Measuring Outcomes in Aesthetic Surgery: A Comprehensive Review of the Literature:

Changes in patient-reported satisfaction and quality-of-life 6 months after rhinoplasty

BACKGROUND

Rhinoplasty is a challenging and demanding procedure in plastic surgery. Surgical success, patient satisfaction, and improved quality-of-life are important outcomes.

OBJECTIVES

This study aimed to evaluate patient-reported satisfaction with appearance, treatment, and decision outcomes as well as quality-of-life after rhinoplasty using validated questionnaires. The role of patient demographics on outcomes was also studied.

METHODS

Patients who underwent a primary rhinoplasty were selected for this cohort study. Patient-reported satisfaction with appearance, treatment, and decision as well as quality-of-life were evaluated with the Utrecht Questionnaire and FACE-Q at intake and 6 months postoperatively.

RESULTS

Overall, 380 patients were included. Patients reported a more positive subjective perception of nasal appearance (VAS score) at 6 months post-surgery compared with preoperative scores (7.9 ± 1.6 vs 3.2 ± 1.4, p < 0.05). Furthermore, higher quality-of-life and body image scores were observed at 6 months postoperatively compared with preoperative scores (7.7 ± 3.5 vs 15.2 ± 4.4, p < 0.05). Patients reported high satisfaction with treatment outcome (70.3 ± 23.4) as well as with their decision to undergo surgery (75.9 ± 23.4) on a scale of 0-100 at 6 months postoperatively. Patients reached similar postoperative scores regardless of their intake scores. Patients ≥30 years and patients with a history of cosmetic surgery were less satisfied postoperatively.

CONCLUSION

Despite differences in appearance satisfaction at intake, most patients showed greater satisfaction with appearance, treatment, and decision outcomes as well as quality-of-life 6 months postoperatively. However, older age and a history of cosmetic surgery influenced these outcomes negatively. These factors should be considered during preoperative management of outcome expectations.

Defining Standard Values for FaceReader Facial Expression Software Output

BACKGROUND

FaceReader is a validated software package that uses computer vision technology for facial expression recognition which has become increasingly popular in academic research to expedite, scale, and decrease the cost of facial emotion analysis. In this study, we compare FaceReader analysis to human evaluator interpretation in order to define standard values for the software output.

METHODS

Randomly generated facial images produced by generative adversarial networks were analyzed using FaceReader and by survey participants (n=496). The age, facial emotion, and intensity of emotion as determined by the software and survey participants were recorded. Results were analyzed and compared.

RESULTS

80 randomly generated images (20 children, 20 young adult, 20 middle aged, and 20 elderly; 38 male and 42 female) were included. Analysis of correlation between most common expression identified by FaceReader and the primary emotion detected by surveyors showed strong correlation (κ = 0.77, 95% CI = 0.64-0.91). On analyzing this correlation by age group, there was fair correlation in children (κ = 0.40, 95% CI = 0.078-0.72), perfect correlation in young adults (κ = 1.0, 95% CI = 1.0-1.0), strong correlation in middle aged adults (κ = 0.79, 95% CI = 0.53-1) and near perfect in elderly adults(κ = 0.9 , 95% CI = 0.7-1.0).

CONCLUSIONS

We provided the first study defining the expected average values generated by FaceReader in generally smiling images. This can be used as a standard in future studies.

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 .

The Patient Journey in Facial Aesthetics: Findings from a European Consensus Meeting on Improving the Quality of Life for Patients Receiving Botulinum Toxin Injections

Purpose

Successful treatment of facial lines with botulinum toxin is largely dependent on patient satisfaction; thus, a structured treatment journey that uses patient-reported outcomes (PROs) is helpful for maximizing botulinum toxin results. To develop a patient-centric approach for botulinum toxin injections in facial aesthetics, a group of clinicians met to provide opinions on an optimal treatment journey that uses PROs to quantify treatment benefits on patient quality of life.

Patients and Methods

A multidisciplinary panel of 9 clinicians with expertise in facial aesthetic procedures convened for an advisory board that was preceded by and followed up with a structured, multistep consensus discussion. Based on current literature, the panel's expertise, structured questions, and group discussion, panelists assessed, reconciled, and agreed upon on a patient journey for botulinum toxin treatment in facial aesthetics.

Results

Panelists agreed that an optimal patient journey includes screening, assessment, treatment, posttreatment, and follow-up visits. A compact, easy-to-complete, and digital PRO questionnaire should be provided before the visit. During screening, thorough assessments are integral for a successful patient journey because they provide an opportunity to understand treatment goals, address patient concerns, discuss risks and benefits, obtain medication lists/medical history, and take pretreatment photographs. Treatment strategies should include discussing and educating on the approach/choice of botulinum toxin and ensuring patients are comfortable. Posttreatment, clinicians should request intense muscle movements to enhance product uptake and be available to address patient concerns. Finally, during follow-up, PRO questionnaires can be provided to gauge patient satisfaction with treatment, and pretreatment photographs can be provided to allow patients to track their progression. Follow-ups should be scheduled with new patients or those reporting low satisfaction.

Conclusion

Establishing a relationship, being aware of the patient's goals, and developing an individualized care plan allows for a structured, patient-centered treatment journey that promotes positive aesthetic outcomes.

Relevance of Self-Consciousness of Appearance on Patient Satisfaction in Primary Rhinoplasty: a 12-Month Follow-up Prospective Study

BACKGROUND

Rhinoplasty procedure has a strong impact on patient quality of life. Plastic surgery patients show a degree of appearance-related distress higher than general population, especially patients undergoing rhinoplasty. Relationship between patient-reported outcome after rhinoplasty and self-consciousness of appearance needs further studies. The aim of this study is to investigate this correlation, considering the surgeon external evaluation as well.

MATERIALS AND METHODS

A total of 50 consecutive patients underwent primary cosmetofunctional rhinoseptoplasty. Appearance-related distress and surgical outcome were assessed by DAS59 (Derriford Appearance Scale 59) and SCHNOS (Standardised Cosmesis and Health Nasal Outcomes Survey), administered before and after surgery. Follow-up period was 12 months. Third-party clinical outcome was evaluated by three plastic surgeons by a scale ranging from 1 (poor outcome) to 5 (excellent outcome).

RESULTS

A first division in Group 1 (satisfied) and Group 2 (unsatisfied) was done. DAS59 mean score in Group 1 showed to be statistically lower than Group 2 (p value < 0.05). Spearman's test showed a large strong positive correlation between preoperative and postoperative DAS59 and SCHNOS-C score variations (Delta 0-12 months) (r = 0.7514, p<0.001), as well as between DAS59 and SCHNOS-O (r = 0.5117, p<0.001) and between SCHNOS-C and SCHNOS-O (r = 0.6928, p<0.001).

CONCLUSION

Rhinoseptoplasty has a significant impact on the patient self-consciousness of appearance, in both negative and positive terms. We emphasize the surgeon's burden, who need to carefully assess and address the patient's expectations during the first evaluation. This distinction is crucial since unrealistic expectations may lead to dissatisfaction even after a properly performed procedure.

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.

How Brow Rotation Affects Emotional Expression Utilizing Artificial Intelligence

BACKGROUND

It is well known that brow position affects emotional expression. However, there is little literature on how and to what degree this change in emotional expression happens. Previous studies on this topic have utilized manual rating; this method of study remains small and labor intensive. Our objective is to correlate manual brow rotations with emotional outcomes using artificial intelligence to objectively determine how specific brow manipulations affected human expression.

METHODS

We included 53 brow-lift patients in this study. Pre-operative patients' brows were rotated to - 20, - 10, +10, and +20 degrees in respect to the central axis of their existing brow using PIXLR, a cloud-based set of image editing tools and utilities. These images were analyzed using FaceReader, a validated software package that uses computer vision technology for facial expression recognition. The primary facial emotion and intensity of facial action units (0 = no action unit detected to 4 = most intense action unit detected) generated by the software were recorded.

RESULTS

265 total images [5 images (pre-operative, - 20 degree brow rotation, - 10, +10, and +20) per patient] were analyzed using FaceReader. The primary emotion detected in the majority of images was neutral. The percentage of disgust in patients' expressions, as detected by FaceReader, increased with increased positive brow rotation (1.76% disgust detected at - 20 degrees, 2.09% at - 10 degrees, 2.65% at neutral, 2.61% at +10 degrees, and 2.95% at +20 degrees). In contrast, the percentage of sadness in patients' expressions decreased with increased positive brow rotation (29.92% sadness detected at - 20 degrees, 21.5% at - 10 degrees, 11.42% at neutral, 15.75% at +10 degrees, and 12.86% at +20 degrees). Our facial action unit analysis corresponded with primary emotion analysis. The intensity of the inner brow raiser decreased with increased positive brow rotation 8.54% at - 20 degrees, 4.21% at - 10 degrees, 1.48% at neutral, 0.84% at +10 degrees, and 0.76% at +20 degrees). The intensity of the outer brow raiser increased with increased positive brow rotation (0.97% at - 20 degrees, 0.45% at - 10 degrees, 1.12% at neutral, 5.45% at +10 degrees, and 11.19% at +20 degrees).

CONCLUSION

We demonstrated that increasing the degree of brow rotation correlated positively with the percentage of disgust and inversely with the percentage of sadness detected by FaceReader. This study demonstrated how different manipulated brow positions affected emotional outcomes using artificial intelligence. Physicians can use these findings to better understand how brow-lifts can affect the perceived emotion of their 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 .

Patient-reported outcomes: A primer for plastic surgeons

Surgical care today is no longer evaluated only on clinical outcomes but also on holistic patient wellbeing. Patient-reported outcomes (PROs) are a representation of the patient's perspective on their results and wellbeing. The aim of this review is to establish PROs as the center of healthcare and plastic surgery, to delineate important PROs in plastic surgery practice and research, to discuss the future of PROs within our discipline, and to encourage surgeons to incorporate PROs into their practice. PROs are an important parallel of clinical outcomes in that they can use the patient's perspective to 1) support clinical findings, 2) detect differences in care when there are no clear clinical differences, 3) track progress longitudinally, and 4) support systemic improvements in healthcare. Plastic surgery as a field is naturally aligned with PROs because, as a discipline, we focus on patient form and function. The emerging forefronts of plastic surgery such as lymphedema care, gender-affirming care, peripheral nerve surgery, migraine surgery, and breast implant illness are critically dependent on PROs. In the next decade, we predict that there will be a continued proliferation of robust PRO measures and integration into healthcare delivery. Outcomes research in surgery should continue to evolve as surgeons provide increasingly more benefits to improve patient wellbeing. Plastic surgeons must continue to play a prominent role in the future of PROs.

Functional and Aesthetic Outcomes of Septal Reconstructions: Results of a Prospective Longitudinal Outcome Study

In order to correct severe septal deformities, complete septal reconstruction is often required to achieve the desired functional and aesthetic results. Several different techniques have been described. Systematic evaluation of the long-term results is crucial to assess and improve the quality of these surgical techniques. A custom-built dashboard (the rhinoplasty health care monitor [RHM]) was used for prospective and longitudinal outcome evaluation of the septal reconstruction. The RHM includes the Nasal Obstruction Symptom Evaluation (NOSE) scale for nasal obstruction and the Utrecht Questionnaire (UQ) for aesthetic outcome results. In total, 58 patients were included for septal reconstructive surgery. The mean preoperative NOSE scale scores decreased from 67.8 ± 19.1 to 12.2 ± 17.5, 1 year after surgery. Mean preoperative UQ scores went from 12.3 ± 6.4 to 6.2 ± 2.7. The beneficial functional and aesthetic effects of the techniques that we currently use to reconstruct the septum are efficient in terms of function and aesthetics.

Assessment of quality of life and self-esteem in male patients with androgenetic alopecia before and after hair transplantation

BACKGROUND

Patients with androgenetic alopecia experience a significant decrease in self-esteem and quality of life. There are several methods by which these factors may be improved.

AIMS

Determining whether patients feel better about themselves with a better quality of life after undergoing hair transplant procedure.

PATIENTS/METHODS

35 people were chosen from Jordan Skin and Hair Clinic in Tehran, Iran. Following hair transplant, follow-up subjects had their quality of life and level of self-esteem assessed using the Rosenberg Self-Esteem Scale (RSES) and Dermatology Life Quality Index (DLQI), respectively. The means of quantitative results were compared using paired T-test. The chi-square test was done to compare preoperative and postoperative characteristics qualitatively. Differences were regarded significant if p < 0.05. Analysis of covariance was applied to evaluate the effect of marital status and educational level on outcome variables (ANCOVA).

RESULTS

Our findings showed a statistically significant difference (p < 0.001) between pre- and post-operative hair transplantation for quality of life, and mean score increased to 2.17. There was a statistically significant difference between the two groups, with an average self-esteem score on RSES rising to 5.35 (p < 0.001). A statistically significant link between educational achievement and quality of life was found (p < 0.001).

CONCLUSION

This study found postoperative psychological aspects of AGA patients significantly improve than preoperative. Our results show that there is a statistically significant difference between the self-esteem and quality of life of AGA patients before and after hair restoration surgery.

"Surgery First" vs "Traditional Sequence" Surgery: A Qualitative Study of Health Experiences in 46 Bimaxillary Orthognathic Patients

Introduction

Orthognathic patients are advocating an active role in selecting their appropriate ortho-surgical treatment, between the surgery first (SF) and the traditional sequence (TS) approaches. The aim of this study was to evaluate, through qualitative analysis, the subjective perceptions of the outcomes of each protocol.

Methods

In-depth interviews were conducted with 46 (10 male and 36 female) orthognathic patients (23 SF and 23 TS) treated with bimaxillary orthognathic surgery by the same surgeon, between 2013 and 2015. Average treatment duration was 6.5 months for SF and 12 months for TS. Inclusion criteria were: the presence of Class III or Class II asymmetries and open bite. Patients were excluded if they refused interviews or stopped attending post-treatment follow-up. Investigated health experiences included overall satisfaction with appearance, self-confidence after surgery, perceived treatment time, functional recovery, and diet restrictions.

Results

All SF and TS patients showed overall satisfaction with their appearance (though TS showed more enthusiastic tones) and approved their degree of functional recovery after surgery. Class III SF patients had earlier improvements in self-confidence after surgery. Orthodontics was considered enduring by both SF and TS patients.

Conclusions

SF patients expressed a higher degree of satisfaction with the reduction in overall treatment time and with the early psychological benefit deriving therefrom. Both SF and TS patients completely approved of the aesthetic outcomes and the functional recovery from which they benefitted due to the entire procedure.

Laser therapy for treating hypertrophic and keloid scars

BACKGROUND

Hypertrophic and keloid scars are common skin conditions resulting from abnormal wound healing. They can cause itching, pain and have a negative physical and psychological impact on patients' lives. Different approaches are used aiming to improve these scars, including intralesional corticosteroids, surgery and more recently, laser therapy. Since laser therapy is expensive and may have adverse effects, it is critical to evaluate the potential benefits and harms of this therapy for treating hypertrophic and keloid scars.

OBJECTIVES

To assess the effects of laser therapy for treating hypertrophic and keloid scars.

SEARCH METHODS

In March 2021 we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL EBSCO Plus and LILACS. To identify additional studies, we also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses, and health technology reports. There were no restrictions with respect to language, date of publication, or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) for treating hypertrophic or keloid scars (or both), comparing laser therapy with placebo, no intervention or another intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted the data, assessed the risk of bias of included studies and carried out GRADE assessments to assess the certainty of evidence. A third review author arbitrated if there were disagreements.

MAIN RESULTS

We included 15 RCTs, involving 604 participants (children and adults) with study sample sizes ranging from 10 to 120 participants (mean 40.27). Where studies randomised different parts of the same scar, each scar segment was the unit of analysis (906 scar segments). The length of participant follow-up varied from 12 weeks to 12 months. All included trials had a high risk of bias for at least one domain: all studies were deemed at high risk of bias due to lack of blinding of participants and personnel. The variability of intervention types, controls, follow-up periods and limitations with report data meant we pooled data for one comparison (and only two outcomes within this). Several review secondary outcomes - cosmesis, tolerance, preference for different modes of treatment, adherence, and change in quality of life - were not reported in any of the included studies. Laser versus no treatment: We found low-certainty evidence suggesting there may be more hypertrophic and keloid scar improvement (that is scars are less severe) in 585-nm pulsed-dye laser (PDL) -treated scars compared with no treatment (risk ratio (RR) 1.96; 95% confidence interval (CI): 1.11 to 3.45; two studies, 60 scar segments). It is unclear whether non-ablative fractional laser (NAFL) impacts on hypertrophic scar severity when compared with no treatment (very low-certainty evidence). It is unclear whether fractional carbon dioxide (CO2) laser impacts on hypertrophic and keloid scar severity compared with no treatment (very low-certainty evidence). Eight studies reported treatment-related adverse effects but did not provide enough data for further analyses. Laser versus other treatments: We are uncertain whether treatment with 585-nm PDL impacts on hypertrophic and keloid scar severity compared with intralesional corticosteroid triamcinolone acetonide (TAC), intralesional Fluorouracil (5-FU) or combined use of TAC plus 5-FU (very low-certainty evidence). It is also uncertain whether erbium laser impacts on hypertrophic scar severity when compared with TAC (very low-certainty evidence). Other comparisons included 585-nm PDL versus silicone gel sheeting, fractional CO2 laser versus TAC and fractional CO2 laser versus verapamil. However, the authors did not report enough data regarding the severity of scars to compare the interventions. As only very low-certainty evidence is available on treatment-related adverse effects, including pain, charring (skin burning so that the surface becomes blackened), telangiectasia (a condition in which tiny blood vessels cause thread-like red lines on the skin), skin atrophy (skin thinning), purpuric discolorations, hypopigmentation (skin colour becomes lighter), and erosion (loss of part of the top layer of skin, leaving a denuded surface) secondary to blistering, we are not able to draw conclusions as to how these treatments compare. Laser plus other treatment versus other treatment: It is unclear whether 585-nm PDL plus TAC plus 5-FU leads to a higher percentage of good to excellent improvement in hypertrophic and keloid scar severity compared with TAC plus 5-FU, as the certainty of evidence has been assessed as very low. Due to very low-certainty evidence, it is also uncertain whether CO2 laser plus TAC impacts on keloid scar severity compared with cryosurgery plus TAC. The evidence is also very uncertain about the effect of neodymium-doped yttrium aluminium garnet (Nd:YAG) laser plus intralesional corticosteroid diprospan plus 5-FU on scar severity compared with diprospan plus 5-FU and about the effect of helium-neon (He-Ne) laser plus decamethyltetrasiloxane, polydimethylsiloxane and cyclopentasiloxane cream on scar severity compared with decamethyltetrasiloxane, polydimethylsiloxane and cyclopentasiloxane cream. Only very low-certainty evidence is available on treatment-related adverse effects, including pain, atrophy, erythema, telangiectasia, hypopigmentation, regrowth, hyperpigmentation (skin colour becomes darker), and depigmentation (loss of colour from the skin). Therefore, we are not able to draw conclusions as to how these treatments compare.  AUTHORS' CONCLUSIONS: There is insufficient evidence to support or refute the effectiveness of laser therapy for treating hypertrophic and keloid scars. The available information is also insufficient to perform a more accurate analysis on treatment-related adverse effects related to laser therapy. Due to the heterogeneity of the studies, conflicting results, study design issues and small sample sizes, further high-quality trials, with validated scales and core outcome sets should be developed. These trials should take into consideration the consumers' opinion and values, the need for long-term follow-up and the necessity of reporting the rate of recurrence of scars to determine whether lasers may achieve superior results when compared with other therapies for treating hypertrophic and keloid scars.

The Importance of Functional Quality in Patient Satisfaction: Cosmetic Injectable Patient Experience Exploratory Study-Part 2

Background

Quality assessment comprises 2 distinct forms: technical quality (TQ) and functional quality (FQ). On the one hand, TQ describes accuracy and excellence, the degree to which procedures are done "correctly." On the other hand, FQ is the way services are delivered and represents how the customer perceives and experiences the treatment or service.

Objectives

To determine the relative importance of functional quality factors in the care of cosmetic injectable patients and return patronage.

Methods

The Cosmetic Injectable Patient Experience Exploratory Study (CIPEES) survey assessed reasons for return patronage to a specific cosmetic injector and the correlation between satisfaction with cosmetic results (patient assessment of TQ) and respondents' trust level in their practitioner, a marker for FQ.

Results

The CIPEES survey collected 1488 responses across 75 countries, with 66% of participants completing all 15 questions. The respondents were 95.6% female and 4.4% male, with ages ranging from 18 years to >65 years old (median 33 years old). The number one ranked reason for returning to a previous cosmetic injector (return patronage) was "Trust in my practitioner's action and ability," closely followed by "Cosmetic result/outcome from the previous treatment/s." Respondents' level of satisfaction with their cosmetic results also correlated highly with trust in their practitioners.

Conclusions

In order to maximize patient satisfaction and return patronage, healthcare practitioners should focus on improving FQ care and value it at least as high as TQ in the delivery of cosmetic injectable treatments.

Assessment of Patient Satisfaction With Appearance, Psychological Well-being, and Aging Appraisal After Upper Blepharoplasty: A Multicenter Prospective Cohort Study

BACKGROUND

To determine the success of an upper blepharoplasty, a popular cosmetic procedure, it is essential to measure outcomes from the patient perspective because these often outweigh objective outcomes.

OBJECTIVES

This study aimed to assess patient-reported satisfaction with facial appearance, psychological well-being, and aging appraisal after upper blepharoplasty with validated questionnaires.

METHODS

This prospective cohort study included upper blepharoplasty patients from 8 outpatient clinics. Patient-reported satisfaction was assessed with the FACE-Q at intake, and 6 and 12 months postoperatively.

RESULTS

In total, 2134 patients were included. High satisfaction with outcome and decision to undergo treatment were measured 6 months postoperatively. Large improvements in FACE-Q scores (range, 0-100) between intake and 6 months postoperatively were seen for satisfaction with appearance (mean, effect size: eyes +48, 2.6; upper eyelids +48, 3.1; facial appearance overall +26, 1.4), psychological well-being (+11, 0.56), and aging appraisal (+22, 1.0). Patients reported they appeared a mean [standard deviation] 3.3 [5.2] years younger postblepharoplasty. No clinically relevant changes were seen between 6 and 12 months. Additionally, improvements in appearance were not dependent on their intake scores, whereas improvements in psychological well-being and aging appraisal were smaller in patients with higher intake scores. Satisfaction with treatment outcome was strongly correlated with appearance satisfaction but not with aging appraisal.

CONCLUSIONS

Significant improvements in patient satisfaction regarding appearance, psychological well-being, and aging appraisal can be seen 6 months after blepharoplasty, and outcomes remain stable up to 12 months postoperatively. These data may be used to inform patients and clinicians and improve the overall quality of care.

LEVEL OF EVIDENCE: 4

Applying Machine Learning to Determine Popular Patient Questions About Mentoplasty on Social Media

PURPOSE

Patient satisfaction in esthetic surgery often necessitates synergy between patient and physician goals. The authors aim to characterize patient questions before and after mentoplasty to reflect the patient perspective and enhance the physician-patient relationship.

METHODS

Mentoplasty reviews were gathered from Realself.com using an automated web crawler. Questions were defined as preoperative or postoperative. Each question was reviewed and characterized by the authors into general categories to best reflect the overall theme of the question. A machine learning approach was utilized to create a list of the most common patient questions, asked both preoperatively and postoperatively.

RESULTS

A total of 2,012 questions were collected. Of these, 1,708 (84.9%) and 304 (15.1%) preoperative and postoperative questions, respectively. The primary category for patients preoperatively was "eligibility for surgery" (86.3%), followed by "surgical techniques and logistics" (5.4%) and "cost" (5.4%). Of the postoperative questions, the most common questions were about "options to revise surgery" (44.1%), "symptoms after surgery" (27.0%), and "appearance" (26.3%). Our machine learning approach generated the 10 most common pre- and postoperative questions about mentoplasty. The majority of preoperative questions dealt with potential surgical indications, while most postoperative questions principally addressed appearance.

CONCLUSIONS

The majority of mentoplasty patient questions were preoperative and asked about eligibility of surgery. Our study also found a significant proportion of postoperative questions inquired about revision, suggesting a small but nontrivial subset of patients highly dissatisfied with their results. Our 10 most common preoperative and postoperative question handout can help better inform physicians about the patient perspective on mentoplasty throughout their surgical course. Level of Evidence V 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 .

Evaluation of reconstructed auricles by convolutional neural networks

The difficulty in determining which structures are crucial to ensure a natural-looking ear has been plaguing surgeons for many years. This preliminary study explores the feasibility of training convolutional neural network (CNN) models to evaluate a reconstructed auricle as accurate as a human would. By visualizing the attention of trained models, the criteria for the design of a natural-looking auricle can be established. A total of 400 pictures were evaluated by 20 volunteers, and 20 labeled datasets were generated, which were then used to train ResNet models that had been pre-trained on ImageNet. The saliency maps and occlusion maps of each trained model were calculated to capture the attention of models. The average accuracy of the 20 models was 0.8245 ± 0.0356 (>0.80), and the evaluation results of the trained model and the medical student showed a significant correlation (P < 0.05). For the attention visualization of auricles labeled as normal, distribution of the highlighted portions corresponded to a linear contour of the helix, the inferior crura of the antihelix, and the contour of the concha. A CNN can provide an evaluation of a reconstructed auricle in a manner similar to that of a medical student. Saliency maps generated by the CNN demonstrate the subjective view, which was consistent with professional opinion.

Improvement in the Appearance and Function of the Hand at 2 Weeks after Percutaneous Needle Fasciotomy for Dupuytren Disease

Background: Percutaneous needle fasciotomy (PNF) has been successfully used for the treatment of contracture bands in the hand in patients with Dupuytren disease. The aim of this study is to determine aesthetic and functional outcomes at 2 weeks following PNF in patients with Dupuytren contracture. Methods: Seventy-five patients undergoing PNF for Dupuytren disease during a 4-month period were included. Patients completed the Visual Analogue Appearance Score (VAAS), Derriford Appearance Score (DAS), and the quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH) preoperatively and at 2 weeks after surgery. In addition, VAAS was done in the immediate postoperative period as well. Results: Seventy-four (99%) patients completed the immediate postoperative VAAS scores and 51 (68%) completed the VAAS, DAS, and QuickDASH at 2 weeks. Preoperative VAAS fell from 6.01 to 1.53 (p < 0.0001) immediately post operation. Two weeks later, VAAS increased to 2.91 but was still significantly lower than preoperatively (p < 0.0001). DAS was unchanged. QuickDASH decreased from 22.4 preoperatively to 12.1 2 weeks later (p = 0.001). Conclusion: PNF for Dupuytren contracture resulted in improvement in both aesthetic and functional outcomes at 2 weeks. Longer term follow-up is required to determine whether these improvements are sustained. Level of Evidence: Level IV (Therapeutic).

Detection of Baseline Emotion in Brow Lift Patients Using Artificial Intelligence

BACKGROUND

The widespread popularity of browlifts and blepharoplasties speaks directly to the importance that patients place on the periorbital region of the face. In literature, most esthetic outcomes are based on instinctive analysis of the esthetic surgeon, rather than on patient assessments, public opinions, or other objective means. We employed an artificial intelligence system to objectively measure the impact of brow lifts and associated rejuvenation procedures on the appearance of emotion while the patient is in repose.

METHODS

We retrospectively identified all patients who underwent bilateral brow lift for visual field obstruction between 2006 and 2019. Images were analyzed using a commercially available facial expression recognition software package (FaceReader™, Noldus Information Technology BV, Wageningen, Netherlands). The data generated reflected the proportion of each emotion expressed for any given facial movement and the action units associated.

RESULTS

A total of 52 cases were identified after exclusion. Pre-operatively, the angry, happy, sad, scared, and surprised emotion were detected on average of 13.06%, 1.68%, 13.06%, 3.53%, and 0.97% among all the patients, respectively. Post-operatively, the angry emotion average decreased to 5.42% (p=0.009). The happy emotion increased to 9.35% (p=0.0013), while the sad emotion decreased to 5.42%. The scared emotion remained relatively the same at 3.4%, and the surprised emotion increased to 2.01%; however, these were not statistically significant.

CONCLUSION

This study proposes a paradigm shift in the clinical evaluation of brow lift and other facial esthetic surgery, implementing an existing facial emotion recognition system to quantify changes in expression associated with facial surgery.

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 .

Characterizing Patient Questions Before and After Rhinoplasty on Social Media: A Big Data Approach

BACKGROUND

As an aesthetic surgery, a successful rhinoplasty is often assessed by patient satisfaction, subject to a diverse array of qualitative factors including patient expectations and happiness with care provided. While substantial effort has been dedicated to understanding patients' post-operative concerns, addressing patients' pre-operative questions has been comparatively less studied. This study analysed pre- and post-operative questions about rhinoplasty on social media to gain insights into patients' concerns and develop targeted educational material.

METHODS

The most viewed rhinoplasty questions on Realself.com, a social media platform for discussions about cosmetic surgeries, were collected and analysed. Questions were then stratified into pre- and post-operative and further assigned categories based on common topics found in the data. Using a machine learning approach, the most common pre- and post-operative questions were determined.

RESULTS

2014 rhinoplasty questions were collected in total, with 957 pre-operative and 1057 post-operative. The most commonly asked pre-operative questions were about appearance (n = 441, 46.1%), function (n = 102, 10.7%), and cost (n = 94, 9.8%). The most commonly asked post-operative questions were about appearance (n = 502, 47.5%), behaviour allowed/disallowed (n = 283, 26.8%), and symptoms after surgery (n = 235, 22.2%). An educational handout with the 10 most common pre- and post-operative questions was developed using machine learning analysis, with the majority of questions about appearance.

CONCLUSIONS

Patients primarily expressed concern about appearance when asking questions about rhinoplasty on social media, along with other aspects of their pre- and post-operative course. The educational handout developed by this study can be applied to address commonly asked patient questions during pre-operative education.

LEVEL OF EVIDENCE V

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 .

Validated Outcome Measures and Postsurgical Scar Assessment Instruments in Auricular Surgery: A Systematic Review

BACKGROUND

The utilization of an assessment instrument that successfully analyzes validated outcome measures for auricular surgery is important for advancing evidence-based medicine.

OBJECTIVE

To systematically review postsurgical scar assessment instruments and outcome measures after auricular surgery to assess if any individual or combination of 2 assessment instruments encompass all relevant, validated auricular outcome measures.

METHODS

Two systematic reviews were conducted using the PubMed/MEDLINE and Ovid databases: one for postauricular surgical outcome measures and another for postsurgical scar assessment instruments. Auricular outcome measure articles were selected for inclusion if they included at least one auricular-specific validated outcome measure, and assessment tool articles were included if they referenced one or more specific tool(s) specifically designed to assess postsurgical scars. Assessment tools were evaluated based on which outcome measures each covered.

RESULTS

There was no single postsurgical scar assessment instrument or combination of 2 instruments that covered all outcome measures within the 5 different categories (psychosocial well-being, functional, objective appearance, subjective appearance, and clinical-related outcomes) after auricular surgery. None of the instruments measured functional outcomes, such as the ability to wear glasses and hearing outcomes.

CONCLUSION

There is currently no existing postsurgical scar assessment instrument that covers all outcome measures after auricular surgery.

Quality of Life and Satisfaction in Transgender Men After Phalloplasty in a Retrospective Study

BACKGROUND

Partly as a result of the increasing attention directed toward transgender individuals and despite much research work on the topic of quality of life (QOL) of transgender, there is still a lack of studies using standardized questionnaires in their evaluation.

AIMS

We designed a survey to evaluate the influence of surgery after phalloplasty (osteofasciocutaneous fibula free flap or osteofasciocutaneous radial free forearm flap) on QOL, emotional stability, self-esteem, and psyche of postoperated transgender men.

METHODS

The present study included 32 transgender men who had undergone gender-affirming surgery (GAS) exclusively in our department between 2000 and 2012. Apart from our self-developed, indication-specific questionnaire with questions on socioeconomic and demographic data as well as postoperative satisfaction, the testing instrument included 4 frequently used, standardized testing instruments, which we compared with normative data. These included (a) a self-assessment test Fragebogen zur Lebenszufriedenheit with questions on QOL consisting of 3 modules (general satisfaction, satisfaction with health, and satisfaction with body image/outer appearance), (b) the Freiburg Personality Inventory, (c) the Rosenberg Self-Esteem Questionnaire, and (d) the Patient Health Questionnaire 4.

FINDINGS

Our self-developed, indication-specific questionnaire showed that 88% of our patients were very satisfied with the aesthetic result, 75% have had sex after surgery, and 72% were very satisfied with sexual function after GAS. Eighty-one percent had a strong improvement of QOL, and 91% would undergo the same treatment again. Eighty-four percent would recommend GAS to others. All patients lived as men fulltime.

DISCUSSION

Our study reveals that GAS plays an important part in the interdisciplinary treatment of transgender individuals as it improves the QOL in transgender men in most aspects of everyday life and has a positive influence on the patients' psyche and self-esteem in a retrospective study.

Evaluation of Aesthetic and Functional Outcomes After Open Rhinoplasty: A Quasi-experimental Study by the Aid of ROE and RHINO Questionnaires

BACKGROUND AND AIMS

Rhinoplasty is one of the common plastic surgery procedures which has a high rate in Iran. There are several tools for assessing the outcomes and quality of life after this surgical procedure which rhinoplasty outcome evaluation (ROE) questionnaire and rhinoplasty health inventory and nasal outcomes are two of them. The aim of this study was to investigate the aesthetic and functional outcomes of rhinoplasty by the aid of ROE and RHINO scales in patients who presented to a referral center in Iran.

MATERIALS AND METHODS

This prospective, quasi-experimental study was performed on patients who referred to the plastic surgery clinic of Imam Khomeini hospital complex during 2017 to 2019 and underwent open rhinoplasty. ROE and RHINO questionnaires were filled by patients before and 6 months after the surgery. Surgical outcomes and aesthetic satisfaction rate were evaluated in different age groups, genders and educational levels. The data were analyzed by version 21 of SPSS software.

RESULTS

ROE score increased from 51.27 ± 10.54 to 79.6 ± 9.67 (P < 0.001). In addition, RHINO score increased from 64.13 ± 11.43 to 83.36 ± 11.03 (P < 0.001). The most common satisfaction factors among patients in this study were "nose feels more natural" in 62% of patients and "tip rotation is good" in 32% of patients. Furthermore, the most common causes of dissatisfaction in patients were "nose too wide" in 25% of patients and "tip bulbous" in 25% of patients.

CONCLUSION

ROE and RHINO scales are effective for assessing rhinoplasty outcomes. The satisfaction rate of rhinoplasty is high in Iran and is related to the natural shape of the nose in addition to the tip rotation.

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 .

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.

Patient-reported outcome measures in external and endonasal functional septorhinoplasty - A propensity score matching study

PURPOSE

Patient satisfaction after functional-aesthetic SRP (faSRP) is highly influenced by the cosmetic result of the surgical procedure. Studies that directly evaluate aesthetic success after external and endonasal faSRP are scarce. The objective of this prospective propensity score matching study was to compare patient-reported satisfaction regarding aesthetic perception following faSRP using the external and endonasal approach in a single-institution single-surgeon survey.

MATERIALS AND METHODS

Out of 161 patients operated by the senior author between October 2011 and March 2017, propensity score matching (PSM) computed 54 patients each following external (group 1) or endonasal faSRP (group 2). Patients reported their satisfaction with the aesthetic appearance of the nose on a visual analogue scale (VAS, 0-10) and five Likert scale questions using the Utrecht questionnaire three and twelve months after surgery.

RESULTS

The mean preoperative VAS score of 3.46 ± 1.06 improved significantly in all patients after faSRP to 4.54 ± 0.38 (F_{(1.69;157.04)} = 634.01, p < 0.001). The VAS increase did not show any correlation to the surgical approach (F(_1;93) = 1.12, p = 0.293). The mean aesthetic sum score (5 = low burden up to 25 = high burden) improved significantly from 13.89 ± 3.78 to 8.46 ± 3.63 after three months (t₍₉₅₎ = 14.021, p < 0.001) and remained almost unchanged after 12 months (8.10 ± 3.76; t₍₉₈₎ = 1.450, p = 0.150) irrespective of the surgical approach (F_{(1,544;143,587)} = 0.126, p = 0.829).

CONCLUSIONS

Both the external and endonasal faSRP allowed for significant improvement in patient's aesthetic self-assessment of similar extent.

Shaved Cartilage Gel Versus Diced Cartilage on Final Dorsal Camouflage: Prospective Study of 200 Patients

Importance: Diced cartilage (DC) is a reported technique that has been used for dorsal camouflage after reduction rhinoplasty. Nevertheless, there are certain issues regarding its use on nasal dorsum, especially its variable resorption rate and risk of graft distortion or migration, especially in thin-skinned patients. Recently, regenerative medicine protocols have been used to overcome drawbacks of methods based on DC. Thus, cartilage embedded in platelet-rich fibrin (PRF) has been described as a promising and reliable alternative to existing procedures. Objective: To compare long-term aesthetic outcomes of two different techniques for dorsal camouflage: DC versus shaved cartilage plus platelet-rich fibrin (SC+PRF)-shaved cartilage gel. Design, Setting, and Participants: This is a prospective, interventional, and longitudinal study at an academic tertiary medical center. Participants were 200 consecutive patients undergoing primary reduction rhinoplasty by spare roof technique (SRT) or component dorsal reduction (CDR). Materials and Methods: The inclusion criteria were primary rhinoplasty, in Caucasian patients with dorsal hump, and camouflage of the dorsum by DC or SC+PRF. Exclusion criteria were ≤18 years of age, revision rhinoplasty and reconstructive rhinoplasty for neoplasic or severe traumatic nasal deformities. The "Utrecht Questionnaire for outcome assessment in aesthetic rhinoplasty" was used. Patients answered it before and after surgery (3 and 12 months after). Results: The study population included 200 patients divided into two groups considering the type of dorsal camouflage: DC (n = 132) and shaved cartilage gel (n = 68). The mean age at the time of surgery was 35.44 years (standard deviation ±9.78) and the study population included 130 females (65.0%) and 70 males (35.0%). Regarding aesthetic outcomes, analyses of postoperative means showed a significant improvement, in both groups, over time. However, self-assessment, based on the visual analogue scale (VAS), at 12 months postsurgery, was higher for patients with SC+PRF than with DC (p = 0.004). Twelve months after surgery, patients with thin skin had better aesthetic outcome with SC+PRF than with DC (p = 0.001). For both reduction rhinoplasty techniques, aesthetic outcomes, based on the VAS at 12 months after surgery, were significantly better for patients with SC+PRF (SRT: p = 0.016; CDR: p = 0.004). For both rhinoplasty approaches, either open or closed, aesthetic outcomes, based on the VAS at 12 months after surgery, were significantly better for patients with SC+PRF (closed approach: p = 0.046; open approach: p = 0.017). Conclusions: SC+PRF provides better long-term aesthetic outcomes, not only for thin-skinned patients, but also for patients who had undergone rhinoplasty by a structured or preservation technique, or by an open or closed approach, for dorsal hump reduction.

The Impact of Mastectomy on Women's Visual Perception of Breast Aesthetics and Symmetry: A Pilot Eye-Tracking Study

BACKGROUND

Little is known about breast cancer survivors' perception of breast attractiveness. A better understanding of this subjective concept could contribute to the improvement of patient-reported outcomes after reconstructive surgeries and facilitate the development of new methods for assessing breast reconstruction outcomes.

OBJECTIVES

The aim of this eye-tracking (ET)-based study was to verify whether mastectomy altered women's visual perception of breast aesthetics and symmetry.

METHODS

A group of 30 women after unilateral mastectomy and 30 healthy controls evaluated the aesthetics and symmetry of various types of female breasts displayed as highly standardized digital images. Gaze patterns of women from the study groups were recorded using an ET system and subjected to a comparative analysis.

RESULTS

Regardless of the study group, the longest fixation duration and the highest fixation number were found in the nipple-areola complex. This area was also the most common region of the initial fixation. Several significant between-group differences were identified; the gaze patterns of women after mastectomy were generally characterized by longer fixation times for the inframammary fold, lower pole, and upper half of the breast.

CONCLUSIONS

Mastectomy might affect women's visual perception patterns during the evaluation of breast aesthetics and symmetry. ET data might improve our understanding of breast attractiveness and constitute the basis for a new reliable method for the evaluation of outcomes of reconstructive breast surgeries.

The Role of Resident-Run Clinics for Aesthetic Surgery Training in the Context of Competency-based Plastic Surgery Education

Resident-run clinics (RRCs) have been suggested as a clinical teaching tool to improve resident exposure in aesthetic plastic surgery education. In exchange for reduced cost aesthetic services, RRCs offer trainees the opportunity to assess, plan, execute, and follow surgical procedures in an independent yet supervised manner. With the transition into a competency-based medical education model involving a switch away from a time-based into a milestones-based model, the role of RRCs, within the context of the evolving plastic surgery curriculum has yet to be determined. To that end, the present study summarizes current models of aesthetic surgery training and assesses RRCs as an adjunct to aesthetics education within the framework of competency-based medical education. Explored themes include advantages and issues of RRCs including surgical autonomy, feasibility, exposure, learners’ perception, ethics, and quality improvement. In addition, attention is focused on their role in cognitive competency acquisition and exposure to non-surgical techniques. RRCs are considered an effective educational model that provides an autonomous learning platform with reasonable patient satisfaction and safety profiles.

Autologous versus prosthetic nasal and auricular reconstruction - patient, professional and layperson perceptions

The aim of this study was to retrospectively evaluate the perceptions of aesthetic outcome following the autologous and prosthetic reconstruction of nasal and auricular defects among patients, professionals (oral and maxillofacial surgeons and ear, nose and throat surgeons) and people unfamiliar with reconstructive surgery. The influence of anatomical subunits on the overall perception of nasal and auricular reconstructions was also determined. A total of 119 patients treated for nasal and auricular defects between 1997 and 2016, with a minimum follow-up period of 6 months, were selected, and photographs of 77 of these patients (65%) were presented in a digital survey and reviewed using a standardized questionnaire. No clinically relevant correlations were found between the age or gender of patients (as well as those of the respondents) and their scores. Prosthetic reconstructions of nasal and auricular defects were considered advantageous over autologous reconstructions in terms of the subjective aesthetic outcome in the view of the professionals, in particular oral and maxillofacial surgeons; however, the patients judged both techniques to be equally effective in terms of aesthetics. No anatomical subunits were found to have a significant impact on the overall match of a nasal or auricular reconstruction with the patient's face.

Satisfaction with cosmetic outcomes of breast reconstruction: Investigations into the correlation between the patients' Breast-Q outcome and the judgment of panels

Objectives

We aimed to determine the relation between breast reconstruction method, patient satisfaction, and surgeon reported cosmetic outcome among women who underwent breast reconstruction after mastectomy.

Study Design

A cross-sectional study of patients treated between 2006 and 2010.

Main Outcome

Women's satisfaction with cosmetic outcomes after breast reconstruction.

Measures

Cosmetic outcomes were evaluated by (1) women using the Breast-Q to rate satisfaction with breasts outcomes, and (2) an independent panel using the Strasser score. The relationships between the Breast-Q rating, Strasser scores, and breast reconstruction methods, including laterality and timing, were evaluated by Mann–Whitney U tests, Spearman's rank correlations, and Wilcoxon signed-rank tests.

Results

Ninety-four women were included. Patients were more satisfied with their breasts if they had undergone autologous, unilateral, or secondary breast reconstruction compared with those who underwent alloplastic, bilateral, or primary breast reconstruction (p-values 0.008, 0.011, and 0.001, respectively). The Strasser system did not reveal significant cosmetic differences, with all breast reconstructions graded as mediocre or poor.

Conclusions

Patient satisfaction with breast outcomes, as measured by the Breast-Q, was described as mediocre or poorly reflected by the Strasser score. If doctors are to support patients to make informed decisions on the optimal method of breast reconstruction, we need a more sensitive, comprehensive tool reflecting patients’ cosmetic outcomes.

Spare Roof Technique: A New Technique for Hump Removal-The Step-by-Step Guide

Humpectomy is one of the most common steps in reduction rhinoplasty among Caucasian patients. The most widespread procedures to address hump removal are both the "en bloc humpectomy" (with reconstruction of the middle third with spreader grafts) and the "split hump technique" (with confection of spreader flaps). The spare roof technique, for rhinoplasty reduction, has been developed over the past 4 years. In this technique, the upper lateral cartilages are completely preserved-even the hidden part under the caudal aspect of the nasal bones. It consists of five main steps: step 1, the upper lateral cartilages are released from the dorsal aspect of the nasal septum; step 2, a 1-mm strip of the dorsal septum is taken in each movement as required; step 3, ostectomy of the caudal aspect of nasal bones, keeping the upper lateral cartilages intact and releasing the "lateral" (left and right) pyriform aperture ligament; step 4, classic medial and lateral osteotomies (closing the open bony roof); and step 5, suturing the upper lateral cartilages to the dorsal septum and thus avoiding the natural spring effect. The outcomes of the first 100 patients have been validated by a prospective, interventional, and longitudinal study performed on patients undergoing primary rhinoplasty by means of the spare roof technique. This study confirms that the spare roof technique significantly improved patient quality of life regarding nose function and appearance. It is a reliable technique that can help deliver consistently good results in Caucasian and Mediterranean patients with a dorsal hump seeking rhinoplasty.

A quantitative, objective method for evaluating the surgical outcomes of baggy eyelid correction using orbital gray scale analysis

BACKGROUND

Baggy lower eyelids (BLEs) are a common cosmetic problem that is treated using various methods. However, validated objective methods for evaluating the treatment are limited.

AIMS

A novel BLE correction procedure, transconjunctival fat resection, and subsequent fat grafting, was assessed using the orbital gray scale (OGS), a previously suggested objective measure for BLEs.

METHODS

All patients were evaluated using both the tear trough rating scale (TTRS), a surgeon-derived evaluation method, and OGS, an objective computer-derived assessment. Changes throughout the surgery and their relationship to clinical characteristics, as well as the association between the two measurements, were statistically analyzed.

RESULTS

A total of 50 patients who underwent surgery were analyzed. No major complications other than wrinkles were observed. All patients showed improvement in both the TTRS scores and OGS values (P < 0.05). Lateral OGS was improved to a greater extent in older patients (P < 0.05). Medial OGS change was associated with improvement of tear trough depression (P < 0.05). Lateral OGS change was related to decreased infraorbital fat herniation (P < 0.05). Total OGS change was related to improvement of both tear trough depression and fat prolapse (P < 0.05).

CONCLUSION

The total OGS change was significantly associated with improvements in tear trough depression and fat bulging. Therefore, it could be a convenient objective evaluation measure for eyelid correction procedures.

Feasibility of Implementing a Breast Reconstruction Database

Objective

To assess whether implementing a breast reconstruction database would be feasible in terms of time commitment, cost, and overall benefits in a tertiary-care hospital.

Methods

A survey was sent to 40 Canadian plastic surgeons who have a practice focused on breast reconstruction. The survey assessed demographics, practice characteristics, database use, and opinions on database construction. Univariate descriptive analyses were performed on all variables.

Results

Thirty-one surgeons responded to the survey (77.5%). Most were from Ontario (29.1%) and worked in an academic center (83.9%). Of all, 45.3% of surgeons performed more than 50 breast reconstructions yearly. Six (19.4%) surgeons utilized databases that were all started for quality improvement and research purposes. Databases included variables such as demographics, type of reconstruction, complications, surgeons involved, and type of implants. Data are input by research assistants (50%) for approximately 4.2 hours per month at a cost below 200$CAD per month. Databases are funded by research grants (50%), hospital funds (33.3%), and/or division funds (16.7%). Of the surgeons without databases, 60% have considered starting a database. Barriers include being too busy (72%) and impressions of the cost being too high (32%). Surgeons commonly felt that a database would be beneficial at their practice (80%), provincially (77.4%), and nationally (67.7%).

Conclusions

Plastic surgeons are open to the idea of constructing a breast reconstruction database and that the costs and time required are lower than expected. Grants or integration with existing databases should be pursued on a provincial level first prior to pursuing a national database.

Spare roof technique in reduction rhinoplasty: Prospective study of the first one hundred patients

OBJECTIVE

Assess the aesthetic and functional outcomes of the first 100 patients who underwent reduction rhinoplasty with the spare roof technique (SRT).

METHODS

Prospective, interventional, and longitudinal study performed on consecutive patients undergoing primary rhinoplasty by SRT. All the surgical procedures were performed by the surgeon who first described this technique. The validated Portuguese version of the Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty was used. Patients completed the questionnaire presurgery and again 3 and 12 months postsurgery. In addition, a visual analogue scale (VAS) was used to score nasal patency for both sides.

RESULTS

The study population included 100 Caucasian Mediterranean patients (33 males; 67 females). Mean age at surgery was 32.8 years. Analysis of the preoperative and postoperative mean aesthetic VAS scores showed a significant improvement from 3.67 to 8.1 (P < 0.001) and 8.44 (P < 0.001), respectively, 3 and 12 months postsurgery. Analysis of the five aesthetic Likert scale questions all showed a highly significant improvement after rhinoplasty. The mean preoperative aesthetic sum score was 13.9, which improved to 8.26 and 7.08, respectively, 3 and 12 months postsurgery (P < 0.001), indicating a significant improvement of subjective body image in relation to nasal appearance. Analysis of the preoperative and postoperative mean functional VAS score showed a significant improvement on both sides.

CONCLUSION

This prospective statistical study confirms that SRT significantly improved patient quality of life regarding nose function and appearance. It is a reliable technique that can help deliver consistently good results in reduction rhinoplasty in Caucasian patients with dorsal hump seeking rhinoplasty.

LEVEL OF EVIDENCE

2 Laryngoscope, 129:2702-2706, 2019.

Does self-consciousness of appearance influence postoperative satisfaction in rhinoplasty?

BACKGROUND

Facial plastic surgeons and patients benefit from knowledge about how psychological aspects can influence the outcome of cosmetic surgery. The influence of preoperative self-consciousness of appearance and its effect on benefit after surgery in rhinoplasty patients has not been explored before in other studies.

METHOD

A prospective study was conducted on patients undergoing (septo)rhinoplasty for a combination of cosmetic and functional problems. Before the operation subjects were asked to complete two questionnaires, the Derriford Appearance Scale (DAS59) to measure distress associated with self-consciousness of appearance and the Rhinoplasty Outcome Evaluation (ROE) to measure satisfaction with their nose. Three months after surgery, they were asked to complete the ROE again and the Glasgow Benefit Inventory to measure benefit of the surgery in daily life. Scores of the pre- and postoperative questionnaires were analyzed and compared. Statistical analysis was performed to determine change after surgery and correlations between the scores.

SUBJECTS

Fifty-five consecutive patients undergoing (septo)rhinoplasty received a letter in which they were asked to participate in the study. Thirty-three patients completed both pre- and postoperative questionnaires. Their mean age was 28 years.

MAIN FINDINGS

Patient satisfaction improved significantly after the surgery. Lower self-consciousness of appearance before surgery was positively correlated with more benefit after the surgery and a greater change in patient satisfaction with their nose. Males have a lower benefit scores than females.

CONCLUSIONS

Patients seeking rhinoplasty have more distress associated with self-consciousness of appearance than a general unconcerned population. They can benefit a lot from a well-executed procedure. A significant improvement in quality of life can be achieved by rhinoplasty. Although males are equally satisfied as females, they benefit less from the surgery in daily life.

The MiRa scale, a new standardised scale for evaluating nasal deformities before and after septorhinoplasty: A prospective study comparing patient satisfaction and the surgeon's assessment

OBJECTIVES

The objective was to assess the reliability of a new standardised scale for evaluating nasal anomalies in order to compare the surgeon's assessment and patient satisfaction.

DESIGN

Monocentric prospective cohort study.

SETTINGS

First, we validated the reliability of the MiRa scale; then, we compared the surgeon's assessment and patient satisfaction.

PARTICIPANTS

Fifty-two patients underwent septorhinoplasty surgery and gave their written consent before inclusion.

MAIN OUTCOME MEASUREMENTS

Primary outcome measurement was to validate the reliability of the MiRa scale: two observers analysed all records twice. Intra-observer reproducibility and interobserver reproducibility were evaluated using the intraclass correlation coefficient (ICC). Secondary outcome measurement was to compare the surgeon's assessment and patient satisfaction: MiRa and ROE (Rhinoplasty Outcome Evaluation) scores were established for each patient prior to and 6 months after surgery.

RESULTS

Using the MiRa scale, ICC for intra- and interobserver reproducibility was, respectively, 95.4% and 96%, showing no statistical difference (P=.70, P=.45). Good correlation scores were, respectively, 93% and 92%. Mean ROE scores were 7.1/24 (SD=11.3) before and 19.3/24 (SD=17.3) after surgery (P<.05). We found an increase in MiRa and ROE scores of +19.75% and +51.25% (P<.05), respectively. The average postoperative ROE score in the primary septorhinoplasty group was 20.4 (SD=14.4) and 17.2 (SD=23.1) in the secondary septorhinoplasty group (P<.05).

CONCLUSION

MiRa scale is a reliable, standardised tool to evaluate surgical outcome in septorhinoplasty surgery. It provides an objective and reproducible score. The surgeon's assessment was more critical than patient satisfaction. Patient satisfaction is more difficult to achieve in cases involving a secondary septorhinoplasty.

Is There a Cosmetic Advantage to Single-Incision Laparoscopic Surgical Techniques Over Standard Laparoscopic Surgery? A Systematic Review and Meta-analysis

Single-incision laparoscopic surgery represents an evolution of minimally invasive techniques, but has been a controversial development. A cosmetic advantage is stated by many authors, but has not been found to be universally present or even of considerable importance by patients. This systematic review and meta-analysis demonstrates that there is a cosmetic advantage of the technique regardless of the operation type. The treatment effect in terms of cosmetic improvement is of the order of 0.63.

All Seasons Vertical Augmentation Mastopexy: A Simple Algorithm, Clinical Experience, and Patient-reported Outcomes

Supplemental Digital Content is available in the text.

Background:

The safety of augmentation mastopexy has been questioned. Staging has been recommended for women deemed to be at higher risk, such as women with greater degrees of ptosis. Most existing studies evaluate women treated with multiple methods, including the traditional Wise pattern. This retrospective study specifically evaluates vertical augmentation mastopexy. A simple algorithm is introduced.

Methods:

From 2002 to 2016, 252 women underwent consecutive vertical augmentation mastopexies performed by the author, with no staged surgery. All patients underwent a vertical mastopexy using a medially based pedicle and intraoperative nipple siting. A subset of women treated from 2012 to 2016 were surveyed to obtain outcome data; 90 patients (inclusion rate, 90%) participated.

Results:

The complication rate was 32.9%, including persistent ptosis, delayed wound healing, scar deformities, and asymmetry. There were no cases of nipple loss. An increased risk of complications was detected for smokers (P < 0.01), but not for combined procedures, secondary breast augmentations, or secondary mastopexies. The revision rate was 15.5%. Persistent nipple numbness was reported by 13.3% of respondents. Eighty percent of women were self-conscious about their breast appearance before surgery; 22% of respondents were self-conscious about their breasts after surgery. Seventy percent of respondents reported an improved quality of life, 94.4% would repeat the surgery, and 95.6% would recommend it.

Conclusions:

A simple algorithm may be used to guide treatment in women who desire correction of ptosis and upper pole fullness. An "all seasons" vertical augmentation mastopexy is safe and widely applicable. Staging is unnecessary.

Avoiding Psychological Pitfalls in Aesthetic Medical Procedures

OBJECTIVE

To assess the prevalence of body dysmorphic disorder (BDD) in an aesthetic surgery setting in the region of Southwest China, and to ascertain the differences in terms of body images between patients in the aesthetic setting and general Chinese population. This study tracked patient satisfaction with their body image changes while undergoing aesthetic medical procedures to identify whether the condition of patients who were presenting with BDD symptoms or their psychological symptoms could be improved by enhancing their appearance. Additionally, this study explored whether there was improvement in quality of life (QoL) and self-esteem after aesthetic medical procedures.

METHODS

A total of 106 female patients who were undergoing aesthetic medical procedures for the first time (plastic surgery, n = 26; minimally invasive aesthetic treatment, n = 42; and aesthetic dermatological treatment, n = 38) were classified as having body dysmorphic disorder symptoms or not having body dysmorphic disorder symptoms, based on the body dysmorphic disorder examination (BDDE), which was administered preoperatively. These patients were followed up for 1 month after the aesthetic procedures. The multidimensional body self-relations questionnaire-appearance scales (MBSRQ-AS) and rosenberg self-esteem scale (RSE-S) were used to assess patients' preoccupation with appearance and self-esteem pre-procedure and 1 month post-procedure. Additionally, 100 female healthy control participants were recruited as a comparative group into this study and they were also assessed using BDDE, MBSRQ-AS, and RSE-S.

RESULTS

A total of 14.2 % of 106 aesthetic patients and 1 % of 100 healthy controls were diagnosed with BDD to varying extents. BDDE scores were 72.83 (SD ± 30.7) and 68.18 (SD ± 31.82), respectively, before and after the procedure for the aesthetic patient group and 43.44 (SD ± 15.65) for the healthy control group (F = 34.28; p < 0.001). There was a significant difference between the groups in subscales of MBSRQ-AS, i.e. appearance evaluation (F = 31.31; p < 0.001), appearance orientation (F = 31.65; p < 0.001), body areas satisfaction (F = 27.40; p < 0.001), and RSE-S scores (F = 20.81; p < 0.001). There was no significant difference, however, in subscales of MBSRQ-AS, i.e. overweight preoccupation (F = 1.685; p = 0.187), self-classified weight (F = 0.908; p = 0.404) between groups. All the subscales of MBSRQ-AS showed significant differences between the aesthetic patients (pre-procedure) and female adult norms from Dr. Cash's result given in Table 4 (p < 0.001). The study also showed that there were no significant differences in the scores of BDDE, MBSRQ-AS, and RSE-S of those fifteen aesthetic patients diagnosed with BDD after aesthetic procedures lasting one month.

CONCLUSION

There was a high prevalence rate (14.2 %) of body dysmorphic disorder in aesthetic procedure seekers, and it seemed that those patients suffering from BDD were more likely to be dissatisfied with the results of the aesthetic medical procedures. However, general aesthetic patients showed improvement in most assessments which indicated that aesthetic medical procedures could not only enhance patient appearance, but also patient low self-esteem and QoL. Self-satisfaction could also be promoted. A screening procedure for BDD including suitable screening questionnaires might be considered for routine use in aesthetic clinical settings to minimize dissatisfaction and complaints.

LEVEL OF EVIDENCE IV

This journal requires that the 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 .

Quality of Life and Aesthetic Plastic Surgery: A Systematic Review and Meta-analysis

Quality of life (QoL) is an important outcome in plastic surgery. However, authors use different scales to address this subject, making it difficult to compare the outcomes. To address this discrepancy, the aim of this study was to perform a systematic review and a random effect meta-analysis.

Evaluation of aesthetic and functional outcomes in rhinoplasty surgery: a prospective study

Introduction

Evaluation of surgery outcome measured by patient satisfaction or quality of life is very important, especially in plastic surgery. There is increasing interest in self-reporting outcomes evaluation in plastic surgery.

Objective

The aim of our study was to determine patient satisfaction in regard to nose appearance and function with the use of a validated questionnaire, before and after rhinoplasty surgery.

Methods

A prospective study was realized at a tertiary centre. All rhinoplasty surgeries performed in adults between February 2013 and August 2014 were included. Many patients underwent additional nasal surgery such as septoplasty or turbinoplasty. The surgical procedures and patients’ characteristics were also recorded.

Results

Among 113 patients, 107 completed the questionnaires and the follow-up period. Analysis of pre-operative and post-operative Rhinoplasty Evaluation Outcome showed a significant improvement after 3 and 6 months in functional and aesthetic questions (p < 0.01). In the pre-operative, patients anxious and insecure had a worse score (p < 0.05). Difference in improvement of scores was not significant when groups were divided on basis of other nasal procedures, primary or revision surgery and open versus closed approach.

Conclusion

We found that patients with lower literacy degree were more satisfied with the procedure. Rhinoplasty surgery significantly improved patient quality of life regarding nose function and appearance.

The comparison between alar cartilage shortening and columellar-septal suture techniques in nasal tip rotation

BACKGROUND

One of the main operative goals achieved with tip surgery is to reach the ideal nasolabial angle. The main purpose of the current study was to compare the effects of alar cartilage vertical incision and shortening (ACS) and columellar-septal suture (CSS) techniques on the nasolabial angle.

METHODS

In this retrospective study, 2 groups were examined: the patients in the first group were operated on using vertical alar cartilage incision and shortening, and the patients in the second group were operated on using columellar-septal cartilage suture. Postoperative photographs between the 2 groups were compared with respect to nasolabial angle differences. Statistical analysis was done with SPSS version 20.

RESULTS

In the postoperative evaluation, 50% of ACS and 72.5% of CSS groups had achieved desired clinical outcomes. Although the efficacy of the CSS group was found to be superior to that of the ACS group, there was no statistically significant difference between the groups. Greater nasolabial angle was gained using the CSS technique; however, the risk for overrotation was higher in the CSS group.

CONCLUSIONS

Both ACS and CSS techniques provide reliable reconstructive option for nasolabial angle modifications. More predictable results were obtained with the ACS technique. The CSS technique is a versatile way of nasolabial angle alteration, but there is a higher risk for overrotation.