Trends in Rhinoplasty Research in Saudi Arabia: A 30-Year Bibliometric Analysis.

Rhinoplasty is one of the most commonly performed aesthetic surgeries. Saudi Arabia has a large number of rhinoplasty publications. Here, we aimed to assess the past, present, and future research output related to rhinoplasty in Saudi Arabia and compare it with global output. We performed a bibliometric analysis to evaluate rhinoplasty research productivity trends in Saudi Arabia from 1995 to 2021 in both cosmetic and reconstructive rhinoplasties. We considered all publications whose first authors were from Saudi Arabia or whose authors contributed significantly to a paper from Saudi Arabia, even though the first author was not from the Kingdom of Saudi Arabia. We evaluated the research quality of the articles using the impact factor of the journal in which the article was published. For each article, the number of authors, number of citations received, study design, region of the first author, and the level of evidence were collected. We gained several insights into the global trends of rhinoplasty in research and its position. We observed a significant increase in the number of publications on rhinoplasty in Saudi Arabia. Although there was no significant increase in the impact factor, most publications had a level of evidence of I or II.

Assessing Point-of-care Ultrasound Knowledge and Utilization among Emergency Physicians in Saudi Arabia: A Cross-sectional Survey.

Background: This study aims to assess the knowledge, perceptions, and utilization of point-of-care ultrasound (POCUS) among emergency physicians (EPs) in Saudi Arabia. Point-of-care ultrasound has emerged as a valuable tool in emergency medicine, providing real-time diagnostic information at the bedside. Understanding the current state of POCUS integration and the factors influencing its adoption is crucial for optimizing patient care in emergency settings. Materials and methods: A cross-sectional study was conducted across various hospitals in Saudi Arabia over six months. The study included 100 EPs, encompassing residents and specialists. Data were collected through an online self-administered questionnaire, exploring demographic factors, POCUS training, equipment availability, and physicians' perceptions. Statistical analyses were performed using SPSS version 28.0, including descriptive statistics and Chi-square tests. Results: The study revealed diverse demographic factors, with a majority of physicians working in regional emergency medical centers. While 84.0% of respondents had used an ultrasound device, varying levels of knowledge about POCUS were observed. Regional disparities and differences in training exposure were evident. The majority expressed positive perceptions of POCUS utility, with 67.0% recognizing its usefulness in primary care health centers. However, 31.0% only partially agreed on its daily practice utility, highlighting potential areas for intervention. Conclusion: This study provides a comprehensive assessment of POCUS awareness, knowledge, and perceptions among EPs in Saudi Arabia. The findings underscore the need for targeted educational initiatives, resource allocation, and regional considerations to enhance POCUS integration. Addressing perceived barriers and regional variations can contribute to the widespread adoption of POCUS, ultimately optimizing patient care in emergency settings. How to cite this article: Almulhim KN, Alabdulqader RA, Alghamd MK, Alqarni AA, Althikrallah FM, Alarfaj AA. Assessing Point-of-care Ultrasound Knowledge and Utilization among Emergency Physicians in Saudi Arabia: A Cross-sectional Survey. Indian J Crit Care Med 2024;28(8):769-776.

Impact of Tranexamic Acid on Bleeding Outcomes and Complication Rates in Facelift: A Systematic Review and Meta-analysis.

BACKGROUND: Rhytidectomy poses a significant risk of bleeding. Several studies have reported the safety profile and efficacy of tranexamic acid (TXA), an antifibrinolytic agent, in minimizing perioperative sequelae, particularly hematoma and bleeding. OBJECTIVES: The aim of this systematic review was to analyze the effect of TXA administration in facelift surgery, its effect with different routes of administration, and to compare different administration routes in reducing intraoperative blood loss, postoperative edema, and ecchymosis in rhytidectomy. METHODS: A systematic literature search was conducted to identify studies that reported on TXA in facelift surgery. The primary outcomes of interest were intraoperative blood loss, time to achieve hemostasis, operation duration, and postoperative hematoma, edema, ecchymosis, drain output, and major and minor complications. Meta-analyses of hematoma, operation duration, drain output, and major and minor complications were performed, and the risk of bias was assessed with ROBINS-I for nonrandomized studies, and Cochrane's RoB 2.0, a tool for randomized controlled trials. RESULTS: In total, 104 articles were included in the initial screening. Out of 388 participants 170 patients were administered TXA, predominantly female (over 91%), with ages from the late 50s to mid-60s. TXA administration varied, with subcutaneous injection being the most common method. The meta-analysis revealed that the pooled prevalence of minor and major hematoma in TXA recipients was remarkably low, with a significant reduction in the risk of minor hematoma (odds ratio [OR] = 0.18, 95% CI 0.05-0.62, P < .001) and no significant difference in major hematoma risk. Interestingly, TXA significantly reduced postoperative drainage compared to the controls (mean difference = -25.59, 95% CI, -30.4--20.77, P < .01). Additionally, neither minor nor major complications were significantly different between the TXA recipients and controls. Specifically, the pooled odds for the incidence of major complications were not significantly different (OR = 1.47, 95% CI, 0.23-9.19, P = .68), and similar results were found for minor complications (OR = 0.59, 95% CI, 0.23-1.48, P = .26). CONCLUSIONS: TXA significantly reduces postoperative drain output and minor hematomas in facelift surgery without increasing major complications. It also reduces edema, ecchymosis, and intraoperative blood loss. However, further studies are required to explore the efficacy of TXA with different dosages and administration routes.

Indications, Stability, and Surgical Outcomes of Using Osteochondral Nasal Septal Graft as a Septal Extension Graft in Rhinoplasty Patients: A Prospective Cohort Study.

Septal extension graft (SEG) is an adaptable tool that controls, supports, and stabilizes the nasal tip projection, rotation, length, and shape. Recent studies comparing SEGs to more conventional columellar strut grafts found that SEGs provided improved results. This prospective cohort study included 66 patients divided into 2 groups based on their indications. Group 1 was patients who underwent septorhinoplasty using osteochondral septal extension graft (OSEG), and group 2 underwent septorhinoplasty using cartilaginous SEG. The main reason for undergoing OSEG was insufficient septal cartilage (P<0.001). The outcomes were not significantly different between both groups, with the % of patients who experienced positive outcomes ranging from 78.8% to 97%. The OSEG is a safe, valid, and effective option in septorhinoplasty that can be used in patients with insufficient cartilaginous septum.

Perception of Rhinoplasty Outcome Utilizing Patients' Photography.

BACKGROUND: Patient satisfaction with rhinoplasty results is evaluated in a manner of subjective and qualitative values, and to a certain degree, it can indicate successful outcomes in rhinoplasty. METHODS: The present study was a descriptive study that assessed the rhinoplasty outcome of adult patients who underwent septorhinoplasty between January 2015 and August 2023 at a single center in Saudi Arabia utilizing Rhinoplasty Outcome Evaluation scores and Nasal Obstruction Symptom Evaluation scores pre-operatively, postoperatively, and postoperatively with showing the patients their photo before surgery. RESULTS: The comparison of Rhinoplasty Outcome Evaluation scores and Nasal Obstruction Symptom Evaluation scores showed statistically significant with P value of 0.000 when comparing these scores pre-operatively, postoperatively, and postoperatively with showing the patient their photos before surgery. CONCLUSION: Presenting patients with pre-operative images may help them recognize changes in their clinical appearance and, consequently, score higher on the postoperative satisfaction scale. It can help the surgeon to increase patient satisfaction postoperatively.

Assessment and diagnostic methods of internal nasal valve: Systematic review and meta-analysis.

Background: Accurate methods are needed to evaluate the anatomy of the internal nasal valve (INV), yet there is currently no ideal measurement technique. Our systematic review aims to establish a comprehensive INV assessment tool, compare different INV diagnostic tools, and establish the most ideal measurement technique for the evaluation of the INV. Methods: A systematic review and meta-analysis were conducted following the PRISMA guidelines, and the study was recorded in PROSPERO under reference number CRD42023407950. A systematic search was performed in PubMed, MEDLINE, The Cochrane Library (Cochrane Databases of Systematic Reviews), and the Cochrane Register of Controlled Trials (CENTRAL) for studies assessing INV that were conducted between 1996 and 2023. Result: Of the 421 total database searches, 23 studies were found, covering a total of 974 patients (6 studies assessed the accuracy of different diagnostic methods, with 2 of these studies comparing two different diagnostic modalities, and 17 studies measured INV angle). Based on the STROBE tool for quality appraisal the mean score was 16.92 ± ± 2.29, indicating a moderate quality. When comparing INV angle values from preoperative and postoperative records as obtained from CT readings, results showed no significant differences between the pre- and postoperative values (MD = -1.8, 95% CI, -4.8 to 1.2, p = .227). Conclusion: Acoustic rhinometry has the highest accuracy, followed by rhinomanometry then CT scan then endoscopy. Meta-analysis showed no significant differences between the pre- and postoperative values and a significant heterogeneity in the reported INV angle values across studies.

Efficacy and Safety of Triamcinolone Acetonide Injections Following Rhinoplasty: A Systematic Review of Recommended Doses, Complications, and Outcomes.

BACKGROUND: Triamcinolone acetonide injections (TAIs) have been suggested to decrease complications following rhinoplasty. This systematic review aimed to assess the efficacy and safety of TAIs following rhinoplasty. METHODS: We performed a systematic literature search on Medline, Embase, Google Scholar, and Cochrane Central Register of Controlled Trials from inception to May 2023, without any timeframe limitations. The following terms were used: (Triamcinolone OR steroid injections OR triamcinolone acetonide) AND (Skin thickness OR supratip edema OR supratip deformity OR Pollybeak deformity) AND (rhinoplasty OR external rhinoplasty). We included randomized controlled trials and observational studies (prospective, retrospective, and case series). RESULTS: In total, six of the 1604 articles met our inclusion criteria. A total of 1524 patients were included in this study. Our results included patient demographics, type of rhinoplasty, post-injection follow-up period, site of injection, type of syringe used, timing of the first dose, volume and concentration used, time interval between doses, response to the injection, and complications of injection. CONCLUSION: To our knowledge, this is the first systematic review to address this issue. Our results demonstrate the ease and safety of TAIs as a first-line treatment, with positive outcomes and limited complications. TAIs can be used early postoperatively to minimize the need for revision surgery. Despite the limited number of studies on TAIs, this study provides the best available evidence that can help surgeons decide when to use the injection, the intervals between doses, and the duration of use. Further randomized controlled trials are required to confirm our findings. LEVEL OF EVIDENCE II: 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 .

Modified Alar Base Reduction: A Novel Technique.

BACKGROUND: Alar base reduction (ABR) surgery is one of the rhinoplasty techniques used to reduce alar flaring, nasal base width, or both. It is crucial for rhinoplasty surgeons to understand and analyze the type of nasal base deformity to achieve satisfactory results and avoid complications. OBJECTIVES: The objective of this study is to describe a novel technique of ABR that addresses alar flaring while avoiding violation of the nostril marginal rim. METHODS: This prospective cohort study included patients with alar flaring who underwent rhinoplasty or septorhinoplasty with ABR using our modified technique. Demographic data, clinical history, aesthetic concerns, and preoperative and postoperative photographs were collected for each patient. The surgical outcome was assessed using subjective scar evaluation scores at 3 and 6 months, the Stony Brook Scar Evaluation Scale at 6 months, and an overall appearance satisfaction score. RESULTS: A total of 8 patients were included in the study. Subjectively, the majority of patients (75%) reported satisfactory scar appearance at the 6-month follow-up. The mean Stony Brook score was 4.7 (SD=0.74). Nostril symmetry was achieved in all patients. Seventy-five percent of the participants expressed satisfaction with the overall appearance. CONCLUSIONS: Our modified ABR technique demonstrates promising results in correcting alar flaring while achieving nostril symmetry with an acceptable scar. Further studies with a larger sample size are needed to evaluate the feasibility of the technique and compare it to other classical techniques. LEVEL OF EVIDENCE: Level IV.

The Association Between Nasal Skin Thickness and Body Mass Index in Preoperative Rhinoplasty Patients: A Prospective Study.

OBJECTIVES: Skin quality plays a major role in aesthetics, particularly in determining the success of rhinoplasty. Efficient preoperative estimation of nasal skin thickness can improve postoperative results and patient satisfaction. This study aimed to report on the relationship between nasal skin thickness and body mass index (BMI) as a possible tool to measure skin thickness preoperatively among rhinoplasty patients. METHODS: This prospective cross-sectional study targeted patients who visited a rhinoplasty clinic at King Abdul-Aziz University Hospital, Riyadh, Saudi Arabia, between January 2021 and November 2021, and agreed to participate in the study. Data on age, sex, height, weight, and Fitzpatrick skin types were collected. The participant visited the radiology department and underwent ultrasound nasal skin thickness measurement for the five different nasal points. RESULTS: The study included 43 participants (16 males and 27 females). The average skin thickness of the supratip area and the tip was significantly higher in males than in females (P < 0.05). The average BMI of the participants was 25.8 ± 5.26 Kg/m2. Participants with a normal BMI or less represented 50% of the study sample, whereas overweight and obese represented one-quarter (27.9%) and one-fifth (21%), respectively. CONCLUSION: BMI was not associated with nasal skin thickness. Differences in nasal skin thickness were found between the sexes.

Surgical Approaches and Outcomes of Short Nose Correction: A Descriptive Systematic Review of the Literature.

OBJECTIVES: The purpose of this study is to describe all published techniques of short nose correction released by surgeons over the years and summarize their outcomes in a descriptive systematic review of the literature. PATIENTS AND METHODS: A computerized literature search was conducted using 5 major databases. All original studies discussing correction methods and/or outcomes of shortened noses were included. The risk of bias was evaluated blindly by 2 reviewers, and the data were descriptively presented. The study protocol was recorded in the International Prospective Register of Systematic Reviews. RESULTS: A total of 24 studies including 1450 patients were included. Lengthening of the nose was performed through a cartilage-only graft in 14 studies, whereas bone graft was used in 3 studies. The mean increase in nasal tip projection in 5 reports ranged from 0.05 to 2.2 mm. The mean nasal length before and after rhinoplasty was reported in 8 studies, with a mean increase ranging from 0.28 to 6.2 mm. Regarding surgical complications, 30 patients had implant deviation or migration, 22 patients experienced postoperative infection, and 12 patients required corrective surgery. CONCLUSIONS: Augmentation of a short nose is a challenging surgical procedure for rhinoplasty. There are several techniques for short nose correction; however, it is difficult to evaluate the outcomes in the absence of a standard tool of assessment. Further analytical studies are warranted to fully evaluate surgical techniques.

A Novel Technique for Spreader Flap by Folding the Dorsal Hump in Patients Undergoing Primary Rhinoplasty.

OBJECTIVES: We describe our novel modified spreader flap, which involves keeping the large cartilaginous septal T hump attached to the upper lateral cartilages to increase the thickness and length of the flap. Our objectives were to assess hump reduction and recurrence, nasal axis deviation, dorsal width, internal nasal valve grade, and Rhinoplasty Outcome Evaluation (ROE) score preoperatively and one year postoperatively. MATERIALS AND METHODS: In a prospective study that included 21 patients who met the criteria, patients were followed up for 1 year after surgery, with an assessment of the dorsal projection, tip projection, axis deviation, dorsal width, and internal nasal valve grade. In addition, the modified Cottle maneuver and Rhinoplasty Outcome Evaluation score were also performed and obtained, respectively. RESULTS: Our novel technique was performed in 20 patients (95.2%). In 1 additional patient, we added a regular auto-spreader flap on the contralateral side. One year postoperatively, the axis was found in the midline in all patients (100%). Assessment of internal valve collapse showed that collapse was reduced to grade 0 in 13 patients (61.9%) and grade 1 in 8 patients (38.1%). There were no hump recurrences or visible irregularities. The results showed a statistically significant difference between the pre- and postoperative values in dorsal projection, dorsal width, and rhinoplasty outcome evaluation score. CONCLUSIONS: This novel technique shows promising statistically significant results in reducing dorsal hump projection and width, correcting axis deviation, and improving internal nasal valve and rhinoplasty outcome evaluation score, while being less cartilage and time-consuming.

Indications, Techniques, and Postoperative Outcomes of Temporalis Fascia Grafting in Rhinoplasty.

OBJECTIVES: To investigate the indication, site, techniques, and complications at the donor and recipient sites of temporalis fascia grafting in rhinoplasty, and patients' satisfaction with the surgical outcomes. METHODS: This retrospective cohort study was performed at King Abdulaziz University Hospital, Saudi Arabia, between January 2015 and January 2020. The predictor variable was the temporalis fascia in different forms. Reported variables comprised individuals' satisfaction, dorsal nasal irregularities, and contour definitions. Moreover, further variables were considered, including age, gender, the reason behind surgery, surgical type, and graft size and site. A rhinoplasty doctor, other than a surgeon, has assessed the dorsal augmentation findings by inspecting and palpating the dorsum. Data analyses were achieved through SPSS. RESULTS: A total of 69 patients were enrolled in this study; 44.9% of them underwent rhinoplasty with the temporalis fascia in cartilage wrapped by the temporalis fascia form, 43.5% in a blanket form, and 11.6% in a ball form. The average subject satisfaction outcome score was 10.44 preoperatively and 19.72 postoperatively ( P = 0.001).No dorsal irregularities were detected by inspection in all forms of the temporalis fascia, whereas 3 patients with the blanket and 2 patients with the cartilage wrapped by the temporalis fascia had irregularities, which were detected on palpation. CONCLUSIONS: In rhinoplasty, the temporalis fascia is a favorable choice for nasal reconstruction since it is simple in harvesting and can be made in different forms and shapes for many purposes.

Tubed Temporalis Fascia for Nasal Dorsal Contouring: A Novel Technique.

INTRODUCTION: Nasal dorsum irregularities may occur after nasal trauma or as a postrhinoplasty complication. Here, we present a novel technique using temporalis fascia (TF) grafting for primary and revision rhinoplasty to repair the nasal dorsum, hide nasal irregularities, and improve nasal contouring. METHODS: This prospective cohort study was conducted from January 2019 to June 2019 and evaluated nasal dorsal contouring using the TF in a tubed form. The outcome variables were patient satisfaction, dorsal irregularity, and contour definition. The predictor variable was the use of tubed TF for dorsal augmentation. Other associated variables were age, sex, indication for surgery, surgery type, and graft size. Patient satisfaction was evaluated using the Rhinoplasty Outcome Evaluation questionnaire. A rhinoplasty specialist other than the surgeon who performed the procedure evaluated the dorsal augmentation outcomes by inspection and palpation of the dorsum. All statistical analyses were performed using the SPSS software. RESULTS: Seventy-four patients (21.6% men and 78.4% women) were treated with the tubed TF. The mean age was 28.97 years. Thin skin was the most common indication (48.6%) for using TF. The graft size was 2-5 cm; inspection and palpation revealed no irregularities. No reception site complications occurred. One patient had a mild hematoma at the donor site. The mean patient satisfaction score was 10.14 preoperatively and 19.95 postoperatively (p = 0.001). DISCUSSION/CONCLUSIONS: Our novel technique of using the TF graft in a tubed form was easy to perform. Furthermore, the tubed TF covers all irregularities, is good for dorsal augmentation, and improves dorsal contouring and definition.

Catgut Versus Polypropylene Sutures for Transcolumellar Incision Closure in Open Rhinoplasty: A Retrospective Cohort Study.

Background Open rhinoplasty, including the transcolumellar approach, is commonly performed as it has fewer side effects and provides superior anatomical control to the surgeons compared to closed rhinoplasty. However, the postoperative scar outcomes, such as scar appearance, vary depending on the type of suture used in wound closure, and the optimal suture type is not firmly established. Objective To compare the impact of catgut versus polypropylene sutures on the postoperative transcolumellar scar outcomes and patient satisfaction following open rhinoplasty. Methods This retrospective cohort study, including 100 patients who underwent transcolumellar open rhinoplasty, was conducted at otolaryngology department of King Abdulaziz University Hospital, Riyadh, KSA. The patients were divided into two groups: the propylene suture group (group 1), which included 15 males and 35 females with a mean age of 31.5 years and underwent surgery using propylene sutures, and the catgut suture group (group 2), which included 10 males and 40 females with a mean age of 30.5 years and underwent surgery using catgut sutures. The postoperative transcolumellar scar outcomes, as determined by visual analogue scale (VAS) and Stony Brook Scar Evaluation Scale (SBSES) scores, and patient satisfaction, as assessed using a self-assessment scale, were compared between groups. Results The scars were unnoticeable in the majority of both groups: 88% in group 1 and 86% in group 2. The VAS and SBSES scores did not significantly differ between groups. Patients' satisfaction rates were also comparable and did not significantly differ between groups (p = 0.341). Conclusion Both catgut and polypropylene sutures lead to similar outcomes and patient satisfaction rates in terms of postoperative rhinoplasty transcolumellar scars. Thus, catgut may be the optimal suture for closing transcolumellar incisions following open rhinoplasty.

Evaluation of Scar Outcome After Alar Base Reduction Using Different Surgical Approaches.

PURPOSE: Alar base reduction was first performed in 1892, when Robert Weir began performing surgery to correct nasal flaring. Our study objective was to investigate scar outcomes after alar base reduction with different surgical approaches. MATERIALS AND METHODS: We performed a retrospective cohort study of patients who underwent alar base reduction at King Abdulaziz University Hospital. The primary predictor variable was wound incision in the alar-facial groove; other variables were age, gender, and time interval. The outcome variable, scar status, was assessed subjectively (unnoticeable, noticeable but acceptable, or noticeable and unacceptable) and objectively by rhinoplasty surgeons using Stony Brook Scar Evaluation Scale scores. Paired t tests were used, with P ≤ .05 considered statistically significant. RESULTS: A total of 70 patients were included, with 35 in each of 2 groups. The incision for alar reduction was placed in the alar-facial groove in group 1; the incision was placed 1 to 2 mm anterior to the alar-facial groove in group 2. Group 1 consisted of 14 men (40%) and 21 women (60%); group 2 consisted of 8 men (22.9%) and 27 women (77.1%). The average Stony Brook Scar Evaluation Scale scores for groups 1 and 2 were 4.62 and 4.48, respectively, and did not differ significantly (P = .196). During subjective scar assessment, 85.7% of patients from group 1 reported that their scars were unnoticeable whereas 14.3% reported that they were noticeable but acceptable. In group 2, 82.9% of patients reported unnoticeable scars whereas 17.1% reported noticeable but acceptable scars. Thus, no significant differences were observed in the subjective assessment between the 2 groups (P = .286). CONCLUSIONS: Alar resection along the alar-facial groove ensures better scar outcomes and hides the scar within that groove, especially in patients with a deep facial groove. Future studies should focus on the best method for limiting scarring in patients without deep facial grooves.

The effect of ketamine versus fentanyl on the incidence of emergence agitation after sevoflurane anesthesia in pediatric patients undergoing tonsillectomy with or without adenoidectomy.

BACKGROUND: Emergence agitation (EA) has been documented as a common side-effect of sevoflurane anesthesia. This prospective, randomized, double-blind, placebo-controlled study was designed to compare the effects of ketamine versus fentanyl, administered 10 min before the end of surgery on the development of EA. METHODS: A total of 120 children aged 3-7 years of American Society of Anesthesiologists I-II physical status were randomly assigned to one of three equal groups receiving either ketamine 0.5 mg/kg (Group K), fentanyl 1 µg/kg (Group F) or saline (Group C) at 10 min before the end of surgery. Post-operative EA was assessed with Aono's four point scale. Recovery times, the post-operative pain and adverse reactions were assessed. RESULTS: There was no significant difference between the three groups regarding recovery and discharge times from post-anesthesia care unit. The incidence of EA was significantly low in Group K and Group F (15% and 17.5%, respectively) compared to the control group (42.5%), with no significant difference between Group K and Group F. There were no significant differences in Children's Hospital of Eastern Ontario Pain Scale between the three groups. The incidence of nausea or vomiting was significantly more in Group F compared to that in other two groups. However, no complications such as somnolence, oxygen desaturation or respiratory depression occurred during the study period and there were no episodes of hallucinations or bad dreams in the ketamine group. CONCLUSION: The intravenous administration of either ketamine 0.5 mg/kg or fentanyl 1 µg/kg before the end of surgery in sevoflurane-anesthetized children undergoing tonsillectomy with or without adenoidectomy reduces the incidence of post-operative agitation without delaying emergence.