatisfied with their appearance

preoperatively. The term ‘‘unsuccessful’’ is used in the

sense of the patient’s dissatisfaction with the result. Most

of the patients in the third quartile were satisfied with the

rhinoplasty and considered it a good result. Patients in the

fourth quartile reported a high level of satisfaction after

surgery, considering it an excellent result.

Analyzing the reasons why four patients kept their \50

score (unsuccessful) postoperatively, it was found that the

cosmetic and functional problems were still objects of

complaint after surgery. The patient who had a preopera-

tive score in the 50 to\75 quartile and who had a score in

the same quartile after surgery, which is considered a good

outcome (Table 4), had an asymmetry upon implanting the

lateral crura of the alar cartilages. Such asymmetry is a

personal anatomical limitation of the patient which made

aesthetic improvement more difficult.

Guyuron et al. in 1981 [12], found that 81.4% of patients

who underwent rhinoplasty were female. The relative fre-

quency of men and women in our sample was 47.5 and

52.5%, respectively, which shows that men are increasingly

concerned about their physical appearance (Table 3). The

mean difference between pre- and postoperative satisfaction

scores was similar for both sex groups (Table 5), an outcome

similar to those reported by other authors [5, 8].

Younger patients have greater expectations about the

aesthetic outcome of a rhinoplasty. This may be due to

their greater need for social acceptance and the increased

difficulty in assimilating body changes resulting from the

surgery [8]. A difference in satisfaction after rhinoplasty

was found between younger and older patients. The \30-

year-old age group had a mean postoperative satisfaction

score lower than the 30 to\50-year-old age group and the

C50-year-old age group. Therefore, younger patients who

undergo rhinoplasty need more detailed preoperative

guidance, with complete information on the limitations of

the surgery, so that a satisfactory outcome can be reached.

When evaluating patients who underwent revision rhino-

plasty, no significant difference was found between pre-

and postoperative satisfaction scores of patients in their

sixth decade [10]. Such a result was not found in our

sample, which was composed of patients who underwent

primary rhinoplasty. In C50-year-old patients, the mean

postoperative satisfaction score was higher than the pre-

operative one (Table 5, Fig. 2).

The final result of rhinoplasty can be observed at the

12 month follow-up. This study found that those patients

who had a longer postoperative follow-up (C60 months)

had a mean difference between pre- and postoperative

satisfaction scores similar to those patients who underwent

surgery in the last 60 months (Table 5).

252 Aesth Plast Surg (2012) 36:248–253

123

Reduction rhinoplasty can be performed with a rasping

technique on patients with a small hump. On patients with

larger humps, an osteotome must be used to remove the

excess nasal bone. After removal of the nasal hump, the

dorsal borders of the septum and the upper lateral cartilages

to the nasal bone profile line are usually adjusted [15]. In

this sample, 45.9% of patients underwent reduction rhi-

noplasty and the mean difference between the pre- and

postoperative satisfaction scores was 48.4 (Table 5;

Fig. 3).

Crooked nose correction is still a challenge. The natural

force of cartilaginous structures and soft tissues (muscles

and conjunctive tissue shortened on the side with the

deviation) continues to acting on the nose after to surgery,

thus making it difficult to achieve optimal postoperative

results. Another factor that can make the already operated

on nose become crooked again is the incomplete correction

of the nasal septum deviation [16–18]. In our patient

sample, 31.1% of surgical procedures were performed to

correct crooked noses and the mean difference between

the pre- and postoperative satisfaction scores was 51.5

(Table 5; Fig. 3).

For patients who need augmentation rhinoplasty, the

most used grafts are autogenous. The most common

autogenous grafts are cartilaginous (nasal septum, auricular

concha) and bony (calvarial, mastoid, iliac crest). Carti-

laginous grafts are used when the defect is not a big; it is

possible to use septal cartilage to correct it. In cases where

the septum cartilage is insufficient or absent, auricular

concha cartilage can be used. Bony grafts are used to

correct big defects, and the most indicated ones are those

from membranous bone (calvarial) since they have a low

long-term absorption rate [19]. In this sample, the mean

difference between the pre- and postoperative satisfaction

scores of such patients was 53.2 (Table 5; Fig. 3).

The ethnic nose has peculiar characteristics that should

be recognized and respected by both the patient and the

surgeon. The main characteristics of the African-American

nose are the wide and depressed dorsum, nasal tip lacking

projection and definition, excess alar flaring, diminished

nasal length and height, acute columellar-labial angle, and

low radix [20]. The mean difference between the pre- and

postoperative satisfaction scores of African-American

patients was 54.2 (Table 5; Fig. 3).

Conclusions

The ROE questionnaire is a tool for evaluating the out-

comes of different surgical procedures used to correct nasal

deformities. In this study, the kind of surgical procedure

used had no influence on the mean difference between

pre- and postoperative satisfaction scores. By using this

tool we found that the younger age group reported lower

postoperative satisfaction scores than older patients.

Conflict of interest The authors have no conflicts of interest or

financial ties to disclose.

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