IJHNS

Catherine Rennie, Hesham Saleh 10.5005/jp-journals-10001-1335

REVIEW ARTICLE

Assessment and the Psychological Aspects

for Septorhinoplasty
1
Catherine Rennie, 2Hesham Saleh

ABSTRACT patients who may have an unfavorable postoperative

In this article the authors discuss the assessment of patients course regardless of objective outcomes.
undergoing septorhinoplasty emphasing the importance of In this article, we propose a systematic approach to
psychological assessement in the preoperative work up. the assessment of patients for septorhinoplasty that will
Patients motivations, anxieties and expectations are reviewed, enable appropriate patient selection and facilitate surgical
key points to help identify problem patients are highlighted and planning. Assessment should include:
specific questions to identfy those that may be suffering BDD
• Consideration of the patients’ motivations, anxieties,
are recommended. Facial proportions and the ideal angles of the
facial esthetic triangle are described. A framework is presented and expectations,
to enable systematic analysis and examination of the face and • Analysis of the face,
nose to promote appropriate patient selection and facilitate • Analysis of the nose,
surgical planning. • Examination, and
Keywords: Body dysmorphia, Psychology, Rhinoloplasty, • Photography.
Rhinoplasty assessment
How to cite this article: Rennie C, Saleh H. Assessment and
Patients’ Motivations, Anxieties,
the Psychological Aspects for Septorhinoplasty. Int J Head Neck and Expectations
Surg 2018;9(1):38-45.
At the first consultation, a clear history of the patients’
Source of support: Nil complaints and symptoms must be taken and docu-
Conflict of interest: None mented. It is crucial to identify any structural, congenital,
traumatic, cosmetic, and/or functional issues. Any past
history of nasal surgery, sinonasal disease, diabetes,
INTRODUCTION
psychopathology, anticoagulant medication, smoking,
Septorhinoplasty remains one of the most technically or cocaine use should be elicited as they could have sig-
challenging procedures in facial plastic surgery. It is nificant implications for future surgery.
among the most popular cosmetic procedures per- It is important to understand the patients’ motiva-
formed worldwide. The rise in the “selfie” culture has tions, anxieties, and expectations. What makes the patient
led more people to seek surgery to create the perfect want to undergo surgery with its associated incon-
online portrait; hence, the number of septorhinoplasties venience and risk often for a seemingly minor defect?
is increasing year on year. Surgeons must apply careful Many people have nasal abnormalities but only a small
consideration to their patient selection as well as to the number choose to have corrective surgery. A number
esthetic and functional analysis of the nose in order of rhinoplasty patients relate their focus on their nose
to achieve the best outcomes for their patients. Under- back to puberty; they describe becoming increasingly
standing the psychological aspects of septorhinoplasty dissatisfied over time when looking at their daily reflec-
is of fundamental importance to the surgeon. Success- tion in the mirror.1 Since the rise in the “selfie” culture,
ful surgery requires realistic patient expectations with patients have become more self-aware of their appear-
achievable goals and it is important to recognize those ance. Increasingly, we are seeing patients who state that
they do not mind their frontal face in photos, but the side
profiles and other angles used in selfies trigger worries in
1
Consultant and Surgeon, 2Consultant Rhinologist Surgeon and their appearance and incite them to do something about
Honorary Senior Lecturer it, often caused by a public photograph. When compared
1,2
Department of Otolaryngology, Charing Cross Hospital with patients seeking other cosmetic procedures, those
Imperial College Healthcare NHS Trust, London, UK seeking rhinoplasty show higher levels of dissatisfaction
Corresponding Author: Catherine Rennie, Consultant and in their personal appearance.2,3 Most patients seeking
Surgeon, Department of Otolaryngology, Charing Cross rhinoplasty are motivated by a desire to change or having
Hospital, Imperial College Healthcare NHS Trust, London, UK, seen favorable outcomes in others.4 It is not usually the
e-mail: [email protected]
severity of their deformity that leads patients to surgery,5

38
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Assessment and the Psychological Aspects for Septorhinoplasty

but more commonly their perceived difference from the Table 1: Red flags
normal in their social environment. The timing for rhino- Body image concerns that are difficult for others to see
plasty often coincides with a loss in self-esteem. Studies Unrealistic expectations of treatment outcomes
have shown that rhinoplasty surgery results in a positive Worrying about body image repeatedly throughout the day or
for long periods
effect on the patients’ body image, which is still present
Use of camouflaging and cover-up strategies
at 2 years following the procedure.6 Constant requests for reassurance
Recognizing potentially problematic patients is one Mirror checking, or avoidance of mirrors
of the greatest challenges for the rhinoplasty surgeon, as Avoidance of social situations
these patients are unlikely to be satisfied with surgical General reduction in quality of life (e.g., no longer socializing)
results. Identifying patients’ body image concerns may Disruption in daily activity
Patient presents with numerous photos (of self or of models/
raise suspicion of a high-risk patient. A number of per-
celebrities)
sonality attributes that are considered unfavorable for Patient presents with detailed ideas of how to improve
cosmetic surgery have been described in the literature. appearance
Examples commonly referred to are patients who are Patient has other areas of body image concern
unreasonably demanding or overly flattering, patients Patient reports multiple previous “ineffective” consultations or
treatments
that insist on secrecy, the so-called surgiholic, as well as
Overly familiar patients
obsessive, perfectionist, and impolite patients. The sim-
plified acronym SIMON (single, immature, male, overly rhinoplasty for medical reasons, whereas the figure was
expectant/obsessive, narcissistic) describes a high-risk much higher at 43% in those seeking rhinoplasty for
patient, whereas the acronym SYLVIA (secure, young, purely cosmetic reasons.11,12
listens, verbal, intelligent, attractive) describes an ideal Three questions based on the Diagnostic and Statisti-
patient.7-9 While these acronyms are recognized as being cal Manual of Mental Disorders, 4th Edition criteria have
overly simplified, they can still provide a guide to the been developed to help surgeons screen for BDD:
surgical team. • Are you worried about your appearance in any way?
There are a number of red flag signs that the surgeon • Does this concern or preoccupy you? That is, do you
should be aware of as these suggest a high-risk patient think about it a lot and wish you could worry about
or one suffering from body dysmorphic disorder (BDD) it less?
(Table 1). In such cases a psychologist’s opinion should • What effect has this preoccupation with your
be sought prior to considering surgery and obtaining a appearance had on your life?13,14
second surgeon’s opinion would be wise before contem- A number of other questionnaires have been devel-
plating surgery. oped that can help identify patients with unrealistic
The BDD describes an altered perception of one’s expectations and those with suspected BDD (Table 2).
own appearance resulting in distress. It is a subjective However, to date, there is no consensus on a specific
feeling of ugliness or physical defect which the patient rhinoplasty questionnaire.
believes is noticeable to others, although the appearance Preoperative psychological assessment is essential in
is within normal limits.10 Typically BDD starts in late all patients where BDD is suspected.10 If BDD and other
adolescence and is chronic in nature, affecting men and psychopathology are ruled out, the patient can then be
women equally. Studies have shown that 33% of patients counseled regarding surgery; however, if the surgeon
seeking rhinoplasty have moderate symptoms of BDD. still has significant concerns it may be necessary to get
However, this is much lower at only 2% of those seeking a second opinion.

Table 2: General and specific questionnaire

Specific
Rhinoplasty Cosmetic surgery General
Rhinoplasty outcome evaluation (ROE)15-20 Cosmetic procedures screening scale21 Derriford appearance scale (DAS59)18,22,23
Expectations of esthetic rhinoplasty scale Body dysmorphic disorder questionnaire Brief fear of negative evaluation scale25
(EARS)24 (BDDQ)25
The Utrecht questionnaire for outcome Yale-Brown obsessive scale modified for Hospital anxiety and depression scale26
assessment in esthetic rhinoplasty26 BDD22
The RHINO scale27 Dysmorphic concern questionnaire28 Glasgow benefit inventory23,29-33
20,34-39
FACE-Q Neuroticism-extraversion-openness five-
factor inventory (NEO-FFI)40
Body dysmorphic disorder examination- Symptom checklist-90-revised (SCL-90-R)40
self report (BDDE-SR)41

International Journal of Head and Neck Surgery, January-March 2018;9(1):38-45 39

Catherine Rennie, Hesham Saleh

Fig. 1: Rhinoplasty improvement scale used by the senior author

Fig. 2: The concept of dividing the symmetric face into thirds and fifths
Determining preoperative expectations is crucial as
poor outcomes are more frequently due to emotional tions of the face vertically divided into equal fifths, each
dissatisfaction rather than technical failure.42,43 The use fifth is approximately equal to the width of one eye; the
of the rhinoplasty improvement scale is helpful in coun- alar base is equal to the intercanthal distance. The nose
seling patients about realistic postsurgical expectations; ideally occupies one-third of the length of the face and
moving up one point on the scale is realistic but anything one-fifth of its width. It is important to also consider the
more than this is unlikely (Fig. 1). protrusion of the chin as well as the fullness and posi-
tion of the lip.
Analysis of the Face Powell and Humphrey47 described the ideal angles of
It is important to consider the face as a whole and not only the facial esthetic triangle (Fig. 3). The accepted dimen-
the nose in isolation. Leonardo da Vinci first described the sions of each of the facial angles are: Nasofrontal angle
ideal measurements and angles of an attractive face44,45; 115 to 135°; nasofacial angle 30 to 40°; nasomental angle
this concept has since been extended by for use in facial 120 to 132°, and the mentocervical angle 80 to 95°. These
plastic surgery by Albrecht Duerer46 and Powell and angles and proportions provide a useful guide in plan-
Humphrey.47 ning procedures but do vary between ethnicities. Each
Facial symmetry has long been seen as an important rhinoplasty should respect the individuals’ wishes,
marker of facial beauty, although minor asymmetry gender, and character.51
may also be associated with the perception of beauty.48 Finally the analysis of the face should include inspec-
Patients may be unaware of minor facial asymmetries tion of skin type utilizing the Fitzpatrick classification,
prior to surgery; it is therefore, important to discuss which divides the skin type based on its color and its
these with the patient and clearly document them as reaction to the first summer exposure.52 The surgeon
it could lead to dissatisfaction and misunderstanding should consider the skin wrinkles on both with and
in the postoperative period. Although a rhinoplasty on without expression.53
an asymmetrical face can lead to dissatisfaction post-
surgery, correcting an asymmetrical nose which causes
the illusion of facial asymmetry can lead to improved
facial symmetry without the need for any other surgical
procedure.49,50
Symmetry is assessed using midline facial landmarks;
a line running through the mid-philtrum of the upper
lip, the midpoint of the glabella, and the midpoint of the
chin allows assessment of symmetry.
Analysis of facial proportions is performed using
the “rule of thirds” and the “rule of fifths” to assess
the face from a frontal view (Fig. 2).45 Horizontal facial
thirds should be approximately equal, the landmarks
defining each third are the trichion to glabella, glabella
to subnasale, and the subnasale to soft tissue menton.
The rule of fifths describes the ideal transverse propor- Fig. 3: Triangles of Powell and Humphrey47

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Assessment and the Psychological Aspects for Septorhinoplasty

Fig. 4: Classifying classic nasal deviations using thirds

Analysis of the Nose • Tip projection: The anterior distance that the nasal
tip protrudes in front of the face. Goode’s ratio
Analysis of the nose comprises of three areas: inspection
determines the ideal projection, where a line drawn
of the external nose, inspection of the internal nose, and
from the alar-facial groove to the nasal tip measures
palpation.
0.55 to 0.60 of the distance from the nasion to the nasal
tip. A ratio less than this equates to an underprojected
Inspection of the External Nose tip and greater than this corresponds to overprojection
• Skin: Failure to assess its quality prior to surgery (Fig. 6).
can significantly impact results. While subtle tip • Lip–chin relationship: In profile the surface of the upper
improvements may be more easily appreciable in thin lip is typically 2 mm anterior to that of the lower lip.
skin, it remains more unforgiving, displaying minor The anterior surface of the upper and lower lips rests
irregularities more readily; by contrast refining and on the nasomental line in an esthetic face (Fig. 7).54
narrowing the nasal tip can be challenging in thick A retrognathic chin lies posterior to this line, and
a prognathic chin lies anterior. A retrognathic chin
sebaceous skin.
can give the illusion of an overprojected tip and the
• Deviations: The nose is divided into upper, middle,
reverse applies to a prognathic chin. Genioplasty or
and lower thirds. The upper third corresponds to
chin implant procedures are therefore, often used in
the bony vault, the middle third to the upper lateral
conjunction with rhinoplasty.55
cartilages and dorsal septum, and the lower third to
• Dorsum: The dorsum is inspected from both frontal
the lower lateral cartilages, caudal septum, and alar
and lateral views. Following the brow-tip line (lateral
base. Nasal deviations are commonly classified by
esthetic lines) should reveal a smooth curvilinear
one-sided shape, c-shaped, or s-shape (Fig. 4).
line connecting the eyebrow superiorly to the nasal
• Length of the nose: Nasal length is measured from
tip inferiorly (Fig. 8). Irregularities in this smooth
the nasion to the tip, which is equal to the distance
curve highlight sources of nasal deformity. In the
between the stomium and the menton. This can also
be calculated mathematically as the distance from the
nasal tip to the stomium multiplied by a constant of
1.6. Nasal length, NT = TS × 1.6 (Fig. 5).

Fig. 5: Nasal length Fig. 6: Determining tip projection using Goode’s ratio

International Journal of Head and Neck Surgery, January-March 2018;9(1):38-45 41

Catherine Rennie, Hesham Saleh

Fig. 8: Front and right oblique views showing the brow-tip

line—note the four tip-defining points

Fig. 7: Lip–chin relationship • Basal view: The width of the alar base approximates to
the intercanthal distance. The ratio of the width of the
lateral view, the height of the dorsum is assessed; the
dorsum of the nose relative to the alar base should be
dorsum is a straight line in men and in women gently
equal to 80% (Fig. 2). From the basal view, the nose can
curves with a supratip break delineating the dorsum
also be divided into thirds. The upper third corresponds
from the nasal tip. There are wide variations in nasal
to the lobule and the lower two-thirds correspond to the
dorsum height and these are often characteristic of
columella. A line that transects the columella at the area
ethnicity.
of medial crural footplate diversion divides the base
• Tip configuration: There are four tip-defining points
into two halves (Fig. 11). The overall basal view outline
identified by light reflection (Fig. 8). These represent
conforms to an isosceles triangle with pear-shaped
the domes, the supratip, and infratip. The tip is assessed
nostrils lying at an angle of 45° to the vertical.57 Multiple
for any asymmetry, bifidity, and rotation. The size and
ethnic variations exist in alar base configuration.
shape of the lower lateral cartilages and skin thickness
are also inspected. Various tip configurations, such Inspection of the Internal Nose
as normal, boxy, bifid, bulbous, and amorphous are
related to these characteristics. Figure 9 depicts these Anterior rhinoscopy and nasal endoscopy should be
commonly encountered tip appearances. performed:
• Tip rotation: Describes the position of the tip along an • Septum: Inspection for deviation, spurs, perforation,
arc with its radius centered on the nasolabial angle. or the presence of a septal button.
The ideal dimension of the nasolabial angle in women • Lateral nasal wall and turbinates: Inspection for
is 95 to 105° and in a man is 90 to 95° (Fig. 10).56 congestion, hypertrophy, and asymmetry.
• Columellar: Shows the relationship between the ala • Internal nasal valve: This must be assessed during
and the columella assessed in the lateral view. The normal quiet respiration at rest, as exaggerated
amount of visible caudal septum is ideally limited effortful breathing is likely to precipitate transient
to 3 to 5 mm (Fig. 10). This is the distance between internal nasal valve collapse in the normal individual.
two parallel lines drawn from the anteriormost and • A better maneuver than Cottle’s is to place a Jobson-
the posteriormost parts of the nasal vestibule. If the Horne probe in the internal nasal valve to prevent the
degree of columellar show is less than this, there may collapse of the upper lateral cartilage and detect its
be columella retraction and if greater than this there effect on inspiration.
may be either a hanging columella or abnormalities • Alar collapse: Must be identified preoperatively, it is a
in the alar margins, such as notching or retraction. measure of external nasal valve collapse. The external

Fig. 9: Common nasal tip morphology

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Assessment and the Psychological Aspects for Septorhinoplasty

Fig. 10: Left—nasolabial angle in men and women. Right—

normal columellar show Fig. 11: Basal view

nasal valve is not a true valve and is identified by useful intraoperative reference, and allows comparison
the area bounded by alar cartilages, septum, and of pre- and postoperative results. In order to achieve
columella. reproducible photographs, a standard patient position is
• Endoscopy to exclude polyps, purulent discharge, or used where the Frankfurt plane is parallel to the floor;
residual adenoidal tissue. the Frankfurt plane is a line that runs from the cephalic
tragus to lower orbital margin (Fig. 3). The standard
photographic views obtained for rhinoplasty are frontal,
Palpation
left and right lateral, left and right oblique, and basal.
• Skin: Palpate for an assessment of skin texture and Additional views, which can be of use, are the close-up
elasticity. frontal view, superior view, base-radix view, and the
• Irregularities: Palpate for underlying irregularities bird’s eye view.60-62
that may be due to skin, soft tissue, cartilage, bone,
or previous graft material. Computer Imaging
• Tip recoil: This is an assessment of the strength of Computer morphing of the preoperative photographs
the lower third of the nose and provides a palpable improves communication with patients, it can help
measure of the degree of underlying tip support.58 manage expectations and is associated with higher
• Alar cartridges: Palpate for thickness, strength, and patient satisfaction.63 It may also help identifying BDD
shape. by highlighting unrealistic expectations.64 More recently,
• Spine and septum: Tip support, confirm presence and 3D surface imaging and manipulation has been used in
quantity of septal cartilage. the assessment of rhinoplasty. Its role is yet to be explored
• Nasal bones: Assess the size, position, and presence of further and compared with standard imaging.65,66
palpable steps. However, it is important that the patient is aware
that image manipulation does not guarantee a specific
outcome, it is only a means of improved communication
Functional Studies
and understanding.
Nasal inspiratory peak flow, acoustic rhinometry, and
rhinomanometry have all been used as objective tests of CONCLUSION
nasal function and to quantify surgical results. However, In this article, we have outlined a systematic framework
the correlation between objective and subjective sensa- for rhinoplasty assessment to enable appropriate patient
tion of nasal patency remains uncertain.59 As a result, selection and facilitate surgical planning. We have high-
studies of nasal function are not performed routinely in lighted the importance of exploring patients’ motivations,
rhinoplasty assessment and are mainly confined to the anxieties, and expectations, to allow early identification
research environment. of potential problem patients. Following the systematic
assessment and examination of the patient, the proposed
surgery can be effectively planned and communicated
Photograph Review
with the patient. A clear surgical plan with each of the
Photography is essential for surgical planning; it enables surgical steps can be drawn up and it is good practice to
an informed discussion with the patient, provides a commit to a written plan.
International Journal of Head and Neck Surgery, January-March 2018;9(1):38-45 43
Catherine Rennie, Hesham Saleh

REFERENCES 20. Joseph AW, Ishii L, Joseph SS, Smith JI, Su P, Bater K, Byrne P,
Boahene K, Papel I, Kontis T, et al. Prevalence of body dys-
1. Haraldsson PO. Psychosocial impact of cosmetic rhinoplasty.
morphic disorder and surgeon diagnostic accuracy in facial
Aesthetic Plast Surg 1999 May;23(3):170-174.
plastic and oculoplastic surgery clinics. JAMA Facial Plast
2. Sperry S, Thompson JK, Sarwer DB, Cash TF. Cosmetic surgery
Surg 2017 Jul;19(4):269-274.
reality TV viewership: relations with cosmetic surgery atti-
21. Veale D, Ellison N, Werner TG, Dodhia R, Serfaty MA, Clarke A.
tudes, body image, and disordered eating. Ann Plast Surg
Development of a cosmetic procedure screening questionnaire
2009 Jan;62(1):7-11.
(COPS) for body dysmorphic disorder. J Plast Reconstr Aesthet
3. Rankin M, Borah GL, Perry AW, Wey PD. Quality-of-life
Surg 2012 Apr;65(4):530-532.
outcomes after cosmetic surgery. Plast Reconstr Surg 1998
22. Carr T, Moss T, Harris D. The DAS24: a short form of the
Nov;102(6):2139-2145.
Derriford Appearance Scale DAS59 to measure individual
4. Shulman O, Westreich M, Shulman J. Motivation for rhino-
responses to living with problems of appearance. Br J Health
plasty: changes in 5970 cases, in three groups, 1964 to 1997.
Psychol 2005 May;10(Pt 2):285-298.
Aesthetic Plast Surg 1998 Nov;22(6):420-424.
23. Herruer JM, Prins JB, van Heerbeek N, Verhage-Damen G,
5. Napoleon A, Lewis CM. Psychological considerations in
Ingels K. Does self-consciousness of appearance influence
lipoplasty: the problematic or "special care" patient. Ann Plast
postoperative satisfaction in rhinoplasty? J Plast Reconstr
Surg 1989 Nov;23(5):430-432.
Aesthet Surg 2018 Jan;71(1):79-84.
6. Tasman AJ. Rhinoplasty – indications and techniques. GMS
24. Naraghi M, Atari M. Development and Validation of the
Curr Top Otorhinolaryngol Head Neck Surg 2007;6:Doc09.
Expectations of Aesthetic Rhinoplasty Scale. Arch Plast Surg
7. Adamson PA, Chen T. The dangerous dozen--avoiding poten-
2016 Jul;43(4):365-370.
tial problem patients in cosmetic surgery. Facial Plast Surg
25. Phillips, KA. The broken mirror: understanding and treating
Clin North Am 2008 May;16(2):195-202.
body dysmorphic disorder. Revised and Expanded Edition.
8. Rohrich RJ. Streamlining cosmetic surgery patient selection–
New York: Oxford University Press; 2005.
just say no! Plast Reconstr Surg 1999 Jul;104(1):220-221.
26. Lohuis PJ, Hakim S, Duivesteijn W, Knobbe A, Tasman AJ.
9. Tardy, ME Jr. Rhinoplasty: the art and the science. Philidelphia
Benefits of a short, practical questionnaire to measure subjec-
(PA): Saunders; 1997.
10. Jakubietz M, Jakubietz RJ, Kloss DF, Gruenert JJ. Body dys- tive perception of nasal appearance after aesthetic rhinoplasty.
morphic disorder: diagnosis and approach. Plast Reconstr Plast Reconstr Surg 2013 Dec;132(6):913e-923e.
Surg 2007 May;119(6):1924-1930. 27. Lee MK, Most SP. A comprehensive quality-of-life instrument
11. Picavet VA, Prokopakis EP, Gabriels L, Jorissen M, Hellings PW. for aesthetic and functional rhinoplasty: the RHINO scale.
High prevalence of body dysmorphic disorder symptoms Plast Reconstr Surg Glob Open 2016 Feb;4(2):e611.
in patients seeking rhinoplasty. Plast Reconstr Surg 2011 28. Mancuso SG, Knoesen NP, Castle DJ. The dysmorphic concern
Aug;128(2):509-517. questionnaire: a screening measure for body dysmorphic
12. Joseph J, Randhawa P, Hannan SA, Long J, Goh S, O’Shea N, disorder. Aust N Z J Psychiatry 2010 Jun;44(6):535-542.
Saleh H, Hansen E, Veale D, Andrews P. Body dysmorphic 29. Robinson K, Gatehouse S, Browning GG. Measuring patient
disorder in patients undergoing septorhinoplasty surgery: benefit from otorhinolaryngological surgery and therapy. Ann
should we be performing routine screening? Clin Otolaryngol Otol Rhinol Laryngol 1996 Jun;105(6):415-422.
2017 Jun;42(3):508-513. 30. Kosowski TR, McCarthy C, Reavey PL, Scott AM, Wilkins EG,
13. Phillips KA. Body dysmorphic disorder: recognizing and treat- Cano SJ, Klassen AF, Carr N, Cordeiro PG, Pusic AL. A system-
ing imagined ugliness. World Psychiatry 2004 Feb;3(1):12-17. atic review of patient-reported outcome measures after facial
14. Palma P, Khodaei I, Tasman AJ. A guide to the assessment cosmetic surgery and/or nonsurgical facial rejuvenation. Plast
and analysis of the rhinoplasty patient. Facial Plast Surg 2011 Reconstr Surg 2009 Jun;123(6):1819-1827.
Apr;27(2):146-159. 31. Hendry J, Chin A, Swan IR, Akeroyd MA, Browning GG. The
15. Alsarraf R. Outcomes research in facial plastic surgery: Glasgow Benefit Inventory: a systematic review of the use and
a review and new directions. Aesthetic Plast Surg 2000 value of an otorhinolaryngological generic patient-recorded
May-Jun;24(3):192-197. outcome measure. Clin Otolaryngol 2016 Jun;41(3):259-275.
16. Alsarraf R, Larrabee WF, Anderson S, Murakami CS, Johnson CM. 32. Herruer JM, Prins JB, van Heerbeek N, Verhage-Damen GW,
Measuring cosmetic facial plastic surgery outcomes: a pilot Ingels KJ. Negative predictors for satisfaction in patients
study. Arch Facial Plast Surg 2001 Jul-Sep;3(3):198-201. seeking facial cosmetic surgery: a systematic review. Plast
17. Picavet VA, Gabriels L, Grietens J, Jorissen M, Prokopakis EP, Reconstr Surg 2015 Jun;135(6):1596-1605.
Hellings PW. Preoperative symptoms of body dysmorphic 33. Kotzampasakis D, Piniara A, Themelis S, Kotzampasakis S,
disorder determine postoperative satisfaction and quality Gabriel E, Maroudias N, Nikolopoulos T. Quality of life of
of life in aesthetic rhinoplasty. Plast Reconstr Surg 2013 patients who underwent aesthetic rhinoplasty: 100 cases
Apr;131(4):861-868. assessed with the Glascow Benefit Inventory. Laryngoscope
18. Gunel C, Omurlu IK. The effect of rhinoplasty on psychosocial 2017 Sep;127(9):2017-2025.
distress level and quality of life. Eur Arch Otorhinolaryngol 34. Schwitzer JA, Klassen AF, Cano SJ, Baker SB, East C, Pusic AL.
2015 Aug;272(8):1931-1935. Measuring satisfaction with appearance: validation of the
19. Lekakis G, Picavet VA, Gabriels L, Grietens J, Hellings PW. FACE-Q Scales for the nose, forehead, cheekbones, and chin.
Body Dysmorphic Disorder in aesthetic rhinoplasty: validat- Plast Reconstr Surg 2015 Oct;136(4 Suppl):140-141.
ing a new screening tool. Laryngoscope 2016 Aug;126(8): 35. Klassen AF, Cano SJ, Schwitzer JA, Scott AM, Pusic AL.
1739-1745. FACE-Q scales for health-related quality of life, early life

44
 IJHNS

Assessment and the Psychological Aspects for Septorhinoplasty

impact, satisfaction with outcomes, and decision to have 50. Nouraei SA, Pulido MA, Saleh HA. Impact of rhinoplasty
treatment: development and validation. Plast Reconstr Surg on objective measurement and psychophysical appre-
2015 Feb;135(2):375-386. ciation of facial symmetry. Arch Facial Plast Surg 2009
36. Klassen AF, Cano SJ, East CA, Baker SB, Badia L, Schwitzer JA, May-Jun;11(3):198-202.
Pusic AL. Development and psychometric evaluation of the 51. Fang F, Clapham PJ, Chung KC. A systematic review of
FACE-Q scales for patients undergoing rhinoplasty. JAMA interethnic variability in facial dimensions. Plast Reconstr
Facial Plast Surg 2016 Jan-Feb;18(1):27-35. Surg 2011 Feb;127(2):874-881.
37. Schwitzer JA, Albino FP, Mathis RK, Scott AM, Gamble L, 52. Monheit, GD. Combination chemical peelings. In: Lowe NJ,
Baker SB. Assessing demographic differences in patient- editor. Textbook of facial rejuvenation: the art of minimally
perceived improvement in facial appearance and quality invasive combination therapy. London: Martin Dunitz; 2002.
of life following rhinoplasty. Aesthet Surg J 2015 Sep;35(7): 53. Glogau RG, Matarasso SL. Chemical face peeling: patient and
784-793. peeling agent selection. Facial Plast Surg 1995 Jan;11(1):1-8.
38. Schwitzer JA, Sher SR, Fan KL, Scott AM, Gamble L, Baker SB. 54. Aufricht G. Combined plastic surgery of the nose and chin;
Assessing patient-reported satisfaction with appearance and resume of twenty-seven years’ experience. Am J Surg 1958
quality of life following rhinoplasty using the FACE-Q appraisal Feb;95(2):231-236.
scales. Plast Reconstr Surg 2015 May;135(5):830e-837e. 55. Guyuron B, Raszewski RL. A critical comparison of osteoplas-
39. Radulesco T, Mancini J, Penicaud M, Dessi P, Michel J. tic and alloplastic augmentation genioplasty. Aesthetic Plast
Assessing normal values for the FACE-Q rhinoplasty module: Surg 1990 Summer;14(3):199-206.
an observational study. Clin Otolaryngol 2018 Feb. 56. Farkas, LG. Anthropometry of the head and face. 2nd ed. New
40. Golshani S, Mani A, Toubaei S, Farnia V, Sepehry AA, York: Raven Press; 1994.
Alikhani M. Personality and psychological aspects of cosmetic 57. Boahene, KD.; Orten, SS.; Hilger, PA. Facial analysis of the rhi-
surgery. Aesthetic Plast Surg 2016 Feb;40(1):38-47. noplasty patient. In: Papel ID, Frodel JL, Holt GR, Larrabee WF,
41. Baykal B, Erdim I, Ozbay I, Oghan F, Oncu F, Erdogdu Z, Nachlas NE, Park SS, Sykes JM, Toriumi DM, editors. Facial
Kayhan FT. Evaluation of relationship between body dys- plastic and reconstructive surgery. 3rd ed. New York: Thieme;
morphic disorder and self-esteem in rhinoplasty candidates. 2009. pp. 477-487.
J Craniofac Surg 2015 Nov;26(8):2339-2341. 58. Tardy ME. Rhinoplasty tip ptosis: etiology and prevention.
42. American Psychiatric Association. Somatoform disorders. Laryngoscope 1973 Jun;83(6):923-929.
Diagnostic and statistical manual of mental disorders: DSM-5. 59. Sulsenti G, Palma P. Tailored nasal surgery for normalization
DSM-5 ed. Washington (DC): American Psychiatric Press Inc; of nasal resistance. Facial Plast Surg 1996 Oct;12(4):333-345.
2013. 60. Tardy, ME Jr.; Broen, M. Principles of photography in facial
43. Goin MK, Rees TD. A prospective study of patients’ psy- plastic surgery. New York: Thieme; 1992.
chological reactions to rhinoplasty. Ann Plast Surg 1991 61. Bond, M.; Bell, A. The IMI National Guidelines for rhinoplasty
Sep;27(3):210-215. and septorhinoplasty photography. London: IMI; 2006.
44. Atalay, B. Math and the Mona Lisa: the art and science of 62. Tardy ME, Dayan S, Hecht D. Preoperative rhinoplasty:
Leonardo da Vinci. New York: Haper Collins; 2006. evaluation and analysis. Otolaryngol Clin North Am 2002
45. Lines PA, Lines RR, Lines CA. Profilemetrics and facial esthet- Feb;35(1):1-27.
ics. Am J Orthod 1978 Jun;73(6):648-657. 63. Ozkul T, Ozkul MH. Computer simulation tool for rhinoplasty
46. Gunter, JP.; Rohrich, RJ.; Adams, WP. Dallas rhinoplasty: planning. Comput Biol Med 2004 Dec;34(8):697-718.
nasal surgery by the masters. St. Louis (MO): Quality Medical 64. Ende KH, Lewis DL, Kabaker SS. Body dysmorphic disorder.
Publishing; 2002. Facial Plast Surg Clin North Am 2008 May;16(2):217-223.
47. Powell, N.; Humphrey, B. Proportions of the aesthetic face. In: 65. Lekakis G, Claes P, Hamilton GS, Hellings PW. Three-
Byrd HS, Hobar PC, editors. Rhinoplasty: a practical guide. dimensional surface imaging and the continuous evolution
New York: Thieme-Stratton; 1984. of preoperative and postoperative assessment in rhinoplasty.
48. Zaidel DW, Cohen JA. The face, beauty, and symmetry: Facial Plast Surg 2016 Feb;32(1):88-94.
perceiving asymmetry in beautiful faces. Int J Neurosci 2005 66. Durer A. "Hierinn sind begriffen vier Bucher von menschli-
Aug;115(8):1165-1173. cher Proportion durch Albrechten Durer von Nurerberg".
49. Chatrath P, De Cordova J, Nouraei SA, Ahmed J, Saleh HA. Hieronymus Andreae Formschneider. Available on https://
Objective assessment of facial asymmetry in rhinoplasty archive.org/details/hierinnsindbegri00dure/page/n3;
patients. Arch Facial Plast Surg 2007 May-Jun;9(3):184-187. accessed on 6 August 2018.

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