Abstract
Background and objectives
Surgical rhinoplasty is a challenging aesthetic procedure, where patient satisfaction is the primary measure of success. This study assessed patients’ perceptions of their nose shapes before and after a surgical consultation, using the Face-Q questionnaire.
Materials and methods
Patients attending preoperative consultations for primary rhinoplasty completed the Face-Q questionnaire; additional questions included those on nasal symmetry and skin regularity. Subsequently, the same questions were answered after standardized clinical assessment-based photos and measurements. The two sets of answers and demographic data analysis were compared. The study group was stratified by age into younger than or equal to, and older than 21 years, and compared using previously mentioned statistical methods.
Results
Forty patients, predominantly women (65 %), with a mean age of 26.5 years, were included. The Face-Q scores significantly changed after the objective assessment (mean change 3.30, p < 0.001). Stratification by age showed statistically significant differences in all questions for participants above 21, while those below 21 exhibited significant changes in all questions except those on columellar symmetry.
Conclusion
A preoperative review of a rhinoplasty patient’s own nasal features through photographs influenced their perception of their nose, highlighting the importance of preoperative counseling in managing patient expectations effectively.
1
Introduction
Rhinoplasty, a surgical procedure aimed at altering the shape and structure of the nose, is one of the most commonly requested aesthetic surgeries worldwide [ ]. It is performed to achieve both functional and cosmetic outcomes, addressing a variety of concerns including nasal obstruction, congenital deformities, traumatic injuries, and purely aesthetic desires. The procedure can be broadly categorized into two types: functional rhinoplasty, which focuses on improving airflow and correcting structural issues, and cosmetic rhinoplasty, which aims to enhance the external appearance of the nose. Some procedures combine both functional and aesthetic goals, especially in cases where a structural issue also leads to cosmetic concerns [ ].
Rhinoplasty dates back to ancient civilizations, but its modern form began to take shape in the 19th century. The first recorded description of rhinoplasty was by John Roe in 1887, who focused on nasal reconstruction following traumatic injury. Over the years, pioneers like Jacques Joseph and Maurice Cottle advanced the techniques, moving from reduction-based procedures to more sophisticated methods involving cartilage grafting and attention to nasal anatomy. These advancements have greatly contributed to rhinoplasty’s current status as both a functional and aesthetic procedure. Today, rhinoplasty is not only used for cosmetic enhancement but also for functional reconstruction, such as in cases of nasal obstruction or trauma [ ].
The procedure involves the manipulation of bone, cartilage, and soft tissue, making it one of the technically challenging surgeries in the field of plastic and reconstructive surgery. It can be performed through either an open or closed approach. In the open technique, an incision is made across the columella, allowing greater visibility and direct access to the nasal structures. In contrast, the closed technique involves incisions inside the nostrils, leaving no visible scarring. The choice of technique often depends on the complexity of the nasal deformity, the patient’s goals, and the surgeon’s expertise. The procedure may involve reshaping the nasal bones, repositioning cartilage, and removing or adding tissue as necessary. Moreover, with the aid of advanced imaging technologies and 3D modeling, surgeons can now predict and plan outcomes more accurately, enhancing both the precision of the procedure and the patient’s satisfaction [ ].
Despite the technological advancements over the past few years, rhinoplasty remains a complex surgery due to the intricacies involved in manipulating delicate nasal structures and achieving the desired aesthetic outcome while preserving or improving nasal function [ , ]. The operation is further complicated by the challenges of three-dimensional visualization during the procedure and limited access to certain areas of the nasal anatomy. Advanced imaging techniques, such as 3D digital planning, and the use of endoscopic tools have improved the surgeon’s ability to visualize and work within the nasal cavity, providing better control and precision [ ].
Patient satisfaction is widely regarded as the ultimate goal of a successful rhinoplasty and is influenced by factors such as age, sex, level of education, ethnicity, and baseline nasal shape [ ]. Among these, the patient’s level of expectation plays a particularly crucial role in determining the perceived outcome. Given the complex nature of the surgery and the challenge of managing patient expectations, post-rhinoplasty satisfaction rates can vary significantly between individuals [ ]. Understanding the expected outcomes from the surgeon’s perspective is critical to determining the feasibility of achieving the patient’s desired results. Unrealistic expectations often arise due to subjective concerns and inadequate preoperative assessments, where factors such as facial proportions and nasal function may not be fully considered. A comprehensive preoperative consultation that includes a detailed nasal analysis, considering overall facial proportions and dynamic assessments, is essential to ensure a balanced and well-suited outcome for the patient [ ]. To mitigate these challenges, a thorough discussion with the patient, as well as careful consideration of both the patient’s cosmetic goals and functional needs, is crucial. This approach is supported by the use of patient-reported outcome measures (PROMs), such as the Face-Q questionnaire, which assess patient satisfaction and quality of life after rhinoplasty [ ]. Performing a comprehensive nasal analysis, including the use of digital imaging or 3D modeling, offers a clearer understanding of potential outcomes. Incorporating the patient’s perspective through tools like the FACE-Q scales, which have been validated to measure satisfaction with the nose and nostrils, is important for managing expectations and ensuring satisfactory surgical outcomes [ ]. Developed by Klassen et al. (2016), the Face-Q was specifically created to measure patient-reported outcomes (PROs) in the context of facial plastic surgery, including rhinoplasty. The Face-Q is widely recognized for its psychometric properties, including its ability to assess satisfaction with facial appearance, psychological and social function, and the aesthetics of specific facial features such as the nose. This tool was rigorously developed through psychometric analysis, including Rasch measurement theory, ensuring its reliability, validity, and sensitivity to changes over time [ ]. Barone et al. reviewed various patient-reported outcome measures (PROMs) used in rhinoplasty, supporting the use of validated tools like Face-Q, while Klassen et al. validated its effectiveness in assessing rhinoplasty outcomes, further ensuring its reliability in capturing patient satisfaction [ , ]. In this study, we aimed to measure patients’ perceptions of their own nasal shape before and after surgical consultation using the Face-Q questionnaire.
2
Materials and Methods
2.1
Study design and population
This was a prospective, observational study conducted at the main author’s clinic between December 2020 and August 2021. A total of 40 patients undergoing preoperative consultation for primary rhinoplasty were enrolled in the study, which aimed to assess patients’ perceptions of their nasal shape before and after receiving detailed anatomical education and facial measurements during their consultation.
The patient selection process involved recruiting individuals scheduled for primary rhinoplasty who agreed to participate in the study. All patients were required to complete the Face-Q questionnaire ( appendix 1 ), providing responses both at the beginning and end of the consultation to assess the immediate impact of the educational intervention. Only patients who completed the questionnaires in full were included in the study. Exclusion criteria included patients presenting for revision rhinoplasty, those who declined participation, those who refused to complete the questionnaires, and individuals with difficulty understanding English, as the questionnaires were provided in that language.
The study participants consisted of adult patients (18 years or older) seeking rhinoplasty for aesthetic or functional reasons. The age cutoff of 18 years used for stratification into age groups was based on the legal age of consent for surgery in the country where the study was conducted. This design ensured the population represented those actively seeking rhinoplasty, focusing on patients undergoing their first (primary) surgery. Patients with complex medical conditions or those undergoing revision procedures were excluded to reduce confounding factors that could affect preoperative expectations and postoperative outcomes. The nasal analysis, which was part of the study, was not part of the routine work-up for rhinoplasty patients but was specifically included for the purposes of this study to evaluate the effects of anatomical education on patient perceptions.
2.2
Ethical clearance
This study was approved by the Institutional Review Board of the Lebanese University.
2.3
Face-Q questionnaire and additional questions
To assess preoperative nasal shape from the patient’s perspective, each patient completed the Face-Q: Satisfaction with Nose questionnaire at the beginning of the consultation and again after an in-depth discussion with the treating physician and capturing photographic images of the patient’s nose. The Face-Q questionnaire is a validated, evidence-based patient-reported outcome measure (PROM) specifically designed to evaluate patient satisfaction and quality of life related to facial aesthetics, particularly in rhinoplasty. The questionnaire focuses on various domains, including satisfaction with appearance, psychosocial wellbeing, and physical symptoms—critical factors for understanding the patient’s experience and expectations before and after surgery. Its validity and reliability have been demonstrated in several rhinoplasty studies, providing valuable insights into the factors influencing patient satisfaction and helping clinicians identify areas requiring attention during the treatment process. The Face-Q tool has been widely accepted in clinical research and practice as a robust measure of patient satisfaction in rhinoplasty (Klassen et al., 2016).
During the consultation, facial proportions were demonstrated by dividing the facial length into three segments and the facial width into five segments, with the aim of analyzing the nasal position relative to these segments. This structured approach assesses nasal anatomy in the context of overall facial aesthetics. Additionally, the nasal tip, cartilaginous tissue, and bony dorsum were anatomically explained to the patient, enhancing their understanding of the underlying structures and helping set realistic expectations for the surgery.
After the discussion, patients filled out the Face-Q questionnaire once more while reviewing the photographs taken earlier. These photographs were used not only to explain the baseline nasal shape but also to outline the surgical plan, allowing patients to visualize potential changes. In addition to the Face-Q, further questions were included to assess baseline symmetry, such as dorsal skin regularity, nostril symmetry, columellar symmetry, and tip symmetry. These specific questions were designed to evaluate the patient’s initial opinions about their nose, potentially influencing their expectations and perceptions of the surgery.
Although these additional questions are not part of a standardized, validated questionnaire, the main author believes they provide essential insights into the patient’s views on nasal asymmetries and perceived flaws. Understanding these baseline asymmetries is critical in helping both the surgeon and the patient set realistic goals and expectations for rhinoplasty. Furthermore, we acknowledge that these supplementary questions were not validated in prior studies, but they aim to complement the Face-Q questionnaire by addressing additional areas of concern that may impact patient satisfaction.
2.4
Statistical analysis
Demographic data, including age and sex, were collected, and paired t-tests were used to compare continuous variables, such as changes in patient satisfaction scores before and after the professional examination. The Paired T-test was specifically selected for this continuous variable comparison as it is appropriate for comparing two related groups (pre- and post-consultation measurements) within the same subjects.
Additionally, an analysis was performed to evaluate whether age influenced patients’ ability to assess their nasal appearance before and after the consultation. To do this, the 40 patients were stratified into two groups: those aged 21 years or above and those younger than 21 years, with 21 being the official cutoff age for maturity in the country where the study was conducted. Paired t-tests were then used within each group to compare pre- and post-consultation scores. This analysis aimed to assess whether age-related differences influenced patients’ self-assessment of their nasal shape after receiving professional anatomical education and photographic analysis.
All patient responses were reviewed and analyzed by an independent reviewer to ensure the accuracy of the results. The statistical significance of the comparisons was determined using a P-value threshold of <0.05. Additionally, a power calculation was performed prior to the study, which indicated that a sample size of 40 patients would provide sufficient power (0.8) to detect a significant difference in patient satisfaction scores at a 95 % confidence level.
2.5
Photography
Photographs ( Figs. 1 and 2 ) were taken using a tripod (Manfroto tripod, model FB 10 Series 075, 141 RC; Manfrotto Nord SRL, Villapaiera Bl., Italy) equipped with a Canon camera (Canon, model EOS 80D; Shimomaruko, Tokyo, Japan) and a Macro Canon lens (Canon) with a height of 18–135 mm. A primary flash, that was also attached to the tripod at a distance of 27 cm from the optical axis of the camera and 75° from the upper right angle to avoid the ‘red-eye effect’, was used on the photographs. Ten different angles were captured to comprehensively document the patient’s nose shape.
