- Email: [email protected]
Teaching and practice patterns of lateral osteotomies for rhinoplasty
Accepted Manuscript Teaching and practice patterns of lateral osteotomies for rhinoplasty
Jenny X. Chen, Elliott D. Kozin, Matthew M. Dedmon, Linda N. Lee PII: DOI: Reference:
S0196-0709(17)30217-X doi: 10.1016/j.amjoto.2017.04.008 YAJOT 1849
To appear in: Received date:
17 March 2017
Please cite this article as: Jenny X. Chen, Elliott D. Kozin, Matthew M. Dedmon, Linda N. Lee , Teaching and practice patterns of lateral osteotomies for rhinoplasty. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yajot(2017), doi: 10.1016/j.amjoto.2017.04.008
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Title: Teaching and Practice Patterns of Lateral Osteotomies for Rhinoplasty
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Authors: Jenny X. Chen*, MD 1, Elliott D. Kozin*, MD 1, Matthew M. Dedmon, MD, PhD 2, Linda N. Lee, MD 1,3
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Affiliations: 1 Department of Otolaryngology, Harvard Medical School, Boston, MA. 2 Department of Otolaryngology, Vanderbilt University, Nashville, TN 3 Department of Otolaryngology, Division of Facial Plastic and Reconstructive Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA Conflicts of Interest: None
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Funding Sources: None
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Financial Disclosures: None
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Keywords: surgical education, facial plastic surgery, intranasal osteotomies, percutaneous osteotomies, rhinoplasty
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Format: American Journal of Otolaryngology
Corresponding Author: Linda N. Lee Massachusetts Eye and Ear Infirmary 243 Charles Street Boston, MA 02114 [email protected]
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P: (617) 523-7900 Abstract
Purpose: Lateral osteotomies are important during rhinoplasty and represent a challenging technique that otolaryngology and plastic surgery trainees must learn. The approaches for
IP
T
osteotomies are difficult to teach as they are accomplished through tactile feedback. Trends in
CR
teaching and practice patterns of lateral osteotomies are poorly described in the literature, and this study aims to fill this knowledge gap.
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Materials and methods: Members of the American Academy of Facial Plastic and Reconstructive Surgery were surveyed to characterize surgeon preferences for intranasal versus
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percutaneous lateral osteotomies and understand how techniques are taught.
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Results: Among surgeons who completed the survey (n=172), 87% reported that they “always”
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or “mostly” use intranasal lateral osteotomies whereas only 8% “always” or “mostly” use percutaneous approaches. There is no significant trend towards changing osteotomy techniques
PT
when teaching trainees. Only 15% of respondents allow trainees to perform lateral osteotomies in more than half of operations.
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Conclusions: Most facial plastic surgeons prefer to use intranasal lateral osteotomies. However,
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many do not allow trainees to perform this critical step during rhinoplasty. This study has implications for both patient care and surgical education.
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1.0 Introduction Lateral osteotomies are essential to functional and cosmetic rhinoplasties and can be performed through percutaneous or transnasal approaches. While some surgeons find a percutaneous approach enables a more controlled fracture and minimizes deep tissue trauma [1],
IP
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others posit that an intranasal approach minimizes morbidity and avoids scarring [2]. Both techniques are important, but difficult to teach, , as they are performed through tactile feedback,
CR
although there is limited literature characterizing this problem. The complications of an
US
incorrectly performed osteotomy include poor aesthetic results as well as poor functional outcomes. Incorrectly performed osteotomies are difficult to correct.
AN
Given the difficulty inherent in teaching these surgical techniques, we sought to better
M
characterize how lateral osteotomies are performed and taught nationwide. This study offers an
ED
up to date understanding of how osteotomies are currently performed by facial plastic surgeons and highlights areas for improvement in surgical education.
PT
2.0 Methods
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This project was approved by the Massachusetts Eye and Ear Infirmary institutional
AC
review board. A survey was designed using Qualtrics Software (Provo, UT) and distributed via e-mail by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) to ~1100 members between September and November 2015. Participation was voluntary and responses were anonymous. Survey data were analyzed with descriptive and analytic statistics using Graphpad Prism (La Jolla, CA) and multivariable regressions were performed using Wessa.net (online version 1.1.23-r7). Paired t-tests were used to determine if surgeons changed osteotomy technique when teaching trainees as compared to when operating alone. Multivariable
ACCEPTED MANUSCRIPT 4
regressions determined variables associated with type of osteotomy used in current practice and type of osteotomy taught. Chi-squared tests were used to determine if timing of training is independent from techniques learned during training.
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3.0 Results
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One-hundred and seventy two surgeons completed the survey. The average respondent
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performs 21 to 50 rhinoplasties annually and completed surgical training 16.3 years ago (SD=11, median=14, Figure 1a, b). 87% of respondents “always” or “mostly” perform intranasal lateral
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osteotomies while 8% “always” or “mostly” use percutaneous approaches (Figure 1c). Similarly, 90% of respondents learned primarily to perform intranasal osteotomies during training (Figure
AN
1d). Notably, the proportion who received significant training in percutaneous techniques has
M
significantly increased among those who finished training in the last 15 years compared with
ED
those who trained earlier (16% vs. 4%, Chi-square test for independence p=0.01). The osteotomy approach preferred was associated with the type respondents learned during training (β=0.54,
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SD=0.13, p<0.001), whereas years since training (p=0.45) and rhinoplasties performed annually
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(p=0.34) were not associated.
Sixty-three percent of AAFRPS members who prefer an intranasal technique attribute
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this to their own training. Thirty-five percent think an intranasal technique provides a better outcome and 17% prefer an intranasal technique because there is no scarring; some believe it gives better control or a more complete osteotomy. Among those who prefer a percutaneous approach, 21% cite their prior training and 57% believe it gives a better outcome; some find there is a lower likelihood of flail segments or better accuracy and control in the cut.
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Among AAFRPS respondents, 74% of (n=128) teach trainees. Respondents do not change technique when teaching compared to when operating alone (paired t-test p=0.78). Technique used when operating alone is most associated with that used when teaching (β=0.94, SD=0.032, p<0.001). Factors not associated include years since training (p=0.75) and number of
IP
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rhinoplasties performed annually (p=0.89). Of note, only 15% of respondents allow trainees to perform lateral osteotomies during
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more than half of operations (Figure 2). In comparison, significantly more respondents allow
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trainees to perform septoplasties (52%, paired t-test p=<0.0001) or harvest auricular cartilage (58%, paired t-test p=<0.0001) during more than half of operations.
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4.0 Discussion
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Among a sample of AAFRPS members, the majority prefer to perform and teach an
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intranasal approach to lateral osteotomies. The choice of techniques is most associated with training experiences. One interesting finding is that surgeons who have completed training in the
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past 15 years are more exposed to percutaneous techniques than those who completed training
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earlier. This may indicate an evolving understanding that both percutaneous and intranasal techniques are important for surgeons to master. Surgeons reported various and sometimes
AC
overlapping reasons for using one technique over another. This may be explained by variables such as patient factors, osteotome size [3], perforated vs. continuous cuts [2], and certainly surgical familiarity with each approach. Additional research comparing the functional and aesthetic outcomes of the two approaches may offer further insight. As the choice of technique is significantly associated with one’s own training, it may be important to expose current residents to both techniques.
ACCEPTED MANUSCRIPT 6
The most notable finding in this study is that very few surgeons allow trainees to perform osteotomies. Strategies should be explored to improve trainee education, particularly as the Accreditation Council for Graduate Medical Education requires graduating otolaryngology and plastic surgery residents to perform a minimum of only 8 or 10 rhinoplasties, respectively [4].
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experiences for plastic surgery and otolaryngology residents [5–7].
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For example, using fresh tissue in surgical simulations has been shown to improve extraclinical
CR
This study is limited by its low response rate. However, this is typical for electronic
US
surveys of busy practicing physicians [8]. Despite this, there were sufficient respondents to power the aforementioned analyses. Moreover, the number of active members and accurate
AN
emails on the AAFPRS mailing list is unknown, such that the true response rate may be higher.
M
As for all voluntary surveys, this study may be limited by selection bias (i.e. those interested in
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rhinoplasty may have been more likely to respond). 5.0 Conclusion
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The majority of facial plastic surgeons surveyed preferred to perform and teach an
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intranasal approach to lateral osteotomies and are heavily influenced by the method they were exposed to during training. It is therefore concerning that trainees are often not allowed to
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practice these high risk procedures. Innovations in surgical education are necessary to address this gap in training.
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Acknowledgements The authors thank the American Academy of Facial Plastic and Reconstructive Surgery
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for disseminating this survey.
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Figure Legends Figure 1. Most facial plastic surgeons prefer an intranasal approach to lateral osteotomies. (a) Number of rhinoplasties respondents performed per year. (b) Number of years of independent surgical practice. (d) Current preferred technique for lateral osteotomy. (d) Technique
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respondents learned during training.
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Figure 2. Surgeons allow trainees to perform lateral osteotomies with lower frequency than other
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portions of rhinoplasty such as septoplasty or harvesting cartilage.
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References [1] Rohrich RJ, Janis JE, Adams WP, Krueger JK. An update on the lateral nasal osteotomy in rhinoplasty: an anatomic endoscopic comparison of the external versus the internal approach. Plast Reconstr Surg 2003;111:2461–2462; discussion 2463.
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doi:10.1097/01.PRS.0000061005.27994.E3.
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[2] Gryskiewicz JM, Gryskiewicz KM. Nasal osteotomies: a clinical comparison of the
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perforating methods versus the continuous technique. Plast Reconstr Surg 2004;113:14451456-1458.
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[3] Becker DG, McLaughlin RB, Loevner LA, Mang A. The lateral osteotomy in rhinoplasty:
AN
clinical and radiographic rationale for osteotome selection. Plast Reconstr Surg 2000;105:1806-1816-1819.
M
[4] ACGME > Program and Institutional Accreditation > Surgical Specialties n.d.
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https://www.acgme.org/acgmeweb/tabid/369/ProgramandInstitutionalAccreditation/Surgical Specialties.aspx (accessed February 2, 2017).
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[5] Sheckter CC, Kane JT, Minneti M, Garner W, Sullivan M, Talving P, et al. Incorporation of
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Fresh Tissue Surgical Simulation into Plastic Surgery Education: Maximizing Extraclinical Surgical Experience. J Surg Educ 2013;70:466–74. doi:10.1016/j.jsurg.2013.02.008.
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[6] Dedmon MM, Kozin ED, Lee DJ. Development of a Temporal Bone Model for Transcanal Endoscopic Ear Surgery. Otolaryngol -- Head Neck Surg 2015;153:613–5. doi:10.1177/0194599815593738. [7] Dedmon MM, Paddle PM, Phillips J, Kobayashi L, Franco RA, Song PC. Development and Validation of a High-Fidelity Porcine Laryngeal Surgical Simulator. Otolaryngol -- Head Neck Surg 2015;153:420–6. doi:10.1177/0194599815590118.
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[8] Scott A, Jeon S-H, Joyce CM, Humphreys JS, Kalb G, Witt J, et al. A randomised trial and economic evaluation of the effect of response mode on response rate, response bias, and item non-response in a survey of doctors. BMC Med Res Methodol 2011;11:126.
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doi:10.1186/1471-2288-11-126.
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Fig. 1
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Fig. 2
Jenny X. Chen, Elliott D. Kozin, Matthew M. Dedmon, Linda N. Lee PII: DOI: Reference:
S0196-0709(17)30217-X doi: 10.1016/j.amjoto.2017.04.008 YAJOT 1849
To appear in: Received date:
17 March 2017
Please cite this article as: Jenny X. Chen, Elliott D. Kozin, Matthew M. Dedmon, Linda N. Lee , Teaching and practice patterns of lateral osteotomies for rhinoplasty. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yajot(2017), doi: 10.1016/j.amjoto.2017.04.008
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Title: Teaching and Practice Patterns of Lateral Osteotomies for Rhinoplasty
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Authors: Jenny X. Chen*, MD 1, Elliott D. Kozin*, MD 1, Matthew M. Dedmon, MD, PhD 2, Linda N. Lee, MD 1,3
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Affiliations: 1 Department of Otolaryngology, Harvard Medical School, Boston, MA. 2 Department of Otolaryngology, Vanderbilt University, Nashville, TN 3 Department of Otolaryngology, Division of Facial Plastic and Reconstructive Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA Conflicts of Interest: None
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Funding Sources: None
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Financial Disclosures: None
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Keywords: surgical education, facial plastic surgery, intranasal osteotomies, percutaneous osteotomies, rhinoplasty
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CE
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Format: American Journal of Otolaryngology
Corresponding Author: Linda N. Lee Massachusetts Eye and Ear Infirmary 243 Charles Street Boston, MA 02114 [email protected]
ACCEPTED MANUSCRIPT 2
P: (617) 523-7900 Abstract
Purpose: Lateral osteotomies are important during rhinoplasty and represent a challenging technique that otolaryngology and plastic surgery trainees must learn. The approaches for
IP
T
osteotomies are difficult to teach as they are accomplished through tactile feedback. Trends in
CR
teaching and practice patterns of lateral osteotomies are poorly described in the literature, and this study aims to fill this knowledge gap.
US
Materials and methods: Members of the American Academy of Facial Plastic and Reconstructive Surgery were surveyed to characterize surgeon preferences for intranasal versus
AN
percutaneous lateral osteotomies and understand how techniques are taught.
M
Results: Among surgeons who completed the survey (n=172), 87% reported that they “always”
ED
or “mostly” use intranasal lateral osteotomies whereas only 8% “always” or “mostly” use percutaneous approaches. There is no significant trend towards changing osteotomy techniques
PT
when teaching trainees. Only 15% of respondents allow trainees to perform lateral osteotomies in more than half of operations.
CE
Conclusions: Most facial plastic surgeons prefer to use intranasal lateral osteotomies. However,
AC
many do not allow trainees to perform this critical step during rhinoplasty. This study has implications for both patient care and surgical education.
ACCEPTED MANUSCRIPT 3
1.0 Introduction Lateral osteotomies are essential to functional and cosmetic rhinoplasties and can be performed through percutaneous or transnasal approaches. While some surgeons find a percutaneous approach enables a more controlled fracture and minimizes deep tissue trauma [1],
IP
T
others posit that an intranasal approach minimizes morbidity and avoids scarring [2]. Both techniques are important, but difficult to teach, , as they are performed through tactile feedback,
CR
although there is limited literature characterizing this problem. The complications of an
US
incorrectly performed osteotomy include poor aesthetic results as well as poor functional outcomes. Incorrectly performed osteotomies are difficult to correct.
AN
Given the difficulty inherent in teaching these surgical techniques, we sought to better
M
characterize how lateral osteotomies are performed and taught nationwide. This study offers an
ED
up to date understanding of how osteotomies are currently performed by facial plastic surgeons and highlights areas for improvement in surgical education.
PT
2.0 Methods
CE
This project was approved by the Massachusetts Eye and Ear Infirmary institutional
AC
review board. A survey was designed using Qualtrics Software (Provo, UT) and distributed via e-mail by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) to ~1100 members between September and November 2015. Participation was voluntary and responses were anonymous. Survey data were analyzed with descriptive and analytic statistics using Graphpad Prism (La Jolla, CA) and multivariable regressions were performed using Wessa.net (online version 1.1.23-r7). Paired t-tests were used to determine if surgeons changed osteotomy technique when teaching trainees as compared to when operating alone. Multivariable
ACCEPTED MANUSCRIPT 4
regressions determined variables associated with type of osteotomy used in current practice and type of osteotomy taught. Chi-squared tests were used to determine if timing of training is independent from techniques learned during training.
T
3.0 Results
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One-hundred and seventy two surgeons completed the survey. The average respondent
CR
performs 21 to 50 rhinoplasties annually and completed surgical training 16.3 years ago (SD=11, median=14, Figure 1a, b). 87% of respondents “always” or “mostly” perform intranasal lateral
US
osteotomies while 8% “always” or “mostly” use percutaneous approaches (Figure 1c). Similarly, 90% of respondents learned primarily to perform intranasal osteotomies during training (Figure
AN
1d). Notably, the proportion who received significant training in percutaneous techniques has
M
significantly increased among those who finished training in the last 15 years compared with
ED
those who trained earlier (16% vs. 4%, Chi-square test for independence p=0.01). The osteotomy approach preferred was associated with the type respondents learned during training (β=0.54,
PT
SD=0.13, p<0.001), whereas years since training (p=0.45) and rhinoplasties performed annually
CE
(p=0.34) were not associated.
Sixty-three percent of AAFRPS members who prefer an intranasal technique attribute
AC
this to their own training. Thirty-five percent think an intranasal technique provides a better outcome and 17% prefer an intranasal technique because there is no scarring; some believe it gives better control or a more complete osteotomy. Among those who prefer a percutaneous approach, 21% cite their prior training and 57% believe it gives a better outcome; some find there is a lower likelihood of flail segments or better accuracy and control in the cut.
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Among AAFRPS respondents, 74% of (n=128) teach trainees. Respondents do not change technique when teaching compared to when operating alone (paired t-test p=0.78). Technique used when operating alone is most associated with that used when teaching (β=0.94, SD=0.032, p<0.001). Factors not associated include years since training (p=0.75) and number of
IP
T
rhinoplasties performed annually (p=0.89). Of note, only 15% of respondents allow trainees to perform lateral osteotomies during
CR
more than half of operations (Figure 2). In comparison, significantly more respondents allow
US
trainees to perform septoplasties (52%, paired t-test p=<0.0001) or harvest auricular cartilage (58%, paired t-test p=<0.0001) during more than half of operations.
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4.0 Discussion
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Among a sample of AAFRPS members, the majority prefer to perform and teach an
ED
intranasal approach to lateral osteotomies. The choice of techniques is most associated with training experiences. One interesting finding is that surgeons who have completed training in the
PT
past 15 years are more exposed to percutaneous techniques than those who completed training
CE
earlier. This may indicate an evolving understanding that both percutaneous and intranasal techniques are important for surgeons to master. Surgeons reported various and sometimes
AC
overlapping reasons for using one technique over another. This may be explained by variables such as patient factors, osteotome size [3], perforated vs. continuous cuts [2], and certainly surgical familiarity with each approach. Additional research comparing the functional and aesthetic outcomes of the two approaches may offer further insight. As the choice of technique is significantly associated with one’s own training, it may be important to expose current residents to both techniques.
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The most notable finding in this study is that very few surgeons allow trainees to perform osteotomies. Strategies should be explored to improve trainee education, particularly as the Accreditation Council for Graduate Medical Education requires graduating otolaryngology and plastic surgery residents to perform a minimum of only 8 or 10 rhinoplasties, respectively [4].
IP
experiences for plastic surgery and otolaryngology residents [5–7].
T
For example, using fresh tissue in surgical simulations has been shown to improve extraclinical
CR
This study is limited by its low response rate. However, this is typical for electronic
US
surveys of busy practicing physicians [8]. Despite this, there were sufficient respondents to power the aforementioned analyses. Moreover, the number of active members and accurate
AN
emails on the AAFPRS mailing list is unknown, such that the true response rate may be higher.
M
As for all voluntary surveys, this study may be limited by selection bias (i.e. those interested in
ED
rhinoplasty may have been more likely to respond). 5.0 Conclusion
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The majority of facial plastic surgeons surveyed preferred to perform and teach an
CE
intranasal approach to lateral osteotomies and are heavily influenced by the method they were exposed to during training. It is therefore concerning that trainees are often not allowed to
AC
practice these high risk procedures. Innovations in surgical education are necessary to address this gap in training.
ACCEPTED MANUSCRIPT 7
Acknowledgements The authors thank the American Academy of Facial Plastic and Reconstructive Surgery
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M
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IP
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for disseminating this survey.
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Figure Legends Figure 1. Most facial plastic surgeons prefer an intranasal approach to lateral osteotomies. (a) Number of rhinoplasties respondents performed per year. (b) Number of years of independent surgical practice. (d) Current preferred technique for lateral osteotomy. (d) Technique
IP
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respondents learned during training.
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Figure 2. Surgeons allow trainees to perform lateral osteotomies with lower frequency than other
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CE
PT
ED
M
AN
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portions of rhinoplasty such as septoplasty or harvesting cartilage.
ACCEPTED MANUSCRIPT 9
References [1] Rohrich RJ, Janis JE, Adams WP, Krueger JK. An update on the lateral nasal osteotomy in rhinoplasty: an anatomic endoscopic comparison of the external versus the internal approach. Plast Reconstr Surg 2003;111:2461–2462; discussion 2463.
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doi:10.1097/01.PRS.0000061005.27994.E3.
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[2] Gryskiewicz JM, Gryskiewicz KM. Nasal osteotomies: a clinical comparison of the
CR
perforating methods versus the continuous technique. Plast Reconstr Surg 2004;113:14451456-1458.
US
[3] Becker DG, McLaughlin RB, Loevner LA, Mang A. The lateral osteotomy in rhinoplasty:
AN
clinical and radiographic rationale for osteotome selection. Plast Reconstr Surg 2000;105:1806-1816-1819.
M
[4] ACGME > Program and Institutional Accreditation > Surgical Specialties n.d.
ED
https://www.acgme.org/acgmeweb/tabid/369/ProgramandInstitutionalAccreditation/Surgical Specialties.aspx (accessed February 2, 2017).
PT
[5] Sheckter CC, Kane JT, Minneti M, Garner W, Sullivan M, Talving P, et al. Incorporation of
CE
Fresh Tissue Surgical Simulation into Plastic Surgery Education: Maximizing Extraclinical Surgical Experience. J Surg Educ 2013;70:466–74. doi:10.1016/j.jsurg.2013.02.008.
AC
[6] Dedmon MM, Kozin ED, Lee DJ. Development of a Temporal Bone Model for Transcanal Endoscopic Ear Surgery. Otolaryngol -- Head Neck Surg 2015;153:613–5. doi:10.1177/0194599815593738. [7] Dedmon MM, Paddle PM, Phillips J, Kobayashi L, Franco RA, Song PC. Development and Validation of a High-Fidelity Porcine Laryngeal Surgical Simulator. Otolaryngol -- Head Neck Surg 2015;153:420–6. doi:10.1177/0194599815590118.
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[8] Scott A, Jeon S-H, Joyce CM, Humphreys JS, Kalb G, Witt J, et al. A randomised trial and economic evaluation of the effect of response mode on response rate, response bias, and item non-response in a survey of doctors. BMC Med Res Methodol 2011;11:126.
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PT
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M
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doi:10.1186/1471-2288-11-126.
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Fig. 1
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Fig. 2