lable at ScienceDirect

Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e9

Contents lists avai

Journal of Cranio-Maxillo-Facial Surgery

journal homepage: www.jcmfs.com

Perceptions and satisfaction of aesthetic outcome following secondarycleft rhinoplasty: Evaluation by patients versus health professionals

Miriam Byrne, Jeffrey C.Y. Chan*, Eoin O’BroinDepartment of Plastic and Reconstructive Surgery, Cork University Hospital, Wilton, Cork, Ireland

a r t i c l e i n f o

Article history:Paper received 17 September 2013Accepted 6 January 2014

Keywords:AestheticPerceptionCleft-lip nasal deformityRhinoplastySatisfaction

* Corresponding author. Department of Plastic, RecoCork University Hospital, Wilton, Cork, Ireland. Tel.: þ

E-mail address: eoin.obroin@hse.ie (E. O’Broin).

1010-5182/$ e see front matter � 2014 European Asshttp://dx.doi.org/10.1016/j.jcms.2014.01.031

Please cite this article in press as: Byrne MEvaluation by patients versus health professi

a b s t r a c t

Objective: To explore how improvement in facial appearance is related to patients’ perception andsatisfaction following cleft rhinoplasty.Design: A cross-sectional survey.Participants: 35 cleft rhinoplasty patients treated between 2005 and 2010. 45 observers comprised ofhealthcare 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 Asher-McDade Aesthetic Index (AMAI) Rating and PPSOSR.Results: Patient satisfaction was high, based on the ROE questionnaire (score 76.1). 91% of patients ratedtheir appearance as improved, 3% remained ‘uncertain’ and 6% felt ‘different but not improved.’ Teenagefemales (score 94.1) showed statistically higher satisfaction, when compared to older females (score75.5), or their male counterparts (score 69.8). The preoperative appearance ratings were not statisticallydifferent between patients and panel members but postoperatively, patients’ rating of their appearancewas statistically higher.

All components of the AMAI were scored between ‘good’ to ‘fair’ (score 9.3). Seventy percent of thepanel rated the postoperative appearance as improved. Interestingly, 10% rated the postoperativeappearance as ‘unchanged’, while 3% reported a ‘worsened’ appearance. There was no correlation be-tween panel assessment of aesthetic outcome and patient satisfaction.Conclusions: Cleft rhinoplasty contributes to subjective patient satisfaction as a result of their perceivedimprovement in appearance and function, even though this was not correlated to objective aestheticrating by panel members.

� 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rightsreserved.

1. Introduction

The majority of published literature concentrates on improvingcleft rhinoplasty techniques but there is a lack of research that focuson the impact of surgery on patients’ perception and satisfactionwith their outcome. Body image attitudes are formulated by one’sthoughts, feelings and behaviour related to their physical appear-ance (Clifford, 1978). Living in a culture that is driven by image andexternal beauty, where major emphasis is typically placed onphysical appearance, cleft deformity exacts additional psychologi-cal and social stressors on these patients (Sousa et al., 2009).

nstructive and Hand Surgery,353 21 4922000.

ociation for Cranio-Maxillo-Facial

, et al., Perceptions and satisonals, Journal of Cranio-Maxi

A patient’s self-image may be adversely affected by a negativeresponse from outsiders, whether it is actual or perceived (Charon,1979; Goffman, 1968; Turner et al., 1997). An interesting studyshowed that despite the three-dimensional facial analysis showingno significant difference in facial asymmetry when compared toorthognathic patients, those with unilateral cleft lip were ratedsignificantly less attractive (Meyer-Marcotty et al., 2011). Further-more, a recent study demonstrated that patients, parents andhealth professionals were more satisfied with the patients’ facialaesthetic appearance than the general public, and suggested thatthe perceptions of the general public may negatively impact on thepatients’ everyday social and professional activities (Gkantidiset al., 2013).

The primary aim of cleft rhinoplasty is to improve facialappearance with the central goal of influencing patient perceptionso that this positively impacts on their satisfaction. In a study of

Surgery. Published by Elsevier Ltd. All rights reserved.

faction of aesthetic outcome following secondary cleft rhinoplasty:llo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.031

Table 1Assessment tools used for evaluating patient satisfaction and for rating aestheticoutcome.

Assessment of patient satisfaction Reference

a Rhinoplasty Outcome Evaluation Questionnaire Alsarraf et al., 2001b Preoperative and Postoperative Semi-quantitative

Ordinal Scale RatingsPitak-Arnnopet al., 2011

c Semi-structured Questionnaire Byrne et al., 2014(this study)

Aesthetic outcome assessment by panel of observers

a Asher-McDade Aesthetic Index Rating Asher-McDadeet al., 1991, 1992

b Preoperative and Postoperative Semi-quantitativeOrdinal Scale Ratings

Pitak-Arnnopet al., 2011

M. Byrne et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e92

adults with facial disfigurement, it was found that the patient’ssocial functioning can be predicted by the patient’s subjectivesatisfaction of their facial appearance (van den Elzen et al., 2012).Previous studies have shown that from both a physical and psy-chological perspective, successful surgical procedures can directlyinfluence patient satisfaction with their appearance, and in turn, afavourable outcome on self confidence and esteem (Lefebvre andMunro, 1978) (Rachmiel et al., 1999). This is particularly pertinentto the population of patients seeking cleft rhinoplasty. The overallobjective of this study was to explore how improvement in facialappearance is related to patient satisfaction following cleftrhinoplasty.

1.1. Aims and hypotheses

The primary aim of this study was to assess patient satisfactionfollowing secondary cleft rhinoplasty at our unit. It was hypoth-esised that patients’ subjective satisfactionwould be high followingcleft rhinoplasty aimed at improving their appearance.

Additionally, we aimed to evaluate the aesthetic outcome of thecleft rhinoplasty performed. In order to evaluate this as objectivelyas possible, a panel of independent observers consisting of varioushealthcare professionals was assembled. Previously validatedassessment tools were used. It was hypothesised that objectiveimprovement in nasal appearance was achieved following cleftrhinoplasty.

Our final aim was to examine whether there was an associationbetween a patients’ satisfaction level (subjective outcome) and anobservers assessment of aesthetic improvement (objectiveoutcome). We hypothesised that patient satisfaction is positivelycorrelated to observer-rated aesthetic outcome, and therefore if theaesthetic outcome was better, patient satisfaction levels would becorrespondingly higher.

2. Material and methods

2.1. Design

This was a cross-sectional study where patients were requiredto complete two sets of assessment tools and a semi-structuredquestionnaire. The assessment tools used were the RhinoplastyOutcome Evaluation (ROE) questionnaire and the pre- and post-operative Semi-quantitative Ordinal Scale Ratings of their nasalappearance. A specifically designed semi-structured questionnairewas used to elicit patients’ beliefs and issues regarding their nasalappearance.

In order to evaluate the postoperative outcome objectively, apanel of observers from various healthcare professional back-grounds was assembled to independently critique and evaluate thepreoperative and postoperative outcomes. This was composed ofPlastic and Reconstructive (3), Ear, Nose and Throat/Maxillofacialsurgeons (3), and Anaesthetic (5) consultants, specifically dealingwith cleft surgery. Senior specialist surgical trainees (Plastics/ENT)(10), senior speech therapists/cleft nurse specialists (4), seniordental trainees (4) and consultant and trainee specialist physicians(10), paediatric ICU and ward nursing staff (6). Two forms ofassessment tools were used: The Asher-McDade Aesthetic IndexRating and the pre- and post-operative Semi-quantitative OrdinalScale Rating.

2.2. Patients

All patients who had undergone cleft rhinoplasty procedures atour unit between 2005 and 2010 were reviewed. Inclusion criteriaconsisted of patients requiring secondary rhinoplasty, having had a

Please cite this article in press as: Byrne M, et al., Perceptions and satisEvaluation by patients versus health professionals, Journal of Cranio-Maxi

previous complete unilateral or bilateral cleft lip repair. All pro-cedures were performed by a single cleft surgeon.

Patient medical case notes were reviewed retrospectively anddemographics and preoperative anatomical cleft deformitiesrecorded, in addition to rhinoplasty techniques employed for eachsurgery. A 20-min telephone interview was conducted with eachpatient to complete the assessment tools described (Table 1). Allinterviews were conducted by the primary author who hadrecently joined the cleft service and had not met or been involvedwith any of the patients’ procedures which had been carried out atleast two years prior to the study.

2.3. Assessment of patient satisfaction

2.3.1. Rhinoplasty Outcome Evaluation QuestionnaireThe Rhinoplasty Outcomes Evaluation questionnaire was

developed to assess patients’ preoperative and postoperative nasalstate (Alsarraf et al., 2001). This consists of 6 questions relating topatients’ opinion on nasal form and function. Each parameter isscored on a scale from 0 to 4, with 0 and 4 reflecting the worst andbest scores, respectively. The total score is divided by 24 andmultiplied 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 OrdinalScale Ratings

This assessment tool consists of a 3-point preoperative and 5-point postoperative rating of patient pre/post operative outcomes.It does not produce an overall score but allowed both patients andobservers to provide a semi-quantitative response (Pitak-Arnnopet al., 2011). Patients/observers were asked to comment on theirpreoperative appearance (3-point scale: ‘liked’, ‘disliked’ or ‘un-certain’). They were also asked to rate their postoperative appear-ance as e (5-point scale: ‘improved’, ‘worsened’, ‘different but notimproved’, ‘unchanged’ or ‘uncertain’).

2.3.3. Semi-structured questionnaireThese questions were designed specifically for this study to

evaluate patient perception on qualitative issues not obtained bythe two standardised assessment tools described above. The semi-structured nature allowed patients to respond in an open-endedmanner while staying within a set framework of questions. Itcontains the following questions:

i. Would you undergo the surgery again, knowing the finalresult?

ii. Which part of nose bothered you most preoperatively?iii. Which part has been most improved by surgery?

faction of aesthetic outcome following secondary cleft rhinoplasty:llo-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 3

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/

dislikevii. 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 photographsPanel satisfaction of patient aesthetic outcomes was assessed

using professional standardised pre- and post-operative medicalphotographs (frontal, lateral, and Worm’s eye views). Briefly, blacklastolite 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 fittedwith a Canon 100 mm macro lens and a master flash (Canon580EX). The aperture was set at f11 with manual focussing, andshutter at 1/8 s for full face and 1/4 s for cup face views.

2.4.2. Asher-McDade Aesthetic Index RatingThe aesthetic outcome was evaluated by 25 panel members

using the Asher-McDade Aesthetic Index Rating (Asher-McDadeet al., 1992, 1991). This assessment tool addresses four nasolabialcomponents (nasal form, nose symmetry, vermillion border, andnasal profile) which were rated separately on 5-point scales (Score1 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 OrdinalScale Ratings

The second outcome tool, the 3-point preoperative and 5-pointpostoperative Semi-quantitative Ordinal Scale Ratings (also usedfor patients satisfaction outcomes as described above) wascompleted by 45 of the panel members (Pitak-Arnnop et al., 2011).

2.5. Cleft rhinoplasty technique

Cleft nasal deformities involve complex three-dimensionaldistortion of all structures. A variety of techniques exist, includingthe less invasive hitching procedures such as the Tajima proceduresto complex open rhinoplasty using multiple grafts. Each case wasassessed on an individual basis, taking into account a multiplicity offactors (Kernahan et al., 1980; Tajima and Maruyama, 1977). How-ever, as tissues are generally distorted and scarred from priorprocedures, the senior author felt it would be difficult to achievethe desired results without direct manipulation of the structures. Inview of this, the open technique was preferred as described byBardach (Bardach et al., 1987) for unilateral clefts or by Millard forbilateral clefts (Millard, 1967).

This typically begins with lifting of the alar base with graft, andapplication of a trans-alar base suture to pull the cleft side in, thusapproximating the ala together. A sub mucosal septal resectionwasthen performed allowing harvest of a posterior septal graft. Thiswas used to straighten and strengthen the anterior septum whilstsimilarly augmenting the dorsal and caudal septum. Autologousgraft from the nasal septumwas used for the majority of cases but,where septal cartilage was insufficient, costal cartilage grafts wereharvested.

Deviation at the level of the nasal bones was straightened withthe low-low-high lateral external osteotomy in-fracture techniqueas first described by Webster et al. (Webster et al., 1977). Lateralosteotomies permitted narrowing of the nose, thus closing the

Please cite this article in press as: Byrne M, et al., Perceptions and satisEvaluation by patients versus health professionals, Journal of Cranio-Maxi

open roof deformity created after hump removal, which resulted inimproved symmetry. Tip surgery involved multiple grafts,including shield grafts to the tip, strut grafts to the ala and a dermalsheet graft if necessary to cover and soften the entire construct.

2.6. Statistical analysis

Data results collected on all parameters were compiled andentered into Microsoft Excel spreadsheets. Statistical analysis wasperformed using GraphPad InStat (Version 3) for Macintosh. Sta-tistical correlation was evaluated using the Spearman’s correlationtest. Comparison between groups was analysed using Fisher’sExact, Chi-Squared and KruskaleWallis tests for non-parametricdata and unpaired t-test for parametric data. The level of statisti-cal significance was set at p value of <0.05. Data is expressed asmean � standard deviation, unless otherwise stated.

3. Results

The study cohort comprised 35 patients, (19 female, 16 male)with a mean age of 27.6 � 11.7 years (14e53 years). All patients hadundergone a prior cleft related procedure e 14 for unilateral cleftlip, (40%), 12 for bilateral cleft lip (34%) and 9 for unilateral cleft lipand palate (26%). Patients assessed had had their cleft rhinoplastyperformed on average 2.6 years (mean) prior to this study (range 16month-5 years).

Thirty-five telephone interviews were conducted. Twenty-fivepanel members were recruited to complete the Asher-McDadeAesthetic Index. Additionally, a total of 45 panel memberscompleted the 3-point and 5-point semi-quantitative ordinal scalerating of pre and post surgery medical photographs.

3.1. Assessment of patient satisfaction

Patient satisfaction was deemed high, based on the RhinoplastyOutcomes Evaluation (ROE) questionnaire mean score of 76.1. Therewas a statistically significantly higher satisfaction rates amongstteenage females (mean score 94.1), when compared to older fe-males (mean score 75.5 for female >20 years, p < 0.05). Similarly,teenage females showed a statistically significant higher satisfac-tion when compared to their male counterparts (p < 0.01, meanscore 69.8 for male < 20 years) (Fig. 1). A similar pattern was notobserved for teenage males.

As expected, all patients disliked their preoperative appearancebased on the Semi-quantitative Ordinal Scale Rating (Fig. 2). Post-operatively, 91% of patients rated their appearance as improved.Three percent of patients remained ‘uncertain’ and 6% felt ‘differentbut not improved’. No patient rated their appearance as worsenedpostoperatively. When asked which part of their nose that theywere most concerned/bothered by prior to surgery, 76% of patientsdescribed the nasal tip/columella area, and the remaining 24%, thenostril and ala combined. Twenty-seven patients (33%) describedthemselves 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 mostsignificantly improved from a cosmetic perspective. Of the totalcohort, 11% found alterations to the columella impacting mostpositively on their appearance, while 17% found improvement tothe ala the most striking constructive change.

We found that the preoperative ratings of appearance were notstatistically different between patients and panel members. Post-operatively there was a statistically higher patient-reported post-operative appearance rating when compared to their preoperativerating (p < 0.01). Similarly, when compared to panel members,

faction of aesthetic outcome following secondary cleft rhinoplasty:llo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.031

76.181

71

79.274.2

94.2

69.7

0

10

20

30

40

50

60

70

80

90

100

All Patients Female Male All <20 yrs All >20 yrs Female <20 yrs Male <20 yrs

Rhi

nopl

asty

Out

com

e Ev

alua

tion

Scor

e

N.S. N.S.

*

Fig. 1. Patient satisfaction level according to age and gender as evaluated by the Rhinoplasty Outcome Evaluation score. A statistically higher satisfaction score amongst teenagefemales (<20 years) was observed when compared to teenage males (p < 0.01).

Fig. 2. The results of the 3-point and 5-point Semi-quantitative Ordinal Scale Rating. Preoperatively, there was no statistically significant different between patients and panelmembers ratings. Postoperatively, the patients’ rating of their appearance was statistically significantly higher when compared to their preoperative rating (p < 0.01) and panelmembers rating (p < 0.05). No patient rated their appearance as worsened postoperatively.

M. Byrne et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e94

there was a statistically higher postoperative appearance (p< 0.05)rate amongst patients.

Concerning patient profile, we found that 70% preferred theirfront profile postoperatively compared with the 30% who favouredtheir side view. There was no statistical difference in ROE scorebetween patients who prefered their front profile (mean score 76.9)versus those who preferred their side profile (mean score 73.5).Patterns in breathing and snoring remained unresolved in ten pa-tients who experienced residual problems following cleft rhino-plasty. Three patients described a worsening, but the majorityreported a favourable outcome subsequent to surgery. When weanalysed satisfaction based on breathing outcomes, there was nocorrelation between those that experienced residual problems andthose that were asymptomatic from this perspective.

All but one patient said they would undergo their cleft rhino-plasty surgery again, knowing the final result. In relation toresultant postoperative scars, 11 patients responded negativelyand still disliked their scar, whereas the remainder of patientswere not bothered by it or found it had improved to some degree.On a simple scale of 1e10, 80% of patients reported a score of 8 or

Please cite this article in press as: Byrne M, et al., Perceptions and satisEvaluation by patients versus health professionals, Journal of Cranio-Maxi

above when asked to rank the improvement attained throughsurgery.

Finally, and encouragingly, when asked whose nose they wouldmost desire, all patients had to think hard about this question,stating they never really thought about it. Sixteen were very happywith their own nose, and felt it no longer impacted on their lives asit had done before surgery. However, amongst the most popularchoices for the ideal nose, Elizabeth Taylor and Kate Middletonranked highest for female patients and Brad Pitt and Barack Obamafor males.

3.2. Assessment by panel of observers

All components of the Asher-McDade Aesthetic Index werescored between ‘good’ to ‘fair’ (Total average score 9.3). The indi-vidual component mean scores are shown in Fig. 3. There was nostatistically significant difference between the individual compo-nents scores.

86% of panel of observers disliked the patients’ preoperativeappearance. Interestingly, 7%ofpanel liked thepatient’spreoperative

faction of aesthetic outcome following secondary cleft rhinoplasty:llo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.031

Fig. 3. Asher-McDade aesthetic index which addresses four nasolabial components(nasal form, nose symmetry, vermillion border, and nasal profile). Each is ratedseparately 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 ‘verypoor’ appearance). There was no statistical significant difference between the indi-vidual components scores.

M. Byrne et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e9 5

appearance while 6% were uncertain. Seventy percent of the panelrated the postoperative appearance as improved. Interestingly, 10%rated the postoperative appearance as ‘unchanged’, while 3% re-ported a ‘worsened’ appearance.

3.3. Association between patient and observers assessments

The patients’ Rhinoplasty Outcome Evaluation scores werecompared to the observers Asher-McDade Aesthetic Index to assessa possible relationship between patient and panel satisfactionlevels. Interestingly, we found that there was no correlation be-tween the two scores (Spearman’s rho ¼ 0.054, p value > 0.05),indicating that panel satisfaction did not necessarily correlate topatient satisfaction (Fig. 4). Representative samples of preoperativeand postoperative photographs with their corresponding satisfac-tion scores are shown in Figs. 5e8.

4. Discussion

Although aesthetic and functional outcomes following cleftrhinoplasty have been reported previously (Anastassov andChipkov, 2003; Gurley et al., 2001; Kane et al., 2000; Salyer, 1986;

Fig. 4. Patients Rhinoplasty Outcome Evaluation Scores were compared with ob-servers ratings based on the Asher-McDade Aesthetic Index. There was no statisticalsignificance correlation noted, based on the Spearman’s correlation test (Spearman’srho ¼ 0.054, p value > 0.05), indicating that panel satisfaction did not necessarilycorrelate to patient satisfaction.

Please cite this article in press as: Byrne M, et al., Perceptions and satisEvaluation by patients versus health professionals, Journal of Cranio-Maxi

Sandor and Ylikontiola, 2006), research to determine patientsatisfaction is limited to date. In this study, we aimed to evaluatewhether cleft rhinoplasty was associated with patient satisfactionfrom an aesthetic and functional perspective. As there is no patientoutcome instrument specific to cleft rhinoplasty currently avail-able, the Rhinoplasty Outcome Evaluation questionnaire (Alsarrafet al., 2001) (commonly used for cosmetic and post-traumaticrhinoplasty), the Semi-quantitative Ordinal Scale Rating and asemi-structured questionnaire were used. In addition we aimed todetermine whether a positive aesthetic outcome would influencepatient-reported satisfaction level. Here, aesthetic outcome wasmeasured objectively by a panel of observers using the Asher-McDade Aesthetic Index and the Semi-quantitative Ordinal ScaleRating. The Asher-McDade Aesthetic Index was specificallydesigned for patients with clefts of the lip and palate, and thus itwas used in this study to assess postoperative outcomes. The Semi-quantitative Ordinal Scale Rating was used as it can be adminis-tered to both patients and panel members, and can be administeredto evaluate both preoperative and postoperative outcomes, there-fore allowing comparisons.

We found that satisfaction levels in our patient cohort were veryhigh. The mean ROE score from our patient cohort was 76.1. Thiswas similar or higher to other previously reported studies. In aBelgian study of thirty patients who underwent secondary cleftrhinoplasty, their reported postoperative ROE score was 73.1 (Henset al., 2011). Meningaud et al. assessed satisfaction of 58 patients inFrance with either post-traumatic or aesthetic rhinoplasties, andshowed that their postoperative ROE score was 69.7 (Meningaudet al., 2008). In a cohort of 26 rhinoplasty patients in Boston,AlSarraf et al. reported postoperative ROE score of 83.3 (Alsarrafet al., 2001). Taking into account possible population differencesbetween these studies, our findings suggest that satisfaction levelsof our cohort were equivalent or higher than those who had un-dergone cosmetic/post-traumatic rhinoplasty.

Our observers rating of postoperative aesthetic outcome was inthe ‘good appearance’ category based on the Asher-McDadeAesthetic Index. We found no correlation between the ROE scoreand the Asher-McDade Aesthetic Index. This indicates that the highlevel of patient-reported satisfaction was not linked to betterobserver-rated aesthetic outcome. This finding, while not intuitivehas consistently been reported in aesthetic surgery and tworecently published studies reported similar patterns after cleftrhinoplasty (Hens et al., 2011; Pitak-Arnnop et al., 2011). A similartrend was replicated in nasal reconstruction surgery. This studyfound that panel satisfaction was lower than patient satisfaction,and that satisfaction level between patient and panel can differcompletely in nasal reconstruction (Moolenburgh et al., 2008).Interestingly, in a study of the general population, self-assessmentof a person’s attractiveness was significantly more positive thanindependent judgements by others, concluding that nothing morethan the beauty of the beholder is in the eyes of the latter (Springeret al., 2012a,b).

We did not identify any specific factor for the lack of correlationbetween patient-reported satisfaction and panel member-ratedaesthetic outcome. Patient-reported satisfaction were generallyhigh postoperatively. Although the panel member-rated outcomeswere high, they were not to the same degree as the patients’.However, it was not within the scope of this study to explore why aminority of panel members reported low scores. There are possibleexplanations hypothesised for this observation. Firstly, patientswere asked to assess their own nose (three-dimensional form andfunction) while the observers were requested to rate complexthree-dimensional deformities based on two-dimensional photo-graphs without information on nasal function or social well-being.Secondly, patient satisfaction was determined using the ROE

faction of aesthetic outcome following secondary cleft rhinoplasty:llo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.031

Fig. 5. Photographs showing preoperative photographs (above) and postoperative photographs (below). Rhinoplasty Outcome Evaluation score ¼ 100. Asher-McDade AestheticIndex total average score ¼ 11.3.

Fig. 6. Photographs showing preoperative photographs (above) and postoperative photographs (below). Rhinoplasty Outcome Evaluation score ¼ 65. Asher-McDade AestheticIndex total average score ¼ 7.6.

M. Byrne et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e96

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

Fig. 7. Photographs showing preoperative photographs (above) and postoperative photographs (below). Rhinoplasty Outcome Evaluation score¼ 75. Asher-McDade Aesthetic Indextotal average score ¼ 9.0.

Fig. 8. Photographs showing preoperative photographs (above) and postoperative photographs (below). Rhinoplasty Outcome Evaluation score ¼ 79. Asher-McDade AestheticIndex total average score ¼ 10.5.

M. Byrne et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e9 7

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) 1e98

questionnaire, an assessment tool that subjectively scores patientoverall satisfaction based on nasal aesthetic, functional and socialfeatures. In contrast, the Asher-McDade Aesthetic Index assessedobservers’ feedback objectively on a set of aesthetic criteria alone.Hence, the Rhinoplasty Outcome Evaluation is subjective, holisticand evaluates overall satisfaction of patients, while the Asher-McDade Aesthetic Index focussed objectively on aesthetic outcome.The same instrument, the Ordinal Scale Rating was used in thisstudy for both patients and panel, but the data captured waslimited because of its broad nature and was limited to single pre-operative and postoperative responses.

A patient’s aesthetic evaluation may be biased by a specificpreoperative deformity that they wished to improve; but anobserver would evaluate their aesthetic outcome based on theoverall/every specific component of the nose. It is possible that apatient’s lifetime experience with their cleft nasal deformityinfluenced his/her expectation towards the results of cleft rhino-plasty. The panel of observers on the other hand, would be morecritical of the aesthetic outcome as theymight perceive that furtherimprovement could be achieved with revision surgery. The pa-tients’ positive aesthetic evaluation of themselvesmay be related totheir well-being. In their study, Springer et al. demonstrated thatone’s well-being can have a significant effect on one’s facial self-perception; those with impaired well-being have impairedperception of their own attractiveness despite the fact that theirattractiveness as assessed by others did not deviate from theaverage (Springer et al., 2012a,b).

Given the ever increasing pressure to conform towhat is sociallyexpected as ‘attractive’ and ‘perfect’, one must question do theseassessment tools actually assess their authentic satisfaction levelsor is it really just reflecting what this cohort of patients are willingto accept? This begs the question, are our current tools for assessingsatisfaction all encompassing, and not just merely reflecting purelysurgical objectives? Moreover, do they adequately incorporate thetrue opinions and ideas of the patient? Due to the anticipatedlimitations of the assessment tools discussed above, we attemptedto determine patients’ perception on qualitative issues not specif-ically obtained by these instruments. A set of semi-structuredopen-ended questions were designed to assess their day to dayemotional and psychological well-being married with their viewson their clinical outcomes following surgery.

At present, there is no specific outcome instrument to measuresatisfaction following cleft rhinoplasty. Recently, a comprehensiveoutcome instrument for evaluationofnasal reconstructions, theNasalAppearance and Function Evaluation Questionnaire, (NAFEQ) wasdeveloped (Moolenburgh et al., 2009). It consists of fourteen ques-tions enquiring nasal function and appearance, rated using a 5-pointLikert scale. A similar questionnaire that evaluates appearance andfunctional concerns specific to cleft rhinoplasty patients could be theway forward. Another recent studyevaluatedpre- andpost-operativefunction using the Nasal Obstructive Symptoms Evaluation scale(NOSE) and reported that nasal symptoms improved following cleftrhinoplasty in a small clinical series (Chaithanyaa et al., 2011). If adetailed evaluation of outcomes and satisfaction is desired, a moredescriptive and qualitative assessment based on detailed semi-structured interview may be best at representing patient percep-tion and level of satisfaction as crucial descriptive information isfrequently not captured using standardised questionnaire.

Research has shown that self-perception plays a pivotal role ininfluencing an individual’s self esteem and psychological adjust-ment affected by cleft lip and palate anomaly (Noar, 1991; Strausset al., 1988). The enormity of influence the media have on thepublic is ever apparent with regards to appearance and ideals. Itwould appear that the media exert similar impact on our patientcohort. We found it therefore not completely unexpected, given

Please cite this article in press as: Byrne M, et al., Perceptions and satisEvaluation by patients versus health professionals, Journal of Cranio-Maxi

this study was conducted around the time of Kate Middleton’smarriage to Prince William, and Elizabeth Taylor’s death, that bothfigures, were foremost on their list of most desired nose profiles.

5. Conclusion

Our findings confirm that satisfaction levels in cleft rhinoplastypatients are generally high following corrective surgery. Addition-ally, we found a high level of aesthetic improvement shared by ourpanel of observers, albeit their satisfaction level may not be to thesame degree. We also observed that satisfaction between patientsand observers did not correlate. This study suggests that althoughobjective improvement may not be apparent to the observer, sec-ondary cleft rhinoplasty contributes to patient satisfaction as aresult of their perceived improvement in appearance and function.

Finally, as surgeons we must remain ever vigilant to the factthat, overcoming the challenges and technicalities that cleft rhi-noplasty surgery poses, and attaining satisfactory surgical out-comes, must be rewarded with at least comparable, if not greaterlevels of patient satisfaction from an aesthetic and psychologicalperspective.

Ethical approval

Clinical Research Ethics Committee (CREC) approval was gran-ted for this study.

FundingNone.

Conflict of interestNone.

References

Alsarraf R, Larrabee Jr WF, Anderson S, Murakami CS, Johnson Jr CM: Measuringcosmetic facial plastic surgery outcomes: a pilot study. Arch Facial Plast Surg 3:198e201, 2001

Anastassov Y, Chipkov C: Analysis of nasal and labial deformities in cleft lip, alve-olus and palate patients by a new rating scale: preliminary report.J Craniomaxillofac Surg 31: 299e303, 2003

Asher-McDade C, Brattstrom V, Dahl E, McWilliam J, Molsted K, Plint DA, et al:A six-center international study of treatment outcome in patients with clefts ofthe lip and palate: Part 4. Assessment of nasolabial appearance. Cleft PalateCraniofac J 29: 409e412, 1992

Asher-McDade C, Roberts C, Shaw WC, Gallager C: Development of a method forrating nasolabial appearance in patients with clefts of the lip and palate. CleftPalate Craniofac J 28: 385e390, 1991 Discussion 390-1

Bardach J, Salyer K, Jackson I: Correction of nasal deformity associated with uni-lateral cleft lip. In: Bardach J, Salyer K (eds), Surgical techniques in cleft lip andpalate. Chicago: Year Book Medical Publishers, 1987

Chaithanyaa N, Rai KK, Shivakumar HR, Upasi A: Evaluation of the outcome ofsecondary rhinoplasty in cleft lip and palate patients. J Plast Reconstr AesthetSurg 64: 27e33, 2011

Charon JM: Symbolic interactionism: an introduction, an interpretation, an inte-gration. Englewood Cliffs, New Jersey: Prentice Hall, 1979

Clifford E: The cleft palate experience: new perspectives on management. Illinois:Springfield, 1978

Gkantidis N, Papamanou DA, Christou P, Topouzelis N: Aesthetic outcome of cleft lipand palate treatment. Perceptions of patients, families, and health professionalscompared to the general public. J Craniomaxillofac Surg 41: 105e110, 2013

Goffman E: Stigma: notes on the management of spoiled identity. Englewood Cliffs,New Jersey: Prentice-Hall, 1968

Gurley JM, Pilgram T, Perlyn CA, Marsh JL: Long-term outcome of autogenous ribgraft nasal reconstruction. Plast Reconstr Surg 108: 1895e1905, 2001 Discus-sion 1906-7

Hens G, Picavet VA, Poorten VV, Schoenaers J, Jorissen M, Hellings PW: High patientsatisfaction after secondary rhinoplasty in cleft lip patients. Int Forum AllergyRhinol: 167e172, 2011

Kane AA, Pilgram TK, Moshiri M, Marsh JL: Long-term outcome of cleft lip nasalreconstruction in childhood. Plast Reconstr Surg 105: 1600e1608, 2000

Kernahan DA, Bauer BS, Harris GD: Experience with the tajima procedure in pri-mary and secondary repair in unilateral cleft lip nasal deformity. Plast ReconstrSurg 66: 46e53, 1980

faction of aesthetic outcome following secondary cleft rhinoplasty:llo-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 9

Lefebvre A, Munro I: The role of psychiatry in a craniofacial team. Plast ReconstrSurg 61: 564e569, 1978

Meningaud JP, Lantieri L, Bertrand JC: Rhinoplasty: an outcome research. PlastReconstr Surg 121: 251e257, 2008

Meyer-Marcotty P, Kochel J, Boehm H, Linz C, Klammert U, Stellzig-Eisenhauer A:Face perception in patients with unilateral cleft lip and palate and patients withsevere Class III malocclusion compared to controls. J Craniomaxillofac Surg 39:158e163, 2011

Millard DR: Bilateral cleft lip and a primary forked flap: a preliminary report. PlastReconstr Surg 39: 59e65, 1967

Moolenburgh SE, Mureau MA, Duivenvoorden HJ, Hofer SO: Validation of a ques-tionnaire assessing patient’s aesthetic and functional outcome after nasalreconstruction: the patient nafeq-score. J Plast Reconstr Aesthet Surg 62: 656e662, 2009

Moolenburgh SE, Mureau MA, Hofer SO: Aesthetic outcome after nasal recon-struction: patient versus panel perception. J Plast Reconstr Aesthet Surg 61:1459e1464, 2008

Noar JH: Questionnaire survey of attitudes and concerns of patients with cleft lipand palate and their parents. Cleft Palate Craniofac J 28: 279e284, 1991

Pitak-Arnnop P, Hemprich A, Dhanuthai K, Yildirim V, Pausch NC: Panel and patientperceptions of nasal aesthetics after secondary cleft rhinoplasty with versuswithout columellar grafting. J Craniomaxillofac Surg 39: 319e325, 2011

Rachmiel A, Aizenbud D, Ardekian L, Peled M, Laufer D: Surgically-assisted ortho-pedic protraction of the maxilla in cleft lip and palate patients. Int J OralMaxillofac Surg 28: 9e14, 1999

Please cite this article in press as: Byrne M, et al., Perceptions and satisEvaluation by patients versus health professionals, Journal of Cranio-Maxi

Salyer KE: Primary correction of the unilateral cleft lip nose: a 15-year experience.Plast Reconstr Surg 77: 558e568, 1986

Sandor GK, Ylikontiola LP: Patient evaluation of outcomes of external rhinoplastyfor unilateral cleft lip and palate. Int J Oral Maxillofac Surg 35: 407e411, 2006

Sousa AD, Devare S, Ghanshani J: Psychological issues in cleft lip and cleft palate.J Indian Assoc Pediatr Surg 14: 55e58, 2009

Springer IN, Schulze M, Wiltfang J, Niederberger U, Russo PA, Moller B, et al: Facialself-perception, well-being, and aesthetic surgery. Ann Plast Surg 69: 503e509,2012a

Springer IN, Wiltfang J, Kowalski JT, Russo PAJ, Schulze M, Becker S, et al: Mirror,mirror on the wall.: self-perception of facial beauty versus judgement byothers. J Craniomaxillofac Surg 40: 773e776, 2012b

Strauss RP, Broder H, Helms RW: Perceptions of appearance and speech byadolescent patients with cleft lip and palate and by their parents. Cleft Palate J25: 335e342, 1988

Tajima S, Maruyama M: Reverse-u incision for secondary repair of cleft lip nose.Plast Reconstr Surg 60: 256e261, 1977

Turner SR, Thomas PW, Dowell T, Rumsey N, Sandy JR: Psychological outcomesamongst cleft patients and their families. Br J Plast Surg 50: 1e9, 1997

van den Elzen MEP, Versnel SL, Hovius SER, Passchier J, Duivenvoorden HJ,Mathijssen IMJ: Adults with congenital or acquired facial disfigurement: impactof appearance on social functioning. J Craniomaxillofac Surg 40: 777e782, 2012

Webster RC, Davidson TM, Smith RC: Curved lateral osteotomy for airway protec-tion in rhinoplasty. Arch Otolaryngol 103: 454e458, 1977

faction of aesthetic outcome following secondary cleft rhinoplasty:llo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.01.031