Board Certification and Surgeon's Fee for Aesthetic Rhinoplasty.

Elective rhinoplasty surgeons' fees vary considerably and are influenced by geographic surgeon density, surgeon's experience, local economic factors, patient demand, and other factors. The American Board of Facial Plastic and Reconstructive Surgery, the American Society of Plastic Surgery, and other organizations certify physicians who profess expertise in rhinoplasty. We sought to determine if specific board certification or experience correlates with higher rhinoplasty fee. An internet search was conducted of seven U.S. metropolitan areas using the search terms "rhinoplasty and "city name." Top search results were surveyed for rhinoplasty fee, years of experience, annual volume of rhinoplasties, board certification, and other demographic data. Using both univariate and multivariate comparisons, the data were analyzed for forces having significant correlation with rhinoplasty fee. Sixty-seven surgeons were included in the study. The average price for ABFPRS certified surgeons was significantly higher than surgeons with other board certifications ($10,550.00 ± 3,722.10 compared with $8,524.50 ± 2816.30, p = 0.0142). The volume of rhinoplasties performed per year was also significantly correlated with fee charged for rhinoplasty by the surgeon (r = 0.37773, p = 0.032). Additionally, surgeons practicing on the West Coast (LA) charged significantly higher fees ($12,059.09 ± 3014.53) compared with the Mid United States. ($8316.07 ± 2449.43) and the East Coast ($9152.86 ± 3639.78) (p = 0.0047). On multivariable linear regression, controlling for volume of rhinoplasty and region of the United States, ABFPRS certified surgeons charged significantly higher fees for rhinoplasty (p = 0.0230). ABFPRS board certification correlates with higher fees charged for rhinoplasty. Other important variables include surgeon's annual rhinoplasty and practice on the West Coast.

Observer Gaze Patterns of Patient Photographs Before and After Facial Feminization.

BACKGROUND: Human interaction begins with visual evaluation of others, and this often centers on the face. Objective measurement of this evaluation gives clues to social perception. OBJECTIVES: The objective of this study was to use eye-tracking technology to evaluate if there are scanpath differences when observers view faces of cisgender men, cisgender women, and transgender women before and after facial feminization surgery (FFS) including when assigning tasks assessing femininity, attractiveness, and likability. METHODS: Undergraduate psychology students were prospectively recruited as observers at a single institution. Their eye movements were recorded by eye-tracking technology when they were presented with frontal photographs of prototypical male, prototypical female, and pre- and post-FFS faces in a random order and then with prompting to assess femininity, attractiveness, and likability. RESULTS: Twenty-seven observers performed the tasks. Participants focused their attention more on the central triangle of post-FFS and prototypical female images and on the forehead of pre-FFS and prototypical male images. Higher femininity ratings were associated with longer proportional fixations to the central triangle and lower proportional fixations to the forehead. CONCLUSIONS: This preliminary study implies the scanpath for viewing a post-FFS face is closer to that for viewing a prototypical female than a prototypical male based on differences viewing the forehead and brow vs the central triangle.

Laterality and severity of nasal obstruction does not correlate between physicians and patients, nor among physicians.

BACKGROUND: Nasal obstruction is a common patient complaint and has a variety of etiologies, and a specific anatomical abnormality can often be found within the nasal cavity on physical examination. In practice, this observed pathology does not always correlate with the laterality, severity, and exact intranasal site of the patients' perceived obstruction. OBJECTIVES: We seek to answer the following questions: 1) Does a physician's evaluation of nasal obstruction correlate with subjective patient complaints? 2) Is there reasonable correlation between physicians of similar training in the routine evaluation of nasal obstruction? METHODS: First, we asked patients presenting to the otolaryngology clinic with a primary complaint of nasal obstruction to fill out a modified NOSE survey. Nasal endoscopy was performed on all subjects to assess all potential sites of obstruction. We then determined whether there is an association between patient complaints and findings on physical examination. Second, we determined if there is correlation between similarly trained physicians in their interpretation of a basic nasal examination. Otolaryngologists were shown a series of standardized videos of an endoscopic nasal examination that were recorded with a primary complaint of nasal obstruction. Findings were reported in an anonymous online survey focusing on laterality, severity, and specific site of perceived obstruction. RESULTS: A total of 38 patients were included in the first part of the study. The Cohen's kappa coefficient was used to determine the interrater agreement between the patient and physician in the degree of nasal obstruction. The kappa coefficient was 0.03 (p value 0.372) for the comparison of the left-sided scores (fair agreement), and 0.16 (p value 0.014) for the right-sided scores (slight agreement). A comparison was also done between the side of the nose the patient felt was most obstructed to the most obstructed side found on physical exam by the otolaryngologist. Thirteen of the 38 patients (34%) had perceived nasal obstruction on the opposite side of that noted to be most obstructed on physical exam. Despite this, the kappa coefficient in this comparison was 0.43 (p value <0.001) revealing moderate agreement between the two groups. Seventeen otolaryngologists participated in the second part of the study. Data extrapolated revealed very little agreement among the physicians in reporting which side of the nose was most obstructed, what anatomical structure contributed to the obstruction the most, and what percentage obstruction was present. DISCUSSION: Based on our findings, patients can reasonably determine based on their symptoms which side is most obstructed, but symptoms do not correlate with severity of obstruction when compared to physical exam. There is also very little consistency between otolaryngologists in their assessment of the degree of nasal obstruction on exam. The results of this study may have far-reaching implications for patient management, surgical intervention, and medicolegal documentation as it relates to the current surgical treatment of nasal obstruction.

Facial Plastic Surgery on Instagram: What Is Trending? What Is Working?

BACKGROUND: Instagram has become a prominent way for facial plastic surgeons to advertise their work and communicate with patients. Some providers develop globally popular profiles, becoming "influencers" in their field. OBJECTIVES: We sought to characterize posts found on top profiles by type and determine the degree of patient interaction within each type. METHODS: A social media tracking tool (Awario, Belarus) compiled a list of the top 33 facial plastic surgery Instagram profiles based on number of followers and "reach," obtained on September 22, 2019. Profiles not belonging to American Board of Facial Plastic and Reconstructive Surgery (ABFPRS)-certified surgeons were excluded, leading to 20 profiles. The most recent 18 posts at the time of data extraction were categorized into: (1) clinical or professional, (2) lifestyle, and (3) patients. The average number of "likes," as a percentage of total followers, was calculated for each category for each profile. Data were gathered from September to November 2019. RESULTS: Most top profiles belong to ABFPRS-certified surgeons and were not verified. Clinical pictures and patient posts were 42.78% and 41.94% of those sampled, respectively. Lifestyle content was 19.05%. Followers interacted with clinical posts the most, having an average of 6.79% of follower interaction. Patient and lifestyle posts had 2.88% and 3.81%, respectively. CONCLUSIONS: Instagram is an important communication tool for facial plastic surgeons to engage in promotion and education. It is important to understand what trends tend to attract followers and engagement. Our study showed that more clinical content, separate from patient pictures, tended to be popular with both providers and followers.

Considerations in Feminization Rhinoplasty.

Rhinoplasty can be a key part of facial feminization for transgender women. Commonly, the required results necessitate significant deprojection of the nose in addition to the reduction of contour irregularities and shaping of the nostrils to a more round appearance. Pitfalls can include disproportion of the tip anatomic subunits, inadvertent creation of epicanthal folds, soft tissue pollybeak creation, and hanging columella among others.

The case of the eyelid silicone granulomas.

Foreign body granulomas can develop even several years after autologous fat or filler injection. In some instances the foreign body granulomas have been found at sites other than the original injection site. We present a case of a 48-year-old male with reported "hyaluronic acid fillers" injected into his upper and lower eyelids several years prior. He subsequently developed periorbital swelling with negative allergic and rheumatologic workup. The patient ultimately underwent a blepharoplasty for improvement of the swelling. Histopathology suggested silicone granulomas of the upper and lower eyelid. This case illustrates the importance of keeping foreign body granulomas on the differential for all patients with a history of facial dermal filler injections. Although hyaluronic acid is the most common dermal filler, providers should suspect the use of other dermal fillers including those not FDA approved particularly when common conservative treatment methods are not sufficient.

Facial Feminization for the Transgender Patient.

This article provides an overview of the key concepts and techniques of facial feminization surgery. The author reviews 20 years of experience with thousands of patients.

Lip Lifting: Not Just Fullness-Everything You Need to Know about Lifting and Creating Youthful, Beautiful Lips.

This article will explain the theories and practice of creating the most beautiful lips. This article also discusses lip lifting, lip augmentation, and lip injectables.

Safety of Combined Facial Plastic Procedures Affecting Multiple Planes in a Single Setting in Facial Feminization for Transgender Patients.

BACKGROUND: The objective is to evaluate the safety of performing multiple combined facial plastic surgical procedures affecting various planes of the face including rhytidectomy, forehead contouring with browlift, cheek implants, rhinoplasty, and mandible contouring in a single setting. METHODS: This is a retrospective study of patients undergoing facial plastic surgery with the senior author at Boston Medical Center from 2005 to 2017. Patients were included if they underwent all of the above procedures in one setting and had not had previous facial surgery. The primary outcome measure was local postoperative complications of tissue necrosis and wound dehiscence. The secondary outcome measures were general postoperative complications of venous thromboembolism and prolonged intubation. RESULTS: A total of 25 patients met inclusion criteria. Four patients experienced an infection-two patients had cheek implant infections delayed by months, one had a facelift hematoma that became infected, and one had an intraoral incision infection. One patient suffered from pulmonary embolism 2 months after surgery in the setting of hormone replacement therapy. All patients were extubated at the end of the case and none required reintubation. All patients had good cosmetic results. CONCLUSION: Despite elevating multiple planes of the face at the same time, there were no complications related to vascular supply in any of the patients. Complications were limited to those known to occur with the individual procedures. This study demonstrates that concurrent procedures that elevate multiple planes in the face in a single setting may be performed safely and with good cosmetic outcomes. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

Scalp Advancement and the Pretrichial Brow Lift.

This article will review considerations for scalp advancement, or forehead shortening, when done in combination with a brow lift. The author's technique for anterior hairline reshaping is presented with particular focus on simultaneous reduction of temporal recession.

Standardization of Guidelines for Patient Photograph Deidentification.

IMPORTANCE: This work was performed to advance patient care by protecting patient anonymity. OBJECTIVES: This study aimed to analyze the current practices used in patient facial photograph deidentification and set forth standardized guidelines for improving patient autonomy that are congruent with medical ethics and Health Insurance Portability and Accountability Act. DESIGN: The anonymization guidelines of 13 respected journals were reviewed for adequacy in accordance to facial recognition literature. Simple statistics were used to compare the usage of the most common concealment techniques in 8 medical journals which may publish the most facial photographs. SETTING: Not applicable. PARTICIPANTS: Not applicable. MAIN OUTCOME MEASURES: Facial photo deidentification guidelines of 13 journals were ascertained. Number and percentage of patient photographs lacking adequate anonymization in 8 journals were determined. RESULTS: Facial image anonymization guidelines varied across journals. When anonymization was attempted, 87% of the images were inadequately concealed. The most common technique used was masking the eyes alone with a black box. CONCLUSIONS: Most journals evaluated lack specific instructions for properly de-identifying facial photographs. The guidelines introduced here stress that both eyebrows and eyes must be concealed to ensure patient privacy. Examples of proper and inadequate photo anonymization techniques are provided. RELEVANCE: Improving patient care by ensuring greater patient anonymity.

The effect of "single" vs "double" eyelids on the perceived attractiveness of Chinese women.

BACKGROUND: A well-defined supratarsal crease has often been considered attractive, representing a significant component in a beautiful upper eyelid. Approximately 50% of East and Southeast Asian women are born with either a minimal or absent supratarsal eyelid crease. Among people of Chinese descent, the creation of a supratarsal crease ("double" eyelid blepharoplasty) is the most common cosmetic surgical procedure, but no comparative study has assessed the height by which an upper eyelid crease is deemed most attractive and depending on cultural background. OBJECTIVES: The authors assess how attractiveness is interpreted by different cultural groups to determine whether double-eyelid blepharoplasty enhances attractiveness according to both Chinese and non-Chinese observers. METHODS: Facial photographs were taken of 19 women of Chinese descent. The photographs were enhanced with computer imaging software to generate 3 additional pictures, depicting low, medium, and high upper eyelid creases on each model. Via an Internet-based survey tool, Chinese and non-Chinese observers were asked to rate the attractiveness of the faces with each potential eyelid position. (Surveys are available online at www.aestheticsurgeryjournal.com, as Appendix 1 and Appendix 2.) RESULTS: Both Chinese and non-Chinese observers considered the medium-height upper eyelid crease most attractive (P < .00001). An absent upper eyelid crease was deemed the least attractive (P < .00001). CONCLUSIONS: These preference data for eyelid height can be used to better counsel patients on perceived attractiveness and expectations for surgical results, since these results further elucidate which facial features are universally considered attractive.

Patient preferences in print advertisement marketing for plastic surgery.

BACKGROUND: Plastic surgeons are competing for their share of a growing but still limited market, thus making advertising an important component in a successful plastic surgery practice. OBJECTIVE: The authors evaluate the variables, characteristics, and presentation features that make print advertisements most effectively pique the interest of individuals selecting a plastic surgeon. METHODS: An online survey was administered to 404 individuals with active interest in plastic surgery from 10 major metropolitan areas. Participants were presented with 5 different advertisements from plastic surgeons throughout the country and were asked a series of both closed- and open-ended questions to assess verity, quality, and marketability of each advertisement. Reponses to open-ended questions were analyzed using the Wordle program (www.wordle.net). RESULTS: The most frequent themes identified for all 5 ads were "Being beautiful is possible" (41%), "I could be beautiful" (24%), "Some people need surgery to be beautiful" (16%), and "Being beautiful is important" (14%). Advertisement 1-featuring 3 women and no pre- or posttreatment photography, no physician photography, and a listing of the 3 physicians' credentials but not a list of the services provided-received the highest overall preference rating. CONCLUSIONS: Factors including emotions felt while reading, unique qualities of the advertisement, list of procedures performed, use of models versus actual patients, and pictures of the plastic surgeons were found to contribute to the respondents' overall perception of advertisements used to market a plastic surgery practice.

Rare Complications in Chondrolaryngoplasty: Preparation for Safe Outcomes.

Chondrolaryngoplasty ("tracheal shave") is a common procedure requested by transgender women as well as cisgender men and women. Management of intraoperative complications is crucial given the risk of damage to the vocal cords and loss of the airway in patients who are not intubated. We present two rare complications of chondrolaryngoplasty and their management.

No Thromboembolic Complications After Facial Feminization Surgery in Transgender Patients Utilizing Estrogen Therapy: A Retrospective Cohort Study.

Purpose: Estrogen therapy is associated with an increased risk of venous thromboembolism (VTE). A large proportion of transfeminine patients use estrogen therapy before undergoing gender-affirming surgery. Many surgeons implement the discontinuation of hormone therapy before surgery. This study sought to evaluate the perioperative risk of VTE in transfeminine patients undergoing the procedure of facial feminization. Methods: Retrospective chart reviews were performed of all patients who underwent facial feminization by a single surgeon at an urban academic institution from 2014 to 2020. Patient characteristics including comorbidities, Caprini score, VTE chemoprophylaxis, and perioperative hormone therapy management were reviewed. The incidences of VTE during perioperative hospital stay and within 1 week and 6 months after the surgical procedure were examined. Results: There were 296 facial feminization procedures performed on 282 distinct patients who met criteria for inclusion in the study. Hormone therapy was prescribed to 83.6% of patients, 69.5% of whom reported that they held these medications before the procedure. Of those holding, 84.1% of patients reported they discontinued these medications between 2 and 4 weeks. No patients received VTE chemoprophylaxis. There were 0 VTE incidents during the patients' perioperative period up to 6 months postprocedure. Conclusion: Our findings support that transfeminine patients who use estrogen hormone therapy are at a minimal risk to experience VTE when undergoing facial feminization procedures. Future directions include evaluating the psychologic effect of discontinuing hormone therapy to help guide perioperative decision making.

Approach to the Transgender Patient: Preoperative Counseling, Setting Expectations, Avoiding Potential Postoperative Pitfalls.

An increasing number of transgender patients are seeking gender-affirming facial surgery, also known as facial feminization surgery. Physicians offering these services must be well versed in how to compassionately care for this patient population. We recommend having a well-informed staff that is knowledgeable about proper verbiage, use of pronouns, and preferred names for transgender patients. We also recommend helping patients to manage expectations and seek realistic goals from the first consultation. A frank discussion about the limits of facial feminization is essential. Discussing the prolonged recovery and expected outcome is of paramount importance preoperatively to avoid postoperative disappointment.

Frontal Bone Cranioplasty for Facial Feminization in Gender-Affirming Surgery: Can Fewer Screws Fixate Bone and Avoid Nonunion?

Background: Facial feminization surgery can include forehead feminizing cranioplasty (FFC). The reshaped bones are fixated together with titanium plates and screws. Objective: To define the authors' preferred plating patterns and measure complications of bony nonunion when less hardware is applied. Methods: A 7-year retrospective review of patients who underwent FFC was conducted. Data collection included cranioplasty technique, fixation patterns, and complications. Traditional fixation (≥2 screws on each side of the osteotomy) was compared with conservative fixation (<2 screws). Results: A total of 483 patients were identified with a median of 241 days of follow-up (interquartile range: 8-528 days). Most patients (77.8%) had frontal bone fixation with microplates and screws. The most common combination was placement of two plates with four screws in total, comprising two screws on each plate, with one screw on each side of the fracture line (305/483, 63.1%). No signs or symptoms of bone flap mobility were noted on examination. Conclusion: Conservative fixation of the anterior table does not appear to increase signs of nonunion in forehead reshaping gender-affirming surgery.

Differences in Female and Male-to-Female Transgender Facial Skin Micro-Vessel Density.

Importance: The risk of hematoma formation after rhytidectomy is gender associated and can lead to postoperative complications. The literature to help explain and elucidate the mechanism behind this gender-associated risk is poorly developed and requires further investigation. Objective: The objective of this study was to compare facial skin micro-vessel density of female and male-to-female (MTF) transgender patients undergoing rhytidectomy to better understand the mechanism of gender-correlated hematoma risk factors. The authors hypothesized that transgender patients would have higher micro-vessel density compared with female patients. Design, Setting, and Participants: This was a prospective histopathological analysis of pre- and post-auricular facial skin samples from patients undergoing primary rhytidectomy. Patient clinical data and skin samples were collected. Histopathological slides were prepared and stained with CD-31, a marker of vessel endothelium, followed by image analysis allowing for micro-vessel stained pixel counts and calculated pixel density comparisons at a single academic hospital. Female, MTF transgender, and male patients >18 years of age were studied. Exposure: Patients undergoing primary rhytidectomy between 2015 and 2018. Main Outcomes: Gender-associated pre- and post-auricular micro-vessel pixel density. Results: Forty-one patients contributed skin samples for analysis. Post-auricular micro-vessel pixel density was greater than pre-auricular density (mean difference post-pre 0.359 percentage points [p.p.], standard error [SE] = 0.135, p = 0.009). The mean post-auricular micro-vessel pixel density was 1.60% (SE = 0.13 p.p.), 2.16% (SE = 0.19 p.p.), and 2.77% (SE = 0.34 p.p.) for female, transgender, and male patients, respectively (p = 0.016). Pre-auricular micro-vessel pixel density showed no difference among females, males, and transgender patients (p = 0.30). Gender was a strong predictor of increased post-auricular micro-vessel pixel density on stepwise linear regression, but it did not predict pre-auricular micro-vessel density. Both preoperative hair removal and a history of hypertension were associated with increased pre-auricular micro-vessel density. Conclusions and Relevance: Facial skin micro-vessel density differs by gender, in addition to pre- and post-auricular locations in patients undergoing rhytidectomy.