The Association between the Complexity of Nasal Deformities and Surgical Time in Rhinoplasty Patients: A Retrospective Single-Center Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

First I would like to congratulate the authors on their work. Assiri and co. have submitted a paper regarding the association between the complexity of nasal deformities and operative time in rhinoplasty. Although this association is logical and intuitive, their method & material, and results demonstrate a clear link. This finding can offer the surgeon the opportunity to foresee this prolonged operative time, especially in the crooked nose and over projection. In the discussion section, they analyze thoroughly all the relevant aspects and compare them to the existing literature.  This study's limitations and strengths are highlighted. This result applies mainly to Middle Eastern patients, but can be extrapolated to other ethnic groups. The authors demonstrated that there is a link between prolonged operative time and SSI risk, prolonged hospital stays, and potentially high rates of revision surgeries.

A few suggestions:

- crooked nose instead of corked. 

- include crooked nose in the Nasal Deformity group.

- avoid superlatives in the article. 

- define when patient satisfaction was measured - weeks, months, year?

- what is the revision rate for this group (functional or aesthetic)? - compared to the no 7 reference?

Author Response

Comment [1]: First I would like to congratulate the authors on their work. Assiri and co. have submitted a paper regarding the association between the complexity of nasal deformities and operative time in rhinoplasty. Although this association is logical and intuitive, their method & material, and results demonstrate a clear link. This finding can offer the surgeon the opportunity to foresee this prolonged operative time, especially in the crooked nose and over projection. In the discussion section, they analyze thoroughly all the relevant aspects and compare them to the existing literature.  This study's limitations and strengths are highlighted. This result applies mainly to Middle Eastern patients but can be extrapolated to other ethnic groups. The authors demonstrated that there is a link between prolonged operative time and SSI risk, prolonged hospital stays, and potentially high rates of revision surgeries.
A few suggestions:
- crooked nose instead of corked. 
Response [1]: Thank you so much for your comments, which significantly improved the quality of our manuscript. In the updated draft, we corrected “corked” into “crooked”
Comment [2]: include crooked nose in the Nasal Deformity group.
Response [2]: Thank you so much for your comments. We added crooked nose in the Nasal Deformity group.

Comment [3]: avoid superlatives in the article. 
Response [3]: Thank you so much for your comments. We avoided superlatives throughout the draft.
Comment [4]: define when patient satisfaction was measured - weeks, months, year?
Response [4]: Thank you so much for your comments. We highlighted that the patient satisfaction was measured by weeks.
Comment [5]: what is the revision rate for this group (functional or aesthetic)? - compared to the no 7 reference?
Response [5]: Thank you so much for your comments. In our group, the revision rate was 6.9% compared to 15% in reference 7.

Reviewer 2 Report

Comments and Suggestions for Authors

Although the topic is interesting and the study well performed, the following points must be improved:

In the Introduction the AA report that the prolonged operative time increases the risk of complications, but they do no consider this aspect in the outcomes of their study;

the AA might compare their results (operation time in different clinical situations) with the average times reported by other qualified surgeons;

the AA might discuss their results also in terms of economic impact. The cost of a functional rhinoplasty can be reimbursed by an Insurance Company while the cost of a cosmetic rhinoplasty is totally supported by the patient: in both cases the fee is calculated on different parameters, but it does not seem to me that a huge variability in terms of operation time is taken into consideration neither by Insurance Companies nor by the patients. The problem might be emphasized.

 

Author Response

Comment [1]: Although the topic is interesting and the study well performed, the following points must be improved: In the Introduction the AA report that the prolonged operative time increases the risk of complications, but they do not consider this aspect in the outcomes of their study.
Response [1]: Thank you for your insightful comment. We appreciate your recognition of the study's importance and the thoroughness of our research. Regarding the consideration of postoperative complications in relation to prolonged operative time, we agree that this is an important aspect of rhinoplasty outcomes. However, due to the retrospective nature of our data collection, we were limited to the information available in existing patient records. Unfortunately, detailed data on postoperative complications were not consistently documented in a manner that would allow for a reliable analysis within the scope of this study.
Comment [2]: the AA might compare their results (operation time in different clinical situations) with the average times reported by other qualified surgeons.
Response [2]: Thank you for your insightful suggestion. We understand the importance of comparing operative times across different clinical situations within the same institution as a means to contextualize our findings. However, due to the retrospective nature of our study, the data necessary for a comprehensive comparison of operative times across qualified surgeons within our institution are not available.
Comment [3]: the AA might discuss their results also in terms of economic impact. The cost of a functional rhinoplasty can be reimbursed by an Insurance Company while the cost of a cosmetic rhinoplasty is totally supported by the patient: in both cases the fee is calculated on different parameters, but it does not seem to me that a huge variability in terms of operation time is taken into consideration neither by Insurance Companies nor by the patients. The problem might be emphasized.
Response [3]: Thank you for your insightful comment. In the updated draft, we discussed the economic implications of variable operative times in the Discussion section. Specifically, we addressed the potential differences in reimbursement practices between functional and cosmetic rhinoplasty, and how these may not fully account for the variability in surgical time. We highlighted the need for a more nuanced approach in fee calculations that considers operative time as a significant factor, which could have implications for both insurance companies and patients.

Reviewer 3 Report

Comments and Suggestions for Authors

I appreciate the opportunity to review the manuscript for publication in MDPI Surgeries. It provides topics on an important aspect of rhinoplasty, specifically the relationship between nasal deformity complexity and surgical time, which has implications for patient outcomes and surgical planning. I feel that the topics are interesting. However, the manuscript remains premature which should be thoroughly modified. I have a few comments as follows.

 

The present study aimed to elucidate the association between nasal deformity types and the operative time in rhinoplasty surgeries. I do not agree that setting the surgical time as main outcomes alone is appropriate study design. Other important factors including successful rates, improvement of nasal patency, and cosmetic changes.   

 

Abstract: The authors had better provide more specific information on the methodology, including sample size and statistical methods used.

 

Study Design and Population:

The exclusion criteria are not fully justified. For instance, why were patients with concurrent facial surgeries excluded?

 

Table 2: “The post-hoc analysis showed that patients with combined dorsal, alar base, and tip deformities had significantly longer operative time than patients with isolated dorsal deformity (<0.001) (Table 2).”

The authors had better create a graph to ensure the differences.

 

Discussion: 

The authors had better expand the literature review to include more studies on the relationship between nasal deformity complexity and surgical outcomes.

It lacks critical engagement with the limitations of the study. The retrospective nature and potential biases (e.g., selection bias, recall bias) should be discussed more comprehensively.

 

There are numerous sites of inadequate use of abbreviations, grammar errors, erratum in the manuscript, and awkward phrasings that detract from this work.

Author Response

Comment [1]: I appreciate the opportunity to review the manuscript for publication in MDPI Surgeries. It provides topics on an important aspect of rhinoplasty, specifically the relationship between nasal deformity complexity and surgical time, which has implications for patient outcomes and surgical planning. I feel that the topics are interesting. However, the manuscript remains premature and should be thoroughly modified. I have a few comments as follows.
 The present study aimed to elucidate the association between nasal deformity types and the operative time in rhinoplasty surgeries. I do not agree that setting the surgical time as the main outcome alone is an appropriate study design. Other important factors include successful rates, improvement of nasal patency, and cosmetic changes.   
Response [1]: Thank you for your thoughtful review. We understand your concern regarding the focus on surgical time as the primary outcome. Our decision to set surgical time as the main outcome was driven by the desire to explore an objective and quantifiable measure that directly correlates with the complexity of nasal deformities. However, we acknowledge that other important outcomes, such as success rates, improvement in nasal patency, and cosmetic results, are essential aspects of rhinoplasty that contribute to the overall evaluation of surgical effectiveness. Unfortunately, due to the retrospective nature of our study, we were limited in our ability to comprehensively assess these factors, particularly in a standardized manner across the diverse patient population included in our analysis.
Comment [2]: Abstract: The authors had better provide more specific information on the methodology, including sample size and statistical methods used.
Response [2]: Thank you for your comment. In the updated draft, we added more information about the method.
Comment [3]: Study Design and Population: The exclusion criteria are not fully justified. For instance, why were patients with concurrent facial surgeries excluded?
Response [3]:To avoid any confounding factor affecting the surgery time . For example some oromaxillofacail surgeries can disrupt the anatomy of the nose and septum
Comment [4]: Table 2: “The post-hoc analysis showed that patients with combined dorsal, alar base, and tip deformities had significantly longer operative time than patients with isolated dorsal deformity (<0.001) (Table 2).” The authors had better create a graph to ensure the differences.
Response [4]: Thank you for your comment. In the updated draft, we added the requested figure.
Comment [5]: Discussion:  The authors had better expand the literature review to include more studies on the relationship between nasal deformity complexity and surgical outcomes. It lacks critical engagement with the limitations of the study. The retrospective nature and potential biases (e.g., selection bias, recall bias) should be discussed more comprehensively.
Response [5]: Thank you for your thoughtful feedback. However, to the best of our knowledge, our study is the first to specifically investigate the association between operative time and deformity complexity in rhinoplasty patients. As such, there is a limited amount of directly comparable literature available to expand upon in this specific area. While there are studies addressing related aspects of rhinoplasty outcomes, such as complication rates, patient satisfaction, and revision surgeries, none have specifically focused on the relationship between deformity complexity and surgical time as we have in this study. Therefore, our literature review was necessarily limited to the available studies that provided relevant background and context for our research.
On the other hand, we provided critical engagement with the limitations of the study in the updated draft.
Comment [6]: There are numerous sites of inadequate use of abbreviations, grammar errors, erratum in the manuscript, and awkward phrasings that detract from this work.
Response [6]: Thank you for your comment. The updated draft was thoroughly revised to account for the inadequate use of abbreviations, grammar errors, and awkward phrasing.

 

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The AA. adequately corrected the paper according to the Reviewer's suggestions.

Reviewer 3 Report

Comments and Suggestions for Authors

I appreciate the opportunity to review again the manuscript for publication in MDPI Surgeries.

I reckon that the manuscript has been revised and improved in part in accordance with the reviewers’ comments. However, the amendments in the revised manuscript still fail to support the highlights of the article. No additional data have been presented.