Letters
COMMENT & RESPONSE
Patient Privacy, Clinical Photographs, and Publication To the Editor I read with interest your editorial on “Patient Privacy, Photographs, and Publication” in JAMA Facial Plastic Surgery.1 It is highly commendable that you have touched on this topic, which the trainees are not familiar with, particularly the legalities of publishing a patient’s photograph. To add to all the issues which you have mentioned, we in Scotland work for the National Health Service, and most of our patients (in my practice, >95%) come from the National Health Service and not the private sector. In the National Health Service, the question arises, who “owns” the patients? I am in the process of writing a book on surgical techniques in nasal tip reconstruction, and I face 2 sets of issues apart from what you mentioned in your editorial. 1. Not only do I need to get an informed consent from the patient to publish the photographs, but I also need permission from the hospital to use their patient’s photograph in my publications, as by law in Scotland the patients whom I treat “belong” to the National Health Service. 2. Also, there seem to be issues regarding publishing these photographs in scientific publications like JAMA Facial Plastic Surgery and publications in books that will bring in monetary gains. If it is for publication in a scientific journal without monetary gain, I will get permission from the hospital without any issues, but if there is a monetary gain involved, for example, in a “book” publication the process to get permission from the hospital is more elaborate and complex. Natarajan Balaji, FRCS, ORL-HNS Author Affiliation: Department of Otolaryngology–Head and Neck Surgery, Monklands Hospital, Airdrie, Scotland, United Kingdom (Balaji). Corresponding Author: Natarajan Balaji, FRCS, ORL-HNS, Department of Otolaryngology–Head and Neck Surgery, Monklands Hospital, Monkscourt Avenue, Airdrie, Scotland ML6 0JS, United Kingdom ([email protected]). Conflict of Interest Disclosures: None reported. 1. Koch CA, Larrabee WF Jr. Patient privacy, photographs, and publication. JAMA Facial Plast Surg. 2013;15(5):335-336.
Nasal Valve Collapse Treatment To the Editor Nasal airway obstruction is a symptom that is frequently experienced by patients and that every nasal surgeon often has to deal with. Despite several medical treatments and surgical techniques available to address this complaint, the best therapeutic strategy for successfully targeting the cause of this symptom is not always clear. Often, patients have more than 1 etiology provoking nasal airway 66
obstruction, making recognition of the several factors involved not straightforward. The article by Sufyan et al,1 recently published in JAMA Facial Plastic Surgery, casts some light on these patients with multifactorial nasal airway obstruction. This Letter addresses treatment for nasal airway obstruction in a group of patients with nasal valve collapse, with and without allergic rhinitis. As expected, the study by Sufyan et al1 demonstrates that medical treatment with nasal steroids in patients with nasal valve collapse without allergic rhinitis is useless. Surgical treatment with alar batten grafts was, as demonstrated by this study, the treatment of choice for these patients. Alar batten grafts are known for improving static as well as dynamic airway obstruction in cases of nasal valve collapse localized at the external nasal valve or at the intervalve area. What was surprising in this study1 was that alar batten grafts were effective in all patients with nasal valve collapse; therefore, alar batten grafts should have had some positive effect in patients with nasal valve collapse localized at the internal nasal valve. Furthermore, this study 1 demonstrated that surgical treatment of nasal valve collapse also leads to a decrease of allergic symptoms in patients with allergic rhinitis. Sixtytwo percent of the patients included in the study reported allergic symptoms, as supported by the Allergic Rhinitis Questionnaire, before treatment of nasal valve collapse, whereas 12 months after surgery addressing the nasal valve, only 6% of patients were receiving treatment with nasal steroids in an effort to manage their allergic symptoms. Sufyan et al1 speculate that this improvement in allergic symptoms would be due to a decrease of inflammatory cytokines in these patients’ nasal airways as a response to the improved airflow achieved by nasal valve surgery. It would be interesting to find how these allergic patients would be doing after a longer follow-up time. It would also be interesting to measure the concentration of inflammatory cytokines in the nasal mucosa of these patients, before and after surgery. The article by Sufyan et al1 is definitely worth reading. It elegantly shows that treatment for patients with nasal valve collapse should be surgical and suggests that alar batten grafts are effective for improving nasal airflow in all patients with nasal valve collapse. This study also demonstrates that surgical treatment of nasal valve collapse significantly improves allergic symptoms in patients with documented allergic rhinitis and decreases the need for nasal steroids in these patients, therefore raising new perspectives to the best treatment of patients with multifactorial nasal obstruction. Rui Xavier, MD
JAMA Facial Plastic Surgery January/February 2014 Volume 16, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a University of Georgia User on 06/18/2015
jamafacialplasticsurgery.com
Letters
Author Affiliation: Department of Otolaryngology–Head and Neck Surgery, Hospital da Arrabida, Porto, Portugal (Xavier). Corresponding Author: Rui Xavier, MD, Department of Otolaryngology–Head and Neck Surgery, Hospital da Arrabida, Rua Aristides Sousa Mendes 210, 4150-088 Porto, Portugal ([email protected]). Conflict of Interest Disclosures: None reported. 1. Sufyan AS, Hrisomalos E, Kokoska MS, Shipchandler TZ. The effects of alar batten grafts on nasal airway obstruction and nasal steroid use in patients with nasal valve collapse and nasal allergic symptoms: a prospective study. JAMA Facial Plast Surg. 2013;15(3):182-186.
Glued Diced Cartilage Graft for Augmentation Rhinoplasty To the Editor We have recently come across the article “Diced cartilage augmentation: early experience with the Tasman technique” by Baker1 in your journal, and congratulate him on his early results. We have had extensive use with using autologous fibrin glue and diced cartilage grafts in augmentation rhinoplasty as described in our article published in 2011.2 Our article, which included 68 patients from 2005 to 2008, is the first and the largest in the literature describing the use of autologous fibrin glue with diced cartilage grafts for dorsal nasal augmentation, which was recognized and cited in his article. We started using this technique after routinely noting inflammatory reactions to the dorsal nasal skin and poor retention of the diced cartilage grafts when wrapped with oxidized regenerated cellulose (Surgicel; Ethicon Inc). Using autologous fibrin glue, there is decreased inflammation and no longer a barrier to cartilage revascularization, which likely leads to better retention of the cartilage grafts. The introduction of the diced cartilage construct via an open or closed approach is easily performed by a syringe with only the end cut off with a handheld battery-operative ophthalmological cautery. This allows the entire syringe to be placed beneath the dorsal nasal skin with the cartilage construct. As the body of the syringe is slowly withdrawn, the plunger is pushed forward, thereby, leaving the diced cartilage construct on the nasal dorsum. With an obliquely cut syringe as the author describes, we am not surprised at his limitation with the closed (endonasal) approach since the cartilage graft would fall out or become dislodged during its insertion. It was very interesting that credit for the use of our technique for augmentation rhinoplasty was given an eponym, the “Tasman technique,” following a presentation in 2011, a month after our article was published online in PubMed.3 We have been sharing our results with this concept since 2008, when it was first presented at the Rhinoplasty Society Annual Meeting,4 and at the International Society of Aesthetic Plastic Surgeons (ISAPS) annual meeting the same year.5 In fact, our presentation won the award for the Best Presentation at the ISAPS meeting in Melbourne, Australia, in 2008. All of which occurred well before Tasman’s series of patient beginning in 2009.6 The problem with eponyms is the proper credit may not be given to the individual, or (more commonly) group of people, who may have contributed to a particular notion or jamafacialplasticsurgery.com
concept. Currently, it appears that our group was the first to describe this technique in the literature, despite when it may have been heard by another. For this reason, a more fitting eponym would be the “Yuksel technique” or the “Baylor technique”, based on the time it was described. However, eponyms do not accurately describe the technique, and for the scientific and medical community, it would best to refer to this technique as a “glued diced cartilage graft” in the future. Anthony Echo, MD Jamal M. Bullocks, MD Eser Yuksel, MD Author Affiliations: The Methodist Hospital, Division of Plastic Surgery, Institute for Reconstructive Surgery, Houston, Texas (Echo); Division of Plastic Surgery, Kelsey-Seybold Clinic, Houston, Texas (Bullocks); Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas (Yuksel). Corresponding Author: Anthony Echo, MD, The Methodist Hospital, Institute for Reconstructive Surgery, 6560 Fannin, Ste 2200, Scurlock Tower, Houston, TX 77030 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Baker SR. Diced cartilage augmentation: early experience with the Tasman technique. Arch Facial Plast Surg. 2012;14(6):451-455. 2. Bullocks JM, Echo A, Guerra G, Stal S, Yuksel E. A novel autologous scaffold for diced-cartilage grafts in dorsal augmentation rhinoplasty. Aesthetic Plast Surg. 2011;35(4):569-579. 3. Tasman A. Diced cartilage glue: a morphometric analysis. Presented at: Advances in Rhinoplasty; May 6, 2011; Chicago, Illinois. 4. Bullocks JB, Stal S, Yuksel E. An algorithm for optimizing dorsal augmentation rhinoplasty highlighting the utility of fragmented cartilage grafts. Presented at: Rhinoplasty Society, American Association of Aesthetic Plastic Surgeons; May 1-7, 2008; San Diego, California. 5. Bullocks JB, Stal S, Yuksel E. A novel autologous scaffold for diced cartilage grafts in dorsal augmentation rhinoplasty. Presented at: 19th Congress of the International Society of Aesthetic Plastic Surgery; February 10-13, 2008; Melbourne, Australia [awarded Best Clinical Paper]. 6. Tasman AJ, Diener PA, Litschel R. The diced cartilage glue graft for nasal augmentation: morphometric evidence of longevity. JAMA Facial Plast Surg. 2013;15(2):86-94.
In reply I am pleased to respond as the surgeon who developed the original technique on which Dr Baker’s report1 was based. We refined our technique and presented it well before the publication by Bullocks et al2 and also demonstrated it in an online video (http://archfaci.jamanetwork .com/multimediaPlayer.aspx?mediaid=5132635). My original article3 did reference Dr Bullocks’s 2011 publication, and it is appropriate to recognize any other presentations that have been made. The procedures are different in significant ways, however. Both techniques are based on bonding of diced cartilage with glue. Distinct differences are the use of fibrin glue (Tisseel) instead of autologous platelet gel and, more important, the preparation of the graft on the table using a variety of molds, as opposed to injecting the cartilage and bonding in situ. In sum, our techniques are not the same, and we did reference previous work in our article. As to the eponym, I agree that it is often pretentious if someone names his or her own procedure, so I did not. The use of “Tasman procedure” by Dr Baker in his preliminary article was presumably simply meant to acknowledge where he JAMA Facial Plastic Surgery January/February 2014 Volume 16, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a University of Georgia User on 06/18/2015
67
COMMENT & RESPONSE
Patient Privacy, Clinical Photographs, and Publication To the Editor I read with interest your editorial on “Patient Privacy, Photographs, and Publication” in JAMA Facial Plastic Surgery.1 It is highly commendable that you have touched on this topic, which the trainees are not familiar with, particularly the legalities of publishing a patient’s photograph. To add to all the issues which you have mentioned, we in Scotland work for the National Health Service, and most of our patients (in my practice, >95%) come from the National Health Service and not the private sector. In the National Health Service, the question arises, who “owns” the patients? I am in the process of writing a book on surgical techniques in nasal tip reconstruction, and I face 2 sets of issues apart from what you mentioned in your editorial. 1. Not only do I need to get an informed consent from the patient to publish the photographs, but I also need permission from the hospital to use their patient’s photograph in my publications, as by law in Scotland the patients whom I treat “belong” to the National Health Service. 2. Also, there seem to be issues regarding publishing these photographs in scientific publications like JAMA Facial Plastic Surgery and publications in books that will bring in monetary gains. If it is for publication in a scientific journal without monetary gain, I will get permission from the hospital without any issues, but if there is a monetary gain involved, for example, in a “book” publication the process to get permission from the hospital is more elaborate and complex. Natarajan Balaji, FRCS, ORL-HNS Author Affiliation: Department of Otolaryngology–Head and Neck Surgery, Monklands Hospital, Airdrie, Scotland, United Kingdom (Balaji). Corresponding Author: Natarajan Balaji, FRCS, ORL-HNS, Department of Otolaryngology–Head and Neck Surgery, Monklands Hospital, Monkscourt Avenue, Airdrie, Scotland ML6 0JS, United Kingdom ([email protected]). Conflict of Interest Disclosures: None reported. 1. Koch CA, Larrabee WF Jr. Patient privacy, photographs, and publication. JAMA Facial Plast Surg. 2013;15(5):335-336.
Nasal Valve Collapse Treatment To the Editor Nasal airway obstruction is a symptom that is frequently experienced by patients and that every nasal surgeon often has to deal with. Despite several medical treatments and surgical techniques available to address this complaint, the best therapeutic strategy for successfully targeting the cause of this symptom is not always clear. Often, patients have more than 1 etiology provoking nasal airway 66
obstruction, making recognition of the several factors involved not straightforward. The article by Sufyan et al,1 recently published in JAMA Facial Plastic Surgery, casts some light on these patients with multifactorial nasal airway obstruction. This Letter addresses treatment for nasal airway obstruction in a group of patients with nasal valve collapse, with and without allergic rhinitis. As expected, the study by Sufyan et al1 demonstrates that medical treatment with nasal steroids in patients with nasal valve collapse without allergic rhinitis is useless. Surgical treatment with alar batten grafts was, as demonstrated by this study, the treatment of choice for these patients. Alar batten grafts are known for improving static as well as dynamic airway obstruction in cases of nasal valve collapse localized at the external nasal valve or at the intervalve area. What was surprising in this study1 was that alar batten grafts were effective in all patients with nasal valve collapse; therefore, alar batten grafts should have had some positive effect in patients with nasal valve collapse localized at the internal nasal valve. Furthermore, this study 1 demonstrated that surgical treatment of nasal valve collapse also leads to a decrease of allergic symptoms in patients with allergic rhinitis. Sixtytwo percent of the patients included in the study reported allergic symptoms, as supported by the Allergic Rhinitis Questionnaire, before treatment of nasal valve collapse, whereas 12 months after surgery addressing the nasal valve, only 6% of patients were receiving treatment with nasal steroids in an effort to manage their allergic symptoms. Sufyan et al1 speculate that this improvement in allergic symptoms would be due to a decrease of inflammatory cytokines in these patients’ nasal airways as a response to the improved airflow achieved by nasal valve surgery. It would be interesting to find how these allergic patients would be doing after a longer follow-up time. It would also be interesting to measure the concentration of inflammatory cytokines in the nasal mucosa of these patients, before and after surgery. The article by Sufyan et al1 is definitely worth reading. It elegantly shows that treatment for patients with nasal valve collapse should be surgical and suggests that alar batten grafts are effective for improving nasal airflow in all patients with nasal valve collapse. This study also demonstrates that surgical treatment of nasal valve collapse significantly improves allergic symptoms in patients with documented allergic rhinitis and decreases the need for nasal steroids in these patients, therefore raising new perspectives to the best treatment of patients with multifactorial nasal obstruction. Rui Xavier, MD
JAMA Facial Plastic Surgery January/February 2014 Volume 16, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a University of Georgia User on 06/18/2015
jamafacialplasticsurgery.com
Letters
Author Affiliation: Department of Otolaryngology–Head and Neck Surgery, Hospital da Arrabida, Porto, Portugal (Xavier). Corresponding Author: Rui Xavier, MD, Department of Otolaryngology–Head and Neck Surgery, Hospital da Arrabida, Rua Aristides Sousa Mendes 210, 4150-088 Porto, Portugal ([email protected]). Conflict of Interest Disclosures: None reported. 1. Sufyan AS, Hrisomalos E, Kokoska MS, Shipchandler TZ. The effects of alar batten grafts on nasal airway obstruction and nasal steroid use in patients with nasal valve collapse and nasal allergic symptoms: a prospective study. JAMA Facial Plast Surg. 2013;15(3):182-186.
Glued Diced Cartilage Graft for Augmentation Rhinoplasty To the Editor We have recently come across the article “Diced cartilage augmentation: early experience with the Tasman technique” by Baker1 in your journal, and congratulate him on his early results. We have had extensive use with using autologous fibrin glue and diced cartilage grafts in augmentation rhinoplasty as described in our article published in 2011.2 Our article, which included 68 patients from 2005 to 2008, is the first and the largest in the literature describing the use of autologous fibrin glue with diced cartilage grafts for dorsal nasal augmentation, which was recognized and cited in his article. We started using this technique after routinely noting inflammatory reactions to the dorsal nasal skin and poor retention of the diced cartilage grafts when wrapped with oxidized regenerated cellulose (Surgicel; Ethicon Inc). Using autologous fibrin glue, there is decreased inflammation and no longer a barrier to cartilage revascularization, which likely leads to better retention of the cartilage grafts. The introduction of the diced cartilage construct via an open or closed approach is easily performed by a syringe with only the end cut off with a handheld battery-operative ophthalmological cautery. This allows the entire syringe to be placed beneath the dorsal nasal skin with the cartilage construct. As the body of the syringe is slowly withdrawn, the plunger is pushed forward, thereby, leaving the diced cartilage construct on the nasal dorsum. With an obliquely cut syringe as the author describes, we am not surprised at his limitation with the closed (endonasal) approach since the cartilage graft would fall out or become dislodged during its insertion. It was very interesting that credit for the use of our technique for augmentation rhinoplasty was given an eponym, the “Tasman technique,” following a presentation in 2011, a month after our article was published online in PubMed.3 We have been sharing our results with this concept since 2008, when it was first presented at the Rhinoplasty Society Annual Meeting,4 and at the International Society of Aesthetic Plastic Surgeons (ISAPS) annual meeting the same year.5 In fact, our presentation won the award for the Best Presentation at the ISAPS meeting in Melbourne, Australia, in 2008. All of which occurred well before Tasman’s series of patient beginning in 2009.6 The problem with eponyms is the proper credit may not be given to the individual, or (more commonly) group of people, who may have contributed to a particular notion or jamafacialplasticsurgery.com
concept. Currently, it appears that our group was the first to describe this technique in the literature, despite when it may have been heard by another. For this reason, a more fitting eponym would be the “Yuksel technique” or the “Baylor technique”, based on the time it was described. However, eponyms do not accurately describe the technique, and for the scientific and medical community, it would best to refer to this technique as a “glued diced cartilage graft” in the future. Anthony Echo, MD Jamal M. Bullocks, MD Eser Yuksel, MD Author Affiliations: The Methodist Hospital, Division of Plastic Surgery, Institute for Reconstructive Surgery, Houston, Texas (Echo); Division of Plastic Surgery, Kelsey-Seybold Clinic, Houston, Texas (Bullocks); Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas (Yuksel). Corresponding Author: Anthony Echo, MD, The Methodist Hospital, Institute for Reconstructive Surgery, 6560 Fannin, Ste 2200, Scurlock Tower, Houston, TX 77030 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Baker SR. Diced cartilage augmentation: early experience with the Tasman technique. Arch Facial Plast Surg. 2012;14(6):451-455. 2. Bullocks JM, Echo A, Guerra G, Stal S, Yuksel E. A novel autologous scaffold for diced-cartilage grafts in dorsal augmentation rhinoplasty. Aesthetic Plast Surg. 2011;35(4):569-579. 3. Tasman A. Diced cartilage glue: a morphometric analysis. Presented at: Advances in Rhinoplasty; May 6, 2011; Chicago, Illinois. 4. Bullocks JB, Stal S, Yuksel E. An algorithm for optimizing dorsal augmentation rhinoplasty highlighting the utility of fragmented cartilage grafts. Presented at: Rhinoplasty Society, American Association of Aesthetic Plastic Surgeons; May 1-7, 2008; San Diego, California. 5. Bullocks JB, Stal S, Yuksel E. A novel autologous scaffold for diced cartilage grafts in dorsal augmentation rhinoplasty. Presented at: 19th Congress of the International Society of Aesthetic Plastic Surgery; February 10-13, 2008; Melbourne, Australia [awarded Best Clinical Paper]. 6. Tasman AJ, Diener PA, Litschel R. The diced cartilage glue graft for nasal augmentation: morphometric evidence of longevity. JAMA Facial Plast Surg. 2013;15(2):86-94.
In reply I am pleased to respond as the surgeon who developed the original technique on which Dr Baker’s report1 was based. We refined our technique and presented it well before the publication by Bullocks et al2 and also demonstrated it in an online video (http://archfaci.jamanetwork .com/multimediaPlayer.aspx?mediaid=5132635). My original article3 did reference Dr Bullocks’s 2011 publication, and it is appropriate to recognize any other presentations that have been made. The procedures are different in significant ways, however. Both techniques are based on bonding of diced cartilage with glue. Distinct differences are the use of fibrin glue (Tisseel) instead of autologous platelet gel and, more important, the preparation of the graft on the table using a variety of molds, as opposed to injecting the cartilage and bonding in situ. In sum, our techniques are not the same, and we did reference previous work in our article. As to the eponym, I agree that it is often pretentious if someone names his or her own procedure, so I did not. The use of “Tasman procedure” by Dr Baker in his preliminary article was presumably simply meant to acknowledge where he JAMA Facial Plastic Surgery January/February 2014 Volume 16, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a University of Georgia User on 06/18/2015
67
