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Experts Develop Evidence-based Clinical Practice Guideline on Rhinoplasty: Provides Framework to Improve Patient Care

February 1, 2017 - 1:07pm

ALEXANDRIA, VA — The American Academy of Otolaryngology—Head and Neck Surgery Foundation addresses the limited literature and availability of multi-disciplinary clinical practice guidelines accessible to clinicians and patients regarding rhinoplasty, with the development of the Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty, published today in Otolaryngology–Head and Neck Surgery.

This is the first evidence-based guideline developed to address rhinoplasty with the goal of providing clinicians, and those involved in the management of these patients, with a logical framework to improve patient care by using a specific set of focused recommendations based upon an established and transparent process that considers levels of evidence, harm-benefit balance, and expert consensus.

“Rhinoplasty ranks among the most commonly performed cosmetic procedures in the United States, with over 200,000 procedures reported in 2014,” said Lisa E. Ishii, MD, MHS, chair of the guideline group. “And prior to these guidelines, limited literature existed on standard pre- and post-management care for patients undergoing this procedure. These guidelines are crucial in building unanimity regarding the peri- and post-operative strategies to maximize patient safety and optimize surgical results for patients.”

According to the American Society of Plastic Surgeons Annual Plastic Surgery Report (2014), of the approximately 217,000 rhinoplasty procedures performed, 75 percent were performed on women, with the most common, 32 percent, age range being between 20-29 years. Total expenditures on rhinoplasty in 2014 exceeded just over one billion (U.S.) dollars and was third only to breast augmentation and fillers. People have rhinoplasty to address some of the following: bumps, humps, or dents on the bridge of the nose; wide or flared nostrils; twisted or crooked nose; upturned, overly round, drooping, or hooked nose tips; improvement of nasal function; or correction to nasal airway obstruction, to name a few.

The guideline, which includes research to support effective identification and treatment of rhinoplasty candidates, was developed as a quality improvement opportunity by creating clear recommendations to use in medical practice. In the guideline are several resources, including the Summary of Evidence-Based Statements, Frequently Asked Questions for Rhinoplasty Patients, Counseling Points for Patients with Obstructive Sleep Apnea (OSA) to Discuss with their Providers, and Frequently Asked Questions for Patient Counseling/Education Regarding Pain Management and Discomfort.

The guideline is endorsed by American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), American Society of Plastic Surgeons (ASPS), American Academy of Sleep Medicine (AASM), American Rhinologic Society (ARS), Society of Otorhinolaryngology Head-Neck Nurses (SOHN), American Society for Aesthetic Plastic Surgery (ASAPS), American Academy of Pediatrics (AAP), and The Rhinoplasty Society.

"We are particularly delighted to have had input and collaboration from all stakeholders to develop guidelines that emphasize both form and function when performing rhinoplasty,” said Dr. Ishii.

The guideline authors are: Lisa E. Ishii, MD, MHS; Travis T. Tollefson, MD, MPH; Gregory J. Basura, MD, PhD; Richard M. Rosenfeld, MD, MPH; Peter J. Abramson, MD; Scott R. Chaiet, MD, MBA; Kara S. Davis, MD; Karl Doghramji, MD; Edward H. Farrior, MD; Sandra A. Finestone, PsyD; Stacey L. Ishman, MD, MPH; Robert X. Murphy, Jr., MD, MS, CPE; John G. Park, MD, FCCP, FAASM; Michael Setzen, MD; Deborah J. Strike; Sandra A. Walsh; Jeremy P. Warner, MD; and Lorraine C. Nnacheta, MPH.

Members of the media who wish to obtain a copy of the guideline or request an interview should contact: Tina Maggio at 703-535-3762, or newsroom@entnet.org. Upon release, the guideline can be found at www.entnet.org.

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AAO-HNSF Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty

What is the purpose of this guideline?

Despite the popularity and importance of rhinoplasty, there are no evidence-based multi-disciplinary clinical practice guidelines to assist clinicians and patients in preoperative consultation, planning care, and working together through shared decision-making to optimize clinical outcomes. This guideline was created to address this need.

What is rhinoplasty?
Rhinoplasty is sometimes referred to as a “nose job” or nose reshaping. It is a surgical procedure that alters the shape or appearance of the nose. It may also aim to improve any breathing problems or correct physical defects in the nose.

What is the prevalence of rhinoplasty?

  • According to the American Society of Plastic Surgeons Annual Plastic Surgery Report (2014), rhinoplasty/nose re-shaping ranked second on the list of the five most common cosmetic surgeries with approximately 217,000 procedures performed.
    • Of those, 162,000 (75 percent) rhinoplasty procedures were performed on women, with the most common (32 percent) age range being between 20-29 years. 
    • Total expenditures on rhinoplasty in 2014 exceeded just over one billion (U.S.) dollars and was third only to breast augmentation and fillers.
  • Individuals with body dysmorphic disorder (BDD), or dysmorphophobia, account for approximately five percent of all patients desiring rhinoplasty; and rhinoplasty is the most common surgical procedure received by patients with BDD.

Why is the rhinoplasty guideline important?
This is the first evidence-based clinical practice guideline developed to address rhinoplasty with the goal of providing clinicians, and those involved in the management of these patients, with a logical framework to improve patient care by using a specific set of focused recommendations based upon an established and transparent process that considers levels of evidence, harm-benefit balance, and expert consensus. As increasing numbers of rhinoplasty procedures are performed, it is important to reduce surgical morbidity, promote appropriate therapy, engage patients in their care, and to coordinate care effectively.

Why is rhinoplasty performed?
The primary reason for surgery can be aesthetic, functional, or both, and may include adjunctive procedures on the nasal septum, nasal valve, nasal turbinates, or the paranasal sinuses. People have rhinoplasty to address some of the following: bumps, humps, or dents on the bridge of the nose; wide or flared nostrils; twisted or crooked nose; upturned, overly round, drooping, or hooked nose tips; poor nasal function; or nasal airway obstruction, to name a few.

SIGNIFICANT POINTS MADE IN THE GUIDELINE:

Communicating Expectations
Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback as to whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record.

Comorbid Conditions
Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs.

Nasal Airway Obstruction
The surgeon, or the surgeon’s designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the pre-operative assessment.

Pre-operative Education
The surgeon, or the surgeon’s designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery.

Counseling for Obstructive Sleep Apnea Patients
The clinician, or the clinician’s designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea (OSA) about the impact of surgery on nasal airway obstruction and how OSA might affect peri-operative management.

Managing Pain and Discomfort
The surgeon, or the surgeon’s designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery.

Outcome Assessment
Clinicians should document patient satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty.

The guideline development group recommended AGAINST certain actions. These include:

  • Post-operative Antibiotics - When a surgeon, or the surgeon’s designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration of more than 24 hours after surgery.
  • Nasal Packing - Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery.

The panel group made the following statement an OPTION:

  • Peri-operative Steroids - The surgeon, or the surgeon’s designee, may administer perioperative systemic steroids to the rhinoplasty patient.

Where can I get more information?
Healthcare providers should discuss all treatment options and find the best approach for the patient. There are printable patient handouts and clinician resources that further explain improving nasal form and function after rhinoplasty and can help with decisions about care options. For more information on rhinoplasty, go to http://www.entnet.org/RhinoplastyCPG

About the AAO-HNS/F
The American Academy of Otolaryngology—Head and Neck Surgery, one of the oldest medical associations in the nation, represents about 12,000 physicians and allied health professionals who specialize in the diagnosis and treatment of disorders of the ears, nose, throat, and related structures of the head and neck. The Academy serves its members by facilitating the advancement of the science and art of medicine related to otolaryngology and by representing the specialty in governmental and socioeconomic issues. The AAO-HNS Foundation works to advance the art, science, and ethical practice of otolaryngology-head and neck surgery through education, research, and lifelong learning. The organization's vision: "Empowering otolaryngologist-head and neck surgeons to deliver the best patient care."

Tina Maggio
Senior Manger, Media & PR
newsroom@entnet.org