the right patients Carlos P érez Bolde Villarreal MD Humanitas Medical Group Mexico Conflict of interest Medical associate director M erck Sharp amp ID: 671619
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Slide1
Rhinoplasty: Are we selecting the right patients?
Carlos Pérez Bolde Villarreal, MDHumanitas Medical GroupMexicoSlide2
Conflict of interest.Medical associate director – Merck Sharp & Dohme, Mexico.Outcomes Research LeadSlide3
AgendaWhat are we doing to select patients for aesthetic rhinoplasty?Key points in facial analysisBehind the scenes of rhinoplasty: pshychology of rhinoplasty.Slide4
Aesthetic RhinoplastyRhinoplasty continues to rank among the most popular surgical cosmetic treatments. In 2014, nose reshaping was the second most common surgical procedure performed in the United States.Success of rhinoplasty may vary according to the aesthetic perception of the patient as well as the preoperative status of the nose. Nasal breathing and psychology of
the patient contribute to the successful outcome.Ozturk K. Eur Arch
Otorhinolaryngol 2015; 272(12):
3709-13
Klassen A. JAMA Facial Plast
Surg
2016;18(1):27-35. Slide5
What are we doing to select patients for aesthetic rhinoplasty?Survey of 41 Otolaryngologist and plastic
surgeons that perform aesthetic rhinoplasty.
Questions
regarding
their practice
and
experience
with
aesthetic
rhinoplasty
.
Descriptive
analysis
of
the
results
.Slide6
Results.Years of practice:39.02% have between 5 to 10 years and more
than 10 years practicing (78.04%)21.95% have less
than 5 years
of
practicePhotographs
100% use to
take
preoperatory
photographs
, 93.75%
by
themselves
.
84.3% use
the
same
background
, 75% use
the
same
distance
, 34.3%
special
flash (
avoiding
shadow
in
the
background
), 15.6%
other
(
same
positions, light in
front
of
patient
, etc.)Slide7
Average time practicingSlide8
Results.Facial Analysis.Powell & Humphrey 34.48%, thirds and fifths 79.31%, divine proportion
27.59%, other 13.79% (Gonzalez Ulloa, digital program, VIEW)
Pérez Bolde – Villarreal.
An
ORL Mex 2008; 53(1):23-28Slide9
Results.Psychological analysis25% perform an analysis
by themselves6.25% refer to psychologist68.75% do not perform any analysis.
82.14% know
what
body dysmorphic
disorder
is
.Slide10
Results57.14% does not document their surgical planFacial analysis and photographs were considered the most important aspects of preop analysis (57.14% and 78.57% respectively on a 5 point likert scale)Pshychological analysis scored the
less important in 25% of the cases.Slide11Slide12
Results at one and six months.˜50 % of the physicians – 50% of patients complaint of imperceptible defects.At 6 months the % of physicians didn’t change – 38% of patients still complaint.˜70 % of the physicians – 60% of patients had constant worries.At 6 months, 50% of physicians had 38% percent of patients with constant worries.Slide13
Results (first month)Slide14
Results (after 6 months)Slide15
Facial analysisAesthetic analysis begins with universally accepted standards for “ideal” proportions, keeping in mind individual uniqueness and how those standards apply to the patient’s
overall facial structure. The goals of analysis are to define external nasal deformities, predict the underlying anatomic variations, and determine the appropriate surgical intervention It
doesn´t matter which
type of analysis
you use, what is important
that
you
document
your
plan.
Park S.
Clinical
and Experimental
Otorhinolaryngology
2011;4(2):55-66Slide16
Psychology of rhinoplasty: HistoryThe face has always been considered the personification of ones soul. It is the representation of the persons identity from the social point of view.Facial appearance is closely tied to the self-image, self-confidence, and self-worth of the individual.The face is the part that first enters in contact and remains the longest in interpersonal relations
.Andretto-Amodeo C.
Aesth.
Plast
. Surg
2007; 31:406-410
.
Davis R. Facial
Plast
Surg
2012;28:374-379.Slide17
Psychology of rhinoplasty: HistoryElements of appearance that have the greatest influence in interpersonal relations are attractiveness, beauty and sexual attraction. A person is considered physically attractive if various groups of judges find him so. This judgement is not constant, it varies in time, differs form one culture to another and is influenced by mass media, art, literature, films, publicity, etc
.With the introduction of cameras embedded in cell phones and widely acceptance of social media, facial aesthetics has been more important than ever before in the human history
Melli C. Clinics in Dermatology 1984;2(4):180-87
Ozturk K. Eur Arch Otorhinolaryngol 2015; 272(12):3709-13
.Slide18
Psychology of rhinoplasty: HistoryFrom the days of Tagliocozzi in the 16th century, there was documentation of negative connotations associated with changing the shape of one’s nose, as it was felt to interfere with the will of God.A dissertation by Dr. Jack Anderson, published in the article “What physicians should know about nasal plastic surgery” J La State Med Soc. 1963; addresses the “morality” of aesthetic rhinoplasty concluding that aesthetic rhinoplasty
, in the context of appropriate motives, conforms to “ . . . administering to the whole individual” and “is not only ethical and permissible but also a necessity in some cases.”Rhinoplasty, USA second place.Karimi K, et al. Arch Facial Plast Surg 2011; 14 (6):442-450
Klassen A. JAMA Facial Plast Surg 2016;18(1):27-35.
.Slide19
Psychology of rhinoplasty: HistoryThe noses aspect is critical not only for the anatomy of the face, but also because this organ frequently is one of the factors that can disturb, consciously or subconsciously, our image of our body and our personality developmentIt has cultural, ethnic, symbolic, and psychological significanceMelli C. Clinics in Dermatology 1984;2(4):180-87.
Bull TR. J Laryngol Otol. 1983;97(10): 901-916.Slide20
BUT… DOES EVERY PATIENT ASKING FOR SURGERY IS A GOOD CANDIDATE? HOW CAN WE DIFFERENCIATE BETWEEN PATIENTS THAT WILL BENEFIT FROM SURGERY FROM THOSE WHO DON´T?Slide21
Psychology of rhinoplasty: HistorySurgical advances following World War I were accompanied by enthusiastic reports of the emotional relief experienced by disfigured individuals who underwent reconstructive surgery
.In the 40´s and 50´s the first psychiatric evaluations
of people
seeking
elective cosmetic
surgery
.
“WARNING”
Surgeons
were cautioned of the psychopathology of the male patient, as well as of
the “insatiable
” surgery patient who sought out numerous cosmetic procedures in
pursuit
of
the
perfect
face
.
Early
investigations
based
mainly
on
clinical
interview,
showed
a 70%
patients
with
psychiatric
disturbances
(
neurotic
depression
and
passive
–
dependent
personality
)
Sarwer
D,
Clinical
Psychology
Review 1998;18(1):1-22Slide22
Clinical
interview not describedDiagnostic criteria?
“Marked
psychological disturbance”
“
deviating
from
the
normal
picture
”
“in
need
of
therapy
”
Sarwer
D,
Clinical
Psychology
Review 1998;18(1):1-22Slide23
PSYCHOLOGICAL ASSESSMENTSClinical InterviewAre the patients soughting for the
same cosmetic procedure, affected by
the same
psychological problem
?
Is
it
different
from
a
patient
searching
for
a “
type-changing
”
surgery
(
reshaping
rhinoplasty
) to a “
restorative
”
surgery
(
facelift
)?
THE MAJORITY OF COSMETIC SURGERY PATIENTS WERE PSYCHOLOGICALLY DISTURBED.
Psychometric
Assessments
Many
tests
(Minnesota
Multiphasic
Personality
Inventory
,
Brief
Symptom
Inventory
,
Eysenck
Personality
Inventory
,
etc
)
The
measures
used
are
not
designed
to
tap
the types of psychopatology specific to these patients.
Sarwer
D,
Clinical
Psychology
Review 1998;18(1):1-22Slide24
Less
psychopathologyNo clear relationship between
given cosmetic
procedures and specific
forms
of
psychopathology
Sarwer
D,
Clinical
Psychology
Review 1998;18(1):1-22Slide25
SATISFACTION WITH RESULTSAproximately 10 to 15% of patients are not satisfied by results
of cosmetic nasal surgery.It has been reported that benefit from rhinoplasty was greatest when the indication was cosmetic rather than functional, but
nasal function has been attributed to significantly influence the outcome of a rhinoplasty.
Success of
rhinoplasty was found to be high in severely deformed and twisted noses with increased physical health in the postoperative period
.
SO
… IN ORDER TO INCREASE SUCCESS RATE, WE SHOULD ONLY DO SURGERY ON SEVERE DEFORMED NOSES FROM WOMEN?
Reichert
M.
Laryngo-Rhino-Otol
2014: 93: 507-513
Ozturk K. Eur Arch Otorhinolaryngol 2015; 272(12):3709-13Slide26
SatisfactionPatient’s satisfaction has been defined as the patient’s perceived improvement in well-being following the intervention.Aproximately 10 to
15% of patients are not satisfied by results of cosmetic
nasal surgery.
A case series of
rhinoplasty revision
showed
that
41% of
the
cases,
asked
for
the
revision
because
they
noted
asymmetries
or
irregularities
in
the
nasal
dorsum
, 33%
asked
for
revision
because
they
noted
not
enough
correction
of nasal
deformity
.
Reichert
M.
Laryngo-Rhino-Otol
2014: 93:
507-513
Ozturk
K.
Eur
Arch
Otorhinolaryngol
2015; 272(12):3709-13Slide27
SATISFACTION WITH RESULTSA case series of rhinoplasty revision showed that 41% of the cases, asked
for the revision because they noted asymmetries
or
irregularities
in the nasal
dorsum
, 33%
asked
for
revision
because
they
noted
not
enough
correction
of nasal
deformity
.
Patient
psychologic
selection
has
been
so
far
neglected
for
patients
that
will
have
a
cosmetic
procedure
.
Reichert
M.
Laryngo-Rhino-Otol
2014: 93: 507-513
Ozturk K. Eur Arch Otorhinolaryngol 2015; 272(12):3709-13Slide28
Patient Satisfaction?A UK Department of Health systematic review identified only 9 specific instruments that demostrated adequate psychometric properties and were developed with patient input. Patient satisfaction with their appearance is an often overlooked outcome, and
able to be measured in facial aesthetics using the FACE-Q scales.Ozturk K. Eur Arch Otorhinolaryngol 2015; 272(12):3709-13Klassen A. JAMA Facial Plast Surg 2016;18(1):27-35. Slide29
Patient reported outcomesPatient-reported outcomes are the patients’ feedback, elicited directly from them without interpretation by the physician or others, on how they perceive the physical, mental, or social condition related to their condition or treatment.Systematic use of PRO tools improves communication and decision making between physicians and patients and enhances patient satisfaction with care.
Ozturk K. Eur Arch Otorhinolaryngol 2015; 272(12):3709-13Ishii L. JAMA Facial Plastic Surgery 2016;18(1):35-36.Slide30
Body dysmorphic disorder (BDD)Is one of the most common
psychiatric conditions found in patients seeking cosmetic
surgery.
About
5% and up to 16.6% is
the
reported
global
prevalence
A
study
in
Iran
showed
a 31.5%
prevalence
among
rhinoplasty
candidates
and 70.7% of
them
had
moderate
to
severe
forms
of BDD.
80% of
plastic
surgeons
in
the
USA
report
they
would
not
operate
a
patient
with
BDD,
but
84% has
unwillingly
operated
at
least
one
.
Fathololoomi MR. J Med Sci 2013;29(1):197-200
Ziglinas P. Eur Arch Otorhinolaruyngol 2014; 271:2355-58Slide31
BDD defined as apreoccupation with an imagined defect
in one’s appearance. Alternatively, if a slight
physical anomaly
is present,
the
person’s
concern
is
markedly
excessive
.
DSM-IV,
the
preoccupation
should
last
for
at
least
an
hour
a day1 and cause
clinically
significant
distress
or
impairment
in social,
occupational
or
other
important
areas
of
functioning
.
Anxiety
and
depression
has a
prevalence
of 26.8% to 40% in
bdd
patients
.
Fathololoomi MR. J Med Sci 2013;29(1):197-200
Ziglinas P. Eur Arch Otorhinolaruyngol 2014; 271:2355-58Slide32
Bdd assessmentBDDQ (sensitivity of 100 % and a specificity of 89–93 %)Are
you very worried about your appearance in
any
way?
Does
this
concern
preoccupy
you
?
That
is
, do
you
think
about
it
a
lot
and
wish
you
could
worry
about
it
less
?
How
much
time do
you
spend
thinking
about
it
? (
more
than
1 h per
day
is
suggestive
and more
than
3
hr
is
highly
specific
for BDD).What effect has this preoccupation had on your life? Has
it
:
Significantly
interfered
with
your
social
life
,
school
work
,
job
,
other
activities
,
or
other
aspects
of
your
life
? Caused you a lot of distress? Affected your family or friends?
Ziglinas
P.
Eur
Arch
Otorhinolaruyngol
2014; 271:2355-58Slide33
BDD assessment Dysmorphic Concern Questionnaire (DCQ) 7 items.Yale Brown Obsessive Compulsive ScaleSlide34
ConclusionComplete surgical plan need to be documented before surgery.Patient
selection should not only have a preoperatory
assessment
purely from
the
rhinological
standpoint
;
psychological
aspects
should
be
considered
as
well
.
Standarization
of
Assessment
.Slide35
Carlos Perez Bolde Villarrealcpvorl@gmail.comSlide36
Andretto-Amodeo C. The central role of the nose in the face
and the phsyche: review of the
nose and the
psyche.
Aesth
.
Plast
.
Surg
2007; 31:406-410
.
Davis R,
Bublik
M.
Psychological
considerations
in
the
revision
rhinoplasty
Patient
. Facial
Plast
Surg
2012;28:374-379.
Bull
TR.
Rhinoplasty
:
aesthetics
,
ethics
and
airway
. J
Laryngol
Otol
. 1983;97(10
):
901-916.
Pérez Bolde – Villarreal C. Pineda F.
Evaluaci´n
dela funcionalidad de la máscara de
Marquardt
para la valoración preoperatoria de pacientes para
rinoseptoplastia
estética.
An
ORL Mex 2008; 53(1):
23-28
Karimi
K, Martin F,
Kneally
Mc
,
Adamson
P.
Ethical
consideration
in
aesthetics
rhinoplasty, a
survey
,
critical
analysis
and
review
.
Arch
Facial
Plast
Surg
2011
; 14 (6):
442-450.
Sarwer
D,
Wadden
T.
Pertschuk
M, Whitaker L.
The
psychology
of
cosmetic
surgery: a review and reconceptualization. Clinical Psychology Review 1998;18(1):1-22Klassen
A, Cano S, East C, Baker S, Badia L, Schwitzer J, Pusic A. Development and psychometric evaluation of the FACE-Q scales for patients undergoing rhinoplasty. JAMA Facial Plast Surg 2016;18(1):
27-35.
Ishii
L. Inlcuding the patient voice in aesthetic rhinoplasty outcomes. A new patient reported outcome tool for rhinoplasty. JAMA Facial Plastic Surgery 2016;18(1):
35-36.
Ozturk
K, Gode S, Karahan C, Midilli R. Assessing the rhinoplasty outcome: inter-rater variability of aesthetic perception in the light of objective facial analysis. Eur Arch Otorhinolaryngol 2015; 272(12):
3709-13Melli C, Giorgini S. Aesthetics in psychosomatic dermatology. Clinics in Dermatology 1984;2(4):180-87Reichert M, Scheithauer M, Hoffmann T, Hellings P, Picavet V. (What rhinoplasty surgeons should know about body dysmorphic disorder. Laryngo-Rhino-Otol 2014: 93: 507-51Fathololoomi MR, Tabrizi AG, Bafghi AF, Noohi SA, Makhdoom A. Body dysmorphic disorder in aesthetic rhinoplasty candidates.J Med Sci 2013;29(1):197-200Park S. Fundamental principles in Aesthetic Rhinoplasty.Clinical and Experimental Otorhinolaryngology 2011;4(2):55-66Ziglinas P. Jan Menger D. The body dysmorphic disorder patient: to perform rhinoplasty or not?Eur Arch Otorhinolaruyngol 2014; 271:2355-58
References