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Purpose: Septorhinoplasty (SR) is one of the most complex surgical procedures of the head and neck. As an elective procedure aiming to enhance patient quality of life, it can be difficult to perform in single-payer healthcare systems due to capacity pressures from acute and oncological surgical demand. We aimed to review national trends in the practice of SR to inform future healthcare planning., Methods: This was a cross-sectional, population-based, longitudinal study of SR cases in Ireland's single-payer (public) healthcare system from 2005 to 2021. Time-series analysis using a linear regression model was performed to analyse trends by operation type, revision rates and length of stay. The impact of the COVID-19 pandemic and introduction of national surgical guidelines was analysed., Results: 1952 SR were performed. Annual mean cases declined in both real (r = - 0.76, p < 0.01) and relative (r = - 0.87, p < 0.01) terms by 31% and 43%, respectively. Ambulatory SR, while initially rarely performed, increased to account for 55% of cases performed. The mean hospital length of stay declined significantly (r = - 0.84, p < 0.01) by 44%., Conclusions: SR increasingly struggles to find its place in Ireland's public healthcare system. New changes in SR practices including the rapid growth of ambulatory surgery and shorter lengths of hospital stay indicate positive responses to the mounting pressures faced by healthcare systems., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

In rhinoplasty, it is necessary to consider the correlation between the anthropometric indicators of the nasal bone, so that it prevents surgical complications and enhances the patient's satisfaction. The penetrating form of high-energy electromagnetic radiation is highly impacted on human health, which has often raised concerns of alternative method for facial analysis. The critical stage to assess nasal morphology is the nasal analysis on its anthropology that is highly reliant on the understanding of the structural features of the nasal radix. For example, the shape and size of nasal bone features, skin thickness, and also body factors aggregated from different facial anthropology values. In medical diagnosis, however, the morphology of the nasal bone is determined manually and significantly relies on the clinician's expertise. Furthermore, the evaluation anthropological keypoint of the nasal bone is nonrepeatable and laborious, also finding widely differ and intralaboratory variability in the results because of facial soft tissue and equipment defects. In order to overcome these problems, we propose specialized convolutional neural network (CNN) architecture to accurately predict nasal measurement based on digital 2D photogrammetry. To boost performance and efficacy, it is deliberately constructed with many layers and different filter sizes, with less filters and optimizing parameters. Through its result, the back-propagation neural network (BPNN) indicated the correlation between differences in human body factors mentioned are height, weight known as body mass index (BMI), age, gender, and the nasal bone dimension of the participant. With full of parameters could the nasal morphology be diagnostic continuously. The model's performance is evaluated on various newest architecture models such as DenseNet, ConvNet, Inception, VGG, and MobileNet. Experiments were directly conducted on different facials. The results show the proposed architecture worked well in terms of nasal properties achieved which utilize four statistical criteria named mean average precision (mAP), mean absolute error (MAE), R -square ( R 2 ), and T -test analyzed. Data has also shown that the nasal shape of Southeast Asians, especially Vietnamese, could be divided into different types in two perspective views. From cadavers for bony datasets, nasal bones can be classified into 2 morphological types in the lateral view which "V" shape was presented by 78.8% and the remains were "S" shape evaluated based on Lazovic (2015). With 2 angular dimension averages are 136.41 ± 7.99 and 104.25 ± 5.95 represented by the nasofrontal angle (g-n-prn) and the nasomental angle (n-prn-sn), respectively. For frontal view, classified by Hwang, Tae-Sun, et al. (2005), nasal morphology of Vietnamese participants could be divided into three types: type A was present in 57.6% and type B was present in 30.3% of the noses. In particular, types C, D, and E were not a common form of Vietnamese which includes the remaining number of participants. In conclusion, the proposed model performed the potential hybrid of CNN and BPNN with its application to give expected accuracy in terms of keypoint localization and nasal morphology regression. Nasal analysis can replace MRI imaging diagnostics that are reflected by the risk to human body., Competing Interests: All authors declare that there is no conflict of interest regarding the publication of this paper., (Copyright © 2022 Ho Nguyen Anh Tuan et al.)

Background: Rate of corrective nasal surgery after maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) has been reported to be 18.7% for functional and aesthetic indications. Objective: Describe a comprehensive strategy to optimize nasal outcomes with MMA for OSA. Methods: A retrospective review of patients undergoing MMA for OSA in a tertiary referral center was performed, with a comprehensive perioperative intervention to optimize nasal outcomes from January 2014 to February 2018. Outcomes included the Apnea-Hypopnea Index (AHI), oxygen saturation (SpO 2 ) nadir, corrective nasal surgery needed after MMA, and Nasal Obstruction Symptom Evaluation (NOSE) scores. Results: AHI after MMA showed significant reduction (-34.65, p  < 0.001), SpO 2 nadir increased (+6.08, p  < 0.001), and NOSE scores decreased (-5.96, p  < 0.001). Corrective nasal surgery needed after MMA was reported in 6.5% (8 of 122) subjects at a mean of 8.5 months, ranging from 1 to 24.7 months. Six subjects underwent either septoplasty and/or valve stenosis repair, and two subjects underwent functional and aesthetic rhinoplasty. Conclusion: A perioperative strategy was applied since 2014 that showed effectiveness in reducing post-MMA corrective nasal surgery to 6.5%.

Summary: Rhinoplasty remains one of the most challenging operations performed by plastic surgeons. The complexity lies in the ability to have a consistent and predictable aesthetic result. The unpredictability is mainly attributable to the interplay of manipulated internal structures and wound healing dynamics. In addition, setting realistic expectations with the patient is essential for achieving high postoperative patient satisfaction. An open rhinoplasty approach enables an accurate and in-depth evaluation and intervention. The authors provide a detailed analysis and discussion on why primary rhinoplasty fails, along with the surgical approach for preventing these failures., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: The nose is at the center of the face and has essential functional and aesthetic properties. Over recent years, rhinoplasty has gained increasing popularity through the influence of "selfies" and social media. As a result, a growing demand for secondary correction has also emerged. Revision rhinoplasty is more complex than primary cases and often requires the use of extranasal grafting material. The authors sought to analyze the indications, techniques, and outcomes after primary and revision rhinoplasty., Methods: A total of 245 patients (153 primary cases and 92 revisions) undergoing surgery at the authors' specialized clinic for facial plastic surgery were included. All patients were treated by an experienced facial plastic surgeon according to the authors' established clinic standards. A retrospective data analysis was performed to evaluate the differences between the groups regarding the indications, intraoperative techniques, and postoperative outcomes., Results: Although more patients sought revision surgery for aesthetic reasons alone than isolated functional issues, almost two-thirds of the revision patients had functional and aesthetic problems in combination. Complex reconstructive techniques, extracorporeal septoplasties, and extranasal grafts were more commonly used in revision cases. The occurrence of another revision during the follow-up period was significantly higher after revision surgery compared to primary rhinoplasty cases (primary rhinoplasty, 10.5 percent; revision surgery, 23.9 percent; p = 0.006)., Conclusions: There are differences between primary and revision rhinoplasty that must be appreciated by the treating surgeon. The patient should be informed about the increased complexity of the secondary procedure, the possible need for extranasal grafts, and the increased risk of a further revision., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: The primary element of a crooked nose is a midline deviation of the nasal pyramid. To date, no surgical strategies have been described as compatible with the philosophy of dorsal preservation. The dorsal preservation technique differs from the Joseph structured rhinoplasty because it preserves both the keystone area and the continuity of the cartilaginous vault. The authors focused on the versatility of the dorsal preservation technique even for the deviated nose, introducing the "Pisa Tower concept.", Methods: From January of 2015 to June of 2019, 280 patients diagnosed as having a crooked nose underwent primary septorhinoplasty with dorsal preservation through an asymmetric bony wedge resection and lowering of the bony pyramid onto the frontal process of the maxilla (the let-down osteotomy), in accordance with the Pisa Tower concept. Inclusion criteria were a preoperative computed tomography examination, nasal axis deviation, a complete photographic examination preoperatively, and at least a 1-year follow-up., Results: The mean nasal axis deviation was 7.62 degrees preoperatively and 1.15 degrees postoperatively (p < 0.05). Of the 84 patients, 47 (55.95 percent) were very satisfied, 33 (39.28 percent) were satisfied, and four (4.76 percent) were unsatisfied with surgical results and required revision surgery., Conclusions: The authors' opinion is that the association of "swinging door" septoplasty with the Pisa Tower concept can be a valid alterative to other techniques when working with the structured rhinoplasty philosophy in patients with a crooked nose. Although this is only a preliminary study, the decreased use of spreaders graft and less aggressive reconstructive methods look very promising., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Abstract: Rhinoplasty in children has raised concerns about its safety in the pediatric population. There is scarcity of evidence describing outcomes and surgical techniques performed in pediatric rhinoplasty. We analyzed post-operative complications and cartilage preferences between plastic surgeons and otolaryngologists.Data was collected through the Pediatric National Surgical Improvement Program from 2012 to 2017. Current Procedure Terminology codes were used for data extraction. Patients were grouped according to type of rhinoplasty procedures (primary, secondary, and cleft rhinoplasty). A comparison between plastic surgeons and otolaryngologists was made in each group in terms of postoperative complications. Additionally, a sub-group analysis based on cartilage graft preferences was performed.During the study period, a total of 1839 patients underwent rhinoplasty procedures; plastic surgeons performed 1438 (78.2%) cases and otolaryngologists performed 401 (21.8%) cases. After analyzing each group, no significant differences were noted in terms of wound dehiscence, surgical site infection, readmission, or reoperation. Subgroup analysis revealed that plastic surgeons prefer using rib and ear cartilage, while otolaryngologists prefer septal and ear cartilage.The analysis of 1839 pediatric patients undergoing three types of rhinoplasty procedures showed similar postoperative outcomes, but different cartilage graft utilization between plastic surgeons and otolaryngologists., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Autologous cartilage grafts have a low risk of infection and extrusion in cleft rhinoplasty. However, harvesting autologous cartilage involves donor-site morbidity and increased time under anesthesia. Irradiated homologous costal cartilage grafts may be an effective alternative., Methods: A retrospective study was performed on patients with a history of cleft lip who underwent rhinoplasty for cleft nasal deformity at Johns Hopkins Hospital from 2009 to 2018. Patients were excluded if their rhinoplasty did not involve a cartilage graft., Results: One hundred sixty-five cleft rhinoplasties (patient age, 2 to 72 years; 52 percent female) were performed. Median follow-up time was 256 days; 30 percent were revision operations. Ninety-six procedures (58 percent) used irradiated homologous costal cartilage grafts, with the remaining using autologous cartilage. Complications resulted from 18 procedures (11 percent), seven (10 percent) involving autologous cartilage and 11 (12 percent) involving irradiated homologous costal cartilage. Most autologous cartilage complications (86 percent) required operative intervention, versus seven of 11 (64 percent) for irradiated homologous costal cartilage. Complications associated with irradiated homologous costal cartilage included infection (n = 5), warping (n = 2), and extrusion (n = 1), while two patients with autologous cartilage experienced collapse and one each experienced resorption, warping, and hypertrophic donor-site scarring. There was no difference between groups regarding complication rate or complications requiring operative intervention (p = 0.3 and p = 0.5, respectively)., Conclusions: Irradiated homologous costal cartilage grafts are equally safe and effective as autologous cartilage for use in cleft rhinoplasty. These grafts are readily available and eliminate donor-site morbidity., Clinical Question/level of Evidence: Therapeutic, III., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Introduction: Guidelines for nasal injury state that assessment should be at 7-10 days post-injury and manipulation within 14 days. We performed a plan, do, study, act improvement cycle to assess whether a dedicated nasal fracture service led to better outcomes., Materials and Methods: A retrospective study was carried out of all patients undergoing manipulation under anaesthesia for nasal trauma between February 2013 and December 2016 in a district general hospital. A dedicated nasal fracture clinic providing manipulation under local anaesthesia was implemented followed by a prospective study of all patients presenting to the clinic between February and November 2017. Main outcome measures included time from injury to otolaryngology assessment, time from injury to manipulation and incidence of secondary septorhinoplasty., Results: The retrospective series involved 525 patients including 381 males (72.6%) and 144 females (27.4%). Mean time from injury to assessment was 10 days. Mean time from injury to surgery was 14.5 days. Mean time from assessment to surgery was five days. The incidence of septorhinoplasty was 2.3%. The prospective series involved 119 patients including 78 males (65.5%) and 41 females (34.5%). Following implementation of a nasal fracture clinic, mean time from injury to assessment and manipulation was 6.1 days and 5.4% of patients underwent septorhinoplasty for secondary deformity., Discussion: Implementation of a nasal fracture clinic providing reduction under local anaesthesia reduced the time to assessment and manipulation. The incidence of septorhinoplasty is low following reduction under general or local anaesthesia. Assessment earlier than seven days is feasible and advice for referral can be changed accordingly.

Background: Dorsal hump reduction during open rhinoplasty disrupts the continuity between the upper lateral cartilages and the dorsal septum. Options to reconstitute the midvault include primary closure of the upper lateral cartilages to the dorsal aspect of the septum, placement of spreader grafts, and creation of spreader flaps. The authors sought to clarify from highly experienced rhinoplasty surgeons their decision-making rationale for midvault reconstruction, distilling down the group consensus into algorithmic guidelines., Methods: A panel of internationally recognized rhinoplasty surgeons participated in a two-part organized communication method. An introductory summit consisted of open discussions on various topics in midvault reconstruction. The summit transcription was analyzed by thematic content analysis to develop a survey encompassing clinical scenarios for primary rhinoplasty, which was then individually administered to each panelist. Data gathered from both parts were used to generate technical guidelines and a decision-making algorithm., Results: The panelists identified the following anatomical features as pertinent to their selection of midvault reconstruction method: size of the dorsal hump reduction, width of the midvault relative to the upper vault, presence of dorsal angulation, and presence of nasal obstructive symptoms. Individual panelist preference was gathered from the 24-scenario survey divided into either cosmetic or functional rhinoplasty cases., Conclusions: Management of the midvault after dorsal hump reduction is important to establish proper aesthetic relationships and to provide functional integrity of the internal valve. Our authors present an algorithmic approach to decision-making based on the systematic analysis practiced by senior rhinoplasty surgeons.

Objectives/hypothesis: To quantify and analyze the concurrent performance of rhinoplasty (RP) (with or without septoplasty) and functional endoscopic sinus surgery (FESS)., Study Design: Cross-sectional analysis., Methods: Current Procedural Terminology codes were used to extract cases of RP (n = 22,360), FESS (n = 99,173), and concurrent RP with FESS (RP + FESS) (n = 1,321) within the State Ambulatory Surgery Databases of California, Florida, Maryland, and New York from 2009 to 2011. Patient demographics, surgeon volume, charge, concurrent nasal procedures, and operating room (OR) time were compared., Results: Among the 1,321 RP + FESS combination cases, a majority involved primary rhinoplasty (n = 697, 52.8%), followed by nasal valve repair (n = 563, 42.6%) and revision rhinoplasty (n = 61, 4.6%). High-volume (n > 30), medium-volume (n = 10-30), and low-volume rhinoplasty surgeons (n ≤ 9) were observed to perform a similar number of FESS + RP combination surgeries (153, 152, and 155, respectively). A majority of RP + FESS involved two or fewer sinuses (65%). Mean OR time for RP + FESS was 189.4 ± 4.2 minutes, approximately 50 minutes shorter than the sum of standalone RP performed individually (138.8 ± 1.0 minutes) and standalone FESS (102.9 ± 0.4 minutes)., Conclusions: RP + FESS more frequently involved fewer sinuses (compared with FESS alone) and was also less likely to involve revision rhinoplasty (compared with rhinoplasty alone); therefore, these cases may be selected for lower sinus disease burden and less complex rhinoplasty compared to standalone procedures. Procedures combining rhinoplasty and sinus surgery had a reduction in OR time compared to the hypothetical sum of two standalone procedures., Level of Evidence: NA Laryngoscope, 130:E311-E319, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: The aim of this national survey is to assess the current practice of functional septorhinoplasty (SRP) surgery in the UK and better inform future practice., Methods: An ENT-UK approved questionnaire was sent out to all 135 consultant members of the British Society of Facial Plastic Surgery (BSFPS). Data was collected on numbers of functional SRPs performed on the NHS, use of outcome measures, psychology and photography support, antibiotic use, referral base and consenting practice., Results: The response rate was 38.5%, with 52 out of 135 completed. The median number of annual SRP cases per surgeon was 40. Most surgeons (95%) used clinical photography as an outcome measure. However, 27% of the respondents use a subjective outcome measurement and 3% of them use an objective outcome measurement. Only 34% had access to psychology support and 60% receive their referrals from primary care. All surgeons counsel patients for aesthetic change, 15% mention CSF leak and 38% mention olfactory disturbance. The key comment from our respondents was to relabel the rhinoplasty procedure as a functional SRP procedure with the aim to remove it from the Procedures of Limited Clinical Value (PoLCV) list., Conclusion: The majority of our respondents perform a large proportion of the SRP surgeries in the UK with each of the respondents performing an average of 40 SRP surgeries per year. There is a need to recatergorise functional septorhinoplasty as a functional operation and recommend functional SRP surgery to be removed from the PoLCV list.

Background: The CLEFT-Q is a patient-reported outcome measure developed for use in patients with cleft lip and/or palate. A significant indicator of the CLEFT-Q's validity relates to its ability to detect differences between the impact of specific aspects of clefting before and after surgery. This study compares relevant sub-scale scores of the CLEFT-Q for patients requiring four specific surgical treatments against those who either have had surgery or never needed surgery., Methods: CLEFT-Q scores and clinical information regarding the past and future need for jaw surgery, lip revision, rhinoplasty, and speech surgery were obtained from the CLEFT-Q field-test data. Eight one-way analysis of variance (ANOVA) models were developed to compare mean scores of relevant CLEFT-Q scales between those who needed surgery, those who have had surgery, and those who never needed surgery. Only patients from high-income countries were included to minimize the impact of any economic confounders that could result in treatment variation. In the rhinoplasly and lip revision models, patients without a cleft lip were excluded. In the jaw surgery and speech surgery models, patients without a cleft palate or alveolus were excluded., Results: The CLEFT-Q field test included 1938 participants from high-income countries. Participants who needed surgery scored significantly lower (worse) than those who have had surgery in each of the eight relevant CLEFT-Q scales (p < 0.001 in each ANOVA)., Conclusion: The ability of the CLEFT-Q to detect differences between groups based on surgical status further supports its validity., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Rhinoplasty is one of the most sought-after procedures in plastic surgery by individuals with body dysmorphic disorder (BDD). The identification of BDD symptoms is a challenge for plastic surgeons. The purpose of this study was to use a specific instrument for detection of BDD symptoms as a screening tool in rhinoplasty candidates and estimate the prevalence and severity of BDD symptoms in this population., Methods: Eighty patients of both sexes seeking rhinoplasty were consecutively recruited at a plastic surgery outpatient clinic of a university hospital from February 2014 to March 2015. In a clinical interview, 50 of them showed an excessive preoccupation with physical appearance associated with clinically significant subjective distress and were, therefore, selected to participate in the study. All participants were assessed using the Brazilian-Portuguese versions of the Yale-Brown Obsessive Compulsive Scale modified for BDD (BDD-YBOCS) and the Body Dysmorphic Symptoms Scale (BDSS), which can be applied by plastic surgeons, who are laypersons in psychology/psychiatry., Results: Twenty-four (48%, 24/50) candidates had BDD symptoms, and 27 (54%, 27/50) showed moderate to severe appearance-related obsessive-compulsive symptoms. A strong correlation was found between the BDSS and BDD-YBOCS scores (r = 0.841, P < 0.001), and a strong agreement was observed between the BDSS cutoff point and body dysmorphic disorder symptom status (kappa = 0.822)., Conclusions: A high prevalence of BDD and moderate to severe appearance-related obsessive-compulsive symptoms was found among aesthetic rhinoplasty candidates. The BDSS may be used as a screening tool for BDD symptoms in plastic surgery patients., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Objectives/hypothesis: To determine the percentage of primary versus revision rhinoplasty cases that require an extranasal source of grafting, as well as age and gender-specific trends., Study Design: Cross-sectional analysis of multistate ambulatory surgery and hospital databases., Methods: Ambulatory rhinoplasty procedures were extracted from the State Ambulatory Surgery Databases for New York, Kentucky, North Carolina, Michigan, and Florida for 2014 to 2015. Cases were examined for simultaneous use of extranasal grafts., Results: A total of 8,510 rhinoplasties were extracted (65.3% female, mean age = 35.6 years), and 11.9% were revision cases (95% confidence interval [CI]: 11.2-12.6). An extranasal, autologous source of grafting was required in 12.7% of cases (5.3% auricular, 95% CI: 4%-6.6%; 1.8% costal, 95% CI: 1%-2.6%). Revision cases were more likely to require a secondary source of grafting (24.4%, 95% CI: 21.8%-27.1% vs. 11.1%, 95% CI: 10.3%-11.8%). In revision cases, the most common graft was auricular cartilage (14.4%, 95% CI: 12.2%-16.6%) followed by costal (7.1%, 95% CI: 5.52%-8.69%). Only 1.1% of primary cases required costal cartilage (95% CI: 0.88%-1.36%) compared to 7.1% of revision cases (95% CI: 5.52%-8.69%). Of the primary cases, 4.1% required auricular cartilage grafting (95% CI: 3.67%-4.57%) compared to 14.4% of revision cases (95% CI: 12.2%-16.6%). Patients who required a graft were older. Significantly more males required autologous grafting than females (P = .047)., Conclusions: Cartilaginous or bony grafting is a critical surgical technique in both primary and secondary rhinoplasties. This is the first study to examine percentages of site-specific autologous grafting from auricular and costal donor sites for primary and revision cases. Gender and age-specific trends associated with specific grafting sites are also identified. These data are important to help guide preoperative counseling and informed consent for all rhinoplasty surgeries., Level of Evidence: NA Laryngoscope, 129:1549-1553, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: Endoscopic approach represents a valid alternative to conventional septoplasty. The aim of this study is to analyze the objective and subjective data on 276 patients, who underwent traditional (147) or endoscopic (129) septoplasty., Methods: This is a prospective observational study on 276 consecutive patients affected by deviated nasal septum (DNS), who underwent isolated septoplasty between 2011 and 2018. 147 of them were treated using an "open" approach, while 129 were treated with an endoscopic approach. The two groups were compared 3 months after surgery: the objective results (complications such as bleeding, hematoma, pain, synechiae, septal tears and incomplete correction), objective (rhinomanometric data) and subjective measurements (NOSE questionnaires)., Results: Both techniques are effective in decreasing nasal obstruction and discharge. Complications such as pain, synechiae, early postoperative bleeding, septal tears and incomplete correction are less frequent in the endoscopic group (p < 0.05). The rhinomanometric analysis reveal improvement in both groups without statistical differences. Subjective questionnaires show a good symptoms relief with an improved quality of life in all 276 patients without statistical difference between the two gropus., Conclusions: Both techniques are effective in reducing nasal obstruction and related symptoms with fewer overall complications in the endoscopic approach. The endoscope provides improved field of view, less mucosal damages and a more anatomic dissection. Finally, such approach can be a valuable teaching tool for assistants, residents and students.

Introduction: This study compared the subjective measurement of difference between the nasal tip and supra tip (TSD) (using eyes) versus objective measurement of TSD (by a ruler) during rhinoplastic surgery to determine the accuracy of subjective measurements among surgeons with varying degrees of experience., Materials and Methods: In this analytical observational study, 40 cosmetic rhinoplasty candidates were involved. Those with the history of rhinoplastic surgery were excluded from the study. At the end of the operation, the surgeon was asked to estimate the TSD subjectively. The researcher, without the intervention of the surgeon, remeasured TSD by a presterile ruler. The researcher recorded both objective and subjective TSD measurements and the experience of the surgeon in rhinoplasty in the checklist., Result: Of 40 cosmetic rhinoplasty candidates, 17 were operated by a surgeon with >10 years' experience (group 1), and 23 by a surgeon with <5 years' experience (group 2). The results indicated that 5 surgeries (29.4%) in group 1 and 6 surgeries (26.1%) in group 2, had 0-mm difference in subjective and objective measurement. The difference of <1 mm between subjective and objective measurement was achieved in 13 surgeries (76.5%) in group 1 and 13 surgeries (56.5%) in group 2 (P = 0.191)., Conclusion: According to the results, it can be concluded that the surgeon's experience is effective in reducing the differences in measurements of TSD in both measurement modes.

Objectives/hypothesis: The time interval at which Nasal Obstruction Symptom Evaluation (NOSE) scores stabilize after functional septorhinoplasty has not been determined. Our goal was to characterize longitudinal trends of patient-reported outcomes of nasal obstruction using the NOSE survey instrument following functional septorhinoplasty., Study Design: Prospective longitudinal cohort study., Methods: Adult patients (≥18 years) with nasal obstruction who underwent functional septorhinoplasty by three different surgeons at a single academic, tertiary referral center were identified. NOSE scores were obtained preoperatively and prospectively during three postoperative intervals defined as early (1-3 months), middle (4-6 months), and late (≥10 months.) Longitudinal analysis included repeated measures analysis of variance and adjustments for multiple comparisons., Results: A total of 49 patients met inclusion criteria. For the total cohort, mean NOSE scores significantly improved between preoperative and early postoperative evaluations (71.4, standard deviation [SD] ± 17.0 vs. 24.2, SD ± 19.5; P < .001) but did not significantly change between early and middle (20.6, SD ± 19.1; P = .543) or middle and late (23.1, SD ± 24.9; P > .999) time intervals., Conclusions: Patients with nasal obstruction who undergo functional septorhinoplasty can be expected to have significant improvement in self -reported nasal obstruction as early as 1 to 3 months postoperatively with a continued, durable, long-standing benefit lasting at least 10 months after surgery. Future studies can consider the 3-month time frame as a proxy for 1 year outcomes to help reduce survey burden., Level of Evidence: 2c Laryngoscope, 129:841-846, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Rhinoplasty is commonly performed in children with congenital anomalies and resultant nasal deformity causing airway obstruction. Little is known regarding patient factors or perioperative sequelae. We define demographic characteristics and perioperative complications for children undergoing rhinoplasty within a large national cohort., Study Design: Retrospective cohort study of children aged ≤ 18 years undergoing rhinoplasty utilizing data from the 2012 to 2015 American College of Surgeons National Surgery Quality Improvement Program-Pediatric public use file., Methods: All children who underwent rhinoplasty were identified. Postoperative complications were defined as 30-day postoperative infection, unplanned readmission and reoperation, and death. Multivariate logistic regression was used to identify predictors of complications. Subgroup analysis was performed based on child age (age < 5 years vs. 5-13 years vs. ≥ 14 years)., Results: Of 1,378 children undergoing rhinoplasty, 21(1.52%) children experienced complications, with the most common being unplanned readmission. Younger children were more likely to experience complications (3.79% aged < 5 years vs. 0.66% aged ≥ 14 years; P = 0.001). Using multivariate logistic regression analysis, we observed a 61% decreased odds of complication with each age group (odds ratio 0.39, 95% confidence interval 0.19, 0.77; P = 0.007). Younger children were more likely to be male (56.2% male aged < 5 years vs. 46.6% male aged ≥ 14 years; P = 0.011), have developmental delay (11.7% aged < 5 years vs. 3.65% aged ≥ 14 years; P < 0.001), and have craniofacial abnormalities (73.2% aged < 5 years vs. 42.1% aged ≥ 14 years; P < 0.001)., Conclusion: Children undergoing rhinoplasty experience few major complications, with the most common being unplanned readmission. Younger children are at greater risk and are more likely to be male with craniofacial abnormalities., Level of Evidence: 4 Laryngoscope, 129:494-499, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: Outpatient management of patients undergoing elective surgical procedures has been associated with significantly decreased health care costs compared with inpatient management. This study investigates current practices in outpatient versus inpatient management of pediatric rhinoplasty patients., Methods: A query was performed of the 2012 to 2014 National Surgical Quality Improvement Program-Pediatric data sets. Patients age 17 or younger undergoing rhinoplasty as the primary surgical procedure were included. Clinical characteristics and complications were compared among patients managed as inpatients versus outpatients using both univariate and multivariate logistic regression analyses., Results: Among 938 pediatric rhinoplasty patients, 199 (21.2%) were managed as inpatients. Multivariate analysis revealed multiple variables significantly associated with an increased odds of inpatient management, including young patient age, presence of a congenital malformation, neurologic or nutritional disease, lengthy procedure time, management by a plastic surgeon compared with an otolaryngologist, and certain procedure types including cleft septorhinoplasty, secondary rhinoplasty with intermediate or major revision, and rib cartilage grafting. Complications among both inpatients and outpatients were rare, with the most common complication being readmission among 15 patients (1.6%)., Conclusions: This study indicates that multiple subgroups of pediatric patients undergoing rhinoplasty procedures have a significantly increased likelihood of inpatient management without any significantly increased likelihood of a complication or need for readmission. Future efforts to manage appropriately selected children on an ambulatory basis may be safe, while improving costs and quality of care.

Background: Nasal septal cartilage and conchal cartilages are preferred sources of grafts in augmentation rhinoplasty. Rib cartilage can also be used, but it may evoke a patient's concerns about a scar and an extensive surgery. In such cases, irradiated homologous costal cartilage (IHCC) can be a useful alternative. However, controversy still exists in many literatures regarding complications with use of IHCC. Therefore, the authors reviewed our experiences with IHCC in rhinoplasty and analyzed the complications in relation to graft location., Methods: A retrospective chart review was made of all patients who underwent rhinoplasty with IHCC between 2007 and 2015. A total of 323 patients were included. The authors considered the cases that required revision surgery for external aesthetic changes as complications. The authors defined major complications, including resorption, infection, fracture, or warping., Results: The total complication rate was 8%. Two fractures (0.6%), 4 fragmentation (1.2%), 4 resorptions (1.2%), 4 infections (1.2%), and 2 warpings (0.6%) were noted. Most of these complications occurred for the septal extension graft. Other complications, including 1 nasal obstruction, 2 visible contours, 3 caudal septal deviations, and 4 cases of unfavorable results (patient unsatisfactions), were noted., Conclusions: Based on the outcomes of this study, the authors concluded that IHCC is a useful and reliable source of cartilage graft and can serve as an alternative graft material for rhinoplasty. However, care must be taken in use of IHCC graft in areas under tension such as septal extension graft, though its complication rate is low.

Background: Celebrities have long influenced the medical decisions of the general population. By analyzing Google search data using Google Trends, we measured the impact of highly publicized plastic surgery-related events on the interest level of the general population in specific search terms. Additionally, we investigated seasonal and geographic trends around interest in rhinoplasties, which is information that physicians and small surgical centers can use to optimize marketing decisions., Methods: Google Trends was used to access search data histories for three separate areas of interest: Kylie Jenner and lip fillers, Joan Rivers and plastic surgery, and rhinoplasty, which were then analyzed using two-tailed, two-sample equal variance t-tests., Results: The average interest level in fillers increased by 30.31 points after Kylie Jenner announced that she received Juvéderm lip injections. The interest level in plastic surgery was decreased by 21.3% the month after Joan Rivers' death. Between January 2004 and May 2017, the average interest level for rhinoplasty was significantly different in January/December (67.91 ± 20.68) and June/July (70.12 ± 18.89) from the remaining calendar months (63.58 ± 19.67). Los Angeles, New York City, and Miami showed consistently high interest levels throughout the time period, while Tulsa, OK, showed a major interest increase between 2015 to 2016 of 65 points., Conclusions: A noticeable impact was observed in both celebrity cases on search term volume, and a seasonal effect is apparent for rhinoplasty searches. As many surgeons already employ aggressive Internet marketing strategies, understanding and utilizing these trends could help optimize their investments, increase social engagement, and increase practice awareness by potential patients., 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 .

Nasal tip support is critical to achieve a lasting result in rhinoplasty. In this article, the authors compared the effects of strut grafts (SG) and caudal septum-based nasal tip supporting techniques (CSB-T) in terms of reaching the desired tip projection.Included in this study were 40 patients (24 women and 16 men) who underwent primary open rhinoplasty via transcolumellar incision between January and June 2012. To achieve a good nasal projection, SG and CSB-T were used for 15 and 25 of these patients, respectively.Certain anatomic landmarks were identified on preoperative, simulative, and 1-year follow-up photos. With these landmarks, certain angular and proportional values were calculated.In the SG, the authors found no statistically significant difference in between simulative goals and postoperative results regarding bending angle. Postoperative nasolabial angle (NLA), tip angle, subnasal-tip/subnasal-radix (SnT/SnR) ratios were significantly lower than the simulation values; radix angle and supratip index values were significantly higher.In the CSB-T group, the authors found no statistically significant difference in between preoperative values and postoperative results regarding NLA, tip angle, bending angle, (SnT/SnR) ratio values. Postoperative supratip index and radix angle measurements were found to be significantly higher than the simulation values.With these findings, the authors concluded that CSB-T support is superior than the SG for supporting the nasal tip in noses that also need shortening in caudal length. In noses that do not need caudal shortening, nasal tip projection can again be supported by the caudal septum by just forming a bridge between lower lateral cartilage and quadrangular septum using a wider SG that mimics septal extension grafts.

Objective: To evaluate the clinical effect of injectable modified sodium hyaluronate gel filler in the treatment of facial profile modification and rejuvenation. Methods: A total of 125 patients who received facial injection of hyaluronate gel from October 2013 to October 2015 were collected. The patients included 62 cases for rhinoplasty, 28 for chin augmentation, 20 for nasolabial fold correction and 15 for lacrimal groove correction. The post-operation results, satisfaction survey and adverse reaction were observed. Results: All the injected positions improved immediately, and the instant average satisfaction score was 9.3±0.7, followed by 8.1±0.7 after 3 months, 6.9±0.8 after 6 month and 5.2±0.8 after 1 year. Thirty cases exhibited swelling, 5 cases bruised, and they all recovered within one week. Conclusions: Sodium hyaluronate is effective and stable in the treatment of facial contour modification and rejuvenation.

Importance: Estimates of the 30-day hospital revisit rate following septorhinoplasty and the risk factors associated with revisits are unknown in the current literature. Surgical 30-day readmission rates are important to establish, as they are increasingly used as a quality care metric and can incur future financial penalties from third-party payers and government agencies., Objective: To determine the rate of 30-day hospital revisits following septorhinoplasty and the risk factors associated with revisits., Design, Setting, and Participants: A retrospective cohort analysis was conducted of 175 842 patients undergoing septorhinoplasty between January 1, 2005, and December 31, 2009, using data from the Healthcare Cost and Utilization Project state inpatient database, state ambulatory surgery database, and state emergency department database from California, Florida, and New York. Information on revisits for these patients was collected from the 3 databases between January 1, 2005, and December 31, 2012. Data analysis was conducted from September 1, 2014, to May 1, 2015., Main Outcomes and Measures: Hospital revisits within 30 days after an index septorhinoplasty and the primary diagnosis at the time of the revisit were the main outcome measures. The revisit rate was calculated within subgroups of patients based on different demographic and clinical characteristics. A multivariable model was then used to determine independent risk factors for the occurrence of a hospital revisit within 30 days of the septorhinoplasty procedure., Results: In total, 11 456 of 175 842 patients (6.5%) who underwent septorhinoplasty procedures revisited the hospital within 30 days of the procedure. Most of these revisits (6353 [55.5%]) were to the emergency department. The most common primary diagnosis was bleeding or epistaxis, occurring in 2150 patients (1.2%). Multivariable logistic regression showed that patients aged 41 to 65 years (adjusted odds ratio [aOR], 1.09; 99% CI, 1.02-1.16) or older than 65 years (aOR, 1.23; 99% CI, 1.06-1.43) had an increased revisit rate, as did black patients (aOR, 1.39; 99% CI, 1.16-1.66); those with Medicare (aOR, 1.55; 99% CI, 1.32-1.81) and Medicaid (aOR, 1.63; 99% CI, 1.33-2.01); those with diagnoses of autoimmune disorders or immunodeficiency (aOR, 2.69; 99% CI, 1.20-6.03), coagulopathy (aOR, 2.06; 99% CI, 1.33-3.20), anxiety (aOR, 1.79; 99% CI, 1.55-2.07), and alcohol use (aOR, 1.70; 99% CI, 1.35-2.14); and those who had a conchal cartilage graft (aOR, 2.01; 99% CI, 1.29-3.14)., Conclusions and Relevance: The study results suggest that patients with more medical comorbidities and lower socioeconomic status most commonly returned to the emergency department for surgical complications, such as bleeding or epistaxis, in the 30-day period after the procedure. These data provide valuable preoperative counseling information for patients and physicians. In addition, this study provides data to third-party payers or government agencies in which postprocedure readmissions in the 30-day period are used as a quality care metric affecting reimbursements and financial penalties., Level of Evidence: 3.

Our aim was to systematically review the prevalence of body dysmorphic disorder (BDD) in a variety of settings. Weighted prevalence estimate and 95% confidence intervals in each study were calculated. The weighted prevalence of BDD in adults in the community was estimated to be 1.9%; in adolescents 2.2%; in student populations 3.3%; in adult psychiatric inpatients 7.4%; in adolescent psychiatric inpatients 7.4%; in adult psychiatric outpatients 5.8%; in general cosmetic surgery 13.2%; in rhinoplasty surgery 20.1%; in orthognathic surgery 11.2%; in orthodontics/cosmetic dentistry settings 5.2%; in dermatology outpatients 11.3%; in cosmetic dermatology outpatients 9.2%; and in acne dermatology clinics 11.1%. Women outnumbered men in the majority of settings but not in cosmetic or dermatological settings. BDD is common in some psychiatric and cosmetic settings but is poorly identified., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Importance: Estimates of the rate of revision septorhinoplasty and the risk factors associated with revision are unknown because the current published literature is limited to small, retrospective, single-surgeon studies with limited follow-up time., Objectives: To determine the rate of revision for septorhinoplasty surgery and to determine the risk factors associated with revision., Design, Setting, and Participants: Retrospective cohort analysis of 175 842 patients undergoing septorhinoplasty between January 1, 2005, and December 31, 2009, from the Healthcare Cost and Utilization Project's State Inpatient Databases, State Ambulatory Surgery and Services Databases, and State Emergency Department Databases from California, Florida, and New York. Revisit information for these patients was then collected from the 3 databases between January 1, 2005, and December 31, 2012, with a minimal follow-up time of 3 years; and study analysis done January 1, 2005, to December 31, 2012., Main Outcomes and Measures: Revision surgery after an index septorhinoplasty was the main outcome measure, and the rate of revision was calculated within subgroups of patients based on different demographic and clinical characteristics. A multivariable model was then used to determine independent risk factors for the performance of revision surgery., Results: The study cohort comprised 175 842 participants who underwent septorhinoplasty procedures; mean (SD) age was 41.0 (15.3) years, and 57.0% were male. The overall revision rate for any septorhinoplasty procedure was 3.3% (5775 of 175 842) (99% CI, 3.2%-3.4%). After separating the patients into primary septorhinoplasty and secondary septorhinoplasty groups, the primary group had an overall revision rate of 3.1% (5389 of 172 324), while the secondary group had an overall revision rate of 11.0% (386 of 3518). Patient characteristics associated with an increased rate of revision include younger age (5.9% [633 of 10 727]), female sex (3.8% [2536 of 67 397]), a history of anxiety (3.9% [168 of 4350]) or autoimmune disease (4.4% [57 of 1286]), and surgery for cosmetic (7.9% [340 of 4289]) or congenital nasal deformities (8.9% [208 of 2334])., Conclusions and Relevance: The study results, derived from a large cohort of patients with long follow-up time, suggest that the rate of revision septorhinoplasty is low, but certain patient characteristics are associated with higher revision rates. These data provide valuable preoperative counseling information for patients and physicians. This study also provides robust data for third-party payers or government agencies in an era in which physician performance metrics require valid risk adjustment before being used for reimbursement and quality initiatives., Level of Evidence: 3.

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., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: Facial cosmetic surgery is becoming more popular. Patients generally indicate they are satisfied with the results. Certain patient characteristics, however, have been described as negative predictors for satisfaction. Psychopathology such as body dysmorphic disorder and personality disorders are notorious. Psychosocial and cultural factors are more difficult to distinguish. This systematic review defines the predictors, other than body dysmorphic disorder, of an unsatisfactory outcome after facial cosmetic surgery. The authors are also interested in whether valid preoperative assessment instruments are available to determine these factors., Methods: An extensive systematic PubMed/MEDLINE and Cochrane Library search was performed. In addition, relevant studies from the reference lists of the selected articles were added. There were no publication-year restrictions, and the last search was conducted on July 20, 2014. All factors described as negative predictors for patient satisfaction after facial cosmetic surgery were identified., Results: Twenty-seven articles were analyzed, including 11 prospective studies, two retrospective studies, one case study, eight reviews, and five expert opinions. The following factors were identified: male sex, young age, unrealistic expectations, minimal deformities, demanding patients, "surgiholics," relational or familial disturbances, an obsessive personality, and a narcissistic personality., Conclusions: This review indicates the possible demographic and psychosocial predictors for an unsatisfactory outcome of facial cosmetic surgery. A brief personality assessment tool that could be used to address predictors preoperatively was not found. The authors suggest use of the Glasgow Benefit Inventory to assess patient satisfaction postoperatively. Further research is being undertaken to develop such an instrument.

Purpose: We sought, first, to evaluate the operative experience of surgeons who have completed postresidency fellowships offered by the American Academy of Cosmetic Surgery (AACS), and second, to compare this cosmetic surgery training to other surgical residency and fellowship programs in the United States. Finally, we suggest how new and existing oral and maxillofacial surgeons can use these programs., Materials and Methods: We reviewed the completed case logs from AACS-accredited fellowships. The logs were data mined for 7 of the most common cosmetic operations, including the median total number of operations. We then compared the cosmetic case requirements from the different residencies and fellowships., Results: Thirty-nine case logs were reviewed from the 1-year general cosmetic surgery fellowships offered by the AACS from 2007 to 2012. The fellows completed a median of 687 total procedures. The median number of the most common cosmetic procedures performed was 14 rhinoplasties, 31 blepharoplasties, 21 facelifts, 24 abdominoplasties, 28 breast mastopexies, 103 breast augmentations, and 189 liposuctions. The data obtained were compared with the minimum cosmetic surgical requirements in residency and fellowship programs. The minimum residency requirements were as follows: no minimum listed for plastic surgery, 35 for otolaryngology, 20 for oral and maxillofacial surgery, 28 for ophthalmology, 0 for obstetrics and gynecology, and 20 for dermatology. The minimum fellowship requirements were as follows: 300 for the AACS cosmetic surgery fellowship, no minimum listed for facial plastic surgery and reconstruction, no minimum listed for aesthetic surgery, 133 for oculoplastic and reconstructive surgery, and 0 for Mohs dermatology., Conclusion: Dedicating one's practice exclusively to cosmetic surgery requires additional postresidency training owing to the breadth of the field. The AACS created comprehensive fellowship programs to fill an essential part in the continuum of cosmetic surgeons' education, training, and experience. This builds on the foundation of their primary board residency program. The AACS fellowships are a valuable option for additional training for qualified surgeons seeking proficiency and competency in cosmetic surgery., (Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Tongue-in-groove (TIG) is a conservative but powerful surgical suture technique to control shape, rotation, and projection of the nasal tip. In this study, statistical analyses were performed to determine the aesthetical and functional effectiveness of TIG rhinoplasty., Study Design: Prospective cohort study including 110 Caucasian or Mediterranean aesthetic rhinoplasty patients treated by one surgeon between 2007 and 2012, with a 1-year follow-up., Methods: Data were collected using the Utrecht Questionnaire, a validated instrument routinely offered to our patients before and 1 year after surgery. Aesthetic results were reflected by change in subjective body image in relation to nasal appearance, scored on five aesthetic questions and a 10-cm visual analog scale (VAS). Functional results were determined by change in subjective nasal airway patency, scored on a 10-cm VAS for both sides., Results: The mean aesthetic sum score (5, low burden-25, high burden) significantly improved from 14.01 to 6.54 (P <.01). The mean aesthetic VAS score (0, very ugly-10, very nice) significantly improved from 3.35 to 7.78 (P < .01). The mean functional VAS score (0, very bad-10, very good) showed a small but significant improvement on both sides (left, 6.83-7.96; right, 6.88-7.80; P <.01)., Conclusion: Statistical analysis of quantified subjective data on nasal aesthetics and function show that TIG is a reliable technique that can help to deliver consistently good results in Caucasian and Mediterranean patients seeking aesthetic rhinoplasty. A small additional functional improvement can be expected., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Psychiatric disorders are known to influence the result of many surgical procedures. Body dysmorphic disorder (BDD) is found in many patients undergoing plastic surgery. The prevalence before functional rhinosurgery has not been examined so far. The aim of this study was to determine the prevalence of depression and BDD before functional rhinosurgery., Material and Methods: 201 patients were prospectively examined with a questionnaire before functional rhinosurgery. Beck-Depression-Index was used to rate depression, the PISA body dsymorphic symptom scale was used to evaluate the likelihood that a patient suffers from body dysmoprhic disorder., Results: 186 patients returned a complete questionnaire. In 33.9% showed a mild or strong indication for a body dysmorphic disorder. Patients who were planned to undergo septorhinoplasty had a significantly higher scores in the PISA-scale compared to patients before septoplasty. 1.7% patients were depressive without a significant difference between the planned surgical procedure., Conclusion: Many patients before functional septorhinoplasty show signs of body dysmorphic disorder. Whether this influences the subjective clinical outcome needs to be evaluated in further studies., (© Georg Thieme Verlag KG Stuttgart · New York.)

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.

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.

Background: Preservation of an adequate cartilaginous L-strut to prevent complications of septoplasty has been long recognized as critical. However, no previous study has examined the dimensions of the L-strut that remain after septoplasty. We hypothesized that differences in exposure and visualization between endoscopic and endonasal techniques would result in differences in preserved L-strut dimensions. We designed this study to determine L-strut dimensions after performance of septoplasty with endonasal and endoscopic technique., Methods: We performed a cadaveric study with 24 heads randomly assigned to undergo endonasal vs endoscopic septoplasty by senior resident surgeons (postgraduate year 4 [PGY-4] and PGY-5). Removal of the skin-soft tissue envelope and mucoperichondrium was performed after septoplasty to permit direct measurement of the L-strut. Minimum and maximum widths were recorded for the caudal and dorsal segments; a single measurement was recorded for the width at the anterior septal angle. Statistical analysis was carried out using the 2-tailed distribution Student t test., Results: There was no significant difference in caudal or anterior septal width between endonasal and endoscopic techniques. There was a statistically significant difference in dorsal segment width for both minimum and maximum values, with endoscopic technique resulting in a narrower dorsal segment than endonasal technique (mean minimum value of 10.8 mm vs 13.2 mm, respectively, p = 0.03; and mean maximum value of 12.6 mm vs 16 mm, respectively, p = 0.01). There was significant variation in resident surgeon performance, with the performance of 1 resident surgeon accounting for the difference in minimum dorsal width., Conclusion: Differences in exposure and visualization between endoscopic and endonasal septoplasty techniques may result in differences in preserved L-strut dimensions. Care should be taken with endoscopic technique to prevent overly aggressive resection of septal cartilage, particularly with learners of this technique., (© 2013 ARS-AAOA, LLC.)

Background: The sheer number of accepted inferior turbinoplasty techniques emphasizes the fact that there is no general agreement on which approach yields optimal results, nor are there data available that describes prevalent techniques in turbinate surgery among plastic surgeons., Objective: The aim of this study was to identify practice patterns among plastic surgeons who perform inferior turbinoplasty during rhinoplasty., Methods: Members of the American Society of Plastic Surgeons were invited to participate in an anonymous, Internet-based survey containing questions related to personal preferences and outcomes in inferior turbinate surgery., Results: A total of 534 members of the American Society of Plastic Surgeons participated in the survey. Most (71.7%) trained in an independent plastic surgery program with prerequisite training in general surgery. More than half (50.6%) had more than 20 years of operative experience; only 15.2% reported performing greater than 40 rhinoplasties per year. The 5 most preferred inferior turbinate reduction techniques were outfracture of the turbinates (49.1%), partial turbinectomy (33.3%), submucous reduction via electrocautery (25.3%), submucous resection (23.6%), and electrocautery (22.5%). Fewer than 10% of the respondents reported the use of newer techniques such as radiofrequency thermal ablation (5.6%), use of the microdebrider (2.2%), laser cautery (1.1%), or cryosurgery (0.6%). Mucosal crusting and desiccation were the most frequently reported complications., Conclusions: The results of this survey provide insights into the current preferences in inferior turbinate reduction surgery. Plastic surgeons are performing more conventional methods of turbinate reduction rather than taking advantage of the many of the more novel technology-driven methods.

Introduction: As rhinoplasty remains among the most challenging and controversial operations in plastic surgery, we sought to elucidate present-day practice characteristics. Members of The Rhinoplasty Society were polled in preparation for the national meeting held in Boston, Mass, on May 2011. The goal was to provide information regarding surgical approaches used as well as technique and practice patterns used., Methods: Two electronic surveys were distributed to members of The Rhinoplasty Society in preparation for the annual meeting. All 76 members received the surveys as well as instructions for completion. The initial survey included 10 questions discussing the preferred approach for rhinoplasty and practice details. The second survey dealt with specific techniques used during rhinoplasty. Data were collected and reviewed., Results: The primary survey yielded a 61.8% response rate, whereas the secondary survey 48.7%. Of all surgeons, 72% reported doing the open approach for primary rhinoplasty more than 50% of the time, whereas the remaining 28% use the closed approach. For secondary rhinoplasty, 76% reported using the open approach in more than half of cases for which they were not the primary surgeons. In contrast, 53% used the closed approach in more than half the cases of secondary surgery if they were the initial surgeons. Revision rates for primary and secondary rhinoplasties were 9.1% and 7.8%, respectively. The difference was not statistically significant. On average, members performed 101 nasal surgeries per year. Previous patient recommendation was the most common reason for referral. Of the members, 54% reported using spreader grafts in more than half of the cases of aesthetic rhinoplasty and 75.7% when pertaining to functional rhinoplasty. Finally, 37.8% of responding members reported using tip grafts more than half the time when performing aesthetic rhinoplasty., Conclusions: Of the responding members of The Rhinoplasty Society, the open approach is the preferred choice for both primary and other surgeons' revision rhinoplasties. Spreader grafts are commonplace in both functional and aesthetic rhinoplasties.

Introduction: Columellar cartilage graft helps improve esthetic results in secondary cleft rhinoplasty for patients presenting with cleft lips. However, inadequate skin coverage of the cartilaginous graft can result in columellar necrosis and graft loss. Moreover, the scar after Millard's primary cheiloplasty may not be esthetic. The aim of this article was to present the columellar flap technique to cover the columellar graft and to improve the scar after unilateral Millard's cheiloplasty., Technical Note: The triangular flap is drawn on the edge of Millard's cheiloplasty scar. It is then moved in a V-Y fashion so as to cover the cartilaginous graft and improve the esthetic aspect of the new columella., Discussion: Four hundred and twelve teenage/adult rhinoplasties were performed in our department over 10 years (October 2001 to October 2011). This flap was used in 10 patients who were followed-up for at least 1 year. There were no severe postoperative complications. Millard's unilateral cheiloplasty scar was less visible. A prospective study is ongoing., (Copyright © 2013. Published by Elsevier Masson SAS.)

Background: The purpose of this study was to identify the most common deformities seen preoperatively in secondary rhinoplasty patients and the required surgical maneuvers to correct them., Methods: A retrospective chart review of 100 consecutive secondary rhinoplasty patients was performed. Preoperative variables included demographics, prior rhinoplasty data, main aesthetic/functional concerns, and the senior author's physical examination of the nose. Details of the operative maneuvers were reviewed., Results: The average patient age was 39.2 years. All patients had previous rhinoplasties performed by other surgeons. The most common preoperative complaints were airway occlusion (65 percent), dorsum asymmetry (33 percent), nostril asymmetry (18 percent), and tip asymmetry (14 percent). The most common preoperative nasal deformities seen by the senior author (B.G.) were dorsal asymmetry (65 percent), wide dorsum (47 percent), nostril asymmetry (41 percent), wide alar base (38 percent), and dorsal hump (30 percent). The senior author saw significantly more nasal deformities than the patients themselves, especially in the following areas: dorsal asymmetry (65 percent versus 33 percent; p = 0.0002), wide dorsum (47 percent versus 13 percent; p < 0.0001), nostril asymmetry (41 percent versus 18 percent; p = 0.0003), wide alar base (38 percent versus 6 percent; p < 0.0001), dorsal hump (30 percent versus 9 percent; p < 0.0001), and columella protrusion (25 percent versus 6 percent; p = 0.0002). The most common revision rhinoplasty surgical maneuvers were septoplasty (71 percent), alar rim graft (67 percent), dorsal graft (63 percent), osteotomy (60 percent), and dorsal hump removal (46 percent)., Conclusions: The high incidence of airway concerns among secondary rhinoplasty patients is alarming and emphasizes the urgent need to pay attention to the airway during primary rhinoplasty. There is often a disparity between what the patient sees and what the surgeon observes.

Introduction: There is still disagreement concerning the significance of sinus x-ray prior to septoplasty: according to the previous guidelines for Diagnostic and Therapy of the German Society for Oto-Rhino-Laryngology and head and neck surgery in 1996, a sinus x-ray prior to septoplasty was seen as "necessary." According to the guidelines from 2010, a suitable radiology imaging is just "optional." In the present study, we analyzed the significance of a sinus x-ray to exclude a chronic sinusitis prior to septoplasty., Patients and Methods: A total of 96 patients were included in this study. All were admitted to the hospital by an ENT specialist for septoplasty with conchotomy. The preoperatively performed sinus x-ray was evaluated with regard to an already existing sinusitis. These results were correlated with the patients' anamnesis and the nasal endoscopic view., Results: A sinus x-ray (occipitomental) was obtained in all 96 patients. No pathological result was observed in 82 patients, while 14 patients showed pathology in the paranasal sinus. After a detailed appraisal of the sinus x-ray with pathology, 7 patients with pathological findings in the paranasal sinus remained. In the other 7 patients, the statement was false positive. In only 3 patients was a CT image obtained, which resulted in modification of the surgical procedure., Conclusion: Our findings show that a routinely performed sinus x-ray is not necessary prior to septoplasty. If there is reasonable suspicion for pathology in the paranasal sinus, radiological imaging is necessary, whereby a CT scan should be performed.

In an effort to try to define the tendencies in the practice of facial plastic surgery in the different countries of Latin America, a survey was conducted from June 2012 to August 2012. Questionnaires were sent to specialists in otolaryngology and facial plastic surgery in the countries of Colombia, Brazil, Venezuela, Ecuador, Chile, Peru, and Mexico. Results are shown and discussed. Comparisons are made with existing surveys performed by the American Academy of Facial Plastic and Reconstructive Surgery., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: There is little evidence-based information on secondary rhinoplasty patient motivations for surgery, satisfaction, or revision rates., Methods: The charts of 150 consecutive patients (121 women and 29 men) who underwent secondary rhinoplasty between July of 2007 and October of 2008 were reviewed; preoperative deformity severity was graded from 1 to 5. The patients' primary reasons for surgery, patient and surgeon satisfaction, and postoperative depression or body dysmorphic disorder were tallied., Results: The average number of prior operations was 3.6. The most commonly expressed reason (41 percent) for undergoing revision was the development of a new deformity after the primary rhinoplasty. Those patients also had the most severe preoperative deformities (p < 0.02). Other motivations were failure to correct the original deformity (33 percent), an intolerable perceived loss of personal, familial, or ethnic characteristics (15 percent), the desire for further improvement in an already acceptable result (10 percent), and a new or unrelieved airway obstruction (1 percent). Ninety-seven percent of patients were happy with their outcomes. Forty patients (27 percent) were depressed before surgery and three (2 percent) displayed evidence of body dysmorphic disorder postoperatively. The depressed and dysmorphic patients did not have worse deformities than those who were not depressed postoperatively (p < 0.8695)., Conclusions: Most secondary rhinoplasty patients have motivations similar to those of our other reconstructive patients and will be pleased with their surgical outcomes. The most severe preoperative deformities were iatrogenic. The unhappy postoperative patients, including those with body dysmorphic disorder, did not have more severe preoperative deformities than the others (i.e., their deformities alone did not justify their unhappiness).

Purpose: Primary cosmetic rhinoplasty is one of the most complex of cosmetic surgical procedures in the maxillofacial area that requires precise consideration to both form and function. The complex and variable anatomy, highly visible position of the nose, and distinct patient desires contribute to the complexity of this procedure. This study reports the combined results of 101 consecutive primary cosmetic rhinoplasties at 2 centers., Patients and Methods: A retrospective chart review was completed on all patients who had primary cosmetic rhinoplasty with or without septoplasty and who were operated on by the senior authors (S.C.B. and H.M.) from June 2006 through December 2008. A standard physical examination, including photo documentation, was completed on each patient preoperatively. All patients were followed periodically after surgery for at least 12 months. Outcome was measured by both subjective and objective measures of cosmetic and functional (breathing) outcome. The following data were collected and analyzed: age of patient, gender, chief cosmetic and functional complaint, details of surgical procedure (including septoplasty, grafts, and donor sites), complications, and report of subjective outcome at final evaluation., Results: One hundred one patients (n = 101, average age 24.4 ± 6.8 years old) were enrolled in the study. Most patients presented for consultation regarding cosmetic rhinoplasty (80%) versus septorhinoplasty (20%). Although most of the patients (63%) were treated with septorhinoplasty, the open rhinoplasty (transcollumellar) incision was used in 61% of patients versus the closed rhinoplasty (39%) technique. The most commonly performed combination of techniques used was the combination of nasal tip modification, with dorsal reduction and nasal osetotomies (54%), followed by tip modification with dorsal reduction (19%), and dorsal reduction with osteotomies (18%) and no tip modification. In the 50 patients who required a graft, in 80% the donor site was the nasal septum. Spreader grafts were used in 14% of patients, and a combination of shield/tip graft was used in 52%. The following complications were observed: unhappy patient 16%, dehiscence at incision 5%, asymmetry requiring revision 6%, and infection 1%. In the 63 patients that had septoplasty, 6 (9.5%) reported that their breathing was not improved. In this series 11 patients (11%) received a revision rhinoplasty., Conclusions: Primary cosmetic rhinoplasty is 1 of the more complex facial cosmetic procedures. The vast majority of complications can be avoided with careful and extensive treatment planning. In this series we found a complication and revision rate similar to that reported in the literature., (Copyright © 2012 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)