Keywords
quality of life - results evaluation (health care) - rhinoplasty - patient satisfaction
Palavras-chave
qualidade de vida - avaliação de resultados (cuidados de saúde) - rinoplastia - satisfação
do paciente
Introduction
The main reasons for which the patients seek the otorhinolaryngologist are the complaints
of nasal obstructions, aesthetics or the association of both. Most articles that approach
the theme of aesthetic surgery offer discussions on surgical techniques, pathways,
complications, sequels and review rates. The evaluation of the final result of the
intervention is not a very common research by the viewpoint of the patient and this
analysis is critical since the patient's satisfaction is a key factor for the surgical
success[1]
[2]
[3]
[4].
In the merely aesthetic surgeries the physician must evaluate the reason why the patient
seeks the procedure. Many times the reason involves the need to satisfy others, social
or professional ambition and the surgeon has a great responsibility to accept or refuse
this demand[5].
Several works were prepared aiming to validate a reliable questionnaire to be applied
to patients submitted to aesthetic surgery and measure the patient's satisfaction
after the surgical procedure[6]
[7]
[8]
[9]
[10]
[11]. Some instruments, like questionnaires that evaluate the quality of life and the
self-image became a gold standard and are intended to replace the simplistic manner
with which the patient was questioned on whether he/she perceived or not a recovery
after rhinoplasty[12]
[13].
The use of a widely accepted questionnaire is very profitable once it standardizes
the evaluation and allows the comparison of different techniques, the measurement
of positive and negative effects and the identification of possible patients who may
not benefit from the surgical procedure[2].
Alssarraf et al were the first authors to offer and test an evaluation tool for several facial
aesthetic procedures, including rhinoplasty, with reliability, internal consistency
and validity of the method[7]
[8]
[14]. The use of this questionnaire is an instrument the surgeon may have available to
objectively analyze some qualitative variables that involve the aesthetic surgery
such as psychological, social and emotional aspects[7]
[8].
The objective of this work is to evaluate the satisfaction of the patients submitted
to reduction rhinoplasty, from the questionnaire Rhinoplasty Outcomes Evaluation (ROE).
Method
53 consecutive patients were identified with jib or rhinomegaly, submitted to reduction
rhinoplasty. The surgeries were performed in the Otorhinolaryngology Service of a
tertiary hospital of the city of São Paulo in the period from January 2000 through
January 2010. The rhinoplasties were made or supervised by the third author.
All patients submitted to reduction rhinoplasty were included with six months to 10
years of postoperative follow up, from 16 years in the female sex and 17 years for
the male sex, who agreed with the Free and Clear Authorization Term in the Institution
after telephone contact.
The patients who were not possible to contact by telephone and were excluded did not
agree with the Free and Clear Authorization Term or did not appear for the interview
([Table 1]).
Table 1.
Reason and frequency of the patients excluded from the sample.
|
Reason
|
N
|
|
No contact was possible
|
17
|
|
Wrong telephone
|
13
|
|
No answer
|
3
|
|
Without telephone number in the hospital register
|
1
|
|
Did not show up
|
8
|
|
In spite of the contact and scheduling of the visit
|
6
|
|
They could not appear to the hospital in the data collection period
|
2
|
|
Total
|
25
|
We performed longitudinal study, of retrospective cut type, on preoperative and postoperative
satisfaction. The patients were invited by telephone to appear at the Institution
where the surgery was made to answer to the ROE questionnaire[7]
[8]. The patients who appeared at the hospital received information concerning the research
and agreed to take part in the study through the Free and Clear Authorization Term.
The project was evaluated and approved by the Ethics Committee in Research of the
Institution (Report no. 20/2010).
The ROE questionnaire was applied twice in the same visit aiming to measure the satisfaction
of the patient at the preoperative and postoperative approaches. The preoperative
answers were based on the viewing of pictures registered in a standardized manner
before the surgical procedure. The postoperative answers were based on the current
result of the patient[11]
[15].
Alssarraf et al tested and validated this instrument (ROE), which, starting with six questions,
enables to evaluate three quality of life subjective domains: physical, mental/emotional
and social, as described in [Graphic 1]
[8].
Graphic 1.
Questionnaire Rhinoplasty Outcomes Evaluation (ROE).
|
1) How much do you like the appearance of your nose?
|
|
2) How much can you breathe through the nose?
|
|
3) How much do you think your friends and acquaintances like your nose?
|
|
4) Do you thing the appearance of your nose limit your professional or social activities?
|
|
5) How much confident are you that your nose has the best possible appearance?
|
|
6) Would you like to change the appearance or the function of your nose with surgery?
|
Each question of the questionnaire was answered with marks of a scale from zero to
four (zero for the most negative and four for the most positive answer). In order
to achieve a final result of the scale the sum of the answers for each question was
made and this result was divided by 24 and multiplied by 100, which provided a value
ranging from zero to 100[8]. The final result was divided into classes according to the quartile: zero to <25
and 25 to <50 (failure); 50 to <75 (good); and ≥75 (excellent).
After collection of the data three variables were obtained: satisfaction note that
the patient had with his/her image before the surgery; note of satisfaction with the
current result; the difference of satisfaction notes between postoperative and preoperative
approaches. We surveyed data regarding: age; sex and time of postoperative follow
up. The data obtained were inserted into electronic worksheets, by using the software
Microsoft Excel (Microsoft Corporation).
For statistical analysis of the data, we used: paired t-test; independent t-test;
Mann-Whitney non-parametric test and Kruskal-Wallys test. The significant p ≤ 0.05
value was considered statistically.
Results
The initial sample of this work was composed by 53 patients, out of whom 28 answered
the questionnaire. The reason for absence of the other patients are described in [Table 1].
The mean age of the 28 patients who took part in the study was of 28.4 years old ± 12.1
corresponding to 21 (75%) of the female sex and seven (25%) of the male sex. All patients
were submitted to reduction rhinoplasty from endonasal approach.
The average satisfaction mark of all patients submitted to rhinoplasty in the preoperative
approach was of 28 ± 11.2 and in the postoperative it reached 76.3 ± 17.6 (Picture
1). We noticed a difference between the average of the postoperative and preoperative
of 48.3 (p < 0.0001).
In the preoperative approach we noticed that 100% of the patients had satisfaction
of <50. In the postoperative there was a 92.9% migration from classification <50 to
classes: 50 to <75 considered to be good (25%); e”75 considered to be an excellent
outcome (67.9%). In spite of 7.1% of the patients having obtained a postoperative
result <50, the initial condition did not get worse ([Table 2]). In the postoperative approach, we noticed that 100% of the patients had an addition
of marks between the preoperative and postoperative approaches, that is, in no patient
the satisfaction mark in the postoperative was lower than in the preoperative approach.
Table 2.
Frequency of the patients submitted to reduction rhinoplasty according the satisfaction
in the preoperative (PRE) and postoperative (POST).
|
Moment
|
|
|
PRE
|
|
Total
|
|
|
|
< 25
|
25 to <50
|
|
|
POST
|
25 to <50 (Failure)
|
N (%)
|
1 (3,6%)
|
1 (3,5%)
|
2 (7,1%)
|
|
50 to <75 (Good result)
|
N (%)
|
3 (10,7%)
|
4 (14,3%)
|
7 (25,0%)
|
|
≥ 75 (Excellent result)
|
N (%)
|
8 (28,6%)
|
11 (39,3%)
|
19 (67,9%)
|
|
Total
|
|
N (%)
|
12 (42,9%)
|
16 (57,1%)
|
28 (100%)
|
As regards to the age of the patients, the sample was divided into two classes: <30
years; and ≥30 years. We noticed the age was a factor that influenced the average
of the difference of the satisfaction marks between preoperative and postoperative
approaches, that is, the patients aged <30 had a lower addition to the satisfaction
than the patients aged ≥30 years (p = 0.015), as described in [Table 3].
Table 3.
Average of the marks between the preoperative and postoperative approaches of the
patients submitted to reduction rhinoplasty according to the age.
|
Reduction
|
< 30 years
|
≥ 30 years
|
Test
Mann-Whitney (p)
|
|
Average
|
40,9
|
58,3
|
|
|
Standard Deviation
|
19,6
|
13,3
|
0,015
|
|
n
|
16
|
12
|
|
The mean time of follow up after rhinoplasty was of 70.8 months, which varied from
six months to 10 years. The sample was divided into two classes according to the follow
up period: 6 to <60 months; and ≥60 months. No statistically significant difference
was noticed in the averages of the satisfaction difference between preoperative and
postoperative, according to the time of follow up ([Table 4]).
Table 4.
Satisfaction marks difference average between the postoperative and preoperative of
the patients submitted to reduction rhinoplasty according to the follow up time.
|
Reduction
|
6 to <60 months
|
≥ 60 months
|
Test Mann-Whitney (p)
|
|
Average
|
41,7
|
50,2
|
|
|
Standard Deviation
|
23,3
|
17,9
|
0,43
|
|
N
|
6
|
22
|
|
Discussion
Some factors may influence the satisfaction of the patients submitted to rhinoplasty
such as their culture, life experience and especially their level of expectation regarding
the final result, which may be realistic or not[11]
[13]. Therefore, it is essential for the surgeon to understand the complaints of the
patient and review the proportions and relationships between the nose and the face
through physical exam. The support of standardized photographic documentation is basic
for the postoperative planning, taking into account the anatomic factors of each patient[15].
An important aspect that was not evaluated in this study is the psychological impact
the aesthetic surgery may offer to the patient. The psychological disorders are not
an absolute contraindication for the performance of the aesthetic procedure, especially
when suitable psychological support is offered to the patient[16].
Recently, several works and review have been carried out to elect an instrument able
to measure and review the postoperative satisfaction from a patient's viewpoint[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]. In this study we used a questionnaire prepared and validated by Alssarraf et al that is an easily applicable instrument, useful for assessing different types
of patients and surgical techniques[6]
[8]
[11].
In this study we noticed that all 28 patients obtained a recovery from the reduction
surgical procedure ([Figure 1]) with the postoperative mark higher than that of the preoperative. The marks difference
average between the postoperative and preoperative approaches was of 48,3 (76.3 in
the postoperative approach and 28 in the preoperative approach), higher than the result
presented by Alssarraf et al of 44.5 (83.3 in the postoperative and 38.8 in the preoperative approach)
Figure 1. Satisfaction marks averages in the preoperative (Pre) and postoperative (Post) approaches
of the patients submitted to reduction rhinoplasty.
Upon analysis of the reasons by which both patients maintained postoperative satisfaction
<50 (failure), we noticed that both the aesthetics and the function remained as important
complaints after the surgical procedure ([Table 2]).
The youngest patients have a higher expectation as regards to the final aesthetic
result, probably due to the stronger social pressure (acceptance in the affective
relationship groups), with difficulty to assimilate self-image changes[9]. In this study, we noticed a statistically significant difference (p = 0.015) between
the averages of the satisfaction marks difference between the postoperative and preoperative
approach for age groups <30 years and ≥30 years ([Table 3]).
The final result of the rhinoplasty may be noticed from 12 months of follow up. In
this study we noticed the patients who had a longer postoperative follow up (≥60 months)
had a mark difference average between the postoperative and preoperative approach
similar to the patients operated in the last 60 months ([Table 4]).
Conclusion
The Rhinoplasty Outcomes Evaluation is a helpful tool to show the satisfaction of
the patients submitted to reduction rhinoplasty. About 92% of the patients submitted
to reduction rhinoplasty consider the postoperative result to be good or excellent.
