Association Between Pain and Patient Satisfaction After Rhinoplasty

Key Points

Question  In rhinoplasty surgery is there an association between postoperative pain and perception of surgical success?

Findings  In this prospective case series survey study of 104 patients who underwent cosmetic and/or functional rhinoplasty, a statistically significant negative association was found between perception of pain and perception of outcome (breathing improvement) in purely functional rhinoplasty. In contrast, among patients who underwent rhinoplasty with simultaneous cosmetic changes, no association between pain and perception of surgical success was found.

Meaning  This prospective study highlights important results that may help guide preoperative rhinoplasty counseling because patients who are interested in purely functional improvement (without cosmetic change) may warrant additional pain-specific counseling to optimize patient satisfaction.

Importance  In light of the current opioid crisis, there exists a demonstrated need to balance adequate postrhinoplasty pain control with measured use of narcotics. If pain is inadequately controlled, patients may be unsatisfied with their elective surgical experience.

Objectives  To characterize the association between patient-reported pain outcomes, objective opioid use, and perception of surgical success.

Design, Setting, and Participants  A case series survey study was conducted from July 2018 to January 2019. Consecutive patients who underwent cosmetic and/or functional rhinoplasty by 2 facial plastic surgeons (D.A.S. and L.N.L.) at an academic medical center were surveyed 1 month after surgery.

Main Outcomes and Measures  The number of oxycodone tablets taken, patient-reported pain outcomes, number of narcotic prescription refills, and patient-reported functional and cosmetic outcomes were recorded. Perception of pain, surgical outcome, and oxycodone intake were also evaluated by sex. Demographic information and perception of surgical results were recorded. Statistical analysis was performed using STATA statistical software (version 12.0, STATA Corp). Spearman rank order correlation was used for ordinal, monotonic variables with P < .05 being considered statistically significant.

Results  Overall, 104 patients were surveyed; 6 were lost to follow-up. Of the participants included, 50 were women with a mean (SD) age of 38 (16.0) years and 48 were men with a mean (SD) age of 38 (16.7) years. Although patients were prescribed a range of 10 to 40 tablets of oxycodone, patients took a mean (SD) of 5.2 tablets (range, 0-23). There were no significant sex differences in perception of pain, perception of outcome, or narcotic use. Among patients undergoing purely functional rhinoplasty, a statistically significant negative association between perception of pain and perception of functional outcome (breathing improvement) was evident. Patients who experienced less pain than they expected had a greater perception of functional improvement (rs = −0.62, P = .001). In contrast, among patients who underwent rhinoplasty with cosmetic improvement, no association was found between pain and perception of surgical outcome (rs = 0.05, P = .64).

Conclusions and Relevance  To our knowledge, this is the first study to prospectively evaluate the association between opioid use, patient-reported pain, and perceived surgical success. These data may help guide preoperative counseling because patients who are interested purely in breathing improvement (without cosmetic change) may warrant additional pain-specific counseling to optimize patient satisfaction.

Level of Evidence  3.

Original Article

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Molecular Characterization of Lipoaspirates Used in Regenerative Head and Neck Surgery

Key Points

Question  What is the composition of lipoaspirates used for lipotransfer in the head and neck, and what is their potential for wound healing in vitro?

Findings  In this case series study of lipoaspirate samples obtained from 15 patients, adipose-derived mesenchymal stem cells were found in high purity and were able to multidifferentiate. The adipose-derived stem/stromal cells and their supernatants had proliferation- and immune-modulating properties in vitro.

Meaning  The findings suggest that lipoaspirates contain a concentration of adipose-derived stem/stromal cells that can be used for regenerative head and neck surgical procedures.

Importance  Adipose-derived mesenchymal stem cells (ASCs) have been used commonly in regenerative medicine and increasingly for head and neck surgical procedures. Lipoaspiration with centrifugation is purported to be a mild method for the extraction of ASCs used for autologous transplants to restore tissue defects or induce wound healing. The content of ASCs, their paracrine potential, and cellular potential in wound healing have not been explored for this method to our knowledge.

Objective  To evaluate the characteristics of lipoaspirates used in reconstructive head and neck surgical procedures with respect to wound healing.

Design, Setting, and Participants  This case series study included 15 patients who received autologous fat injections in the head and neck during surgical procedures at a tertiary referral center. The study was performed from October 2017 to November 2018, and data were analyzed from October 2017 to February 2019.

Main Outcomes and Measures  Excessive material of lipoaspirates from subcutaneous abdominal fatty tissue was examined. Cellular composition was analyzed using immunohistochemistry (IHC) and flow cytometry, and functionality was assessed through adipose, osteous, and chondral differentiation in vitro. Supernatants were tested for paracrine ASC functions in fibroblast wound-healing assays. Enzyme-linked immunosorbent assay measurement of tumor necrosis factor (TNF), vascular endothelial growth factor (VEGF), stromal-derived factor 1α (SDF-1α), and transforming growth factor β3 (TGF-β3) was performed.

Results  Among the 15 study patients (8 [53.3%] male; mean [SD] age at the time of surgery, 63.0 [2.8] years), the stromal vascular fraction (mean [SE], 53.3% [4.2%]) represented the largest fraction within the native lipoaspirates. The cultivated cells were positive for CD73 (mean [SE], 99.90% [0.07%]), CD90 (99.40% [0.32%]), and CD105 (88.54% [2.74%]); negative for CD34 (2.70% [0.45%]) and CD45 (1.74% [0.28%]) in flow cytometry; and negative for CD14 (10.56 [2.81] per 300 IHC score) and HLA-DR (6.89 [2.97] per 300 IHC score) in IHC staining; they differentiated into osteoblasts, adipocytes, and chondrocytes. The cultivated cells showed high expression of CD44 (mean [SE], 99.78% [0.08%]) and CD273 (82.56% [5.83%]). The supernatants were negative for TNF (not detectable) and SDF-1α (not detectable) and were positive for VEGF (mean [SE], 526.74 [149.84] pg/mL for explant supernatants; 528.26 [131.79] pg/106 per day for cell culture supernatants) and TGF-β3 (mean [SE], 22.79 [3.49] pg/mL for explant supernatants; 7.97 [3.15] pg/106 per day for cell culture supernatants). Compared with control (25% or 50% mesenchymal stem cell medium), fibroblasts treated with ASC supernatant healed the scratch-induced wound faster (mean [SE]: control, 1.000 [0.160]; explant supernatant, 1.369 [0.070]; and passage 6 supernatant, 1.492 [0.094]).

Conclusions and Relevance  The cells fulfilled the international accepted criteria for mesenchymal stem cells. The lipoaspirates contained ASCs that had the potential to multidifferentiate with proliferative and immune-modulating properties. The cytokine profile of the isolated ASCs had wound healing–promoting features. Lipoaspirates may have a regenerative potential and an application in head and neck surgery.

Level of Evidence  NA.

Original Article

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Extended Butterfly Graft for Functional and Cosmetic Correction of Saddle Nose Deformity

A middle-aged woman presented with saddle nose deformity after prior rhinoplasty. The patient related concerns of chronic nasal obstruction, which had worsened in the years since her procedure. She was also concerned about the appearance of her nose. She wished to have the deformity corrected and to have normal breathing restored.

Examination demonstrated severe nasal saddling with collapse of the cartilaginous dorsum and a deficient bony dorsum due to prior overresection. In addition, the upper lateral cartilages demonstrated an inverted-V deformity. Her nasal tip was overrotated, and the lower lateral cartilages (LLCs) were weakened, producing a pinched nasal deformity (Figure 1). Findings of the Cottle maneuver were positive. Marked internal nasal valve collapse was present, causing substantial functional deficit. Much of the septal cartilage had been resected.

Original Article

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Review of Facial Trauma Surgery: From Primary Repair to Reconstruction

There are no better authors to write about the advances in any field than those who are actively shaping it. The editors of this text combine nearly 8 decades of clinical experience to provide the most current and comprehensive approach to evaluating and managing facial trauma. True to its subtitle, this book covers everything from the first encounter with the patient with facial trauma in the emergency department all the way through final reconstruction.

The authors include increasingly relevant topics in the field, such as intraoperative imaging, virtual surgical planning, and vascularized composite allotransplantation, that previously may have been considered tangential but are now integral to modern facial trauma surgery. In our increasingly digital world, the book appropriately includes an easy-to-use electronic book, which includes a collection of high-quality videos that walk the viewer through many of the evaluation methods, clinical examination findings, and surgical techniques that are described in the text.

Original Article

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Changes in Opioid Prescribing Habits for Patients Undergoing Rhinoplasty and Septoplasty

Key Points

Question  Has there been a decrease in the amount of opioids prescribed to patients following rhinoplasty and/or septoplasty since the Vermont opioid prescribing legislation took effect on July 1, 2017, and if so, are patients experiencing more postoperative pain?

Findings  In this case-control study of 80 adults, the mean number of opioid pills prescribed to patients after the Vermont opioid prescribing legislation decreased from 17.5 to 9.7, which was associated with a statistically significant decrease in the mean morphine milligram equivalents that were prescribed (130.9 to 73.2). There was no statistically significant difference in the number of postoperative telephone calls for pain, second prescriptions, or increased complaints of pain at the postoperative visit.

Meaning  Since there was no increase in patients’ complaints about postoperative pain or a need for a second prescription after surgery, the decreased amount of opioids prescribed seems sufficient for pain control.

Importance  Opioid prescriptions have increased substantially over the last 2 decades, contributing to the opioid epidemic. Physician practices and legislative changes play a key role in decreasing prescription opioid use.

Objective  To evaluate changes in opioid prescribing habits for patients undergoing rhinoplasty and/or septoplasty before and after the adoption of new opioid legislation.

Design, Setting, and Participants  This single-institution case-control study examined opioid prescribing habits for 80 patients who were undergoing rhinoplasty and septoplasty with or without turbinate reduction at the University of Vermont between March 2016 and May 2018. Patients were excluded if they underwent concomitant endoscopic sinus surgery or were younger than 14 years. Patients were divided by surgery date before or after legislative changes on July 1, 2017.

Exposures  Rhinoplasty and septoplasty with or without turbinate reduction.

Main Outcomes and Measures  Patient demographics and opioid prescriptions were recorded. Patients were evaluated if they reported pain during follow-up, called the office, or received a second prescription. The Vermont Prescription Monitoring System was queried to determine if opioid prescriptions were filled within 30 days of the procedure. The 2 groups were compared to test the hypothesis that opioid prescriptions had decreased after legislative changes.

Results  Of a total of 80 participants, the mean (SD) age in the before (15 women [37.5%]) and after (16 women [40.0%]) groups were 41.4 years and 40.6 years, respectively. There was a statistically significant decrease in the number of pills prescribed to the after group (17.5 to 9.7; P < .001) as well as a decrease in the morphine milligram equivalents that were prescribed (130.9 to 73.2; P < .001). There was no statistical difference in the number of postoperative telephone calls for pain, second prescriptions, or increased complaints of pain at the postoperative visit.

Conclusions and Relevance  Recent laws in Vermont regarding opioid prescribing were implemented in 2017 to curb the ongoing opioid epidemic. Our observations of patients undergoing septoplasties and rhinoplasties found a significant reduction in opioid prescriptions. This was not associated with an increase in patient complaints about postoperative pain or the need for a second prescription after surgery. This shows that we may safely be able to decrease the number of narcotic medications that we prescribe.

Level of Evidence  3.

Original Article

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Investigation of the Longevity of the Endoscopic Midface Lift

Key Points

Question  Is the endoscopic preperiosteal midface lift an effective technique, and do the results last?

Findings  In this retrospective review, there was a significant, objective improvement (decrease) in midfacial height after the endoscopic preperiosteal midface lift that persisted for at least 5 years and up to 15 years. Validated regional and global aesthetic scales demonstrated lasting improvement in midface appearance over time.

Meaning  There is a persistent improvement in midfacial height after the endoscopic preperiosteal midface lift that is achieved without complete disruption of the midfacial ligaments.

Importance  To our knowledge, until now, the efficacy and durability of the transtemporal endoscopic preperiosteal midface lift has not been reported in the literature.

Objective  To determine the efficacy and longevity of the endoscopic preperiosteal midface lift using objective measurements and validated aesthetic scales.

Design, Setting, and Participants  This retrospective review included patients 18 years or older who were treated for aging midface by endoscopic midface lift by the senior author (A.E.W.) between June 2000 and August 2016. Patients were categorized based on length of follow-up into 3 groups: (1) short-term (1-3 years), (2) intermediate-term (3-5 years), and (3) long-term (>5 years).

Interventions or Exposures  Endoscopic preperiosteal midface lift.

Main Outcomes and Measures  (1) Objective measurements of midfacial height (the width of the interzygomatic distance of the midface to the medial canthus [WIZDOM-MC]), (2) validated regional aesthetic scales, and (3) global aesthetic scoring systems measured preoperatively, 3 to 6 months postoperatively, and at the most recent follow-up visit.

Results  Adult patients 18 years or older (median [range] age, 59 [31-79] years) who were treated for aging midface by undergoing an endoscopic midface lift were included in this study. The medical records of 143 patients were reviewed (135 women and 8 men). The endoscopic midface lift resulted in objective improvement in midfacial height. The median WIZDOM-MC decreased by 3.4 mm after the endoscopic midface lift (interquartile range [IQR], 2.3-4.4 mm; P < .001), thus shortening the elongated lower eyelid. At 5 to 15 years after surgery, there was a sustained decrease in median WIZDOM-MC of 2.1 mm (IQR, 0.8-3.1 mm; P < .001). Improvement in the infraorbital hollow was also sustained in patients at more than 5 years’ follow-up (IQR, 0-1.0; P < .001). Improvements in upper cheek fullness and lower cheek fullness were maintained at 3 to 5 years and tended to be at baseline at more than 5 years. Global aesthetic improvement scores remained significantly improved at 5 to 15 years’ follow-up.

Conclusions and Relevance  There is a significant, objective improvement in midfacial height after the endoscopic midface lift that persists for up to 15 years. Validated midfacial scales and global aesthetic scoring systems demonstrate sustained improvement in midface appearance over time. Surgery that minimally disrupts the zygomatic and orbicularis retaining ligaments can provide long-lasting aesthetic improvements.

Level of Evidence  4.

Original Article

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Outcomes of Extracorporeal Septoplasty and Its Modifications for L-Strut Septal Deviation

Key Points

Question  Is extracorporeal septoplasty (including modified techniques) effective in the treatment of severe L-strut septal deviation?

Findings  In this meta-analysis of 31 studies, 5 reporting change in Nasal Obstruction Symptom Evaluation scores indicate both a clinical and statistically significant improvement of nasal obstruction, but heterogeneity was high.

Meaning  Although extracorporeal septoplasty and its modifications may be effective methods to reduce nasal airway obstruction for deviations of the septal L-strut, standardized reporting of outcomes and sound methodology of study design is needed.

Importance  While extracorporeal septoplasty (ECS) and its modifications have been previously studied, to our knowledge, no systematic review of surgical outcomes and complications of this technique has been performed.

Objective  To evaluate the evidence of surgical outcomes and complications of ECS (including modified techniques) to treat severe L-strut septal deviation defined as deviation within 1.0 cm of the caudal or dorsal septum.

Data Sources  MEDLINE, Embase, CINAHL, CENTRAL, Scopus, and Web of Science databases and reference lists were searched from inception to April 2018 for clinical and observational studies. Search terms included extracorporeal, septoplasty, and septum.

Study Selection  Selection criteria were defined according to the population, intervention, comparison, and outcome framework. Relevant studies were selected by 2 independent reviewers based on abstracts and full texts.

Data Extraction and Synthesis  Data were extracted using standardized lists chosen by the authors according to Cochrane Collaboration guidelines. Data were collected and synthesized with ranges reported, as well as assessment of bias and heterogeneity when applicable. Analysis started in February 2019.

Main Outcomes and Measures  Outcomes assessed included functional nasal airway improvement by objective measurements and subjective measurements (Nasal Obstruction Symptom Evaluation [NOSE] and visual analog scale scores); complications including bleeding, infection, dorsal irregularities, and other functional or cosmetic deficits; and as revision surgery rates.

Results  Of 291 records initially obtained, 31 were considered relevant after review according to PRISMA guidelines. All studies except 1 randomized clinical trial (3.2%) were observational in nature, with 21 retrospective studies (67.7%) and 9 prospective studies (29.0%). Conventional ECS was performed in 16 studies (51.6%), and modified ECS was performed in 15 studies (48.4%). The sample size varied from 10 to 567, and the mean age varied from 22.5 to 46 years. Of 31 studies, 14 (45%) were of good methodology. Meta-analysis was performed on 5 studies reporting change in NOSE scores, with pooled effect of −60.0 (95% CI, −67.8 to −52.2) points, but heterogeneity was high, with I2 = 96%. When comparing complications between modified and conventional ECS, the relative risk for infections was 0.95 (95% CI, 0.34-2.7); for bleeding, 0; for nasal dorsal irregularities, 0.29 (95% CI, 0.16-0.53); for other cosmetic complications, 4.3 (95% CI, 0.87-21.1); for other functional complications, 0.47 (95% CI, 0.20-1.1); and for revision operations, 1.4 (95% CI, 0.83-2.3).

Conclusions and Relevance  Of the 31 studies included in this systematic review, less than half were of good methodology, and a significant level of heterogeneity was found regarding type of outcome measure used and reporting of complications. To improve the level of evidence, better study methodology, standardization of surgical outcomes measures, and reporting of complications are needed.

Original Article

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A Practical Precaution Relevant to Facial Injections

To the Editor We read with interest the case report by Sebaratnam et al.1 Recently a new type of white adipose tissue (WAT), dermal WAT (dWAT), has been identified and is recognized as playing a role in skin processes such as hair follicle growth, thermoregulation, wound healing, and signal transmission.2 This layer lies in the reticular dermis encasing mature hair follicles.3 In addition this fat compartment is associated with specific adipose stem cell phenotypes (CD24+), distinctly different from subcutaneous WAT, suggesting unique functions of this fat depot.2 Dermal WAT is organized in cone-like structures (often identified in deeper skin graft donor areas) and is particularly associated with scarring when exposed at that depth.4 Importantly, dWAT appears to have a unique relationship with the hair follicle and dynamic reciprocity is seen between these 2 anatomic regions through WNT signaling pathway and its major mediator cadherin-associated protein β 1 (CTNNB1 or β-catenin).5 Research of this signaling has revealed that dWAT is directly stimulated in unison with anagen and regresses through telogen.5 This is a logical relationship when one considers the evolutionary function both regions serve in relation to thermoregulation.

Original Article

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A Practical Precaution Relevant to Facial Injections—Reply

In Reply We greatly appreciate the insights provided by Widgerow regarding a potential mechanism through which deoxycholic acid treatment could lead to a telogen effluvium.1 The hair follicle unit intimately interacts with dermal white adipose tissue (dWAT). As the hair follicle moves through the anagen, catagen, and telogen phases, there is progressive rearrangement of dermal adipocytes as well as variation in the thickness of the dWAT.2 The expansion of the dWAT follows the burgeoning of anagen hair follicles mediated by multiple signaling pathways including hedgehog, Shh, bone morphogenetic proteins, and WNT. Similarly, catagen causes regression of the dWAT, in part through lipolysis.3 Defects in the generation of immature adipocytes in the dWAT have previously been proposed to block follicle stem cell activation.4 The inflammatory response induced by deoxycholic acid may cause such a defect, with the panniculitis at the injection site leading to a reduction in the availability of immature adipocytes. This, in turn, could potentially deplete the signals propelling hair follicle units into the anagen phase, with a relative preponderance of follicles in catagen and telogen. Arresting this transition through the hair follicle cycle could lead to the telogen effluvium observed clinically. As the panniculitis abates over a period of weeks, adipocytes may be able to regain their physiological functioning, which would account for the reversal of the telogen effluvium that is observed in most patients. Our hypothesis is speculative, but offers a biologically plausible mechanism to account for the clinical changes observed in this emerging therapy.

Original Article

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The Tripod Concept of the Upper Nasal Third

Key Points

Question  Can we describe a concept related to the well-known tripod theory with extrapolation to the upper nasal third as it pertains to cosmetic rhinoplasty?

Findings  In this study of 10 lay individuals and 10 rhinoplasty-trained individuals who evaluated manipulated photographs of 3 women who had not had surgery, lay individuals were more likely to choose an ideal nasal profile based on surrounding facial architecture, while individuals with rhinoplasty training tended to separate the ideal nose from the surrounding face (statistically significant). Projection was recognized as being altered by both rhinoplasty-trained and lay individuals (although not statistically significant), whereas subjective changes in rotation were significantly more elusive to the lay individual (statistically significant).

Meaning  Simple alteration of the upper nasal third can result in an improved nasal profile without specific alteration of tip architecture.

Importance  The tripod theory of the upper nasal third parallels the concept of the well-known nasal tip tripod. We are evaluating the idea that one can simply alter the upper nasal angles reliably without the complex physics associated with the nasal tip to achieve a pleasing cosmetic result.

Objective  To describe a concept related to the well-known tripod theory with extrapolation to the upper nasal third as it pertains to cosmetic rhinoplasty.

Design, Setting, and Participants  This is a prospective study in which lateral photographs of 3 women who had not undergone surgery (age range, 20-50 years) were selected for digital manipulation of the nasal radix with subsequent alteration of the nasofrontal and nasofacial angles via imaging software. The altered images were analyzed by 20 blinded individuals between July 2009 and June 2017 to assess how changes in the height of the nasal dorsum and radix alone affect nasal appearance and the perception of ideal nasal angles. The study took place at a tertiary center, and the patients chosen for evaluation had nasal architecture that only required subtle changes rather than structure that demonstrated glaringly obvious overprojection or underprojection and rotation or a large dorsal bony hump. Analysis began June 2018.

Main Outcomes and Measures  Overall trend in recognition of objective and subjective alterations in projection and rotation for the rhinoplasty- and non–rhinoplasty-trained evaluators.

Results  Ten medically trained and 10 lay individuals (13 women [65%]; mean [SD] age, 38 [8.6] years) analyzed digitally manipulated photographs of 3 women (age range, 20-50 years) who had not undergone surgery. Lay individuals were more likely to choose an ideal nasal profile based on surrounding facial architecture (28 of 30 [93%]), while individuals with rhinoplasty training tended to separate the ideal nose from the surrounding face (18 of 30 [60%]) (P < .001). Projection was consistently and accurately recognized as being altered by both rhinoplasty-trained and lay individuals (95% CI, −0.18 to 0.38; P = .60 and 95% CI, −0.26 to 0.33; P > .99 for most and least projected), whereas subjective changes in rotation were significantly more elusive to the lay individual (95% CI, −0.04 to 0.52; P = .12 and 95% CI, 0.11 to 0.65; P = .01 for most and least rotated).

Conclusions and Relevance  Predictable and consistent aesthetic results are the primary aim in rhinoplasty. Alterations in the upper nasal tripod are more reliable with extrapolated healing than with the tripod of the nasal tip. Ultimately, simple alteration of the upper nasal third can result in an improved nasal profile without specific alteration of tip architecture.

Level of Evidence  NA.

Original Article

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