Rhinoplasty
The Beneficial Effects of Postrhinoplasty Taping: Fact or Fiction?
Aesthetic Surgery Journal 2014, Vol 34(1) 56–60 © 2013 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www.sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X13515879 www.aestheticsurgeryjournal.com
Kyle A. Belek, MD; and Ronald P. Gruber, MD
Level of Evidence: 5 Keywords taping, rhinoplasty, edema Accepted for publication July 12, 2013.
Initial patient perceptions of rhinoplasty results are complicated by early postoperative edema, ecchymosis, and distortion. Upon removal of the nasal splint, the patient must make a mental adjustment to the appearance of his or her new nose and not allow normal postoperative changes to prevent a smooth recovery. Patients may exhibit a variety of emotions, including anxiety, distress, or even anger (Figure 1). They may also express no opinion at all, for fear of insulting the surgeon. A very small group may even progress to a severe disorder known as postrhinoplasty dissatisfaction syndrome.1 The immediate period following splint removal after rhinoplasty may represent a time of significant anxiety for both the patient and the surgeon. The complex history of pre- and postoperative evaluation of rhinoplasty patients has received significant attention in the literature. Studies of patient selection criteria and outcomes date back to the 1940s and have been reviewed extensively.2 Several studies have suggested a high incidence of psychopathology among patients pursuing rhinoplasty.3-5 With careful selection, appropriate patients
undergoing rhinoplasty can have favorable outcomes and even respond with “elation” as well as significantly improved self-confidence.6,7 However, despite careful evaluation, significant negative psychological reactions may be seen even in Dr Belek is a staff surgeon in the Department of Surgery, Division of Plastic and Reconstructive Surgery, Alta Bates Summit Medical Center, Oakland, California. Dr Gruber is a Clinical Associate Professor in the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University, and Adjunct Clinical Associate Professor in the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California–San Francisco, San Francisco, California. This paper was presented at the 17th Annual Rhinoplasty Society Meeting; May 3, 2012; Vancouver, British Columbia, Canada. Corresponding Author: Dr Kyle A. Belek, University of California, San Francisco, 3318 Elm Street, Oakland, CA 94609, USA. E-mail: [email protected]
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Abstract Background: Initial patient perceptions of rhinoplasty results are complicated by early postoperative edema, ecchymosis, and distortion. Anecdotal evidence suggests that taping the nose immediately upon splint removal aids with the patient’s psychological adjustment to his or her new appearance. Objectives: The authors attempt to assess the overall impact of taping after splint removal on patient well-being while providing statistical validation regarding the utility of this intervention. Methods: The authors evaluated the reaction of 24 postoperative rhinoplasty patients on the day of splint removal by photographing them and noting their verbal responses. Those patients who were obviously happy received no taping and were dismissed from the study. The remainder of the patients received flesh-colored tape (3M, St Paul, Minnesota) and their subsequent reactions were noted and photographed. Results: Of 24 consecutive patients, 16 received tape. Fifteen of those taped initially displayed a flat affect (group A), while 1 was clearly unhappy (group B). The remaining 8 patients were obviously happy (group C) and were excluded from taping. Thirteen (86%) of those in group A displayed immediate subjective improvement after taping (χ2 = 12.8; P < .001). The lone patient in group B continued to be unhappy and required ongoing reassurance. Conclusions: Application of tape immediately upon splint removal after rhinoplasty improves initial patient perceptions. Taping can provide a simple and risk-free intervention for patients who do not express immediate satisfaction.
Belek and Gruber 57
Results
Figure 1. Immediate response upon removal of the nasal splint after rhinoplasty. This patient was assigned to group A and received tape application.
patients who have been screened and deemed suitable for cosmetic surgery.2 A particularly important time in the recovery phase is when the patient first sees his or her new nose. In the event that a patient is not immediately pleased with the result, there is very little that the surgeon can do to minimize this initial emotional trauma. A simple, inexpensive, and reliable intervention that can be provided at this critical time in a patient’s recovery is needed. Anecdotal reports suggest that placing tape over the nose can provide a psychological “bridge” and allow the patient to adjust to his or her new appearance by providing a partial view of the nose but also allowing several more days of coverage while edema and ecchymosis subside. In this article, we provide evidence to support this theory.
Methods The study design consisted of photographing 24 consecutive postrhinoplasty patients immediately upon splint removal as they looked in the mirror. Patients who were subjectively pleased with their results were excluded from the study. Patients were enrolled from January of 2012 through March
Of the 24 patients evaluated in this study, 19 were women and 5 were men. Nine patients were undergoing primary rhinoplasty, while 15 were undergoing secondary rhinoplasty. Patient ages ranged from 16 to 62 years. Fifteen patients exhibited no discernible smile and a delayed verbal response when looking in the mirror for the first time (group A). One patient was obviously unhappy and quite anxious about the immediate results (group B). Eight patients were happy with an obvious smile (group C). Thirteen (86%) of those in group A exhibited an immediate improved demeanor after taping (photographic changes confirmed by blinded observers; Figures 2 and 3). The lone patient in group B continued to be unhappy and required reassurance for several months. The patients in group C were dismissed from the study. Of note, the verbal response corresponded in more than 95% of cases with the facial expression change. Improvement with taping in group A reached significance.
Statistical Analysis The frequencies of the observed and expected emotional reactions of the 15 patients after taping are presented in Table 1. A demonstrable improvement in the emotional reaction to their nose was observed in 13 patients. The expected reactions assumed that, on average, about onethird of patients are susceptible to placebo effects of the intervention.8 The patients in group A had an improved affect in 86.7% of cases (P < .001).
Discussion While patient selection is critical for rhinoplasty,7,9-11 the patient’s opinion of the result is not always predictable.
Downloaded from http://asj.oxfordjournals.org/ by guest on November 13, 2015
of 2012. Depending on their responses, they were placed into 1 of 3 groups. Those with a flat or delayed expression received flesh-colored tape (3M, St Paul, Minnesota) to the nose (group A). Patients who were clearly upset or overtly anxious received taping as well (group B). Patients who had a positive facial expression received no tape (group C). Patients’ verbal responses were also noted by the senior author (RPG). The type of tape used for this study had no elastic properties and was skin toned, allowing the patient to gradually adjust to his or her new nose while masking some of the edema and ecchymosis. Benzoin was applied prior to tape application. After taping, the patient was immediately returned to the mirror and photographed again. Any change in facial expression in the photographs was evaluated by 3 blinded judges; a majority vote of at least 2 was required for decision. Patients’ verbal responses at this stage were again noted by the senior author. Patients were then instructed to wear the tape for 4 to 5 days, at which time they were told to either remove it themselves or to return to the clinic for removal.
58
Aesthetic Surgery Journal 34(1)
Anecdotal reports have suggested that taping the nose immediately upon splint removal may help ease the transition for the dissatisfied patient. The use of taping after rhinoplasty has also been described for the purposes of decreasing edema as well as further defining the supratip break.12,13 This study focused on the immediate period following splint removal that is so critical in the recovery phase. Since initial emotions upon splint removal are unpredictable and of varying severity, the goal of this article was to offer an intervention that will help the patient in the immediate setting. Current management of the disappointed postrhinoplasty patient with reasonable objective results consists of continued reassurance. Both the patient and the surgeon may feel helpless at this point. Taping—a simple, risk-free, and inexpensive intervention— provides the surgeon with something he or she can do to assist the patient in the emotional process of accepting a new appearance. Flesh-colored tape applied immediately upon nasal splint removal hides many postsurgical distortions. It also provides the patient with more time for emotional
adjustment. A placebo effect of the tape would be expected to account for approximately 30% improvement, at most. However, our data showed that taping led to a significant improvement in subjective results and recovery in the acute phase. Although the long-term effects of this technique were not measured in our study, the surgeon and patient both clearly benefit from the short-term gains. The limitations of this study include its small sample size, lack of randomization, lack of long-term follow-up, and potentially confounding variables. However, despite having small numbers, a statistically significant effect was measured. A randomized trial would, of course, be preferable but may not be necessary to pursue in this case, due to the benign nature of the treatment and the clear benefit shown.
Conclusions Taping of the nose immediately upon splint removal following rhinoplasty provides subjective improvement in
Downloaded from http://asj.oxfordjournals.org/ by guest on November 13, 2015
Figure 2. The same patient shown in Figure 1, a 30-year-old woman, presented with a complaint of an unaesthetic nose and underwent an open secondary rhinoplasty. She is shown (A) immediately upon splint removal 6 days postoperatively and (B) after the administration of tape.
Belek and Gruber 59
Disclosures
Table 1. Frequencies of Observed and Expected Reactions Emotional Reaction to Nose Improved Not improved Total
Observed Frequency, No. (%)
Expected Frequency, No. (%)a
Contribution to χ2b
13 (86.7)
5 (33.3)
12.8
2 (13.3)
10 (73.3)
6.4
15
19.2
15
a
Expected frequency based on placebo effect.8 A χ2 goodness-of-fit test was applied to test the null hypothesis that the frequencies of the observed reactions were not significantly different from the frequencies of the expected reactions. b
the immediate postoperative period. Allowing a partial view of the nose while covering normal edema and ecchymosis allows the patient to gradually adjust psychologically to his or her new nose. We encourage anyone who performs rhinoplasty to utilize this simple and inexpensive intervention.
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding The authors received no financial support for the research, authorship, and publication of this article.
References 1. Gruber RP, Roberts C, Schooler W, et al. Preventing postsurgical dissatisfaction syndrome after rhinoplasty with propranolol: a pilot study. Plast Reconstr Surg. 2009;123:1072-1078. 2. Stevens LMM. Psychological aspects of plastic surgery. In: Mathes SJ, Hentz VR, eds. Plastic Surgery. Philadelphia, PA: Elsevier; 2006:67-91. 3. Hay GG, Heather BB. Changes in psychometric test results following cosmetic nasal operations. Br J Psychiatry. 1973;122:89-90.
Downloaded from http://asj.oxfordjournals.org/ by guest on November 13, 2015
Figure 3. A 46-year-old man presented with a complaint of an unaesthetic nose and underwent an open secondary rhinoplasty. He is shown (A) immediately upon splint removal 6 days postoperatively and (B) after the administration of tape.
60
4. Gipson M, Connolly FH. The incidence of schizophrenia and severe psychological disorders in patients 10 years after cosmetic rhinoplasty. Br J Plast Surg. 1975;28:155159. 5. Wright MR, Wright WK. A psychological study of patients undergoing cosmetic surgery. Arch Otolaryngol. 1975;101:145-151. 6. Linn L, Goldman IB. Psychiatric observations concerning rhinoplasty. Psychosom Med. 1949;11:307-314. 7. Goin MK, Rees TD. A prospective study of patients’ psychological reactions to rhinoplasty. Ann Plast Surg. 1991;27:210-215. 8. Spiegel D. Placebos in practice. BMJ. 2004;329:927-928.
Aesthetic Surgery Journal 34(1)
9. Meyer L, Jacobsson S. The predictive validity of psychosocial factors for patients’ acceptance of rhinoplasty. Ann Plast Surg. 1986;17:513-520. 10. Meyer L, Jacobsson S. Psychiatric and psychosocial characteristics of patients accepted for rhinoplasty. Ann Plast Surg. 1987;19:117-130. 11. Honigman RJ, Phillips KA, Castle DJ. A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004;113:1229-1237. 12. Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer look. Plast Reconstr Surg. 2000;105:1140-1153. 13. Hoefflin SM. Postoperative nighttime nasal taping to decrease swelling. Plast Reconstr Surg. 1989;84:375.
Downloaded from http://asj.oxfordjournals.org/ by guest on November 13, 2015
The Beneficial Effects of Postrhinoplasty Taping: Fact or Fiction?
Aesthetic Surgery Journal 2014, Vol 34(1) 56–60 © 2013 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www.sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X13515879 www.aestheticsurgeryjournal.com
Kyle A. Belek, MD; and Ronald P. Gruber, MD
Level of Evidence: 5 Keywords taping, rhinoplasty, edema Accepted for publication July 12, 2013.
Initial patient perceptions of rhinoplasty results are complicated by early postoperative edema, ecchymosis, and distortion. Upon removal of the nasal splint, the patient must make a mental adjustment to the appearance of his or her new nose and not allow normal postoperative changes to prevent a smooth recovery. Patients may exhibit a variety of emotions, including anxiety, distress, or even anger (Figure 1). They may also express no opinion at all, for fear of insulting the surgeon. A very small group may even progress to a severe disorder known as postrhinoplasty dissatisfaction syndrome.1 The immediate period following splint removal after rhinoplasty may represent a time of significant anxiety for both the patient and the surgeon. The complex history of pre- and postoperative evaluation of rhinoplasty patients has received significant attention in the literature. Studies of patient selection criteria and outcomes date back to the 1940s and have been reviewed extensively.2 Several studies have suggested a high incidence of psychopathology among patients pursuing rhinoplasty.3-5 With careful selection, appropriate patients
undergoing rhinoplasty can have favorable outcomes and even respond with “elation” as well as significantly improved self-confidence.6,7 However, despite careful evaluation, significant negative psychological reactions may be seen even in Dr Belek is a staff surgeon in the Department of Surgery, Division of Plastic and Reconstructive Surgery, Alta Bates Summit Medical Center, Oakland, California. Dr Gruber is a Clinical Associate Professor in the Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University, and Adjunct Clinical Associate Professor in the Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California–San Francisco, San Francisco, California. This paper was presented at the 17th Annual Rhinoplasty Society Meeting; May 3, 2012; Vancouver, British Columbia, Canada. Corresponding Author: Dr Kyle A. Belek, University of California, San Francisco, 3318 Elm Street, Oakland, CA 94609, USA. E-mail: [email protected]
Downloaded from http://asj.oxfordjournals.org/ by guest on November 13, 2015
Abstract Background: Initial patient perceptions of rhinoplasty results are complicated by early postoperative edema, ecchymosis, and distortion. Anecdotal evidence suggests that taping the nose immediately upon splint removal aids with the patient’s psychological adjustment to his or her new appearance. Objectives: The authors attempt to assess the overall impact of taping after splint removal on patient well-being while providing statistical validation regarding the utility of this intervention. Methods: The authors evaluated the reaction of 24 postoperative rhinoplasty patients on the day of splint removal by photographing them and noting their verbal responses. Those patients who were obviously happy received no taping and were dismissed from the study. The remainder of the patients received flesh-colored tape (3M, St Paul, Minnesota) and their subsequent reactions were noted and photographed. Results: Of 24 consecutive patients, 16 received tape. Fifteen of those taped initially displayed a flat affect (group A), while 1 was clearly unhappy (group B). The remaining 8 patients were obviously happy (group C) and were excluded from taping. Thirteen (86%) of those in group A displayed immediate subjective improvement after taping (χ2 = 12.8; P < .001). The lone patient in group B continued to be unhappy and required ongoing reassurance. Conclusions: Application of tape immediately upon splint removal after rhinoplasty improves initial patient perceptions. Taping can provide a simple and risk-free intervention for patients who do not express immediate satisfaction.
Belek and Gruber 57
Results
Figure 1. Immediate response upon removal of the nasal splint after rhinoplasty. This patient was assigned to group A and received tape application.
patients who have been screened and deemed suitable for cosmetic surgery.2 A particularly important time in the recovery phase is when the patient first sees his or her new nose. In the event that a patient is not immediately pleased with the result, there is very little that the surgeon can do to minimize this initial emotional trauma. A simple, inexpensive, and reliable intervention that can be provided at this critical time in a patient’s recovery is needed. Anecdotal reports suggest that placing tape over the nose can provide a psychological “bridge” and allow the patient to adjust to his or her new appearance by providing a partial view of the nose but also allowing several more days of coverage while edema and ecchymosis subside. In this article, we provide evidence to support this theory.
Methods The study design consisted of photographing 24 consecutive postrhinoplasty patients immediately upon splint removal as they looked in the mirror. Patients who were subjectively pleased with their results were excluded from the study. Patients were enrolled from January of 2012 through March
Of the 24 patients evaluated in this study, 19 were women and 5 were men. Nine patients were undergoing primary rhinoplasty, while 15 were undergoing secondary rhinoplasty. Patient ages ranged from 16 to 62 years. Fifteen patients exhibited no discernible smile and a delayed verbal response when looking in the mirror for the first time (group A). One patient was obviously unhappy and quite anxious about the immediate results (group B). Eight patients were happy with an obvious smile (group C). Thirteen (86%) of those in group A exhibited an immediate improved demeanor after taping (photographic changes confirmed by blinded observers; Figures 2 and 3). The lone patient in group B continued to be unhappy and required reassurance for several months. The patients in group C were dismissed from the study. Of note, the verbal response corresponded in more than 95% of cases with the facial expression change. Improvement with taping in group A reached significance.
Statistical Analysis The frequencies of the observed and expected emotional reactions of the 15 patients after taping are presented in Table 1. A demonstrable improvement in the emotional reaction to their nose was observed in 13 patients. The expected reactions assumed that, on average, about onethird of patients are susceptible to placebo effects of the intervention.8 The patients in group A had an improved affect in 86.7% of cases (P < .001).
Discussion While patient selection is critical for rhinoplasty,7,9-11 the patient’s opinion of the result is not always predictable.
Downloaded from http://asj.oxfordjournals.org/ by guest on November 13, 2015
of 2012. Depending on their responses, they were placed into 1 of 3 groups. Those with a flat or delayed expression received flesh-colored tape (3M, St Paul, Minnesota) to the nose (group A). Patients who were clearly upset or overtly anxious received taping as well (group B). Patients who had a positive facial expression received no tape (group C). Patients’ verbal responses were also noted by the senior author (RPG). The type of tape used for this study had no elastic properties and was skin toned, allowing the patient to gradually adjust to his or her new nose while masking some of the edema and ecchymosis. Benzoin was applied prior to tape application. After taping, the patient was immediately returned to the mirror and photographed again. Any change in facial expression in the photographs was evaluated by 3 blinded judges; a majority vote of at least 2 was required for decision. Patients’ verbal responses at this stage were again noted by the senior author. Patients were then instructed to wear the tape for 4 to 5 days, at which time they were told to either remove it themselves or to return to the clinic for removal.
58
Aesthetic Surgery Journal 34(1)
Anecdotal reports have suggested that taping the nose immediately upon splint removal may help ease the transition for the dissatisfied patient. The use of taping after rhinoplasty has also been described for the purposes of decreasing edema as well as further defining the supratip break.12,13 This study focused on the immediate period following splint removal that is so critical in the recovery phase. Since initial emotions upon splint removal are unpredictable and of varying severity, the goal of this article was to offer an intervention that will help the patient in the immediate setting. Current management of the disappointed postrhinoplasty patient with reasonable objective results consists of continued reassurance. Both the patient and the surgeon may feel helpless at this point. Taping—a simple, risk-free, and inexpensive intervention— provides the surgeon with something he or she can do to assist the patient in the emotional process of accepting a new appearance. Flesh-colored tape applied immediately upon nasal splint removal hides many postsurgical distortions. It also provides the patient with more time for emotional
adjustment. A placebo effect of the tape would be expected to account for approximately 30% improvement, at most. However, our data showed that taping led to a significant improvement in subjective results and recovery in the acute phase. Although the long-term effects of this technique were not measured in our study, the surgeon and patient both clearly benefit from the short-term gains. The limitations of this study include its small sample size, lack of randomization, lack of long-term follow-up, and potentially confounding variables. However, despite having small numbers, a statistically significant effect was measured. A randomized trial would, of course, be preferable but may not be necessary to pursue in this case, due to the benign nature of the treatment and the clear benefit shown.
Conclusions Taping of the nose immediately upon splint removal following rhinoplasty provides subjective improvement in
Downloaded from http://asj.oxfordjournals.org/ by guest on November 13, 2015
Figure 2. The same patient shown in Figure 1, a 30-year-old woman, presented with a complaint of an unaesthetic nose and underwent an open secondary rhinoplasty. She is shown (A) immediately upon splint removal 6 days postoperatively and (B) after the administration of tape.
Belek and Gruber 59
Disclosures
Table 1. Frequencies of Observed and Expected Reactions Emotional Reaction to Nose Improved Not improved Total
Observed Frequency, No. (%)
Expected Frequency, No. (%)a
Contribution to χ2b
13 (86.7)
5 (33.3)
12.8
2 (13.3)
10 (73.3)
6.4
15
19.2
15
a
Expected frequency based on placebo effect.8 A χ2 goodness-of-fit test was applied to test the null hypothesis that the frequencies of the observed reactions were not significantly different from the frequencies of the expected reactions. b
the immediate postoperative period. Allowing a partial view of the nose while covering normal edema and ecchymosis allows the patient to gradually adjust psychologically to his or her new nose. We encourage anyone who performs rhinoplasty to utilize this simple and inexpensive intervention.
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding The authors received no financial support for the research, authorship, and publication of this article.
References 1. Gruber RP, Roberts C, Schooler W, et al. Preventing postsurgical dissatisfaction syndrome after rhinoplasty with propranolol: a pilot study. Plast Reconstr Surg. 2009;123:1072-1078. 2. Stevens LMM. Psychological aspects of plastic surgery. In: Mathes SJ, Hentz VR, eds. Plastic Surgery. Philadelphia, PA: Elsevier; 2006:67-91. 3. Hay GG, Heather BB. Changes in psychometric test results following cosmetic nasal operations. Br J Psychiatry. 1973;122:89-90.
Downloaded from http://asj.oxfordjournals.org/ by guest on November 13, 2015
Figure 3. A 46-year-old man presented with a complaint of an unaesthetic nose and underwent an open secondary rhinoplasty. He is shown (A) immediately upon splint removal 6 days postoperatively and (B) after the administration of tape.
60
4. Gipson M, Connolly FH. The incidence of schizophrenia and severe psychological disorders in patients 10 years after cosmetic rhinoplasty. Br J Plast Surg. 1975;28:155159. 5. Wright MR, Wright WK. A psychological study of patients undergoing cosmetic surgery. Arch Otolaryngol. 1975;101:145-151. 6. Linn L, Goldman IB. Psychiatric observations concerning rhinoplasty. Psychosom Med. 1949;11:307-314. 7. Goin MK, Rees TD. A prospective study of patients’ psychological reactions to rhinoplasty. Ann Plast Surg. 1991;27:210-215. 8. Spiegel D. Placebos in practice. BMJ. 2004;329:927-928.
Aesthetic Surgery Journal 34(1)
9. Meyer L, Jacobsson S. The predictive validity of psychosocial factors for patients’ acceptance of rhinoplasty. Ann Plast Surg. 1986;17:513-520. 10. Meyer L, Jacobsson S. Psychiatric and psychosocial characteristics of patients accepted for rhinoplasty. Ann Plast Surg. 1987;19:117-130. 11. Honigman RJ, Phillips KA, Castle DJ. A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004;113:1229-1237. 12. Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer look. Plast Reconstr Surg. 2000;105:1140-1153. 13. Hoefflin SM. Postoperative nighttime nasal taping to decrease swelling. Plast Reconstr Surg. 1989;84:375.
Downloaded from http://asj.oxfordjournals.org/ by guest on November 13, 2015
