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Nellis JC, Ishii M, Bater KL, et al. Association of Rhinoplasty With Perceived Attractiveness, Success, and Overall Health. JAMA Facial Plast Surg. 2018;20(2):97–102. doi:10.1001/jamafacial.2017.1453
What is the effect of rhinoplasty on social perceptions of attractiveness, health, and success?
In this survey study of 473 blinded, naive observers rating independent patient images of 13 unique patient faces before and after rinoplasty, rhinoplasty was associated with patients appearing more attractive, healthier, and more successful.
These findings highlight the positive perceptions of rhinoplasty.
To date, the impact of rhinoplasty surgery on social perceptions has not been quantified.
To measure the association of rhinoplasty with observer-graded perceived attractiveness, success, and overall health.
Design, Setting, and Participants
In a web-based survey, blinded casual observers viewed independent images of 13 unique patient faces before or after rhinoplasty. Delphi method was used to select standardized patient images, confirming appropriate patient candidacy and overall surgical effect. Observers rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, where higher scores corresponded to more positive responses. A multivariate mixed-effects regression model was used to determine the effect of rhinoplasty while accounting for observer biases. To further characterize the effect of rhinoplasty, estimated ordinal rank change was calculated for each domain.
Main Outcomes and Measures
The primary objective was to measure the effect of rhinoplasty on observer-graded perceived attractiveness, success, and overall health.
A total of 473 observers (mean age, 29 years [range, 18-73 years]; 305 [70.8%] were female) successfully completed the survey. On multivariate regression, patients after rhinoplasty were rated as significantly more attractive (rhinoplasty effect, 6.26; 95% CI, 5.10-7.41), more successful (rhinoplasty effect, 3.24; 95% CI, 2.32-4.17), and overall healthier (rhinoplasty effect, 3.78; 95% CI, 2.79-4.81). The ordinal rank change for an average individual’s perceived attractiveness, success, and overall health was a positive shift of 14, 9, and 10 out of 100 rank positions, respectively.
Conclusions and Relevance
As perceived by casual observers, rhinoplasty surgery was associatedwith perceptions that in patients appeared significantly more attractive, more successful, and healthier. These results suggest patients undergoing rhinoplasty may derive a multifaceted benefit when partaking in social interactions. Furthermore, these results facilitate improved patient discussions aiming to provide more precise surgical expectations with an understanding that these results represent optimal outcomes.
Level of Evidence
Rhinoplasty surgery is one of the most common facial plastic surgery procedures performed in the United States undertaken by both men and women seeking to improve their facial appearance.1 Prior studies2-4 have shown that nasal deformity alters facial perception, evidenced by an attentional distraction to the nose and resulting in an attractiveness penalty, which can be corrected by rhinoplasty surgery. Furthermore, a growing body of literature highlights the importance of facial appearance, suggesting that facial appearance influences the assignment of positive attributes, employment decisions, and voting decisions.5-9 Hence, improving facial appearance may have a positive impact on both a patient’s self-concept and his or her social interactions.
Identifying patient motivations and expectations regarding rhinoplasty remains essential when engaging in patient-physician surgical decision-making.10 Nonetheless, patient counseling relies on an understanding of the realistic effect of rhinoplasty to facilitate evidence-based discussions. In studies using validated patient-reported instruments, patients report improved satisfaction with facial appearance, satisfaction with the nose, psychological health, and quality of life after rhinoplasty.11,12 While many studies have examined patient-reported outcomes after rhinoplasty, few studies have examined the impact of rhinoplasty on social perceptions.13,14 Given the importance of facial appearance on social interactions, further evidence is needed to understand and quantify the effect of rhinoplasty on social perceptions. Improved understanding of the potential effect of rhinoplasty would significantly assist physicians in navigating patient discussions and setting appropriate surgical expectations.
The aim of the present study was to quantify naive, observer-rated, perceived attractiveness, success, and overall health of patients who have undergone rinoplasty. We hypothesize that patients after rhinoplasty surgery will be perceived as more attractive, healthier, and more successful in society.
Johns Hopkins institutional review board approval was received for this study. A total of 473 casual observers participated in the study from June 1, 2016, to December 31, 2016. As previously described,15,16 surveys were posted to various public websites aiming to recruit a sample of observers from the general population. Surveys were distributed to social media sites, local community sites, student listserv messages, university announcement sites, and online discussion forums. All individuals 18 years or older who spoke English were eligible. Electronic informed consent was obtained from all study participants, and all data were deidentified. Participants were not compensated, and they were excluded if younger than 18 years or had schizophrenia, autism, or another affective psychiatric condition because these disorders have been shown to alter facial perception.17,18 Participants who did not complete the entire survey were removed from the study. Observers were naive to the specific study objectives and assumed to be independent.
Thirty-five subject facial photographs were identified from image databases of male and female patients who had undergone rhinoplasty by 1 of 5 facial plastic surgeons at an academic or private practice. Subject images representing an optimal rhinoplasty outcome were selected by each facial plastic surgeon. Preoperative and postoperative photographs were captured in a standardized fashion using similar technique, room layout, lighting, camera, and background. In addition, standardization reduced the effects of potential confounders, such as image quality, head position, facial expression, and jewelry. All patients had postoperative images taken at least 6 months after primary rhinoplasty and had not undergone other cosmetic surgeries (eg, upper or lower facial rejuvenation surgery). The mean (SD) patient age was 34.0 (8.5) years, and 76% of the patients were female. Delphi method, which involves the facial plastic surgery experts anonymously rating rhinoplasty patient outcomes, was used to select 13 standardized subjects confirming patient candidacy and overall surgical effect. This method verified that study subjects represented an optimal rhinoplasty effect while minimizing other patient confounders. All selected patients had provided consent for the use of the images in the survey. From the pool of 26 images (13 preoperative and 13 postoperative), 13 images were randomly and evenly inserted into surveys built using Qualtrics survey software (Qualtrics LLC). No survey contained more than 1 photograph of the same patient to limit the priming effect of presenting repeated measures. Participants were given introductory instructions on completing the survey while providing information that observers would view images of patients either before or after rhinoplasty surgery, but the surgical status for patient images was not provided. In addition, surveys collected demographic data from observers including observer age, sex, race, and highest level of education as well as asking if observers had prior rhinoplasty themselves or had friends or family who underwent rhinoplasty.
Naive observers were randomly presented 13 independent patient images asking to rate their attractiveness, perceived success, and perceived overall health. Observers were blind to operative status of each patient image, and the order of image presentation was randomized. A visual analog scale using a normalized slider bar with 1-point increments was used to answer the facial perception questions. Observers rated the attractiveness of the face from 0 (least attractive) to 100 (most attractive). Next, observers rated “How successful do you think this person is?” from 0 (complete failure) to 100 (extremely successful) and “How healthy do you think this person appears?” from 0 (extremely unhealthy) to 100 (extremely healthy).
Data were analyzed using Stata SE software (version 13; Stata Corp). Multiple analytic techniques were used in this study with the experiment-wide significance level set at α = .05. Demographic characteristics of study observers were examined. Next, a multivariate mixed-effects regression model was used to determine the effect of rhinoplasty on the fixed effects, including attractiveness, success, and overall health, while separating variances due to random effects caused by observer biases. Next, to further characterize effect size, ordinal rank change was estimated by scaling and integrating the normal distributions for each of the 4 measured domains using Mathematica statistical software (version 10.4; Wolfram). The variance between study patients was used to calculate ordinal rank change in perceived attractiveness, success, and overall health. The ordinal rank represents the rank position of an individual out of 100 random individuals rank ordered from lowest to highest score for a specific domain. For our analysis, we calculated the change in ordinal rank of an average individual (ie, 50th rank position) out of 100 individuals after rhinoplasty for each domain of interest.
A total of 473 casual observers participated in the study from June 2016 to December 2016. Of this sample, 431 participants fully completed the web-based survey and were eligible for inclusion (Table 1). Most of the observers were white (302 [70.1%]), female (305 [70.8%]), and educated with a 4-year college degree (220 [51.0%]). The mean age was 29 years (range, 18-73 years). Most observers had no prior rhinoplasty surgery (96%) and did not know any family members or friends who underwent rhinoplasty surgery (59%).
In Table 2, the observer ratings of attractiveness, perceived success, and perceived health are presented. The results showed that patients after rhinoplasty had higher mean attractiveness scores, higher mean perceived success scores, and higher mean perceived overall health scores as rated by casual observers. Additional analysis was performed to quantify the effect of rhinoplasty on attractiveness, perceived success, and perceived overall health.
Previous studies investigating facial attractiveness have suggested that facial attractiveness is positively associated with perceived health.19,20 With consideration of these studies, a multivariate mixed-effects regression model is presented in Table 3 showing the effect of rhinoplasty surgery on observer ratings of attractiveness, perceived success, and perceived overall health while accounting for the random effects of observer bias. Patients after rhinoplasty were rated as significantly more attractive (constant, 50.12; 95% CI, 48.86-51.38; rhinoplasty effect, 6.26; 95% CI, 5.10-7.41), more successful (constant, 58.14; 95% CI, 57.08-59.21); rhinoplasty effect, 3.24; 95% CI, 2.32-4.17), and overall healthier (constant, 61.45; 95% CI, 60.35 to 62.56; rhinoplasty effect, 3.78; 95% CI, 2.79-4.81).
The estimated ordinal rank change as a measure of the effect size of rhinoplasty surgery in the domains of attractiveness, perceived success, and perceived overall health is shown in the Figure. In a group of 100 random individuals rank ordered from lowest to highest, an average patient (ie, position 50) undergoing rhinoplasty surgery would expect to shift their rank to appear more attractive to an additional 14 individuals compared with before surgery. Also, an average patient undergoing rhinoplasty surgery would shift the patient’s rank to 9 individuals more successful (ie, position 59) and 10 individuals healthier (ie, position 60).
In this study, naive observers blinded to patient operative status (ie, preoperative vs postoperative) rated independent images of patients after rhinoplasty surgery as significantly more attractive, more successful, and overall healthier. As one the largest studies investigating the effect of rhinoplasty on social perception, this study used the collective ratings of casual observers to measure the effect of rhinoplasty surgery. In accordance with Sir Francis Galton’s Vox Populi principle, the average ratings from a large sample of individuals provided an estimate for the effect of rhinoplasty that closely approximates the true effect.16,21,22 These findings suggest a significant improvement in patient appearance influencing random observers’ impression of a person in several areas of social perception. By improving observer perceptions, rhinoplasty surgery potentially benefits patients by having a positive effect on social interactions.
Several studies have examined the role of nasal deformity on attractiveness. However, few studies have specifically quantified the impact of rhinoplasty surgery on attractiveness. A study23 comparing digitally modified teeth and noses to unaltered control images found images with nasal deformity as less attractive. Furthermore, Moolenburgh et al24 found that patients with nasal deformity were less attractive than control patients without nasal deformities. However, these studies did not directly investigate the effect of rhinoplasty surgery. In a survey with 25 observers, Chinski et al14 found a significant positive difference in the perception of beauty comparing photographs before and after rhinoplasty. Comparably, our results found that patients appeared significantly more attractive after rhinoplasty. Furthermore, multivariate regression quantified the effect of rhinoplasty surgery while accounting for the random effects of observer bias. To better understand this effect, we presented another measure of effect size by estimating rank change on attractiveness. The average patient, rank position 50, after rhinoplasty surgery would expect to shift rank 14 positions higher in attractiveness in a group of 100 random individuals. When discussing rhinoplasty surgery with patients, the facial plastic surgeon may find this reference helpful in conveying specific potential surgical outcomes and setting appropriate patient expectations.
In addition to improving attractiveness, rhinoplasty surgery may provide other perceptual benefits during social interactions. In a prior study surveying 64 college students, Cash and Horton13 demonstrated a positive correlation between physical attractiveness, self-assertiveness, intelligence, potential for life success, and personal likeability in patients who underwent cosmetic rhinoplasty surgery. Furthermore, Dayan et al25 found that postoperative facial cosmetic surgery patients, which included rhinoplasty patients, were graded as more attractive, better in social skills, more successful in dating, more athletic, and more financially successful. Similarly, our results demonstrated that patients after rhinoplasty had improved perceived success and overall health. The various perceptual benefits patients experience after rhinoplasty surgery may be related to the improvement in overall facial attractiveness.
Prior studies have suggested that individuals who are perceived as more attractive experience meaningful social benefits—what is known as a “halo effect.” Dion et al9 found that observers assume that attractive individuals have socially desirable personalities, lead overall happier lives, and enjoy more fulfilling occupational success compared with less attractive individuals. In addition, studies have shown that individuals perceived as more attractive have an increased likelihood of being hired for a job, receive more lenient court judgments, and experience more success as a political candidate.26-28 Furthermore, observers’ first impression of a face, as measured by the response of the amygdala, has been shown to be positively associated with observers’ subjective judgment of leadership ability and reflect objective measures of success.29 Finally, Rhodes and colleagues19,20 suggested that the preference for an attractive face results from an evolutionary adaptation to select high-quality mates (ie, healthy genes) and consequently, a healthy facial appearance increases observer perceptions of attractive traits. Moreover, the cognitive processing of attractiveness can occur without conscious awareness.30 Thus, these findings support our study results showing that patients benefit from rhinoplasty surgery by improving casual observers’ perceptions of attractiveness as well as perceptions of success and overall health. While surgery does not directly improve a patient’s success or health, the potent effect on observers’ subconscious perceptions may result in more positive interactions when patients engage in society.
There are several limitations in this pilot study investigating the association of rhinoplasty surgery with observer perceptions of attractiveness, success, and overall health. First, the survey instrument includes patients, selected using the Delphi method, representing an optimal candidacy and surgical outcome. Thus, the results do not reflect the spectrum of rhinoplasty surgical outcomes, which are significantly affected by several factors, including patient variability, etiology of deformity, surgeon expertise, and surgical technique. In representing optimal rhinoplasty surgical outcomes, the results cannot generalize to all potential patient outcomes. Thus, perceptions of optimal rhinoplasty outcomes may not mirror perceptions of the agglomeration of rhinoplasty outcomes in society. In addition, the inferences from our results are consigned to observer perceptions of attractiveness, success, and health and do not reflect the patients’ tangible experience concerning health and success. Furthermore, this study does not address a patient’s self-perceived change across the domains of interest. Concerning our observer population, a large proportion of our observers are young, educated, white women. This sample likely resulted from using a web-based survey to recruit random participants. However, a prior study31 found that ratings of attractiveness are not significantly different between sexes as opposed to ratings of beauty or cuteness. Moreover, the effect of observer race on perceptions of nasal deformity is not well understood at this time. Despite our participant population not reflecting the general US population, the aggregation of a large, random, and independent sample permitted the use of the vox populi principle. This technique has been successfully used in other studies investigating social perceptions.16 Thus, we are confident that the large group’s estimate closely approximates the true value for each domain. Finally, the large variance in ratings of perceived attractiveness, success, and overall health suggest that various factors influence observer perceptions with significant differences in observer biases. Moreover, the survey instrument did not measure all factors affecting each domain of interest. In our analysis, we account for them in the residual variances of the regression model.
Despite these limitations, the data suggested that patients after rhinoplasty surgery are perceived as more attractive, more successful, and overall healthier. To better reflect the rhinoplasty patient population, future investigations should include patients with various surgical outcomes, which would improve generalizability to all potential surgical outcomes. These studies could investigate the various patient factors, such as specific physical findings, influencing surgical outcomes. Additional studies could measure the effect of surgery on other social perception domains, such as willingness to communicate, confidence, and intellect. Finally, future efforts could examine the effect of observer race on perceptions of nasal deformity for various racial groups. Aiming to improve surgical discussions with patients, this study provides quantitative data regarding the potential optimal effect of rhinoplasty surgery, which physicians may use to better navigate patient expectations.
In this study, rhinoplasty surgery resulted in patients appearing more attractive, more successful, and overall healthier to casual observers in society. These findings propose that patients experience an improvement in social interactions stemming from the positive effect of rhinoplasty surgery on observer perceptions. Furthermore, these results may improve physician-patient discussions about rhinoplasty surgery by providing a reference for an optimal outcome. However, variability in surgical outcomes must be considered when establishing surgical expectations and considering the effect on social perceptions.
Corresponding Author: Lisa E. Ishii, MD, MSH, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins Outpatient Center, Johns Hopkins University, 601 N Caroline St, Baltimore, MD 21287 (firstname.lastname@example.org).
Accepted for Publication: July 1, 2017.
Published Online: October 19, 2017. doi:10.1001/jamafacial.2017.1453
Author Contributions: Dr Nellis had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Nellis, M. Ishii, Bater, Bryne, L. E. Ishii.
Acquisition, analysis, or interpretation of data: Nellis, M. Ishii, Bater, Papel, Kontis, Boahene, L. E. Ishii.
Drafting of the manuscript: Nellis, M. Ishii.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Nellis, M. Ishii, Bater, L. E. Ishii.
Obtained funding: M. Ishii.
Administrative, technical, or material support: Nellis, Papel, Kontis, L. E. Ishii.
Study supervision: M. Ishii, L. E. Ishii.
Conflict of Interest Disclosures: None reported.
Disclaimer: Dr Boahene is a member of the editorial board of JAMA Facial Plastic Surgery, and Dr L. E. Ishii is an associate editor and section editor of the journal, but they were not involved in any of the decisions regarding review of the manuscript or its acceptance.
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