Discussion Discussion: Individualized Asian Rhinoplasty: A Systematic Approach to Facial Balance Bahman Guyuron, M.D. Cleveland, Ohio
T
he article by Dr. Li et al. discusses a systematic approach for a rhinoplasty on the Asian nose. Having a methodical, precise, and judiciously designed surgical plan plays a cardinal role in the success of this operation, and the effort of the authors in producing consistent results is admirable. One wonders how the information obtained from the examination is transferred to the operating room in order to reliably produce the intended results. In other words, since there does not seem to be a measurable and reproducible documentation of the process, such as computer measurements or rendering or analysis of the life-size pictures,1 it is unclear as to how this information is accurately applied intraoperatively. For assessment of the outcomes, the photographs were shown to the patients 6 months postoperatively. Most rhinoplasty results are evolving, and what may be pleasing at 6 months may not be the same at 1 year. The authors state that when there was disparity in the scoring between the surgeon and the patient, it resulted in surgery. It would help to know what happened when the patient scored the results very low, while the surgeon was pleased with the outcome and scored it high. This would produce disparity in the score and thus an indication for a revision, although in the surgeon’s view, the outcome was successful. It seems to me that the low scoring by both the surgeon and the patient should have indicated a revision. The divergence in the score that they have referred to translates, in my mind, to the patient and surgeon not being on the same page, and this would be a reason to pause and to not rush into a revision. Considering that 16 percent of patients had limited satisfaction, why would only 2 to 5 percent of the patients be subjected to revision? On the second patient, the authors refer to the presence of a silicone implant in the dorsum. The question is how does the authors’ systematic analysis take into consideration the thickness of From the Department of Plastic Surgery, Case Western Reserve University. Received for publication December 3, 2013; accepted December 10, 2013. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000255
the existing implant, the removal of which was part of the surgical plan? One other question pertains to the assessment of the alar base. Is holding the fingers in a certain position reliable, considering that even 0.5 mm may make a difference in the rhinoplasty outcome? Why would the authors not use one of the many tools that would accomplish this with significantly more reliability? Finally, those of us who are passionate about rhinoplasty have an unwritten rule that any rhinoplasty report should have a minimum of a front, profile, and basilar views. This article would have had more scientific value had it included all of the standard views. Obviously, the authors have devoted a great deal of thought to developing an organized approach to aid in the detection of flaws and the design of the surgical plan. Developing a simple and systematic algorithm for rhinoplasty is extremely difficult because the dynamics of rhinoplasty are utterly complicated and interplays that occur as a result of different maneuvers reduce the predictability of the procedures and make the computation of the end result less reliable. However, any effort, like this report, aimed at improving the consistency of rhinoplasty is greatly appreciated by those of us who care about the rhinoplasty field. This is another genuine and splendid effort in a collective crusade to conquer the most perplexing plastic surgery procedure, and we are grateful to Dr. Li and his co-authors for sharing this well–thought-out approach with us. Bahman Guyuron, M.D. 29017 Cedar Road Cleveland (Lyndhurst), Ohio 44124 [email protected]
REFERENCE 1. Guyuron B. Precision rhinoplasty: Part I. The role of life-size photographs and soft-tissue cephalometric analysis. Plast Reconstr Surg. 1988;81:489–499.
Disclosure: The author has no financial interest to declare in relation to the content of this Discussion or of the associated article.
www.PRSJournal.com
33e
T
he article by Dr. Li et al. discusses a systematic approach for a rhinoplasty on the Asian nose. Having a methodical, precise, and judiciously designed surgical plan plays a cardinal role in the success of this operation, and the effort of the authors in producing consistent results is admirable. One wonders how the information obtained from the examination is transferred to the operating room in order to reliably produce the intended results. In other words, since there does not seem to be a measurable and reproducible documentation of the process, such as computer measurements or rendering or analysis of the life-size pictures,1 it is unclear as to how this information is accurately applied intraoperatively. For assessment of the outcomes, the photographs were shown to the patients 6 months postoperatively. Most rhinoplasty results are evolving, and what may be pleasing at 6 months may not be the same at 1 year. The authors state that when there was disparity in the scoring between the surgeon and the patient, it resulted in surgery. It would help to know what happened when the patient scored the results very low, while the surgeon was pleased with the outcome and scored it high. This would produce disparity in the score and thus an indication for a revision, although in the surgeon’s view, the outcome was successful. It seems to me that the low scoring by both the surgeon and the patient should have indicated a revision. The divergence in the score that they have referred to translates, in my mind, to the patient and surgeon not being on the same page, and this would be a reason to pause and to not rush into a revision. Considering that 16 percent of patients had limited satisfaction, why would only 2 to 5 percent of the patients be subjected to revision? On the second patient, the authors refer to the presence of a silicone implant in the dorsum. The question is how does the authors’ systematic analysis take into consideration the thickness of From the Department of Plastic Surgery, Case Western Reserve University. Received for publication December 3, 2013; accepted December 10, 2013. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000255
the existing implant, the removal of which was part of the surgical plan? One other question pertains to the assessment of the alar base. Is holding the fingers in a certain position reliable, considering that even 0.5 mm may make a difference in the rhinoplasty outcome? Why would the authors not use one of the many tools that would accomplish this with significantly more reliability? Finally, those of us who are passionate about rhinoplasty have an unwritten rule that any rhinoplasty report should have a minimum of a front, profile, and basilar views. This article would have had more scientific value had it included all of the standard views. Obviously, the authors have devoted a great deal of thought to developing an organized approach to aid in the detection of flaws and the design of the surgical plan. Developing a simple and systematic algorithm for rhinoplasty is extremely difficult because the dynamics of rhinoplasty are utterly complicated and interplays that occur as a result of different maneuvers reduce the predictability of the procedures and make the computation of the end result less reliable. However, any effort, like this report, aimed at improving the consistency of rhinoplasty is greatly appreciated by those of us who care about the rhinoplasty field. This is another genuine and splendid effort in a collective crusade to conquer the most perplexing plastic surgery procedure, and we are grateful to Dr. Li and his co-authors for sharing this well–thought-out approach with us. Bahman Guyuron, M.D. 29017 Cedar Road Cleveland (Lyndhurst), Ohio 44124 [email protected]
REFERENCE 1. Guyuron B. Precision rhinoplasty: Part I. The role of life-size photographs and soft-tissue cephalometric analysis. Plast Reconstr Surg. 1988;81:489–499.
Disclosure: The author has no financial interest to declare in relation to the content of this Discussion or of the associated article.
www.PRSJournal.com
33e
