Assessing the safety and tolerability of rhinologic surgery under local anesthetic: an 8-year retrospective analysis.

PURPOSE: Office-based rhinologic procedures (OBRP) have become widely available in North America due to technological advances and appropriate patient selection. Nevertheless, the literature exploring the safety of these procedures remains limited. The objective of this study was to further evaluate the safety, tolerability and efficacy of these procedures with a more robust sample size to allow for capture of rare events. METHODS: A retrospective chart review of all patients who underwent OBRP from May 2015 to March 2023. Information regarding patient demographics, the indication for surgery, wait time, tolerability, intra- and postoperative complications, need for revisions, and type of revision (if applicable) was recorded. RESULTS: 1208 patients underwent OBRP during the study period. No patients were excluded. These included turbinoplasties (35%), endoscopic sinus surgeries (ESS) (26%), septoplasties (15%), nasal fracture reductions (7%), and a variety of other procedures. For ESS procedures, the anterior ethmoids and the maxillary sinuses were the most common sinuses treated. 1.1% of procedures were aborted prior to completion. The post-operative complication rate was 3.2%, with 2 major complications (significant bleeding and sepsis) encountered. The mean follow-up overall was 11 months and for ESS it was 15.8 months. CONCLUSION: Office-based rhinologic procedures are well tolerated and safe for the appropriate patient and associated with shorter wait-times as well as avoidance of general anesthesia. The complication rates are similar to or lower than previously reported rates for rhinologic surgeries done in the operating room. The low rates of revision surgery also demonstrate the efficacy of these procedures.

Evaluation of septal perforation size using a novel measuring device.

BACKGROUND: Nasal septal perforations can be managed with a septal button prosthesis. While they do not restore the physiological function of the septal mucosa, they are able to improve laminar nasal airflow. With the development of septal buttons sized specifically to perforations, accurate measurement of perforations has become more important for patient satisfaction and comfort. This task can be difficult to accomplish in the clinical setting. In this study, 2 new instruments developed to measure septal perforations were evaluated for accuracy and ease of use. METHODS: Two types of measuring devices ("sizers") were created via 3D printing. One type included six serial, progressively sized instruments (serial sizers) and the other included two instruments with several size gradations (graded sizers). Septal perforations of varying sizes were surgically created in five fresh-frozen cadaver heads. Using a headlight and nasal speculum, 15 otolaryngology trainees and consultants were asked to measure the perforations (length × height) via four different methods: "eyeball" estimation, a ruler, the serial sizers, and the graded sizers. They were also asked to evaluate the methods themselves. An accurate measurement was defined as ± 1 mm of the true measurement. A combination of Chi-square analysis and ANOVA was used to assess the accuracy and ease of use of the four methods. RESULTS: Chi-square analysis showed that the sizers were more accurate than the two traditional methods (eyeball and ruler) for measuring perforation length (73% vs. 44%, p = 4.8 × 10-7) and height (71% vs. 50%, p = 0.0003). ANOVA showed that the eyeball method overestimated perforation length significantly more than the other three methods (p = 0.002), and was also significantly less accurate than the other three methods (p < 0.001). Chi-square analysis did not show any correlation between participant training experience and measurement accuracy for any of the three methods. Participant comments and scores demonstrated a clear preference for the two sizers over the traditional methods. CONCLUSIONS: The two novel sizers studied here were significantly more accurate and easier to use than traditional methods for measuring nasal septal perforations. With broader implementation and study of these devices, there is potential to improve patient care surrounding septal perforations.

Impact of nasal surgery on speech resonance.

OBJECTIVES: The nose and paranasal sinuses contribute to speech resonance and changes to these structures may alter speech nasality. This change may influence one's vocational and social functioning and quality of life. Our investigation explored objective and subjective changes in nasality following nasal surgery in a prospective and longitudinal fashion. METHODS: Recordings of sustained vowel and sentence stimuli and voice-related quality of life measurements were obtained preoperatively and at 2, 4, 8, and 24 weeks postoperatively from individuals undergoing nasal and/or sinus surgery. Objective measures of fundamental frequency, jitter, shimmer, and harmonic to noise ratio (HNR) were determined. Pre- and postoperative speech samples were assessed by 15 naïve listeners. RESULTS: In all, 15 subjects completed the study. Neither speakers nor listeners perceived a subjective change in nasality following surgery. No statistically significant change in microacoustic measures were identified. Although nasal sentences did not reveal differences for 3 microacoustic measures, a difference in HNR was identified. CONCLUSIONS: Patients undergoing nasal surgery did not exhibit subjective changes in resonance postoperatively. Aside from a difference in HNR for the nasal sentence, objective microacoustics remained unchanged. These results demonstrate the stability of oranasal resonance despite nasal surgery and provide valuable data for patient informed decision-making.

Postoperative nasal debridement after endoscopic sinus surgery: a randomized controlled trial.

OBJECTIVES: Postoperative debridement is a controversial subject in the rhinology literature. The objective of this randomized controlled trial was to determine the effect of regular debridement versus no debridement on disease-specific outcomes and patient inconvenience. METHODS: Patients with chronic rhinosinusitis with polyposis who were to undergo basic sinus surgery (antrostomy, ethmoidectomy, and polypectomy) were randomized to either debridement (at postoperative weeks 2 and 4) or no debridement, and their outcomes were assessed at 4 weeks and at 6 months with the Lund-Kennedy Endoscopic Score (LKES), the Sino-Nasal Outcome Test-21 (SNOT-21), a visual analog scale for postoperative pain, and a novel scoring system for postoperative inconvenience (Post-Operative Inconvenience Scale; POIS). All patients were instructed to use high-volume saline rinses twice daily. RESULTS: At 4 weeks after operation, there was no difference between the groups in regard to LKESs (control group, 2.1 of 20; debridement group, 2.4 of 20; p = 0.59) or SNOT scores (control group, 9.1; debridement group, 8.3; p = 0.47). The visual analog scale pain scores showed significance (control group, 19 mm; debridement group, 38 mm; p = 0.019), as did the POIS scores (control group, 18.3; debridement group, 6.1; p = 0.002). At 6 months after surgery, again no difference was seen between the groups on either LKESs or SNOT scores. CONCLUSIONS: In our patient population, debridement after surgery did not affect disease-specific outcomes.

Comparison of purified plant polysaccharide (HemoStase) versus gelatin-thrombin matrix (FloSeal) in controlling bleeding during sinus surgery: a randomized controlled trial.

OBJECTIVES: Purified plant polysaccharide (HemoStase) is a plant-derived hemostatic agent that has not previously been used in sinus surgery. This study was conducted to evaluate the effectiveness of this novel agent in the control of nasal bleeding during endoscopic sinus surgery. The volume of bleeding during endoscopic sinus surgery was hypothesized to not be statistically significantly different between a control group (gelatin-thrombin matrix; FloSeal) and an experimental group (purified plant polysaccharide; HemoStase). METHODS: Eighteen patients with a history of chronic rhinosinusitis in whom maximal medical therapy failed who underwent endoscopic sinus surgery were randomized into one of two groups (control FloSeal group or experimental HemoStase group). In the control group, sites in the nose that were actively bleeding during the operation were controlled with FloSeal. In the experimental group, sites in the nose that were actively bleeding during the operation were controlled with HemoStase. The main outcome measure was total operative blood loss. Blood loss was the sum of blood removed by suction during the surgery (recorded in milliliters) and blood on surgical sponges (weighed and converted to milliliters). Statistical analysis was performed with the t-test and the Mann-Whitney U test. RESULTS: The amounts of blood loss (mean +/- SEM) were not significantly different between the FloSeal (262 +/- 15 mL) and HemoStase (265 +/- 33 mL) groups (p = 0.93). CONCLUSIONS: The results of this study demonstrate the use of a novel product for the control of intraoperative bleeding during endoscopic sinus surgery.

Revision rates after endoscopic sinus surgery: a recurrence analysis.

OBJECTIVES: Chronic rhinosinusitis with nasal polyposis is often refractory to medical and surgical management, especially in patients with asthma and aspirin intolerance. We used a contemporary database to investigate recurrence and revision surgery rates following endoscopic sinus surgery. METHODS: We performed a cohort study using a survival analysis technique. Records were reviewed of 549 patients with nasal polyposis who underwent endoscopic sinus surgery over a 10-year period. The main outcome measure was disease-free and surgery-free survival following endoscopic sinus surgery, investigated with Kaplan-Meier analyses. RESULTS: Patients with Samter's triad were significantly more likely to have a recurrence and undergo a second surgery following recurrence (risk-odds ratio, 2.7; 95% confidence interval, 1.5 to 3.2; p < 0.01) than were patients without asthma or with only asthma from the triad. The presence of initial frontal sinus disease also increased the likelihood of revision surgery (risk-odds ratio, 1.6; 95% confidence interval, 1.2 to 1.8; p < 0.05). CONCLUSIONS: This is the first study to use survival analysis to document revision surgery rates following endoscopic sinus surgery. Revision surgery occurs at a high rate, especially in patients with asthma, Samter's triad, or frontal sinus disease. Patients should routinely be informed during clinical consultations about the likelihood of recurrence. Early intervention for frontal sinus disease may be considered.

The subtle nuances of intranasal corticosteroids.

BACKGROUND: In the specialty of Otolaryngology - Head and Neck Surgery, intranasal corticosteroids are the mainstay treatment for inflammatory processes within the nasal cavity. All too often, physician prescribing patterns are based on previous training, personal experience, and interactions with industry. The purpose of this commentary is to review the nuances of each intranasal corticosteroid. COMMENTARY: There are nine intranasal corticosteroids approved for use in Canada. Each are discussed in detail, including their indication, bioavailability, effects on intranasal environment, and factors around patient adherence. Off-label use of budesonide irrigations is also discussed and cost information is presented in reference format for all available intranasal corticosteroids. CONCLUSION: Although the efficacy of each intranasal corticosteroid has been shown to be similar, prescribing should be tailored based on bioavailability, intranasal environment, and factors that impact patient adherence such as dosing, cost and tolerability.

Effect of low salicylate diet on clinical and inflammatory markers in patients with aspirin exacerbated respiratory disease - a randomized crossover trial.

BACKGROUND: Aspirin-exacerbated respiratory disease (AERD) is characterized by eosinophilic rhinosinusitis, nasal polyposis, and bronchial asthma, along with the onset of respiratory reactions after the ingestion of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetylsalicylic acid (ASA). In addition to the therapeutic routines and surgical options available, a low dietary intake of food salicylate has been suggested as adjunctive therapy for this condition. This study aimed to assess the influence of a short-term low salicylate diet on inflammatory markers in patients with AERD and whether that would result in symptomatic improvement. METHODS: Prospective study with randomization to either a high or low salicylate diet for 1 week, followed by cross-over to the other study arm. Participants were asked to record their dietary salicylate for each week of the study. Urinary creatinine, salicylate and leukotriene levels were measured at the time of recruitment, end of week one and end of week two and the SNOT-22 questionnaire was filled out at the same time points. RESULTS: A total of seven participants completed the study. There was no statistical difference in the urinary salicylate and leukotriene levels between the two diets; nevertheless, participants on low salicylate diet reported improved SNOT-22 symptoms scores (p = 0.04), mainly in the rhinologic, ear/facial, and sleep dysfunction symptom domains. In addition, these last two domains outcomes were more significant than the minimal clinically important difference. CONCLUSIONS: A short-term low salicylate diet may not result in biochemical outcomes changes but seems to provide significant symptomatic relief for patients with AERD. TRIAL REGISTRATION: NCT01778465 ( www.clinicaltrials.gov ).

Use of tissue glues in endoscopic pituitary surgery: a cost comparison.

BACKGROUND: Post-operative cerebrospinal fluid (CSF) leaks are a common complication of endoscopic pituitary surgery and account for a significant proportion of hospital costs associated with this procedure. Tisseel® is a tissue glue commonly used as an adjunct in dural repair but is not optimal for this purpose. DuraSeal® has several properties advantageous for dural repair but is not widely accepted in Canada partly due to its increased cost. OBJECTIVE: A cost analysis of DuraSeal® versus Tisseel® in endoscopic pituitary surgery. METHODS: A cost analysis was performed based on typical endoscopic pituitary surgery cases performed at our tertiary care institution. Operating room, hospital admission, and surgical sealant costs were obtained directly while estimates of patient recovery time and post-operative CSF leak rates were based on consensus values reported in the literature. Outcomes were reported for various possible clinical scenarios of sealant use. RESULTS: In a model where surgical sealant is employed only in high-risk cases, use of DuraSeal® allows for a yearly cost savings of at least $4486.72. If surgical sealant is used in all cases, regular use of DuraSeal® versus Tisseel® either marginally reduces yearly costs or increases them by a maximum of $7619.25, depending on the case volume and estimated post-operative CSF leak rate. CONCLUSION: In most clinical scenarios, use of DuraSeal® in endoscopic pituitary surgery may reduce overall yearly hospital costs compared to Tisseel®.

Image-guided transnasal endoscopic techniques in the management of orbital disease.

PURPOSE: To assess the utility of image-guided transnasal endoscopic surgery for a variety of orbital diseases requiring decompression of at least one orbital wall. METHOD: A descriptive case series of consecutive orbital procedures requiring decompression of at least one wall. All procedures were performed using a transnasal endoscopic approach and an intraoperative image-guided LandmarX system for anatomical guidance. RESULTS: A 3-year review yielded 17 cases, including 6 cases with compressive mucoceles, 4 neoplasms, 4 patients with proptosis secondary to Graves' Ophthalmopathy, 1 case of an intraorbital abscess, 1 fungal mycetoma, and 1 hemangioma. These cases all had improved postoperative clinical status without any serious complications. The LandmarX system was a valuable intraoperative tool in all 17 cases. CONCLUSIONS: The endoscopic transnasal approach to orbital decompression surgery allows for good visualization and is minimally invasive. Using this approach in conjunction with the LandmarX image-guided system allows for improved anatomical localization and provided good results in all cases.

Nasal Lymphoma Presenting With Contralateral Proptosis and Vision Changes: A Case Report and Literature Review.

Non-Hodgkin lymphoma (NHL) is a hematological malignancy that can sometimes originate from the nasal cavities and paranasal sinuses. Patients who present with these tumors typically report sinonasal symptoms. However, a diagnostic challenge can arise when a patient's primary complaints include unique complex symptoms limited to the contralateral side of the tumor. This report describes the case of an 83-year-old man who presented to our center with a left-sided mass and right-sided proptosis with vision loss. After a nasal biopsy was taken, the patient was referred to the ophthalmology department to diagnose the cause of his ocular symptoms, which were not believed to be related to the mass. When biopsy results later returned as diffuse large B-cell lymphoma (DLBCL), an emergent repeat biopsy following lymphoma protocol was performed to confirm the diagnosis. A CT scan of the head and orbits showed generalized enlargement of the right optic nerve and extraocular muscles, and a positron emission tomography (PET) scan showed increased 18F-fluorodeoxyglucose (FDG) uptake in the right ethmoid sinus and orbit. The left-sided mass and right-sided symptoms resolved simultaneously with chemotherapy. This is the first documented case of a sinonasal mass causing ocular symptoms exclusively on the contralateral side. The presented diagnostic challenge highlights the importance of thorough investigations.

Estimation of the hyperelastic parameters of fresh human oropharyngeal soft tissues using indentation testing.

Patient-specific finite element (FE) modeling of the upper airway is an effective tool for accurate assessment of obstructive sleep apnea (OSA) syndrome. It is also useful for planning minimally invasive surgical procedures under severe OSA conditions. A major requirement of FE modeling is having reliable data characterizing the biomechanical properties of the upper airway tissues, particularly oropharyngeal soft tissue. While some data characterizing this tissue's linear elastic regime is available, reliable data characterizing its hyperelasticity is scarce. The aim of the current study is to estimate the hyperelastic mechanical properties of the oropharyngeal soft tissues, including the palatine tonsil, soft palate, uvula, and tongue base. Fresh tissue specimens of human oropharyngeal tissue were acquired from 13 OSA patients who underwent standard surgical procedures. Indentation testing was performed on the specimens to obtain their force-displacement data. To determine the specimens' hyperelastic parameters using these data, an inverse FE framework was utilized. In this work, the hyperelastic parameters corresponding to the commonly used Yeoh and 2nd order Ogden models were obtained. Both models captured the experimental force-displacement data of the tissue specimens reasonably accurately with mean errors of 11.65% or smaller. This study has provided estimates of the hyperelastic parameters of all upper airway soft tissues using fresh human tissue specimens for the first time.

Contemporary decongestant practices of Canadian otolaryngologists for endoscopic sinus surgery.

BACKGROUND: Cocaine has traditionally been the topical decongestant most frequently used for visualization of the surgical field in Endoscopic Sinus Surgery (ESS). Alternatives include xylometazoline, oxymetazoline, and epinephrine. The understanding of the safety profile of each agent is changing, as are the practices of Otolaryngologists-Head & Neck Surgeons. The objective of this study is to determine decongestant use practices in ESS across Canada, which has not previously been studied. METHODS: A cross-sectional survey design using a 24-item electronic questionnaire was distributed to actively practicing members of the Canadian Society of Otolaryngology-Head and Neck Surgery via email. A French translated version of the survey was also available. Questions explored the respondents' demographics and decongestion practices for ESS. RESULTS: Ninety-six surveys from otolaryngologists practicing in Canada were completed (19% response rate). The average time in practice was 16.5 years (range 1-50 years, SD 12.0 years). Twenty-six (27%) of respondents use some form of cocaine solution for topical decongestion in ESS. Over a total of over 1500 combined practice-years, eight respondents (8%) personally experienced an adverse event that could be attributed to cocaine, including two mortalities. One cardiac even was directly attributable to the patients' use of recreational cocaine in the immediate pre-operative period. CONCLUSION: The popularity of cocaine for topical decongestion in ESS in present-day Canada is less than in surveys from other countries. However, there are few reported adverse events with long-term consequences that are attributable to intraoperative cocaine. Considering the beneficial effects of cocaine for visualization and pain control, this change in practice warrants further investigation.

Multilevel Palate and Tongue Base Surgical Treatment of Obstructive Sleep Apnea: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate multilevel palate and tongue base surgery as a method of treatment of obstructive sleep apnea by comparing the pre- and postoperative apnea-hypopnea index. METHODS: We conducted a systematic review. MEDLINE and Embase databases were searched in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for conducting systematic reviews. Two authors screened all articles and performed methodological quality assessment. Relevant articles where reviewed in detail. Standard inclusion criteria were applied for article selection. Relevant data were extracted and summarized, a difference of means random-effects model was performed. Our primary outcome measure was change in apnea-hypopnea index pre-/postsurgical treatment. RESULTS: Of 1,172 studies identified from January 2006 to March 2017, 46 studies met inclusion criteria and were included in the systematic review. This included 11 surgical subgroups and 1,806 patients. Methodological quality and risk of bias assessments were completed. There was strong male predominance 86.8 (standard deviation [SD] = 10.3%), and the average age was 46.8 (SD = 4.0) years. All studies included overweight to obese patients (average body mass index = 29.1 [SD = 3.5]). The average preoperative apnea-hypopnea index was 39.0 (SD = 15.4), and the average postoperative apnea-hypopnea index decreased to 18.3 (SD = 7.5). Meta-analysis data yielded a decrease in apnea-hypopnea index of -23.67 with a 95% confidence interval of -27.27 to -20.06. CONCLUSIONS: Non-maxillomandibular advancement, multilevel surgical procedures for obstructive sleep apnea demonstrate significant improvements in reduction of apnea-hypopnea index following surgery in addition to improvement in many other sleep-specific outcomes. Future research should include larger, higher-level studies that compare surgical treatments and identify factors associated with outcomes. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1712-1721, 2019.

Postoperative Continuous Positive Airway Pressure Use and Nasal Saline Rinses After Endonasal Endoscopic Skull Base Surgery in Patients With Obstructive Sleep Apnea: A Practice Pattern Survey.

BACKGROUND: Endoscopic skull base surgery continues to evolve in its indications, techniques, instrumentation, and postoperative care. As surgery of the skull base will often violate dura, intraoperative and postoperative cerebrospinal fluid (CSF) leak is not uncommon and represents a potential conduit for air and bacterial contamination. Patients with obstructive sleep apnea (OSA) requiring continuous positive airway pressure (CPAP) therapy undergoing skull base surgery represent a challenging group. However, there appears to be a paucity of consensus regarding the postoperative management of this patient population. The objective of this study is to examine practice patterns and expert opinion on the use of postoperative CPAP and nasal saline in patients with OSA. METHODS: A 14-item survey was generated by consensus among expert authors and distributed online to members of the North American Skull Base society and other international skull base community members. Data were analyzed for median, mean, and standard deviation variables. Subgroup analysis was completed between surgeons from different geographical locations and operative experience. SPSS22 was utilized for all complex statistical analysis and figures. RESULTS: Seventy-one responses were collected from skull base surgeons. In patients with OSA, respondents would resume patients' CPAP therapy after a mean of 10.1 days (median, 7; standard deviation [SD], 10.2), without a CSF leak. In the presence of a small CSF leak, the mean duration would increase to 14.3 days (median, 14; SD, 9.8) and to 20.7 days (median, 21; SD, 11.8) in the presence of a larger leak. A surgeon's choice to attribute the relationship between delaying the start of nasal saline and CPAP after the endoscopic skull base surgery with progressively more challenging skull base repair was found to be statistically significant ( P < .001). CONCLUSION: Saline and CPAP therapies are initiated after the endoscopic skull base surgical repairs by surgeons at an increasing temporal delay in relation to the degree and complexity of the skull base defect repaired.

The relationship between acute mastoiditis and antibiotic use for acute otitis media in children.

OBJECTIVE: To determine the relationship between prior antibiotic use and the development of acute mastoiditis (AM) in children. DESIGN: Retrospective review. SETTING: Tertiary pediatric center. PATIENTS: We identified 129 patients with AM who were admitted to our center between 1996 and 2005. MAIN OUTCOME MEASURE: Proportion of children who developed AM. RESULTS: A total of only 67 patients (51.9%) had undergone any antimicrobial treatment prior to hospital admission. In 1996, 64% of patients with AM had received antibiotics for acute otitis media (AOM) prior to admission (n = 7 of 11), but this percentage had steadily decreased to 27% by 2005 (n = 4 of 15). The yearly number of cases of AM treated in our institution has remained stable over this period. A subperiosteal abscess was identified in 45 patients (34.9%), while the remainder (n = 84) had postauricular inflammation only (65.1%). Nineteen patients with a subperiosteal abscess (42%) and 48 patients without a subperiosteal abscess (57%) had undergone prehospitalization antimicrobial therapy for suppurative AOM. There was no significant difference in antibiotic use between the numbers of patients with or without a subperiosteal abscess. Regarding the sensitivity of bacteria isolated from patients with a subperiosteal abscess, only 1 patient was infected with an organism that was not sensitive to the prehospitalization antibiotic prescribed. CONCLUSION: Use of antibiotics to treat suppurative AOM in children might not influence the subsequent development of AM.

Impact of cosmetic facial surgery on satisfaction with appearance and quality of life.

OBJECTIVES: To assess perioperative quality-of-life (QOL) changes in a facial plastic surgery patient population and to ascertain factors determinative of QOL changes. A notable paucity of objective scientific measurements of QOL exists within the facial plastic surgery literature. METHODS: A 3-year prospective cohort study. The patient population, which comprised a consecutive series of patients 16 years or older, undergoing cosmetic nasal or facial surgery, was obtained from the senior author's (P.A.A.) private surgical practice. All patients presenting for surgery were offered participation. The main outcome measure was the 59-item Derriford Appearance Scale (DAS59), a valid and reliable instrument assessing psychological distress associated with self-consciousness of facial appearance. Three patient score subgroupings were established: group 1, the DAS59 scores for all patients; group 2, the DAS59 score according to sex; and group 3, the DAS59 score according to the main surgical procedure. Surveys were administered to eligible patients at the final preoperative clinic visit and at 3 months after surgery. Data from the case-control groups were analyzed by a blinded statistician with appropriate t tests. RESULTS: A total of 93 patients were enrolled with a 100% response rate (82 females [88%] and 11 males [12%]). The most common procedures were rhinoplasty (49%) and surgery for the aging face (51%). Marked differences in perioperative QOL were noted across all DAS59 domains for group 1 and for all females in group 2. Male patients in group 2 analysis experienced QOL improvement only from DAS59 domain 2 (General Self-consciousness of Facial Appearance). Rhinoplasty and surgery for the aging face improved patients' QOL but differed with respect to which DAS59 domains were affected. CONCLUSIONS: Quality of life was enhanced by facial plastic surgery in this patient population. Male and female patients seem to have different needs to be met from facial cosmetic surgery and correspondingly different areas of improvement in QOL. Rhinoplasty and surgery for the aging face act on different domains of QOL.