JAMA facial plastic surgery最新文献

Importance: The number of available rhinoplasty outcome measurement instruments has increased rapidly over the past years. A large heterogeneity of instruments of different quality now exists, causing difficulty in pooling and comparing outcome data.

Objective: To critically appraise, summarize, and compare the measurement properties of all patient-reported outcome measures (PROMs) that measure functional or aesthetic symptoms of patients undergoing rhinoplasty, using consensus-based methodology and guidelines. This facilitates an evidence-based recommendation on the most suitable instrument to measure rhinoplasty outcomes and identifies promising instruments worthy of further research.

Evidence review: A systematic literature search of Embase, Medline, and Web of Science was conducted from the databases' respective inception dates to May 18, 2018. Thirty-three articles evaluating 1 or more measurement properties of instruments measuring symptoms related to nasal breathing or satisfaction with nasal appearance in patients who had undergone septoplasty and/or rhinoplasty were included. Measurement properties were graded according to the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines for systematic reviews of PROMs.

Findings: The search strategy identified 33 studies that used 12 different measurement instruments. In general, high-quality studies on measurement properties of instruments measuring aesthetic and/or functional symptom-specific outcome of rhinoplasty are scarce. The Nasal Obstruction Symptom Evaluation (NOSE) scale demonstrated high-quality evidence for sufficient structural validity, internal consistency, reliability, construct validity, and responsiveness, along with favorable interpretability and feasibility aspects, and was therefore selected as the most suitable instrument to measure functional outcome. Among instruments measuring aesthetic outcome, the FACE-Q and Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) aesthetic subscale are recommended for further study. Future studies on the measurement properties of the identified PROMs, in particular content validity studies, are necessary.

Conclusions and relevance: Three instruments with high potential for further use were identified in a systematic review of rhinoplasty outcome instruments using a standardized, consensus-based methodology: the NOSE, FACE-Q, and SCHNOS. These findings may contribute to standardized collection of outcome data in rhinoplasty.

Importance: Periorbital ecchymosis and edema are commonly associated with rhinoplasty and are the principal limiting factors for return to daily activities after rhinoplasty. Several methods have been evaluated to minimize these sequelae including creation of subperiosteal tunnels, which involves elevating the vascular periosteal layer, preserving it from trauma when creating osteotomies.

Objective: To assess the efficacy of the creation of subperiosteal tunnels prior to lateral osteotomies during rhinoplasty for reducing postoperative ecchymosis and edema.

Design, setting, and participants: A randomized, blinded, matched-paired, prospective, clinical trial took place between April 1 and August 30, 2015, in a private practice in a stand-alone clinic and surgical center. All patients who were undergoing aesthetic rhinoplasty requiring bilateral lateral osteotomies were offered inclusion in the trial. All 34 enrolled patients completed the follow-up requirements.

Intervention: Creation of subperiosteal tunnels prior to lateral osteotomies on 1 randomly selected side.

Main outcomes and measures: Three blinded evaluators independently graded the degree of ecchymosis and edema on a visual analog scale of 0 to 10 on each side of the nose on postoperative days 2 and 7. Each patient had 1 side that was randomly selected to undergo creation of subperiosteal tunnels. A difference in mean score between sides of the nose was calculated for each patient using a paired t test.

Results: Of the 34 patients (28 females and 6 males; mean [SD] age, 27.3 [9.2]), the mean (SD) difference in ecchymosis scores between sides on day 2 was -0.05 (1.94) (95% CI, -0.43 to 0.33) and on day 7 was -0.22 (1.23) (95% CI, -0.47 to 0.02), favoring the side without tunnels. The mean (SD) difference in edema scores on day 2 was -0.21 (1.66) (95% CI, 0.53-0.12) and on day 7 was -0.29 (1.11) (95% CI, -0.51 to -0.07). There were no clinically significant differences between sides in terms of postoperative ecchymosis and edema.

Conclusions and relevance: Ecchymosis and edema can have significant postoperative practical, emotional, and financial effects on patients. Creation of subperiosteal tunnels prior to lateral osteotomies showed no clinically significant differences in edema and ecchymosis after the procedure.

Level of evidence: 1.

Trial registration: isrctn.org Identifier: ISRCTN42741475.

Importance: The main treatment of lower eye bags is changing from fat removal techniques to fat repositioning techniques. However, fat repositioning techniques have potential complications because of disruption of the middle lamellae, leading to contracture and shortening.

Objective: To determine whether transconjunctival fat removal followed by resected fat grafting is an effective alternative method of eye bag treatment.

Design, setting, and participants: This retrospective study of 229 consecutive patients who underwent transconjunctival fat removal followed by resected fat grafting from November 1, 2011, to October 31, 2017, was conducted by review of medical records from the Seoul H Dermatology Clinic in Seoul, Korea.

Main outcomes and measures: Comparison of patient satisfaction and modified Goldberg scores before and after surgery.

Results: A total of 229 patients (mean [SD] age, 41.24 [11.11] years; range, 20-69 years; 164 [71.6%] female) underwent transconjunctival fat removal followed by resected fat grafting. Of the 229 patients, 224 (97.8%) were satisfied with their surgical results, and major improvements were seen in the mean (SD) preoperative and postoperative scores for orbital fat prolapse (preoperative: 1.94 [0.63]; postoperative: 0.07 [0.21]), tear trough depression (preoperative: 1.61 [0.75]; postoperative: 0.33 [0.42]), skin transparency (preoperative: 1.15 [0.97]: postoperative: 0.22 [0.37]), and triangular malar mound (preoperative: 0.37 [0.61]; postoperative: 0.34 [0.58]). Although the orbicularis prominence worsened after surgery, this outcome should be interpreted as a good result for Asian patients. Skin elasticity deteriorated postoperatively.

Conclusions and relevance: The findings suggest that transconjunctival fat removal followed by resected fat grafting is an effective and safe technique to treat lower eyelid fat herniation without increased complication rates and provides good patient and surgeon satisfaction.

Level of evidence: 4.

Importance: Reconstructing Mohs defects often requires grafting in the form of full-thickness skin grafts (FTSGs) and composite grafts. These grafts can be complicated by a variable and often indeterminable survival rate. Other researchers have found that delaying FTSG reconstruction improves graft outcomes, but the optimal interval between excision and reconstruction remains unclear, and no study has examined the association between delaying composite graft reconstruction and graft survival.

Objective: To review the outcomes of Mohs micrographic surgery defect reconstruction using FTSG and composite grafts with respect to patient- and surgery-specific variables, particularly early vs delayed reconstruction.

Design, setting, and participants: This retrospective, single-institution cohort study assessed patients who underwent Mohs reconstructive surgery from January 1, 2012, to January 1, 2018. No patients had to be excluded for inadequate follow-up or incomplete medical records. Delayed reconstruction was defined as greater than 6 days after Mohs excision, the third quartile of the interval to reconstruction among our cohort.

Main outcomes and measures: Primary outcome was postoperative complications, including hematoma, infection, dehiscence, epidermolysis, and partial or full graft loss.

Results: A total of 320 defects were reconstructed with FTSG or composite grafts in 310 patients (median [range] age, 68 [21-96] years; 167 female [53.9%]) during the 6-year study period. The mean interval between the ablative and reconstructive operations was 4.73 days (range, 0-35 days). Univariate logistic regression was used to determine the significant indicators among patient and defect characteristics analyzed. A multivariate logistic regression model found delayed reconstruction to have a protective association (odds ratio, 0.52; 95% CI, 0.27-0.97; P = .046) and male sex to have a harmful association (odds ratio, 2.51; 95% CI, 1.52-4.20; P < .001) with postoperative complications.

Conclusions and relevance: This study found that delaying reconstruction in FTSGs and composite grafts was associated with decreased rates of postoperative complications, and male sex was associated with an increased risk of postoperative complications. The findings suggest that this strategy can be considered in patients at increased risk for developing postoperative complications, such as current smokers, patients with large defects, and patients who require use of composite grafts.

Level of evidence: 3.

Importance: The association of nasal airway obstruction with health is significant, and the health care resources utilized in open septorhinoplasty need to be included in health economic analyses.

Objectives: To describe the association of nasal airway obstruction and subsequent open septorhinoplasty with patient health.

Design, setting, and participants: A prospective case series study was conducted from September 30, 2009, to October 29, 2015, at 2 tertiary rhinologic centers in Sydney, Australia, among 144 consecutive adult patients (age, ≥18 years) with nasal airway obstruction from septal and nasal valve disorders.

Interventions: Open septorhinoplasty.

Main outcomes and measures: Patients were assessed before undergoing open septorhinoplasty and then 6 months after the procedure. Health utility values (HUVs) were derived from the 36-Item Short Form Health Survey. Nasal obstruction severity was also measured using the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire and the Sino-Nasal Outcome Test 22 questionnaires.

Results: A total of 144 patients (85 women and 59 men; mean [SD] age, 38 [13] years) were assessed. The baseline mean (SD) HUV for patients in this study was 0.72 (0.09), which was below the weighted mean (SD) Australian norm of 0.81 (0.22). After open septorhinoplasty, the mean (SD) HUV improved to 0.78 (0.12) (P < .001). Improvements in HUV were associated with changes in disease-specific patient-reported outcome measures, including Nasal Obstruction Symptom Evaluation scores (r = -0.48; P = .01) and Sino-Nasal Outcome Test 22 scores (r = -0.68; P = .01).

Conclusions and relevance: Patients with nasal airway obstruction reported baseline HUVs that were lower than the Australian norm and similar to those in individuals with chronic diseases with significant health expenditure. There was a clinically and statistically significant improvement in HUVs after open septorhinoplasty that was associated with a reduction in Nasal Obstruction Symptom Evaluation and Sino-Nasal Outcome Test 22 scores. Outcomes from this study may be used for health economic analyses of the benefit associated with open septorhinoplasty.

Level of evidence: 4.