Hamilton, Grant

Importance: Predicting nasal soft tissue envelope (STE) thickness is an important component of the preoperative evaluation for rhinoplasty that presently lacks validated tools. Objective: Assess for patient facial features and factors that can help predict nasal STE thickness. Design, Setting, and Participants: Retrospective review and prospective assessment conducted at an academic tertiary referral center. This study included 190 adult patients and four expert raters. The patients had high-resolution maxillofacial CT scans and standardized facial photographs on file and did not have a history of nasal fracture, septal perforation, rhinoplasty, or other surgery or medical conditions altering nasal form. Main Outcomes and Measures: Assess each face for features that could help predict nasal STE thickness: sebaceous quality of skin, visibility of nasal tip cartilages, presence of freckles, presence of telangiectasias, Fitzpatrick skin type, patient age, sex, and body mass index (BMI). Measure actual nasal STE thickness using high-resolution CT scans. Analyze which facial features and patient factors help predict nasal STE thickness. Results: Pearson correlations were calculated between actual nasal STE thickness and patient facial features and factors. These showed that more sebaceous skin, telangiectasias, higher Fitzpatrick skin type, male sex, and higher BMI were associated with a thicker nasal STE. Increased visibility of nasal tip cartilages, freckles, lower Fitzpatrick skin type, female sex, and lower BMI were associated with a thinner nasal STE. Conclusions and Relevance: There are patient facial features and factors that can help surgeons predict nasal STE thickness before rhinoplasty. An accurate prediction of nasal STE thickness can improve preoperative planning for rhinoplasty, allowing implementation of pre-, intra-, and post-operative treatments to optimize the nasal STE, which may ultimately improve patient outcomes and satisfaction.

AbstractSaddle nose deformities are among the most challenging problems in rhinoplasty. These patients have often had previous surgery and may have complicated medical histories. Reconstructing the septum is a necessary prerequisite to correcting the contour of the nose. With proper planning and thoughtful execution, patients suffering from disfiguring saddle noses can be safely operated on—even those with vasculitic diseases.

AbstractThis paper describes a method for setting up an automated and reliable digital profileplasty technique for use in Adobe Photoshop. Digital imaging software can be used to extrapolate more exact measurements during profileplasty. The digital profileplasty technique is helpful to provide intraoperative guidance during surgery.

Background: The main objective of this study was to prospectively analyze which personality traits, clinical psychiatric states, and patient decision-making characteristics predict who will be less satisfied after facial plastic surgery. Methods: This prospective study enrolled 60 adult subjects into one of three groups: aesthetic, functional, and reconstructive facial plastic surgery procedures (n = 20 in each group) from November of 2011 to February of 2016. Self-report surveys of personality traits (i.e., NEO Personality Inventory-Revised), psychiatric state (i.e., Patient Health Questionnaire, Generalized Anxiety Disorder, Health Anxiety Inventory–Short Form), and decision-making characteristics (maximizer/satisficer survey) were given during the preoperative clinic visits. In postoperative follow-up, satisfaction questionnaires at 3, 6, and 12 months were administered. Data analysis examined associations between patient satisfaction, decision-making characteristics, and psychiatric variables. Results: Bivariate analyses showed that maximizer/satisficer decision-making style was significantly related to patient satisfaction scores in the year following surgery. This difference reached statistical significance at 6 months and remained a strong trend at 12 months. Patients who were less than extremely satisfied at both postoperative time points were more likely to portray the maximizer decision-making style. No other variables were associated with patient satisfaction at any time point. Maximizer/satisficer survey scores were not associated with self-reports of depression, anxiety, or illness anxiety. Mean scores on the maximizer/satisficer survey did not differ among the aesthetic, functional, and reconstructive groups. Conclusions: The maximizer/satisficer survey captures an aspect of patient care not traditionally measured by standard clinical psychometric screening tools to help predict satisfaction. A short questionnaire targeting consumer decision-making may be a helpful tool for preoperative counseling.

Background: In this paper, the author describes a novel step-by-step setback procedure for correcting protruding lobules; the success of correcting protruding lobules depends on the nature and severity of the auricular lobule deformity. Although the auricular lobules occupy small areas on either side of the head, protruding or misshapen lobules exert a significant and sometimes exaggerated disfiguring influence on the otherwise aesthetically pleasing appearance of the ears. Because the lobule is a soft structure without a cartilage skeleton, the correction of a protruding ear and lobule is always a challenge. Methods: Protruding lobule abnormalities stem from deformities of the cauda helicis (cartilaginous helical tail) of the auricular lobule, soft tissue, and/or a shortage of anterior skin; however, the abnormalities are usually a combination of all of the above. Therefore, surgical procedures should address all of the causes of lobule deformity and preserve as much tissue and blood supply as possible. Achieving a successful intervention depends on reducing the tension that affects the entire lobule. Results: This is a retrospective analysis of 660 patients who had otoplasty performed by the first author between January 2010 and December 2017. Correction of the ear lobule was needed in 398 (60.3%) patients. Of these, 44.6% patients were male, 55.4% female and the average age was 9 years (range 4-18 years). In this patient cohort, 356 (89.4%) required bilateral and 42 (10.5%) unilateral ear lobule correction. Standardized pre- and postoperative images were recorded for each patient. Conclusion: The goal of a setback procedure is a natural and harmonious auricular lobule appearance that is achieved through simple, optimal surgery that addresses all of the features of the auricular anatomy.

Importance Preoperative assessment of nasal soft-tissue envelope (STE) thickness is an important component of rhinoplasty that presently lacks validated tools. Objective To measure and assess the distribution of nasal STE thickness in a large patient population and to determine if facial plastic surgery clinicians can predict nasal STE thickness based on visual examination of the nose. Design, Setting, and Participants This retrospective review and prospective assessment of 190 adult patients by 4 expert raters was conducted at an academic tertiary referral center. The patients had high-resolution maxillofacial computed tomography (CT) scans and standardized facial photographs on file and did not have a history of nasal fracture, septal perforation, rhinoplasty, or other surgery or medical conditions altering nasal form. Data were analyzed in March 2019. Main Outcomes and Measures Measure nasal STE thickness at defined anatomic subsites using high-resolution CT scans. Measure expert-predicted nasal STE thickness based on visual examination of the nose using a scale from 0 (thinnest) to 100 (thickest). Results Of the 190 patients, 78 were women and the mean (SD) age was 45 (17) years. The nasal STE was thickest at the sellion (mean [SD]) (6.7 [1.7] mm), thinnest at the rhinion (2.1 [0.7] mm), thickened over the supratip (4.8 [1.0] mm) and nasal tip (3.1 [0.6] mm), and thinned over the columella (2.6 [0.4] mm). In the study population, nasal STE thickness followed a nearly normal distribution for each measured subsite, with the majority of patients in a medium thickness range. Comparison of predicted and actual nasal STE thickness showed that experts could accurately predict nasal STE thickness, with the highest accuracy at the nasal tip ( r , 0.73; prediction accuracy, 91%). A strong positive correlation was noted among the experts’ STE estimates ( r , 0.83-0.89), suggesting a high level of agreement between individual raters. Conclusions and Relevance There is variable thickness of the nasal STE, which influences the external nasal contour and rhinoplasty outcomes. With visual analysis of the nose, experts can agree on and predict nasal STE thickness, with the highest accuracy at the nasal tip. These data can aid in preoperative planning for rhinoplasty, allowing implementation of preoperative, intraoperative, and postoperative strategies to optimize the nasal STE, which may ultimately improve patient outcomes and satisfaction. Level of Evidence NA .

AbstractThe nasal dorsum is an important component of a rhinoplasty and may be the primary motivation for seeking surgery. The nasal dorsum is a complex three-dimensional shape that is shrouded by local anesthetic and edema during surgery. This makes an accurate assessment of the surgical changes challenging. Complications related to dorsal modification include imbalances from over- or underresection of the structures of the nasal dorsum, inadequate or overaugmentation, an open-roof deformity, pollybeak, saddle nose, inverted-V, warped cartilage, visible grafts, contour problems, graft malposition, and extrusion. This review will discuss the common problems that can occur with dorsal modification during rhinoplasty.