Eur Arch Otorhinolaryngol
DOI 10.1007/s00405-014-3282-1
RHINOLOGY
The effect of rhinoplasty on psychosocial distress level and quality
of life
Ceren Günel • Imran Kurt Omurlu
Received: 16 August 2014 / Accepted: 3 September 2014
Ó Springer-Verlag Berlin Heidelberg 2014
Abstract The aim of this study was to evaluate psycho-
social distress and improvement in quality of life (QoL) of
patients undergoing rhinoplasty and compare the level of
distress associated with the types of rhinoplasty. A total of
79 patients who underwent external rhinoplasty were
enrolled in the study. The patients were grouped due to
primary, secondary, functional and cosmetic rhinoplasty.
The patients were evaluated four times: preoperative
evaluation, 4th, 12th, and 24th weeks postoperatively and
completed questionnaires including the rhinoplasty out-
come evaluation (ROE) scale, nasal obstruction symptom
evaluation (NOSE) scale, and Derriford Appearance Scale
24 every four visit. The revision cases and patients with
cosmetic indication have more emotional distress than
others at the preoperative and early postoperative period
(p \ 0.005). However, the distress level equalize and
return baseline values beyond 12 weeks. The ROE and
NOSE scores of all patients were very significantly
improved by the rhinoplasty (p \ 0.001). To our knowl-
edge, this is the first study to evaluate changes in distress of
patients undergoing rhinoplasty using DAS-24 scale. The
psychosocial distress has a significant impact on quality of
life and, therefore, it is an important factor to assess the
success of surgery. In addition, regardless of initial demand
and type of surgery, rhinoplasty provides improvement in
C. Günel (&)
Department of Otolaryngology-Head and Neck Surgery, Adnan
Menderes University Medical School Hospital, Aytepe Mevkii,
09100 Aydın, Turkey
e-mail: drgunel@hotmail.com
I. K. Omurlu
Department of Biostatistic, Adnan Menderes University Medical
School Hospital, Aydın, Turkey
nasal obstruction, and a positive impact on QoL in most of
the patients undergoing rhinoplasty.
Keywords Rhinoplasty
Quality of life
NOSE scale

ROE scale
DAS-24 scale
Introduction
Nose is crucial because of its central position in the face.
The nasal shape is frequently one of the factors that affect
our personality development and body image. Therefore,
rhinoplasty is one of the most performing surgical proce-
dures in the field of facial aesthetic surgery [1]. Patients
usually have complaints which include both aesthetic and
functional aspects of the nose.
Every rhinoplasty procedure has difficulties due to
individual differences and patient’s expectations. Tradi-
tional assessments of a surgery success focus morbidity,
complications, sequelae, and objective changes in nasal
shape. However, patient’s perspective and satisfaction are
the most important determinants of success or failure of a
rhinoplasty procedure [2]. Besides, surgeon needs to assess
or quantify the level of psychosocial distress patients
experience following rhinoplasty [3].
In cosmetic surgery, various instruments have been used
to assess outcomes. There are a few studies that have
evaluated psychosocial distress of patients undergoing
rhinoplasty [4–6].
The Derriford Appearance Scale (DAS) 24 is an
assessment tool that measures negative emotions and
behaviours caused by problems of appearance. Current
studies have proven it to be a reliable method of assessing
appearance-related QOL after aesthetic surgeries [7, 8]. To
our knowledge, this is the first study to evaluate changes in
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distress of patients undergoing rhinoplasty using DAS-24 was multiplied by five to base the scale out of a possible
scale. score of a 100 for analysis.
The primary goal of this study was to quantify the The Derriford Appearance Scale 24 is a valid test, which
degree of psychosocial distress experienced by patients at can be a useful tool to assess problems of appearance [7]. It
predetermined time points following rhinoplasty and has been used in a variety of aesthetic surgeries [7, 8]. Each
compare the level of distress associated with the types of question was graded in a 4-point scale. The minimum score
rhinoplasty. In addition, we evaluated satisfaction and was 10 and maximum score was 96. The patients with
improvement in quality of life (QoL) of patients who higher scores indicate higher levels of psychosocial dys-
underwent primary, secondary, functional and cosmetic function with regard to physical appearance.
rhinoplasty procedure using Rhinoplasty outcome evalua- The Kolmogorov–Smirnov test was used to evaluate
tion (ROE) scale and Nasal obstruction symptom evalua- whether the distribution of continuous variables were
tion (NOSE) scale. normal. Independent samples t test was used to compare
normally distributed independent variables and descriptive
statistics are presented as mean ± standard deviation.
Materials and methods Mann–Whitney U test was used to compare the non-nor-
mally distributed independent variables and descriptive
This prospective clinical study was conducted at a tertiary statistics are presented as median (25–75 %). Descriptive
medical centre between 1 June 2012 and 1 February 2014. statistics are presented as frequency (%) for categorial
It was approved by the local ethical committee, and written variables. p values below 0.05 were considered statistically
informed consents were obtained from the subjects. A total significant.
of 79 patients who presented to the out patient clinic with
complaints of difficulty in nasal breathing and nasal
deformity were included. Patients with chronic medical Table 1 Patients characteristic
conditions and malignancy, previous nasal surgery, sino- Mean age ± SD (years) 24.14 ± 4.997
nasal inflammatory disease, chronic rhinosinüsitis, cranio- Male n (%) 49 (62)
facial syndrome conchal hypertrophy were excluded from Females n (%) 30 (38)
the study. \30 years n (%) 66 (83.5)
The patients were grouped as primary, secondary, C30 years n (%) 13 (16.5)
functional and cosmetic rhinoplasty. All patients were
Primary rhinoplasty n (%) 57 (72.2)
operated upon by the same surgeon (C.G.) using the
Secondary rhinoplasty n (%) 22 (27.8)
external septorhinoplasty approach. An early postopera-
Functional rhinoplasty n (%) 20 (25.3)
tive assessment involved the removal of the transcolu-
Cosmetic rhinoplasty n (%) 59 (74.7)
mellar sutures, and splints on the 7th day after surgery.
Patients were divided into four time points; preoperative
evaluation, early follow-up evaluation (4th weeks post-
operatively), intermediate follow-up evaluation (12th
100
weeks postoperatively), and late follow-up evaluation
(24th weeks postoperatively). Patients completed ques- Primary
tionnaires including the ROE, NOSE and DAS-24 scale 80 * Secondary

every four visit. *

Mean DAS Score

The ROE questionnaire is a rhinoplasty-specific out- 60

come instrument which comprises a total of 6 questions

regarding the physical, emotional, and social fields [9]. 40

This questionnaire has excellent test–retest reliability and

internal consistency scores following surgical interventions 20
[10]. Each question is scored from 0 to 4. The total score is
converted to 100 by dividing by 24 and multiplying by 100. 0
The nasal obstruction symptom evaluation scale is a
disease-specific quality of life instrument for use in nasal -20
obstruction and it was developed by Steward and et al. Preop 4th week 12th week 24th week

[11]. All the patients were asked 5-item self-reporting Fig. 1 Derriford Appearance Scale 24 (distress) scores listed by time
questions. Each response is assigned a score ranging from 0 point for primary and secondary rhinoplasty groups. The star
to 4, indicating the severity of the symptom. The total score represents a value of p \ 0.05

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90 and functional groups (p \ 0.001). Majority of patients had

80 the greatest postoperative psychosocial distress at the early
Functional
70 Cosmetic
postoperative visit. However, the early postoperative DAS-
*
24 scores were significantly higher in the secondary and
60
Mean DAS Score

cosmetic groups than others (p = 0.008, p = 0.004). At

*
50 later follow-ups, levels of psychosocial distress had
40 decreased and returned to baseline values for each groups.
30
Preoperative and postoperative ROE and NOSE scores
are summarized in Table 2 and 3. The ROE and NOSE
20
scores of all patients were very significantly improved by
10 the rhinoplasty (p \ 0.001). There were no significant
0 differences in postoperative ROE and NOSE scores
between primary versus secondary rhinoplasty and func-
-10
Preop 4th week 12th week 24th week tional versus cosmetic group as shown in Table 2. There
Fig. 2 Derriford Appearance Scale 24 (distress) scores listed by time
were no significant difference in the mean ROE improve-
point for functional and cosmetic rhinoplasty groups. The star ment scores of subgroups when we compared range by age,
represents a value of p \ 0.05 and sex (p = 0.239, p = 0.944) Table 4.

Results Discussion

All 79 patients responded to the preoperative and postop-
erative questionnaires. The characteristics of the patients
are summarized in Table 1. The Derriford Appearance
Scale scores at each time point are shown in Figs. 1, 2.
The preoperative DAS-24 scores were significantly
higher in the secondary and cosmetic groups than primary
This study provides a measure of the psychosocial distress
associated with rhinoplasty procedure. The vast majority of
patients had higher distress scores at the entire healing
process for each groups. We attribute this situation to
patients who could not reach to expected appearance due to
early healing process. This distress especially was higher in

Table 2 Mean patient Questionnaires Score p value

satisfaction scores of primary
and secondary rhinoplasty Primary (n = 57) Secondary (n = 22)
groups
Preop. ROEb 43.00 (37–56) 29.50 (25.75–59.25) 0.071
ROE 4th week postop. 74.77 ± 15.178 73.41 ± 16.684 0.650
ROE 12th week postopb 75.00 (66–84) 79.00 (64.5–92.75) 0.510
ROE rhinoplasty outcome
b
evaluation, NOSE nasal ROE 24th week postop 84.00 (77.5–90) 75.00 (75–95) 0.364
obstruction symptom evaluation Preop. NOSEa 60.00 (30–75) 52.50 (37.5–70) 0.822
a
Analytic method: independent NOSE 4th week postop. 29.38 ± 23.971 31.59 ± 19.048 0.635
samples t test NOSE 12th week postopb 20.00 (1.25–30) 22.50 (13.75-35) 0.240
b
Analytic method: Mann– NOSE 24th week postopb 10.00 (0–15) 10.00 (5–16.25) 0.134
Whitney test

Table 3 Mean patient Questionnaires Score p value

satisfaction scores of functional
and cosmetic rhinoplasty groups Functional rhinoplasty (n = 20) Cosmetic rhinoplasty (n = 58)
b
Preop. ROE 20 (35.5–45.75) 45 (33–58) 0.394
ROE 4th week postopa 77.00 ± 13.875 73.48 ± 16.060 0.453
ROE 12th week postopb 75 (75–85) 75 (65–87) 0.389
ROE rhinoplasty outcome
evaluation, NOSE nasal ROE 24th week postopb 85 (80–93.75) 80 (75–90) 0.150
obstruction symptom evaluation Preop. NOSEa 52.75 ± 33.383 51.72 ± 27.267 0.896
a
Analytic method: independent NOSE 4th week postopa 22.75 ± 17.357 32.50 ± 23.754 0.118
samples t test NOSE 12th week postopb 22.5 (6.25–30) 20 (10–31.25) 0.885
b
Analytic method: Mann– NOSE 24th week postop b
5 (0–13.75) 10 (5–15) 0.131
Whitney test

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Table 4 Mean ROE improvement scores of subgroups more greater emotional distress at the preoperative period
Mean improvement scores p value
as in this study has shown. The surgeon may have hes-
itated to decide indication of rhinoplasty for these rea-
Age sons. A few studies compared the effect of the primary
\30 years 38 (29–50) 0.239 and secondary rhinoplasty or cosmetic and functional
C30 years 46 (36.5–54.5) indications on QoL after surgery. Cingi et al. [17] found
Gender the levels of patient satisfaction and improvement in QoL
Male 40 (30–50.5) 0.944 are similar after primary and secondary rhinoplasty.
Female 40.5 (28–49) Meningaund et al. [2] reported primary or secondary
Analytic method: Mann–Whitney test rhinoplasty and functional or nonfunctional criteria did
ROE rhinoplasty outcome evaluation
not influence the improvement of ROE scores. Our results
support that whatever the initial demand (functional/cos-
metic) of rhinoplasty may be QoL was improved. In our
the secondary rhinoplasty group and cosmetic indication.
opinion, these factors may increase preoperative emo-
We can speculate that patients who are undergoing sec-
tional distress but do not affect on improvement in QoL
ondary rhinoplasty, and cosmetic indication exert more
following surgery.
emotional concern than patients who undergoing primary
Improvement in nasal obstruction is one of the factors
rhinoplasty, and functional indication at least in our patient
which influence success of rhinoplasty. Nasal obstruction
population. Surgeon should consider this difference to
is usually due to nasal septal deviation. The success of
patient selection.
surgery can be assessed by objective and subjective
Outcome assessments have been usually performed at
methods in patient with nasal obstruction [13]. The
the 1–12 months after rhinoplasty because healing process
NOSE scale is a disease-specific instrument designed to
continues [2, 12, 13]. The improvement in self-esteem
assess nasal obstruction and reliable method to evaluate
starts from 3rd month and continues to 2 years [12]. The
septal surgery. This instrument is brief and easy to
evaluation of patients 3 months after surgery provides
complete [11]. Kahveci et al. [18] suggested the use of
enough time to psychological improvement. Our results
NOSE scale to evaluate outcomes of septoplasty. We
show the adequate time period for subjective outcomes
found that patients who underwent rhinoplasty had very
following rhinoplasty procedure. The mean level of distress
significant improvement in nasal obstruction as from 4th
normalized at assessments beyond 4 weeks and was
week. However, patients who have functional indication
equivalent to preoperative DAS levels beyond 12 weeks
had more higher improvement of NOSE score than
(Figs. 1, 2). We suggest the success of surgery should not
patients who have cosmetic indication but the difference
be assessed before 3 months following surgery.
was not statistically significant. We determined that nasal
The second aim of this study was to evaluate the effect
obstruction was improved by rhinoplasty procedure
of rhinoplasty procedure on improvement QoL. The ROE
regardless of initial demand.
and NOSE questionnaires were applied to the study
patients for the quantitative outcome measurement of rhi-
noplasty. The ROE questionnaire has excellent test–retest
Conclusions
reliability and internal consistency scores following surgi-
cal interventions [9, 10]. Our preoperative ROE scores
This is the first study to evaluate changes in distress of
increased significantly after surgery for each group
patients undergoing rhinoplasty using DAS-24 scale. The
(p \ 0.001). Recent studies showed that women are more
DAS-24 ia an instrument for accurate assessment of the
sensitive to their appearance than men [14, 15]. According
psychosocial distress. The revision cases and patients who
to the other studies, the people younger than 30 years tend
have cosmetic indication have more emotional distress than
to be more sensitive to their appearance than older people
others at the preoperative and early postoperative period.
[14, 16]. However, Meningaund et al. [2] showed age and
The psychosocial distress has a significant impact on
sex did not alter ROE improvement score after rhinoplasty
quality of life and, therefore, it is an important factor to
procedure. When the mean improvement ROE score was
assess the success of surgery. Regardless of the initial
compared with respect to age and sex, we determined age
demand and type (primary/secondary) of rhinoplasty pro-
and sex did not affect patient satisfaction and QoL after
vide improvement in nasal obstruction, and a positive
rhinoplasty in our study.
impact on QoL in most of the patients.
Secondary rhinoplasty has more surgical difficulty than
primary because it has more deformity. Besides, patients Conflict of interest None of the authors has any conflict of interest,
with secondary rhinoplasty, and cosmetic indication have financial or otherwise.

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