Abstract
Purpose
The aim of the study was to demonstrate whether rhinoplasty alone is a rejuvenating procedure for the aging face.
Materials and methods
Photographs of the right profile of 48 white females older than 55 years were recorded using standardized techniques. Each of the subjects’ noses underwent computer-simulated rhinoplasty to conform to aesthetic canons of the ideal nose. Forty-eight evaluators, blinded to the purpose of the study, were shown either the natural right profile or the morphed image. The evaluators then estimated subject age.
Results
Evaluators were divided into younger and older cohorts. Computer-simulated rhinoplasty alone did not prove to be statistically rejuvenating (Hotelling-Lawley Trace, P = .203). This finding held true for both the younger and older cohort of evaluators ( P = .98). Although not statistically significant, evaluators estimated the age of the morphed images to be 6.5 years (mean) younger than actual age for all subjects.
Conclusions
Rhinoplasty alone is not statistically rejuvenating in the profile view of white females older than 55 years. However, age estimation may be less accurate than was hypothesized for the profile view, possibly because of other visual queues.
1
Introduction
Rhinoplasty is considered to be an important adjunct to rhytidectomy, blepharoplasty, and browplasty among facial plastic and reconstructive surgeons; however, the patient population considering surgical treatment for the aging face does not typically focus on the role of the aging nose. Although seemingly intuitive that the aforementioned procedures would yield a more rejuvenated face, there have never been objective data demonstrating that rhinoplasty alone is an effective facial rejuvenating procedure.
The perception of age is a topic almost exclusively studied by clinical psychologists, who have made great strides in the past 2 decades at quantifying and testing the accuracy of the average person’s ability to estimate the age of a stranger . Recent data by these psychologists suggest that the layperson (herein termed evaluator ) is accurate at estimating the age of a stranger (herein termed subject ), especially when the subject is within the same age bracket as the evaluator .
Advances in technology have led to the increased use of digital morphing, both as an educational tool for surgical residents and as a method of communication with patients . Computer-simulated imaging can be especially helpful in demonstrating the surgeon’s goals and in preoperatively managing patient expectations regarding possible postoperative results of blepharoplasty, browplasty, rhinoplasty, rhytidectomy, and facial resurfacing procedures . Computer-simulated imaging in rhinoplasty has recently been validated to accurately reflect postoperative results at 6 months . Although digital morphing software has been studied in the perception of facial attractiveness , no previous studies have been performed that assess the perceived age differences that can be achieved with the use of computer simulation.
The aging nose undergoes characteristic changes, both gross and microscopic, including the skin and soft tissue envelope, cartilaginous framework, and maxilla . These changes are typically addressed in both cosmetic and functional rhinoplasty and serve as the basis for the proposed hypothesis of this study. The typical geriatric changes that alter the nasal profile were addressed with computer-simulated imaging software at the radix/starting point of the nose, dorsal hump, tip projection, tip rotation, and ala/columellar relationship based on widely held aesthetic ideals .
The significance of this study was to prove or disprove that rhinoplasty alone is a rejuvenating procedure and to offer quantitative information to the patient seeking facial rejuvenation. We hypothesized that rhinoplasty alone will be appreciated by layperson evaluators to have a rejuvenating effect for the entire face.
2
Materials and methods
Approval was obtained from the Institutional Review Board from the University of Florida (Gainesville) to complete this study (institutional review board no. 444-2007). The first 48 white females older than 55 years who agreed to participate in the study were enrolled. After consent to photograph was obtained, digital photographs of the right profile of each of the subjects were taken in a standardized format using a NikonD70 Digital SLR camera fitted with a 60-mm Nikon macro lens and lit with Nikon Macro Speedlight SB-29s (Nikon, San Diego, CA).
The Frankfort horizontal plane is a standard used for lateral photos in facial analysis and extends from the superior aspect of the external auditory canal to the inferior border of the infraorbital rim (transition between lower eyelid and cheek) while the subject’s gaze is straight ahead, parallel to the floor. A standard distance between the blue backdrop and the subject was used in all photographs. A standard distance from the photographing principal investigator and the subject was also used, with each photograph containing the head, ear, and larynx of all subjects.
The 48 photographs were then loaded into MarketWise software, version 7.0 (United Imaging, Inc, Winston-Salem, NC). Digital alterations of the nose were performed by the authors to conform to previously described and widely accepted aesthetic canons .
Once completed, 2 booklets were produced, labeled booklet “A” and booklet “B.” Each booklet contains 48 high-resolution 6 × 9″ glossy photographs of each of the subjects. Randomization of subjects before organization of the booklets was designated by the biostatistician. Either a morphed or an unmorphed photograph of each of the subjects was placed into each booklet, with one booklet containing the complement photograph of the other. For example, if a morphed picture of subject 1 was placed into booklet A, then the unmorphed photograph of subject 1 was placed into booklet B. Each booklet then contained 24 morphed and 24 unmorphed photographs of each of the subjects, assigned randomly. The evaluator saw only a morphed or an unmorphed photograph of each subject.
Once the booklets were completed, consent was obtained from 48 evaluators who were recruited to fall into 2 cohorts—24 falling into a younger cohort aged 18 to 25 and 24 in an older cohort aged 45 to 75. Each of these evaluators were randomly assigned to be shown the photographs in booklet A or booklet B and asked to estimate the age of each of the subjects they were shown to a 5-year age range. After all data acquisition was completed, the services of a biostatistician were used for statistical analysis.
2
Materials and methods
Approval was obtained from the Institutional Review Board from the University of Florida (Gainesville) to complete this study (institutional review board no. 444-2007). The first 48 white females older than 55 years who agreed to participate in the study were enrolled. After consent to photograph was obtained, digital photographs of the right profile of each of the subjects were taken in a standardized format using a NikonD70 Digital SLR camera fitted with a 60-mm Nikon macro lens and lit with Nikon Macro Speedlight SB-29s (Nikon, San Diego, CA).
The Frankfort horizontal plane is a standard used for lateral photos in facial analysis and extends from the superior aspect of the external auditory canal to the inferior border of the infraorbital rim (transition between lower eyelid and cheek) while the subject’s gaze is straight ahead, parallel to the floor. A standard distance between the blue backdrop and the subject was used in all photographs. A standard distance from the photographing principal investigator and the subject was also used, with each photograph containing the head, ear, and larynx of all subjects.
The 48 photographs were then loaded into MarketWise software, version 7.0 (United Imaging, Inc, Winston-Salem, NC). Digital alterations of the nose were performed by the authors to conform to previously described and widely accepted aesthetic canons .
Once completed, 2 booklets were produced, labeled booklet “A” and booklet “B.” Each booklet contains 48 high-resolution 6 × 9″ glossy photographs of each of the subjects. Randomization of subjects before organization of the booklets was designated by the biostatistician. Either a morphed or an unmorphed photograph of each of the subjects was placed into each booklet, with one booklet containing the complement photograph of the other. For example, if a morphed picture of subject 1 was placed into booklet A, then the unmorphed photograph of subject 1 was placed into booklet B. Each booklet then contained 24 morphed and 24 unmorphed photographs of each of the subjects, assigned randomly. The evaluator saw only a morphed or an unmorphed photograph of each subject.
Once the booklets were completed, consent was obtained from 48 evaluators who were recruited to fall into 2 cohorts—24 falling into a younger cohort aged 18 to 25 and 24 in an older cohort aged 45 to 75. Each of these evaluators were randomly assigned to be shown the photographs in booklet A or booklet B and asked to estimate the age of each of the subjects they were shown to a 5-year age range. After all data acquisition was completed, the services of a biostatistician were used for statistical analysis.
3
Results
The PROC GLM procedure in SAS (version 9.1; SAS Institute, Cary, NC) was used to conduct the statistical analysis. Parameters were determined to be statistically significant at the significance level 0.05.
Evaluators under different conditions (morphed and unmorphed) were treated as replicates, with means taken to be the response. Multivariate repeated measure of morphed and unmorphed score was performed to test for treatment (morphed vs unmorphed), evaluator age (young vs old), as well as their interaction effect. Booklet A vs B was also considered as an effect in the study model. Residual analysis was conducted to determine the log transformation of the response to satisfy the Gaussian distribution assumption.
Forty-eight white females agreed to participate as subjects. The age of these subjects ranged from 55 to 93 (mean, 70.5; median, 70; SD, 9.8). During the digital morphing, we performed alterations to the radix of 60% of the subjects (29/48), altered the ala/columellar relationship in 65% (31/48), reduced the dorsal hump in 83% (40/48), altered tip projection in 77% (37/48), and tip rotation in 67% (32/48).
Hotelling-Lawley Trace shows morphing manipulation to have no significant effect ( P = .203) and morphing manipulation by evaluator age cohort interaction is similarly found to lack significance ( P = .980). No significant result was found between subject effect book and evaluator age cohort ( P = .408; .268).
To compare the evaluators’ score to the subjects’ actual age, we took the average of 48 evaluators’ scores of each subject and compared that age estimate to the subject’s actual age using one sample t test. P < .0001 shows that the evaluators’ observation is younger than subjects’ true age significantly whether the image has been morphed. The mean difference between true age and evaluator’s guess is 6.53.
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