April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Original Investigation Research

Standardized Cosmesis and Health Nasal Outcomes Survey

questionnaire. For the task, 4 main concepts were consid- ered relevant: (1) nasal obstruction, (2) overall nasal cosme- sis, (3) specific nasal cosmesis, and (4) social perception of na- sal appearance ( Figure 1 ). At a university-based facial plastic and reconstructive surgery clinic, 18 patients undergoing rhi- noplasty were interviewed in a face-to-face fashion between October 2016 and February 2017. The patients were ap- proached by one of the principal investigators (S.P.M.). Each interview lasted for 20minutes and consisted of open-ended questions about the most important outcomes of rhinoplasty expected or perceived by the respondents. Using the concep- tual framework shown in Figure 1, the respondents were also asked to rank the items in the order of importance. Theywere also asked to estimate the importance of nasal obstruction vs nasal cosmesis with the combination of both totaling 100%. Next, using the conceptual framework shown in Figure 1 as a guideline, 5 senior surgeons with primary expertise in rhino- plasty were interviewed. Based on the results of the patients’ and the experts’ interviews, a preliminary set of question- naire items was suggested. Each item was put into a Likert- type scale from 0 to 5 with 0 indicating “no problem” and 5 indicating “extreme problem.” To eliminate potential ambi- guity, the preliminary questionnaire (eFigure 1 in the Supple- ment ) containing 13 items was administered to 5 patients in the formof cognitivedebriefing interviews. Patientswere asked to think aloud as theywere reading the questionnaire instruc- tions and items. They were also asked to suggest improve- ments to clarify and simplify the questions. Phase 2: Item Reduction The preliminary 13-itemquestionnaire was administered to a sample of the 191 English-speaking patients between Febru- ary and April 2017. No instructions other than “please fill this questionnaire out” were given. The NOSE scale 4 was concur- rently administered to all the respondents. To minimize po- tential redundancy, all the itemswithSpearman correlation co- efficients greater than 0.85 were removed resulting in a final 10-item scale ( Figure 2 ). Correlations were calculated using SPSS statistical software (version 22; IBM Corp).

Phase 3: Psychometric Evaluation The internal consistencyof SCHNOSwas examinedusingCron- bach α; α ≥ .90 was considered excellent,α ≥ .80 good, α ≥ .70 acceptable, α ≥ .60 questionable, α ≥ .50 poor, and α < .50was considered unacceptable. In addition, the Cronbach α 1-sided 95% CI was calculated. Exploratory factor analysis was used toapproximate the construct structureof the SCHNOS ( Table 1 ). According to the objective and the design of the study, the SCHNOS consisted of 2 separate domains. The first 4 items describe the severity of nasal obstruction experienced by a re- spondent. The final 6 items describe the severity of a subjec- tive cosmetic disadvantage and overall state ofmood and self- esteem due to nasal problems. The goal was to determine if each of these 2 domains of the SCHNOS measure only 1 latent trait (eg, disability) or if there are other possible significant la- tent variables affecting the results within each of the do- mains. The resultswere analyzedbothnumerically andgraphi- cally. Exploratory factor analysis (principal factors)was applied with a minimum eigenvalue for retention set at greater than 1.0 (Kaiser rule). Retained and excluded factors were also ex- ploredvisuallyona screeplot (visual approximationalongwith parallel analysis). Composite scores for nasal obstruction and

Figure 2. Final StandardizedCosmesis andHealthNasal Outcomes Survey

Over the past month, howmuch of a problemwas the following:

No problem

Extreme problem

1. Having a blocked or obstructed nose 2. Getting air through my nose during exercise 3. Having a congested nose 4. Breathing through my nose during sleep 5. Decreased mood and self-esteem due to my nose 6. The shape of my nasal tip 7. The straightness of my nose 8. The shape of my nose from the side

0 1 2 3

5 4

1 2 3

5 4

0

1 2 3 1 2 3

5 4 5 4

0 0

1 2 3

5 4

0

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

5 4 5 4 5 4 5 4 5 4

0 0 0 0 0

9. How well my nose suits my face 10. The overall symmetry of my nose

Table 1. Exploratory Factor Analysis of the SCHNOS—Factors, Eigenvalues, Factor Loadings (Pattern Matrix), and Unique Variances

Loading on Retained Factor

Uniqueness

Factor

Eigenvalue

Difference

Proportion

Cumulative

Nasal obstruction domain (n = 181, unrotated) Blocked or obstructed nose Getting air through the nose during exercise

3.13 0.00

3.13 0.07 0.03

1.05 0.00

1.05 1.05 1.03 1.00 1.00 0.99 1.05 1.05 1.04 1.02

0.92 0.90 0.83 0.88 0.74 0.86 0.83 0.90 0.90 0.88

0.15 0.19 0.31 0.22 0.46 0.26 0.31 0.20 0.19 0.23

Congested nose

−0.06 −0.09

−0.02 −0.03

Breathing through the nose during sleep

<0.01

Nasal cosmesis domain (n = 185, unrotated) Decreased mood and self-esteem due to the nose

−0.10

<0.01

−0.02

Shape of the nasal tip Straightness of nose

4.35 0.28

4.08 0.29 0.03 0.03 0.03

0.99 0.06 0.00

The shape of nose from the side How well nose suits the face Overall symmetry of the nose

−0.01 −0.05 −0.07

−0.01 −0.02

Abbreviation: SCHNOS, Standardized Cosmesis and Health Nasal Outcomes Survey.

(Reprinted) JAMA Facial Plastic Surgery January/February 2018 Volume 20, Number 1

jamafacialplasticsurgery.com

© 2017 American Medical Association. All rights reserved.

22