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Interest in facial plastic surgery and in particular rhinoplasty has never been greater. From his wealth of experience in the field, Professor Palma outlines the potential problems of this increasing popularity and how they may be addressed, areas on which he will focus in one of the opening keynote lectures at ERS2018.


The major advances in ENT surgery during the 20th Century also witnessed the rise of facial plastic surgery (FPS) as a major field of progress with an exponential growth rate. At present, FPS has been firmly established as a core part of ENT training, practice and development. The wealth of experience, new scientific advances, and technical achievements have pushed the boundaries of FPS beyond all expectations, and have now influenced the arts, fashion industry, social media and our everyday working lives. We simply cannot look at the news, or the internet without seeing an article about the highs and lows of FPS.

The growth of FPS as a subspecialty of ENT has had a major impact on surgical education. Residents are now required to have a firm understanding of the basic principles of this field, and post-graduate training programmes culminate in examinations aimed to provide a uniformly high level of practice.

However, we face many challenges. Even if we ignore the rogue practitioners who provide suboptimal practice, patients are constantly bombarded with the ever shifting ideals of human beauty. The rise of egocentricity, the ‘selfie’ culture and medicolegal cases have darkened the horizon in a very promising field. Furthermore, in many countries, there are no clear guidelines about the training required before a surgeon can claim to be a facial plastic surgeon. This has resulted in a supersaturated market and caused confusion for patients who are faced with a plethora of doctors on the internet and social media.

“The reader is invited to attend the ERS Congress in April 2018 where the emphasis will be firmly on a step-wise approach to ongoing professional development and, above all, the provision of safe and satisfactory results for our patients.”

Rhinoplasty occupies a privileged position in FPS due to its popularity and media exposure. The increasing number of attendees at international conferences testifies to its success. As the Coordinator of the facial plastic surgery element of the European Rhinologic Society (ERS) Congress 2018, my colleagues and I have constructed a progressive, and logical approach to the various challenges faced by FPS, and rhinoplasty in particular.


Figure 1. Preoperative (top) and one-year postoperative (bottom) profile views of a typical Middle-East ethnic rhinoplasty. Patient’s subjective complaint was about the hump and hanging columella. Especially in ethnic rhinoplasty, the surgeon should focus on recreating profile balance by harmonious repositioning of the main aesthetic landmarks of the profile view: radix, nasion, supratip, pronasale, infratip, columellar show and subnasale. This can be elegantly achieved through an endonasal approach.


Rhinoplasty, both in its primary and revision forms, has now become an international stimulant in the development of surgical techniques but also presents a minefield of problems. Vast numbers of people in all five continents undergo rhinoplasty every year, for both purely cosmetic purposes (Figure 1) and aesthetic-oriented functional surgery (Figure 2). International conferences, dissection courses and journals have now increased to such staggering numbers that simply keeping up with their names is a full time occupation. How, in this forest of courses and conferences, are we to decide which ones to attend and what to recommend to our patients? Amalgamation of some courses and closer cooperation between the various academic institutes may help to increase their impact.


Figure 2. Preoperative (top) and postoperative (bottom) base views of a paradigmatic post-traumatic displacement of the caudal septum. The endonasal retropositioning of the septo-spinal complex allowed the recreation of a more functional and aesthetical relationship between the infratip and the height of the nostrils, as well as improving the symmetry of the entire base view.


Often the field of nasal reconstruction for congenital, trauma or cancer cases is artificially separated from cosmetic rhinoplasty. This divergence between the two fields is counter-productive, and prevents the surgeon from increasing his or her own technical capabilities. In addition to the rise of surgical skills, the increasing popularity of injectables and other minimally-invasive procedures has created a whole new area of research and practice that needs to be integrated into a more unified approach to the challenges faced by FPS surgeons and their patients. It is often claimed that herding cats is an impossible venture; rather than creating this problem, we need to address the growth of FPS at all levels.

To clarify some of the issues for the future of rhinoplasty and FPS from a wider perspective, we need to address four basic issues. First, the fundamental issue of education has to be addressed. At present, there is no uniformity in the education of FPS or rhinoplasty at undergraduate or post-graduate levels. Although examinations in North America and Europe have made a positive impact in this regard, the rest of the world seems to be developing along its own course. We certainly have a lot to learn from each other. South-East Asia now leads the world in terms of the sheer numbers of people seeking facial plastic procedures. There are rising stars in the Middle East who have made valuable contributions to the development of rhinoplasty. Unification of educational pathways and examinations will not only ensure a more holistic approach to training, but also benefit patients who now enjoy access to international travel with increasing ease and affordability.

Secondly, passing an examination does in no way guarantee excellence in practice. The long learning curve of rhinoplasty mandates ongoing, post-graduate training. A network of surgical leaders already exists who accept post-graduate surgeons for mentorship programmes. Coordination of these mentors, and the development of more centres of excellence around the world, specifically in less affluent areas, will provide younger surgeons with the opportunity to continuously improve their skills. Furthermore, through their familiarity with masters of surgery, younger practitioners will be able to refer more complex cases for higher levels of opinion and ensure patient safety and satisfaction.

Thirdly, as rhinoplasty can be the most frustrating operation to master, surgeons must provide evidence that they are operating on adequate numbers to maintain and develop their skills. The age of the ‘occasional’ rhinoplasty operation is now over.

Finally, a system of ongoing self-assessment and review by experts in rhinoplasty will ensure ongoing personal development, and the integration of new evidence-based practice into a surgeon’s everyday practice. A career in rhinoplasty has to be nurtured at every turn of the road, and should be best regarded as a never-ending task, rather than a set of fixed skills.

With these aims in mind, the FPS part of the 2018 ERS Congress programme will foster the various strands of development necessary for professional development, such that a fresh ENT graduate can make safe progress into the dark woods of rhinoplasty, and emerge unscathed on the other side. Guidance from peers along this tortuous path at regular intervals will help to protect the public from rogue practitioners and increase their trust in the medical profession.

“It is often claimed that herding cats is an impossible venture; rather than creating this problem, we need to address the growth of FPS at all levels.”

The impact of social media, e-marketing, and internet presence is now an unavoidable fact of life. As our training concentrates on acquiring the necessary skills for patient management, many surgeons are often left bewildered by the plethora of options available to them, not to mention the quagmire of negative reviews that can leave an indelible mark on cyberspace. Training in these issues has now become vital for the survival of surgeons in a hostile and negative cyberspace.

With these aims in mind, the reader is invited to attend the ERS Congress in April 2018 where the emphasis will be firmly on a step-wise approach to ongoing professional development and, above all, the provision of safe and satisfactory results for our patients.



1. Palma P, Khodaei I. The Dichotomy of Rhinoplasty Practice: from the Conference Floor to the Operating Room. Facial Plast Surg 2014;30:103-12.
2. Lee MK, Most SP. Evidence-based medicine: rhinoplasty. Facial Plast Surg Clin North Am 2015;23(3):303-12.
3. Palma P, Khodaei I, Vasilenko I. Aesthetic rhinoplasty as a surface-contour operation. From analysis to surgery. Personal concepts. Facial Plastic Surg 2016;32:587-98.
4. Ishii LE, Tollefson TT, Basura GJ, et al. Clinical practice guideline: improving nasal form and function after rhinoplasty. Otolaryngol Head Neck Surg 2017;156(S2):s1-s30.
5. Most SP. The rhinoplasty clinical practice guideline. Neither a cookbook for, recipe of, nor reduction sauce of the complex art of rhinoplasty. Jama Facial Plast Surg 2017;19(2):85-86.

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Pietro Palma (Prof)

The Milan Face Clinic, Milan, Italy; Dept Otorhinolaryngology Head & Neck Surgery, University of Insubria, Varese, Italy.

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