Patient complaints with primary versus revision rhinoplasty: analysis and practice implications

The Role of Spreader Grafts in Reduction Septorhinoplasty: A Randomized Clinical Trial With Quality of Life Assessment

OBJECTIVE

To evaluate the impact of spreader grafts in reduction septorhinoplasty on quality of life (QOL) outcomes.

TRIAL DESIGN

Randomized clinical trial (RCT).

METHODS

Individuals over 15 years old with nasal obstruction were evaluated for functional and aesthetic septorhinoplasty from October 2018 to October 2022 at a facial plastic surgery clinic of a tertiary university hospital in Brazil. Participants were randomly allocated to subjects with or without spreader grafts.

PRIMARY OUTCOME

Relative changes in specific Nasal Obstruction Symptom Evaluation in the Portuguese language (NOSE-p). Outcomes were assessed at least 6 and 12 months postoperatively (PO ≥ 6 and PO ≥ 12 m). The participants and those assessing the outcomes were blinded to group assignment.

RESULTS

A 50 patients were included, 25 randomized to each group, mainly Caucasians with moderate/severe allergic rhinitis symptoms. Mean age was 32.89 ± 13.36 years and 68% were female. Septorhinoplasty improved specific quality-of-life scores irrespective of using spreader grafts (p < 0.001). There was no difference between subjects submitted or not to placement of spreader grafts in NOSE-p score in PO ≥ 6 m (-60.0 vs. -66.6%; p = 0.37); ROE in PO ≥ 6 m (71.83 vs. 79.56; p = 0.35), NO-VAS in PO ≥ 6 m (13.00 vs. 8.00; p = 0,35), NOSE p in PO ≥ 12 m (-53.14% vs. -68.33%; p = 0.28), ROE in PO ≥ 12 m (76.33 vs. 79.53; p = 0.645), NO-VAS in PO ≥ 12 m (13.00 vs. 11.50; p = 0.60).

CONCLUSIONS

Reduction septorhinoplasty was associated with improvement in quality of life regarding nasal obstruction irrespective of using spreader grafts in a 7.88-month follow-up.

LEVEL OF EVIDENCE: 2

TRIAL REGISTRATION

ClinicalTrials.gov identifier: (NCT0449946).

The Incidence of Nasal Tip and Upper Lip Malposition in Primary Rhinoplasty

BACKGROUND

For an optimal aesthetic plan for correction of nasal tip disharmony, it is crucial to note lip and tip disproportions.

OBJECTIVES

In this study we sought to investigate the incidence of preoperative upper lip malposition in primary rhinoplasty patients.

METHODS

In total, 150 consecutive primary rhinoplasty patients were included. The position of the upper lip was measured during smiling relative to the incisors and gum line, and categorized as ideal, inadequate incisor show, or excessive gum show. Nasal length was categorized based on soft tissue cephalometic analysis of life-size photographs as long, ideal, or short. Tip projection was categorized as overprojected, ideal, or underprojected. The columella was categorized as hanging, ideal, or retracted.

RESULTS

Standardized photographs of 139 primary rhinoplasty patients met inclusion criteria. Forty-seven (34%) patients had an ideal upper lip position, 83 (61%) inadequate incisor show, and 7 (5%) excessive gum show. Sixteen (12%) had a short nose, 45 (33%) ideal length, and 76 (55%) a long nose. Fourteen (10%) had an underprojected tip, 38 (28%) had an ideal tip projection and 85 (62%) an overprojected tip. None of the nasal parameters were predictive of upper lip position. Tip overprojection (odds ratio [OR] 3.03, P = .02) and hanging columella (OR 2.97, P = .001) were predictive of a long nose. Tip underprojection was predictive of short length (OR 35, P < .0001).

CONCLUSIONS

There is a high incidence of upper lip malposition in patients undergoing primary rhinoplasty. It is vital for the rhinoplasty surgeon to identify it preoperatively and plan the surgical maneuvers accordingly to prevent exacerbating an insufficient incisor show or excessive gum show.

LEVEL OF EVIDENCE: 4

Comparison of 1 Year Nasal Tip Projection Results of Triple Cartilage Combining Suture (Flexible Tongue-in-Groove) and Classical Tongue-in-Groove Techniques

Objectives: In the present study, we compared patient satisfaction with classical tongue-in-groove (TIG) technique and triple cartilage combining suture (TCCS; flexible tongue-in-groove) techniques applied to the nasal tip in rhinoplasty. Methods: In this retrospective study, 80 patients who underwent rhinoplasty operations with TIG or TCCS techniques applied to the tip region were included. There were 40 patients in both groups. All patients in groups 1 and 2 were evaluated by the criteria written below at preoperative, postoperative first month, and postoperative first year: (1) Rhinoplasty Outcomes Evaluation Questionnaire (ROE), (2) tip projection (cm), (3) nasal dorsum length (cm), (4) tip projection ratio (Goode), (5) nasofrontal angle, and (6) nasolabial angle. Results: The patients were followed up at 84.32 ± 19.38 months in the TIG group and 87.47 ± 18.01 months in the TCCS group. Our results showed that preoperative, postoperative first-month, and first-year tip projection (P = .013, P = .022, and P = .020, respectively), and nasal dorsum length values (P = .009, P = .020, and P = .020, respectively) of the TCCS group were significantly lower than those in the TIG group. There was a positive correlation between the postoperative first month and postoperative first year ROE scores. Lower preoperative tip projection ratio (Goode) values and higher nasolabial angle values were related to higher ROE scores showing patient satisfaction. Conclusion: For the patient satisfaction after tip rhinoplasty, lower projection ratio (Goode) and higher nasolabial angle values were related to ROE scores. Although there are no significant results, lower tip projection results in the TCCS group may be related to more patient satisfaction due to natural appearance.

Comparison of Nasal Airways After Classical Structural Rhinoplasty and Dorsal Preservation Rhinoplasty

Purpose: To investigate whether there was a difference in the nasal airway dimensions after dorsal preservation and classical structural rhinoplasty. Introduction: The surgical approach to rhinoplasty has improved over many decades. The first was the classic structural rhinoplasty (CSR) developed by Joseph, where the excess tissues are removed from the dorsal hump. In the following decades, dorsal preservation rhinoplasty (DPR) was established to prevent complications associated with CSR. Methods: One hundred twenty-four patients without self-reported nose obstruction syndromes underwent DPR or CSR according to the authors' shared surgical regime. Nasal airway dimensions of rhinoplasty patients were measured preoperatively and postoperatively with acoustic rhinometry (AR), and minimum cross-sectional areas (MCA) and internal nasal volumes (VOL) were acquired. Results: Dorsal preservation rhinoplasty was performed on 64 patients (51.6%), while classical structural rhinoplasty was performed on the remaining 60 (48.4%). There were no significant differences between the 2 techniques regarding VOL and MCA. (MCA1left side DPR vs CSR P = .539, VOL1 right side DPR vs CSR P = .843). Conclusion: We postulate that nasal airway dimensions do not predict or indicate whether the DPR or CSR technique will be/have been used in rhinoplasty surgery, and the employed technique does not significantly alter the dimensions of the nasal airways. Any significant change in nasal airway dimensions is more likely due to the septal intervention.

Nonsurgical Correction of Surgical Rhinoplasty Complications with Hyaluronic Acid Fillers: A Retrospective Review of 2088 Cases

Background

Surgical rhinoplasty is a highly complex cosmetic procedure with significant revision rates. Unfortunately, surgical revision rhinoplasty is associated with many challenges. Nonsurgical correction of surgical rhinoplasty complications with injectable hyaluronic acid fillers is an alternative with less cost and downtime. In this article, we present the first author's experience with 2088 cases of nonsurgical revision rhinoplasty, including technical considerations, patient-reported outcomes, and adverse events.

Methods

A retrospective chart review was completed on patients 18 years and older who received nonsurgical rhinoplasty treatment between March 2018 and August 2022. Patient demographic data, and data on indications for treatment, volume of filler used, patient-reported satisfaction, and adverse events (including erythema, infection, vascular occlusion, and necrosis) were collected up to 1 year after the initial injection.

Results

A total of 2088 patient cases are included in this study. The most common indications for treatment included bridge collapse or asymmetry (49.0%), an under-projected tip (44.0%), and surface irregularity/scarring (35.4%). The mean volume of filler used at initial treatment was 0.49 mL (SD 0.19). Median patient satisfaction immediately after treatment was 9 (visual analog scale ranging from 1 to 10). The most common adverse event reported at the 2-week follow-up was erythema (36.4%). Three patients presented with skin necrosis (0.47%). All three of these were transient and self-resolving.

Conclusions

Nonsurgical correction of rhinoplasty complications with hyaluronic acid fillers can be a safe, minimally invasive option with high patient satisfaction and immediate and predictable results. This should be considered first line before surgical revision.

Awareness of rhinoplasty surgery among the population in the Jazan Region, Saudi Arabia

Background

Cosmetic and plastic surgery is becoming increasingly prevalent all over the world among both men and women. Saudi Arabia ranks 22nd among the top 25 countries with the world's highest rates of cosmetic surgeries. This study aimed to assess the awareness of the population in the Jazan region regarding rhinoplasty surgery and to identify their main determinants.

Material and Methods

A cross-sectional study of 425 participants was conducted at four randomly selected malls in Gizan City. A self-administered questionnaire was first developed to collect the data necessary to fulfill the research objectives, data were analyzed using Statistical Package for the Social Sciences (SPSS) version 22. The quantitative data were reported as a mean and standard deviation, and the qualitative data were reported as frequency and percentage. Regarding tests for significance, the Chi-square test used a P value less than 0.05 as an indicator of significance. Logistic regression was used to detect the predictors of poor knowledge of rhinoplasty surgery.

Results

The mean age of the participants was 39.46 ± 10.08. Of the participants, 53.6% have poor knowledge while 36.0% have good knowledge regarding rhinoplasty surgery. Moreover, 60.2% have an unfavorable attitude while 23.6% have a favorable attitude toward rhinoplasty surgery. The most important predictors of poor knowledge of rhinoplasty surgery are as follows: (a) old age (OR = 4.89), (b) illiteracy (OR = 4.12), (c) intermediate education (OR = 3.65), and (d) male sex (OR = 1.18).

Conclusion

There was a low level of knowledge regarding rhinoplasty surgery among the study participants, most of the participants had negative (unfavorable) attitudes toward rhinoplasty surgery. Mass media plays an important role as a source of information. We recommend further studies to find out other personal factors affecting knowledge and attitude toward rhinoplasty surgery.

Perception of Rhinoplasty Outcome Utilizing Patients' Photography

BACKGROUND

Patient satisfaction with rhinoplasty results is evaluated in a manner of subjective and qualitative values, and to a certain degree, it can indicate successful outcomes in rhinoplasty.

METHODS

The present study was a descriptive study that assessed the rhinoplasty outcome of adult patients who underwent septorhinoplasty between January 2015 and August 2023 at a single center in Saudi Arabia utilizing Rhinoplasty Outcome Evaluation scores and Nasal Obstruction Symptom Evaluation scores pre-operatively, postoperatively, and postoperatively with showing the patients their photo before surgery.

RESULTS

The comparison of Rhinoplasty Outcome Evaluation scores and Nasal Obstruction Symptom Evaluation scores showed statistically significant with P value of 0.000 when comparing these scores pre-operatively, postoperatively, and postoperatively with showing the patient their photos before surgery.

CONCLUSION

Presenting patients with pre-operative images may help them recognize changes in their clinical appearance and, consequently, score higher on the postoperative satisfaction scale. It can help the surgeon to increase patient satisfaction postoperatively.

Radix's Importance for Plastic Surgeons: A Descriptive Cross-Sectional Study

Background

Considering the importance of the nose in the beauty of the face, accurate and systematic three-dimensional nasal analysis of the nose before the procedure is essential. The radix, and so the nasofrontal and nasofacial angles, play an essential role in forming an aesthetically pleasing nose because they influence the length and projection of the nose. We aimed to measure information about the pre-operative radix position in our region.

Method

Pre-operative images were taken from our cases in the profile view. A checklist including radix location and projection, nasofrontal angle, and nasofacial angle were extracted from these images.

Results

Overall, 200 (100 males and 100 females) cases were enrolled. Thirty-two male cases and 48 females had abnormal radix position. Radix projection were normal in only 36 male cases and 18 females. The mean nasofrontal angle in the male and female groups was 119.2 and 128.2 respectively. The mean nasofacial angle was 29.8 in the female groups and 32.6 in the male group.

Conclusion

The reality of the current society of Iranian patients can be very different from the predictions of surgeons and can be far away from the statistics mentioned in western books. We tried to notify surgeons to thoroughly examine the patients prior to surgical operation by measuring parameters such as projection and position of the radix and nasofrontal and nasofacial angles.

Comparison Between Patient and Plastic Surgeon Aesthetic Analysis in Rhinoplasty Consultation

The surgeon's aesthetic analysis of the nose is based on scientific measures of its proportions and dimensions. Because the primary aim of rhinoplasty is targeted at the patient's satisfaction with self-image, patients' perception and satisfaction are of paramount importance. The aim of this study was to evaluate surgeon versus patient nasal aesthetic analysis.

Method

A cross-sectional study was conducted on 57 primary rhinoplasty consultations during the period June and September 2017 at the Plastic Surgery Clinic in King Fahad Hospital-Hofuf. The surgeon and the patients were handed identical questionnaires before the consultations. The questionnaire has 27 components regarding the nasal appearance.

Results

The surgeon's and the patients' perceptions regarding reliability was assessed by Cohen's Kappa and Pearson's correlation coefficient. There was moderate agreement with the overall appearance of the nose (κ = 0.2-0.39). The most agreed-upon components were "dorsal hump" (κ = 0.6, P = 0.001) and "tip drops down" (κ = 0.41, P = 0.002). The columella and the suitability of the front part of the nose had the largest disagreement (κ = -0.06 and κ = -0.09, respectively). The level of agreement among most of the questionnaires' components was slight or nonexistent (κ = 0.004-0.39).

Conclusions

The surgeon and patients have a minimum agreement regarding the view of nasal appearance, mostly with the suitability of the front part and the columella. The parts of the nose agreed upon the most were "dorsal hump" and "tip drops down". Exploring the differences between patient and surgeon aesthetic analysis of the nose will aid in addressing the discrepancies and improving surgical outcome and satisfaction.

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.

Lessons from Self-Assessment of Post-Rhinoplasty Complaints; Analysis of 192 Candidates of Secondary Rhinoplasty

Background

Rhinoplasty as the most common aesthetic surgical operations aims to correct deformities of the different structures of the nose with each case its own challenges. We aimed to highlight the importance of self-assessment for rhino surgeons.

Methods

This retrospective descriptive study was done on 192 patients in Ordibehesht Hospital, Isfahan, Iran from April 2017 to Jun 2021. candidate for secondary rhinoplasty, with mandatory aesthetic and optional functional purposes, having previously undergone rhinoplasty with the same or another surgeon. Patients with initial rhinoplasty by the first author were assigned to group 1 (n=102) and the patients who were operated by the other surgeons were in the group 2 (n=90). Data were collected using an author made checklist divided into three parts: overall demographic questions, questions about the patients' aesthetic and functional complaints and objective evaluation by the surgeon.

Results

The most frequent reported complaints led to their current rhinoplasty were about the nasal tip with 161 cases (83.9%), upper nasal part with 98 cases (51%) and mid-nose (middle nose) with 81 cases (42.2%). Besides, respiratory problem was observed in 58 patients (30.2%). Surgeon's skill was significantly associated with occurrence of these two complaints; so that these two complaints were more common in group2 than group1 (P value <0.05).

Conclusion

Such assessments resulted to improve the surgical outcomes due to finding the more prevalent problems in own patients than the other surgeons' patients and determining the reasons that leads to change the techniques with regard to the researches and consulting with the colleagues.

Evaluation of Skin-Soft Tissue Envelope Thickness by Ultrasonography after Primary and Revision Rhinoplasty

BACKGROUND

Excessive nasal edema is among the complications after rhinoplasty translating into Skin-Soft Tissue Envelope (SSTE) thickening and disruption in the nasal framework's definition. Revision rhinoplasties are suspected of causing even more nasal edema. The objective postoperative SSTE thickness between revisionary and primary rhinoplasties is compared in this study.

METHODS

A study was conducted over a recorded database of eligible candidates who had attended the senior author's private clinic in a 12-month period and underwent primary and revisionary open-approach rhinoplasties. The SSTE thickness was measured by ultrasonography in each nasion, rhinion, supratip, and tip region at months 1, 3, 6, and 12 after each episode of rhinoplasty. Paired T-test was used for pairwise comparisons of the corresponding region-time thicknesses between primary and revisionary rhinoplasties. Repeated measure ANOVA tests were used to assess mean thickness changes over time after each surgery-P < 0.05 indicated significance.

RESULTS

Of the 36 participants analyzed, the SSTE was significantly thicker after revisionary surgery in all the follow-up sessions and nasal regions, except for the 1-month follow-up in the nasion (p = 0.273) and 12-month follow-up in the rhinion (p = 0.050). Mean nasal SSTE thickness showed decreasing trends in each region after either primary or revisionary surgery, with a lower level of resolution in the nasion region after revision rhinoplasty (p < 0.001).

CONCLUSIONS

The nasal SSTE had been significantly thicker in most regions after revisionary procedures than primary ones, and the swelling had subsided slightly slower. Surgeons are recommended to consider revisionary rhinoplasties based on these findings cautiously.

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 .

RealSelf Social Media Analysis of Rhinoplasty Patient Reviews

BACKGROUND

Social media has become increasingly important for patients when deciding whether they should undergo rhinoplasty. The purpose of this study is to analyze patient satisfaction of rhinoplasty procedures through RealSelf social media reviews.

METHODS

We collected data from 583 rhinoplasty reviews published on the RealSelf portal. In posts dated between 2016 and 2020, we included those which were labeled as "Worth It" and "Not Worth It." Posts that were labeled as "Unsure" or were left unlabeled were excluded from the study. In addition, posts not including the cost of their rhinoplasty were excluded. Taking into account patient demographics and cost of the procedure, we analyzed reasons for choosing to undergo surgery, reasons for choosing surgeons, and reasons for liking or disliking their procedure.

RESULTS

Of the 583 reviews analyzed, most (45.4%) were categorized from the 18-24 years age group and there was an overall 93.8% satisfaction rate. While there was no statistically significant difference in the cost of rhinoplasty surgeries between "Worth It" and "Not Worth It" groups, the average cost of recorded rhinoplasties was US$ 8043 with a standard deviation ± $3296. According to our analysis, younger patients aged 18-24 years relied more on social media to choose their surgeons and desired a more natural appearance to their nose while older ones preferred compatible physician personalities and increased self-esteem for rhinoplasty.

CONCLUSION

This study offers a unique perspective into the distinguishing characteristics of different age groups and the values they place in pursuing rhinoplasty, choosing their surgeons, and why they like/dislike their surgical outcomes.

The Safety and Efficacy of Spreader Grafts and Autospreaders in Rhinoplasty: A Systematic Review and Meta-analysis

BACKGROUND

The aim of this study was to systematically evaluate the evidence of surgical outcomes and complications of spreader grafts and autospreader flaps in the context of middle vault reconstruction after dorsal hump removal.

MATERIAL AND METHODS

A systematic review was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. Inclusion and exclusion criteria were based on the population, intervention, comparison, and outcome (PICO) framework. Medline (via PubMed), EMBASE, Cinahl, Scopus, and Web of Science were searched for Clinical and observational studies published in peer-reviewed academic journals with abstracts available that reported rhinoplasty employing either spreader graft or autospreader flap techniques and were published prior to March, 2021.

RESULTS

Fifty-two of 1129 relevant studies were included in the qualitative analysis. Thirty-four studies (65.4%) were related to spreader graft (SG), 10 (21.1%) studies of autospreader flap (AF) alone and 8 (13.5%) studies involving both grafts. Meta-analysis was performed on 17 studies reporting change in NOSE scores, with pooled effect of - 23.9 (95% CI, - 26.7 to - 21.1) points. High heterogeneity with I² = 99%. Summary data showed no differences between groups, AF group versus no graft (p = 0.7578), AF versus SF group (p = 0.9948), and SG group versus no graft (p = 0.6608).

CONCLUSION

Based on available data, change in NOSE scores after rhinoplasty was similar in procedures that used spreader graft only or autospreader flap only.

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.

Primary and Revision Rhinoplasty: A Single Surgeon Experience and Patient Satisfaction

There is minimal information describing the common characteristics among patients seeking primary/revision rhinoplasty. Success is traditionally interpreted from the surgeon's viewpoint, without considering the patient's perspective. The study's aims were to (1) identify/compare anatomic and functional characteristics commonly found in patients seeking primary and revision rhinoplasties; (2) assess patient satisfaction using a survey; and (3) explore whether graft choice (auricular cartilage versus rib cartilage) affects patient satisfaction and outcome in revision rhinoplasty.

Laser-Assisted Rhinoplasty: The Future Generation Rhinoplasty Technique to Preserve Anatomy? A Series of Patients Compared to Patients Undergoing Standard Open Rhinoplasty

BACKGROUND

Rhinoplasty is the cosmetic procedure that is most difficult to master. Anatomical preservation should represent the main goal of rhinoplasty. One emerging tool appears to be erbium:yttrium-aluminum-garnet laser bone and cartilage reshaping. The authors developed a new small laser hand probe to perform what we called laser-assisted rhinoplasty. The authors evaluate the feasibility of the laser-assisted rhinoplasty and the aesthetic and functional result of laser-assisted rhinoplasty compared to classic rhinoplasty.

METHODS

A total of 50 patients were enrolled and randomized into two cohorts: the first cohort of patients was submitted to classic rhinoplasty, and the second cohort to laser-assisted rhinoplasty. The laser beam was used to perform both the resection of the crura and the resection of the nasal hump and osteotomies.

RESULTS

Laser-assisted rhinoplasty is a safe and reproducible technique. At a clinical assessment, lateral crura reshaping showed a visible step or excessive skin retraction in 12 percent of the classic rhinoplasty population with thick cartilage and/or thin skin, and this was not present in the laser-assisted rhinoplasty population at 12-month follow-up. The patient satisfaction rate was higher in the laser-assisted rhinoplasty population compared with standard open rhinoplasty. The authors also clinically noted a reduction in edema in the immediate postoperative period in the laser-assisted rhinoplasty population and a more rapid complete resolution of the swelling.

CONCLUSION

The laser-assisted rhinoplasty technique is feasible and safe and has no major complication, and the aesthetic and functional results can be superimposed onto classic rhinoplasty but with a higher degree of intraoperative precision, higher patient satisfaction, a cleaner field, and less bleeding.

Readability Assessment of Online Rhytidectomy Patient Information

Patients frequently access online resources for medical information. The National Institutes of Health and the American Medical Association recommend that to be understood by the average American, patient information should be presented at or below the sixth to seventh academic grade level. The popularity of rhytidectomy (facelift) is rising, and providers are frequently using the Internet to attract patients. All rhytidectomy information provided by 100 private practice Web sites in New York City, Los Angeles, Chicago, Houston, and Phoenix was analyzed using Readable.io software. The information was also assessed using the Flesch-Kincaid Grade Level, Gunning-Fog Index, Coleman-Liau Index, Simple Measure of Gobbledygook, Automated Readability Index, Flesch Reading Ease Score, and Fry Reading Graph tools. Analyzed material was written at a higher academic grade level than recommended for the average American. The overall average grade level was 10.99 ± 1.39. Online patient education materials about rhytidectomy provided by private practice clinics in 5 major cities of the United States were written at academic grade levels above the National Institutes of Health and American Medical Association recommended levels. This may lead to rhytidectomy patients having unrealistic or inaccurate expectations related to their surgical procedure.

A Cartilage Dicing Tool for Rapid Preparation of Rhinoplasty Grafts

Over 220,000 rhinoplasties are performed in the U.S. annually, with approximately 90% of all procedures requiring the use of cartilage autografts or allografts to augment nasal structure or contour. Prior to implantation, graft cartilage is shaped into the desired form by facial plastic surgeons through carving, crushing, or dicing, and molding of the tissue. The use of diced cartilage has been shown in literature to be the optimal technique for creating contour grafts, permitting increased graft moldability, and resulting in the fewest postoperative complications. Despite superior clinical outcomes, adoption of diced techniques is challenged by the laborious, time-intensive process of dicing tissue, which requires up to 2 h in the operating room and is currently performed manually with a blade. Manual dicing can result in inconsistently sized pieces, which can increase risk of graft breakage. Existing cartilage processing tools are primarily intended for crushing tissue and are unsuitable for dicing. This work describes the design and validation of an easy-to-use, effective device for rapid, consistent cartilage dicing. Cartilage sizing analysis demonstrated that the device produced approximately five times more diced cartilage within 5 min compared to manual dicing. The rapid dicer (RD) device consistently dices cartilage to a size suitable for grafting while significantly decreasing processing time and cartilage loss compared to current methods. Future development will focus on performing further user testing of the device to design a more ergonomic instrument casing.

Prevalence of considering revision rhinoplasty in Saudi patients and its associated factors

Background

Primary rhinoplasty outcomes may not meet individual expectations. Consequently, reoperation may be advocated to improve results. This study examines the prevalence of individuals considering revision rhinoplasty, while identifying the main cosmetic and functional complaints and factors associated.

Methodology

This is a cross-sectional study conducted in Saudi Arabia using a self-reported online questionnaire distributed through social media channels. The sample included 1370 participants who were all Saudi nationals over the age of 16 who had undergone primary rhinoplasty at least 1 year prior.

Results

The prevalence of individuals considering revision rhinoplasty was 44.7%. The primary reason for considering it was the desire for further esthetic improvement in an already acceptable result (50.16%). The most common cosmetic complaints subjectively reported were poorly defined nasal tip (32.35%). The most prevalent nasal function symptom was nasal obstruction (56.9%). Significant factors associated with considering revision rhinoplasty included the physician not understanding the patient’s complaints, short consultation time, low monthly income, inadequate information about the expected results, not using computer imaging to predict outcomes, lack of rapport with the surgeon, and inadequate information about the risks and complications.

Conclusions

A thorough understanding of patient concerns and expectations, as well as thoughtful consideration of risk factors, may help surgeons achieve more successful outcomes and potentially reduce the incidence of revision rhinoplasties.

Level of evidence

III

Secondary Rhinoplasty: Aesthetic and Functional Concerns

Background

Aesthetic and functional concerns, especially after multiple revision rhinoplasties, continue to provide a challenge even for the experienced surgeon.

Objective

This study aimed to report the results in terms of "secondary rhinoplasty," performed by the senior author after previous rhinoplasty.

Methods

This descriptive prospective study was carried on 150 patients with surgical indication of secondary rhinoplasty and they were asked to fill out the questionnaire divided into 3 parts: overall epidemiological questions, questions of patients' aesthetic and functional complaints, and objective evaluation by the surgeon. The nasal problems in the upper and middle regions were divided into high or low, broad or narrow, crooked, irregularity of nasal bridge, or other alterations. The patients included in the study had surgical programming of secondary rhinoplasty, with mandatory aesthetic and optional functional purposes, having previous rhinoplasty with the same or different surgeon.

Results

There were 136 females and 14 males with the mean age of 31.52 (6.36) years. The most common complaints were related to the nose tip with 123 cases included deviated tip and pinched (bilateral) with 25.3%, 30.7%, and 25.3%, middle nose with 78 cases included mid vault deviation, inverted V, and polly beak with 31.3%, 18%, and 9.3%, and upper nasal region with 69 cases included dorsum irregularity and wide dorsum with the rates of 22.7% and 16.7%, respectively; respiratory problem was reported in 13 cases.

Conclusion

Unilateral or bilateral twisting at the nasal tip had the highest percentages, and the lowest incidence was in relation to the complaints of the upper nasal part.

Three-dimensional Morphing and Its Added Value in the Rhinoplasty Consult

Background:

The evolving literature on 3D surface imaging demonstrates that this technology is becoming the preferred simulation technique in hospitals and research centers. However, no study has demonstrated before the superiority of this facility over standard 2D simulation during preoperative evaluation in rhinoplasty.

Methods:

One hundred seventy-two consecutive patients requesting rhinoplasty were included. Patients answered a questionnaire following a 2D simulation and subsequently experienced 3D morphing. A single question was answered regarding the added value of the latter by patients and surgeons, respectively.

Results:

In our survey, satisfaction with 2D morphing reached 61%. Ninety-five percentage of the same group considered 3D simulation an added value over 2D. Additionally, 84% of patients requesting revision rhinoplasty admitted that 3D computer simulation has helped them understand the aims of surgery, in contrast to 61% of patients from the primary group. Furthermore, patients unsatisfied with their 2D simulation got reassured following 3D simulation to undergo surgery at a higher percentage (67%), compared with the group initially satisfied with 2D (48%). Women appeared reassured by 3D imaging in higher percentage (63%) compared with men (42%). The 2 surgeons, however, found 3D simulations to be an added value in 66% and 74% of all patients.

Conclusions:

The overwhelming majority of our patients considered 3D simulation an added value over 2D. Patients initially unsatisfied with 2D morphing, revision rhinoplasty patients, and women seemed to be the groups that appreciated more 3D than 2D computer simulation. In contrast, surgeons considered the facility of 3D an added value in two-thirds of the patients.

Functional Rhinoplasty

Understanding nasal anatomy and physiology are the most important points for successful functional rhinoplasty. Anatomic structures playing major roles in nasal breathing functions include the septum, and internal and external nasal valves, so physical examination of these regions is essential. Planning for functional rhinoplasty involves the identification of the sites of nasal airway obstruction or old trauma, and addressing those regions during the operation with a number of different techniques that have been described.

Patient Satisfaction After Rhinoplasty: A Social Media Analysis

BACKGROUND

Compared to other cosmetic procedures, rhinoplasty has a relatively low patient satisfaction rate, due to the difficulty of the procedure, and potentially unrealistic patient expectations. Understanding the reasons behind patient dissatisfaction is key to improving outcomes. Previous authors have done surgeon-initiated surveys, expert ratings, and morphologic measurements, to measure rhinoplasty success. No study has analyzed online reviews by patients to identify reasons for dissatisfaction with rhinoplasty.

OBJECTIVES

The goal of this study was to analyze satisfaction patterns in rhinoplasty using online reviews.

METHODS

All primary rhinoplasty reviews on RealSelf (Seattle, WA), a social media website for patients undergoing cosmetic surgery, were reviewed. The researchers recorded patient gender, whether they were satisfied, and the reasons for satisfaction or dissatisfaction. Male and female patients were compared, using chi-squared analysis.

RESULTS

There were 2326 reviews for primary rhinoplasty (2032 females, 294 males). The overall satisfaction rate was 83.6%. Significantly more females than males were satisfied (87.6% vs 56.1%, P < .001). Among males, the most common reasons for dissatisfaction were residual dorsal hump, under-rotated tip, and a nose that was too small. Among females, the most common reasons for dissatisfaction were residual dorsal hump, under-rotated tip, and bulbous tip. Among dissatisfied patients, females were significantly more likely than males to precisely verbalize the morphologic or functional reason for their dissatisfaction.

CONCLUSIONS

We found that males had lower satisfaction with rhinoplasty, and were more vague when expressing reasons for dissatisfaction, than females. Social media provides a novel way to understand reasons for patient dissatisfaction after cosmetic surgery.

Finite Element Model Analysis of Cephalic Trim on Nasal Tip Stability

IMPORTANCE

Alar rim retraction is the most common unintended consequence of tissue remodeling that results from overresection of the cephalic lateral crural cartilage; however, the complex tissue remodeling process that produces this shape change is not well understood.

OBJECTIVES

To simulate how resection of cephalic trim alters the stress distribution within the human nose in response to tip depression (palpation) and to simulate the internal forces generated after cephalic trim that may lead to alar rim retraction cephalically and upward rotation of the nasal tip.

DESIGN, SETTING, AND PARTICIPANTS

A multicomponent finite element model was derived from maxillofacial computed tomography with 1-mm axial resolution. The 3-dimensional editing function in the medical imaging software was used to trim the cephalic portion of the lower lateral cartilage to emulate that performed in typical rhinoplasty. Three models were created: a control, a conservative trim, and an aggressive trim. Each simulated model was imported to a software program that performs mechanical simulations, and material properties were assigned. First, nasal tip depression (palpation) was simulated, and the resulting stress distribution was calculated for each model. Second, long-term tissue migration was simulated on conservative and aggressive trim models by placing normal and shear force vectors along the caudal and cephalic borders of the tissue defect.

RESULTS

The von Mises stress distribution created by a 5-mm tip depression revealed consistent findings among all 3 simulations, with regions of high stress being concentrated to the medial portion of the intermediate crus and the caudal septum. Nasal tip reaction force marginally decreased as more lower lateral cartilage tissue was resected. Conservative and aggressive cephalic trim models produced some degree of alar rim retraction and tip rotation, which increased with the magnitude of the force applied to the region of the tissue defect.

CONCLUSIONS AND RELEVANCE

Cephalic trim was performed on a computerized composite model of the human nose to simulate conservative and aggressive trims. Internal forces were applied to each model to emulate the tissue migration that results from decades of wound healing. Our simulations reveal that the degree of tip rotation and alar rim retraction is dependent on the amount of cartilage that was resected owing to cephalic trim. Tip reaction force is marginally reduced with increasing tissue volume resection.

LEVEL OF EVIDENCE

NA.

Revision Rhinoplasty

Revision rhinoplasty is one of the most challenging operations the facial plastic surgeon performs given the complex 3-dimensional anatomy of the nose and the psychological impact it has on patients. The intricate interplay of cartilages, bone, and soft tissue in the nose gives it its aesthetic and function. Facial harmony and attractiveness depends greatly on the nose given its central position in the face. In the following article, the authors review common motivations and anatomic findings for patients seeking revision rhinoplasty based on the senior author's 30-year experience with rhinoplasty and a review of the literature.

Evaluating current functional airway surgery during rhinoplasty: a survey of the American Society of Plastic Surgeons

BACKGROUND

Despite numerous reports outlining technical modifications in rhinoplasty, few publications discuss the importance of the perioperative assessment and surgical management of the nasal airway. This study's objective is to increase awareness regarding the functional aspects of rhinoplasty surgery and to encourage surgeons to incorporate functional airway management into their rhinoplasty practice.

METHODS

A web-based survey was given to all members of the American Society of Plastic Surgeons (ASPS). Survey results were analysed to determine if surgeons' experience, annual rhinoplasty volume, or postgraduate training affected their results. The relationship between surgeon satisfaction with the outcome of the airway management and the frequency of performing an inferior turbinate reduction was investigated.

RESULTS

Of the 4,383 listed ASPS members, 671 (21%) completed the web-based survey. Surgeons who performed a preoperative internal nasal exam were more satisfied with their results (p = 0.016) and report lower rates of postoperative nasal airway obstruction (p = 0.054). Inferior turbinate reduction did correlate to postoperative satisfaction with the nasal airway (p < 0.001). Overall, 85% of respondents were satisfied with their management of the nasal airway and 87% of respondents agreed that there is a need for more instructional courses on this topic.

CONCLUSION

There is considerable variation in the results and techniques of assessment and treatment of the nasal airway. Rhinoplasty volume and inferior turbinate reduction are associated with surgeon satisfaction of management of the nasal airway. Functional airway considerations should be incorporated into routine rhinoplasty training, assessment, and treatment.

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.

Presenting concerns and surgical management of secondary rhinoplasty

BACKGROUND

Secondary rhinoplasty is a challenging surgical procedure, and patients seeking this procedure tend to be difficult to please. However, psychological and functional improvements in patients and high satisfaction rates are achievable with secondary rhinoplasty.

OBJECTIVES

The authors reviewed a series of secondary rhinoplasties and tabulated patient concerns, underlying deformities, and corrective surgical procedures.

METHODS

The authors conducted a retrospective review of 109 patients for whom the senior author (B.M.) performed secondary rhinoplasty from 2009 to 2012. Concerns causing the patients to seek surgery and management of the secondary procedures were described.

RESULTS

The mean patient age at time of surgery was 33.2 years (range, 18-61 years), and most patients (71.6%) were women. The mean number of previous procedures was 1.6 (range, 1-8). Chief presenting concerns were asymmetry (36.7%), large tip (24.8%), and breathing difficulties (22.0%). The most common clinical findings were nostril asymmetry (33.9%), septal deviation (32.1%), overresection (26.6%), and tip asymmetry (26.6%).

CONCLUSIONS

Patients seeking secondary rhinoplasty present with various concerns. Preoperative identification of the underlying problems and determination of the techniques required to correct them are important to successful secondary procedures. LEVEL OF EVIDENCE 4: Therapeutic.

Why some patients are unhappy: part 1. Relationship of preoperative nasal deformity to number of operations and a history of abuse or neglect

BACKGROUND

Trauma (neglect or abuse) can create body shame (different from body dissatisfaction), driving some patients to seek aesthetic surgery. We hypothesized that a trauma history would be related to the severity of the original deformity and the drive to undergo repeated operations.

METHODS

Descriptive statistics were computed for 100 secondary rhinoplasty patients, 50 of whom originally had dorsal humps, 21 of whom had straight, functional noses, and 29 of whom had subjectively normal noses but underwent multiple rhinoplasties. This latter group fulfills criteria for body dysmorphic disorder.

RESULTS

Compared with patients with hump noses, patients with normal primary noses were 2.9 times more likely to be demanding 2.5 times more likely to be depressed, had undergone 3.0 times more rhinoplasties and other aesthetic operations, and were 3.8 times more likely to have confirmed trauma histories. Patients who had undergone more than three operations were 92.7 percent women; 85 percent originally had straight noses and had undergone an average of 7.56 rhinoplasties and 5.78 aesthetic operations; 85.4 percent had histories of abuse or neglect.

CONCLUSIONS

Secondary rhinoplasty patients with normal preoperative noses, who fulfill the criteria for body dysmorphic disorder, had significantly higher prevalences of depression, demanding conduct, previous rhinoplasties and other aesthetic operations, and confirmed trauma histories than patients who originally had dorsal deformities or straight noses with functional symptoms. To the authors' knowledge, this is the first report of such associations. A history of childhood trauma may impact adult patient behavior and therefore the surgical experience.

Why some patients are unhappy: part 2. Relationship of nasal shape and trauma history to surgical success

BACKGROUND

A previous report indicated that secondary rhinoplasty patients with normal preoperative noses displayed significantly higher prevalences of depression, demanding behavior, previous aesthetic operations, and confirmed trauma (abuse/neglect) histories than patients who originally had dorsal deformities or straight noses with functional symptoms. The authors hypothesized that abuse or neglect might also influence patient satisfaction and suggest screening criteria.

METHODS

One hundred secondary rhinoplasty patients stratified by their original nasal shapes were examined by bivariate analysis to determine the characteristics associated with surgical satisfaction. Mediation analysis established intervening factors between total surgery number and patients' perceived success. Random forests identified important patient attributes that predicted surgical success; logistic regression confirmed these effects.

RESULTS

Satisfied patients originally had dorsal humps, three or fewer previous operations, were not demanding or depressed, were not looking for perfect noses, and had no trauma histories. Dissatisfied patients originally had subjectively normal noses, more than three operations, were depressed, had demanding personalities, and had trauma histories. Patients who had undergone the most operations were most likely to request more surgery and least likely to be satisfied. A trauma (abuse/neglect) history was the most significant mediator between patient satisfaction and number of operations and the most prominent factor driving surgery in patients with milder deformities.

CONCLUSIONS

Potentially causative links exist between trauma (abuse/neglect), body image disorders, and obsessive plastic surgery. Body dysmorphic disorder may be a model of the disordered adaptation to abuse or neglect, a variant of posttraumatic stress disorder. Our satisfied and dissatisfied patients shared common characteristics and therefore may be identifiable preoperatively.

Revision rhinoplasty: panel discussion, controversies, and techniques

What is the single most difficult challenge in revision rhinoplasty and how do you address it? During revision rhinoplasty, when dorsal augmentation is necessary and septal and ear cartilage is not available, what is the best substance for correcting the problem? If rib cartilage is used for dorsal augmentation during revision rhinoplasty, what is the technique to prevent warping of the graft? Alloplast in the nose--when, where, and for what purpose? Does the release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid-one-third nasal pinching in reductive rhinoplasty?'

ANALYSIS

Over the past 5 years, how has your technique evolved or what have you observed and learned in performing revision rhinoplasty?