Evaluation of Measurement Properties of Patient-Reported Outcome Measures After Rhinoplasty: A Systematic Review

Can artificial ıntelligence detect the anti-aging effect of rhinoplasty?

BACKGROUND

The quest for eternal youth has been a common theme in many cultures for centuries. While we have yet to discover a way to preserve youth eternally, we have made significant progress in understanding the aging process and in developing pharmaceuticals, surgical techniques, and technologies. In addition to rhinoplasty's facial beautification effect, we investigated whether it had a facial anti-aging effect using an artificial intelligence (AI)-based program. We also examined the correlation between patient satisfaction and the anti-aging effect of rhinoplasty.

METHODS

This study included 244 patients who underwent functional septorhinoplasty (FSRP) between January 2018 and August 2020 at Inonu University, Department of Otorhinolaryngology. Preoperative and postoperative photographs in our archive were evaluated using an AI-based age analysis program. In addition, the participants evaluated preoperative and postoperative nose satisfaction with the FACE-Q survey in the postoperative period.

RESULTS

One hundred two males (41.8%) and 142 females (58.2%) were included in the study. The mean preoperative age determined by the program was 25.9 ± 6.1, and the mean postoperative age was 25.7 ± 5.8. Despite the mean follow-up period of the patients was 25.3 ± 8.7 months, our study showed no significant difference between the mean preoperative and postoperative ages. The mean general satisfaction of the patients increased postoperatively.  Conclusion: Despite the average follow-up period, the absence of a significant difference between preoperative and postoperative perceived mean age may be interpreted as a possible anti-aging effect of rhinoplasty. This effect was more prominent in older patients and in women.

The Application of a New Framework Construction Technique in Autologous Costal Cartilage Rhinoplasty

Background

In this study, the clinical efficacy of a new framework construction technique for costal cartilage rhinoplasty was investigated.

Methods

From January 2020 to February 2022, patients who underwent rhinoplasty in the department of plastic and reconstructive surgery of Zhejiang Provincial People's Hospital were enrolled. The sixth costal cartilage was made into the nasal columellar support graft (strut), the nasal tip graft integrated scaffold, and the septal extension grafts. The strut and septal extension grafts were sutured to construct the framework. Adobe Photoshop 6.0 was used to measure a series of aesthetic indices preoperatively and at 9 months postoperatively, including the nasal length, tip projection, nasofrontal angle, columellar/lobular angle, and nasolabial angle. The visual analog scale score and rhinoplasty outcome evaluation score were used to assess patient satisfaction. A paired t test was used for data analysis, and a P value of less than 0.05 was considered to indicate statistical significance.

Results

A total of 65 patients aged 19-43 years (average age 26.0 y) were enrolled. No short-term complications occurred. All patients were followed up for 9-23 months. There were statistically significant differences in all measurements (P < 0.05), which suggested that the aesthetic defects of the nose were corrected and that no obvious deflection or rotation of the nasal tip occurred. The visual analog scale score and rhinoplasty outcome evaluation score indicated a significant improvement in patient satisfaction (P < 0.05).

Conclusions

This new framework construction technique for costal cartilage rhinoplasty can reduce the risk of framework deflection and nasal tip rotation and provide a satisfactory nasal columellar shape.

The Rhinoplasty Health Care Monitor: An Update on the Practical and Clinical Benefits after 10 Years of Prospective Outcome Measurements

The era of value-based health care is characterized by an increasing interest in patient-reported health outcomes. For this purpose we developed the rhinoplasty health care monitor (RHM), a streamlined outcome measurement protocol, including all rhinoplasty patients since 2014. Statistical analyses of patient-reported outcome data are automated and visually presented on a custom web-based dashboard. We describe the clinical and practical benefits of the RHM and discuss how routine prospective outcome measurements have upgraded our care standards. For this prospective study, 979 consecutive patients referred for functional (revision) rhinoplasty from April 2014 to August 2023 were included. Preoperative and 3- and 12-month postoperative scores on the Nasal Obstruction Symptom Evaluation scale (NOSE), Utrecht Questionnaire (UQ), and visual analog scales (VAS) were obtained. Of 979 referred patients, 599 (61.2%) were eligible for rhinoplasty. One year postoperatively, mean NOSE scale sum score improved from 69.1 ± 22.8 to 23.1 ± 23.5 (p < 0.001). Functional VAS scores improved from 4.1 ± 2.8 (left) and 4.1 ± 2.8 (right) to 7.5 ± 1.9 (left) and 7.3 ± 2.0 (right; p < 0.001). Mean UQ sum score improved from 12.0 ± 6.4 to 6.8 ± 3.3 and aesthetic VAS score improved from 4.5 ± 2.5 to 7.4 ± 1.7 (p < 0.001) 1 year postoperatively. Benefits of the outcome routine were improved patient selection, data-driven expectation management and patient empowerment, and targeted critical appraisals of surgical performance. In conclusion, routine, automated, prospective outcome monitoring provides physicians with a response to the increasing demand for data-driven insights in health outcomes. The limited effort that is needed to gather and monitor outcome data is heavily repaid by valuable insights into aspects of care that can be improved.

Patient Selection, Outcome, and Unhappy Patients in Rhinoplasty

This article discusses the process of patient selection for rhinoplasties and the many different psychological aspects that come into play. It is important to identify the warning signs and apply a multidisciplinary approach to the surgeons practice, in collaboration with specialist rhinoplasty psychologists. Patients' motivations and surgeon factors are also discussed, as this can lead to unhappy and unsatisfactory postoperative outcomes. Potential reasons for adverse outcomes throughout the pre- and postoperative periods are also described. Finally, a brief guide is provided to reduce the risks of an unhappy patient.

Patient Selection, Outcome, and Unhappy Patients in Rhinoplasty

This article discusses the process of patient selection for rhinoplasties and the many different psychological aspects that come into play. It is important to identify the warning signs and apply a multidisciplinary approach to the surgeons practice, in collaboration with specialist rhinoplasty psychologists. Patients' motivations and surgeon factors are also discussed, as this can lead to unhappy and unsatisfactory postoperative outcomes. Potential reasons for adverse outcomes throughout the pre- and postoperative periods are also described. Finally, a brief guide is provided to reduce the risks of an unhappy patient.

Lollipop-Like Costal Cartilage Graft with a Peach-Shaped Head for East Asian Rhinoplasty

BACKGROUND

Nasal tip refinement is a challenging step of East Asian rhinoplasty due to complex anatomical defects. Autologous costal cartilage grafts are commonly used to provide nasal tip support. This study aims to evaluate the efficacy and safety of a modified technique using a lollipop-like cartilage graft with a peach-shaped head.

METHODS

A retrospective review was conducted on Chinese patients who underwent primary rhinoplasty with the modified technique between November 2018 and March 2021 at our center. Preoperative and postoperative facial photographs, patient-reported outcome measures including the visual analog scale (VAS) and the rhinoplasty outcome evaluation (ROE), as well as surgery-related complications, were collected for outcome assessment.

RESULTS

A total of 31 adult patients were included in this retrospective cohort study, with a mean follow-up period of 17.12 ± 3.89 months. The majority of patients (28/31; 90.3%) expressed satisfaction with the aesthetic outcomes, as evidenced by a significant increase in mean VAS score from 3.97 ± 1.52 preoperatively to 7.39 ± 0.22 postoperatively (P < 0.01), and a significant increase in mean ROE score from 11.77 ± 2.33 to 17.22 ± 2.47 (P < 0.01). Photogrammetric analysis also demonstrated significant improvements in nasal anatomical measurements. Among the three patients with unsatisfactory feedback, two had mild columella deviations and one had a mild dorsum deviation. No other notable complications were reported.

CONCLUSION

The current study supports the safety and utility of the modified technique utilizing the lollipop-like costal cartilage graft with a peach-shaped head for major tip refinement in East Asian patients.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A prospective study of psychological adjustment during and after forehead flap nasal reconstruction

The psychological effects of staged nasal reconstruction with a forehead flap were prospectively investigated. Thirty-three patients underwent nasal reconstruction with forehead flaps between March 2017 and July 2020. Three questionnaires were used to assess psychosocial functioning before surgery (time 1), 1 week after forehead flap transfer (time 2), 1 week after forehead flap division (time 3), and after refinement procedures (time 4). The patients were categorized into three groups according to the severity of nasal defects. Between- and within-group comparisons were conducted. All patients reported increased satisfaction with their appearance during nasal reconstruction. For most patients, levels of distress and social avoidance were highest before reconstruction (time 1). Both levels decreased as reconstruction advanced, and were significantly improved by times 3 and 4. The stage of reconstruction had a greater effect on these levels than did severity of nasal defect. Nasal reconstruction with forehead flap is beneficial physically and psychologically. Psychological evaluation before and after surgery facilitates patient-surgeon interactions and further enhances outcomes.

First Phase Development of a Patient-reported Outcome Measure for Midface Oncology

Background

Facial cancer surgery involving the midface (comprising the lower eyelids, nose, cheeks, and upper lip) can have debilitating life-changing functional, social, and psychological impacts on the patient. Midface symptoms are inadequately captured by existing patient-reported outcome measures (PROMs). PROMs are increasingly used for individual patient care, quality improvement, and standardized reporting of treatment outcomes. This study aimed to present our findings from the first phase of the development of a midface, specifically periocular and nasal, PROM.

Methods

After international guidance for PROM development, the first phase comprised identification of salient issues and item generation. Fifteen patients who had midface surgery and 10 clinicians from various specialties with more than 5 years' experience treating these patients were recruited. Semi-structured interviews explored aesthetic, functional, social, and psychological outcomes, with specific attention to deficiencies in current PROMs. Thematic analysis was used to develop an item pool, and group interviews with clinicians were carried out to create and refine PROM scales.

Results

Qualitative data from patient interviews were grouped into aesthetic, functional, and psychosocial domains for the eyelids and nose. Ninety-nine draft items were generated across these domains. Following focus group discussions, the final version of the midface-specific PROM contained 31 items (13 eye-specific, 10-nose-specific, eight general midface items).

Conclusions

This midface-specific PROM is valuable in assessing and comparing patient-reported outcomes in those who have undergone complex resection and reconstruction of the midface. This PROM is currently undergoing field testing.

Patient-Reported Outcomes Measures in Rhinoplasty: Need for Use and Implementation

Patient-reported outcome metrics (PROMs) are increasingly utilized to capture data about patients' quality of life. PROMs play an important role in the value-based health care movement by providing a patient-centered metric of quality. There are many barriers to the implementation of PROMs, and widespread adoption requires buy-in from numerous stakeholders including patients, clinicians, institutions, and payers. Several validated PROMs have been utilized by facial plastic surgeons to measure both functional and aesthetic outcomes among rhinoplasty patients. These PROMs can help clinicians and rhinoplasty patients participate in shared decision making (SDM), a process via which clinicians and patients arrive at treatment decisions together through a patient-centered approach. However, widespread adoption of PROMs and SDM has not yet been achieved. Further work should focus on overcoming barriers to implementation and engaging key stakeholders to increase the utilization of PROMs in rhinoplasty.

Functional and Aesthetic Outcomes of No-Dissection Nasal Dorsum Using Subdorsal Septal Excision in Preservation Rhinoplasty

BACKGROUND

Dorsal preservation (DP) caused privilege change in the concept of rhinoplasty and a promising superior functional and aesthetic transformation in rhinoplasty surgery. Avoiding dissection of the dorsal nasal bone and cartilage will leave the soft-tissue envelope intact, leading to a fine and smooth appearance, faster operation with less subsequent edema, and overall preservation of the dorsal aesthetic line.

METHODS

This prospective study included 113 patients who underwent DP rhinoplasty for nasal hump treatment with minimum dissection of nasal dorsum soft-tissue envelope. Results were evaluated using the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS).

RESULTS

The mean preoperative SCHNOS score was 7.21; the mean obstructive score was 2.95 ± 1.068 and the mean aesthetic score was 4.27 ± 0.771. The average lowering of the dorsal hump was 4.4 mm. Approximately 96% of patients showed improvement in the SCHNOS score after surgery, 86.7% (98 patients) showed improvement in the obstructive symptoms and 95.6% (108 patients) showed improvement in the aesthetic score. Complications were seen in 22.11% (most commonly residual hump in 13.27% of cases and dorsal indentation in 5.31%), bleeding was seen in 2.65%, and granuloma formation at the dorsal osteotomy site was seen in 0.88%. There was a very significant improvement in the aesthetic, obstructive, and overall SCHNOS score ( P = 0.000) for each parameter.

CONCLUSIONS

DP rhinoplasty is a safe and very effective procedure, with very low risk of complications. Most of the treated patients have improvement of the obstructive and aesthetic outcome after surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Incidence and Risk Factors of Postoperative Complications After Rhinoplasty: A Multi-Institutional ACS-NSQIP Analysis

OBJECTIVE

Despite the popularity of rhinoplasty, outcome research has been mainly limited to single-surgeon or single-institution reports. Therefore, we performed a multi-institutional analysis to present a broader portrait of the postoperative outcomes and risk factors for adverse events after rhinoplasty surgery.

METHODS

We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2009-2019) to identify patients who underwent rhinoplasty. The postoperative outcomes of interest included 30-day mortality, reoperation, readmission, and surgical and medical complications. We also analyzed risk factors for complication occurrence, including patient comorbidities and preoperative laboratory values.

RESULTS

We identified 835 patients, 72% (n=602) of whom underwent a primary, 21% (n=175) a secondary, and 6.7% (n=58) a cleft nasal deformity procedure. The average patient age was 41±17 years, with most patients being female (n=472; 57%) and white (n=643; 77%). Complications rates were generally low, with reoperation (n=19; 2.3%) and superficial incisional infection (n=9; 1.1%) account for the most common general and surgical adverse event, respectively. Multivariable analysis revealed male sex ( P =0.04) and higher ASA scores ( P <0.0001) as risk factors for complications. Low serum albumin ( P =0.04) and hematocrit ( P =0.003) levels were associated with the occurrence of any complication, whereas low serum albumin ( P =0.02) also correlated with the incidence of surgical adverse events.

CONCLUSION

Complication rates after rhinoplasty were overall low and seemed to correlate with male sex and ASA scores. We identified preoperative albumin and hematocrit as predictive biomarkers of adverse events. Preoperative nutritional optimization and management of low hematocrit may improve postoperative outcomes.

Clinical Benefits of the Utrecht Questionnaire for Aesthetic Outcome Assessment in Rhinoplasty: An Update

Presently, there is no consensus on which patient-reported outcome measurement (PROM) instrument is best suited to assess the aesthetic outcomes of rhinoplasty. In this regard, at least seven different validated PROMs are available from the literature, each one with advantages and disadvantages.In this article, we review the development, validation, international translation, and clinical application of the Utrecht Questionnaire (UQ). The UQ was developed in 2009 with the idea to be a short and practical tool for the rhinoplasty surgeon to assess the aesthetic outcomes of rhinoplasty. The questionnaire was then validated in 2013. Body image in relation to nasal appearance is quantified with five simple questions on a 5-point Likert scale and a Visual Analogue Scale score. We discuss how the UQ can easily be incorporated and become an important asset in a rhinoplasty practice. Practical benefits, such as its role in the shared decision-making process, patient expectations management, identification of unsuitable patients, avoiding revision surgery, and the evaluation of the surgeon's personal performance curve, are exemplified. Currently, the UQ has been translated and validated in four languages, providing scientific opportunities to generate and compare international data for advances in rhinoplasty. We describe some of the significant scientific contributions of leaders in the field of rhinoplasty that used the UQ.

The Difference in Scar-Related Quality of Life in Open Versus Closed Septorhinoplasty

INTRODUCTION

The open and closed techniques are the main surgical techniques to perform septorhinoplasty. Although the open technique offers a better view of the pertinent anatomy and facilitates surgical access, it creates an external scar that could affect patients' satisfaction and quality of life (QoL). This study aims to compare the open and closed techniques using the SCAR-Q patient-reported outcome measure.

METHODS

In this retrospective study, we have included patients who had their nasal surgery one year ago, in the period between April 2020 and April 2021. The SCAR-Q assessment tool to study patients' satisfaction with appearance, symptoms, and psychological impact of open and closed septorhinoplasty techniques.

RESULTS

A total of 77 patients were included in this analysis. Of these, 39 (50.6%) patients underwent a closed septorhinoplasty, and 38 (49.4%) patients underwent an open approach. The mean (SD) age was 29.6 (8.1) years, and most patients were females (59.7%). The overall SCAR-Q questionnaire responses were very positive across all scales in our cohort, the median (IQR) scores were 91.0 (73.0-100.0) for the appearance scale, 89.0 (70.0-100.0) for the symptoms scale, and 100.0 (87.0-100.0) for the psychological impact scale. However, we have found no differences in SCAR-Q scores regarding appearance, symptoms, and psychological impact between open and closed septorhinoplasty.

CONCLUSION

We have found no significant differences in QoL between open and closed techniques of septorhinoplasty. Larger studies are needed to further validate this finding.

Patient dissatisfaction following rhinoplasty: a 10-year experience in Iran

BACKGROUND

The nose is one of the most prominent parts of the face and plays a significant role in peoples' self-satisfaction as well as quality of life. Rhinoplasty is considered as one of the most numerous and delicate cosmetic surgeries all around the world that can be performed for functional issues, esthetic issues, or both. In this study, we aimed to evaluate the dissatisfaction of patients who had undergone rhinoplasty surgery and inform the surgeons to improve the surgical techniques to prevent probable future complaints.

METHOD

This retrospective cross-sectional study was conducted to report various aspects of dissatisfaction of patients following rhinoplasty. All available files in the Fars Forensic Medicine Department between 2011 and 2020 were reviewed, and the required information was extracted.

RESULTS

Out of 117 patients, 68.4% were females and 31.6% were males. Most of the patients were in the age range of 30-34 years. In terms of educational attainment, the highest frequency is associated with academically educated patients and the lowest with a diploma. The majority of cases filed for litigation less than 6 months after their rhinoplasty. The first rank among the factors of dissatisfaction with surgeries belonged to "respiratory problems" (36.8%) followed by "dissatisfaction with the general shape of the nose" (34.2%).

CONCLUSION

Our study shows that middle-aged female patients may be more difficult to satisfy. In general, at younger ages, patients complain about esthetics, and with aging, most patients feel dissatisfied with nasal function.

Validation of the Nasal Obstruction Symptom Evaluation Scale in Mexican Adults

BACKGROUND

Nasal obstruction is a feeling of impaired airflow through the nose, caused by diverse factors with high prevalence. There are numerous methods to study it, being the most important subjective instrument the Nasal Obstruction Symptom Evaluation score, NOSE, with good structural validity and internal consistency. It has been translated and validated in several languages, including European Spanish, but hasn't been validated in Mexico.

AIM

Adapt and validate the NOSE scale to the Spanish language for a Mexican adult population.

METHODS

This study was conducted from May-August 2015. The scale was translated from English to Spanish and assessed by two experts to confirm its acceptability, being retranslated later. Adult subjects with native Mexican Spanish were recruited from the outpatient clinic, with chronic rhinopathy and without evidence of respiratory pathology. Both groups filled the scale, and anthropometric data were collected. A subgroup completed the instrument again after one month. STATA 15.1 was used for analysis.

RESULTS

The sample were 261 subjects. Cronbach alpha was 0.89, intraclass correlation coefficient 0.84, agreement limits -9.62 to 16.29. There was a statistically significant difference in score between groups. The area under the ROC curve was 0.855, with 83% sensibility and 76% specificity for a 20 total score. Moderate to strong item-total association was found with Spearman. The response model showed moderate item discrimination. In the factorial analysis, one factor was found, with an Eigenvalue of 3.21.

CONCLUSION

The adaptation of the NOSE scale is reliable and valid for its application in Mexican adult population.

Assessment of Different Middle Vault Reconstruction Techniques in Rhinoplasty from Multiple Patient-Reported Outcome Measures

It is important to assess the patient satisfaction with shape and function by patient-reported outcome measures (PROMs) following structural or dorsal preservation rhinoplasty (DPR) techniques on the middle nasal vault. To analyze the results of different middle vault rhinoplasty techniques with multiple PROMs and compare their differences according to the findings of PROMs. Four different techniques were performed for the middle vault: spreader graft, L-strut graft, DPR with high strip (DPRwHS), DPR with low strip. The outcomes were evaluated preoperatively, 2 and 12 months postoperatively with the following PROMs: Nasal Obstruction Symptom Evaluation (NOSE), Rhinoplasty Outcomes Evaluation, and Standardized Cosmesis and Health Nasal Outcomes Survey. This study included 129 patients. All techniques provided significant improvements in all PROMs (p < 0.001), except DPRwHS in NOSE. Between postoperative short- and longer-term, no significant differences were observed in DPR groups (p > 0.05), unlike structural techniques. In this comparative study of different middle nasal vault rhinoplasty techniques, we did not detect a difference in the improvement of the patient-reported outcomes of DPR techniques from as early as 2 months to 1 year postoperative.

Multi-dimensionality of patient reported outcome measures in rhinoplasty satisfaction

Background The FACE-Q rhinoplasty module (nose and nostrils), Utrecht Questionnaire and NOSE-scale are validated Dutch patient-reported outcome measures (PROMs) to evaluate rhinoplasty satisfaction. The objective of this study was to analyze the dimensionality of the measured variables in these four existing questionnaires. Additionally, we investigated the ability of the PROMS to measure change. Methods A prospective single center study was performed in a consecutive cohort of 106 Dutch-speaking patients. Patients were invited to fill in four PROMs: FACE-Q rhinoplasty module (nose and nostrils), Utrecht Questionnaire and NOSE-scale, preoperatively and 3 months postoperatively. Item quality was calculated in all four questionnaires. The ability of the questionnaires to differentiate between pre-and postoperative patients was determined with a binary logistic regression. Exploratory factor analysis was performed to determine the latent dimensions. Results Item quality was confirmed in all questionnaires. Backward binary logistic regression revealed that NOSE and FACE-Q nose module were the best discriminant factors pre- and postoperatively. Combination of these two questionnaires gave a specificity of 97,33% and a sensitivity of 94.52% to discriminate between pre-and post-operative cases. Exploratory factor analysis identified the presence of 4 dimensions: 1) cosmesis of the nose 2) cosmesis of the nostrils 3) nasal function and 4) psychosocial well-being in rhinoplasty patients. Lack of factorial invariance in the pre- as compared to the postoperative phase was detected, especially with the FACE-Q nose and to a lesser extent with the Utrecht questionnaire.

Translation, Cultural Adaptation and Validation of the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) in Italian

BACKGROUNDS

Rhinoplasty necessarily concerns functional and cosmetic aspects, and outcomes of both should be assessed in each patient. There has been a lack in the literature in Italian for a comprehensive tool for assessing both aspects of rhinoplasty. The objective is to translate and validate the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) into Italian.

METHODS

Forward and back-translation was used. Content validity was evaluated by experts and by patient interviews. Internal consistency was assessed by a Cronbach's alpha. The structure validity was assessed by an exploratory factor analysis.

RESULTS

Cognitive interviews of 10 rhinoplasty patients resulted in a good overall comprehension of the SCHNOS. Of the 411 respondents, 281 (32%) were women, and the average age was 33.6 (11.3) years. The alpha was excellent for both the obstruction domain (SCHNOS-O) (0.90) and the cosmetic domain (SCHNOS-C) (0.94). All the correlations between repeated measures were moderate to very strong. The exploratory factor analysis demonstrated unidimensionality of both the SCHNOS-O and the SCHNOS-C scores.

CONCLUSIONS

The SCHNOS was successfully translated and validated in Italian and can be recommended for a clinical use among rhinoplasty patients.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Cross-Cultural Evaluation of the Dutch FACE-Q Rhinoplasty Questionnaires Using Rasch Analysis

BACKGROUND

The English version of the FACE-Q rhinoplasty module, developed according to Rasch measurement theory, has recently been translated into Dutch. Before conclusions can be drawn from the Dutch version, this translation must also fit the item analysis by the Rasch model.

OBJECTIVES

The primary aim of this study was to evaluate cross-cultural equivalence between the Dutch and English versions of the FACE-Q rhinoplasty module by applying Rasch methodology.

METHODS

Rasch analysis performed with Winsteps (Beaverton, OR) was used to evaluate the Dutch version of the FACE-Q nose and nostrils scales with data from a prospective consecutive cohort of 100 Dutch-speaking septorhinoplasty patients. New Dutch-related conversion tables were constructed for the FACE-Q nose and nostrils scales and compared to the original ones. Psychometric cross-validation was performed by receiver operating characteristics (ROC) analysis.

RESULTS

Both questionnaires adequately met the requirement of invariance. Within an acceptable range, some issues with item and person fit were found, as well as some local item dependency and differential item functioning. However, comparison of the Dutch- and English-related conversion tables by ROC analysis demonstrated identical results for the FACE-Q nose and nostrils scales.

CONCLUSIONS

Item analysis by the Rasch model on the data of a Dutch-speaking population proved the conceptual correspondence with the original English version.

Comparison of the Distribution of Standardized Cosmesis and Health Nasal Outcomes Survey Scores Between Symptomatic and Asymptomatic Patients

Background: The Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) is a validated patient-reported outcome measure that evaluates subjective cosmetic and functional complaints. The goal of this study was to compare scores between patients with and without nasal complaints. Methods: This is a retrospective review of SCHNOS-O (obstructive) and SCHNOS-C (cosmetic) scores in patients presenting for functional or cosmetic concerns between 2019 and 2020. Receiver operating characteristic curve analysis was used to determine the score that best separated symptomatic from asymptomatic patients. SCHNOS scores were also subdivided to define severity of presenting complaints. Results: In total, 414 patients were included. A SCHNOS-O score of 40 differentiated patients with and without nasal obstruction. Patients may be categorized as having mild (<40), moderate (45-70), and severe (75-100) nasal obstruction based on the SCHNOS-O score. A score of 30 on the SCHNOS-C differentiated patients with and without aesthetic concerns. Patients may be categorized as having mild (<33.3), moderate (33.3-66.6), and severe (>66.6) aesthetic distress based on the SCHNOS-C. Conclusion: An understanding of SCHNOS scores that differentiate symptomatic for asymptomatic patients can aid in the preoperative evaluation of rhinoplasty patients.

Impact of intraoperative Cone-Beam Computed Tomography use on patient satisfaction after closed nasal reduction

Background: The aim of the study was to assess, whether there is a difference in aesthetic and functional patient satisfaction between closed nasal reductions with intraoperative Cone-Beam Computed Tomography (CBCT) and without using intraoperative medical imaging. Methods: A monocentric, retrospective cohort study of 43 patients (20 patients treated with intraoperative CBCT and 23 patients treated without intraoperative imaging) was conducted. Subjective postoperative aesthetic and functional aspects of the nose were assessed. Additionally, questions comparing the aesthetics and function of the nose before and after the accident and on the desire of revision surgery were asked. Results: Both the SCHNOS-C and total SCHNOS score in the non-CBCT group were higher than the respective scores of the CBCT-group. The comparison of SCHNOS-C between male subjects of the two groups showed no statistical significance. The comparison of SCHNOS-C between male and female subjects over both groups showed significantly higher scores for female subjects. Conclusions: Patients undergoing surgery with intraoperative CBCT imaging showed better aesthetical outcomes than patients, treated without intraoperative imaging. However, the difference showed no clinical importance, so that both strategies appear to have comparable outcomes regarding postoperative aesthetics and function of the nose. Gender instead of the different strategies could contribute to the demonstrated differences. Female subjects seem to be less satisfied with the aesthetics of their nose postoperatively, potentially being more sensitive to remaining nasal deformities after surgery.

Self-reported questionnaires for lymphoedema: a systematic review of measurement properties using COSMIN framework

INTRODUCTION

Lymphoedema may develop as a result of numerous genetic and traumatic causes; however, treatment for cancer is the most common cause of its development in more economically developed nations. This systematic review critically appraised, compared and summarised the measurement properties of lymphoedema-specific self-reported questionnaires (SRQs) measuring various patient-reported outcomes including quality of life (QOL), function, morbidity, and symptoms.

METHODS

Seven databases were searched to identify studies of the measurement properties of SRQs. Two review teams independently evaluated the quality of the individual studies using the risk of bias tool from the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN). Measurement properties of the SRQs presented in the studies were then rated. Study level ratings were summarised for an SRQ if they were reported in multiple studies, and their overall quality of the evidence were then graded.

RESULTS

Forty articles, reporting on 19 SRQs were identified from 8615 records. The focus of the 19 SRQs included eight on QOL, four on symptoms, two on function, and two on impairment. The other three SRQs were on illness perception, self-efficacy, and patient-relevant treatment benefit, respectively. Eight and three SRQs were upper limb and lower limb-specific, respectively, whereas seven questionnaires were for both upper and lower limb lymphoedema. One SRQ was developed for head and neck lymphoedema. According to the COSMIN framework, none of the SRQs reviewed had sufficient evidence to support all nine measurement properties. In lower limb questionnaires, the LYMQOL-leg has sufficient content, structural, and construct validity as well as internal consistency and reliability. For upper limb lymphoedema questionnaires, the Lymph-ICF-UL had sufficient content and construct validity as well as reliability.

CONCLUSION

LYMQOL-leg SRQ is recommended with confidence for evaluation of QOL of people with lower limb lymphoedema while the Lymph-ICF-UL is recommended for evaluation of the QOL of the breast cancer-related lymphoedema with some confidence. In view of the high level of the indeterminate ratings of the measurement properties of the existing SRQs, further research is desirable.

The Rhinoplasty Health Care Monitor: Using Validated Questionnaires and a Web-Based Outcome Dashboard to Evaluate Personal Surgical Performance

Background: Self-assessment provides valuable feedback in the life-long process of mastering rhinoplasty. This study presents a method to measure and evaluate data-based performance of a single surgeon using a web-based dashboard. Methods: In this prospective analytic cohort study, all patients referred to the senior author for functional-aesthetic (revision) rhinoplasty between April 2014 and September 2020 are included. Patients completed the Nasal Obstruction Symptom Evaluation (NOSE) scale, Utrecht Questionnaire (UQ), and visual analog scales before and after rhinoplasty. Questionnaire scores were exported to a customized web-based dashboard: the rhinoplasty health care monitor. Supported by real-time graphic output, this monitor automatically analyzes functional and aesthetic outcomes. Results: Of 603 referred patients, 363 were eligible for rhinoplasty. Mean NOSE scale scores decreased from 66.6 ± 23.5 to 23.2 ± 24.0 (p < 0.001), and mean UQ scores decreased from 12.2 ± 6.3 to 7.1 ± 3.9 (p < 0.001) 1 year after surgery. The rhinoplasty health care monitor visualizes numerous outcome parameters that help the surgeon to analyze results, identify learning needs, and detect trends in performance development. Conclusions: This automated outcome dashboard transparently measures individual surgeon performance. Gauging performance provides means to enhance surgical development and, consequently, patient satisfaction.

Reliability and Validity of Physical Tools and Measurement Methods to Quantify Hand Swelling: A Systematic Review

OBJECTIVE

Hand swelling may result from injury or trauma. Various physical assessment tools and measurement methods can be used to quantify the volume or size of the hand or fingers; however, the reliability and validity of each tool and measurement method have not been evaluated. The purpose of this study was to evaluate the reliability and validity of physical assessment tools and methods used to quantify hand and finger volume orsize.

METHODS

MEDLINE, CINAHL, EMBASE, Web of Science, and Scopus were searched using key terms related to swelling, edema, volume, size, hand, measures, reliability, and validity. Cross-sectional or longitudinal studies that assessed reliability and/or validity of physical assessment tools or measurement methods to quantify hand swelling were included. Two examiners independently extracted data from the included articles and appraised the articles' quality using the Consensus-Based Standards for the Selection of Health Measurement Instruments methodology. Data extracted from studies analyzing reliability and validity were grouped by type of assessment tool and measurement method.

RESULTS

Five physical assessment tools used for quantification of hand swelling were evaluated, including tape measure, water volumeter, bioimpedance spectroscopy, ring gauge, 3-dimensional techniques. All assessment tools had good to excellent reliability (ICC = 0.74 - 0.99), and moderate to high validity (Pearson coefficient = 0.58 - 0.99), for quantification of the volume or size of the hand or fingers.

CONCLUSION

All measurement methods with these tools had good to excellent reliability and moderate to high validity. The evidence underpinning the figure-of-eight technique, which uses a tape measure, was the highest. Because these physical assessment tools and measurement methods assess different aspects and regions of the hand, which one is selected depends on the region of interest for assessment and the availability of tools.

IMPACT

Reliable tools and measurement methods are available to measure the size or volume of the hand and fingers, either together or separately. The best tool will depend on the aim of assessment and tool availability.

LAY SUMMARY

Hand swelling can occur with injuries, burns, or lymphedema. This review shows that tools are available to accurately measure swelling in any part of thehand.

Dutch Translation and Validation of the FACE-Q Rhinoplasty Module

FACE-Q was developed by Klassen et al in 2010 as a validated psychometric evaluation instrument for patients undergoing aesthetic surgery. The aim of this study was to translate, adapt, and validate the FACE-Q rhinoplasty module into a Dutch version of the FACE-Q questionnaire conceptually equivalent to the original English version. "Satisfaction with nose" and "satisfaction with nostrils" questionnaires were used and translated from English into Dutch. The translation process and cross-cultural adaptation were conducted in accordance to the International Society for Pharmacoeconomics and Outcomes Research and World Health Organization guidelines. Psychometric validation was performed prospectively on a patient cohort of 30 patients. Each step in the translation process allowed us to make changes to achieve a conceptual translation equivalent to the original version. Psychometric validation revealed highly significant values for internal consistency, test-retest reliability, and responsiveness. The use of international translation guidelines, with a strict translation-back-translation process, led to a Dutch version of the FACE-Q rhinoplasty module. Statistical validation proved the conceptual correspondence with the original English version. The FACE-Q rhinoplasty module is an adequate instrument for determining successful aesthetic surgery based on patient satisfaction. This tool measures twofold: the degree of success with respect to the patient as well as being an assessment tool for the surgeon. We hope this will provide an additional tool to the clinician evaluating the Dutch-speaking rhinoplasty patient.

Future Direction in Rhinoplasty: Functional Improvements for a Better Outcome

The nose plays both an aesthetic and functional role in the human body. Physiologically, the nose is an important part of the upper airway. Aesthetically, it is the central focal point of the face. Thus, rhinoplasty has evolved to be both an aesthetic and functional surgery, as the manipulation of the aesthetic subunits of the nose inadvertently leads to the functional alterations of the nose. While the aesthetic goals of rhinoplasty are well described in the literature, functional outcomes from rhinoplasty have been more challenging to delineate. Rhinoplasty can have an impact on the sense of smell, sleep apnea, oxygenation, cognitive function, cardiovascular function, and voice. We have systematically reviewed the current literature in regard to functional rhinoplasty and septoplasty to summarize current surgical maneuvers and their impact on nasal function, along with physiological and perceived functional changes from rhinoplasty.

Evaluation of nasal tip shape in patients with severe caudal septal deviation after modified extracorporeal endonasal septoplasty

OBJECTIVES

The aim of this prospective study was to evaluate the effect of modified extracorporeal endonasal septoplasty on nasal tip shape and function in patients with severe caudal septal deviation.

METHODS

The study population comprised of 55 patients undergoing modified extracorporeal endonasal septoplasty, which called marionette septoplasty. To analyse the aesthetic objective outcomes, postoperative photographs were measured for projection index (PI), tip projection (TP), nasolabial angle (NLA), tip deviation angle (TDA), nasofrontal angle (NFA), supratip height (STH), columellar height (CH), at three times (2 weeks, 3, and 6 months after surgery) and were compared with preoperative photographs. Functional and aesthetic outcomes were also evaluated using nasal obstruction symptom evaluation (NOSE) scale and standardized cosmesis and health nasal outcomes survey (SCHNOS).

RESULTS

Between the pre- and post-operative 6th-month examinations, a significant increase in PI and TP were 7%, and 5% respectively. There was a significant alteration in the NLA and TDA values following the last examination (mean difference ± standard error of mean 9.68 ± 0.9° and 1.5 ± 0.8°, respectively). Moreover, the technique did not make a significant change in the final NFA, STH, and CH, measurements. Following surgery, the NOSE and SCHNOS scores were decreased significantly and the improvement continued over time until the last examination.

CONCLUSION

The present study findings suggest that the marionette septoplasty technique is an effective to correct and stabilize severe caudal septal deviations. This technique also can provide tip support and protection with a low incidence of dorsal irregularity.

Natural History of the Standardized Cosmesis and Health Nasal Outcomes Survey After Rhinoplasty

OBJECTIVES/HYPOTHESIS

To explore the natural history of nasal obstruction and cosmesis following rhinoplasty by utilizing the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS).

STUDY DESIGN

Retrospective chart study.

METHODS

This study was carried out at a tertiary referral center, preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE), SCHNOS-Obstruction (SCHNOS-O), and SCHNOS-Cosmesis (SCHNOS-C) scores in patients who underwent rhinoplasty for functional, cosmetic, or both reasons from June 2017 to May 2019 were reviewed and analyzed. Postoperative intervals were defined as <2 months, 2 to 5 months, 5 to 8 months, 8 to 12 months, and >12 months.

RESULTS

A total of 302 patients (67% women), with a mean age (standard deviation [SD]) of 35 (13) years, who underwent rhinoplasty for functional (90, 30%), cosmetic (124, 41%), and combined functional and cosmetic (88, 29%) reasons, met inclusion criteria. The mean follow-up period (SD, range) was 5 months (4.2 months, 13 days-1.8 years). Compared to the preoperative mean NOSE score, SCHNOS- O, and SCHNOS-C scores, postoperative mean scores for the functional and combined subgroup were significantly lower (P < .05) across all five postoperative intervals. In the cosmetic subgroup, postoperative mean SCHNOS-C scores were significantly lower (P < .05) across all postoperative intervals compared to the mean preoperative scores.

CONCLUSIONS

The natural history of the SCHNOS-O and SCHNOS-C score in patients who underwent rhinoplasty demonstrates 1) after functional rhinoplasty, an improvement in nasal breathing symptoms is attained as early as <2 months postoperatively; and 2) after cosmetic rhinoplasty, an improvement in nasal cosmesis is seen as early as <2 months postoperatively. These improvements in nasal breathing and cosmesis are sustained through a follow-up interval >12 months.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E116-E123, 2021.

Normative data for the Nasal Obstruction Symptom Evaluation Scale in the general Australian population

BACKGROUND

Recent changes to the Australian Medicare Benefits Scheme have introduced the NOSE Score as a criteria threshold for funding rhinoplasty. On review of the literature, however, there is minimal normative Nasal Obstruction Symptom Evaluation (NOSE) score data to provide context for these changes.

METHODS

Participants were recruited according to the general Australian population distribution of age (18-65 years), gender and geographical locations using the market research company Pureprofile. The data included demographic details, risk factors for nasal obstruction such as smoking, obstructive sleep apnoea, use of continuous positive airway pressure, history of nasal trauma, operations to the nose and a history of cleft lip/palate and each participant completed the NOSE Scale. Analysis of data included descriptive statistics, independent t-tests and one-way analysis of variances to assess differences in NOSE scores between risk factors.

RESULTS

The NOSE score was completed by 247 males and 255 females with a mean age of 41(±13.39) years. The cohort had a mean NOSE score of 16 (±18.89) with a range from 0 to 95. A total of 48 respondents had a NOSE score greater than the Medicare threshold of >45. Cleft lip/palate, obstructive sleep apnoea and continuous positive airway pressure use were shown to have a statistically significant impact on NOSE score while other variables including body mass index, gender, smoking, location and other surgery to the nose were not shown to significantly impact results.

CONCLUSIONS

This study found that 9.6% of the general Australian population would have a NOSE score >45 and qualify for the Medicare Benefits Scheme rhinoplasty benefit.

Post-rhinoplasty outcomes in an Indian population assessed using the FACE-Q appraisal scales: a prospective observational study

OBJECTIVES

The primary goal of rhinoplasty is patient satisfaction and improved quality of life. The present study was conducted to assess patient satisfaction with face and nose appearance, and quality of life after rhinoplasty.

METHODS

Patients presenting for rhinoplasty completed the FACE-Q survey. This is a new instrument that measures patient-reported outcomes in those undergoing aesthetic procedures. The FACE-Q scales include satisfaction with facial appearance overall, satisfaction with the nose, psychological well-being, psychosocial distress and social function.

RESULTS

Sixty-five patients completed the FACE-Q at pre-operative and at post-operative follow-up visits. Post-operative scores increased significantly in terms of: satisfaction with facial appearance (p < 0.0001, t = 15.639, degrees of freedom = 64); social function (p < 0.0001, t = 12.208, degrees of freedom = 64); psychosocial distress (p < 0.0001, t = 13.864, degrees of freedom = 64); psychological function (p < 0.0001, t = 12.681, degrees of freedom = 64); and satisfaction with nose (p < 0.0001, t = 16.421, degrees of freedom = 64). Most patients reported more than 79 per cent satisfaction with the post-operative outcome.

CONCLUSION

The FACE-Q is an adequate instrument for determining successful aesthetic surgery based on patient satisfaction.

Closed Rhinoplasty with a Mushroom-Shaped Costal Cartilage Graft in East Asian Patients

BACKGROUND

The most challenging part of rhinoplasty is nasal tip management. For East Asian patients with a bulbous under projected nasal tip with thick skin, autologous cartilage is considered the gold-standard graft material to provide strong support to the nasal tip and effectively increase tip projection. The present study aimed to evaluate the outcomes of closed rhinoplasty with a mushroom-shaped costal cartilage graft in East Asian patients.

METHODS

From February 2018 to May 2019, 52 patients underwent rhinoplasty with a mushroom-shaped costal cartilage graft in our institution. Rhinoplasty was performed through a bilateral endonasal incision. Postoperatively, all patients were photographed and asked to complete a satisfaction survey online or by telephone.

RESULTS

The mean follow-up period was 15.8 months (range 12-21 months). Twenty-four of 52 patients agreed to participate in this study. Postoperatively, the mean nasofrontal angle was 137.7 ± 3.7°, mean nasolabial angle was 94.1 ± 6.2°, mean nasal tip angle was 79.4 ± 5.2°, and mean columellar/lobular angle was 44.7 ± 2.4°. The mean tip projection/nasal length index was 0.53 ± 0.07, and the mean columellar/lobular length index was 1.21 ± 0.22. There were no prolonged functional complications. Most patients (23/24; 95.8%) were satisfied with the aesthetic results.

CONCLUSION

The present results suggest that the mushroom-shaped costal cartilage graft in closed rhinoplasty is a good choice for the correction of a bulbous under projected nasal tip.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Factors Associated With Patient Satisfaction After Nasal Breathing Surgery

This cohort study examines subjective patient-reported outcomes after nasal breathing surgery and identifies factors associated with patients’ perception of the procedure’s value.

Assessment of Rhinoplasty Outcomes with FACE-Q Rhinoplasty Module: Norwegian Linguistic Validation and Clinical Application in 243 Patients

Patient satisfaction after rhinoplasty is a growing area of research. The FACE-Q Rhinoplasty Module, used to assess these values, requires translation to national languages.