1 Introduction

Cosmetic rhinoplasty is a popular facial plastic surgery conducted worldwide. However, contraindications exist for certain patients due to body dysmorphic disorder, unstable mental states, or unrealistic expectations, which may result in negative psychological implications and decreased quality of life following the surgery [1].

Considering the potential negative psychological implications of cosmetic rhinoplasty, ongoing research is being conducted to enhance both physical and psychological outcomes, and to identify potential risks involved. Nevertheless, it is important to note that rhinoplasty can serve both cosmetic and functional purposes, with many studies reporting improvements in postoperative quality of life and decreased psychological distress, regardless of the initial cause for the surgery [2,3,4].

Furthermore, several studies examining the psychological state of patients undergoing rhinoplasty have revealed significant differences in social functioning, vitality [5], anxiety [6] and personality patterns potentially indicative of psychological risk when compared to control groups [7]. These findings collectively emphasize the necessity of a psychological evaluation adjunct for patients seeking cosmetic rhinoplasty to identify underlying psychological problems that may adversely affect the patient's outcome. Nonetheless, it is broadly recognized that the presence of psychiatric disturbances or psychological distress should not automatically disqualify an individual from undergoing the surgery as appropriate support and a thorough understanding of the patient's motivations can mitigate potential risks and optimize positive outcomes [8]. By incorporating a psychological evaluation prior to cosmetic rhinoplasty, clinicians can better identify underlying psychological issues that could have the potential to affect the patient's requested outcome, allowing for appropriate support and care to be provided to mitigate potential risks and enhance positive results. Additionally, providing information on the potential positive impact of cosmetic rhinoplasty on patients' psychological state and QOL can aid individuals who are considering the procedure in making an informed decision. In consideration, the present systematic review aims to investigate how cosmetic rhinoplasty impacts patients' psychological state and quality of life by examining changes before and after the procedure.

2 Methods

The reporting of this systematic literature review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. (Fig. 1).

Fig. 1
figure 1

Flow diagram of the systematic study selection process

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PubMed, Google Scholar, Mendeley and FindIt@MSP were searched between 2008 and 2023 and English text only for terms documented in Table 1. Two additional articles were found via reference searching. The titles, abstracts, and full text were reviewed by two reviewers to determine whether they met the inclusion criteria specified in Fig. 2. The inclusion criteria were as follows: (1) a survey/questionnaire/interview assessment of psychological implications pre and post-op for cosmetic rhinoplasty; and (2) outcomes examining QOL and psychological implications for cosmetic rhinoplasty. We excluded non-English papers, papers older than 2007, opinion based articles, case reports, case series, meta-analyses and systematic reviews, qualitative studies, studies examining Body Dysmorphic Disorder, studies only including functional rhinoplasty, patients under the age of 18, studies only using post-operative data results, and studies which examined only surgical outcomes and surgical techniques of cosmetic rhinoplasty. Body Dysmorphic Disorder (BDD) was omitted from this study due to the presence of underlying psychological dysfunction in affected patients. Individuals with BDD exhibit a tendency for pursuing multiple surgical procedures targeting various aspects of their body. Given that this study specifically concentrates on cosmetic rhinoplasty procedures, the inclusion of BDD subjects may compromise the validity of psychological outcome measures. This is because individuals with BDD commonly experience dissatisfaction with multiple facets of their body, making it challenging to isolate the psychological impact of cosmetic rhinoplasty alone. The inclusion of BDD patients may lead to misleading results regarding psychological outcomes. Notably, individuals with BDD often report low satisfaction rates, and engage in excessive repetitive behaviors as a response to their preoccupations.

Table 1 Identification of studies via databases
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Fig. 2
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Risk of bias visualization. D1: Bias arising from the randomization process. D2: Bias due to deviations from intended interventions. D3: Bias due to missing outcome data. D4: Bias in measurement of the outcome. D5: Bias in selection of the reported result. D6: Overall risk of bias

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A total of 16 articles were included for data analysis. The study characteristics and results for each study are demonstrated in Table 2. A risk-of-bias assessment of all included studies was performed and the visualization can be seen in Fig. 2.

Table 2 Reviewed Study Characteristics and Result
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3 Results

In total, 3646 records were identified and, following the removal of duplicates, 51 were screened. Overall, 16 articles met the inclusion criteria and were summarized in this review. Twelve of the studies were prospective cohort, 1 longitudinal retrospective, 1 semi-experimental, 1 quasi-experimental, and 1 described as cross-sectional study. Included studies were published between 2008 and 2022.

3.1 Patient characteristics

The studies included in this review reported outcomes from patients who sought rhinoplasty for cosmetic reasons. All participants underwent cosmetic rhinoplasty during the study period. Patients were evaluated both preoperatively and postoperatively in every study. The present review is based on the psychological assessment of over 2700 patients whose ages range between 18 and 65 years old. These patients were followed-up at various intervals postoperatively ranging from 3 months to 5 years. The majority of the study participants were females of reproductive age. Majority of the studies reported demographic information of the participants. Some studies included in this review provided data based on international participants from different countries around the globe.

3.2 Psychological outcomes

The results of the studies consistently demonstrated that the patients reported statistically significant improvements in their social functioning and relationships following the rhinoplasty procedure. The data also indicated that the patients self-reported an improvement in their self-perception and body image, which may have contributed to their enhanced social functioning. Specifically, the patients reported a decrease in their level of dissatisfaction with their body, and nearly all of the studies reported improvements in their satisfaction with the size and shape of their nose. These positive outcomes were observed across a range of follow-up periods, from 3 months to 5 years post-operatively, and the improvements were found to be stable even when the patients were followed up over the long-term.

In addition to evaluating the physical outcomes of rhinoplasty, several studies also assessed the psychological well-being of the patients. The results showed improvements in various psychological domains, including anxiety, depression, emotional state, and body dysmorphia. For instance, Moss & Harris [16] found a significant reduction in anxiety and depression among participants at the 12-month follow-up, as measured by the Beck Depression Inventory (BDI) scale. Similarly, Margraf et al [5] reported positive outcomes in anxiety, social phobia, depression, and body dysmorphia perceived by the participants. Other studies also found a decrease in psycho-social distress after rhinoplasty [4].

3.3 Quality of life

Out of all the studies included in this assessment, nine studies evaluated the participants for changes in their quality of life following rhinoplasty. These studies reported a significant improvement in the participants' quality of life, as measured by the Rhinoplasty Outcomes Evaluation (ROE) questionnaire. The ROE questionnaire is a reliable tool that has been used extensively in research to assess patient-reported outcomes following rhinoplasty [20]. Other tools, including the Body Image Inventory, and the EuroQol 5D questionnaire, were used to evaluate the impact of rhinoplasty on the quality of life of their participants [5].

The improvement in quality of life reported by most studies could be explained by a change in the participants' perception of themselves, an improvement in their body image, an increase in self-esteem, and greater social participation and confidence. However, it should be noted that one study found no statistically significant difference in the quality of life of the participants except for a significant change in the psychological domain [19].

4 Discussion

This systematic review identified 16 published studies on the psychological implications and quality of life after Cosmetic Rhinoplasty.

The psychological impact and enhanced quality of life after cosmetic rhinoplasty are multifaceted. Improvement in self-esteem [3, 8, 12, 17] and body image [12, 18] may have important implications for increased social functioning. Likewise, improvements in aesthetic outcomes can coherently lead to a reduction in psycho-social distress [4]. Quality of life enhancement can also be attributed to improvement in self-esteem and body image, leading to a decrease in anxiety and depression [16]. However, all but one of the studies analyzed in the present review were limited by the short post-operative survey period and therefore lack sufficient evidence to support long term outcome reports. Only one of the 16 studies used reported significant improvement in general appearance satisfaction and self-esteem after rhinoplasty which was consistent at a 2-year postoperative follow-up [18]. The psychological implications of cosmetic surgery can be complex and long lasting. Including long term studies in the examination of these implications is essential as it allows for a more accurate understanding of how patients' mental health and quality of life may be impacted over time, as well as allowing time for any development of longer-lasting psychological disturbance or comorbidities to appear [21]. Identifying such patterns is critical because it can inform clinical decision-making for patients receiving treatment for appearance-related disorders with underlying psychological components. In a similar systematic review investigating the influence of surgical and minimally invasive facial cosmetic procedures on psychosocial outcomes, Imadojemu et al. [22] concluded that several psychological domains were significantly improved following cosmetic procedures. The results of this study are congruent with the findings of the present systematic review, illustrating enhanced external validity of the current study. Furthermore, in a study examining the long term quality of life before and after cosmetic rhinoplasty, Mohammadshahi et al. [23] demonstrated that patient satisfaction and quality of life improved with an increasing length of time after surgery, indicating a positive correlation between the two variables. By demonstrating the long-term effects of the relationship between cosmetic surgery and improved quality of life, the study conducted by Mohammadshahi et al. [24] strengthens the validity of the present systematic review. Overall, the results of the present study strongly suggest a significant positive improvement in quality of life and psychological impact post surgery. However, the self-reported nature of these studies makes it challenging to draw conclusive evidence, and further research is essential to better elucidate the relationship between the psychological implications and quality of life after Cosmetic Rhinoplasty.

Limitations of the current study include lack of blinding, paid participation, surgeon directed studies, and the use of self-reported questionnaires in the selected studies. While these self-reported questionnaires are considered the gold standard for assessing the quality of life (QoL) and well-being of the participants, they may not offer reliable and valid evidence for the psychological improvement of participants. These limitations pose a risk of sampling bias, recall bias, and the Hawthorne effect among participants, threatening the validity of the data presented in these studies.

Additionally, some patients included in these studies underwent rhinoplasty for both functional and cosmetic reasons. It is important to note this potential heterogeneity in the study population. Efforts to specifically highlight and select a subgroup of patients undergoing rhinoplasty exclusively for cosmetic reasons were limited by the information provided in individual studies. This limitation could have influenced the measurements of patient satisfaction and quality of life (QoL) outcomes.

Despite the limitations, this systematic review offers clinicians an up-to-date compilation of existing evidence, enabling them to gain a more comprehensive understanding of the therapeutic benefits of cosmetic rhinoplasty. This enhanced awareness among psychiatrists and cosmetic surgeons can be beneficial for both clinicians and patients, providing them with the necessary tools to make informed decisions about the potential risks and benefits of undergoing this procedure.

5 Conclusion

Cosmetic rhinoplasty has been demonstrated to provide positive outcomes for those seeking to enhance their physical appearance and mental well-being. The literary evidence supports the beneficial impact on a range of psychological factors including self-esteem, body image, overall mental health, and psycho-social distress with a corresponding improvement in quality of life. However, in order to provide more robust evidence of the psychological benefits of cosmetic procedures, future research should consider collecting data through structured interviews conducted by mental health professionals and psychiatry-dermatology-plastic surgery liaison services to better evaluate patient quality of life [24].