Adverse Childhood Experiences (ACEs) in 252 Board-Certified Plastic Surgeons: Prevalences, ACE Clustering, and Effects on Adult Health and Behaviors, Including Self-Defined Depression, Work Addiction, and Burnout.

BACKGROUND: The CDC/Kaiser Adverse Childhood Experiences (ACE) study documented that ACEs predict adult health and self-harming behaviors. ACEs have been documented in physicians and are higher in physicians treated for problematic behavior. Plastic surgeons have never been assayed. OBJECTIVES: Might ACE prevalences in plastic surgeons predict their adult health and/or behavior? METHODS: 252 ABPS-certified plastic surgeons (72% men, 28% women, ) completed the 10-question CDC/Kaiser ACE survey by de-identified email. Data was collected on adult health and behaviors previously associated with ACEs in the literature. RESULTS: 42% of plastic surgeons had 1 or more ACEs; 9.9% had 4 or more. Emotional abuse was 2 times higher than the control CDC/Kaiser population, though other ACEs were lower. Gender differences existed: women suffered more sexual abuse (17% vs. 8%), physical neglect (7% vs. 1%), violence against their mothers (7% vs. 2%), and self-defined burnout (32% vs. 17%). ACEs occurred in clusters. Total ACEs predicted autoimmune disorders, chronic pain/fatigue, self-defined depression, irritable bowel, antidepressant/anxiolytic use, alcohol abuse, >3 marriages, >10 sexual partners, sex and work addiction, eating disorders, and self-defined burnout (all p< 0.020). Emotional abuse predicted alcohol abuse. Sexual abuse predicted sex addiction. Emotional neglect predicted autoimmune disease, antidepressant/anxiolytic use, eating disorder, and work addiction. Physical neglect predicted chronic fatigue/chronic pain, depression, and burnout (all p< 0.001 or less). CONCLUSIONS: Adverse childhood experiences occurred in 42% of our 252-member plastic surgeon cohort and predicted 13 adult illnesses and self-harming behaviors that can impair surgeons' lives and performances. Recognition may facilitate their recognition and treatment.

The Principles and Practice of Primary Endonasal Rhinoplasty.

ABSTRACT: The purpose of this article is to provide a guide for plastic surgeons, regardless of experience level, seeking to improve his/her endonasal rhinoplasty skills and comfort level. We have presented the advantages of our technique and its unifying principles and demonstrated how endonasal rhinoplasty can be used to achieve safe, anatomical, and predictable outcomes. Endonasal rhinoplasty is a separate thought process from open rhinoplasty and should not be viewed as a competing but rather parallel technique that is broadly applicable to many nasal deformities.We have described the basic goals of all rhinoplasties and highlighted 2 false assumptions that are responsible for most adverse rhinoplasty outcomes and 4 anatomical deficits that surgeons must recognize preoperatively to maximize function, proportion, and contour. Finally, the majority of primary rhinoplasties can be performed with 1 of 2 operative strategies that depend on the relationship of the dorsum to the lower nose. Because surgeons often presume that they will not be able to "see well enough" in endonasal rhinoplasty or worry they have not been adequately trained in the technique, we have provided a step-by-step guide to help overcome such fears and help these surgeons to achieve results that will exceed their patients' goals.

Novel Selection Tools in Rhinoplasty Patients.

With no consensus document or guideline to help us compute the psychological make-up of rhinoplasty candidates and in the light of new perspectives of some key opinion leaders in the field of patient selection, the goals of this article are to offer a glimpse of the current literature together with the knowledge gaps, introduce some new tools for the preoperative consultation, help us identify who among our patients is at greatest risk for a poor outcome, and explain how childhood trauma can be linked to body shame and postoperative dissatisfaction.

The Principles and Practice of Endonasal Rhinoplasty: Special Topics for Clinics in Plastic Surgery Journal.

Endonasal rhinoplasty is a minimally invasive approach in which esthetic and functional improvements are made solely through intranasal, without transcolumellar, incisions and with limited soft tissue and skeletal disruption. In addition to intentionally limiting surgical dissection, the rhinoplasty surgeon must preoperatively recognize and surgically correct 4 common anatomic variants which predictably create all 3 patterns of secondary deformity. In combination, respecting these principles gives the surgeon greater predictability in achieving esthetic and functional improvements, and the ability to limit the adverse effects of skin contractility and postoperative scar contracture, thus reducing the risk of secondary deformity, patient dissatisfaction, and reoperation.

The Prevalence of Adverse Childhood Experiences, Body Shame, and Revision Request Rate in 218 Plastic Surgery Patients: What Drives Postoperative Dissatisfaction?

BACKGROUND: What drives patients who are unhappy despite good results? Adverse childhood experiences are common, can impair adult health, and can cause body shame. Neither adverse childhood experiences nor body shame has been studied in surgical patients. The authors report adverse childhood experience prevalences in a plastic surgical population and investigate associations from adverse childhood experiences to body shame and to postoperative dissatisfaction. METHODS: Two hundred eighteen consecutive patients (86 percent aesthetic and 14 percent reconstructive) completed the Adverse Childhood Experiences Survey and the Experience of Shame Scale. A one-sample test of proportions, logistic regression, and mediation analysis assessed outcomes. RESULTS: Compared to the Kaiser/Centers for Disease Control and Prevention medical population, our patients had higher overall adverse childhood experience prevalences (79.8 percent versus 64 percent), emotional abuse (41 percent versus 11 percent), emotional neglect (38 percent versus 15 percent), family substance abuse (36 percent versus 27 percent), and family mental illness (29 percent versus 19 percent, all p < 0.001). Fifty-two percent of our patients had body shame. Adverse Childhood Experiences score predicted body shame (OR, 1.22; p = 0.003). Compared to unshamed patients, body shame was associated with more adverse childhood experiences (85 percent versus 72 percent), higher median Adverse Childhood Experiences score (3.5 versus 2), more cosmetic operations (three versus zero), more health problems (three versus two), higher antidepressant use (39 percent versus 19 percent), substance abuse history (16 percent versus 5 percent), and demands for additional pain medication (18 percent versus 5 percent). Body shame predicted requests for surgical revision (49 percent versus 17 percent; OR, 4.61; all p ≤ 0.0001). CONCLUSIONS: Adverse childhood experience were common in our patients. Adverse Childhood Experiences score predicted body shame, which predicted revision requests. If body shame preceded and drove surgery, revision requests were likely. Patients desiring revisions had recognizable characteristics. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Defining the Histologic Support Structures of the Nasal Ala and Soft Triangle: Toward Understanding the Cause of Iatrogenic Alar Retraction.

BACKGROUND: As rhinoplasty techniques have evolved to more extensive dissections, the incidence of iatrogenic deformities, such as alar rim retraction, has risen. Its mechanism is presently unknown. This study examined the microscopic anatomy of the nasal ala to define architectural support elements at the histologic level to determine why rhinoplasty dissection creates such deformities. METHODS: Eight cadaveric noses were harvested and sectioned through the soft triangle and ala. Various tissue stains were performed. Slides were examined using light microscopy. Anatomical features pertaining to cartilage, skin, mucosa, elastic fibers, and muscle were documented. RESULTS: Four male and four female noses were sectioned. The median cadaver age was 64 years (range, 47 to 83 years). On Elastica van Gieson stain, distinct elastic fibers span from the vestibular lining to the caudal margin of the lower lateral cartilage, and from the caudal edge of the lower lateral cartilage to the external alar skin. In the nasal ala midsection, trichrome stains reveal that skeletal muscle is located far beyond the lower lateral cartilage, close to the free alar margin. The soft triangle shows a distinct microanatomical structure, with heavy longitudinal condensations of elastin. These histologic findings have not been previously reported. CONCLUSIONS: A distinct anatomical alar wall endoskeleton has been identified. It is obligatorily disrupted by specific rhinoplasty maneuvers when dissection is carried out over the lateral crura and into areas without cartilaginous support. This microanatomy may explain factors that contribute to postoperative alar wall retraction. Leaving this area undisturbed or performing adjunctive measures with rhinoplasty can provide structural support to the external valves, thus minimizing the risk of deformity.

Psychiatric Disorders in Facial Plastic Surgery.

Body dysmorphic disorder and borderline personality disorder are common in esthetic practices and occur in up to 15% of patients. Operating on these patients may not only lead to dissatisfaction but may also worsen their premorbid condition and can induce negative behavior toward the practice. Preventing surgery and referring patients for cognitive therapy is essential. An adequate understanding of these conditions and the available screening tools is indispensable for all esthetic practitioners. Unrealistic emotional attribution to a facial shape, multiple procedures, a near-normal nose at the outset, childhood trauma, multiple comorbid mental conditions, and social dysfunction are red-flags to consider.

Indications and use of composite grafts in 100 consecutive secondary and tertiary rhinoplasty patients: introduction of the axial orientation.

The fragile alar rims are complex structures whose specialized and supportive skin ensures the competence of the external valves and the patency of the inlets to the nasal airways. A chart review was performed of 100 consecutive secondary or tertiary rhinoplasty patients in whom the author had placed composite grafts before February 1999. Follow-up continued for at least 12 months. In 94 percent of the patients, composite grafts were harvested from the cymba conchae by removing the cartilage with its adherent anterior skin. In 6 percent of the patients, independently indicated alar wedges supplied the grafts. Six patients required secondary procedures to thin the alar rims, but such revisions have not been necessary since primary contouring of the cartilaginous graft component was instituted. Three auricular donor-site complications (one keloid, two thickened graft contours) were successfully revised through office procedures. Prior cosmetic rhinoplasty in a patient with normal alar cartilage anatomy exceeded all other etiologies as the cause of the deformity for which composite grafts were indicated (50 percent). The second most common etiology was deformity from prior rhinoplasty in a patient with alar cartilage malposition (33 percent of patients). Congenital deformities (7 percent of patients), trauma (6 percent), and prior tumor ablation (4 percent) comprised the remaining etiologies. Composite grafts were used most frequently to correct alar notching or asymmetry in rim height (43 percent of patients) or to provide an increase in apparent or real nasal length (28 percent). External valvular incompetence (14 percent of patients), nostril or vestibular stenosis (11 percent), or combined vestibular stenosis and lateral alar wall collapse (4 percent) were less common indications. Most composite grafts were oriented in the coronal plane (parallel to the alar rims). However, nostril or vestibular stenosis was corrected by sagittally placed composite grafts, and a third orientation (axial plane), to the author's knowledge not described previously, was used in patients with combined nostril stenoses and flattening of the alar walls. In this secondary rhinoplasty series, iatrogenic alar rim deformities or stenoses following cosmetic rhinoplasty dominated other causes requiring composite graft reconstruction (83 percent of patients). Of these 83 patients, 39.7 percent had preexisting alar cartilage malpositions, further supporting the importance of making accurate anatomical diagnosis part of every preoperative rhinoplasty plan.

Differing characteristics in 100 consecutive secondary rhinoplasty patients following closed versus open surgical approaches.

Open rhinoplasty has unquestionably become more popular during the past two decades because of the putative diagnostic and technical advantages that direct transcolumellar access offers. To test the hypothesis that patients initially treated by the opened or closed approaches differed in the secondary deformities that developed, a retrospective study was conducted of 100 consecutive secondary rhinoplasty patients (66 women and 34 men) operated on by the author before February of 1998. Sixty-four percent had previously undergone closed rhinoplasties and 36 had undergone open rhinoplasties; the incidence of prior open rhinoplasty had increased steadily over the survey years, from 21 percent in 1996 to more than 50 percent in 1998, 1999, and 2000 (p < 0.05). The data generated indicate the following. First, the open rhinoplasty patients had undergone more operations (3.1 versus 1.2) and had more presenting complaints (5.8 versus 2.6) than the closed rhinoplasty patients. Second, although the most common presenting complaint among prior closed rhinoplasty patients was an overresected dorsum (50 percent) or tip (33 percent) or internal valvular obstruction (42 percent), prior open rhinoplasty patients complained more frequently than the closed rhinoplasty patients of these problems and also external valvular obstruction (50 percent, p < 0.0001), short nose (39 percent, p < 0.001), wide columella (36 percent, p < 0.001), narrow nose (31 percent, p < 0.001), columellar scar (25 percent, p < 0.001), and symptomatic columellar struts (19 percent, p < 0.001). Only excessive nasal length was more prevalent among closed rhinoplasty patients (20 percent, p < 0.01). Third, ranking of deformities differed significantly (p < 0.0001) between the two groups, so that complaints related to the nostrils, nasal tip, nasal length, or columella were more common among the open rhinoplasty patients than among those previously treated endonasally. Fourth, the relative frequencies of surgical complaints also differed: whereas patients previously treated endonasally were 6.7 times more likely to complain of long noses, patients previously treated by open rhinoplasty complained more frequently of the following: excessive columellar width (open approach, 36 percent of patients; closed approach, none), hard columellar struts (open approach, 19 percent of patients; closed approach, none), external valvular obstruction (4.5 times as frequent with the open approach as it was with the closed approach), alar/nostril distortion (four times as frequent), and narrow nose (3.9 times). Although the most common complaints among all postrhinoplasty patients remain the overresected dorsum, tip, or (internal valvular) airway obstruction, the author's data suggest that patients previously treated by the open approach are more likely to have postsurgical deformities and complaints referable to those anatomic structures most easily reached by transcolumellar exposure and to techniques that can be performed more readily or aggressively through that access route.

Why some patients are unhappy: part 1. Relationship of preoperative nasal deformity to number of operations and a history of abuse or neglect.

BACKGROUND: Trauma (neglect or abuse) can create body shame (different from body dissatisfaction), driving some patients to seek aesthetic surgery. We hypothesized that a trauma history would be related to the severity of the original deformity and the drive to undergo repeated operations. METHODS: Descriptive statistics were computed for 100 secondary rhinoplasty patients, 50 of whom originally had dorsal humps, 21 of whom had straight, functional noses, and 29 of whom had subjectively normal noses but underwent multiple rhinoplasties. This latter group fulfills criteria for body dysmorphic disorder. RESULTS: Compared with patients with hump noses, patients with normal primary noses were 2.9 times more likely to be demanding 2.5 times more likely to be depressed, had undergone 3.0 times more rhinoplasties and other aesthetic operations, and were 3.8 times more likely to have confirmed trauma histories. Patients who had undergone more than three operations were 92.7 percent women; 85 percent originally had straight noses and had undergone an average of 7.56 rhinoplasties and 5.78 aesthetic operations; 85.4 percent had histories of abuse or neglect. CONCLUSIONS: Secondary rhinoplasty patients with normal preoperative noses, who fulfill the criteria for body dysmorphic disorder, had significantly higher prevalences of depression, demanding conduct, previous rhinoplasties and other aesthetic operations, and confirmed trauma histories than patients who originally had dorsal deformities or straight noses with functional symptoms. To the authors' knowledge, this is the first report of such associations. A history of childhood trauma may impact adult patient behavior and therefore the surgical experience.

Why some patients are unhappy: part 2. Relationship of nasal shape and trauma history to surgical success.

BACKGROUND: A previous report indicated that secondary rhinoplasty patients with normal preoperative noses displayed significantly higher prevalences of depression, demanding behavior, previous aesthetic operations, and confirmed trauma (abuse/neglect) histories than patients who originally had dorsal deformities or straight noses with functional symptoms. The authors hypothesized that abuse or neglect might also influence patient satisfaction and suggest screening criteria. METHODS: One hundred secondary rhinoplasty patients stratified by their original nasal shapes were examined by bivariate analysis to determine the characteristics associated with surgical satisfaction. Mediation analysis established intervening factors between total surgery number and patients' perceived success. Random forests identified important patient attributes that predicted surgical success; logistic regression confirmed these effects. RESULTS: Satisfied patients originally had dorsal humps, three or fewer previous operations, were not demanding or depressed, were not looking for perfect noses, and had no trauma histories. Dissatisfied patients originally had subjectively normal noses, more than three operations, were depressed, had demanding personalities, and had trauma histories. Patients who had undergone the most operations were most likely to request more surgery and least likely to be satisfied. A trauma (abuse/neglect) history was the most significant mediator between patient satisfaction and number of operations and the most prominent factor driving surgery in patients with milder deformities. CONCLUSIONS: Potentially causative links exist between trauma (abuse/neglect), body image disorders, and obsessive plastic surgery. Body dysmorphic disorder may be a model of the disordered adaptation to abuse or neglect, a variant of posttraumatic stress disorder. Our satisfied and dissatisfied patients shared common characteristics and therefore may be identifiable preoperatively.

What motivates secondary rhinoplasty? A study of 150 consecutive patients.

BACKGROUND: There is little evidence-based information on secondary rhinoplasty patient motivations for surgery, satisfaction, or revision rates. METHODS: The charts of 150 consecutive patients (121 women and 29 men) who underwent secondary rhinoplasty between July of 2007 and October of 2008 were reviewed; preoperative deformity severity was graded from 1 to 5. The patients' primary reasons for surgery, patient and surgeon satisfaction, and postoperative depression or body dysmorphic disorder were tallied. RESULTS: The average number of prior operations was 3.6. The most commonly expressed reason (41 percent) for undergoing revision was the development of a new deformity after the primary rhinoplasty. Those patients also had the most severe preoperative deformities (p < 0.02). Other motivations were failure to correct the original deformity (33 percent), an intolerable perceived loss of personal, familial, or ethnic characteristics (15 percent), the desire for further improvement in an already acceptable result (10 percent), and a new or unrelieved airway obstruction (1 percent). Ninety-seven percent of patients were happy with their outcomes. Forty patients (27 percent) were depressed before surgery and three (2 percent) displayed evidence of body dysmorphic disorder postoperatively. The depressed and dysmorphic patients did not have worse deformities than those who were not depressed postoperatively (p < 0.8695). CONCLUSIONS: Most secondary rhinoplasty patients have motivations similar to those of our other reconstructive patients and will be pleased with their surgical outcomes. The most severe preoperative deformities were iatrogenic. The unhappy postoperative patients, including those with body dysmorphic disorder, did not have more severe preoperative deformities than the others (i.e., their deformities alone did not justify their unhappiness).