Evidence-Based Medicine: Rhinoplasty

Clinical Practice Patterns and Evidence-Based Medicine in Rhinoplasty: A 10-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery

BACKGROUND

The American Board of Plastic Surgery (ABPS) has collected data on cosmetic surgery from member surgeons since 2003. These data offer valuable information on national trends in clinical practice.

OBJECTIVES

The present study was performed to analyze trends in rhinoplasty over the last decade.

METHODS

Tracer data were compared between two cohorts 2012-2016 (early cohort "EC") and 2017-2021 (recent cohort "RC"). Data included patient demographics and surgical techniques. Results were considered in the context of current EBM-based guidance in the plastic surgery literature.

RESULTS

Data from 730 rhinoplasties (270 EC and 460 RC) were analyzed. The median age was 30 years, and the most common patient concern was the nasal dorsum (79%). In the RC group, fewer patients voiced concerns about tip projection (58% vs 43%, p = 0.0002) and more complained of functional airway problems (38% vs 49%, p = 0.004). An open approach was most common (83%). Septoplasty (47% vs 52%, p = 0.005), caudal septum repositioning (14% vs 23%, p = 0.002), and tip rotation maneuvers (32% vs 49%, p < 0.0001) became more popular. There was also an increase in the use of spreader grafts (35% vs 45%, p = 0.01) and columellar strut grafts (42% vs 50%, p = 0.04), while there has been a decrease in alar base resection (17% vs 10%, p = 0.007) and non-cartilaginous dorsum/radix augmentation (9% vs 4%, p = 0.02).

CONCLUSIONS

ABPS tracer data provide an excellent resource for the objective assessment of procedures in plastic surgery. The present study is the first to highlight evolving trends in rhinoplasty over the last 10 years.

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 .

Evaluating the therapeutic and reconstructive efficacy of flap transplantation techniques in managing nasal tissue deficiency resulting from post-rhinoplasty surgical infections

Rhinoplasty is a frequently performed aesthetic surgery with a high procedural volume. Despite the operational ease and safety profile of biocompatible materials such as silicone and inflatable prosthetics, postoperative complications like surgical site infections can lead to significant clinical challenges. These complications necessitate effective therapeutic and reconstructive interventions. This study aims to evaluate the efficacy of different flap transplantation techniques for early treatment of post-rhinoplasty nasal tissue deficiencies. A retrospective study was conducted from May 2018 to May 2023, involving 38 patients divided into a control group receiving standard anti-infective treatment and an observation group undergoing early flap grafting procedures. Efficacy was evaluated using objective metrics-namely, nasal appearance, function and flap condition-each assessed through a 10-point scoring system, and subjective metrics such as patient satisfaction gauged through self-administered questionnaires. Statistical analyses were performed using SPSS version 27.0. Both groups were statistically comparable in terms of demographics such as age, marital status and educational background. The observation group displayed significantly improved outcomes in terms of nasal aesthetics (mean score 7.92 ± 1.00), nasal function (mean score 8.47 ± 0.51) and flap condition (mean score 7.89 ± 1.12) compared to the control group. Flap transplantation techniques demonstrated superior therapeutic and reconstructive efficacy in the management of nasal tissue deficiencies arising from post-rhinoplasty surgical infections. These findings contribute to evidence-based recommendations for optimal clinical practice.

Are Antibiotics Needed in Septorhinoplasty? An Evidence-Based Approach

The use of prophylactic antibiotics in the context of septorhinoplasty (SRP) is a frequently debated topic among plastic surgeons. Most surgeons routinely use antibiotics to prevent the dreaded physical and psychological morbidity of postoperative infections, although this practice is controversial. With antimicrobial resistance becoming a global threat, however, optimizing antibiotic prescribing is essential. The current evidence would suggest that the rate of postoperative infection is low and routine antibiotic use is unnecessary in SRP surgery. Rates range from 0.5 to 2% in simple SRP surgery, majority of which are minor nasal infections which respond to oral antibiotics and do not require hospital admission. In cases of complex SRP, defined as revision cases or where grafts or implants have been utilized, infection rates can be much higher with an incidence of 7 to 11%, and as such utilization of antibiotics is reasonable. When considering the regime to be utilized, a single preoperative dose of intravenous antibiotics has the same efficacy in reducing the incident of postoperative infection as a postoperative 7-day course of oral antibiotics. In the authors' practice, all patients receive a single intravenous dose of antibiotics on induction, and in the case of utilization of a graft from a nonnasal site, this is complimented with an oral course of postoperative antibiotics. With this approach, infections rates are at the lowest range of available published literature.

Relationship between surgical rhinoplasty and Demodex infestation: a case-control study

Background/aim

Human Demodex mites are parasites that live in the pilosebaceous unit and can cause demodicosis. While demodicosis may occur as a primary skin disease, it may also result from immunosuppression and topical or systemic immunosuppressive therapies. Surgical rhinoplasty is one of the most commonly performed cosmetic procedures, and it is the cause of a variety of cutaneous complications, particularly acne, as it affects the skin's adnexal structures. Thus, this study aimed to investigate whether the cutaneous changes in surgical rhinoplasty patients render them vulnerable to Demodex infestation.

Materials and methods

Individuals who had undergone rhinoplasty (patients) and age- and sex-matched healthy volunteers (controls) were included in this prospective case-control study. To determine the Demodex density, samples were collected from the malar and nasal regions of both the patients and controls using the standard superficial skin biopsy method.

Results

A total of 50 rhinoplasty patients and 50 healthy controls were enrolled in the study. The Demodex density on the nose was significantly higher in the rhinoplasty patients (p = 0.0001). Furthermore, the frequency of xerosis and pustules was significantly higher in the rhinoplasty patients compared to the control group (p = 0.046 and p = 0.001, respectively).

Conclusion

Surgical rhinoplasty may be a risk factor for demodicosis, and patients will recover faster after surgery with proper diagnosis and treatment.

The efficacy of cryotherapy in reducing edema and ecchymosis in patients who underwent rhinoplasty: A narrative review

OBJECTIVE

The aim of this article was to showcase current literature on the efficacy of different postoperative and intraoperative cryotherapy techniques in reducing edema, ecchymosis, and pain in patients who have undergone rhinoplasty.

BACKGROUND

Rhinoplasty has some unfavorable postoperative temporary side effects, such as edema, ecchymosis, and pain, which hinder the patients' daily activities. Several interventions have been proposed in the literature, including cryotherapy, which refers to cold application to the desired facial area in patients who have undergone rhinoplasty.

METHODS

Specific keywords were used, and PubMed, Scopus, and Embase databases were searched. Two extensive selection rounds were performed to finally include 27 articles; the first round was based on the title and abstract, while the second was based on the full article.

DISCUSSION

The articles were split into postoperative and intraoperative categories based on the time cryotherapy was administered during the surgery. They were then subdivided depending on the specific cryotherapy technique used, and a detailed description of the method of application and improvement in patients' edema, ecchymosis, and pain was noted. Articles that compared different cryotherapy techniques were also compared with articles that discussed previously used techniques.

CONCLUSION

Cryotherapy has shown promising outcomes in reducing edema, ecchymosis, and pain after rhinoplasty and bleeding. It is crucial to build further studies upon these outcomes and develop guidelines for surgeons to effectively use these cryotherapy techniques in their practice.

Periorbital Ecchymosis Post Closed Rhinoplasty: Natural History, Risk Factors, and Validation of a New Scoring System

Postrhinoplasty periorbital ecchymosis is an inevitable side effect contributing to patients' psychological aspect and early postoperative morbidity. Efforts are constantly being made to reduce ecchymosis using different methods with varying success. To evaluate treatment response, it is mandatory to have a reliable score. Several studies suggest other scoring systems, but none has been postrhinoplasty-specific, validated, and accepted. This study aimed to demonstrate the natural history of postrhinoplasty ecchymosis, find potential risk factors for worsening patterns, and suggest a useful and reliable periorbital ecchymosis scoring system for postrhinoplasty follow-up.

Methods

This prospective study included 183 patients who underwent closed rhinoplasty by the same surgeon and the same principle method. Photographs of the periorbital ecchymosis were taken on postoperative days 1, 2, and 7. The periorbital area was divided into quarters, and three independent physicians assigned the dominant color of each quarter.

Results

There were no significant variations between the three physicians' scoring. The interobserver consistency defined as an excellent scoring system reliability, according to our statistical analysis. The postoperative ecchymosis demonstrated a consistent pattern of spread over time, dominating the medial quarters on early postoperative days 1 and 2, following into the lower lateral quarters in postoperative day 7. We found no correlation between patient demographics and clinical characteristics to ecchymosis patterns and temporal spread.

Conclusions

Our study suggests a reliable and easy-to-use postrhinoplasty ecchymosis scoring system. This scoring method can be used for postrhinoplasty ecchymosis assessment and as a research-validated tool to quantify different perioperative treatments to reduce ecchymosis and estimate mid-face trauma.

Investigation of the effects of intranasal desmopressin on the bleeding of the patients during open septorhinoplasty: A randomized double-blind clinical trial

Objectives

Rhinoplasty is one of the most common cosmetic surgeries in the world. Lack of adequate local homeostasis may lead to excessive bleeding during the operation, which increases the time of operation and recovery period, and the prevalence of complications. This study investigated the effects of nasal desmopressin on the quality of the surgical field and the volume of bleeding during rhinoplasty.

Materials and methods

This double-blind randomized clinical trial was performed on 120 patients aged 18-40 years who were candidates for rhinoplasty. Patients were randomly divided into three groups: low-dose desmopressin group and high-dose desmopressin group and placebo group. Hemodynamic changes and surgical field based on BOEZAART criteria, and the volume of bleeding were calculated.

Results

In this study 115 women (95.8%) and 5 men (4.2%) participated. The mean age of patients was (27 ± 6.8). Bleeding volume in high dose desmopressin group was (21.7 cc ± 12.3), (27.7 cc ± 12.3) in low dose group, and (38.3 cc ± 12.3) in the placebo group, The difference in blood volume among the three groups was statistically significant with p < 0.005. Clean surgical field according to BOEZAART classification was marginally significant in both desmopressin groups. The differences in blood pressure, heart rate, blood and urine sodium, and hemoglobin before and after surgery between groups there not statistically significant.

Conclusion

Based on the results of the present study topical nasal spray desmopressin can reduce surgical field bleeding during rhinoplasty. To generalize the results to other surgeries in the ENT field it is recommended to conduct studies.

PMMA-collagen Gel in Nonsurgical Rhinoplasty Defects: A Methodological Overview and 15-year Experience

Nonsurgical rhinoplasty (NSR) is an alternative to surgical rhinoplasty for patients who desire correction of mild-to-moderate aesthetic nasal defects but do not wish to undergo surgery due to concern about risks, recovery time, or cost. Although not a surrogate, NSR can be a more accessible and more precise modality for achieving aesthetic goals. Furthermore, for certain types of defects, the precision possible with filler injection versus surgery can make NSR the preferred procedure. In these instances, polymethylmethacrylate (PMMA)-collagen gel is a valuable tool for appropriate candidates due to its permanence and its favorable safety profile when injected appropriately.

The Role of Nasal Sill Correction in Secondary Cleft Rhinoplasty

BACKGROUND

Evaluating outcomes after cleft rhinoplasty can be challenging because of the lack of objective measures that would lead to a more desirable outcome.

METHODS

This study is a 10-year retrospective review of 30 consecutive patients who underwent secondary unilateral cleft rhinoplasty performed by a single surgeon. Subjective ratings were made using the Unilateral Cleft Lip Surgical Outcomes Evaluation (UCL SOE), which rates 4 components (nose, cupid's bow, lateral lip, and free vermillion) with a score of 0 to 2. Multiple anthropometric measurements (nostril height ratio, width ratio, medial ¼ height ratio, sill ratio, nostril area ratio, columellar angle, tip projection ratio, and nasolabial angle) were taken using a free National Institutes of Health program, ImageJ. Standardized photographs were compared at T0 (preoperatively), T1 (<6 weeks postoperatively), and T2 (>6 weeks postoperatively).

RESULTS

There were 30 patients who met our inclusion criteria: 10 males (66.7%) and 20 females (66.7%). Of these patients, 26 (86.7%) had a complete cleft lip and 4 (13.3%) had an incomplete cleft lip. The patients' average age at time of surgery was 16.2 years with a mean follow-up of 17.9 months. Subjective scores in both nasal and overall UCL SOE ratings improved from T0 to T1, 0.7 to 1.2 (P ≤ 0.001) and 3.6 to 4.7 (P ≤ 0.001), respectively. Visual analog scores in nasal and overall UCL SOE ratings improved between T0 and T2, 0.7 to 0.9 (P = 0.023) and 3.6 to 4.8 (P = 0.002), respectively. Of all the objective measures, nasal sill ratio and cleft height to width ratio correlated with improved subjective ratings across multiple time points.

CONCLUSIONS

Our study shows that objective measures such as nasal sill and nostril shape (cleft height to width ratio) correlate with improved subjective visual analog scale using the UCL SOE. The nasal sill is an often overlooked, yet essential, part of creating an aesthetically pleasing nose during cleft rhinoplasty.

Preoperative Evaluation of the Rhinoplasty Patient

Requiring both high-level technical skills and artistic sense, rhinoplasty continues to be one of the most challenging procedures in plastic surgery despite its popularity. A thorough preoperative consultation of the rhinoplasty patient forms the foundation of a successful case. During the consultation, the physician should obtain a detailed medical and nasal history, understand the patient's areas of concern, conduct a nasal analysis, and evaluate the patient's candidacy for surgery. This article reviews the key functional, esthetic, and psychosocial considerations that should be taken into account during a preoperative consultation for a rhinoplasty patient.

Effect of clinical photography on postprocedure patient satisfaction in female patients who underwent nonsurgical rhinoplasty

STUDY DESIGN

A prospective clinical study.

BACKGROUND

To the best of our knowledge, there is no study in the literature that addresses the effect of showing comparative photographs in the follow-up period to patients who had undergone nonsurgical rhinoplasty on patient satisfaction.

OBJECTIVES

To examine the effect of showing preprocedure and postprocedure photographs to patients in the follow-up period on patient satisfaction.

METHODS

It was a nonsimultaneous prospective study that included patients suitable for nonsurgical rhinoplasty. Photographs were taken during routine follow-up after 1 month of the procedure, and patients were asked to fill the Derriford Appearance Scale 24 (DAS24) and Rhinoplasty Outcome Evaluation (ROE) questionnaires. Next, after the preprocedure and postprocedure photographs were shown to the patients, they were asked to complete the DAS24 and ROE questionnaires again.

RESULTS

The study included 265 female patients. The mean age of the patients was 35.11 ± 8 (18-61 years). Before the preprocedure and postprocedure photographs were shown, the DAS24 score was 52.2 ± 14.26 and the ROE score was 75.91 ± 11.91. After the photographs were shown, the DAS24 score was found to be 40.80 ± 13.25 and the ROE score as 87.722 ± 8.56. Therefore, significant improvement in DAS24 and ROE scores and an increase in patient satisfaction were observed after the preprocedure and postprocedure photographs were shown (p = 0.01, p < 0.05).

CONCLUSION

Showing preprocedure and postprocedure photographs in the follow-up period to patients who underwent nonsurgical rhinoplasty leads to greater patient satisfaction with the surgery and their self-image.

3D Virtual Planning for Rhinoplasty Using a Free Add-On for Open-Source Software

BACKGROUND

Rhinoplasty is one of the most frequent aesthetic surgeries; the procedure can be challenging for inexperienced surgeons, and positive outcomes depend on good communication with the patient, proper planning, and precise execution. Three-dimensional (3D) technology has emerged to address these issues, but specific software for 3D planning tends to be expensive.

OBJECTIVES

This study presents a simple, low-cost method for 3D simulation to plan rhinoplasty.

METHODS

This preliminary report describes 3D rhinoplasty planning in a series of 3 cases employing free software and an add-on especially developed for rhinoplasty (Blender and RhinOnBlender, respectively). The photogrammetry protocol, which can be performed easily with a smartphone, is described in detail along with all the steps in 3D planning.

RESULTS

The software and add-on automated the process, making the tool environment accessible to surgeons who are not familiar with graphic design software. The surgeries were uneventful in all cases, and the patients were satisfied with the outcomes.

CONCLUSIONS

3D graphic technology has provided significant advances in health research, improvement, and teaching for surgeons and communication between surgeons and patients. Free open-source software and add-ons are excellent options that offer proven utility, affordability, and ease of utilization to healthcare providers.

The Nonsurgical Rhinoplasty: A Retrospective Review of 5000 Treatments

BACKGROUND

Nonsurgical rhinoplasty with injectable dermal fillers has become an increasingly popular alternative to surgical procedures, in view of its relative low cost, convenience and rapid recovery, and low risk profile. The safety and efficacy of nonsurgical rhinoplasty remains a relatively contentious and ambiguous matter, given that there are few large-scale series reporting results or complications. This study reports the experience of a single clinician performing nonsurgical rhinoplasty in the largest cohort to date.

METHODS

Patient demographics, indications, treatment details, and outcomes of patients treated between March of 2016 and January of 2019 were reviewed. The nonsurgical rhinoplasty technique described previously by Harb was used using hyaluronic acid dermal filler.

RESULTS

Nonsurgical rhinoplasty was performed in 5000 patients. The commonest indication was dorsal hump (44 percent). Swelling and erythema were self-limiting side effects encountered in approximately half of patients. Infection was seen in two patients, and localized skin necrosis was observed in three patients.

CONCLUSIONS

Nonsurgical rhinoplasty is a safe procedure with positive aesthetic results when performed by an experienced clinician. Knowledge of nasal anatomy, comprehensive training, and use of appropriate materials are key in ensuring safety and results.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Lateral Osteotomy Fixation Technique in Rhinoplasty

Rhinoplasty is the most challenging facial aesthetic surgical procedure according to many plastic surgeons. Nasal bone osteotomies, especially lateral osteotomies, have a complicated history. If lateral osteotomy is not stable after osteotomy during intraoperative period, stabilization is attempted with internal and external nasal splints but it is not possible to be confident about the stabilization since it is not fully fixed and cannot be observed directly. The authors presented the technique stabilization of the lateral osteotomy inferior tip with cerclage wire, if there is a stabilization problem or step-off deformity after lateral osteotomy.

Nasal Analysis: Considerations for Ethnic Variation

As the United States continues to be more ethnically and racially diverse, it is important for the rhinoplasty surgeon to have an appreciation and understanding of nasal variations that exist to plan for and execute ethnically congruent results. The nasal analysis is a critical component of the patient evaluation, which has been used as a tool by surgeons to identify deviations from anatomical norms or canons. In this article, the authors describe common nasal anatomical variations that exist between ethnic groups as a guide for nasal analysis. Understanding these variations will facilitate and help define important cultural aesthetics, which can be used to plan for rhinoplasties in a diverse patient population.

Effects of Bilateral Infraorbital and Infratrochlear Nerve Block on Emergence Agitation after Septorhinoplasty: A Randomized Controlled Trial

Emergence agitation is common after septorhinoplasty, and postoperative pain is the main risk factor for this condition. Infraorbital and infratrochlear nerve block have been reported to facilitate pain management in patients after nasal procedures. The effect of peripheral nerve block on the incidence of emergence agitation has not been evaluated. Sixty-six patients that were scheduled for septorhinoplasty were assigned to receive bilateral infraorbital and infratrochlear nerve block with either 8 mL of 0.5% ropivacaine (Block group) or isotonic saline (Sham Block group). The incidence of emergence agitation was evaluated using the Riker sedation-agitation scale. Analgesic consumption, hemodynamic parameters, postoperative pain scores, adverse events, and patient satisfaction with analgesia were evaluated. The incidence of emergence agitation was lower in the Block group than in the Sham Block group (6 (20.0%) versus 20 (62.5%), p = 0.002). The mean intraoperative remifentanil consumption was lower in the Block group than in the Sham Block group (0.074 ± 0.014 μg/kg/min. versus 0.093 ± 0.019 μg/kg/min., respectively, p < 0.0001), as was the proportion of patients that needed postoperative tramadol administration and median postoperative pain score at 0–2 h after surgery (9 (30.0%) versus 21 (65.6%), p = 0.011; 3.0 (2.0–4.0) versus 4.0 (3.0–4.0), p < 0.0001, respectively). Hemodynamic parameters and the incidence of adverse events were similar between the two groups. The median patient satisfaction score with respect to analgesia was higher in the Block group than in the Sham Block group (3.5 (3.0–4.0) versus 3.0 (3.0–4.0), respectively, p = 0.034). The preoperative bilateral infraorbital and infratrochlear nerve block decreased the incidence of emergence agitation after septorhinoplasty.

Hematomas in Aesthetic Surgery

Hematomas represent one of the most common postoperative complications in patients undergoing aesthetic surgery. Depending on the type of procedure performed, hematoma incidence and presentation can vary greatly. Understanding the risk factors for hematoma formation and the preoperative considerations to mitigate the risk is critical to provide optimal care to the aesthetic patient. Various perioperative prevention measures may also be employed to minimize hematoma incidence. The surgeon's ability to adequately diagnose and treat hematomas after aesthetic surgery is not only crucial to patient care but also minimizes the risk of further complications or long-term sequelae. Understanding hematoma development and management enhances patient safety and will lead to overall increased patient satisfaction after aesthetic surgery.

Assessment of Functional Rhinoplasty with Spreader Grafting Using Acoustic Rhinomanometry and Validated Outcome Measurements

BACKGROUND

Rhinoplasty is 1 of the most common aesthetic and reconstructive plastic surgical procedures performed within the United States. Yet, data on functional reconstructive open and closed rhinoplasty procedures with or without spreader graft placement are not definitive as only a few studies have examined both validated measurable objective and subjective outcomes of spreader grafting during rhinoplasty. The aim of this study was to utilize previously validated measures to assess objective, functional outcomes in patients who underwent open and closed rhinoplasty with spreader grafting.

METHODS

We performed a retrospective review of consecutive rhinoplasty patients. Patients with internal nasal valve insufficiency who underwent an open and closed approach rhinoplasty between 2007 and 2016 were studied. The Cottle test and Nasal Obstruction Symptom Evaluation survey was used to assess nasal obstruction. Patient-reported symptoms were recorded. Acoustic rhinometry was performed pre- and postoperatively. Average minimal cross-sectional area of the nose was measured.

RESULTS

One hundred seventy-eight patients were reviewed over a period of 8 years. Thirty-eight patients were included in this study. Of those, 30 patients underwent closed rhinoplasty and 8 open rhinoplasty. Mean age was 36.9 ± 18.4 years. The average cross-sectional area in closed and open rhinoplasty patients increased significantly (P = 0.019). There was a functional improvement in all presented cases using the Nasal Obstruction Symptom Evaluation scale evaluation.

CONCLUSIONS

Closed rhinoplasty with spreader grafting may play a significant role in the treatment of nasal valve collapse. A closed approach rhinoplasty including spreader grafting is a viable option in select cases with objective and validated functional improvement.

Adverse Event Incidences following Facial Plastic Surgery Procedures: Incorporating FACE-Q Data to Improve Patient Preparation

BACKGROUND

Before creation and validation of the FACE-Q by Pusic et al., adverse event types and incidences following facial cosmetic procedures were objectively measured and reported by physicians, potentially leading to misrepresentation of the true patient experience. This article analyzes and compares adverse event data from both FACE-Q and recent review articles, incorporating patient-reported adverse event data to improve patient preparation for facial cosmetic procedures.

METHODS

FACE-Q adverse event data were extracted from peer-reviewed validation articles for face lift, rhinoplasty, and blepharoplasty, and these data were compared against adverse effect risk data published in recent Continuing Medical Education/Maintenance of Certification and other articles regarding the same procedures.

RESULTS

The patient-reported adverse event data sets and the physician-reported adverse event data sets do contain overlapping elements, but each data set also contains unique elements. The data sets represent differing viewpoints. Furthermore, patient-reported outcomes from the FACE-Q provided incidence data that were otherwise previously not reported.

CONCLUSIONS

In the growing facial cosmetic surgery industry, patient perspective is critical as a determinant of success; therefore, incorporation of evidence-based patient-reported outcome data will not only improve patient expectations and overall experience, but will also reveal adverse event incidences that were previously unknown. Given that there is incomplete overlap between patient-reported and physician-reported adverse events, presentation of both data sets in the consultation setting will improve patient preparation. Furthermore, use of validated tools such as the FACE-Q will allow surgeons to audit themselves critically.

Evidence-Based Medicine: Secondary Correction of Cleft Lip Nasal Deformity

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the components of unilateral and bilateral cleft lip nasal deformity. 2. Assess the deformity. 3. Design a treatment plan for secondary correction of cleft lip nasal deformity. 4. Discuss methods for managing suboptimal outcomes.

SUMMARY

Correction of cleft lip nasal deformity has been addressed in this Maintenance of Certification/Continuing Medical Education series a number of times-a testament to the complexity of the topic. In this addition to the series, the authors provide a principle-based approach toward management of unilateral and bilateral cleft lip nasal deformity with an emphasis on timing intervention, role for intermediate correction, and methods for cleft rhinoplasty after completion of nasal growth.

Incidence and Preoperative Risk Factors for Major Complications in Aesthetic Rhinoplasty: Analysis of 4978 Patients

Background

Rhinoplasty remains one of the most common aesthetic procedures performed in the United States. Current literature on rhinoplasty complications is inconclusive and is based on retrospective reviews and small cohorts.

Objectives

The purpose of this study was to examine the incidence and identify predictive risk factors for major complications following rhinoplasty alone or in combination with other aesthetic operations in a large, prospective, multicenter database study.

Methods

A prospective cohort of patients undergoing rhinoplasty between May 2008 and May 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications, defined as complications requiring an emergency room visit, hospital admission, or a reoperation within 30 days of the index operation. Univariate and multivariate analysis evaluated potential risk factors for major complications including age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, and combined procedures.

Results

A total of 129,007 patients were identified, of which 4978 (3.9%) underwent a rhinoplasty. The overall complication rate was 0.7% (n = 37). Hematoma was the most common complication (0.2%), followed by infection (0.2%), and pulmonary complications (0.1%). Age ≥40 years was found to be an independent risk factor for developing complications. Age ≥40 years was found to have a relative risk of 2.05 (P = 0.04) for any major complication. Complications increased from 0.58% in rhinoplasty alone cases to 1.02% (P < 0.05) with the addition of 1 other body region to 2.09% with the addition of 2 other body regions (P < 0.05). The risk of pulmonary complications increased from 0.1% to 1% (P < 0.05) with the addition of rhinoplasty with 2 other body regions. Gender, type of facility, smoking status, and BMI ≥25 did not appear to significantly impact the risk for major complications.

Conclusions

The major complication rate following rhinoplasty remains low. The risk is increased with age ≥40 years and with the addition of other cosmetic procedures. Pulmonary complications, although rare, do occur, and also increase when combining rhinoplasty with other aesthetic surgery. These findings are important to consider when planning rhinoplasty and educating patients on the safety of combined aesthetic surgeries.

Level of Evidence

2.

Evidence and evidence gaps in therapies of nasal obstruction and rhinosinusitis

Therapeutic decisions in otorhinolaryngology are based on clinical experience, surgical skills, and scientific evidence. Recently, evidence-based therapies have gained increased attention and importance due to their potential to improve the individual patient's treatment and their potential at the same time to reduce treatment costs. In clinical practice, it is almost impossible to stay ahead of the increasing mass of literature and on the other hand critically assess the presented data. A solid scientific and statistical knowledge as well as a significant amount of spare time are required to detect systematic bias and other errors in study designs, also with respect to assessing whether or not a study should be part of an individual therapeutic decision. Meta-analyses, reviews, and clinical guidelines are, therefore, of increasing importance for evidence-based therapy in clinical practice. This review is an update of the availability of external evidence for the treatment of nasal obstruction and rhinosinusitis. It becomes evident that both groups of diseases differ significantly in the availability of external evidence. Furthermore, it becomes obvious that surgical treatment options are normally based on evidence of significantly lower quality than medical treatment options.

Infraorbital and infratrochlear nerve blocks combined with general anaesthesia for outpatient rhinoseptoplasty: A prospective randomised, double-blind, placebo-controlled study

INTRODUCTION

We conducted a study to determine the efficacy of bilateral extraoral infraorbital and infratrochlear nerve blocks during outpatient rhinoseptoplasty under general anaesthesia.

PATIENTS AND METHODS

In this prospective, double-blind, randomised, controlled trial, 40 adult patients undergoing outpatient rhinoseptoplasty under general anaesthesia were assigned to receive bilateral infraorbital and infratrochlear nerve blocks with either 10mL of 0.25% levobupivacaine (Group LB) or isotonic saline (control group). Patients in Group LB received 0.1mL/kg of isotonic saline as a placebo and patients in the control group received 0.1mL/kg of morphine. The primary endpoint was total perioperative morphine consumption (intraoperative and in the post-anaesthesia care unit). The secondary endpoints were pain scores, time spent in the post-anaesthesia care unit and the outpatient ward, block-related complications and patient satisfaction.

RESULTS

The total dose of perioperative morphine was lower in Group LB than in the control group (2.5±2.8mg versus 9.5±3.5mg, respectively, P<0.001). The mean±SD or median [IQR] times spent in the post-anaesthesia care unit (60±10min and 78±33min, respectively, P<0.03) and in the outpatient ward (210 [178-223] min versus 275 [250-300] min, respectively, P<0.001) were lower in Group LB than in the control group. There were no differences between groups for other endpoints.

CONCLUSION

Bilateral extraoral infraorbital and infratrochlear nerve blocks performed with 0.25% levobupivacaine during general anaesthesia combining remifentanil and desflurane reduce the perioperative dose of morphine and the time spent in the post-anaesthesia care unit and the outpatient ward in adult patients undergoing outpatient rhinoseptoplasty.