Nitin Chauhan

Perceived Age Change After Aesthetic Facial Surgical Procedures: Quantifying Outcomes of Aging Face Surgery

OBJECTIVE To quantify the degree of perceived age change after aesthetic facial surgical procedures to provide an objective measure of surgical success. METHODS Sixty patients undergoing various aging face surgical procedures were randomly chosen for analysis. Preoperative and postoperative photographs were evaluated. Raters were presented with photographs in a random assortment and were asked to estimate the age of the patient. Perceived age difference was defined as the difference between the chronological age and the estimated age, and the change in this value after surgery was the chief outcome of interest. Statistical models were designed to account for any effects of interrater differences, preoperative chronological age, rater group, photograph order, or surgical procedure performed. RESULTS Our patient population was divided into the following 3 groups based on the surgical procedure performed: group 1 (face- and neck-lift [22 patients]), group 2 (face- and neck-lift and upper and lower blepharoplasty [17 patients]), and group 3 (face- and neck-lift, upper and lower blepharoplasty, and forehead-lift [21 patients]). Adjusted means demonstrated that patient ages were estimated to be 1.7 years younger than their chronological age before surgery and 8.9 years younger than their chronological age after surgery. The effect was less substantial for group 1 patients and was most dramatic for group 3 patients, who had undergone all 3 aging face surgical procedures. CONCLUSIONS Our study is novel in that it quantifies the degree of perceived age change after aging face surgical procedures and demonstrates a significant and consistent reduction in perceived age after aesthetic facial surgery. This effect is more substantial when the number of surgical procedures is increased, an effect unrelated to the preoperative age of a patient and unaffected by other variables that we investigated. The ability to perceive age correctly is accurate and consistent.

Cephalic Positioning of the Lateral Crura: Implications for Nasal Tip-plasty

OBJECTIVE To apply a mathematical model to determine the relative effectiveness of various tip-plasty maneuvers while the lateral crura are in cephalic position compared with orthotopic position. METHODS A Matlab (MathWorks, Natick, Massachusetts) computer program, called the Tip-Plasty Simulator, was developed to model the medial and lateral crura of the tripod concept in order to estimate the change in projection, rotation, and nasal length yielded by changes in crural length. The following rhinoplasty techniques were modeled in the software program: columellar strut graft/tongue-in-groove, lateral crural steal, lateral crural overlay, medial/intermediate crural overlay, hinge release with alar strut graft, and lateral crural repositioning. RESULTS Using the Tip-Plasty Simulator, the directionality of the change in projection, rotation, and nasal length produced by the various tip-plasty maneuvers, as shown by our mathematical model, is largely the same as that expected and observed clinically. Notably, cephalically positioned lateral crura affected the results of the rhinoplasty maneuvers studied. CONCLUSIONS By demonstrating a difference in the magnitude of change resulting from various rhinoplasty maneuvers, the results of this study enhance the ability of the rhinoplasty surgeon to predict the effects of various tip-plasty maneuvers, given the variable range in alar cartilage orientation that he or she is likely to encounter.

Waiting for thyroid surgery: A study of psychological morbidity and determinants of health associated with long wait times for thyroid surgery†

Patients with thyroid pathology tend have longer surgical wait times. Uncertainty during this wait can have negative psychologically impact. This study aims to determine the degree of psychological morbidity in patients waiting for thyroid surgery.

Alar Soft-Tissue Techniques in Rhinoplasty Algorithmic Approach, Quantifiable Guidelines, and Scar Outcomes From a Single Surgeon Experience

OBJECTIVES To describe various techniques, including alar base reduction, alar flaring reduction, and alar hooding reduction and present a decision-making treatment algorithm and quantifiable guidelines for soft-tissue excision, along with scar outcomes from a single-surgeon practice. The soft tissue of the nasal tip, ala, and nostrils is important in overall nasal tip dynamics. Excisional alar contouring is an essential part of many successful cosmetic rhinoplasty outcomes. METHODS The various soft-tissue excision techniques are described in detail and an algorithm is provided. Quantitative analysis of excision parameters was performed using statistical analysis. Finally, qualitative scar analysis was performed and scar outcomes were statistically derived. RESULTS Seventy-four patients were female and 26 were male. Of the procedures reviewed, 47% involved alar soft-tissue excision. Alar base reduction was performed in 46 patients (46%). Alar flare reduction was performed in 16 patients (16%). Alar hooding reduction was performed in 2 patients (2%). Mean scar outcome scores ranged from 0.55 to 0.69. CONCLUSIONS Alar soft-tissue techniques are often necessary to achieve a balanced outcome and superior results when performing rhinoplasty surgery. Therefore, they should be an integral part of every rhinoplasty evaluation and surgical plan as indicated.

Refining Vertical Lobule Division in Open Septorhinoplasty

OBJECTIVE To review the indications, surgical techniques, and results of vertical lobule division (VLD) of the alar cartilages as they relate to the M-Arch Model. DESIGN Retrospective study of patients who underwent VLD of the lower lateral cartilages at a private facial plastic surgery practice in a major university teaching hospital. RESULTS Vertical lobule division decreased projection in 34 of 41 patients, narrowed a wide or boxy tip in 25, corrected knuckling or bossae in 20, corrected tip asymmetry in 14, corrected a hanging columella in 14, increased rotation in 12, and decreased rotation in 6. No statistically significant correlation was noted between the location of VLD and the indication for which it was performed. One patient required revision surgery to increase rotation. CONCLUSIONS Vertical lobule division remains a reliable and safe technique with predictable outcomes in tip repositioning. It allows for preservation of a strong tip complex, while adding versatility to tip refinement.

Rosacea: pathophysiology and management principles.

This article presents an overview of the pathophysiology, epidemiology, and clinical presentations of rosacea. It also presents the therapeutic spectrum for effective management of this challenging and often confusing clinical entity.

Nasal tip refinement: analysis of surgical technique, efficacy, and secondary effect of skin thickness.

BACKGROUND Effective control and refinement of the nasal tip is an integral component of the rhinoplasty operation. A multitude of techniques exist to complement the rhinoplasty surgeons approach, but attaining consistent and long-lasting results is still challenging due to the complex interplay between nasal anatomy and surgical technique. OBJECTIVES The authors sought to determine whether the degree of tip narrowing with rhinoplasty is associated with the narrowing technique selected by the surgeon and whether there is an association between skin thickness and tip narrowing. METHODS A retrospective chart review was conducted of all patients undergoing rhinoplasty in a single-surgeon practice between April 2004 and November 2006. Demographic information and specific operative techniques were recorded. Standard basal views of pre- and postoperative photographs were examined by two blinded observers, who measured nasal tip width relative to interpupillary distance with imaging software. Skin thickness was assessed and categorized by a surgical expert according to Fitzpatrick classification. RESULTS Forty patients were identified with adequate follow-up and complete data sets. A statistically significant reduction in tip width pre- and postoperatively was seen (P = .041). No significant difference in tip narrowing between various techniques was found (P = .309), and no significant association between tip narrowing and skin thickness was identified (P = .186). CONCLUSIONS Although tip-narrowing techniques are effective in rhinoplasty, the specific technique employed may not be clinically relevant. Furthermore, skin thickness may not be as significant a factor in tip narrowing as is commonly believed.

Evolution in nasal tip contouring techniques: a 10-year evaluation and analysis.

question was asked regarding the area of medicine the students were interested in. Having such a question may have offered more information about those who responded compared with those who did not decide to participate. However, if such a question was asked, it could also induce biased assumptions about the respondents. Another difficulty we encountered was the time of the year in which the survey was distributed. More schools and students may have agreed to participate in the survey if it had been distributed earlier in the school year. Last, it should be stated that using different terms for the various specialists mentioned in the study would have most likely led to different results. For example, if the title “facial plastic surgeon” or “otolaryngologist–head and neck surgeon” was used alone instead of being combined, it can be assumed that the responses would have been different than those we received. The title “facial plastic/ENT surgeon” was originally used in the study by Rosenthal et al, and we decided to include this title as well in an effort to provide continuity for comparing our results with those of previous studies. In conclusion, this study suggests that medical students view multiple specialists as qualified to perform aesthetic and reconstructive facial surgery. Most importantly, this study suggests that the facial plastic and reconstructive surgeon is perceived as most qualified to perform multiple aesthetic and reconstructive facial procedures when being compared to other specialists. In order for the facial plastic and reconstructive surgeon to maintain its positive perception among medical students it is important for otolaryngology– head and neck programs to incorporate facial plastic and reconstructive surgery education into their medical student curriculums. The plastic surgery literature has demonstrated positive results from similar endeavors. Vallino and Brown and Kim et al demonstrated that exposure to plastic surgery in medical school increased the overall knowledge and the breadth of the specialty. The same idea could be applied to otolaryngology–head and neck surgery programs across the country by incorporating facial plastic and reconstructive surgery education within their medical student rotation curriculums.

Periorbital Rejuvenation: Reticular Vein Treatment

The safety profile of certain techniques, such as sclerotherapy, is questionable in a region as precarious as the periorbital region, where complications related to vision would be catastrophic. Other safe techniques such as phlebectomy can be performed with successful outcomes but are operator dependent, require a reasonable degree of technical ability, and can result in scarring and other complications. The aim of this article is to explore newer, laser-based treatment of these periorbital veins, discuss the physiology and the therapeutic efficacy, and better delineate the safety profile and evolution of the technique that has led to the present treatment paradigm.

The risks and the identification of ingested button batteries in the esophagus: a child safety issue.

Ingestion of foreign bodies is a common problem in children; frequently, the swallowed foreign body will become lodged in the upper esophagus causing distress to the child. Although coins are the most frequently ingested foreign body, they are very similar in shape and appearance to a button battery. Button batteries can be very difficult to distinguish from coins to the untrained eye. In contrast to a coin, a button battery lodged in the upper aerodigestive tract poses a significant health risk due to potential for esophageal burn and perforation and delays in diagnosis may lead to potentially fatal complications or long-term esophageal stenosis. Therefore, when that foreign body is a battery, correct and early identification is critical. The child must be referred urgently for removal because of the high risk of caustic damage and perforation. The current method of differentiation on plain x-rayVthe ‘‘double density,’’ where a radioluscent halo is seen on AP views; or ‘‘lateral step’’ where a notch is seen on the lateral neck viewVis not as easy to identify with the untrained eye as is suggested in the literature. If misdiagnosed as a coin, referral may be delayed with potentially fatal consequences.