An Audit of Outcomes in Cosmetic Rhinoplasty with Mandatory Psychiatric Evaluation Protocol.

With the high demand of rhinoplasty surgery, careful selection and management of aspirants, as well as proper assessment of outcomes after surgery, is imperative for successful outcome and learning from it. The aim of this study was to answer two important questions: 1. What is the success rate in cosmetic rhinoplasty?, and 2. How best to identify candidates who would achieve good outcomes. In this study group, we excluded patients with any functional concerns, and those confounding factors that could in any way influence the satisfaction from a cosmetic surgery in patient perception. This study is a part of the trilogy of articles on 'Psychology of Rhinoplasty' submitted to this volume of Facial Plastic Surgery, using Mandatory Psychiatric Evaluation (MPE) to optimise candidacy. 184 patients (144 female, 40 male) aged 16-63 (M = 31.09) met criteria and were used in this study (follow-up 3-122 months, M = 70.18 months), and outcome satisfaction was assessed using a Visual Analogue Scale (VAS) score and a five-point Likert scale. The mean improvement between pre-operative (M = 4.26) and post-operative VAS scores (M = 8.47) was 4.23. Most patients were happy or very happy (95.1%) about the surgical outcome, where the patients who were very happy generally scored between 8-10 on the VAS (77.2%), and those who were happy generally scoring 6-7.9 (21.2%). Some patients, however, were neutral (3.3%) or unhappy (1.6%) about their surgical outcome, and generally scored around 7 or less on the VAS. The successful outcomes in 95.1% patients reflects a carefully designed protocol for rhinoplasty candidacy, and yet, showed 4.9% with poor satisfaction despite these efforts. An ever present proportion of unhappy outcomes is a reality of this popular surgery.

Body Dysmorphic Disorder: A Decade of Mandatory Psychiatric Evaluation in Cosmetic Rhinoplasty Aspirants.

The aim of rhinoplasty is to make the patient happier with their nose. The patient's perception plays a substantial role in their outcome satisfaction. Body dysmorphic disorder (BDD) is an obsessive-compulsive disorder concerning body image, which negatively distorts the patient's perception, rendering them dissatisfied with the outcome even if the results are close to the defined objectives. In this paper, we present a protocol with a two-specialist approach (rhinoplasty surgeon and a psychiatrist) to standardize BDD diagnosis using the DSM-5 criteria. The patients deemed suitable for cosmetic rhinoplasty by the rhinoplasty surgeon's first consultation were sent for Mandatory Psychiatric Evaluation (MPE) for further consultation and second opinion. MPE was employed with a semi-structured clinical interview by a psychiatrist incorporating the Cosmetic Procedure Screening Questionnaire and Appearance Anxiety Inventory. From 2010 to 2023, 1,602 patients attended our practice seeking cosmetic rhinoplasty, out of which, 892 were sent for MPE to the same psychiatrist. The MPE identified 2.5% (22/892) patients as having mild BDD; out of which, 15 were considered suitable for surgical intervention and underwent successful rhinoplasty (follow up: 1-10 years, M = 4.33 years). Although BDD is considered a contraindication in rhinoplasty, our experience shows that borderline and mild BDD can be offered surgery with good insight and support system. Moderate to severe BDD in our practice was filtered out at the first stage and was not offered surgical intervention. BDD among rhinoplasty aspirants is not as prevalent as previously reported. Standardized diagnostic protocols and studying the severity of BDD when present has clarified management of BDD in rhinoplasty aspirants in our practice. MPE is not easy to incorporate in every rhinoplasty practice, but we aim to present guidelines arising from our ongoing experience to help management of BDD in rhinoplasty.

Surgical Rhinoplasty in Mild Forms of Body Dysmorphic Disorder: Safety, Protocols, and Long-Term Outcomes.

Body dysmorphic disorder (BDD) is an obsessive-compulsive disorder concerning body image which negatively distorts the patient's perception of their appearance. In rhinoplasty, surgery on patients with severe BDD is considered contraindicated as patients are often dissatisfied and their BDD symptoms rarely improve. For patients with borderline to mild BDD, however, there has been some preliminary evidence to show that they can benefit from surgical rhinoplasty. In our first article on this series of BDD in rhinoplasty, we presented our two-specialist protocol using mandatory psychiatric evaluation (MPE) to assess patient's suitability. In this present article, we used this protocol to identify a group of borderline to mild BDD patients, performed surgical rhinoplasty on this group, and evaluated the outcome using a visual analog scale (VAS) and a five-point Likert scale. From 2010 to 2023, 1,602 patients attended our practice seeking cosmetic rhinoplasty, out of which, 892 were sent for MPE to the same psychiatrist. The MPE identified 2.5% (22/892) patients as having mild BDD, out of which, 15 were considered suitable for surgical intervention and underwent successful rhinoplasty (follow-up 6-95 months, M = 54.13 months). Five of 15 patients scored 10/10 on the VAS and were very happy, 8 of 15 patients scored 7 to 9/10 on the VAS and were happy, and 2 of 15 patients scored 6/10 on the VAS but were still happy. Although all patients were happier, 3 of 15 patients requested revision rhinoplasty which was not offered as was planned and discussed before the initial intervention. This study shows that in the presence of safe protocols, including a two-specialist model, safe outcomes can be expected even in the long term. Further, the request for revision surgery appears to be common in borderline to mild BDD cases, and we like to warn the patients against it before surgery.

Recovery of Elective Facial Plastic Surgery in the Post-Coronavirus Disease 2019 Era: Recommendations from the European Academy of Facial Plastic Surgery Task Force.

The impact of the COVID-19 pandemic has resulted in widespread disruption to routine surgical services across the globe. As the peak of the initial pandemic passes, surgeons will increasingly resume elective work to address the backlog. Whilst urgent cases such as cancer work will be prioritized, the safe resumption of facial plastic surgery will remain an ongoing challenge; particularly if there are secondary waves of infection. Rhinoplasty and nasal reconstructive surgery in particular poses a unique challenge to address due to the due to the potential for aerosolizing the virus. A task force of facial plastic surgeons from the European Academy of Facial Plastic Surgery has collaborated to create this document detailing recommendations for resuming a safe facial plastic surgery practice. These include the need to embrace telemedicine, advice on surgical prioritization, planning of clinical area flow plans, advice on pre-/peri- and postoperative care as well as recommendations on training for residents and well-being for surgeons. The recommendations have been made in line with the best available evidence in the literature and are applicable to facial plastic surgery colleagues from around the world in order to resume a safe practice.

Warfarin-induced sublingual hematoma mimicking Ludwig angina: Conservative management of a potentially life-threatening condition.

Sublingual hematoma secondary to excessive anticoagulation is a rare, life-threatening condition. Reports in the literature have emphasized the importance of a prompt reversal of the causative coagulopathy by intravenous administration of vitamin K and fresh frozen plasma. In the event of an unstable airway, surgical intervention via tracheostomy or cricothyroidectomy is advocated. We report a case of sublingual hematoma that was treated conservatively, and we discuss the presentation and management of this entity.

Pediatric rhinoplasty in an academic setting.

Nasal septal surgery and rhinoplasty are controversial in children. Traditionally, an attitude of restraint has been employed by most surgeons till an empirical age of 16 to 18 years. This is to avoid the possible adverse effects that the growth spurts may have on the nose and midface region. Some authors, however, have claimed a paucity of evidence that such untoward effects of surgery are frequent. Research has shown that surgical intervention limited to certain areas of the bony and cartilaginous nasal framework is less likely to affect natural growth patterns. There is a growing consensus toward early intervention, especially in a select group of patients, where deferring the surgery may turn out to be the poorer option in the short and the long term, and suggestions have been made that conservative guidelines may be employed to minimize the unwarranted results. This article presents our experience with septorhinoplasty in children over the last two decades in an academic setting. We have retrospectively studied the pediatric patients who underwent septorhinoplasty at the Academic Medical Centre, Amsterdam, Netherlands. There were 106 children aged between 3 and 19 years who underwent nasal surgery between February 1994 and August of 2007. Sixty-six of these were boys and 40 were girls. Their follow-up ranged from 12 to 157 months with a mean follow-up period of 53 months. Eighteen patients underwent revision surgery. The clinical circumstances, indications for surgery, extent of surgical interference, and outcome in 106 patients are discussed. Importantly, the patients in this series have been followed for variable periods after puberty and adolescence, allowing for assessment beyond the nasal and midfacial growth spurts. Based on our experience, we have outlined the clinical guidelines that we follow for surgery in this age group of patients.

Open rhinoplasty in children.

Septorhinoplasty in children carries the risk of growth disturbance of the nose and premaxilla. The open or external approach has the advantage that the cartilaginous nasal skeleton remains intact. This open approach enables the surgeon to excise dermoid cysts and to realign lower lateral cartilages (unilateral cleft) without disturbing the integrity of the cartilaginous skeleton. In our experience, absolute indications for open rhinoplasty in children include dermoid cyst, cleft lip nose, and septal abscess. Relative indications include septal deviations causing severe nasal airway obstruction and or progressive distortion of the nose. In this article, we discuss the indications, advantages, disadvantages, and operative technique of open rhinoplasty in children. Our indications for open rhinoplasty in children and some selected cases are illustrated.

Use of an intra-operative nerve stimulator in identifying the hypoglossal nerve.

Previously, the hypoglossal nerve has not undergone intra-operative monitoring during neck operations in which the nerve is at risk. As society becomes increasingly litigious, this may change. This study describes the technique and the microvoltages used in 10 patients for intra-operative stimulation of the hypoglossal nerve with the Magstim nerve stimulator. We confirm that the technique is possible, simple and safe, with minimal disturbance to the patient, anaesthetist and surgeon.