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A Patient- and Observer-Rated Analysis of the Impact of Lateral Rhinotomy on Facial Aesthetics
Edgar A. Lueg, MD;
Jonathan C. Irish, MD;
Mark R. Katz, MD;
Dale H. Brown, MBChB;
Patrick J. Gullane, MBChB
Arch Facial Plast Surg. 2001;3:241-244.
ABSTRACT
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Objective To determine, using patient- and observer-rated
facial disfigurement measures, whether a lateral rhinotomy imparts
significant aesthetic morbidity.
Design Retrospective and subject-controlled study in a large,
tertiary-referral, academic otolaryngology department. Twenty-one
consecutive patients who had undergone lateral rhinotomy for the
treatment of inverted papilloma were studied in the long-term.
Main Outcome Measures Scores on the following: (1) the
novel Patient-Rated Facial Disfigurement Analogue Scale questionnaire
and (2) the reliable and validated Observer-Rated Facial Disfigurement
9-Point Likert Scale.
Results Patients rated their facial appearance as minimally
altered and significantly less apparent to others. The observers in
this study, a surgeon (J.C.I.) and a psychiatrist (M.R.K.), rated the
patients' facial disfigurement as minimally visible. Patients seem to
rate how apparent their appearance is to others in a similar fashion to
observers. The observer-rated facial disfigurement scale used is valid
and reliable.
Conclusion Patient- and observer-rated facial disfigurement
measures suggest that a lateral rhinotomy does not impart significant
aesthetic morbidity.
INTRODUCTION
LATERAL RHINOTOMY, although first described by Moure in 1902,1 was only popularized as
an approach to the maxilla by Doyle in 1968.2 During the
past 30 years, it has developed a reputation as a versatile and
minimally morbid approach to the midface.3-13 However, an
exhaustive search of the English-language literature failed to discover
any quantitative evidence, supporting most researchers' general
assertions that lateral rhinotomy does not impart significant
functional or aesthetic morbidity. In an earlier report,14
we provided quantitative evidence that lateral rhinotomy does not
impart significant functional morbidity. The present report seeks to
determine, using patient- and observer-rated facial disfigurement
measures, whether a lateral rhinotomy imparts significant aesthetic
morbidity.
POPULATION AND METHODS
DESIGN
The study design was retrospective and subject controlled. The
study setting was a large, tertiary-referral, academic
otolaryngology–head and neck surgery department. The study population
was all patients who were referred to the Head & Neck Surgical Oncology
Service, Department of Otolaryngology, The University Health Network,
The University of Toronto, Toronto, Ontario, servicing an estimated 7
million people from southern Ontario and the greater metropolitan
Toronto area, between July 1, 1993, and December 31, 1996.
Predetermined inclusion criteria selected all patients with a
pathologically verified inverted papilloma, resected through a standard
lateral rhinotomy, at least 6 months previously, without evidence of
tumor recurrence by flexible nasal endoscopy at last follow-up.
All lateral rhinotomies were performed by 3 experienced head and neck
surgeons at The Toronto Hospital, Toronto (J.C.I., D.H.B., and
P.J.G.). All 3 surgeons design their incisions in a similar
fashion. The superior third of the incision is placed midway between
the midline nasal dorsum and the medial canthus. The middle third of
the incision is placed in a gently curving fashion a few millimeters
dorsal to the cheek-nasal inflection to lay entirely on the nasal
dorsal skin. The inferior third of the incision is placed 1 mm lateral
to the nasolabial groove and sulcus to lay entirely on the cheek-lip
skin.
A search of The Toronto Hospital tumor database produced 31
potential candidates. Predetermined criteria excluded any patients who
underwent previous surgery of the nose or paranasal sinuses
(n = 2), who had significant concurrent medical
conditions (n = 1), who had evidence of tumor recurrence
by flexible nasal endoscopy before testing (n = 0), or
who refused to participate (n = 7). Of the 7
patients who refused to participate, all stated reasons of
inconvenience related to the significant travel distance to the
tertiary medical center.
The remaining 21 consecutive surgical patients (14 men [67%] and 7
women [33%]) were the subjects of this study. Consistent with the
literature,5, 9, 11, 13 their mean age was 58 years
(range, 34-72 years).
OUTCOME MEASURES
Patient-Rated Facial Disfigurement Analogue Scale
All patients were administered a 2-item analogue scale questionnaire
(Figure 1). They were
asked to place a single mark across a 100-mm line scale representing:
(1) the extent to which their facial appearance had been altered by
surgery and (2) the extent to which their surgery is apparent to other
people. Anchors were provided at the left ("not at all") and right
("worst possible") ends of the analogue scale. The portion of the
100-mm line to the left of the patient's mark measured in millimeters
represents the value for the scale and is expressed as a percentage of
the total length of the line (eg, 15mm = 15%).
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Figure 1.
Patient-Rated Facial Disfigurement Analogue Scale.
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Observer-Rated Facial Disfigurement 9-Point Likert Scale
The disfigurement scale used was a single-item
9-point Likert scale measuring the degree of postoperative facial
disfigurement (Figure
2).15 Disfigurement
is defined as a visible and negative alteration in appearance
caused by disruption of skin, soft tissue, or bony structure, and is
printed on the rating sheet. The observer is then asked to rate
the patient's facial disfigurement, taking into account the size of
the disfigured area, the degree of face/neck shape distortion, the
extent of impairment in facial expression, and the visibility of the
disfigured area. Guideposts for 1 (minimally visible
disfigurement, visible close range only), 5 (moderately visible
disfigurement), and 9 (very visible disfigurement, visible from afar)
points of disfigurement are provided. Anchors on the left ("minimal
disfigurement") and right ("severe disfigurement") ends orient
the observer.
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Figure 2.
Observer-Rated Facial Disfigurement 9-Point Likert Scale.
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This observer-rated disfigurement scale was only recently developed and
was the first, to our knowledge, to examine disfigurement using a valid
and reliable observer-rated measure. It possesses discriminant and
convergent validity. It also possesses interobserver reliability, with
a high surgeon and nonsurgeon concordance (intraclass correlation
coefficient of 91%).15
The projected images of standard anterior (passive and natural smile),
oblique, and lateral view 35-mm color photographs were rated
independently by a head and neck surgical oncologist (J.C.I.) and a
psychiatrist specializing in psychosocial oncology (M.R.K.).
Both observers were familiar with this disfigurement
scale.15 The subject's unoperated-on side provided an
internal control of the patient's preoperative aesthetic state against
which the observers could compare the disfigurement imparted by the
lateral rhinotomy. The first 9 patients were examined by the surgeon
twice, approximately 3 years apart, to assess the degree of
intraobserver stability (test-retest) of this novel rating scale.
STATISTICAL ANALYSIS
All statistical analyses were performed from the original raw data by a
professional statistician using SAS statistical software (SAS Institute
Inc, Cary, NC). Simple univariate analysis was performed for
all data sets. Associations between analogue patient-rated (parametric)
data were determined using a Pearson product moment correlation test.
Associations between observer-rated (nonparametric) data were
determined using a Spearman rank correlation test. Correlation matrices
were performed for all subjects (N = 21), men
(n = 14), women (n = 7), patients 60 years
and older (n = 12), and patients younger than 60 years
(n = 9). Given the well-known differences in
skin quality, thickness, texture, laxity, healing, and disfigurement
tolerance between male and female patients and between older and
younger patients, we analyzed these subsets independently for
correlations and significant differences between them. Comparisons of
differences between male and female patients and between older and
younger patients were performed by the Wilcoxon 2-sample rank sum t test.
RESULTS
PATIENT-RATED FACIAL DISFIGUREMENT ANALOGUE SCALE
The patients' mean rating of the extent to which their facial
appearance had been altered by surgery was 13% from not at all (13 of
100 mm; range, 0-80 mm; SD, 18.6 mm). The patients' mean
rating of the extent to which their surgery was apparent to other
people was 5% from not at all (5 of 100 mm; range, 0-50 mm; SD, 11.8
mm). The difference between these 2 patient-rated
disfigurement measures was statistically significant
(P = .01). Although women rated their
appearance to be more altered (mean, 20% vs 9%) and apparent (mean,
8% vs 4%) than men, these differences did not reach statistical
significance (P>.05). Younger patients rated their
appearance to be more altered (mean, 17% vs 9%) and apparent (mean,
10% vs 2%) than older patients; however, again, these differences did
not reach statistical significance (P>.05).
Patients' rating of how their appearance was altered correlated
significantly with how their appearance was apparent to others
(R = 0.76, P<.001).
OBSERVER-RATED FACIAL DISFIGUREMENT 9-POINT LIKERT SCALE
Of 9 total points, the surgeon's (J.C.I.) mean rating of facial
disfigurement was 1.7 points (range, 1-4 points; SD, 0.78 points),
while the psychiatrist's (M.R.K.) mean rating
was 2.1 points (range 1-5 points; SD, 1.07 points). The
difference between these 2 observers was not statistically significant
(P>.05). The surgeon's and psychiatrist's
ratings of facial disfigurement correlated highly for the subjects as a
whole (R = 0.74,
P = .001, N = 21), and for the
male (R = 0.67, P = .008,
n = 14), female (R = 0.84,
P = .02, n = 7), older
(R = 0.62, P = .03,
n = 12), and younger (R = 0.90,
P = .001, n = 9) patient subsets.
There were no significant differences between male and female
observer-rated disfigurement scores and between old and young
observer-rated disfigurement scores (P>.05 for
both).
ASSOCIATION BETWEEN PATIENT AND OBSERVER FACIAL DISFIGUREMENT
RATINGS
The patients' rating of the extent to which their facial appearance
had been altered by surgery did not correlate significantly with either
the surgeon's (R = 0.29,
P = .20) or the psychiatrist's
(R = 0.38, P = .09)
ratings of facial disfigurement. However, the patients' rating of the
extent to which their surgery was apparent to other people correlated
significantly with the surgeon's facial disfigurement rating
(R = 0.45, P = .04), and
almost significantly with the psychiatrist's rating
(R = 0.37,
P = .10).
COMMENT
We developed an analogue scale measurement tool for the patient-rated
assessment of postoperative facial disfigurement. The benefit of this
method is its simplicity, in understandability and analysis. The
significant correlation between patient-patient ratings
(P<.001), and between patient-observer ratings
(P = .04), suggests that this measure is valid
and reliable within this group of patients.
Patients rated their appearance to be minimally altered (13%) and
significantly (P = .01) less apparent to others
(5%). More than one third (8 of 21 patients) rated
themselves as not disfigured at all (0 of 100 mm), and almost two
thirds (13 of 21 patients) believed that their incision was not at all
apparent to others (0 of 100 mm). Although women rated their
appearance to be more altered and apparent than men, these differences
were not significant. Younger patients also rated their appearance to
be more altered and apparent than older patients; again, these
differences were not significant. Patients' rating of how their
appearance was altered
correlated highly with their rating of how
apparent their surgery was to others (P<.001).
For the observer-rated measure, we used a novel, valid, and
reliable observer-rated facial disfigurement Likert
scale.15 Before the development of this scale, the best
available measures used only coarse categorical ratings (eg, minor vs
extensive) and grouped all patients with a specific surgical procedure
into a single rating. This new observer-rated scale defines
disfigurement on the rating sheet as a visible and negative alteration
in appearance caused by disruption of skin, soft tissue, or bony
structure. Raters are then asked to assess a patient's disfigurement,
taking into account the size of the disfigured area, the degree of
face/neck shape distortion, the extent of impairment in facial
expression, and the visibility of the disfigured area. Unlike
many head and neck surgical incisions, lateral rhinotomy is entirely
unilateral. This means that the unoperated-on side provides an internal
subject control of the preoperative aesthetic state against which the
observer can rate the disfigurement caused by surgery. This
observer-rated disfigurement scale has demonstrated discriminant and
convergent validity. The former refers to a low correlation with
sociodemographic variables such as income level, which one would not
reasonably expect to be associated with disfigurement, while the latter
refers to a high correlation with clinical variables such as
postoperative complications, which one would reasonably expect to be
associated with disfigurement. It has also been shown to have
a high degree of interobserver reliability, with
an interrater concordance between surgeon and nonsurgeon observer
of 91%.15 This indicates that independent observers using
this scale will rate a patient's degree of disfigurement similarly.
However, while a significant improvement over previous observer-rated
facial disfigurement scales, it does have certain shortcomings. First,
it was originally developed and tested among patients with head and
neck cancer, a group that might reasonably be expected to judge their
own disfigurement differently than patients with benign tumors.
However, in this study, patient-observer concordance (convergent
validity P = .04) and observer-observer
concordance (interobserver reliability P = .001)
was significant. These findings support the fact that this
observer-rated facial disfigurement scale is also valid and reliable
for patients undergoing surgery for benign tumors. Second, the
intraobserver reliability (test-retest stability) of this measure had
not previously been determined. Within this study, the surgeon's
earlier ratings of facial disfigurement for the first 9 subjects almost
correlated significantly with his ratings 3 years later
(R = 0.63, P = .07),
suggesting that this rating scale also possesses intraobserver
reliability.
The surgeon (mean, 1.7 of 9.0 points) and psychiatrist (mean, 2.1 of
9.0 points) rated the lateral rhinotomy as minimally disfiguring
(visible only from close range). Their ratings were also
highly correlated for the group as a whole and for the male, female,
older, and younger subsets. Almost half the patients (10/21) were given
the lowest possible disfigurement rating (1 point, minimally
disfigured, visible only from afar) by either the surgeon or the
psychiatrist. Only 2 patients were rated above 3 points by either the
surgeon or the psychiatrist.
The patients' rating of the extent to which their facial
appearance had been altered by surgery did not correlate significantly
with either the surgeon's or the psychiatrist's ratings of facial
disfigurement. However, the patients' rating of the extent to which
their surgery is apparent to other people did correlate significantly
with the surgeon's facial disfigurement rating
(P = .04), and almost significantly with the
psychiatrist's facial disfigurement rating
(P = .10). This supports the finding
by Katz et al15 that patients rate the extent to which
their facial disfigurement is apparent to others in a fashion similar
to observers.
The most important finding in this study, which supports what is
already widely accepted by experienced facial surgeons, is that
well-planned facial incisions do not necessarily impart significant
aesthetic morbidity in themselves. The quantitative evidence presented
in this study should be reassuring to any patient undergoing facial
incisions. However, several factors did seem to increase the risk of
perceived or actual aesthetic morbidity. Being young and female,
probably related to differences in skin quality and disfigurement
tolerance, were 2 factors that were associated with an increased
likelihood of rating oneself as more altered and apparent after
surgery. The observers in this study also noted that most of the more
visible disfigurement was the result of failure to obtain perfect
superior-inferior alignment of the wound closure at either the medial
canthus or the ala and the late alar retraction. Interestingly, the
youngest patient, a woman, who appeared to have a technically imperfect
superior-inferior alar closure and significant late alar retraction,
was the only subject to rate her appearance toward the severely
disfigured end of the scale (altered, 80 of 100 mm; apparent, 50 of 100
mm). She also received the single highest observer facial
disfigurement ratings (surgeon, 4 of 9 points; psychiatrist, 5 of 9
points).
Patients rate their own appearance from a lateral rhinotomy as
minimally altered and significantly less apparent to others. Observers
also rate the facial disfigurement as minimally visible. Patients
appear to rate how apparent their disfigurement is to others in a
similar way to observers. The observer-rated facial disfigurement scale
used in this study appears to have discriminant and convergent validity
and interobserver and intraobserver reliability. Patient- and observer-rated facial disfigurement measures suggest that a lateral
rhinotomy does not impart significant aesthetic morbidity.
AUTHOR INFORMATION
Accepted for publication February 20, 2001.
Presented at the American Academy of Facial Plastic and Reconstructive
Surgery Spring Meeting, Orlando, Fla, May 13, 2000.
We thank Joseph L. Whittaker, Jr, BSc, MPH, clinical outcomes analyst,
Analytic Services, Los Angeles Medical Center, The Kaiser Foundation,
Los Angeles, Calif, for his monumental effort in finding the important
clinical needles in a daunting haystack of data.
Corresponding author: Edgar A. Lueg, MD, Head & Neck Surgical Oncology
and Microvascular Reconstruction, Department of Head & Neck Surgery,
Southern California Permanente Medical Group, 4900 Sunset Blvd, Bldg M,
Floor 6, Los Angeles, CA 90027 (e-mail: edgar.a.lueg{at}kp.org).
From
Head & Neck Surgical Oncology and Microvascular Reconstruction,
Department of Head & Neck Surgery, Southern California Permanente
Medical Group, Los Angeles Medical Center, Los Angeles (Dr Lueg); and
Head & Neck Surgical Oncology Service, Department of Otolaryngology,
Wharton Head & Neck Center
(Drs Irish, Brown, and Gullane), and
Psychosocial Oncology, Department of Psychiatry (Dr Katz), The
University Health Network, The University of Toronto, Toronto,
Ontario.
REFERENCES
| |
1. Moure EJ. Traitment des tumors malignes primitives de l'ethmoide. Rev Laryngol Otol Rhinol (Bord). 1902;23:401-412.
2. Doyle PJ. Approach to tumors of the nose, nasopharynx, and paranasal
sinuses. Laryngoscope. 1968;78:1756-1762.
FULL TEXT
|
ISI
| PUBMED
3. Neel HB, Whicker JH, Devine KD, et al. Juvenile angiofibroma: review of
120 cases. Am J Surg. 1973;126:547-556.
FULL TEXT
|
ISI
| PUBMED
4. Harrison DF. Lateral rhinotomy: a neglected operation. Ann Otol
Rhinol Laryngol. 1977;86(pt 1):756-759.
5. Schramm VL, Myers EN. How I do it: lateral rhinotomy. Laryngoscope. 1978;88:1042-1045.
PUBMED
6. Pope TH. Surgical approach to tumors of the nasal cavity. Laryngoscope. 1978;88:1743-1748.
PUBMED
7. Mertz JS, Pearson BW, Kern EB. Lateral rhinotomy: indications,
technique, and review of 226 patients. Arch Otolaryngol. 1983;109:235-239.
ISI
| PUBMED
8. Smith O, Gullane PJ. Inverting papilloma of the nose: analysis of 48
patients. J Otolaryngol. 1987;16:154-156.
PUBMED
9. Bernard PJ, Biller HF, Lawson WL, Lebenger J. Complications following
lateral rhinotomy: review of 148 patients. Ann Otol Rhinol
Laryngol. 1989;98:684-692.
ISI
| PUBMED
10. Osguthorpe JD, Weisman RA. Medial maxillectomy for lateral nasal wall
neoplasms. Arch Otolaryngol Head Neck Surg. 1991;117:751-756.
FULL TEXT
|
ISI
| PUBMED
11. Lawson WL, Ho BT, Shaari CM, Biller HF. Inverted papilloma: a report of
112 cases. Laryngoscope. 1995;105:282-288.
PUBMED
12. Weisman R. Lateral rhinotomy and medial maxillectomy. Otolaryngol
Clin North Am. 1995;28:1145-1156.
PUBMED
13. Sessions RB, Humphrey DH. Technical modifications of the medial
maxillectomy. Arch Otolaryngol. 1983;109:575-577.
PUBMED
14. Lueg EA, Irish JC, Roth Y, Brown DH, Gullane PJ. An objective analysis
of the impact of lateral rhinotomy and medial maxillectomy on nasal
airway function. Laryngoscope. 1998;108:1320-1324.
PUBMED
15. Katz MR, Irish JC, Devins GM, Rodin GM, Gullane PJ. Reliability and
validity of an observer-rated disfigurement scale for head and neck
cancer patients. Head Neck. 2000;22:132-141.
FULL TEXT
|
ISI
| PUBMED
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