Revision Rhinoplasty: Conservation versus Deconstruction.

Revision rhinoplasty requires the surgeon to strike a careful balance between conservation and deconstruction. Contemporary rhinoplasty has focused on structural cartilage grafts. These grafts resist static and dynamic forces produced by tissue contraction, gravity, and pressure gradients during respiration. However, the simultaneous use of multiple grafts also leads to an increased deconstruction of natural supports. In this article, we discuss some simple yet effective techniques in revision rhinoplasty in a case-based format.

Stretched Earlobe Piercings Negatively Impact Casual Observer Perceptions.

Patients with stretched earlobes seek reconstruction to mitigate social stigma. To date, there have been no studies measuring the impact of stretched earlobe piercings on casual observer perceptions. One-hundred seventy-three casual observers were enrolled via public-access web sites. Participants were randomly shown frontal and profile views of six subjects with stretched earlobe piercings and four controls. Participants evaluated photos for first impressions using a survey containing choices regarding personal attributes. Latent class analysis was performed to categorize observer ratings. Analysis of variance (ANOVA), bootstrap analysis, and permutations testing were used to evaluate the relationship between perceived attractiveness, success, and approachability scoring and stretched earlobe status. Latent class analysis categorized responses into three classes: positive, negative, and neutral. Patients with stretched earlobe piercings were significantly less likely to be classified as positive by observers without body modifications (i.e., tattoos and piercings) in comparison to control photos (30.9 and 40.1%, p = 0.007) and more likely to be classified as negative (38.5 and 28.1%, p = 0.002). These changes were abolished when photos were evaluated by observers with body modifications (p > 0.05). ANOVA revealed that stretched earlobe piercings and observer body modification status have a significant effect on rated approachability (F [1,1726] = 4.08, p = 0.04) and successfulness (F[1,1726] = 9.67, p = 0.002; F [1,1726] = 70.33, p < 0.0005). No significance was found for rated attractiveness (p > 0.05). Patients with stretched earlobe piercings were more likely to be classified as having negative affect display and being less approachable and successful compared with controls when evaluated by observers without body modifications. This effect was abolished when photos were evaluated by observers with body modifications. These findings validate patient motivations for seeking stretched earlobe repair.

Surgical Nasal Implants: Indications and Risks.

Rhinoplasty often requires the use of grafting material, and the goal of the specific graft dictates the ideal characteristics of the material to be used. An ideal material would be biologically inert, resistant to infection, noncarcinogenic, nondegradable, widely available, cost-effective, readily modifiable, and easily removable, have compatible biomechanical characteristics, retain physical properties over time, and not migrate. Unfortunately, no material currently in existence meets all of these criteria. In modern rhinoplasty, autologous grafts are the gold standard against which all other nasal implants are measured and offer the safest long-term results for most patients. They are easily manipulated, have inherent stability and biomechanical characteristics similar to the native nasal framework, and confer minimal risk of complications. Modern homologous and alloplastic materials have gained considerable support in recent years because they are readily available in endless quantity, do not require a second surgical site for harvest, and are generally considered safe if most circumstances, but they confer additional risk and have biomechanical characteristics different from that of the native nasal framework. To address some of these issues, we provide a contemporary review of autologous, homologous, and alloplastic materials commonly used in rhinoplasty surgery.

Spreader Grafts in Functional Rhinoplasty.

Management of the middle vault is paramount to achieving optimal aesthetic and functional outcomes in rhinoplasty. The ideal treatment for middle vault complications, such as internal nasal valve collapse, inverted-V deformity, and middle vault dorsal asymmetry, is prevention. Risk factors for middle vault problems in rhinoplasty that may be identified in preoperative consultation include short nasal bones, long and weak upper lateral cartilages, thin skin, previous trauma or surgery, preoperative positive Cottle maneuver, tension nose deformity, and anteriorly positioned inferior turbinates. When any of these risk factors are identified, preventive measures should be pursued. These include preservation of middle vault support structures, judicious resection in dorsal hump reduction, use of conservative osteotomies, and reconstruction of the cartilaginous middle vault with structural grafting. Spreader grafts have become the workhorse in middle vault reconstruction. They are invaluable in restoring nasal dorsal aesthetic lines, repairing or maintaining the internal nasal valve, and buttressing a corrected crooked nose. Functional and aesthetic problems related to the middle nasal vault are among the most common reasons for patients seeking revision rhinoplasty. Although complications in rhinoplasty are inevitable, underlying their etiology and instituting prophylactic treatment can significantly help reduce their occurrence.

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, 134:3548-3554, 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.

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.

Rhytidectomy: principles and practice emphasizing safety.

There is an unprecedented acceptance of rhytidectomy by today's society. No longer limited to the affluent few, middle class citizens are devoting their expendable income to achieve a more youthful appearance that is natural and inconspicuous. Despite recent difficult economic times, the mindset of the working population continues to be welcoming of rhytidectomy as a way to achieve a refreshed look while expecting minimal downtime and morbidity. To achieve these results, the current literature has described an array of techniques; however, there is no consensus on a preferred method, which reflects limitations and advantages inherent to every style of face-lifting. Each individual patient will have specific needs, and it is key for the facial plastic surgeon to select a technique that can address those areas most affected by the aging process. Whichever method used, an emphasis on safety is of the utmost importance. A solid understanding of the relevant anatomy is imperative as is the awareness of how to best avoid complications. Rhytidectomy can be a challenging procedure, and although complications are fortunately rare, they can be cosmetically devastating and poorly accepted by the elective cosmetic patient. This article aims at providing a summary of the history, the anatomy, and the currently accepted methods in rhytidectomy, emphasizing principles and practices of safety.

The crooked nose.

Straightening a crooked nose is a challenge. Several techniques exist ranging from simple to technically complex. It is important to approach the nose systematically and to remember that perfection may be impossible to achieve. If straightening is not attainable, softening grafts or onlay grafts should be used to camouflage subtle irregularities.

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.

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.

Difficult Necks and Unresolved Problems in Neck Rejuvenation.

Neck rejuvenation attempts to correct the unattractive features that result from the process of facial aging. The aesthetic goals of surgery include creating a well-defined jaw contour, optimal cervicomental angle, smooth-appearing skin, and a healthy redistribution of soft tissue volume. Unique patient characteristics create inherent challenges that may limit the degree to which improvement can be made. Psychological expectations and motivations influence patient satisfaction and must be understood through careful evaluation and counseling. This article describes common difficult situations encountered during neck rejuvenation and discusses unresolved problems. Several clinical examples along with specific surgical solutions are included.

A Dual Approach to Understanding Facial Perception Before and After Blepharoplasty.

IMPORTANCE: Blepharoplasty consistently ranks among the most common facial plastic surgery procedure sought by both men and women. Despite the popularity of blepharoplasty, there has been little research focused on quantifying how eyelid surgery changes facial perceptions. OBJECTIVES: To quantify the effect of blepharoplasty on facial perceptions and measure patient-reported ratings of fatigue before and after surgery to compare observer and patient perceptions. DESIGN, SETTING, AND PARTICIPANTS: A web-based survey experiment was conducted from January to February 2017, featuring photographs of female patients before and after blepharoplasty. Observers were randomly shown independent images of each patient and asked to rate perceived age, attractiveness, health, and energy level. Respondents saw only preoperative or postoperative photographs of each patient to reduce bias due to priming. Patient-reported outcomes were also collected. MAIN OUTCOMES AND MEASURES: A multivariate mixed effects regression model was used to quantify the changes in each domain after surgery. Ordinal rank change was calculated to provide a measure of clinical effect size across the domains. To analyze patient-reported outcomes, a Kruskal-Wallis test followed by Mann-Whitney tests were performed to determine if there were differences in patient-perceived tiredness based on operative status. RESULTS: A total of 401 participants (243 women, 152 men, and 6 not specified; mean age 25.9 years [range, 18-73 years]) successfully completed the survey and evaluated before-and-after photographs of 10 female patients (mean age, 59.8 years). The multivariable mixed effects model revealed that individuals are perceived as appearing significantly younger (-1.04 years; 95% CI, -1.70 to -0.37 years) and more attractive (coefficient, 4.92; 95% CI, 3.91-5.93) after blepharoplasty. Ratings of perceived health (coefficient, 4.33; 95% CI, 3.28-5.37) and energy level (coefficient, 9.83; 95% CI, 8.51-11.16) also improved significantly. After undergoing blepharoplasty, patients had significantly improved ratings of energy level compared with those who had not undergone blepharoplasty. CONCLUSIONS AND RELEVANCE: This is the first study, to date, aimed at quantifying the perceptions of facial aesthetic changes following blepharoplasty. The data demonstrate that individuals are rated as appearing more youthful, attractive, and healthy following blepharoplasty. Furthermore, both patients and casual observers perceived a significant improvement in energy level following blepharoplasty, a meaningful finding as the appearance of fatigue is a chief concern of the patients before they undergo blepharoplasty. LEVEL OF EVIDENCE: NA.

Association of Rhinoplasty With Perceived Attractiveness, Success, and Overall Health.

IMPORTANCE: To date, the impact of rhinoplasty surgery on social perceptions has not been quantified. OBJECTIVE: To measure the association of rhinoplasty with observer-graded perceived attractiveness, success, and overall health. DESIGN, SETTING, AND PARTICIPANTS: In a web-based survey, blinded casual observers viewed independent images of 13 unique patient faces before or after rhinoplasty. Delphi method was used to select standardized patient images, confirming appropriate patient candidacy and overall surgical effect. Observers rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, where higher scores corresponded to more positive responses. A multivariate mixed-effects regression model was used to determine the effect of rhinoplasty while accounting for observer biases. To further characterize the effect of rhinoplasty, estimated ordinal rank change was calculated for each domain. MAIN OUTCOMES AND MEASURES: The primary objective was to measure the effect of rhinoplasty on observer-graded perceived attractiveness, success, and overall health. RESULTS: A total of 473 observers (mean age, 29 years [range, 18-73 years]; 305 [70.8%] were female) successfully completed the survey. On multivariate regression, patients after rhinoplasty were rated as significantly more attractive (rhinoplasty effect, 6.26; 95% CI, 5.10-7.41), more successful (rhinoplasty effect, 3.24; 95% CI, 2.32-4.17), and overall healthier (rhinoplasty effect, 3.78; 95% CI, 2.79-4.81). The ordinal rank change for an average individual's perceived attractiveness, success, and overall health was a positive shift of 14, 9, and 10 out of 100 rank positions, respectively. CONCLUSIONS AND RELEVANCE: As perceived by casual observers, rhinoplasty surgery was associatedwith perceptions that in patients appeared significantly more attractive, more successful, and healthier. These results suggest patients undergoing rhinoplasty may derive a multifaceted benefit when partaking in social interactions. Furthermore, these results facilitate improved patient discussions aiming to provide more precise surgical expectations with an understanding that these results represent optimal outcomes. LEVEL OF EVIDENCE: NA.

Association Between Facial Rejuvenation and Observer Ratings of Youth, Attractiveness, Success, and Health.

IMPORTANCE: Surgical procedures for the aging face-including face-lift, blepharoplasty, and brow-lift-consistently rank among the most popular cosmetic services sought by patients. Although these surgical procedures are broadly classified as procedures that restore a youthful appearance, they may improve societal perceptions of attractiveness, success, and health, conferring an even larger social benefit than just restoring a youthful appearance to the face. OBJECTIVES: To determine if face-lift and upper facial rejuvenation surgery improve observer ratings of age, attractiveness, success, and health and to quantify the effect of facial rejuvenation surgery on each individual domain. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical experiment was performed from August 30 to September 18, 2016, using web-based surveys featuring photographs of patients before and after facial rejuvenation surgery. Observers were randomly shown independent images of the 12 patients; within a given survey, observers saw either the preoperative or postoperative photograph of each patient to reduce the possibility of priming. Observers evaluated patient age using a slider bar ranging from 30 to 80 years that could be moved up or down in 1-year increments, and they ranked perceived attractiveness, success, and health using a 100-point visual analog scale. The bar on the 100-point scale began at 50; moving the bar to the right corresponded to a more positive rating in these measures and moving the bar to the left, a more negative rating. MAIN OUTCOMES AND MEASURES: A multivariate mixed-effects regression model was used to understand the effect of face-lift and upper facial rejuvenation surgery on observer perceptions while accounting for individual biases of the participants. Ordinal rank change was calculated to understand the clinical effect size of changes across the various domains after surgery. RESULTS: A total of 504 participants (333 women, 165 men, and 6 unspecified; mean age, 29 [range, 18-70] years) successfully completed the survey. A multivariate mixed-effects regression model revealed a statistically significant change in age (-4.61 years; 95% CI, -4.97 to -4.25) and attractiveness (6.72; 95% CI, 5.96-7.47) following facial rejuvenation surgery. Observer-perceived success (3.85; 95% CI, 3.12-4.57) and health (7.65; 95% CI; 6.87-8.42) also increased significantly as a result of facial rejuvenation surgery. CONCLUSIONS AND RELEVANCE: The data presented in this study demonstrate that patients are perceived as younger and more attractive by the casual observer after undergoing face-lift and upper facial rejuvenation surgery. These procedures also improved ratings of perceived success and health in our patient population. These findings suggest that facial rejuvenation surgery conveys an even larger societal benefit than merely restoring a youthful appearance to the face. LEVEL OF EVIDENCE: NA.

Association of Face-lift Surgery With Social Perception, Age, Attractiveness, Health, and Success.

IMPORTANCE: Evidence quantifying the influence of face-lift surgery on societal perceptions is lacking. OBJECTIVE: To measure the association of face-lift surgery with observer-graded perceived age, attractiveness, success, and overall health. DESIGN, SETTING, AND PARTICIPANTS: In a web-based survey, 526 casual observers naive to the purpose of the study viewed independent images of 13 unique female patient faces before or after face-lift surgery from January 1, 2016, through June 30, 2016. The Delphi method was used to select standardized patient images confirming appropriate patient candidacy and overall surgical effect. Observers estimated age and rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, with higher scores corresponding to more positive responses. To evaluate the accuracy of observer age estimation, the patients' preoperative estimated mean age was compared with the patients' actual mean age. A multivariate mixed-effects regression model was used to determine the effect of face-lift surgery. To further characterize the effect of face-lift surgery, estimated ordinal-rank change was calculated for each domain. MAIN OUTCOMES AND MEASURES: Blinded casual observer ratings of patients estimated age, attractiveness, perceived success, and perceived overall health. RESULTS: A total of 483 observers (mean [SD] age, 29 [8.6] years; 382 women [79.4%]) successfully completed the survey. Comparing patients' preoperative estimated mean (SD) age (59.6 [9.0] years) and patients' actual mean (SD) age (58.4 [6.9] years) revealed no significant difference (t2662 = -0.47; 95% CI, -6.07 to 3.72; P = .64). On multivariate regression, patients after face-lift surgery were rated as significantly younger (coefficient, -3.69; 95% CI -4.15 to -3.23; P < .001), more attractive (coefficient, 8.21; 95% CI, 7.41-9.02; P < .001), more successful (coefficient, 5.82; 95% CI, 5.05 to 6.59; P < .001), and overall healthier (coefficient, 8.72; 95% CI, 7.88-9.56; P < .001). The ordinal rank changes for an average individual were -21 for perceived age, 21 for attractiveness, 16 for success, and 21 for overall health. CONCLUSIONS AND RELEVANCE: In this study, observer perceptions of face-lift surgery were associated with views that patients appeared younger, more attractive, healthier, and more successful. These findings highlight observer perceptions of face-lift surgery that could positively influence social interactions. LEVEL OF EVIDENCE: NA.

Reconstruction of congenital and acquired auricular scaphal deficiencies.

Although complications from piercing of the helical rim are unusual, infections in this area after piercing can produce devastating changes in the cartilaginous framework. Scaphal height is also reduced in certain congenital pinna anomalies. We developed a method of scaphal reconstruction that uses a composite graft harvested from the ipsilateral conchal bowl. The conchal bowl defect is repaired with an ipsilateral full-thickness graft of postauricular skin. This technique restores scaphal height and helical contour with minimal donor site morbidity.