Clarification of a Suspension Technique for Unstable Nasal Bones—Reply

In Reply Many thanks for the letter and comments relating to the recently published Surgical Pearl.1 We are very grateful to you for drawing our attention to the work of Maliniac,2 of which the authors were unaware. I remember during my higher surgical training once being told that if I thought I had had an original idea, I should check the German literature. Although that is not completely accurate in this case, the point is well made.

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Is a rhinoplasty right for you?

Ongoing dissatisfaction with one or more physical features of your nose, as well as functional or aesthetic problems due to injury or trauma, are just some of the common reasons why patients decide to undergo rhinoplasty surgery.

Commonly known as a “nose job,” rhinoplasty consistently ranks among the top ten most sought-after plastic surgery procedures. While it may seem like a straightforward surgery, rhinoplasty requires a high level of experience and training to produce superior quality results. If you do decide that a rhinoplasty is right for you, it is important to seek a qualified plastic surgeon that has an eye for aesthetics and detail.

What is rhinoplasty?

Your nose is composed of cartilage, soft tissue and small bones, all of which work together to create the shape and appearance of your nose. Any changes made to any one of these components can significantly alter the appearance of your nose, which is why rhinoplasty can be an intricate, complicated procedure.

During rhinoplasty surgery, your plastic surgeon works on, and with, these individual parts, utilizing a range of techniques to alter the nose both aesthetically and functionally. The techniques used for your rhinoplasty will depend on both your personal goals as well as on the natural anatomical makeup of your nose and any previous trauma or surgery that might have occurred there.

What are the reasons to consider a rhinoplasty?

To change the way your nose looks

Many people considering rhinoplasty want to change the shape and appearance of their nose, which is known as cosmetic rhinoplasty. Depending on the anatomical makeup of your nose and the look one is looking for, cosmetic rhinoplasty may only involve minor changes in structure that are reflected in visibly noticeable improvements.

However, in some cases, altering multiple components of the internal structure of the nose will be necessary to achieve the look you want. Cosmetic rhinoplasty is typically done to change the overall shape of the nose, making it wider, larger, narrower or smaller – with the goal being to improve the overall proportion and balance of the face. To that end, the tip of your nose can be altered as well.

To improve your breathing

Injuries, genetic abnormalities and growths inside the nose can impede the flow of air into the nose and make breathing difficult. Under these conditions, rhinoplasty can include work on the passageways that the air takes and the changes in shape or structure of the nose are designed so air can flow through normally.

This type of procedure will likely involve altering the septum. The septum is the long, large piece of cartilage tissue that runs along the very center of the nose. Changing the position or size of the septum typically is considered a medically necessary surgery because the goal entails a marked improvement in function, and may be covered by health insurance. Sometimes, work on the soft tissue inside the nostril can improve the airflow by widening the space between the septum and the sidewalls and soft tissue of the nose, commonly referred to the nasal valve area.

To complement your ethnicity

Ethnic rhinoplasty is an approach that changes the appearance of the nose, but in doing so, remains true to the patient’s ethnicity – enhancing one’s nose and balancing your features without sacrificing the various nasal features that characterize different ethnicities. The objective is to give an individual a beautiful, natural-looking nose that remains in harmony with the rest of the face and unique features.

Are you a good candidate for rhinoplasty?

The decision to undergo rhinoplasty is a personal one, based on dissatisfaction with certain features of one’s nose and the desire for a different look. The presence of one or more undesired nasal features may well make you a good candidate for rhinoplasty, some common reasons include:

  • A crooked septum that makes the nose appear off-center
  • A bump on the bridge of the nose
  • A wide nose
  • A thick nasal tip, asymmetric, or an overly projecting, or even drooping, tip
  • Cosmetic irregularities due to injury or trauma

Who should you see for a rhinoplasty?

While there are many surgeons who might be technically qualified to perform rhinoplasty procedures, you want to entrust the alterations of the focal point of your face to someone with extensive experience and training in the procedure. You want to make certain that the plastic surgeon you choose possesses the level of expertise necessary to deliver the superior results you expect.

Considering how precise this procedure can be, it’s especially important to choose a plastic with extensive training and experience in aesthetic surgery of the face – being a member of the American Society of Plastic Surgeons and board certified by the American Board of Plastic Surgery helps assure one that the surgeon is qualified and undertakes continual education of the procedure.

The views expressed in this blog are those of the author and do not necessarily reflect the opinions of the American Society of Plastic Surgeons.

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New Safety Eyewear

Wolters Kluwer Health

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Measuring Outcomes of Mohs Defect Reconstruction Using Eye-Tracking Technology

Key Points

Question  Does surgical reconstruction of Mohs facial defects normalize facial attention?

Findings  This case series finds that Mohs defects alter causal observer attention, distracting from other important facial features such as the eyes; the degree of distraction is a factor of defect size and location, with larger and more centrally located defects drawing the most attention. Surgical reconstruction is associated with normalized attentional distraction for many patients, restoring a normal pattern of observer attention.

Meaning  Eye tracking allows objective measurement of how Mohs defects and their reconstruction change facial attention; while facial defects are associated with altered normal facial attention, reconstructive surgery has the potential to normalize facial attention in many cases.

Importance  Objectively measuring how Mohs defect reconstruction changes casual observer attention has important implications for patients and facial plastic surgeons.

Objective  To use eye-tracking technology to objectively measure the ability of Mohs facial defect reconstruction to normalize facial attention.

Design, Setting, and Participants  This observational outcomes study was conducted at an academic tertiary referral center from January to June 2016. An eye-tracking system was used to record how 82 casual observers directed attention to photographs of 32 patients with Mohs facial defects of varying sizes and locations before and after reconstruction as well as 16 control faces with no facial defects. Statistical analysis was performed from November 2018 to January 2019.

Main Outcomes and Measures  First, the attentional distraction caused by facial defects was quantified in milliseconds of gaze time using eye tracking. Second, the eye-tracking data were analyzed using mixed-effects linear regression to assess the association of facial defect reconstruction with normalized facial attention.

Results  The 82 casual observers (63 women and 19 men; mean [SD] age, 34 [12] years) viewed control faces in a similar and consistent fashion, with most attention (65%; 95% CI, 62%-69%) directed at the central triangle, which includes the eyes, nose, and mouth. The eyes were the most visually important feature, capturing a mean of 60% (95% CI, 57%-64%) of fixation time within the central triangle and 39% (95% CI, 36%-43%) of total observer attention. The presence of Mohs defects was associated with statistically significant alterations in this pattern of normal facial attention. The larger the defect and the more centrally a defect was located, the more attentional distraction was observed, as measured by increased attention on the defect and decreased attention on the eyes, ranging from 729 (95% CI, 526-931) milliseconds for small peripheral defects to 3693 (95% CI, 3490-3896) milliseconds for large central defects. Reconstructive surgery was associated with improved gaze deviations for all faces and with normalized attention directed to the eyes for all faces except for those with large central defects.

Conclusions and Relevance  Mohs defects are associated with altered facial perception, diverting attention from valuable features such as the eyes. Reconstructive surgery was associated with normalized attentional distraction for many patients with cutaneous Mohs defects. These data are important to patients who want to know how reconstructive surgery could change the way people look at their face. The data also point to the possibility of outcomes prediction based on facial defect size and location before reconstruction. Eye tracking is a valuable research tool for outcomes assessment that lays the foundation for understanding how reconstructive surgery may change perception and normalize facial deformity.

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What’s behind the cost of Botox and injectable fillers?

cost of Botox and injectable fillers

The price of popular cosmetic treatments like Botox and dermal fillers is a factor that many people take into consideration before booking their appointment. While you certainly want to choose a provider and treatment option that fits within your budget, you also need to be careful of providers who lack sufficient training and expertise and who could put your health and safety at risk.

To help you get the most bang for your buck while ensuring you’re getting an authentic product administered by a trained professional, consider these tips.

How much do fillers and Botox cost?

Knowing what the average cost of fillers and Botox in your area can help you gauge whether or not a certain provider’s price is fair and/or suspiciously low. According to 2018 pricing data from the ASPS, the average cost of hyaluronic acid fillers is $682 per syringe. Most people require more than one syringe to achieve the desired results.

Botox, on the other hand, is measured in units and typically costs around $10 to $15 per unit. An average dosage of 30-40 units might be used to treat the forehead and eye area, for example, making the total cost around $300 to $600.

Keep in mind, however, that these averages can vary based on your location. So, do your research by comparing prices from a few reputable providers in your area before making a decision.

If you are working cosmetic treatments into your recurring budget, you’ll also want to factor in approximately how long each treatment will last before requiring a touch-up visit. In general, hyaluronic acid fillers can last anywhere from 6 to 18 months, while Botox usually lasts 3 to 6 months. So, while the upfront costs of fillers, for example, might seem higher, know that you may not need another treatment for a year or more.

Why “bargain shopping” for Botox isn’t your best bet

When pricing out an injectable filler or Botox treatment, consider that the cost of the product is only one component of the total price. You’re also paying for a trained, certified and experienced professional to properly administer those products to safely achieve beautiful, natural-looking results.

For this reason, bargain hunting for Botox, fillers and other cosmetic treatments isn’t recommended. It is unfortunately still common to hear horror stories of untrained, unlicensed providers offering cosmetic services at a steep discount and causing long-lasting damage to patients. This is a key reason why choosing a board-certified plastic surgeon, or a medical spa facility operated by a board-certified plastic surgeon, is one of the most important decisions you can make when shopping for injectables.

A few red flags to look for when choosing a filler or Botox provider include:

  • Prices that seem too good to be true
  • Lack of information or before and after pictures on their website or in their office
  • Refusal to show you the product packaging or labeling
  • A dirty, disorganized office or clinic

It is also worth mentioning that while “Botox parties” have become popular, these events are not a safe way to receive injections unless they are carefully administered in a clinic environment. Botox, fillers and other professional cosmetic treatments should always be performed in a sterile medical office and by a trained professional.

How to save on Botox and fillers the safe way

Fortunately, there are many different ways to help make the cost of fillers and Botox more affordable while still getting safe, high-quality results. The best way to save is to look for promotions from your trusted provider – again, being wary of low-ball price offers from questionable sources. Some plastic surgeons will offer a discount if you purchase multiple syringes or units, or discounts when packaging surgical and nonsurgical services. Others may have rewards or loyalty programs that make treatments more affordable over time.

Another option is to discuss financing during your consultation. Some offices may offer financing options so that you can pay for your treatment in smaller chunks over a longer period of time, rather than paying in one lump sum upfront.

If the cost of fillers or Botox is a concern for you, discuss your specific goals with a board-certified plastic surgeon and don’t be afraid to be honest about your budget. Working together, you can find the right treatment options that will help you look refreshed without breaking the bank.

The views expressed in this blog are those of the author and do not necessarily reflect the opinions of the American Society of Plastic Surgeons.

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New Imaging Technology

Wolters Kluwer Health

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Spontaneity Assessment in Dually Innervated Gracilis Smile Reanimation Surgery

Key Points

Question  Can a video time-stamping method be used to measure spontaneity of smile after dually innervated gracilis smile reanimation surgery?

Findings  In this cohort study of 25 patients treated with dually innervated gracilis free muscle transfers vs 24 patients treated with masseteric nerve–driven transfers (n = 11) or cross-face nerve graft–driven gracilis (n = 13), a spontaneous smile was present in a median of 33% of smiles, which was more than was present in masseteric nerve–driven transfers (20%) but less than in cross-face nerve graft–driven smile reanimation surgery (75%).

Meaning  Dual innervation may improve synchronicity compared with masseteric nerve transfer but not to the level of cross-face nerve graft–driven gracilis free muscle transfer.

Importance  Surgeons have sought to optimize outcomes of smile reanimation surgery by combining inputs from nerve-to-masseter and cross-face nerve grafts. An objective assessment tool could help surgeons evaluate outcomes to determine the optimal neural sources for smile reanimation.

Objective  To evaluate the use of a novel video time-stamping method and standard outcome measurement tools to assess outcomes of facial reanimation surgery using various innervation strategies.

Design, Setting, and Participants  Cohort study assessing the outcomes of dually innervated gracilis free muscle transfers vs single-source innervated gracilis transfer performed at a tertiary care facial nerve center between 2007 and 2017 using a novel, video time-stamping spontaneity assessment method. The statistical analyses were performed in 2018.

Interventions  Dually innervated gracilis free muscle transfers or single-source innervated gracilis transfer.

Main Outcomes and Measures  Spontaneous smiling was assessed by clinicians and quantified using blinded time-stamped video recordings of smiling elicited while viewing humorous video clips.

Results  This retrospective cohort study included 25 patients (12 men and 13 women; median [range] age, 38.4 [29.3-46.0] years) treated with dually innervated gracilis free functional muscle graft for unilateral facial palsy between 2007 and 2017. Smile spontaneity assessment was performed in 17 patients and was compared with assessment performed in 24 patients treated with single-source innervated gracilis transfer (ie, nerve-to-masseter–driven or cross-face nerve graft–driven gracilis [n = 13]) (demographic data not available for NTM and CFNG cohorts). The use of time-stamped video assessment revealed that spontaneous synchronous oral commissure movement in a median percentage of smiles was 33% in patients with dually innervated gracilis (interquartile range [IQR], 0%-71%), 20% of smiles in patients with nerve-to-masseter–driven gracilis (IQR, 0%-50%), and 75% of smiles in patients with cross-face nerve graft–driven gracilis (IQR, 0%-100%). Clinicians graded smile spontaneity in dually innervated cases as absent in 40% (n = 6 of 15), trace in 33% (n = 5 of 15) and present in 27% (n = 4 of 15). No association was demonstrated between clinician-reported spontaneity and objectively measured synchronicity.

Conclusions and Relevance  Dually innervated gracilis free muscle transfers may improve smile spontaneity compared with masseteric nerve–driven transfers but not to the level of cross-face nerve graft–driven gracilis transfers. Quantifying spontaneity is notoriously difficult, and most authors rely on clinical assessment. Our results suggest that clinicians may rate presence of spontaneity higher than objective measures, highlighting the importance of standardized assessment techniques.

Level of Evidence  4.

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Finding the right plastic surgeon for you

finding the right plastic surgeon for you

Plastic surgery has come a long way in the decades since it first became popular. Not only have plastic surgery techniques advanced in sophistication and safety, but both men and women have also become much more comfortable with the idea of enhancing their appearance via plastic surgery.

In fact, plastic surgery procedures like breast augmentation and liposuction are consistently rated as the most popular surgeries worldwide. In 2018 alone, plastic surgeons in the United States saw over 250,000 patients for each procedure.

If you’ve decided to take the plunge, you’ve probably spent a lot of time wondering how to find a good plastic surgeon. Even if you perform an internet search for phrases like “find the best plastic surgeon in Seattle” or “the best plastic surgeons near me,” there are likely dozens of options for you.

Finding the right plastic surgeon for you

The truth of the matter is that there is no “one size fits all” practice or surgeon. Even if you’re getting the exact same breast implants as your neighbor, you may find that her surgeon may not feel like the right fit for you, and that’s okay. Plastic surgery can be a fantastic and positive experience, and potentially life-changing, so remember not to rush the process. It’s also a very individualized experience, so what makes sense for your neighbor may not make sense for you. Experienced surgeons understand this and will not pressure you into making a decision or rush you into a procedure before you’re ready.

There are several criteria that you can use to judge whether or not a particular surgeon is right for you and your procedure. Finding a qualified plastic surgeon can be easier when you look for these minimum criteria:

Look for board certification in plastic surgery

Any plastic surgeon who ends up on your short list should be board-certified by the American Board of Plastic Surgery (ABPS). In fact, before you go through the process of scheduling a consultation, you’ll want to check to see if the surgeon in question has the proper credentials.

Medical credentials can often be confusing if you’re unfamiliar with the jargon, so it’s helpful to know what to look for. In your search, look for board certification from the American Board of Plastic Surgery. This means he or she has undergone a rigorous board certification process by the only plastic surgery board recognized by the American Board of Medical Specialties.

Additionally, while you’re at it, check to see if the provider you’re considering is a member of the American Society of Plastic Surgeons. While not a certifying organization, ASPS is well-respected, and its members must also maintain a rigorous set of training and patient safety standards to qualify for membership.

These credentials are important markers that signal you can trust the surgeon in question to be highly trained and qualified to perform your procedure. This is especially crucial in light of the fact that many untrained doctors are calling themselves “cosmetic surgeons” these days.

Study the surgeon’s style and approach

In addition to training and medical knowledge, cosmetic plastic surgery requires some artistry as well. Because every woman’s body is unique, the “best” plastic surgeon for a breast augmentation for example is much more likely to be one whose style of work is in line with your aesthetic goals and who can tailor a treatment to your unique situation to meet those goals. This is one reason why you can’t just search a phrase like “the best plastic surgeons near me” on the internet and choose the top result.

Good plastic surgery requires the provider to be able to customize his or her treatment to your situation and needs. Review the surgeon’s gallery of patient cases and before and after photos to get a sampling of his work and look for a variety of excellent results.

During consultations, don’t hesitate to ask for additional pictures, case studies or patient testimonials. Patient reviews on patient forums can also provide honest feedback from patients regarding their experiences with potential surgeon candidates.

Vet the facility

An accredited and accommodating facility is another important thing to look for when choosing a plastic surgeon.

Because cosmetic plastic surgeries can generally happen outside of the hospital, it’s especially important to ensure that the facility your procedure will take place in is held to the highest standards of safety, quality and patient care.

In order to find out if a facility is accredited by a credible organization, you should look for at least one of the following certifications:

  • State licensure
  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
  • American Association for Accreditation of Ambulatory Surgery Facilities (AAASF)
  • Accreditation Association for Ambulatory Health Care
  • Title XVIII Medicare participation

Find someone you trust

Much like finding the right family doctor or personal trainer, it may take a few tries before you meet a surgeon you feel comfortable enough with to trust. Having a personal rapport and ease of communication with your surgeon and surgical staff can mean the difference between a good plastic surgery experience and a great one.

When you find a surgeon that you connect with, you’ll be able to feel more confident about your surgery and you’ll be able to have open honest and important discussions about aesthetic goals, lifestyle, overall health and any questions or concerns that you might have.

The right provider will also outline a realistic timeline for recovery based on your medical history and help you through the recovery process.

Look for honesty

Finally, it’s not a plastic surgeon’s job to tell you what you want to hear. The best surgeons will give you honest, straightforward guidance on the best approach to your situation and the realistic results you can expect.

Choose a qualified plastic surgeon for your procedure

Understanding how to find a good plastic surgeon is the first step towards achieving your aesthetic goals. Choosing a safe, experienced, board-certified plastic surgeon that you connect with can help you on your journey towards a happier, more confident you.

The views expressed in this blog are those of the author and do not necessarily reflect the opinions of the American Society of Plastic Surgeons.

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CPR Coaching Device

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Functional Outcomes, Quantitative Morphometry, and Aesthetic Analysis of Articulated Alar Rim Grafts in Septorhinoplasty

Key Points

Question  Is the articulated alar rim graft (AARG) associated with improved function of the nasal airway and aesthetic outcomes?

Findings  This case series of 90 patients examined the creation, placement, and function of the AARG. A retrospective review showed statistically significant improvement in Nasal Obstruction Symptom Evaluation Survey scores in patients who had AARGs placed; aesthetic analysis by raters on a Likert scale showed cosmetic improvement in patients with a deep alar margin furrow; and morphometric analysis of preoperative and postoperative nasal base shapes showed a trend toward a more equilateral ideal shape.

Meaning  The AARG may improve the functional airway in select patients and the aesthetics of the nose in patients with a significant alar margin furrow or a pinched-appearing nasal tip.

Importance  The design, use, and indications for the articulated alar rim graft (AARG) and the functional and aesthetic improvements that can be achieved have not been fully characterized.

Objective  To analyze the functional and aesthetic outcomes of AARG placement on nasal airway function, nasal base shape change, and appearance.

Design, Setting, and Participants  A case series study of patients who underwent septorhinoplasty with placement of AARG at University of California, Irvine Medical Center, from 2015 to 2018 was carried out. Surgical data recorded included stage of rhinoplasty (primary vs revision), use of spreader grafts, rim grafts (and dimensions), caudal septal extension graft (CSEG), lateral crural tensioning (LCT), and turbinate reductions.

Main Outcomes and Measures  Preoperative and postoperative Nasal Obstruction Symptom Evaluation Survey (NOSE) surveys were analyzed and correlated with AARG geometry, use of CSEG, and the LCT maneuver. Preoperative and postoperative alar base views were evaluated by fitting base shape to a parametric numerical model to categorize each to 1 of 6 shape categories. Blinded reviewers rated alar furrow severity and the alar ridge presence using a Likert scale for both preoperative and postoperative images to subjectively gauge aesthetic outcomes.

Results  Overall, 90 patients with both preoperative and postoperative NOSE scores who underwent septorhinoplasty and placement of an AARG were included. Of the 90 patients, 60 were women (mean age, 38.2 years). Patient NOSE scores (70.4 preoperatively to 25.1 postoperatively) significantly improved from preoperation to postoperation (P < .001), regardless of AARG size, CSEG, or LCT. Alar base shape parametric analysis showed preoperative to postoperative improvements were significant for anterior-to-posterior ratio mass distribution (95% CI, −0.16 to 0.02; P = .05) and vertical projection-to-horizontal base width ratio (95% CI, 0.01-0.32; P = .02) in flat noses and cloverleafing for narrow noses (95% CI, −0.05 to −0.01; P = .001); enhancement approached significance for reduction in lateral scalloping in cloverleaf noses (P = .06). Aesthetic analysis showed that there was a statistically significant improvement for the alar furrow (95% CI, −0.68 to −0.29 for rater 1; −0.54 to −0.27 for rater 2; and −0.59 to −0.27 for rater 3; P < .001) for all raters and for the alar ridge (95% CI, 0.16-0.48; P < .001) for 1 rater.

Conclusions and Relevance  To our knowledge, this is the first study to demonstrate that AARG use is associated with statistically significant improvement in NOSE scores. Placement of AARGs may improve posterior mass ratios in flat noses and lateral cloverleafing in narrow noses as suggested by quantitative shape change parameter analysis. The placement of AARGs was associated with aesthetic and functional enhancement in the cloverleaf deformity, which is associated with a prominent alar furrow, and often external nasal valve collapse. Patient selection is key when placing AARGs.

Level of Evidence  NA.

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