Evaluation of Hypermobility in Rhinoplasty: A Case-Control and Cross-Sectional Study

By Omer Faruk Kocak¹, Mahmut Alpayci², Canser Yilmaz Demir¹, Server Ilter¹, Nazim Bozan³

Affiliations

1. Department of Plastic and Aesthetic Surgery, Yuzuncu Yil University Hospital, Van, Turkiye
2. Department of Physical Medicine and Rehabilitation, Fizyocenter Hospital, Diyarbakir, Turkiye
3. Department of Otorhinolaryngology, Yuzuncu Yil University Hospital, Van, Turkiye

doi: 10.29271/jcpsp.2025.12.1603

ABSTRACT
Objective: To determine the frequency and severity of joint hypermobility (JH) in rhinoplasty patients and to assess rhinoplasty satisfaction in rhinoplasty cases with JH.
Study Design: Comparative cross-sectional study.
Place and Duration of the Study: Department of Plastic and Aesthetic Surgery, Yuzuncu Yil University Hospital, Van, Turkiye, between February and May 2024.
Methodology: A total of 108 participants (54 rhinoplasty patients and 54 matched healthy controls) were examined in this study. Patients and healthy controls were compared in terms of the frequency and severity of JH. The Beighton scoring system was used to assess hypermobility. Rhinoplasty patients with JH (Beighton score ≥4) and without JH (Beighton score <4) were compared in terms of rhinoplasty outcomes. The rhinoplasty outcome evaluation (ROE) questionnaire was used as an outcome measure.
Results: Rhinoplasty patients and healthy controls were statistically similar in terms of frequency (p = 1.0) and severity (p = 0.754) of JH. No significant correlation was found between hypermobility scores and rhinoplasty results in rhinoplasty patients (n = 54; r = 0.015; p = 0.916; Spearman’s correlation test). Rhinoplasty patients with and without JH were similar in terms of rhinoplasty results (15.30 ± 6.82 vs. 16.16 ± 4.92; p = 0.645). No significant correlation was found between JH scores and rhinoplasty results (p = 0.916).
Conclusion: JH does not appear to be associated with rhinoplasty and should not be a concern in rhinoplasty. It is not necessary to consider JH to ensure rhinoplasty satisfaction.

Key Words: Rhinoplasty, Satisfaction, Joint hypermobility, Beighton score.

INTRODUCTION

Rhinoplasty is a popular surgical procedure performed worldwide. A significant improvement in quality of life has been reported after rhinoplasty.¹ However, postoperative respiratory and cosmetic dissatisfaction may occur.² Although studies have reported satisfactory outcomes, it is important to evaluate the potential factors associated with dissatisfaction, even if it is rare. To date, several factors such as pain, function, and aesthetic appearance have been reported to be associated with dissatisfaction after rhinoplasty.^2,3 However, the causes of dissatisfaction are not fully understood. Therefore, potential factors associated with dissatisfaction in rhinoplasty need to be addressed.

Joint hypermobility (JH) refers to joint movement beyond the normal physiological range, and its symptoms extend far beyond the musculoskeletal system. Some hypermobility disorders (e.g., Ehlers-Danlos syndrome) are associated with poor wound healing, vascular fragility, and surgical complications.⁴ JH is associated with biomechanical instability,⁵ pes planus, ankle sprain,⁶ skin changes, and recurrent hernias.⁷

Hypothetically, given that JH is associated with the aforementioned disorders and complaints,^4-7 tissue-related problems, such as a crooked nose, may be more common in patients with JH. Therefore the frequency and severity of JH may be higher in rhinoplasty cases. Furthermore, poor wound healing, vascular fragility,⁴ and soft tissue laxity and friability,⁷ observed in JH may negatively affect rhinoplasty satisfaction. Therefore, it is worth investigating whether hypermobility plays a negative role in rhinoplasty satisfaction.

This study aimed to determine the frequency and severity of JH in rhinoplasty cases and to evaluate rhinoplasty satisfaction in rhinoplasty cases with JH.

 

METHODOLOGY

This study was conducted in the Department of Plastic and Aesthetic Surgery, Yuzuncu Yil University Hospital, Van, Turkiye, between February and May 2024. A total of 108 participants (54 rhinoplasty patients and 54 matched healthy controls) were studied. Matching was based on demographic characteristics such as age, gender, body mass index (BMI), occupation, education level, and marital status. These characteristics are potential factors that may affect nasal function and appearance.^8-11 Therefore, they were taken into consideration when matching healthy controls, and homogeneity between rhinoplasty cases and healthy controls was tried to be achieved.

The study included both case-control and cross-sectional designs. Rhinoplasty cases and matched healthy controls were compared in terms of JH frequency and severity. Cross-sectionally, rhinoplasty cases with and without JH were compared in terms of rhinoplasty satisfaction. In addition, the correlation between JH severity and rhinoplasty satisfaction in rhinoplasty cases was evaluated.

All patients underwent open technique rhinoplasty to improve nasal function and aesthetics. Open rhinoplasty has been reported to provide significant improvements in nasal obstruction symptoms and rhinoplasty outcomes.¹²

The rhinoplasty outcomes evaluation (ROE) questionnaire was used to determine the satisfaction rate with nasal function and appearance. This questionnaire is a validated tool for assessing rhinoplasty outcomes.¹³ The ROE questionnaire inc-ludes six questions that assess rhinoplasty-related outcomes, with higher scores indicating higher satisfaction with nasal cosmetics and function.¹³

The Beighton hypermobility scoring scale was used to assess JH status. This scoring system has high inter- and intra-rater reliability and is widely used to detect the presence or absence and severity of JH.¹⁴ According to the Beighton scoring system, joint laxity is assessed on a nine-point movement scale, and a total score ≥4 is required to define JH, according to the traditional cut-off value (Beighton hypermobility score ≥4).⁶ A higher Beighton score indicates more severe JH (Table I).¹⁴

The same specialist applied both the inclusion and exclusion criteria. Individuals who had undergone rhinoplasty were contacted by telephone and invited to participate in the study. Rhinoplasty cases with I-shaped crooked nose correction and those who gave consent for participation were included in the study.

The exclusion criteria were as follows: conditions that make the Beighton score difficult to assess such as limited joint mobility (e.g., congenital anomalies, infection, amputation, contracture, and fracture), muscular dystrophy, spinal deformity, autoinflammatory diseases, pregnancy, severe obesity (BMI ≥40), and psychiatric disorders. Because joint mobility is affected by ageing,¹² patients <18 or >45 years of age were excluded to ensure homogeneity. Revision rhinoplasty and C- or S-shaped crooked nose correction were also excluded.

IBM^® SPSS^® version 27 was used for statistical analysis. The Kolmogorov-Smirnov normality test was applied when evaluating the rhinoplasty (n = 54) and control (n = 54) groups. Only BMI scores were normally distributed in both groups. The Shapiro-Wilk normality test was applied when comparing rhinoplasty patients with (n = 10) and without (n = 44) JH. Weight, BMI, and ROE scores were normally distributed in both patients with and without JH. Accordingly, the Mann-Whitney U test, Student’s t test and Spearman’s correlation test were used for continuous variables, and the tests used are mentioned below the tables. Continuous variables analysed with parametric tests were reported as mean and standard deviation (SD), while data analysed with nonparametric tests were reported as median (IQR). Categorical variables were evaluated using Fisher's exact test and were reported as frequency.

RESULTS

According to the Beighton scoring system, joint laxity was assessed  on  a  nine-point  movement  scale  (Table  I).

Rhinoplasty patients and healthy controls were similar in terms of age (p = 0.532), gender (p >0.99), BMI (p = 0.413), marital status (p = 0.248), employment (p = 0.639), and education (p = 0.836; Table II). The frequency (p = 1.0) and severity (p = 0.754) of JH were similar between rhinoplasty patients and healthy controls (Table II). There was no significant correlation between the ROE and Beighton scores in rhinoplasty patients (n = 54; r = 0.015; p = 0.916; Spearman’s correlation test).

No significant difference was found between rhinoplasty patients with and without JH in terms of age (p = 0.755), gender (p = 0.069), BMI (p = 0.520), marital status (p = 0.161), employment (p = 0.203), education (p = 0.067), postoperative period (p = 0.203), and rhinoplasty satisfaction (p = 0.645, Table III).

Table II: Individual characteristics of the participants: statistical comparison between the groups according to the Beighton and ROE scores.

Parameters	Rhinoplasty patients (n = 54)	Healthy controls (n = 54)	p-value
Age (years)	29.5 (12.5)	32 (11.5)	0.532*
Female/Male	33/21	33/21	>0.99**
Weight (kg)	66.0 (13.25)	67 (20.25)	0.754*
Height (m)	1.67 (0.13)	1.67 (0.15)	0.798*
BMI (kg/m2)	23.75 ± 2.37	24.18 ± 3.0	0.413***
Single/Married	23/31	30/24	0.248**
Working/Not working	41/13	44/10	0.639**
University/High school	36/18	38/16	0.836**
Postoperative period, years	3.0 (4.5)	-	-
Hypermobility (Beighton score ≥4), n (%)	10 (18.5%)	9 (16.7%)	1.0*
Beighton score	0.0 (2.0)	0.0 (2.0)	0.754**
ROE score	16.0 ± 5.26	-	-
Data are expressed as mean ± SD or median (IQR) or frequency (percentage). *Mann-Whitney U test; **Fisher’s exact test; ***Student’s t-test. ROE: Rhinoplasty outcome evaluation questionnaire.

Table III: Comparison between rhinoplasty patients with (Beighton score ≥4) and without (Beighton score <4) JH.

Parameters	Beighton score ≥4 (n = 10)	Beighton score <4 (n = 44)	p-value
Age, (years)	28.5 (20.75)	30 (11.75)	0.755*
Female/Male	9/1	24/20	0.069**
Weight (kg)	67.11 ± 9.26	68.65 ± 12.92	0.148***
Height (m)	1.63 (0.07)	1.68 (0.12)	0.051*
BMI (kg/m2)	24.19 ± 1.89	23.65 ± 2.47	0.520***
Single/Married	2/8	21/23	0.161**
Working/Not working	6/4	36/8	0.203**
University/High school	4/6	32/12	0.067**
Postoperative period, years	0.8 (5.55)	3.5 (4.03)	0.203*
Beighton score	5.5 (1.5)	0.0 (2.0)	<0.001*
ROE score	15.30 ± 6.82	16.16 ± 4.92	0.645***
ROE: Rhinoplasty outcome evaluation questionnaire; Values are expressed as mean ± SD or frequency. *Mann-Whitney U test; **Fisher’s exact test; ***Student’s t-test.

DISCUSSION

This study focused on the possible association between JH and rhinoplasty. The statistical analysis showed that rhinoplasty patients and matched healthy controls were similar in terms of frequency and severity of JH. Furthermore, rhinoplasty patients with and without JH were similar in terms of rhinoplasty satisfaction, and no significant correlation was found between JH and rhinoplasty scores. These were the first findings in the literature and showed that there is no significant relationship between JH and rhinoplasty satisfaction.

Previous studies have reported significant improvements in quality of life after rhinoplasty.¹ However, postoperative dissatisfaction may occur,² although its underlying risk factors are not yet fully understood. Previous studies have reported that nasal pain, dysfunction, and poor appearance outcomes can negatively affect rhinoplasty satisfaction.^2,3 As rhinoplasty is a common procedure, cases of dissatisfaction can also be encountered. Therefore, it is important to identify and address potential factors associated with postoperative dissatisfaction, even if such cases are relatively uncommon.

Considering that JH is associated with poor wound healing, vascular fragility, surgical complications,⁴ soft tissue laxity and friability, and skin changes,⁷ it can be hypothesised that tissue problems such as a crooked nose may be more common in patients with JH. Therefore, the frequency and severity of JH may be higher in rhinoplasty patients. This potential association was explored in the present study. To the best of the authors’ knowledge, this is the first study on this subject, and it shows that rhinoplasty is not associated with the frequency and severity of JH.

Furthermore, JH was examined in this study as a possible factor influencing rhinoplasty satisfaction. Given the multifaceted negative effects of JH on tissues,^4-7 this investigation is based on a plausible background. However, rhinoplasty satisfaction was similar between patients with and without JH. No significant differences or correlations were observed between JH and postoperative satisfaction, suggesting that no significant association exists between JH and rhinoplasty outcomes.

Given the broad spectrum of hypermobility problems^4-7 and the interaction of the nasal morphology with other structures,¹⁵ some concerns may arise regarding the possible effects of JH on rhinoplasty. However, the current study did not support the validity of these concerns, consistent with the opinion of Shomorony et al.¹⁶ who noted that concerns regarding rhinoplasty outcomes in the presence of JH should be low¹⁶ because JH is mainly associated with collagen types I and III,^16,17 whereas the nasal septal cartilage is composed mainly of type II collagen.¹⁸

The primary limitations of this study are its single-centre design, small sample size, and the traditional cut-off score used for the definition of JH (Beighton score ≥4).⁶ This is not a standard method, and different cut-off scores have been used in the literature.¹⁸ However, a higher cut-off score does not change the results, and ≥4 is the most commonly used cut-off value.¹⁹ Considering that different populations have different JH scores, the current findings may not be generalisable.²⁰ A comparative discussion could not be made due to the absence of studies on this subject. This study focused on the relationship of JH with rhinoplasty satisfaction but did not consider specific rhinoplasty-related issues, such as bleeding, tissue healing, recovery, and revision.

CONCLUSION

There is no association between JH and rhinoplasty. JH should not be a concern for rhinoplasty. It is not necessary to control JH as a factor for rhinoplasty satisfaction. This is the first study on this subject, and its limitations should be considered.

ETHICAL  APPROVAL:
Ethical approval was obtained from the Ethics Committee of Yuzuncu Yil University, Faculty of Medicine, Van, Turkiye (Board Decision No. 2024/02-21; Approval date: 16 February 2024).

PATIENTS’  CONSENT:
Informed consent was obtained from the participants for the publication of the data.

COMPETING  INTEREST:
The  authors  declared  no  conflict  of  interest.

AUTHORS’  CONTRIBUTION:
OFK, MA, CYD: Conceptualised the study and drafted the manuscript.
CYD, SI: Cared for patients and provided samples; intellectually contributed to the manuscript and discussion.
MA, NB: Performed the statistical analysis; intellectually contri- buted to the manuscript and discussion.
All authors approved the final version of the manuscript to be published.

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