Mental health
status among the candidates for rhinoplasty: a case-control study
Ali Tavassoli 1, Maryam Zavarmosavi 2, Mohadese
Khodadadi 3, Armon Massoodi 4*,
Zahra Geraili 3
1 Department of ENT, School of Medicine, Babol
University of Medical Sciences, Babol, Iran
2
Kavosh Cognitive Behavior Sciences and Addiction Research Center,
Department of Psychiatry, School of Medicine, Guilan
University of Medical Sciences, Rasht, Iran
3
Student Research Committee,Babol University of Medical
Sciences, Babol, Iran
4
Department of psychiatry, School of Medicine, Social Determinants Of Health
Research Center, Research Institute for Health, Shahid Yahya nezhad hospital, Babol University
of Medical Science, Babol, Iran
*Corresponding
Author: Armon Massoodi
* Email: armonmassoodi@gmail.com
Abstract
Introduction: Mental health problems and personality disorders may influence
individuals’ motivation to request cosmetic surgeries. The aim of this study
was to assess mental health status and personality disorders among the
candidates for rhinoplasty.
Materials
and Methods: This case-control study was conducted in 2019–2020. Participants were
45 candidates for rhinoplasty and 45 individuals with no request for
rhinoplasty purposefully selected from the ear nose throat clinics of Ruhani hospital, Babol, Iran.
Data collection instruments were the Symptom Checklist-90 Revised (SCL-90-R)
and the Millon Clinical Multiaxial Inventory (MCMI).
The SPSS software (v. 16.0) was employed for data analysis through the
independent-sample t and the Chi-square tests at a
significance level of less than 0.05.
Results: In the case group, 28.9% of participants had at least one psychiatric
symptom and 7.26% had at least one personality disorder. The prevalence of
psychiatric symptoms and personality disorders in the case group was
significantly more than in the control group (P < 0.05).
Conclusion: Compared with individuals with no request for rhinoplasty, the
prevalence of psychiatric symptoms and personality disorders is high among the
candidates for rhinoplasty. Therefore, a preoperative mental health assessment
is essential to improve post-rhinoplasty outcomes.
Keywords: Psychiatry, Personality disorder, Mental health, Rhinoplasty
Introduction
Rhinoplasty
is plastic surgery on the nose mostly for cosmetic purposes, during which the
skin, cartilage, or bones of the nose are manipulated to change its shape or
function. Based on the incision type, rhinoplasty is classified as open or
closed (1). Cosmetic surgeries are among the most frequent surgeries worldwide
with increasing prevalence. The prevalence of these surgeries in the United
States increased by 198% from 1992 to 2000 and reached 1.3 million cases. Iran
is among the top-ranked countries respecting cosmetic surgeries so more than 4
million dollars are yearly spent on these surgeries (2). The high prevalence of
rhinoplasty in Iran has turned the country into the capital for rhinoplasty in
the world (3–5). One of the main reasons for the high prevalence of rhinoplasty
in Iran is the Islamic covering of Iranian women which covers all parts of the
body except for the face and the hands (6–8).
Rhinoplasty
is associated with many different complications. The early complications of
rhinoplasty include bleeding, septal hematoma, obstruction, smelling alterations,
edema, adhesion of the incisions, and infection. Its long-term complications
are scar hypertrophy, septal perforation, nostril collapse, and stenosis (9).
Accordingly, rhinoplasty is among the most difficult surgeries even for the
surgeons who routinely perform it (1).
Evidence
shows that mental health problems can increase the likelihood of the request
for elective rhinoplasty. Psycho-behavioral disorders, characterized by
recurring or fixed alterations in thinking, mood, emotions, or behaviors,
personal upset or discomfort, or functional problems (10), can affect
individuals’ decisions and lives. Previous studies reported the high prevalence
of mental health and personality disorders among the candidates for rhinoplasty
and the potential effects of these disorders on their decisions for cosmetic
surgeries (11, 12). On the other hand, the high prevalence of rhinoplasty among
young adults in Iran (13) implies that they opt for the surgery mostly to
improve their appearance and self-confidence without having any actual medical
indication (14). On the other hand, dissatisfaction with rhinoplasty outcomes
is higher among individuals with mental health and personality disorders and
hence, these individuals are not good candidates for cosmetic rhinoplasty (7).
Dissatisfaction with rhinoplasty outcomes is in turn associated with a higher
risk of postoperative psychiatric problems such as social isolation and
self-destructive behaviors (15, 16). Accordingly, individuals with mental
health or personality problems who undergo cosmetic rhinoplasty may finally
decide to initiate legal prosecution against their surgeons or show aggression
against them (12).
The
high prevalence of elective rhinoplasty and its complications among individuals
with mental problems highlights the need for studies into the relationship between
rhinoplasty prevalence and mental health problems. Some studies in this area
reported no significant difference between the general population and the
candidates for plastic surgery respecting mental health problems such as
depression and anxiety (17–20). However, some studies showed that mental
problems had a significant relationship with the request for elective
rhinoplasty. For example, a study showed that the use of psychiatric medications
among the candidates for rhinoplasty was higher than in the general population
(21). A case-control study on fifty candidates for rhinoplasty also revealed
that the most prevalent personality disorders were avoidant and narcissistic
disorders (22) and a study on 96 candidates for rhinoplasty found
obsessive-compulsive disorder, depression, and anxiety as the most important
psychiatric findings (23).
The
contradictory results of previous studies into the relationship between mental
health problems and rhinoplasty highlight the necessity for further studies in
this area. Moreover, to the best of our knowledge, there are limited data in
this area in the sociocultural context of Iran. Therefore, the present study
was designed and conducted to narrow these gaps. The aim of the study was to
assess mental health status and personality disorders among the candidates for
rhinoplasty.
Materials and Methods
Design
This
case-control study was conducted in 2019–2020.
Participants
and setting
The
study setting was Ruhani hospital, Babol, Iran. The study population of the case group
consisted of the candidates for rhinoplasty who were referred to the ear nose
throat clinics of the hospital, while the population of the control group
consisted of individuals who were referred to these clinics to receive
non-cosmetic services and were not an applicant for rhinoplasty. Groups were
matched respecting participants’ demographic characteristics. Sampling was
performed purposefully based on the following criteria: age of 18–40 years no
affliction by severe psychiatric disorders (such as schizophrenia), chronic
debilitating diseases (such as multiple sclerosis and cancer), cognitive
disorders, and mental retardation (for all participants), request for rhinoplasty
(for participants in the case group), and no request for rhinoplasty (for
participants in the control group). Exclusion criteria were voluntary
withdrawal from the study and having a rhinoplasty in the past and the development
of any post-rhinoplasty complication.
Sample
size calculation
The
sample size was calculated with a 
of 6.14, a 
of 11.71, a 
of 5.70, a 
of 8.49 (31), a confidence level of 0.95, and
a power of 0.90. The sample size calculation formula (Figure 1) revealed that
at least 35 participants were needed per group. Nonetheless, 45 participants
were recruited to each group to compensate for probable withdrawals.
Sample size calculation formula:
Data
collection instruments
The
Symptom Checklist-90 Revised (SCL-90-R) and the Millon
Clinical Multiaxial Inventory (MCMI) were employed for data collection. The
SCL-90-R is among the most commonly used diagnostic instruments in psychiatry.
It was first introduced by Lipman et al., in 1973 and was then revised based on
clinical experiences and psychometric evaluations and its final version was
introduced by Derogatis et al., in 1976. It has
ninety items on psychiatric symptoms in nine main dimensions, namely
somatization, obsession-compulsion, interpersonal sensitivity, depression,
anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Items
are scored on a five-point scale from zero (“Not at all”) to 4 (“Extremely”).
Scores 1 and more show ailment and scores 3 and more show severe disorder and
psychosis. Derogatis et al. reported the acceptable
criterion validity of this checklist and several other studies reported the
acceptable validity and reliability of the Persian SCL-90-R with a Cronbach’s
alpha of 0.85 (24).
MCMI
is a standard self-reported inventory first introduced in 1977 and was revised
and re-introduced in 1994 by the American Psychology Association. It has 175
Yes/No items on personality disorders and their associated symptoms in 28
subscales and five main categories, namely modifying indices, clinical
personality patterns, personality pathology, clinical syndrome, and severe
clinical syndrome. One of the strengths of this inventory is the use of base
rates instead of standard scores which enables clinical experts to make more
strict interpretations of the scores. Based on base rate, scores are
interpreted as follows: less than 70: healthy; 70–75: likelihood of developing
disorder; 75–85: the significant likelihood of disorder; more than 85:
personality disorder. In the present study, MCMI was used to study the
following personality disorders: schizoid, avoidant, depressive, dependents,
histrionic, narcissistic, antisocial, sadistic, obsessive-compulsive,
negativistic, masochistic, schizotypal, borderline, and paranoid disorders.
Sharifi et al., culturally adapted and psychometrically evaluated the Persian
version of this inventory in Iran and reported its acceptable reliability with
Cronbach’s alpha values of 0.85–0.97 (25).
Data
analysis
The
SPSS software (v. 16.0) was employed for data analysis. Group comparisons were
made using the independent-sample t and the Chi-square tests. The level
of significance was set at less than 0.05.
Ethical
considerations
The
Ethics Committee of Babol University of Medical Sciences,
Babol, Iran, approved this study (code:
IR.MUBABOL.REC.1399.191). Permissions for data collection were also obtained
from the Research Administration of this university and the authorities of the
study setting. Participants were informed about the study aim and data
confidentiality and their personal written informed consent was obtained.
Results
Participants
were 45 candidates for rhinoplasty (the case group) and 45 individuals who were
referred to the study setting to receive non-cosmetic services (the control
group). The mean participants’ age was 27.04±6.9 years in the case group and
28.35±6.32 years in the control group. Most participants in these groups were
female (66.7% vs. 55.6%) and married (51.1% vs. 57.8%). There were no
significant differences between the groups respecting participants’ age,
gender, marital status, and educational level (P > 0.05) (Table 1).
Discussion
This study assessed mental health status and personality disorders
among the candidates for rhinoplasty. Findings showed that 26% of the
candidates for rhinoplasty and 6% of participants in the control group had at
least one psychiatric problem according to the criteria of the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (26). A study
in New York showed that 45.75% of the candidates for cosmetic surgeries had at
least one psychiatric problem according to DSM-IV (27). A study in Iran also
revealed that more than half of the candidates for rhinoplasty had at least one
psychiatric symptom (28). The prevalence of psychiatric problems in these two
studies is more than in the present study which may be due to the differences
among the studies respecting their sample size.
In the present study, obsessive-compulsive disorder, depression,
and anxiety were the most prevalent psychiatric symptoms among the candidates
for rhinoplasty which is in agreement with the findings of a previous study
(23). Another study reported depression and anxiety as the most prevalent
psychiatric symptoms among the candidates for rhinoplasty (29). However, a
study showed that the request for rhinoplasty had no significant relationship
with mental health and its depression, anxiety, and maladjustment subscales
(30). This contradiction may be due to the difference between the studies in
terms of their mental health assessment instrument which was the General Health
Questionnaire in that study (30) and SCL-90-R in the present study.
We also found that psychiatric symptoms, such as depression,
sensitivity, anxiety, and psychoticism, among female participants were more
prevalent than in their male counterparts. This is in agreement with the
findings of a study into the psychopathological symptoms of the candidates for
cosmetic surgeries in the Netherland (10). A cross-sectional study on one
hundred candidates for rhinoplasty also showed that depression, somatization,
obsession, sensitivity, and anxiety were more prevalent among female participants
(31). Compared with men, women more invest in their appearance due to factors
such as their mental characteristics, social norms, media norms, and peer
effects. A study reported that the body is the main source of identity for
women and psychological mechanisms and social factors move them towards
cosmetic surgeries (32).
Our findings also showed that 7.26% of the candidates for
rhinoplasty had at least one personality disorder. A previous study showed that
18% of the candidates for rhinoplasty and 4% of participants in the control
group had at least one personality disorder, with significant between-group
differences (22). A case-control study also showed that 20% of the candidates
for rhinoplasty had personality disorders. However, the difference between the
case and the control groups respecting personality disorders was insignificant
(33) which contradicts our findings. This contradiction may be due to the
differences between the studies respecting their sample size.
The most prevalent personality disorders among the candidates for
rhinoplasty in the present study were histrionic (42.2%), obsessive-compulsive
(28.7%), and narcissistic (23.8%) disorders. This is in agreement with the
findings of most previous studies. For example, a study showed that the most
prevalent personality disorders among the candidates for cosmetic surgeries
were narcissistic (8.4%) and obsessive-compulsive (13.2%) disorders (27).
Another study reported obsessive disorder as the most prevalent personality
disorder (23%) among the candidates for rhinoplasty (7). The most prevalent
personality disorders among the candidates for rhinoplasty in another study
were narcissistic (25%), dependent (12%), and histrionic (10%) disorders (34).
Limitations
One of the limitations of the
present study was that mental health status and personality disorders were not
assessed through structured clinical interviews. Moreover, the study was
conducted on a small sample of individuals selected from a single hospital and
hence, the findings may have limited generalizability.
Conclusions
This study shows the high prevalence
of psychiatric problems (such as paranoid ideation, obsessive-compulsive
disorder, interpersonal sensitivity, depression, somatization, and
psychoticism) and personal disorders (such as histrionic and narcissistic disorders)
among the candidates for rhinoplasty. Psychological interventions to improve
body image and reduce psychiatric problems are recommended to reduce the rate
of unnecessary rhinoplasty surgeries. As individuals may decide on having
rhinoplasty due to cognitive, personality, and interpersonal reasons, careful
preoperative assessment of their mental health status and their reasons for
requesting rhinoplasty is essential to improve surgery outcomes and
satisfaction. Cosmetic surgeons may need to request for psychiatric
consultation for the candidates for rhinoplasty who seem to have mental health
problems. The present study also shows the higher prevalence of psychiatric
symptoms and personality disorders among female and single candidates for
rhinoplasty. Therefore, careful preoperative screening tests for these
individuals are essential.
Recommendations
Multicenter studies on larger
samples with the use of structured clinical interviews are recommended to
produce firmer evidence respecting mental health status and personality
disorders among the candidates for rhinoplasty. Moreover, future studies in
this area are recommended to perform mental health assessments both before and
after cosmetic surgeries and evaluate the effects of psychological
interventions on the candidates for these surgeries who have psychiatric
symptoms and personality disorders.
Author
contribution
AT, MZ, MKh and ZG did
this research and write manuscript, AM guidance and assisted in data
collection and analysis of the results.
Acknowledgments
We would like to thank the authorities and the staff of Babol University of Medical Sciences, Babol,
Iran, who helped us conduct this study.
Conflict of interest
None of the authors declare any conflict of interest.
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