Published on January 6, 2017
Rhinoplasty: Are we selecting the right patients?: Rhinoplasty : Are we selecting the right patients ? Conflict of interest.: Conflict of interest . Medical associate director – M erck Sharp & Dohme , Mexico. Outcomes R esearch Lead Agenda: Agenda What are we doing to select patients for aesthetic rhinoplasty? Key points in facial analysis Behind the scenes of rhinoplasty : pshychology of rhinoplasty . Aesthetic Rhinoplasty: Aesthetic Rhinoplasty Rhinoplasty continues to rank among the most popular surgical cosmetic treatments. In 2014, nose reshaping was the second most common surgical procedure performed in the United States. Success of rhinoplasty may vary according to the aesthetic perception of the patient as well as the preoperative status of the nose. Nasal breathing and psychology of the patient contribute to the successful outcome. What are we doing to select patients for aesthetic rhinoplasty? : What are we doing to select patients for aesthetic rhinoplasty ? Survey of 41 Otolaryngologist and plastic surgeons that perform aesthetic rhinoplasty . Questions regarding their practice and experience with aesthetic rhinoplasty . Descriptive analysis of the results . Results.: Results . Years of practice : 39.02% have between 5 to 10 years and more than 10 years practicing (78.04%) 21.95% have less than 5 years of practice Photographs 100% use to take preoperatory photographs , 93.75% by themselves . 84.3% use the same background , 75% use the same distance , 34.3% special flash ( avoiding shadow in the background ), 15.6% other ( same positions, light in front of patient , etc.) Average time practicing: Average time practicing Results.: Results . Facial Analysis . Powell & Humphrey 34.48%, thirds and fifths 79.31%, divine proportion 27.59%, other 13.79% (Gonzalez Ulloa, digital program , VIEW) Results.: Results . Psychological analysis 25% perform an analysis by themselves 6.25% refer to psychologist 68.75% do not perform any analysis. 82.14% know what body dysmorphic disorder is . Results: Results 57.14% does not document their surgical plan Facial analysis and photographs were considered the most important aspects of preop analysis (57.14% and 78.57% respectively on a 5 point likert scale) Pshychological analysis scored the less important in 25% of the cases. Results at one and six months.: Results at one and six months. ˜50 % of the physicians – 50% of patients complaint of imperceptible defects. At 6 months the % of physicians didn’t change – 38% of patients still complaint. ˜70 % of the physicians – 60% of patients had constant worries. At 6 months, 50% of physicians had 38% percent of patients with constant worries. Results (first month): Results ( first month ) Results (after 6 months): Results ( after 6 months ) Facial analysis: Facial analysis Aesthetic analysis begins with universally accepted standards for “ideal” proportions , keeping in mind individual uniqueness and how those standards apply to the patient’s overall facial structure . The goals of analysis are to define external nasal deformities , predict the underlying anatomic variations , and determine the appropriate surgical intervention It doesn ´t matter which type of analysis you use, what is important that you document your plan. Psychology of rhinoplasty: History: Psychology of rhinoplasty : History The face has always been considered the personification of ones soul. It is the representation of the persons identity from the social point of view . Facial appearance is closely tied to the self-image, self-confidence, and self-worth of the individual. The face is the part that first enters in contact and remains the longest in interpersonal relations . Psychology of rhinoplasty: History: Psychology of rhinoplasty : History Elements of appearance that have the greatest influence in interpersonal relations are attractiveness, beauty and sexual attraction. A person is considered physically attractive if various groups of judges find him so. This judgement is not constant, it varies in time, differs form one culture to another and is influenced by mass media, art, literature, films, publicity, etc . With the introduction of cameras embedded in cell phones and widely acceptance of social media, facial aesthetics has been more important than ever before in the human history . Psychology of rhinoplasty: History: Psychology of rhinoplasty : History From the days of Tagliocozzi in the 16th century, there was documentation of negative connotations associated with changing the shape of one’s nose, as it was felt to interfere with the will of God. A dissertation by Dr. Jack Anderson, published in the article “What physicians should know about nasal plastic surgery” J La State Med Soc. 1963; addresses the “morality” of aesthetic rhinoplasty concluding that aesthetic rhinoplasty , in the context of appropriate motives, conforms to “ . . . administering to the whole individual” and “is not only ethical and permissible but also a necessity in some cases .” Rhinoplasty , USA second place. . Psychology of rhinoplasty: History: Psychology of rhinoplasty : History The noses aspect is critical not only for the anatomy of the face, but also because this organ frequently is one of the factors that can disturb, consciously or subconsciously, our image of our body and our personality development It has cultural, ethnic, symbolic, and psychological significance . Slide 20: BUT … DOES EVERY PATIENT ASKING FOR SURGERY IS A GOOD CANDIDATE? HOW CAN WE DIFFERENCIATE BETWEEN PATIENTS THAT WILL BENEFIT FROM SURGERY FROM THOSE WHO DON ´T? Psychology of rhinoplasty: History: Psychology of rhinoplasty : History Surgical advances following World War I were accompanied by enthusiastic reports of the emotional relief experienced by disfigured individuals who underwent reconstructive surgery . In the 40´s and 50´s the first psychiatric evaluations of people seeking elective cosmetic surgery . “WARNING” Surgeons were cautioned of the psychopathology of the male patient, as well as of the “insatiable ” surgery patient who sought out numerous cosmetic procedures in pursuit of the perfect face . Early investigations based mainly on clinical interview, showed a 70% patients with psychiatric disturbances ( neurotic depression and passive – dependent personality ) Slide 22: Clinical interview not described Diagnostic criteria ? “ Marked psychological disturbance ” “ deviating from the normal picture ” “in need of therapy ” PSYCHOLOGICAL ASSESSMENTS: PSYCHOLOGICAL ASSESSMENTS Clinical Interview Are the patients soughting for the same cosmetic procedure , affected by the same psychological problem ? Is it different from a patient searching for a “ type-changing ” surgery ( reshaping rhinoplasty ) to a “ restorative ” surgery ( facelift )? THE MAJORITY OF COSMETIC SURGERY PATIENTS WERE PSYCHOLOGICALLY DISTURBED. Psychometric Assessments Many tests (Minnesota Multiphasic Personality Inventory , Brief Symptom Inventory , Eysenck Personality Inventory , etc ) The measures used are not designed to tap the types of psychopatology specific to these patients . Slide 24: Less psychopathology No clear relationship between given cosmetic procedures and specific forms of psychopathology SATISFACTION WITH RESULTS: SATISFACTION WITH RESULTS Aproximately 10 to 15% of patients are not satisfied by results of cosmetic nasal surgery . It has been reported that benefit from rhinoplasty was greatest when the indication was cosmetic rather than functional, but nasal function has been attributed to significantly influence the outcome of a rhinoplasty . Success of rhinoplasty was found to be high in severely deformed and twisted noses with increased physical health in the postoperative period . SO … IN ORDER TO INCREASE SUCCESS RATE, WE SHOULD ONLY DO SURGERY ON SEVERE DEFORMED NOSES FROM WOMEN? Satisfaction: Satisfaction Patient’s satisfaction has been defined as the patient’s perceived improvement in well-being following the intervention . Aproximately 10 to 15% of patients are not satisfied by results of cosmetic nasal surgery . A case series of rhinoplasty revision showed that 41% of the cases, asked for the revision because they noted asymmetries or irregularities in the nasal dorsum , 33% asked for revision because they noted not enough correction of nasal deformity . SATISFACTION WITH RESULTS: SATISFACTION WITH RESULTS A case series of rhinoplasty revision showed that 41% of the cases, asked for the revision because they noted asymmetries or irregularities in the nasal dorsum , 33% asked for revision because they noted not enough correction of nasal deformity . Patient psychologic selection has been so far neglected for patients that will have a cosmetic procedure . Patient Satisfaction?: Patient Satisfaction? A UK Department of Health systematic review identified only 9 specific instruments that demostrated adequate psychometric properties and were developed with patient input. Patient satisfaction with their appearance is an often overlooked outcome, and able to be measured in facial aesthetics using the FACE-Q scales. Patient reported outcomes: Patient reported outcomes Patient-reported outcomes are the patients’ feedback, elicited directly from them without interpretation by the physician or others, on how they perceive the physical, mental, or social condition related to their condition or treatment . Systematic use of PRO tools improves communication and decision making between physicians and patients and enhances patient satisfaction with care . Body dysmorphic disorder (BDD): Body dysmorphic disorder (BDD) I s one of the most common psychiatric conditions found in patients seeking cosmetic surgery . About 5% and up to 16.6% is the reported global prevalence A study in Iran showed a 31.5% prevalence among rhinoplasty candidates and 70.7% of them had moderate to severe forms of BDD. 80% of plastic surgeons in the USA report they would not operate a patient with BDD, but 84% has unwillingly operated at least one . BDD: BDD defined as apreoccupation with an imagined defect in one’s appearance . Alternatively , if a slight physical anomaly is present , the person’s concern is markedly excessive . DSM-IV, the preoccupation should last for at least an hour a day1 and cause clinically significant distress or impairment in social, occupational or other important areas of functioning . Anxiety and depression has a prevalence of 26.8% to 40% in bdd patients . Bdd assessment: Bdd assessment BDDQ ( sensitivity of 100 % and a specificity of 89–93 %) Are you very worried about your appearance in any way ? Does this concern preoccupy you ? That is , do you think about it a lot and wish you could worry about it less ? How much time do you spend thinking about it ? ( more than 1 h per day is suggestive and more than 3 hr is highly specific for BDD). What effect has this preoccupation had on your life ? Has it : Significantly interfered with your social life , school work , job , other activities , or other aspects of your life ? Caused you a lot of distress ? Affected your family or friends ? BDD assessment: BDD assessment Dysmorphic Concern Questionnaire (DCQ) 7 items . Yale Brown Obsessive Compulsive Scale Conclusion: Conclusion Complete surgical plan need to be documented before surgery . Patient selection should not only have a preoperatory assessment purely from the rhinological standpoint ; psychological aspects should be considered as well . Standarization of Assessment .