The Association between the Complexity of Nasal Deformities and Surgical Time in Rhinoplasty Patients: A Retrospective Single-Center Study

Abstract

Previous reports showed that prolonged operative time increases the risk of surgical site infection rates, prolonged hospital stays, and potentially higher rates of revision surgeries. In the context of rhinoplasty, the type of nasal deformity may complicate the surgical procedure and increase the operative time. We aimed to investigate the association between the type of nasal deformity and operative time in rhinoplasty patients. This retrospective chart review studies 349 patients who underwent primary and secondary rhinoplasty procedures due to various nasal deformities in King Saud University-Medical City. The primary outcome of the present study was the association between operative time, defined as the time from the initial incision to the completion of skin closure, and the type of nasal deformity. The association between the type of deformity and operative time was assessed using one-way ANOVA and Bonferroni post hoc analysis. There was a statistically significant association between the type of nasal deformity and operative time (p < 0.001). Patients with dorsal, alar base, and tip deformities had significantly longer operative times than patients with isolated dorsal deformities (208.01 ± 57.73 min) (p < 0.001). The analysis also showed that the presence of crooked nose deformities (p < 0.001), an inverted V deformity (p = 0.01), internal nasal valve collapse (p = 0.025), axis deviation (p = 0.003), over-projection, and under-projection significantly increased surgical duration. The complexity of nasal deformities significantly impacts the operative time in rhinoplasty surgeries; more complex deformities that require extensive surgical procedures are associated with a longer operative time. Further research is warranted to corroborate these findings and investigate other potential influencing factors.

1. Introduction

Rhinoplasty is a highly prevalent surgical procedure within the field of facial plastic surgery. Previous statistics showed that nearly 352,555 rhinoplasties were performed in the United States (US) alone in 2020, ranking it as the third most commonly performed aesthetic surgery [1]. Rhinoplasty is indicated for a wide range of conditions, including aesthetic improvement, restoration after trauma, or alleviating functional concerns such as breathing difficulties. Hence, it is broadly classified into cosmetic and functional types [2]. The techniques for rhinoplasty have evolved significantly over the years. The two primary surgical approaches currently include open and closed techniques [3]. The open approach, often utilized for more complex cases, involves an external incision along the columella, allowing for increased visualization and manipulation of nasal structures [4]. The closed approach involves incisions confined to the inside of the nose, potentially leading to less visible scarring and faster recovery time, though it offers less visibility [5]. Several factors can affect the outcomes of rhinoplasty, including the surgeon’s experience, anatomical features, and postoperative care [6].

Despite its popularity in clinical practice, rhinoplasty remains a challenging surgical procedure due to the complexity of nasal anatomy and the importance of achieving satisfactory functional and aesthetic goals, leading to a revision rate as high as 15% [7]. The need for the accurate manipulation of nasal structures, an individualized approach to achieve patient needs, and the technical challenges of some surgical processes (such as tip modification and septoplasty) contribute to the complexity of rhinoplasty [5]. The type of nasal deformity can significantly increase the complexity of rhinoplasty, influencing both the surgical approach and the outcome [8]. Certain structural deformities may involve extensive manipulation or be associated with breathing difficulties that necessitate complex functional rhinoplasty [9]. In addition, achieving a satisfactory aesthetic result for nasal deformities can be challenging and often requires complex reconstructive procedures [10,11].

Therefore, the presence of nasal deformities alters the surgical plan and can complicate the surgical procedure and increase the operative time. The operative time in rhinoplasty can be significantly affected by the presence and type of nasal deformities due to the need for additional steps and complex techniques. Prolonged operative time in surgical procedures, including rhinoplasty, can negatively impact intra- and postoperative outcomes [12]. Intraoperatively, prolonged operative time was associated with an increased risk of blood loss [13]. In addition, recent reports showed that prolonged operative time increases the risk of surgical site infection rates, prolonged hospital stays, and potentially higher rates of revision surgeries [14].

Hence, in the context of rhinoplasty, it is crucial to characterize the risk of prolonged operative time amongst different types of nasal deformity. The present study investigated the association between the type of nasal deformity and operative time in rhinoplasty patients. By identifying at-risk patients, appropriate preoperative planning can be performed to mitigate the risks associated with prolonged operative time.

2. Materials and Methods

2.1. Study Design and Data Collection

This retrospective chart review was conducted at King Saud University-Medical City, Riyadh, Saudi Arabia. We reviewed the medical records of patients who underwent primary and secondary rhinoplasty procedures due to various nasal deformities between January 2020 and May 2023. Patients were included if they underwent rhinoplasty for nasal deformity correction and had complete data regarding the duration of surgery in their medical records. One senior facial plastic surgeon performed all the surgeries. We excluded patients who had concurrent facial surgery, those with incomplete medical records, or those who had emergency surgery. The following data were collected from the medical records of eligible patients: age, sex, nationality, type of nasal deformity, surgical approaches, operative time, and postoperative patient satisfaction (by weeks). The primary outcome of the present study was the association between operative time, defined as the time from the initial incision to the completion of skin closure, and the type of nasal deformity.

2.2. Statistical Analysis

Descriptive analysis was employed using mean ± standard deviation (SD) for numerical data and number (percentage) for categorical data. The association between the type of deformity and operative time was assessed using one-way ANOVA and Bonferroni post hoc analysis. In addition, patients were categorized into average and prolonged operative time according to the median time of the overall cohort. The association between operative time categories and preoperative characteristics was assessed using an independent T-test or one-way ANOVA with Bonferroni post hoc analysis. p-Values < 0.05 were considered statistically significant. We conducted statistical analyses using the Statistical Package for the Social Sciences (SPSS) software (version 28.0) for Windows.

2.3. Ethical Considerations

This retrospective study was approved by the IRB committee of King Saud University-Medical City (Ref No. 23/0310/IRB). The need for informed consent was waived due to the retrospective nature of the study. The present report was prepared according to the STROBE statement [15].

3. Results

A total of 349 patients were included in the present study. The average age of the patients was 31.5 ± 8.1 years, and the majority of the patients were females (54.4%). Most patients were of Saudi nationality (95.7%, n = 334). In terms of nasal deformities, the most common deformity was a combination of dorsal, alar, and tip deformities, present in 49.9% of patients (n = 174). The next most common was dorsal deformity in combination with tip deformity, found in 20.9% of patients (n = 73). Patients underwent different types of surgeries, the most common being open septo-rhinoplasty, which was performed in 40.7% of cases (n = 142). The second most common surgery was open septo-rhinoplasty combined with submucous diathermy (SMD), which was performed in 20.6% of cases (n = 72). The mean operative time across all procedures was 197.01 ± 63.07 min. Finally, the overall patient satisfaction rate was high, with 96% (n = 335) of patients reporting satisfaction with the outcome of their rhinoplasty (

Table 1. Characteristics of the included patients (n = 394).

Variables		Patients (n = 349)
Age, mean ± SD		31.5 ± 8.1
Male, No. (%)		159 (45.6%)
Nationality, No. (%)	Saudi Non-Saudi	334 (95.7%) 15 (4.3%)
Nasal Deformity, No. (%)	Dorsal deformity	159 (45.6%)
	Alar base deformity	10 (2.9%)
	Tip deformity	15 (4.3%)
	Dorsal deformity + alar base	33 (9.5%)
	Dorsal deformity + tip deformity	73 (20.9%)
	Alar deformity + tip deformity	13 (3.7%)
	Dorsal deformity + alar deformity + tip deformity	174 (49.9%)
	Crooked nose	122 (34.95%)
Surgery, No. (%) Variables	Open septo-rhinoplasty	142 (40.7%)
	Close septo-rhinoplasty	29 (8.3%)
	Revision open septo-rhinoplasty	7 (2%)
	Revision close septo-rhinoplasty	2 (0.6%)
	Open septo-rhinoplasty + SMD	72 (20.6%)
	Open septo-rhinoplasty cartilage graft + auricular	9 (2.6%)
	Open septo-rhinoplasty + temporalis fascial graft	5 (1.4%)
	Open septo-rhinoplasty + turbinoplasty	35 (10%)
	Open septo-rhinoplasty resection + alar base	7 (2%)
	Close septo-rhinoplasty + SMD	3 (0.9%)
	Revision close septo-rhinoplasty	2 (0.6%)
	Close septo-rhinoplasty fascial graft + temporalis	1 (0.35)
	Revision open septo-rhinoplasty + auricular cartilage graft + temporalis fascia graft	13 (3.7%)
	Open septo-rhinoplasty + auricular cartilage graft + temporalis fascia graft	22 (6.3%)
Operative time, mean ± SD		197.01 ± 63.07
Patient satisfaction, No. (%)		335 (96%)

).

There was a statistically significant association between the type of nasal deformity and operative time (p < 0.001). Patients presenting with isolated dorsal deformity required shorter operative time, averaging 157.9 ± 86.35 min. In contrast, those with a combination of alar base and tip deformities had longer operative time, averaging 215.54 ± 49.53 min. Cases involving combined dorsal, alar base, and tip deformities also led to extended operative times (208.01 ± 57.73 min). The post hoc analysis showed that patients with combined dorsal, alar base, and tip deformities had significantly longer operative time than patients with isolated dorsal deformities (p < 0.001) (Figure 1).

The analysis also showed that patients with crooked nose deformities had significantly longer operative times (213.64 ± 61.8 min) compared to those without this deformity (188.08 ± 62.4 min, p < 0.001). The presence of an inverted V deformity (ITH) also led to increased operative times (209.05 ± 60.6 min) compared to those without (190.71 ± 62.6 min, p = 0.01). Similar results were found for internal nasal valve collapse (211.09 ± 60.3 min vs. 192.96 ± 63.4 min, p = 0.025) and axis deviation (213.63 ± 62.2 min vs. 190.98 ± 62.4 min, p = 0.003). Furthermore, over-projection and under-projection significantly increased surgical duration (p = 0.011 and =0.024, respectively;

Table 2. Association between nasal deformities or anatomical features and operative time.

Variables		Operative Time	p-Value
Nasal Deformity, mean ± SD	Dorsal deformity	157.9 ± 86.35	<0.001
	Alar base deformity	211 ± 88.78
	Tip deformity	167.47 ± 62.59
	Dorsal deformity + alar base	185.73 ± 51.67
	Dorsal deformity + tip deformity	193.37 ± 58.98
	Alar deformity + tip deformity	215.54 ± 49.53
	Dorsal deformity + alar deformity tip deformity	208.01 ± 57.73
Crooked nose, mean ± SD	Yes	213.64 ± 61.8	<0.001
	No	188.08 ± 62.4
ITH, mean ± SD	Yes	209.05 ± 60.6	0.010
	No	190.71 ± 62.6
Internal nasal valve collapse, mean ± SD	Yes	211.09 ± 60.3	0.025
	No	192.96 ± 63.4
Axis deviation, mean ± SD	Yes	213.63 ± 62.2	0.003
	No	190.98 ± 62.4
Over-projection, mean ± SD	Yes	227.15 ± 63.2	0.011
	No	194.59 ± 62.6
Under-projection, mean ± SD	Yes	212.21 ± 56.9	0.024
	No	193.2 ± 64

).

The mean operative time for open septo-rhinoplasty was 191.92 ± 49.8 min, while closed septo-rhinoplasty averaged 114.66 ± 50.8 min (p < 0.001). Revision open septo-rhinoplasty took 152.86 ± 78.3 min, and revision closed septo-rhinoplasty required 62.50 ± 67.2 min. When additional procedures were performed, the times varied: open septo-rhinoplasty combined with spreader graft was 208.9 ± 54.9 min, with auricular cartilage graft was 221.22 ± 58.8 min, with temporalis fascial graft was 236 ± 43.5 min, with turbinoplasty was 238.49 ± 56.4 min, and with alar base resection was 202.14 ± 58.5 min. For closed septo-rhinoplasty combined with SMD, the time was 113 ± 40.9 min, 235 min for temporalis fascial graft, and 65 min for turbinoplasty. Revision open septo-rhinoplasty with auricular cartilage and temporalis fascia grafts took 231.1 ± 68.5 min, while open septo-rhinoplasty with these combined grafts took 231.27 ± 54.3 min. Additionally, the mean operative times were significantly different between males (206.04 ± 64.3 min) and females (189.46 ± 61.2 min) with a p-value of 0.014, and between Saudi (198.1 ± 63.6 min) and non-Saudi patients (173.27 ± 44.4 min) with a p-value of <0.001. (

Table 3. Association between nasal deformities and other parameters.

Variables		Operative Time	p-Value
Surgery, mean ± SD	Open Septo-rhinoplasty	191.92 ± 49.8	<0.001
	Close Septo-rhinoplasty	114.66 ± 50.8
	Revision Open Septo-rhinoplasty	152.86 ± 78.3
	Revision Close Septo-rhinoplasty	62.50 ± 67.2
	Open Septo-rhinoplasty + SMD	208.9 ± 54.9
	Open Septo-rhinoplasty + Auricular Cartilage Graft	221.22 ± 58.8
	Open Septo-rhinoplasty + Temporalis Fascial Graft	236 ± 43.5
	Open Septo-rhinoplasty + Turbinoplasty	238.49 ± 56.4
	Open Septo-rhinoplasty + Alar Base Resection	202.14 ± 58.5
	Close Septo-rhinoplasty + SMD	113 ± 40.9
	Close Septo-rhinoplasty + Temporalis Fascial Graft	235
	Close Septo-rhinoplasty + Turbinoplasty	65
	Revision Open Septo-rhinoplasty + Auricular Cartilage Graft + Temporalis Fascia Graft	231.1 ± 68.5
	Open Septo-rhinoplasty + Auricular Cartilage Graft + Temporalis Fascia Graft	231.27 ± 54.3
Sex, mean ± SD	Male	206.04 ± 64.3	0.014
	Female	189.46 ± 61.2
Nationality, mean ± SD	Saudi	198.1 ± 63.6	<0.001
	Non-Saudi	173.27 ± 44.4

).

4. Discussion

The present study aimed to elucidate the association between nasal deformity types and the operative time in rhinoplasty surgeries. Our findings indicate a significant relationship between nasal deformity types and operative time. The complexity of nasal deformities and certain anatomical factors, including a crooked nose, ITH, internal nasal valve collapse, axis deviation, over-projection, and under-projection, contributed to prolonged surgical duration in our cohort. In addition, the complexity of the surgical approach significantly influenced operative times, which is likely attributed to the fact that complex deformities require more extensive surgical approaches. Patient sex also played a role, with male patients typically requiring longer operative times. These findings present crucial considerations for surgical planning and management in rhinoplasty procedures, potentially contributing to improved surgical outcomes and patient satisfaction.

This is the first cohort study that established the significant impact of nasal deformities on the operative time in rhinoplasty patients. In particular, patients with complex deformities, such as a combination of alar base and tip deformities or a combination of dorsal, alar base, and tip deformities, necessitated longer operative times. The surgical challenges in these patients can explain such findings. Patients presenting with complex deformities necessitate a higher degree of surgical intervention, multiple surgical maneuvers, and a holistic approach to achieving satisfactory functional and aesthetic outcomes. For instance, combining a dorsal deformity with an alar base or a tip deformity requires a thorough understanding of the interplay between different nasal structures and the meticulous execution of surgical techniques [16,17]. In return, the chance of using time-consuming techniques, such as grafting or advanced suturing techniques, is high to achieve satisfactory outcomes, extending the operative time [18]. Complex nasal deformities usually require intraoperative modifications of the surgical plan, contributing further to a longer operative time [19].

Our findings have several clinical implications. The association between the complexity of nasal deformity and operative time highlights the need for meticulous preoperative assessment and planning. Surgeons should consider appropriate preoperative planning in patients with complex deformities. Second, understanding the impact of the complexity of nasal deformities on operative time allows for better patient counselling, which can significantly affect patient satisfaction [20]. In addition, the surgeon’s experience should play a role in managing complex nasal deformities to optimize operative efficiency and postoperative outcomes. Lastly, these findings may have implications for surgical scheduling and resource allocation in healthcare facilities. Understanding that surgeries for complex deformities will take longer can help in better operating room management, ensuring adequate time for these cases, which can contribute to more efficient use of healthcare resources.

One of the interesting findings of the present study is the distribution of nasal deformities in the Saudi population. The current evidence suggests ethnic variations in nasal deformities among rhinoplasty patients [21,22]. The Middle Eastern nose is characterized by several distinct features, including thick sebaceous skin often associated with enlarged pores, a pronounced dorsal hump, an under-projected tip, a deep radix, larger nostrils, and a wide alar base contribute to the overall impression of a broad nose and septal deviation [23]. In the present study, the most common deformity was a combination of dorsal, alar, and tip deformities, followed by a combination of dorsal and tip deformities. Alharethy et al. showed that the most common nasal deformities in patients undergoing rhinoplasty in Saudi Arabia were a broad dorsum and bulbous columella, followed by deviation [24]. Such results are in line with previous reports from Turkey [22] and Iran [25]. The ethnic characteristics of the Middle Eastern nose might have contributed to the prolonged operative time in patients with complex deformities in our cohort. According to Daniel, rhinoplasty in Middle Eastern patients necessitates an extensive surgical maneuver to ensure that the aesthetic outcomes respect the patient’s ethnic heritage and functional integrity [23].

In addition to the clinical considerations, the economic implications of variable operative times in rhinoplasty are significant and warrant attention. Insurance often covers functional rhinoplasties; however, the reimbursement models used by insurance companies typically rely on standardized rates that may not account for the variability in operative time associated with different levels of deformity complexity [26]. This can lead to discrepancies where procedures that require extended surgical time due to higher complexity are reimbursed at the same rate as those requiring less time, potentially undervaluing the surgeon’s effort and the use of resources. On the other hand, cosmetic rhinoplasties are entirely financed by the patient. Similar to functional rhinoplasties, their operative cost often does not reflect the operative time variability. Future research could explore the development of more nuanced cost structures and reimbursement models that better align with the complexity and time required for these procedures.

We acknowledge that the present study has certain limitations, mainly due to the retrospective nature of our study. One of the main concerns with retrospective studies is the possibility of selection bias. Our study relied on existing medical records from a single center, and the patient population included may not fully represent the broader population of rhinoplasty patients. Patients selected for surgery at our institution may differ in terms of demographic characteristics, deformity complexity, or surgeon experience from those treated at other centers. This could limit the generalizability of our findings. Another concern in the present study is recall bias. Although recall bias is more commonly associated with patient-reported outcomes, it can also affect the accuracy of data recorded retrospectively. The information documented in medical records may not always capture the full complexity of the surgical procedures or the nuances of the deformities being treated. This could result in an underestimation or overestimation of the actual surgical time required for certain deformities. Additionally, our study design did not allow for the collection of real-time data, which limits our ability to account for all variables that might influence surgical time, such as intraoperative decision making, surgeon fatigue, or unforeseen complications. While our study focused on surgical time as the primary outcome, we recognize that other important factors, such as postoperative functional and aesthetic results, were not included in our analysis. Future studies should aim to include these outcomes to provide a more holistic assessment of the impact of nasal deformity complexity on rhinoplasty success.

Firstly, this study is inherently limited by its retrospective nature, which may increase the risk of recall and misclassification bias. The study population mainly consisted of Saudi nationals and were from a single center only; the lack of ethnic diversity and multi-center data collection limits the generalizability of the findings to wider, more diverse populations. In addition, this study did not consider other potentially significant factors that could influence operative time, such as surgeon experience, specific surgical instruments, intraoperative complications, or preoperative patient health status, including comorbidities or medication use. Data such as hospital stay and complications were also unavailable to assess patient outcomes after surgery.

5. Conclusions

The present study showed that the complexity of nasal deformities significantly impacts the operative time in rhinoplasty surgeries; more complex deformities that require extensive surgical procedures are associated with a longer operative time. In addition, our analysis showed that specific anatomical factors, such as the presence of a crooked nose or over-projection, and male sex are associated with longer operative time. Thus, a thorough preoperative assessment considering these factors could potentially aid in optimal surgical planning and patient management. However, further research is warranted to corroborate these findings and investigate other potentially influencing factors.