Development and Psychometric Evaluation of the FACE-Q Scales for Patients Undergoing Rhinoplasty

Klassen AF, Cano SJ, East CA, Baker SB, Badia L, Schwitzer JA, Pusic AL.

PubMed 26605889 Publisher (DOI)Free full text (PMC)

What this paper says

Built and tested with 158 patients in three countries, the FACE-Q rhinoplasty module produced a 10-item nose scale and a 5-item nostril scale that reliably detected improvement after surgery.

Overview

Rhinoplasty results have usually been judged by observers looking at photographs, but appearance is subjective and the patient's own view is what the surgery is for. This paper reports how the rhinoplasty section of FACE-Q was built and tested for reliability, validity and ability to detect change.

Sections of note

Patients aged 18 or over were recruited between July 2010 and March 2015 at plastic surgery clinics in the United States, England and Canada.
158 of 169 invited patients took part, a 93.5 percent response rate.
The most common adverse effect reported was the skin of the nose looking thick or swollen.
Rasch measurement analysis reduced the item pool to a 10-item Satisfaction With Nose scale and a 5-item Satisfaction With Nostrils scale.
Reliability was high: person separation index 0.91 and Cronbach alpha 0.96 for the nose scale, 0.89 and 0.96 for the nostrils scale.
Scores were higher after surgery than before on all five scales (p less than 0.001). Among 23 patients giving both preoperative and postoperative data, all five scales improved (p at or below 0.003), with effect sizes from 0.6 to 2.3.

What it means for a patient

This is the questionnaire that many later rhinoplasty studies use, so it shapes what published outcomes actually measure.
Patients bothered by a specific side effect scored lower on satisfaction, so the tool captures the link between problems and overall opinion.
Only 23 patients were measured both before and after surgery, which is a small basis for the before-and-after comparison.
The study validates a measuring instrument. It does not test any surgical technique or report complication rates.

Why this paper matters

Without a validated way to ask patients what they think, rhinoplasty research is left with surgeon-graded photographs. Building and testing that instrument across three countries is the groundwork that makes comparable outcome studies possible. What it cannot show is which operations produce the best scores.

Terms

Patient-reported outcome instrument: a formally tested questionnaire measuring the patient's own view.
Psychometric evaluation: testing whether a questionnaire measures consistently and accurately.
Rasch measurement theory: a statistical method for checking that questionnaire items form a proper scale.
Cronbach alpha: a measure of internal consistency, how well the items hang together.
Effect size: how large a change is, expressed in standard units.

Summary written by rhinoplasty.cc from the abstract, 2026-09-08; not medical advice. The authors' own abstract follows.

Abstract

Importance: Rhinoplasty continues to rank among the most popular cosmetic surgical treatments. Measuring what the nose looks like has typically involved the use of observer-reported or physician-reported outcome measures (eg, photographs). While objective outcomes are important, facial appearance is subjective, and asking patients what they think about the appearance of their nose is of paramount importance. The patient perspective can be measured using patient-reported outcome instruments.

Objective: To describe the development and psychometric evaluation of the FACE-Q scales and adverse effects checklist designed to measure rhinoplasty outcomes.

Design, Setting, And Participants: A questionnaire was completed by patients recruited between July 13, 2010, and March 1, 2015. Psychometric methods were used to select the most clinically sensitive items for inclusion in item-reduced scales as well as to examine reliability, validity, and ability to detect clinical change. The setting was plastic surgery clinics in the United States, England, and Canada. Participants were preoperative and postoperative patients 18 years or older undergoing rhinoplasty.

Main Outcomes And Measures: Responses and validation measures of the FACE-Q scales and adverse effects checklist.

Results: In total, 158 of 169 patients invited to participate in the study were enrolled (response rate, 93.5%). The most common adverse effect was the skin of the nose looking thick or swollen. Rasch measurement theory analysis led to the refinement of a 10-item Satisfaction With Nose Scale and a 5-item Satisfaction With Nostrils Scale. The person separation index and Cronbach α were 0.91 and 0.96, respectively, for the Satisfaction With Nose Scale and 0.89 and 0.96, respectively, for the Satisfaction With Nostrils Scale. All items had ordered thresholds and good item fit. Satisfaction with the nose and nostrils was incrementally lower in participants bothered by specific adverse effects (eg, the skin of the nose looking thick or swollen). Patient satisfaction on the Satisfaction With Nose Scale and the Satisfaction With Nostrils Scale and on 3 additional FACE-Q scales (ie, Satisfaction With Facial Appearance Scale, Psychological Function Scale, and Social Function Scale) was higher after surgery than before surgery (P < .001 for all, independent samples t test). Twenty-three participants who provided preoperative and postoperative data reported improvement on all 5 scales (P ≤ .003 for all). The effect sizes ranged from 0.6 to 2.3. Significant individual-level change was reported by most participants for the Satisfaction With Nose Scale, Satisfaction With Nostrils Scale, Satisfaction With Facial Appearance Scale, and Social Function Scale.

Conclusions And Relevance: A FACE-Q scales rhinoplasty module can be used in clinical practice, research, and quality improvement to incorporate the patient perspective in outcome assessments.

Level Of Evidence: NA.

Abstract as indexed by PubMed; the article is open access (PubMed Central).