The Rhytidectomy Scar: Analysis of Patient and Surgeon Perspectives.

An understanding of patient preference is vital for surgeons to create outcomes that align with the goals of patients undergoing cosmetic surgery. This study analyzes the perception of the rhytidectomy scar from the perspective of cosmetic patients and surgeons. Cross-sectional surveys were administered in-person to cosmetic patients and online to facial plastic and reconstructive surgeons in the United States. Participants were presented with standardized lateral view photographs of preauricular scars for 10 patients at least 12 months post rhytidectomy procedure. A variety of rhytidectomy incisions were chosen to include pre- versus post-tragal incisions, blunted hair tuft, hypopigmentation, narrow versus wide scar healing. Participants were asked to rate the outcome of the preauricular rhytidectomy scar using the Likert scale from 1 to 10. Quantitative analysis indicates that while both surgeons and cosmetic patients viewed hypopigmented scars less favorably, surgeons were more concerned with pre-tragal incision and blunted hair tuft. Furthermore, the number of rhytidectomies performed by surgeons resulted in more critical analysis of the scars presented in this study. Qualitative analysis of the frequent use of "natural" in the patient comments suggests the importance of maintaining a sense of "normalcy" as well. In contrast, the surgeon comments are most frequently about the relationship between the scar and surrounding anatomical structures, suggesting a descriptive focus on the technicality of scar placement and subsequent anatomical result. Cosmetic patients are primarily concerned about scar appearance while surgeons are more focused on the technical orientation of the scar. An understanding and comparison of the language and perceptions of surgeons and cosmetic patients regarding rhytidectomy scars are vital in creating aesthetic results and managing patient expectations.

Progressive Improvement in Static Glabellar Lines After Repeated Treatment With DaxibotulinumtoxinA for Injection.

BACKGROUND: DaxibotulinumtoxinA for Injection (DAXI) is a novel botulinum toxin in development that has demonstrated efficacy on dynamic glabellar lines. OBJECTIVE: To evaluate the effect of repeated DAXI treatment on static glabellar lines. METHODS: This post hoc analysis included adults with moderate or severe dynamic glabellar lines who were treated with 40U DAXI in the SAKURA clinical program. Glabellar line severity was evaluated through validated subject and investigator scales. RESULTS: Overall, 568 subjects received 3 DAXI treatments. Most subjects were White (92.3%) and female (85.7%). At baseline, 9.0% and 27.3% of subjects had no static glabellar lines based on subject and investigator assessment, respectively. Four weeks after DAXI Treatment Cycle 1, the proportion of subjects with no static glabellar lines increased to 57.9% and 64.8% based on subject and investigator assessment, respectively. At Week 4 after DAXI Treatment Cycles 2 and 3, the proportion further increased to 68.7% and 71.5%, respectively, based on subject assessment and 75.0% and 77.6% based on investigator assessment. CONCLUSION: Subjects who received repeated DAXI treatment showed progressive improvement in their static glabellar lines. The extended duration of therapeutic benefit with DAXI on dynamic glabellar lines likely provides a long period of muscle inactivity/hypoactivity, during which dermal remodeling can occur.

DaxibotulinumtoxinA for Injection for the Treatment of Glabellar Lines: Efficacy Results From SAKURA 3, a Large, Open-Label, Phase 3 Safety Study.

BACKGROUND: DaxibotulinumtoxinA for Injection (DAXI) is botulinum toxin Type A formulated with a novel peptide excipient. Two pivotal, single-treatment, placebo-controlled trials demonstrated efficacy and safety for moderate or severe glabellar lines. OBJECTIVE: To further evaluate DAXI in a large, open-label, repeat-treatment study. METHODS: Subjects (n = 2,691) were enrolled from the preceding pivotal trials or de novo and received 40U DAXI. Those who received repeat treatments could be retreated when they returned to baseline on the Investigator Global Assessment-Frown Wrinkle Severity (IGA-FWS) and Patient FWS (PFWS) scales at/after 12 weeks and up to 36 weeks after treatment. RESULTS: High (>96%) response rates (none or mild severity) on the IGA-FWS scale were seen after each of the 3 treatments, with peak response between Weeks 2 to 4. At Week 24, ≥32% had a response of none or mild severity. Peak response rates of ≥92% were observed at Weeks 2 to 4 on the PFWS scale. The median duration for return to moderate or severe severity was 24 weeks. The safety profile was favorable and consistent with previous trials. CONCLUSION: DaxibotulinumtoxinA for Injection efficacy was highly consistent across treatment cycles. These results confirm the previously observed efficacy rates and duration of response.

A Randomized, Comparator-Controlled Study of HARC for Cheek Augmentation and Correction of Midface Contour Deficiencies.

BACKGROUND: HARC is a soft and flexible hyaluronic acid filler containing lidocaine, manufactured using XpresHAn® technology, restoring natural-looking volume and soft contours. OBJECTIVES: To evaluate safety and effectiveness of HARC for cheek augmentation and correction of midface contour deficiencies compared to a control product HAJV (hereafter referred to as Control). Primary objective was to demonstrate non-inferiority of HARC compared to the Control, by blinded evaluation of change from baseline in midface fullness 12 weeks after last injection, using a 4 grade midface volume scale (MMVS). MATERIALS AND METHODS: Subjects over the age of 21 with loss of fullness in the midface area (MMVS score 2, 3, or 4) were randomized 2:1 to treatment with HARC(n=142) or Control (n=68). Optional touch-up was allowed after 4 weeks. Study assessments included MMVS, aesthetic improvement, subject satisfaction, and safety. Subjects were followed for 48 weeks. RESULTS: Overall, most subjects were female (89%) and mean age was 53 years (range 24-80). Total mean volume injected was 4.3 mL for HARC and 4.9 mL for Control. Primary objective was met; mean change from baseline in MMVS score at week 12: -1.4 (HARC), -1.3 (Control), 95% CI: -0.22, 0.06. HARC effectiveness was supported by a high degree of aesthetic improvement and subject satisfaction throughout 48 weeks. Related adverse events were generally mild and transient. CONCLUSIONS:  HARC was well tolerated and non-inferior to Control for correction of midface fullness at 12 weeks after last injection. Aesthetic improvement and subject satisfaction were high and lasted through week 48.  J Drugs Dermatol. 2021;20(9):949-956. doi:10.36849/JDD.6191.

The Valuation of Rhytidectomy in Different Economic Markets.

This study demonstrates that the trend of how rhytidectomy is valued can be used to determine not only the pricing of this good but also how receptive developing economic markets are to the export of cosmetic facial plastic surgery. This study seeks to analyze and compare the value of rhytidectomy in an established market and an emerging market. A cross-sectional survey was administered through public online forums to 162 casual observers in the United States and 74 casual observers in India. Participants were shown pre- and postoperative photos of 10 patients who underwent cosmetic rhinoplasty and 2 patients who did not undergo surgery. Observers were asked to quantify the perceived change in attractiveness, change in age, and willingness to pay (WTP). There is a similar nonlinear trend between WTP and change in attractiveness in both the United States and India. Baseline values of rhytidectomy in the United States and India have a similar ratio of 2.122 compared with the ratio between both countries in the 2018 Big Mac index. The comparison of the trend in WTP in the United States and India shows that facial cosmetic surgery functions as a luxury good in both an established market and an emerging market. Our model successfully approximates the relationship between each country's purchasing power parity. Since the market behavior of rhytidectomy can be predicted based on purchasing power parity, there may be an untapped market for facial cosmetic surgery among populations with growing economies.

The Art of Camouflage: When Can a Revision Rhinoplasty Be Nonsurgical?

Rhinoplasty surgery is known to have revision rates up to 20%. Surgical revisions include the risk of anesthesia and scarring. The skilled injector may offer nonsurgical alternatives to patients when considering revision surgery. Injections can be done to improve symmetry or improve/camouflage deformities that are possibly too minor for surgery but bothersome to the patient. Injections can be performed using different filler materials, but these treatments also carry inherent risks.

Nonsurgical Rhinoplasty.

"Nonsurgical rhinoplasty" refers to the use of injectable temporary fillers used to augment select areas of the nose to achieve improved appearance or function in select patients. Nonpermanent fillers can be used safely and must be properly chosen based on their properties and the desired effect. In addition to proper patient and product selection, a thorough understanding of nasal anatomy, analysis of the deformity, and recommended injection techniques are absolutely necessary to obtain good outcomes and avoid complications. The proper plane for injection is the deep fatty layer, just superficial to the perichondrium and periosteum. Erring on the side of undercorrection, small incremental boluses, and constant reassessment are the best way to avoid overfilling or producing irregularities and asymmetries. The most devastating and feared complications are vascular compromise, tissue necrosis, and even blindness, making the nose a challenging area to treat with fillers. The surgeon wishing to use fillers in the nose should be familiar with proper technique, recognition of developing problems, and have a practical plan in place for immediate reversal and treatment.

Women in Facial Plastic and Reconstructive Surgery: The State of the Academy and Why It Matters.

Facial plastic and reconstructive surgery has historically been a male-dominated field. It is critical to assess the current state of female representation within our Society to better gauge how we reflect the changing needs of our community and our patients. Although we have made headway in fostering a community ripe for progress, we must continue to create and promote equal opportunities, dissuade microaggressions, address burnout, and capitalize on the innate strengths of our female constituents. With the data presented in this study, we hope to further illuminate the benefits of women engagement in our Academy while recommending sustainable actions to create a culture of allyship.

Correcting for Rater Effects in Operating Room Surgical Skills Assessment.

OBJECTIVE: To estimate and adjust for rater effects in operating room surgical skills assessment performed using a structured rating scale for nasal septoplasty. METHODS: We analyzed survey responses from attending surgeons (raters) who supervised residents and fellows (trainees) performing nasal septoplasty in a prospective cohort study. We fit a structural equation model with the rubric item scores regressed on a latent component of skill and then fit a second model including the rating surgeon as a random effect to model a rater-effects-adjusted latent surgical skill. We validated this model against conventional measures including the level of expertise and post-graduation year (PGY) commensurate with the trainee's performance, the actual PGY of the trainee, and whether the surgical goals were achieved. RESULTS: Our dataset included 188 assessments by 7 raters and 41 trainees. The model with one latent construct for surgical skill and the rater as a random effect was the best. Rubric scores depended on how severe or lenient the rater was, sometimes almost as much as they depended on trainee skill. Rater-adjusted latent skill scores increased with attending-estimated skill levels and PGY of trainees, increased with the actual PGY, and appeared constant over different levels of achievement of surgical goals. CONCLUSION: Our work provides a method to obtain rater effect adjusted surgical skill assessments in the operating room using structured rating scales. Our method allows for the creation of standardized (i.e., rater-effects-adjusted) quantitative surgical skill benchmarks using national-level databases on trainee assessments. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Aesthetic analysis in rhinoplasty: surgeon vs. patient perspectives: a prospective, blinded study.

OBJECTIVE: To determine how patients seeking cosmetic rhinoplasty analyze themselves compared to their surgeon's analysis. Simply stated, "Does your surgeon view your nose the same as you?" STUDY DESIGN: Prospective, blinded study. METHODS: All primary rhinoplasty consultations completed a nasal analysis questionnaire. The patients' facial plastic surgeons completed an identical questionnaire. The results were compared and analyzed. RESULTS: Data underwent statistical analysis and subsequent factor analysis was performed. 132 patients participated in the study. Questions were grouped together based on factors: overall appearance, skin quality, tip dimensions, straightness, nostril show, and width. The only factor with reasonable surgeon/patient correlation was factor 1, overall appearance, with correlation 0.6473, p<0.001. CONCLUSIONS: Surgeons and patients are in agreement with the overall appearance of the nose, but differ in their analysis regarding the details. This information can be used to guide future discussions during consultations and most importantly help to better gauge and manage patient expectations.

Nonsurgical rhinoplasty.

Interest in liquid, or nonsurgical rhinoplasty, has increased in demand as patients pursue less invasive techniques to achieve their aesthetic goals. Improved filler technology and refinement in injection techniques have made liquid rhinoplasty a reasonable choice for well-selected patients in both primary and revision rhinoplasty cases. This article reviews nasal anatomy, injection techniques, selected applications, and safety measures pertinent to performing nonsurgical rhinoplasty.

Do Attending and Trainee Surgeons Agree on What Happens in the Operating Room During Septoplasty?

Background: Surgeons must select cases whose complexity aligns with their skill set. Objectives: To determine how accurately trainees report involvement in procedures, judge case complexity, and assess their own skills. Methods: We recruited attendings and trainees from two otolaryngology departments. After performing septoplasty, they completed identical surveys regarding case complexity, achievement of goals, who performed which steps, and trainee skill using the septoplasty global assessment tool (SGAT) and visual analog scale (VAS). Agreement regarding which steps were performed by the trainee was assessed with Cohen's kappa coefficients (κ). Correlations between trainee and attending responses were measured with Spearman's correlation coefficients (rho). Results: Seven attendings and 42 trainees completed 181 paired surveys. Trainees and attendings sometimes disagreed about which steps were performed by trainees (range of κ = 0.743-0.846). Correlation between attending and trainee responses was low for VAS skill ratings (range of rho = 0.12-0.34), SGAT questions (range of rho = 0.03-0.53), and evaluation of case complexity (range of rho = 0.24-0.48). Conclusion: Trainees sometimes disagree with attendings about which septoplasty steps they perform and are limited in their ability to judge complexity, goals, and their skill.

How Old Do I Look? Exploring the Facial Cues of Age in a Tasked Eye-Tracking Study.

Importance: This is the first eye-tracking study to use a tasked age estimation paradigm to explore the facial cues of age as seen by casual observers. Objectives: Determine where observers gaze on faces when tasked with estimating an individual's age. Design, Setting, and Participants: This was a prospective controlled experiment, which took place at an academic tertiary referral center. In total, 220 casual observers (80 untasked, 140 tasked) viewed frontal facial images of women while an infrared eye-tracking monitor recorded their eye movements and fixations in real time. Main Outcomes and Measures: Multivariate Hotelling's analysis followed by planned posthypothesis testing was used to compare fixation durations for predefined regions of interest, including the central triangle, upper face, midface, lower face, and neck between tasked and untasked observers. Results: A total of 80 observers (mean age 23.6 years, 53% female) successfully completed the first untasked eye-tracking experiment. A total of 140 observers (mean age 26.1 years, 60% female) successfully completed the second age estimation experiment. On multivariate analysis, there were significant differences in the distribution of attention between observers in the two experiments (T2 = 99.70; F(5,2084) = 19.9012, p < 0.0001). On planned posthypothesis testing, observers attended significantly more to the lower third of the face (0.20 s, p < 0.0001, 95% confidence interval (CI) 0.14-0.27 s) and neck (0.05 s, p = 0.0074, 95% CI 0.01-0.08 s) and less to the upper third of the face (-0.27 s, p < 0.0001, 95% CI -0.40 to -0.14 s) when tasked. There was no significant difference in time spent on the whole face in the two experiments, suggesting that peripheral elements such as hair color or jewelry did not significantly influence gaze patterns. Conclusions and Relevance: Humans form judgments about others every day of their lives, and age perception colors their every interaction. To our knowledge, this study is the first to use eye tracking to investigate facial cues of age. The results showed that when tasked with estimating age, casual observer visual attention was shifted toward the lower face when compared with those who were untasked. These data inform our understanding of facial age perception and potential areas to target for facial rejuvenation. Level of Evidence: NA.

Normal Gaze Patterns of the Face in Lateral View.

Importance: Current efforts to quantify the attentional distraction of facial deformities have been limited to deformities that are best perceived when the face is in frontal view, and there remains a paucity of knowledge of societal perception of the face in lateral view. To date, no attempts have been made to characterize the fixation patterns of the face in lateral view. Objective: To characterize the fixation patterns and gaze patterns of the face in lateral view. Design, Setting, and Participants: This was a prospective randomized controlled trial at an academic tertiary medical center. Eighty participants (mean age 23.6 ± 1.7 years, 52.5% female) gazed freely at 11 images of faces in lateral view for 10 s each as an infrared eye-tracker recorded eye movements in real time. Main Outcomes and Measures: Recorded eye movements are superimposed on the images to visualize areas of interest (AOIs) that attract the most attention. Fixation duration targeted at each AOI is transformed into relative fixation of the entire face and neck. Hotelling's test of variance followed by post hoc t-testing assessed for the significance of fixation differences between the mouth and cheeks. Results: Participants spent an average of 6.0 (95% CI 5.8-6.2) s gazing at the face and neck areas of each image. Of this attention, 2.8 s or 49.8% (45.4-54.2%) was directed toward the eye, followed distantly by the nose (mean, 95% CI) (16.4%, 14.5-18.3%), cheek (12.0%, 11.4-14.5%), neck (4.6%, 3.8-5.4%), and mouth (4.0%, 3.4-4.6%). These differences were found to be significant by Hotelling's analysis and post hoc testing. A student's t-test also indicated observers directed significantly more attention within the eye-nose-cheek triangle [4.6 s or 79.5% (75.6-83.5)] compared with the eye-nose-mouth triangle [4.1 s or 71.2% (66.9-75.5)] (p < 0.001). Conclusions and Relevance: When perceiving novel faces in lateral view, casual observers preferentially directed attention toward the eye, nose, and cheek. These findings suggest that we draw from a slightly different collection of features to build a schema of the sagittal face, which may serve to complement the central triangle and build upon a three-dimensional model of the "normal" human face. Level of Evidence: NA.

The history of injectable facial fillers.

In an attempt to maintain a youthful appearance or to reconstruct facial deformities, physicians have greeted new technologies with excitement. In the late 1800 s, shortly after the invention of the syringe, chemical agents were used for facial augmentation. Unfortunately, history has taught us that new technologies must be used with care, because complications can occur, sometimes many years after initial treatment. The first injectable filling agent was paraffin, whose use was abandoned after complications of migration, embolization, and granuloma formation were described. More recently, silicone use was banned by the U.S. Food and Drug Administration (FDA) because of similar complications. In 1981, bovine collagen was the first agent to be approved by the FDA for cosmetic injection. Since its approval, dozens of injectable filling agents have been developed, and many are already FDA approved for cosmetic use. This article will review the highlights of the evolution of facial filling agents.

Injectable calcium hydroxylapatite microspheres (Radiesse).

Injectable calcium hydroxylapatite (Radiesse) received FDA approval in 2006 for the correction of facial lipoatrophy and moderate to severe facial wrinkles. This product consists of microspheres of a synthetic bone suspended in a methylcellulose gel matrix. Because the product is thicker than the hyaluronic acids, it is used for the correction of moderate to severe wrinkles, such as deep nasolabial folds. It is also used "off-label" to treat multiple areas of the face, nose, and hands. Radiesse is injected into the subdermal plane, and correction lasts approximately 1 year after injection.

Assessment of the Influence of "Other-Race Effect" on Visual Attention and Perception of Attractiveness Before and After Rhinoplasty.

IMPORTANCE: The "other-race effect" describes the phenomenon in which individuals demonstrate greatest recognition ability among faces of their own race. Thus, in our multicultural world, it follows that race influences social interactions. However, the association of race with perception of plastic surgery outcomes has not been studied. OBJECTIVE: To objectively measure how the other-race effect influences perception of white and Latin American patients undergoing rhinoplasty by using eye-tracking technology and survey methodology. DESIGN, SETTING, AND PARTICIPANTS: In the first part of the study, 134 participants viewed 32 paired facial images of white and Latin American patients, either prerhinoplasty or postrhinoplasty, on an eye-tracking system that recorded observer scan paths. In the second part of this study, the same patient images were individually graded by a separate group of 134 participants for degree of racial identification and perceived attractiveness. MAIN OUTCOMES AND MEASURES: The primary outcome was to measure the influence of patient and observer race on perception of rhinoplasty outcomes. For the eye-tracking part, planned hypothesis testing was conducted using an analysis of variance to compare patient race, rhinoplasty status, and attractiveness with respect to visual fixation time. RESULTS: Of the 134 eye-tracking participants, 68 (51%) were women and the mean (SD) age was 26.4 (7.7) years; of the 134 graders, 64 (48%) were women and the mean (SD) age was 25.0 (6.9) years. Rhinoplasty did not affect racial identity scores among either same-race or other-race evaluators. Visual fixation times for white faces were significantly increased compared with Latin American faces among all casual observer groups (white observers mean change, -20.14 milliseconds; 95% CI, -29.65 to -10.62 milliseconds; P < .001; Asian observers mean change, -39.04 milliseconds; 95% CI, -48.95 to -29.15 milliseconds; P < .001; and African American observers mean change, -20.73 milliseconds; 95% CI, -37.78 to -3.69 milliseconds; P < .02), with the exception of Latin American observers (mean change, -7.8 milliseconds; 95% CI, -29.15 to 14.39 milliseconds; P < .51). With respect to attractiveness, white graders reported a significant postrhinoplasty increase across both races (white patients mean change, 8.07 points; 95% CI, 5.01-11.12 points; P < .001; and Latin American patients mean change, 3.69 points; 95% CI, 0.87-6.49 points; P = .01), whereas Latin American graders only observed a significant attractiveness increase in their own race (Latin American patients mean change, 10.50 points; 95% CI, 1.70-19.32 points; P = .02). Neither perceived attractiveness nor rhinoplasty status influenced fixation times. CONCLUSIONS AND RELEVANCE: Both patient and observer race influence visual attention and perception of attractiveness before and after rhinoplasty. These findings underscore the importance of counseling patients that the influence of rhinoplasty, as perceived by the casual observer, may vary by race or ethnicity of the observer group. LEVEL OF EVIDENCE: NA.

Association Between Surgical Trainee Daytime Sleepiness and Intraoperative Technical Skill When Performing Septoplasty.

IMPORTANCE: Daytime sleepiness in surgical trainees can impair intraoperative technical skill and thus affect their learning and pose a risk to patient safety. OBJECTIVE: To determine the association between daytime sleepiness of surgeons in residency and fellowship training and their intraoperative technical skill during septoplasty. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study included 19 surgical trainees in otolaryngology-head and neck surgery programs at 2 academic institutions (Johns Hopkins University School of Medicine and MedStar Georgetown University Hospital). The physicians were recruited from June 13, 2016, to April 20, 2018. The analysis includes data that were captured between June 27, 2016, and April 20, 2018. MAIN OUTCOMES AND MEASURES: Attending physician and surgical trainee self-rated intraoperative technical skill using the Septoplasty Global Assessment Tool (SGAT) and visual analog scales. Daytime sleepiness reported by surgical trainees was measured using the Epworth Sleepiness Scale (ESS). RESULTS: Of 19 surgical trainees, 17 resident physicians (9 female [53%]) and 2 facial plastic surgery fellowship physicians (1 female and 1 male) performed a median of 3.00 septoplasty procedures (range, 1-9 procedures) under supervision by an attending physician. Of the 19 surgical trainees, 10 (53%) were aged 25 to 30 years and 9 (47%) were 31 years or older. The mean ESS score overall was 6.74 (95% CI, 5.96-7.52), and this score did not differ between female and male trainees. The mean ESS score was 7.57 (95% CI, 6.58-8.56) in trainees aged 25 to 30 years and 5.44 (95% CI, 4.32-6.57) in trainees aged 31 years or older. In regression models adjusted for sex, age, postgraduate year, and technical complexity of the procedure, there was a statistically significant inverse association between ESS scores and attending physician-rated technical skill for both SGAT (-0.41; 95% CI, -0.55 to -0.27; P < .001) and the visual analog scale (-0.75; 95% CI, -1.40 to -0.07; P = .03). The association between ESS scores and technical skill was not statistically significant for trainee self-rated SGAT (0.04; 95% CI, -0.17 to 0.24; P = .73) and the self-rated visual analog scale (0.19; 95% CI, -0.79 to 1.2; P = .70). CONCLUSIONS AND RELEVANCE: The findings suggest that daytime sleepiness of surgical trainees is inversely associated with attending physician-rated intraoperative technical skill when performing septoplasty. Thus, surgical trainees' ability to learn technical skill in the operating room may be influenced by their daytime sleepiness. LEVEL OF EVIDENCE: NA.