Rapid Communication
593
Quality of Life in Patients Who Underwent Rhinoplasty Ramin Zojaji, MD1 Mozhdeh Keshavarzmanesh, MD2 Hamid Reza Arshadi, MD3 Morteza Mazloum Farsi Baf, MD4 Sarvenaz Esmaeilzadeh, MD4 1 Department of Otohinolaryngology, Faculty of Medicine, Islamic
Azad University, Mashhad Branch, Mashhad, Iran 2 Department of Otohinolaryngology, Mashhad, Iran 3 Department of Psychiatry, Faculty of Medicine, Islamic Azad University, Mashhad Branch, Mashhad, Iran 4 Faculty of Medicine, Islamic Azad University, Mashhad Branch, Mashhad, Iran
Address for correspondence Ramin Zojaji, MD, Arya Teaching Medical Hospital, ENT Dept., Islamic Azad University, Golestan 5, East Golestan Street, Jahanbany Street, Mashhad, Khorasan Razavi, Iran, postal code 9137714641 (e-mail:
[email protected]).
Abstract
Keywords
► ► ► ► ►
rhinoplasty quality of life general health GHQ-28 WHOQOL-BREF
Despite developments in the therapeutic field of cosmetic surgery, there is a little information about the effects of cosmetic procedures on quality of life (QOL), especially in Iran. Rhinoplasty is the most common cosmetic surgeries. The aim of this study was to evaluate QOL and General Health before and after rhinoplasty. Patients aged 18 to 55 years seeking cosmetic rhinoplasty were included in this study. Demographic information such as age, sex, marital status, and education of patients were recorded. General Health Questionnaire (GHQ-28) and World Health Organization Quality of Life (WHOQOL-BREF) questionnaire were completed by a single investigator for all patients, before and 3 months after rhinoplasty. A total of 50 patients were enrolled in this study. Overall, 78% were women and 22% were men. QOL did not change significantly (p < 0.05) except for its psychological domain, which did not depend on sex, age, marital, and educational status. Also, general health changes after rhinoplasty was not statistically significant (p > 0.05) and it did not depend on age, sex, and marital status. It seems that cosmetic rhinoplasty has no significant effect on general health and QOL except for its psychological health domain.
Primary cosmetic rhinoplasty is one of the most complex plastic surgeries in the maxillofacial area.1 It is one of the most popular cosmetic surgeries in Iran. Rhinoplasty is amongst the most common surgical procedures in Iran and according to a recent report, rhinoplasty with a rate of 2.75% (180 per 100,000 population) has the 7th rank among the first 50 common invasive procedures in Iran.2 Natural vaginal delivery, cataract operation, cesarean delivery, coronary angiography, varicocele surgery, and appendectomy had the rank 1 to 6 before rhinoplasty.2 Rhinoplasty was the second most common cosmetic surgery performed in the United States in 2011.3 As cosmetic rhinoplasty changes patient facial appearance, it may affect various aspects of patient’s health that could be
Issue Theme Reconstruction of the Orbit; Guest Editor, Rainer Schmelzeisen, MD, DDS, PhD, FRCS
identified by measuring quality of life (QOL).4 This tool could reflect the long-term outcome of procedure quantitatively by assessment of physical, social, psychological, and emotional aspects of life.4 QOL has been defined by the World Health Organization (WHO) as perception of persons of their position in the life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.5 Also, WHO has defined “health” as “a state of complete physical, mental, and social well-being not merely the absence of disease.”6 Various instruments have been developed for measuring QOL. World Health Organization Quality of Life (WHOQOL)100 and its short version WHO-BREF are two instruments developed by WHO for this purpose.7,8
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1393699. ISSN 0736-6825.
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The effects of cosmetic surgeries on QOL have been assessed in previous studies.9–11 QOL changes after cosmetic surgeries has been evaluated in various studies that according to the type of surgery different results have been obtained.12–16 Some studies have shown improvement in QOL and self-esteem after plastic surgery,16,17 but some other studies did not show beneficial effects of cosmetic surgery on patients QOL and mental health.18 As in most cases, esthetic surgeries are performed to improve individuals’ satisfaction with their appearance and also to improve their psychological health by improving self confidence and self-esteem,11,19 we sought to know whether such improvement really is obtained following cosmetic rhinoplasty or not. So, this study aimed to investigate the effect of esthetic rhinoplasty on the patient’s general health and QOL.
Patients and Method This prospective study was conducted on 50 individuals seeking cosmetic rhinoplasty between April 2012 and April 2013 in a private clinic in Mashad, Iran. Participants were selected among individuals seeking cosmetic rhinoplasty for the first time without any other indications except for cosmetic reason, aged between 18 and 55 years and their literacy was at least of third level of guidance school. Those with known history of psychiatric disorders and contraindication for general anesthesia were excluded. Participants were selected among eligible patients by simple random sampling. The study was conducted in accordance with the Helsinki Declaration and the protocol was approved by the ethics committee at the Medical faculty of Mashhad Branch, Islamic Azad University. All patients gave verbal informed consent before enrollment. General Health Questionnaire 28 (GHQ-28) and WHOQOLBREF questionnaire were used to assess general health and QOL in the study participants. GHQ-28 and WHOQOL-BREF were completed for all patients by the same interviewer before and 3 months after cosmetic rhinoplasty. GHQ-28 is a 28-item questionnaire developed as a screening tool for assessment of mental well being. GHQ-28 has four subscales that assess somatic symptoms (items 1–7), anxiety (items 8–14), social withdrawal (items 15–21), and depression (items 22–28).20 Each item has four optional responses scoring between 0 and 3 as score 0 is for “not at all,” score 1 for “no more than usual,” score 2 for “rather more than usual,” and score 3 for option “much more than usual.” The total possible score of the GHQ-28 ranges from 0 to 84, and this score can be calculated also for each subscale separately. Persian version of GHQ-28 has been used in various studies in Iran previously and its validity has been approved with Cronbach α of 97%.21,22 WHOQOL-BREF which is a short version of the original instrument (WHOQOL-100) was used for assessment of patients’ QOL in our study. It comprises 26 items each rated on a 5-point Likert scale.7,8 WHOQOL-BREF inventory measures Facial Plastic Surgery
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four domains of physical health (seven items), psychological health (six items), social relationships (three items), and environmental health (eight items).8 In addition to these domains, WHOQOL-BREF has two overall items for QOL and general health.8 Each domain has 4 to 20 scores and higher scores reflect better QOL, but there is no overall score for this inventory.7,8 Persian version of WHOQOL-BREF has been adopted and applied in previous studies and its validity and reliability has been approved with Cronbach α of greater than 0.70 for each domain.23,24
Statistical Analysis SPSS software version 15.00 (SPSS Inc., Chicago, IL) for Windows was used for data analysis. To test data distribution normality, Kolmogorov–Smirnov test was applied. Data are presented as mean and standard deviation for numerical quantitative data and the number and percentage for categorical data. For comparison of QOL and general health before and 3 months after rhinoplasty, paired t-test or Wilcoxon test were used as appropriate. Also, to compare independent samples, student t-test, analysis of variance, Mann– Whitney U, and Kruskal–Wallis tests were applied appropriately. The significance level was set at p value less than 0.05.
Results Among 50 participants, 39 (78%) were women and 11 (22%) men. Mean age of the patients was 26.4 7.3 years (range, 18–59 years) and 34% (17) of patients were married and others were single. Three months after rhinoplasty, the only psychological health of patients improved significantly (paired t-test, p ¼ 0.001) and no significant changes were observed in other domains of the WHOQOL-BREF including physical health, social relationship, and environmental health as well as overall score of QOL (p > 0.05) (►Table 1). Also, after 3 months of rhinoplasty, no significant changes were seen in the general health score (GHQ-28 score) as well as its four subscales including somatic symptoms, anxiety, social withdrawal, and depression symptoms (►Table 2). No significant difference was found between males and females as well as various age groups regarding GHQ-28 and WHOQOL-BREF score changes after 3 months of cosmetic rhinoplasty (p > 0.05) (data not shown). There was no significant difference between married and single patients in terms of changes in GHQ-28 and WHOQOLBREF and their subscales scores after rhinoplasty (p > 0.05) (data not shown). Also, such difference was not found between the patients with various educational levels as well (p > 0.05) except for the somatic symptoms score which improved significantly in patients with higher educational levels after rhinoplasty (Kruskal–Wallis test, p ¼ 0.02) (data not shown).
Discussion Our study results showed that cosmetic rhinoplasty has significant effects neither on general health nor on QOL,
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Table 1 Quality of life status according to WHOQOL-BREF and their domains score in the study participants before and 3 months after rhinoplasty and their changes
a
WHOQOL-BREF domains
Before rhinoplasty (mean SD)
After 3 mo of rhinoplasty (mean SD)
Changes (mean SD)
p-Value
Physical health
76.9 12.3
75.3 12.6
1.6 10.9
0.314a
Psychological health
63.6 17.0
69.8 14.2
6.3 12.9
0.001a,b
Social relationships
69.3 17.0
72.7 14.6
3.3 14.4
0.108a
Environmental health
69.8 13.6
68.6 13.8
1.2 11.3
0461a
General quality of life
69.9 12.6
71.6 11.3
1.7 9.4
0.204a
Paired t-test. p < 0.05 significant.
b
a
GHQ-28 items
Before rhinoplasty (mean SD)
After 3 mo of rhinoplasty (mean SD)
Changes (mean SD)
p-Value
Somatic symptoms
3.1 1.9
3.0 2.0
0.1 2.1
0.806a
Anxiety symptoms
3.5 2.7
2.9 2.4
0.6 3.0
0.251a
Social functioning
6.7 2.0
6.1 2.3
0.6 2.7
0.187a
Depression symptoms
2.0 2.5
1.6 2.7
0.3 1.6
0.151a
General Health
15.3 6.1
13.6 6.4
1.7 7.3
0.141a
Wilcoxon signed-ranks test.
while it improves psychological health of patients significantly. Won et al in their study of 96 patients, which used Derriford Appearance Scale 59 questionnaire, showed improvement of QOL after septorhinoplasty in Asian population.25 They concluded that septorhinoplasty has a positive effect on QOL in Asians (26). Saleh et al applied rhinoplasty outcome evaluation (ROE) and Nasal Obstruction Symptoms Evaluation (NOSE) questionnaires in their study and analyzed data of 113 patients after rhinoplasty.26 They found significant improvement in patient’s QOL regarding the external appearance and function of the nose.26 Findings of this study were replicated by Cingi et al study using the same questionnaire (ROE) in Turkey.27 In another study in Turkey on 50 patients with nasal obstruction, QOL was evaluated after rhinoplasty using (NOSE) scale and Glasgow Benefit Inventory.28 This study also found improved QOL following esthetic rhinoplasty.28 In a previous study in Iran, Fatemi et al evaluated QOL in 75 patients after rhinoplasty.16 To investigate QOL, they completed SF-36 version 2, NOSE, and Rosenberg self-esteem scale (RSES) questionnaires before and 6 months after rhinoplasty for the patients and found significant improvement in QOL in all the three questionnaires.16 Despite of Fatemi et al study in Iran that found significant improvement in QOL after rhinoplasty,16 our study could not find any significant changes in general health and QOL except for psychological health domain. The difference of Fatemi et al results and ours may be due to using different instrument for
QOL assessment16; they used SF-36, NOSE, and RSES questionnaires whereas we applied GHQ-28 and WHOQOL-BREF questionnaires. WHO questionnaire (WHOQOL-BREF) and GHQ-28 were used for the first time in our study for assessment of QOL following esthetic rhinoplasty and had not been applied in similar studies previously. Small sample size, no assessment of patient satisfaction with nose shape and function and lack of matched control group are main limitations of our study. Future studies with a greater sample size, longer follow-up period, and using other instruments for assessment of QOL are warranted to confirm our findings. In conclusion, it seems that cosmetic rhinoplasty has no significant effect on general health and its subscales and QOL as well. It may only improve psychological well being of patients significantly.
Funding The study did not receive fund from any funding source. Conflict of Interest The authors have no conflict of interest to declare.
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