Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e9
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Perceptions and satisfaction of aesthetic outcome following secondary cleft rhinoplasty: Evaluation by patients versus health professionals Miriam Byrne, Jeffrey C.Y. Chan*, Eoin O’Broin Department of Plastic and Reconstructive Surgery, Cork University Hospital, Wilton, Cork, Ireland
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 17 September 2013 Accepted 6 January 2014
Objective: To explore how improvement in facial appearance is related to patients’ perception and satisfaction following cleft rhinoplasty. Design: A cross-sectional survey. Participants: 35 cleft rhinoplasty patients treated between 2005 and 2010. 45 observers comprised of healthcare professionals. Main outcome measures: Evaluation of patient satisfaction including Rhinoplasty Outcome Evaluation (ROE) questionnaire, Preoperative and Postoperative Semi-quantitative Ordinal Scale Rating (PPSOSR) and a specifically designed semi-structured questionnaire. Evaluation by panel of observers using AsherMcDade Aesthetic Index (AMAI) Rating and PPSOSR. Results: Patient satisfaction was high, based on the ROE questionnaire (score 76.1). 91% of patients rated their appearance as improved, 3% remained ‘uncertain’ and 6% felt ‘different but not improved.’ Teenage females (score 94.1) showed statistically higher satisfaction, when compared to older females (score 75.5), or their male counterparts (score 69.8). The preoperative appearance ratings were not statistically different between patients and panel members but postoperatively, patients’ rating of their appearance was statistically higher. All components of the AMAI were scored between ‘good’ to ‘fair’ (score 9.3). Seventy percent of the panel rated the postoperative appearance as improved. Interestingly, 10% rated the postoperative appearance as ‘unchanged’, while 3% reported a ‘worsened’ appearance. There was no correlation between panel assessment of aesthetic outcome and patient satisfaction. Conclusions: Cleft rhinoplasty contributes to subjective patient satisfaction as a result of their perceived improvement in appearance and function, even though this was not correlated to objective aesthetic rating by panel members. Ó 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Aesthetic Perception Cleft-lip nasal deformity Rhinoplasty Satisfaction
1. Introduction The majority of published literature concentrates on improving cleft rhinoplasty techniques but there is a lack of research that focus on the impact of surgery on patients’ perception and satisfaction with their outcome. Body image attitudes are formulated by one’s thoughts, feelings and behaviour related to their physical appearance (Clifford, 1978). Living in a culture that is driven by image and external beauty, where major emphasis is typically placed on physical appearance, cleft deformity exacts additional psychological and social stressors on these patients (Sousa et al., 2009).
* Corresponding author. Department of Plastic, Reconstructive and Hand Surgery, Cork University Hospital, Wilton, Cork, Ireland. Tel.: þ353 21 4922000. E-mail address: [email protected] (E. O’Broin).
A patient’s self-image may be adversely affected by a negative response from outsiders, whether it is actual or perceived (Charon, 1979; Goffman, 1968; Turner et al., 1997). An interesting study showed that despite the three-dimensional facial analysis showing no significant difference in facial asymmetry when compared to orthognathic patients, those with unilateral cleft lip were rated significantly less attractive (Meyer-Marcotty et al., 2011). Furthermore, a recent study demonstrated that patients, parents and health professionals were more satisfied with the patients’ facial aesthetic appearance than the general public, and suggested that the perceptions of the general public may negatively impact on the patients’ everyday social and professional activities (Gkantidis et al., 2013). The primary aim of cleft rhinoplasty is to improve facial appearance with the central goal of influencing patient perception so that this positively impacts on their satisfaction. In a study of
1010-5182/$ e see front matter Ó 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2014.01.031
Please cite this article in press as: Byrne M, et al., Perceptions and satisfaction of aesthetic outcome following secondary cleft rhinoplasty: Evaluation by patients versus health professionals, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.031
2
M. Byrne et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e9
adults with facial disfigurement, it was found that the patient’s social functioning can be predicted by the patient’s subjective satisfaction of their facial appearance (van den Elzen et al., 2012). Previous studies have shown that from both a physical and psychological perspective, successful surgical procedures can directly influence patient satisfaction with their appearance, and in turn, a favourable outcome on self confidence and esteem (Lefebvre and Munro, 1978) (Rachmiel et al., 1999). This is particularly pertinent to the population of patients seeking cleft rhinoplasty. The overall objective of this study was to explore how improvement in facial appearance is related to patient satisfaction following cleft rhinoplasty.
previous complete unilateral or bilateral cleft lip repair. All procedures were performed by a single cleft surgeon. Patient medical case notes were reviewed retrospectively and demographics and preoperative anatomical cleft deformities recorded, in addition to rhinoplasty techniques employed for each surgery. A 20-min telephone interview was conducted with each patient to complete the assessment tools described (Table 1). All interviews were conducted by the primary author who had recently joined the cleft service and had not met or been involved with any of the patients’ procedures which had been carried out at least two years prior to the study. 2.3. Assessment of patient satisfaction
1.1. Aims and hypotheses The primary aim of this study was to assess patient satisfaction following secondary cleft rhinoplasty at our unit. It was hypothesised that patients’ subjective satisfaction would be high following cleft rhinoplasty aimed at improving their appearance. Additionally, we aimed to evaluate the aesthetic outcome of the cleft rhinoplasty performed. In order to evaluate this as objectively as possible, a panel of independent observers consisting of various healthcare professionals was assembled. Previously validated assessment tools were used. It was hypothesised that objective improvement in nasal appearance was achieved following cleft rhinoplasty. Our final aim was to examine whether there was an association between a patients’ satisfaction level (subjective outcome) and an observers assessment of aesthetic improvement (objective outcome). We hypothesised that patient satisfaction is positively correlated to observer-rated aesthetic outcome, and therefore if the aesthetic outcome was better, patient satisfaction levels would be correspondingly higher. 2. Material and methods 2.1. Design This was a cross-sectional study where patients were required to complete two sets of assessment tools and a semi-structured questionnaire. The assessment tools used were the Rhinoplasty Outcome Evaluation (ROE) questionnaire and the pre- and postoperative Semi-quantitative Ordinal Scale Ratings of their nasal appearance. A specifically designed semi-structured questionnaire was used to elicit patients’ beliefs and issues regarding their nasal appearance. In order to evaluate the postoperative outcome objectively, a panel of observers from various healthcare professional backgrounds was assembled to independently critique and evaluate the preoperative and postoperative outcomes. This was composed of Plastic and Reconstructive (3), Ear, Nose and Throat/Maxillofacial surgeons (3), and Anaesthetic (5) consultants, specifically dealing with cleft surgery. Senior specialist surgical trainees (Plastics/ENT) (10), senior speech therapists/cleft nurse specialists (4), senior dental trainees (4) and consultant and trainee specialist physicians (10), paediatric ICU and ward nursing staff (6). Two forms of assessment tools were used: The Asher-McDade Aesthetic Index Rating and the pre- and post-operative Semi-quantitative Ordinal Scale Rating. 2.2. Patients
2.3.1. Rhinoplasty Outcome Evaluation Questionnaire The Rhinoplasty Outcomes Evaluation questionnaire was developed to assess patients’ preoperative and postoperative nasal state (Alsarraf et al., 2001). This consists of 6 questions relating to patients’ opinion on nasal form and function. Each parameter is scored on a scale from 0 to 4, with 0 and 4 reflecting the worst and best scores, respectively. The total score is divided by 24 and multiplied by 100, resulting in a satisfaction score on a scale of 100. A score of >85 indicates an excellent score with the patient being ‘very satisfied’. 2.3.2. Preoperative and Postoperative Semi-quantitative Ordinal Scale Ratings This assessment tool consists of a 3-point preoperative and 5point postoperative rating of patient pre/post operative outcomes. It does not produce an overall score but allowed both patients and observers to provide a semi-quantitative response (Pitak-Arnnop et al., 2011). Patients/observers were asked to comment on their preoperative appearance (3-point scale: ‘liked’, ‘disliked’ or ‘uncertain’). They were also asked to rate their postoperative appearance as e (5-point scale: ‘improved’, ‘worsened’, ‘different but not improved’, ‘unchanged’ or ‘uncertain’). 2.3.3. Semi-structured questionnaire These questions were designed specifically for this study to evaluate patient perception on qualitative issues not obtained by the two standardised assessment tools described above. The semistructured nature allowed patients to respond in an open-ended manner while staying within a set framework of questions. It contains the following questions: i. Would you undergo the surgery again, knowing the final result? ii. Which part of nose bothered you most preoperatively? iii. Which part has been most improved by surgery?
Table 1 Assessment tools used for evaluating patient satisfaction and for rating aesthetic outcome. Assessment of patient satisfaction
Reference
a Rhinoplasty Outcome Evaluation Questionnaire b Preoperative and Postoperative Semi-quantitative Ordinal Scale Ratings c Semi-structured Questionnaire
Alsarraf et al., 2001 Pitak-Arnnop et al., 2011 Byrne et al., 2014 (this study)
Aesthetic outcome assessment by panel of observers a Asher-McDade Aesthetic Index Rating
All patients who had undergone cleft rhinoplasty procedures at our unit between 2005 and 2010 were reviewed. Inclusion criteria consisted of patients requiring secondary rhinoplasty, having had a
b Preoperative and Postoperative Semi-quantitative Ordinal Scale Ratings
Asher-McDade et al., 1991, 1992 Pitak-Arnnop et al., 2011
Please cite this article in press as: Byrne M, et al., Perceptions and satisfaction of aesthetic outcome following secondary cleft rhinoplasty: Evaluation by patients versus health professionals, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.031
M. Byrne et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e9
iv. Has surgery improved function (breathing & snoring)? v. Which view of the nose do you prefer (front or side)? vi. How do you find the resultant scars postoperatively? Like/ dislike vii. Rate improvement on a scale of 0e10 (where 0 ¼ no improvement, 10 ¼ the desired outcome?) viii. Whose nose would you most desire to have? 2.4. Assessment by panel of observers 2.4.1. Clinical photographs Panel satisfaction of patient aesthetic outcomes was assessed using professional standardised pre- and post-operative medical photographs (frontal, lateral, and Worm’s eye views). Briefly, black lastolite was placed at 3 ft behind the patient and slave flashes (Canon 550EX) were directed towards the patient on tripods at 6 ft (vertical height) on either side. The Canon 5D camera was fitted with a Canon 100 mm macro lens and a master flash (Canon 580EX). The aperture was set at f11 with manual focussing, and shutter at 1/8 s for full face and 1/4 s for cup face views. 2.4.2. Asher-McDade Aesthetic Index Rating The aesthetic outcome was evaluated by 25 panel members using the Asher-McDade Aesthetic Index Rating (Asher-McDade et al., 1992, 1991). This assessment tool addresses four nasolabial components (nasal form, nose symmetry, vermillion border, and nasal profile) which were rated separately on 5-point scales (Score 1 means a ‘very good’ appearance, score 2 a ‘good’ appearance, score 3 a ‘fair’ appearance, score 4 a ‘poor’ appearance and score 5 a ‘very poor’ appearance). 2.4.3. Preoperative and postoperative Semi-quantitative Ordinal Scale Ratings The second outcome tool, the 3-point preoperative and 5-point postoperative Semi-quantitative Ordinal Scale Ratings (also used for patients satisfaction outcomes as described above) was completed by 45 of the panel members (Pitak-Arnnop et al., 2011). 2.5. Cleft rhinoplasty technique Cleft nasal deformities involve complex three-dimensional distortion of all structures. A variety of techniques exist, including the less invasive hitching procedures such as the Tajima procedures to complex open rhinoplasty using multiple grafts. Each case was assessed on an individual basis, taking into account a multiplicity of factors (Kernahan et al., 1980; Tajima and Maruyama, 1977). However, as tissues are generally distorted and scarred from prior procedures, the senior author felt it would be difficult to achieve the desired results without direct manipulation of the structures. In view of this, the open technique was preferred as described by Bardach (Bardach et al., 1987) for unilateral clefts or by Millard for bilateral clefts (Millard, 1967). This typically begins with lifting of the alar base with graft, and application of a trans-alar base suture to pull the cleft side in, thus approximating the ala together. A sub mucosal septal resection was then performed allowing harvest of a posterior septal graft. This was used to straighten and strengthen the anterior septum whilst similarly augmenting the dorsal and caudal septum. Autologous graft from the nasal septum was used for the majority of cases but, where septal cartilage was insufficient, costal cartilage grafts were harvested. Deviation at the level of the nasal bones was straightened with the low-low-high lateral external osteotomy in-fracture technique as first described by Webster et al. (Webster et al., 1977). Lateral osteotomies permitted narrowing of the nose, thus closing the
3
open roof deformity created after hump removal, which resulted in improved symmetry. Tip surgery involved multiple grafts, including shield grafts to the tip, strut grafts to the ala and a dermal sheet graft if necessary to cover and soften the entire construct. 2.6. Statistical analysis Data results collected on all parameters were compiled and entered into Microsoft Excel spreadsheets. Statistical analysis was performed using GraphPad InStat (Version 3) for Macintosh. Statistical correlation was evaluated using the Spearman’s correlation test. Comparison between groups was analysed using Fisher’s Exact, Chi-Squared and KruskaleWallis tests for non-parametric data and unpaired t-test for parametric data. The level of statistical significance was set at p value of 20 years, p < 0.05). Similarly, teenage females showed a statistically significant higher satisfaction when compared to their male counterparts (p < 0.01, mean score 69.8 for male < 20 years) (Fig. 1). A similar pattern was not observed for teenage males. As expected, all patients disliked their preoperative appearance based on the Semi-quantitative Ordinal Scale Rating (Fig. 2). Postoperatively, 91% of patients rated their appearance as improved. Three percent of patients remained ‘uncertain’ and 6% felt ‘different but not improved’. No patient rated their appearance as worsened postoperatively. When asked which part of their nose that they were most concerned/bothered by prior to surgery, 76% of patients described the nasal tip/columella area, and the remaining 24%, the nostril and ala combined. Twenty-seven patients (33%) described themselves as having a ‘boxers flat nose’. Not surprisingly therefore, 44% of patients found the greatest improvement at the nasal tip, with 28% specifically identifying the nostril as the area most significantly improved from a cosmetic perspective. Of the total cohort, 11% found alterations to the columella impacting most positively on their appearance, while 17% found improvement to the ala the most striking constructive change. We found that the preoperative ratings of appearance were not statistically different between patients and panel members. Postoperatively there was a statistically higher patient-reported postoperative appearance rating when compared to their preoperative rating (p < 0.01). Similarly, when compared to panel members,
Please cite this article in press as: Byrne M, et al., Perceptions and satisfaction of aesthetic outcome following secondary cleft rhinoplasty: Evaluation by patients versus health professionals, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.031
4
M. Byrne et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e9
* N.S.
N.S.
Rhinoplasty Outcome Evaluation Score
100
94.2
90 80
76.1
81
79.2 71
70
74.2
69.7
60 50 40 30 20 10 0
All Patients
Female
Male
All 20 yrs
Female
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Perceptions and satisfaction of aesthetic outcome following secondary cleft rhinoplasty: Evaluation by patients versus health professionals Miriam Byrne, Jeffrey C.Y. Chan*, Eoin O’Broin Department of Plastic and Reconstructive Surgery, Cork University Hospital, Wilton, Cork, Ireland
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 17 September 2013 Accepted 6 January 2014
Objective: To explore how improvement in facial appearance is related to patients’ perception and satisfaction following cleft rhinoplasty. Design: A cross-sectional survey. Participants: 35 cleft rhinoplasty patients treated between 2005 and 2010. 45 observers comprised of healthcare professionals. Main outcome measures: Evaluation of patient satisfaction including Rhinoplasty Outcome Evaluation (ROE) questionnaire, Preoperative and Postoperative Semi-quantitative Ordinal Scale Rating (PPSOSR) and a specifically designed semi-structured questionnaire. Evaluation by panel of observers using AsherMcDade Aesthetic Index (AMAI) Rating and PPSOSR. Results: Patient satisfaction was high, based on the ROE questionnaire (score 76.1). 91% of patients rated their appearance as improved, 3% remained ‘uncertain’ and 6% felt ‘different but not improved.’ Teenage females (score 94.1) showed statistically higher satisfaction, when compared to older females (score 75.5), or their male counterparts (score 69.8). The preoperative appearance ratings were not statistically different between patients and panel members but postoperatively, patients’ rating of their appearance was statistically higher. All components of the AMAI were scored between ‘good’ to ‘fair’ (score 9.3). Seventy percent of the panel rated the postoperative appearance as improved. Interestingly, 10% rated the postoperative appearance as ‘unchanged’, while 3% reported a ‘worsened’ appearance. There was no correlation between panel assessment of aesthetic outcome and patient satisfaction. Conclusions: Cleft rhinoplasty contributes to subjective patient satisfaction as a result of their perceived improvement in appearance and function, even though this was not correlated to objective aesthetic rating by panel members. Ó 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Aesthetic Perception Cleft-lip nasal deformity Rhinoplasty Satisfaction
1. Introduction The majority of published literature concentrates on improving cleft rhinoplasty techniques but there is a lack of research that focus on the impact of surgery on patients’ perception and satisfaction with their outcome. Body image attitudes are formulated by one’s thoughts, feelings and behaviour related to their physical appearance (Clifford, 1978). Living in a culture that is driven by image and external beauty, where major emphasis is typically placed on physical appearance, cleft deformity exacts additional psychological and social stressors on these patients (Sousa et al., 2009).
* Corresponding author. Department of Plastic, Reconstructive and Hand Surgery, Cork University Hospital, Wilton, Cork, Ireland. Tel.: þ353 21 4922000. E-mail address: [email protected] (E. O’Broin).
A patient’s self-image may be adversely affected by a negative response from outsiders, whether it is actual or perceived (Charon, 1979; Goffman, 1968; Turner et al., 1997). An interesting study showed that despite the three-dimensional facial analysis showing no significant difference in facial asymmetry when compared to orthognathic patients, those with unilateral cleft lip were rated significantly less attractive (Meyer-Marcotty et al., 2011). Furthermore, a recent study demonstrated that patients, parents and health professionals were more satisfied with the patients’ facial aesthetic appearance than the general public, and suggested that the perceptions of the general public may negatively impact on the patients’ everyday social and professional activities (Gkantidis et al., 2013). The primary aim of cleft rhinoplasty is to improve facial appearance with the central goal of influencing patient perception so that this positively impacts on their satisfaction. In a study of
1010-5182/$ e see front matter Ó 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2014.01.031
Please cite this article in press as: Byrne M, et al., Perceptions and satisfaction of aesthetic outcome following secondary cleft rhinoplasty: Evaluation by patients versus health professionals, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.031
2
M. Byrne et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e9
adults with facial disfigurement, it was found that the patient’s social functioning can be predicted by the patient’s subjective satisfaction of their facial appearance (van den Elzen et al., 2012). Previous studies have shown that from both a physical and psychological perspective, successful surgical procedures can directly influence patient satisfaction with their appearance, and in turn, a favourable outcome on self confidence and esteem (Lefebvre and Munro, 1978) (Rachmiel et al., 1999). This is particularly pertinent to the population of patients seeking cleft rhinoplasty. The overall objective of this study was to explore how improvement in facial appearance is related to patient satisfaction following cleft rhinoplasty.
previous complete unilateral or bilateral cleft lip repair. All procedures were performed by a single cleft surgeon. Patient medical case notes were reviewed retrospectively and demographics and preoperative anatomical cleft deformities recorded, in addition to rhinoplasty techniques employed for each surgery. A 20-min telephone interview was conducted with each patient to complete the assessment tools described (Table 1). All interviews were conducted by the primary author who had recently joined the cleft service and had not met or been involved with any of the patients’ procedures which had been carried out at least two years prior to the study. 2.3. Assessment of patient satisfaction
1.1. Aims and hypotheses The primary aim of this study was to assess patient satisfaction following secondary cleft rhinoplasty at our unit. It was hypothesised that patients’ subjective satisfaction would be high following cleft rhinoplasty aimed at improving their appearance. Additionally, we aimed to evaluate the aesthetic outcome of the cleft rhinoplasty performed. In order to evaluate this as objectively as possible, a panel of independent observers consisting of various healthcare professionals was assembled. Previously validated assessment tools were used. It was hypothesised that objective improvement in nasal appearance was achieved following cleft rhinoplasty. Our final aim was to examine whether there was an association between a patients’ satisfaction level (subjective outcome) and an observers assessment of aesthetic improvement (objective outcome). We hypothesised that patient satisfaction is positively correlated to observer-rated aesthetic outcome, and therefore if the aesthetic outcome was better, patient satisfaction levels would be correspondingly higher. 2. Material and methods 2.1. Design This was a cross-sectional study where patients were required to complete two sets of assessment tools and a semi-structured questionnaire. The assessment tools used were the Rhinoplasty Outcome Evaluation (ROE) questionnaire and the pre- and postoperative Semi-quantitative Ordinal Scale Ratings of their nasal appearance. A specifically designed semi-structured questionnaire was used to elicit patients’ beliefs and issues regarding their nasal appearance. In order to evaluate the postoperative outcome objectively, a panel of observers from various healthcare professional backgrounds was assembled to independently critique and evaluate the preoperative and postoperative outcomes. This was composed of Plastic and Reconstructive (3), Ear, Nose and Throat/Maxillofacial surgeons (3), and Anaesthetic (5) consultants, specifically dealing with cleft surgery. Senior specialist surgical trainees (Plastics/ENT) (10), senior speech therapists/cleft nurse specialists (4), senior dental trainees (4) and consultant and trainee specialist physicians (10), paediatric ICU and ward nursing staff (6). Two forms of assessment tools were used: The Asher-McDade Aesthetic Index Rating and the pre- and post-operative Semi-quantitative Ordinal Scale Rating. 2.2. Patients
2.3.1. Rhinoplasty Outcome Evaluation Questionnaire The Rhinoplasty Outcomes Evaluation questionnaire was developed to assess patients’ preoperative and postoperative nasal state (Alsarraf et al., 2001). This consists of 6 questions relating to patients’ opinion on nasal form and function. Each parameter is scored on a scale from 0 to 4, with 0 and 4 reflecting the worst and best scores, respectively. The total score is divided by 24 and multiplied by 100, resulting in a satisfaction score on a scale of 100. A score of >85 indicates an excellent score with the patient being ‘very satisfied’. 2.3.2. Preoperative and Postoperative Semi-quantitative Ordinal Scale Ratings This assessment tool consists of a 3-point preoperative and 5point postoperative rating of patient pre/post operative outcomes. It does not produce an overall score but allowed both patients and observers to provide a semi-quantitative response (Pitak-Arnnop et al., 2011). Patients/observers were asked to comment on their preoperative appearance (3-point scale: ‘liked’, ‘disliked’ or ‘uncertain’). They were also asked to rate their postoperative appearance as e (5-point scale: ‘improved’, ‘worsened’, ‘different but not improved’, ‘unchanged’ or ‘uncertain’). 2.3.3. Semi-structured questionnaire These questions were designed specifically for this study to evaluate patient perception on qualitative issues not obtained by the two standardised assessment tools described above. The semistructured nature allowed patients to respond in an open-ended manner while staying within a set framework of questions. It contains the following questions: i. Would you undergo the surgery again, knowing the final result? ii. Which part of nose bothered you most preoperatively? iii. Which part has been most improved by surgery?
Table 1 Assessment tools used for evaluating patient satisfaction and for rating aesthetic outcome. Assessment of patient satisfaction
Reference
a Rhinoplasty Outcome Evaluation Questionnaire b Preoperative and Postoperative Semi-quantitative Ordinal Scale Ratings c Semi-structured Questionnaire
Alsarraf et al., 2001 Pitak-Arnnop et al., 2011 Byrne et al., 2014 (this study)
Aesthetic outcome assessment by panel of observers a Asher-McDade Aesthetic Index Rating
All patients who had undergone cleft rhinoplasty procedures at our unit between 2005 and 2010 were reviewed. Inclusion criteria consisted of patients requiring secondary rhinoplasty, having had a
b Preoperative and Postoperative Semi-quantitative Ordinal Scale Ratings
Asher-McDade et al., 1991, 1992 Pitak-Arnnop et al., 2011
Please cite this article in press as: Byrne M, et al., Perceptions and satisfaction of aesthetic outcome following secondary cleft rhinoplasty: Evaluation by patients versus health professionals, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.031
M. Byrne et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e9
iv. Has surgery improved function (breathing & snoring)? v. Which view of the nose do you prefer (front or side)? vi. How do you find the resultant scars postoperatively? Like/ dislike vii. Rate improvement on a scale of 0e10 (where 0 ¼ no improvement, 10 ¼ the desired outcome?) viii. Whose nose would you most desire to have? 2.4. Assessment by panel of observers 2.4.1. Clinical photographs Panel satisfaction of patient aesthetic outcomes was assessed using professional standardised pre- and post-operative medical photographs (frontal, lateral, and Worm’s eye views). Briefly, black lastolite was placed at 3 ft behind the patient and slave flashes (Canon 550EX) were directed towards the patient on tripods at 6 ft (vertical height) on either side. The Canon 5D camera was fitted with a Canon 100 mm macro lens and a master flash (Canon 580EX). The aperture was set at f11 with manual focussing, and shutter at 1/8 s for full face and 1/4 s for cup face views. 2.4.2. Asher-McDade Aesthetic Index Rating The aesthetic outcome was evaluated by 25 panel members using the Asher-McDade Aesthetic Index Rating (Asher-McDade et al., 1992, 1991). This assessment tool addresses four nasolabial components (nasal form, nose symmetry, vermillion border, and nasal profile) which were rated separately on 5-point scales (Score 1 means a ‘very good’ appearance, score 2 a ‘good’ appearance, score 3 a ‘fair’ appearance, score 4 a ‘poor’ appearance and score 5 a ‘very poor’ appearance). 2.4.3. Preoperative and postoperative Semi-quantitative Ordinal Scale Ratings The second outcome tool, the 3-point preoperative and 5-point postoperative Semi-quantitative Ordinal Scale Ratings (also used for patients satisfaction outcomes as described above) was completed by 45 of the panel members (Pitak-Arnnop et al., 2011). 2.5. Cleft rhinoplasty technique Cleft nasal deformities involve complex three-dimensional distortion of all structures. A variety of techniques exist, including the less invasive hitching procedures such as the Tajima procedures to complex open rhinoplasty using multiple grafts. Each case was assessed on an individual basis, taking into account a multiplicity of factors (Kernahan et al., 1980; Tajima and Maruyama, 1977). However, as tissues are generally distorted and scarred from prior procedures, the senior author felt it would be difficult to achieve the desired results without direct manipulation of the structures. In view of this, the open technique was preferred as described by Bardach (Bardach et al., 1987) for unilateral clefts or by Millard for bilateral clefts (Millard, 1967). This typically begins with lifting of the alar base with graft, and application of a trans-alar base suture to pull the cleft side in, thus approximating the ala together. A sub mucosal septal resection was then performed allowing harvest of a posterior septal graft. This was used to straighten and strengthen the anterior septum whilst similarly augmenting the dorsal and caudal septum. Autologous graft from the nasal septum was used for the majority of cases but, where septal cartilage was insufficient, costal cartilage grafts were harvested. Deviation at the level of the nasal bones was straightened with the low-low-high lateral external osteotomy in-fracture technique as first described by Webster et al. (Webster et al., 1977). Lateral osteotomies permitted narrowing of the nose, thus closing the
3
open roof deformity created after hump removal, which resulted in improved symmetry. Tip surgery involved multiple grafts, including shield grafts to the tip, strut grafts to the ala and a dermal sheet graft if necessary to cover and soften the entire construct. 2.6. Statistical analysis Data results collected on all parameters were compiled and entered into Microsoft Excel spreadsheets. Statistical analysis was performed using GraphPad InStat (Version 3) for Macintosh. Statistical correlation was evaluated using the Spearman’s correlation test. Comparison between groups was analysed using Fisher’s Exact, Chi-Squared and KruskaleWallis tests for non-parametric data and unpaired t-test for parametric data. The level of statistical significance was set at p value of 20 years, p < 0.05). Similarly, teenage females showed a statistically significant higher satisfaction when compared to their male counterparts (p < 0.01, mean score 69.8 for male < 20 years) (Fig. 1). A similar pattern was not observed for teenage males. As expected, all patients disliked their preoperative appearance based on the Semi-quantitative Ordinal Scale Rating (Fig. 2). Postoperatively, 91% of patients rated their appearance as improved. Three percent of patients remained ‘uncertain’ and 6% felt ‘different but not improved’. No patient rated their appearance as worsened postoperatively. When asked which part of their nose that they were most concerned/bothered by prior to surgery, 76% of patients described the nasal tip/columella area, and the remaining 24%, the nostril and ala combined. Twenty-seven patients (33%) described themselves as having a ‘boxers flat nose’. Not surprisingly therefore, 44% of patients found the greatest improvement at the nasal tip, with 28% specifically identifying the nostril as the area most significantly improved from a cosmetic perspective. Of the total cohort, 11% found alterations to the columella impacting most positively on their appearance, while 17% found improvement to the ala the most striking constructive change. We found that the preoperative ratings of appearance were not statistically different between patients and panel members. Postoperatively there was a statistically higher patient-reported postoperative appearance rating when compared to their preoperative rating (p < 0.01). Similarly, when compared to panel members,
Please cite this article in press as: Byrne M, et al., Perceptions and satisfaction of aesthetic outcome following secondary cleft rhinoplasty: Evaluation by patients versus health professionals, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.031
4
M. Byrne et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e9
* N.S.
N.S.
Rhinoplasty Outcome Evaluation Score
100
94.2
90 80
76.1
81
79.2 71
70
74.2
69.7
60 50 40 30 20 10 0
All Patients
Female
Male
All 20 yrs
Female
