National Interdisciplinary Rhinoplasty

Methods 

A comprehensive questionnaire was sent to 7368 members of the American Society of Plastic Surgeons (ASPS), the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS), and the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). The survey was compiled using responses to the following questions:

Results 

A total of 1923 surveys were completed for analysis. The questionnaire was broken down into three categories: background, technique, and postoperative practices. For results examination, the responses of otolaryngologists and facial plastic surgeons were grouped into one category (ENT). Thirty-five percent of respondents have been in practice for ≥20 years, 30% for 11 to 20 years, 16% for six to 10 years, and 19% for zero to five years. The majority of respondents are in private practice (52%), with 18% in academic practice and 30% in single- or multispecialty practice. Sixty percent charge only a facility fee for revisions; however, 13% charge an additional surgeon's fee.

The youngest patient age at which surgeons will perform rhinoplasty was highly variable, although the most common age was 18 years old for males (35%) and 16 years old for females (37%). Twenty-one percent of respondents said that they would operate on females who were 15 years of age. The majority of surgeons prefer general anesthesia for rhinoplasty procedures, with 71% of respondents using general anesthesia >90% of the time.

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Figure 1. Percentage of survey respondents who identified themselves as specialists in otolaryngology or facial plastic surgery (ENT), plastic surgery (PLA), or both.

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Figure 2. Number of rhinoplasties performed per year. Of the 1923 survey respondents, 32% perform zero to 10, 32% perform 11 to 20, 22% perform 21 to 50, 9% perform 50 to 100, and 5% perform more than 100 rhinoplasties per year.

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Figure 3. Revision rates by percentage of cases. Of the 1923 survey respondents, 58% reported performing revisions in 58% of their cases, 33% reported revisions in 6% to 10% of their cases, 8% reported revisions in 11% to 20% of their cases, and 9% reported revisions in more than 20% of their cases.

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Figure 4. A, Surgical approaches used for primary rhinoplasty (n = 1923). According to the survey, 1% of surgeons use both open and closed approaches equally, 15% use primarily closed approaches, 42% use primarily open approaches, 9% use only closed approaches, and 33% use only open approaches. B, Surgical approaches used for revision rhinoplasty. Seven percent of surgeons use both open and closed approaches equally, 13% use primarily close approaches, 40% use primarily open approaches, 7% use only closed approaches, and 33% use only open approaches.

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Figure 5. A, Most common indications (by percentage; n = 1923) for the open surgical approach: twisted nose (58%), dorsal reduction (13%), spreader grafts (49%), columellar strut (40%), dorsal septal deflection (37%), tip contouring (57%), and tip grafts (55%). B, Most common indications (by percentage; n = 1923) for the closed surgical approach: twisted nose (12%), dorsal reduction (62%), spreader grafts (14%), columellar strut (17%), dorsal septal deflection (18%), tip contouring (24%), and tip grafts (15%).

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Figure 6. A, Frequency of nasal packing by percentage of cases. Thirty-seven percent of survey respondents reported using nasal packing 0% to 20% of the time, 9% reported 21% to 40%, 7% reported 41% to 60%, 8% reported 61% to 80%, and 39% reported using nasal packing in 81% to 100% of cases. B, Average number of days the nasal packing is left in place. Eighty-one percent of respondents leave the packing for zero to three days, 18% for four to seven days, and 1% for eight or more days (n = 1923).

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Figure 7. Average length of follow-up for rhinoplasty patients. Of the 1923 survey respondents, 5% reported a postoperative follow-up of less than three months, 4% of three months, 14% of six months, 50% of one year, 13% for two years, and 14% for more than two years.

With respect to operative techniques, most surgeons are primarily using open approaches and general anesthesia for most indications except simple dorsal hump reductions, in which case the closed approach is used most often. Of those surgeons using the closed approach, 40% use an intracartilaginous approach, while 30% use a delivery approach and 30% use an intracartilaginous approach. Most surgeons prefer the endonasal approach to nasal osteotomy as compared to percutaneous osteotomy. Alloplastic implants are not used commonly, with 77% of respondents using them only 0% to 5% of the time, and 12% using them 6% to 10% of the time. When used, silicone is the most popular option, followed closely by Gortex (Gore, Newark, DE) and Medpor (Porex, Newman, GA).

The vast majority of surgeons use an external nasal splint, with 83% of respondents reporting that they use them 81% to 100% of the time. Eighty-eight percent of respondents leave external splints on for four to seven days. Eighty-four percent of respondents use postoperative steroid injections only 0% to 20% of the time. When they are used, postoperative steroid injections are typically begun within one to three months (36%). The majority of surgeons (59%) do not routinely prescribe postoperative oral steroids. However, the majority of surgeons (81%) do routinely prescribe postoperative antibiotics.

There are a number of subanalysis examinations yielding statistically significant findings (Figure 8, Figure 9, Figure 10, Figure 11), including a statistically significant difference in the use of antibiotics based on length of time in practice. Of those in practice for zero to five years, 90% routinely prescribe antibiotics. Of those in practice for more than 20 years, 69% routinely prescribe them (P < .0001). With respect to the use of external nasal splints, 90% of otolaryngology-trained surgeons use splints 81% to 100% of the time, as compared to plastic surgeons, 80% of whom use splints 81% to 100% of the time (P = .0449). The use of internal nasal packing was bimodal, with 37% using it 0% to 20% of the time and 39% using it 80% to 100% of the time. When used, the majority of surgeons leave the packing in place for an average of zero to three days. Looking at the use of postoperative steroids, 26% of otolaryngology-trained surgeons routinely prescribe steroids, compared to plastic surgeons, of whom only 16% routinely prescribe steroids (P = .0101). A similar trend is also seen with the use of postoperative antibiotics.

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Figure 8. Relative number of rhinoplasties performed per year according to length of time in practice (zero to five, six to10, 11–20, and >20 years).

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Figure 9. The surgical approach of choice for primary surgery according to length of time in practice (zero to five, six to 10, 11–20, and >20 years). Approaches were defined as equally open and closed (both), primarily closed (>Cl), primarily open (>Op), only closed (Closed), and only open (Open).

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Figure 10. The surgical approach of choice for revision surgery according to length of time in practice (zero to five, six to 10, 11–20, and >20 years). Approaches were defined as equally open and closed (both), primarily closed (>Cl), primarily open (>Op), only closed (Closed), and only open (Open).

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Figure 11. Annual number of rhinoplasty procedures per specialty. ENT, otolaryngology and facial plastic surgeons; PLA, plastic surgery.

There is a significant difference in the number of rhinoplasties performed per year based on type of practice, with academic surgeons consistently performing more rhinoplasties per year than those in solo practice or specialty groups (P = .0015). Furthermore, there are significant differences in the approach to the nose based on the number of years in practice. Specifically, the longer a surgeon has been in practice, the more likely it is that the closed approach is used (P < .0001).

Looking across all specialties, the majority of revision rates fell between 0% to 5%, although roughly 30% of respondents have revision rates between 6% and 10%. The most common length of postoperative follow-up is one year, although the distribution was equal for six months, two years, and more than two years.

Discussion 

Rhinoplasty remains one of the most challenging operations in plastic surgery, with a great variety of techniques available to successfully navigate these challenges. A 2005 article by Adamson and Galli1 looked at current trends in rhinoplasty techniques. The authors pointed out certain trends—such as the popularity of the open technique—but focused primarily on otolaryngology-trained surgeons. Some articles have focused on evolving trends in rhinoplasty and have detailed previously- and currently-favored techniques.2 Others have reviewed their own personal experiences with rhinoplasty and their individual evolutions over time.3, 4, 5 The present survey uniquely highlights the current trends in rhinoplasty surgery across different specialties.

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Figure 12. Percentage of survey respondents by practice type who reported performing a certain number of rhinoplasties annually (zero to 10; 11–20; 21–50; 50–100; and >100). ACA, academic; MSG, multispecialty group; Solo, solo practice; SSG, single specialty group.

Looking at the general background results of the survey, the majority of respondents were members of ASPS, although there were more than enough responses from members of AAFPRS and AAO-HNS to gain adequate representation from all specialties. While at first glance a response rate of 26% appears low for a survey study, one has to keep in mind that this survey was sent to as many members as possible within each society (to cast a wide net). A large number of members within AAO-HNS do not perform rhinoplasty and only a moderate percentage of members of ASPS perform rhinoplasty. Taking this into account, we feel that a 26% response rate does likely represent those performing rhinoplasty regularly within these large groups, both of which have many members who do not perform this operation and therefore did not respond to the survey.

Perhaps some of our most interesting findings came from the subanalyses of comparisons between length of time in practice, type of practice, and differences or similarities between specialties. Looking at data about specialties, we found that revision rates are not different between plastic surgeons and facial plastic surgeons, nor was the revision rate different based on length of time in practice or approach used (open vs closed technique). Based on this survey's results, the number of rhinoplasties performed per year is significantly related to length of time in practice. In addition, facial plastic surgeons are more likely to have a functional component to the procedure compared to plastic surgeons, who are more likely to perform purely cosmetic rhinoplasty. However, there were no differences between specialties with respect to approaches to the nose. The approach to the nose based on length of time in practice is highly significant, with trends showing that the longer a physician is in practice, the more likely he/she is to use the closed approach. This statistic is true for both primary and revision rhinoplasties. This is not likely a result of a direct correlation between time in practice and a preference for the closed approach, but rather a result of a difference in training over time. Surgeons in practice for longer periods of time were more likely to be trained using the closed approach, with the open approach only recently becoming a more popular training technique.

Further subanalysis reveals that those who are in practice longer are not more or less likely to prescribe postoperative steroids, but they are less likely to prescribe postoperative antibiotics. Facial plastic surgeons are more likely to use postoperative steroid injections as compared to plastic surgeons. Academicians tend to perform more rhinoplasties per year than those in solo practice and single- or multispecialty groups. However, revision rates between these groups are not significantly different.

Conclusions 

There is no uniform consensus regarding general rhinoplasty trends, including trends in intraoperative techniques and postoperative care. Certain trends, however, can be seen in all areas. In general, the longer a surgeon is in practice and the more private practice–oriented he or she is, the more likely it is that closed techniques are favored. Subanalyses show interesting trends comparing specialties and number of years in practice to other specific survey results. These trends show that overall, there are some similarities amongst different specialties, but there are also statistically significant differences.