Advances in rhinoplasty

A world-class rhinoplasty unit at Mediclinic Morningside takes a multidisciplinary approach to one of the most complex surgical procedures.

Rhinoplasty improves the external shape of the nose. Apart from cosmetic reasons, many patients turn to rhinoplasty surgery to fix breathing issues, congenital abnormalities or nasal deformities as a result of a nose injury or trauma. Generally patients consider rhinoplasty surgery to fix structural issues such as the size or width of the nose, the angle or shape of the tip of the nose, the bridge of the nose, and the size of the nostrils.

Four prominent cosmetic and reconstructive plastic surgeons, including team leader Dr Peter Scott, now comprise the Mediclinic Morningside Rhinoplasty Unit. Together with leading ENT and maxillofacial specialists, they perform state-of-the-art nose surgery in a multidisciplinary setting that is unique in private practice.

Dr Scott has served on the board of the Association of Plastic Reconstructive and Aesthetic Surgeons of Southern Africa (APRASSA) since 2007 and the International Society of Aesthetic Plastic Surgery (ISAPS) and is a past president of South African Melanoma Advisory Board, SORSSA. He is also a member of South African Society for Surgery of the Hand (SASSH), Rhinoplasty Society Europe (RSE), and an international member of ASAPS and ASPS.

Dr Ewa Siolo is dedicated to the reconstruction of facial and body defects due to birth disorders, trauma, burns, and disease. She is involved in innovative stem cell research and is regarded as one of the leaders in the field of using fat injections in the breast, nose and face. She serves as ISAPS National Secretary for South Africa.

Dr Chris Snijman served on the Executive Committee of APRASSA for 12 years (including as president from 2016-18), is the Immediate Past President of APRASSA and holds the position of Chief Ombudsman Plastic Surgery South Africa. Professor Tim Christofides, the fourth member of the team, has been a Professor of Plastic and Reconstructive Surgery at the Johannesburg Hospital for a number of years. His specialty is cleft palate surgery. He is the current President of APRASSA.

“As a multidisciplinary team, we now work closely with several ENT and maxillofacial specialists because we don’t only look at the patient’s nose, we look at the shape of their whole face,” Dr Scott explains. “This is extremely important. If somebody has a terrible overbite for instance, they’re going think their nose is too big, but in reality, their chin is too small. If necessary, we also get psychologists involved, as rhinoplasty is a very exacting surgery and a patient needs to be realistic about the expected outcome.”

Generally, a patient at the Mediclinic Morningside Rhinoplasty Unit will first see an ENT surgeon – Dr Tim Els, Dr Mark Torres Holmes or Dr Kwame Adzatia; and then the maxillofacial and oral surgeon – Dr Yusuf Suleman. “They’ll establish the platform of the patient’s face and if necessary, get orthodontists involved in moving teeth around,” says Dr Scott.

“There are two aspects to a successful rhinoplasty. The patient must have a nose they can breathe out of (functional rhinoplasty) and one that looks aesthetically pleasing. As part of our multidisciplinary approach, a patient will see an ENT surgeon for the functional aspect and one of the main plastic surgeons on the team for the aesthetic aspect. The follow-up appointment is then a combined meeting two or three members of the team simultaneously, at no extra cost to the patient. We’ll talk through their case with them and give them time to work out their expectations. We never see a patient and simply book the surgery. We plan everything very carefully.”

The ENT surgeon will do scans and X‑rays of the nose, including the latest technology called cone beam scan. “These are beneficial because they offer less radiation and give a very clear picture of the cartilage of the nose,” Dr Scott explains. “Another world-class innovation our ENT surgeons will soon be able to perform is being able to track airflow in the nose definitely. If the air flow is diminished, we know the patient has a functional problem, which means they can get adequately compensated by their medical insurance.”

Once the functional aspect of the nose has been evaluated, patients then see one of the four leading cosmetic and reconstructive plastic surgeons on the team at the Mediclinic Morningside Rhinoplasty Unit. “Our revolutionary imaging technology offers a 3D picture of the result they can expect from their rhinoplasty procedure,” says Dr Scott. “We analyse the portrait together to ensure we’re on the same page as the patient. The patient is able to review it at home, then come back in to discuss it further. We make the disclaimer that it’s not 100% accurate, as results can vary – it’s simply a useful tool.”

One of the biggest advances in rhinoplasty technology over the past year or two is Piezo, an ultrasonic device that enables experienced surgeons to shape the bones of the nose non‑destructively. “In other words, instead of using a hammer, chisel and a rasp, we’re able to shave down the bones very delicately and shape them,” says Dr Scott. “This means we don’t always fracture the bones these days. And the advantage for the patients is they get very little bruising or swelling, which is a big win because noses take a long time to heal before you get the final results.”

The Mediclinic Morningside Rhinoplasty Unit now uses a new surgical technique – the anterior approach – which also causes less trauma to the nose. Developed by German professor Wolfgang Gubisch, known as the “godfather of nose surgery” in Europe, this approach entails going from the top of the nose, instead of working inside. “This means you can see exactly what’s going on,” says Dr Scott. “It also allows surgeon to expose the entire septum, to see the cartilages in position without any distortion at all, which facilitates very accurate measurements too.

“From there, we still have to perform quite a bit of cartilage grafting, where we put in structural grafts to open up the breathing and support the tip of the nose. And while that technology has been around for quite a while, it’s getting modified all the time.”

Another essential element in a successful rhinoplasty is treating the skin of the nose. After surgery, the little sebaceous oil glands get very swollen and the nose looks “thick and boggy”, Dr Scott says. “Together with dermatologists, we’ve developed a system of Retin-A products because it’s no good having a beautiful skeleton on the nose with thick, oily skin. It’s routine in our practice because we stay up to date with all international advances and evolution.”

At the Mediclinic Morningside Rhinoplasty Unit, up to 40% of patients are revision cases. “It’s at that level because people know we’re a multidisciplinary team that has the necessary expertise and experience to perform redo cases,” says Dr Scott. “Often, we invite the original surgeon to assist us in the redo operation. That’s actually first prize because it means they’re learning, upskilling, and keeping a positive relationship with the patient.

“If somebody comes to us with a botched nose with terribly scarred skin, Dr Siolo will inject nano fat into the nose or microfat with stem cells. This softens the scar tissue and provides a little layer on the nose to make the next layer of surgery safe. We also use microfat injections after a few months if there are still tiny irregularities that need treatment after surgery.”

Keeping abreast of international trends and innovations ­– and willingly sharing their expertise and findings with other surgeons – means the Mediclinic Morningside Rhinoplasty Unit is an outstanding example of multidisciplinary excellence that can compete with the best international outfits.