Aesthetic Nasal Surgery Research Articles

Cadaveric Costal Cartilage Grafts in Rhinoplasty and Septorhinoplasty: A Systematic Review and Meta-Analysis of Patient-Reported Functional Outcomes and Complications.

Irradiated cadaveric costal cartilage (CC) has been utilized as an alternative to autologous cartilage (AC) in functional and aesthetic nasal surgery. The impact of graft choice between AC and CC on functional outcomes in rhinoplasty has yet to be studied. A systematic review was performed in PubMed, Embase, and Cochrane databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify comparative studies evaluating the efficacy and safety of CC in nasal surgery. Functional and aesthetic outcomes and complications were reviewed and compared between AC and CC. Meta-analytic comparisons were performed when appropriate using data from comparative studies using a random-effects model. Four studies met inclusion criteria. The indication for surgery was functional in the majority of cases, and 34.6% of cases were revision rhino- or septorhinoplasties. Disparate data across studies prevented meta-analysis on functional outcomes; however, qualitative review of function outcomes demonstrated comparable outcomes between the CC and AC groups. No differences in graft infection, warping, and resorption rates were detected. Analysis of all graft-related complications was higher in the CC group (P = 0.02); however, when AC donor site-related complications were included, no significance between the two groups was observed. In conclusion, limited, high quality data was available for analysis. Of the available studies, this systematic review suggest that the use of AC or CC may lead to comparable results in terms of functional outcomes. More long-term studies directly comparing AC and CC functional outcomes would be welcomed.

Facial perception, self-esteem and psychosocial well-being in patients after nasal surgery due to trauma, cancer and aesthetic needs (cluster analysis of multiple interrelations)

Background: Facial anthropometric measurements in relation to self-esteem and self-perception have become a very popular topic, not only in anthropological and psychological research, but also in plastic reconstructive surgery.Aim: To compare the interrelations between facial perception, self-esteem and psychosocial well-being in patients after nasal surgery due to trauma, cancer and aesthetic needs.Subjects and methods: In total, ninety patients after nasal surgery (due to trauma, cancer and aesthetic reasons), and thirty control persons underwent facial anthropometry and answered questions related to facial perception (FP), self-esteem (SE) and psychosocial well-being (PW). Cluster analysis was performed.Results: Facial measurements were not related to the perception of the whole face in all investigated persons. The whole face and nasal perception were interrelated in the majority of male groups and in the control female group. SE in females from the control and cancer groups was not related to real facial parameters or FP, however, in females after aesthetic surgery it was related to nasal tip protrusion. SE in females after nasal surgery due to trauma was strongly related to FP. SE in almost all groups of males was related to real facial parameters, and in males after aesthetic surgery it was related to FP. PW was mostly linked to SE in males and females after aesthetic surgery, in other groups it was related to FP.Conclusions: FP was most frequently not related to real facial measurements; however, it was related to PW. Patients after aesthetic nasal surgery had specific relations between FP, SE and PW.

Reductive Nasal Profileplasty.

Reductive nasal profileplasty is often the pillar of aesthetic nasal surgery. The surgeon must be knowledgable in the key tenants of preoperative analysis and examination to better approach the core elements for hump takedown. Photo imaging or morphing is a practical and technically easy means to open the discussion with the patients to determine their specific goals and ensure that these goals align with their needs functionally. Various approaches can be taken dependent upon the demands from the patient's anatomy and surgical goals planned preoperatively. The component resection technique is described in detail, as well as discussions regarding the need to predict and prophylactically treat the possible long- and short-term sequelae that can occur with reductive nasal profileplasty. Complementary procedures should also be considered to achieve the most balanced nasal and facial aesthetic.

Evaluation of sleep quality and risk of obstructive sleep apnea in patients referred for aesthetic rhinoplasty.

ImportanceAesthetic rhinoplasty is the fifth surgical procedure most performed worldwide by plastic surgeons. With the growing demand for rhinoplasty, there is an unmet need for research into the profile of patients who seek aesthetic nasal surgery in an attempt to improve not only cosmetic dissatisfactions, but also the manifestations of other, possibly interrelated disorders, especially sleep disturbances. ObjectiveTo evaluate the sleep quality and the risk of Obstructive Sleep Apnea in patients referred for aesthetic rhinoplasty, as well as the association of these conditions with nasal symptoms. Design: Cross-sectional study performed at the period of June/2016 to August/2017. Setting: Department of Otolaryngology and Head and Neck Surgery - Universidade Federal de São Paulo. Participants: Patients of both sexes, aged 18 to 65 years, who were referred for aesthetic rhinoplasty. We evaluated 46 patients, two of whom were excluded because they were outside the inclusion age criteria. Main Outcome(s) and Measure(s): Anterior rhinoscopy and the following validated surveys were used. Pittsburgh Sleep Quality Index; Epworth Sleepiness Scale; Nasal Obstruction Symptom Evaluation scale; Berlin Questionnaire. The visual analog scale for snoring was also used. ResultsOf the 44 participants, 18 (41%) were males and 26 (59%) were females. 82% had poor sleep quality. 46% presented excessive daytime sleepiness. There was a high risk for Obstructive Sleep Apnea in 27%. Regarding to nasal symptoms, the mean score in the Nasal Obstructive Symptoms Evaluation was 66.25±25.38. When comparing the groups with good and poor sleep quality, we observed a higher risk for Obstructive Sleep Apnea (p=0.05) in patients with poor sleep quality. Patients at high risk for Obstructive Sleep Apnea had higher scores on the Nasal Obstructive Symptoms Evaluation (p=0.001) and on the analogue snoring scale (p<0.001) compared to patients at low risk. ConclusionsWe observed a high occurrence of poor sleep quality in participants. All participants who were at high risk for obstructive sleep apnea were also classified as having poor sleep quality. An association was also observed between the presence of high risk for obstructive sleep apnea and presence of nasal symptoms.

Persistent Nasal Infantile Hemangioma: A Surgical Treatment Algorithm.

Treatment of infantile hemangioma is usually medical. The nose is one of the most important aesthetic and functional units of the face; therefore, surgical management is preferred in persistent lesions (fibro-fatty tissue component) that do not respond to medical treatment. Herein, the authors analyze the results of surgical nasal hemangioma treatment in their center, a literature review and propose an algorithm for surgical management. A retrospective analysis of 23 persistent nasal hemangioma operated between 1996 and 2014 at our institution was made. The authors recollected the following demographic and clinical data: hemangioma subtype, phase of evolution, affected aesthetic nasal subunit, previous treatment, surgery type, complications and follow-up period. The Strasser scale was chosen for assessment of postoperative photographic results. Surgical treatment was performed. Age average was 6.8 years old (range 2-19). Mixed hemangioma was the most common subtype (83%). Surgery was mainly performed in the involution phase (87%). The most affected aesthetic subunit was nasal tip (44%). All lesions received previous medical treatment. The most common surgical technique was open rhinoplasty approach. Follow-up was an average of 26.6 months. Aesthetic results according to the Strasser method included: 3 excellent scores, 15 good, 5 regular, and none poor. Surgery was performed on patients in order to correct nasal persistent hemangiomas sequel. The nose has serious psychosocial impact and mixed infantile hemangiomas appear to have a higher rate of persistent hemangioma requiring surgery, but further studies are needed. Aesthetic outcome with surgical procedures chosen were acceptable and no complications were reported.

The Indian nose: An anthropometric analysis

Anthropometric measurements of the nose are of great importance in planning aesthetic nasal surgery. Abundant literature is available on anthropometric analysis of Caucasians and Orientals, without similar references on the Indian nose and its regional differences. Thus, we conducted a descriptive cross-sectional epidemiological study of 1000 volunteers, with equal number of subjects derived from five geographic groups, namely North, Central, West, South, and the Himalayan region, to determine differences in nasal morphology of Indian population and among its various regions. The objective was to establish a standard Indian data for guidance in nasal surgery. All measurements were deduced using photographic analysis. The mean nasal height and width of our study population was 50.48 and 36.59mm, respectively. Nasal profile varied among all five regions of the country. North Indians had the longest (52.69mm nasal height) but the narrowest nose (35.01mm width), thus having a leptorrhine nose with Caucasoid features. South Indians had the broadest nose (nasal width=38.66mm), whereas subjects from the Himalayan region had the shortest nose (nasal height=47.2mm). Indians on average had a mesorrhine nose as compared to Caucasians and Orientals who have a leptorrhine nose and Africans who have a platyrrhine nose. We thus conclude that the Indian nose should be considered a different entity in comparison to the nose of Caucasian, Oriental, and African populations. There are obvious differences in the facial architecture of people from different regions within the country. Therefore, appropriate adjustments need to be made according to different racial descents during nasal surgeries so as to give patients results that blend harmoniously with other facial features.

Corrective Nasal Surgery after Maxillomandibular Advancement for Obstructive Sleep Apnea: Experience from 379 Cases.

Objective Efficacy of maxillomandibular advancement (MMA) in the treatment of obstructive sleep apnea (OSA) is associated with degree of maxillary advancement. Large maxillary advancement leads to profound changes of the nasolabial region. We present the incidence and indications of post-MMA corrective nasal surgery in a large cohort. Study Design Case series with chart review. Setting University medical center. Subjects and Methods A total of 379 subjects with OSA underwent MMA at Stanford Hospital (surgeons: S.Y.L., R.W.R.) from August 1992 to December 2015. Data were collected on age, sex, American Society of Anesthesiologists score, polysomnography parameters, and history of nasal surgery. Primary outcome parameters were the incidence and indications of post-MMA corrective nasal surgery. Results Of 379 subjects, the surgical success rate was 76.3% based on the change in respiratory disturbance index. Seventy-one subjects (18.7%) underwent corrective nasal surgery after MMA, whereas 48 underwent functional nasal surgery and 23 underwent both functional and aesthetic nasal surgery. Lower oxygen saturation nadir and higher baseline respiratory disturbance index were associated with increased likelihood of post-MMA corrective nasal surgery. Conclusion MMA surgical success is associated with degree of maxillary advancement, which is especially significant in patients with severe OSA. Patients must be counseled on its impact in nasal function and aesthetics. Our series, the largest to date to address this question, suggests that the incidence of post-MMA corrective nasal surgery is at least 18.7%. Prospectively, refinement in MMA techniques is needed to minimize postoperative compromise in nasal form and function.

Lower Lateral Cartilages: An Anatomic and Morphological Study in Noses of Black Southern Africans

The anatomy of the nose of different ethnic groups has been widely researched in order to facilitate a better understanding of the individual nose as a foundation for improving surgical outcomes. The only anatomical research of the lower lateral cartilages (LLCs) available to the surgeon working with an African patient is to extrapolate data from studies already published on African Americans. The aim of this descriptive cadaveric study was to assess the normal anatomy of the LLCs in noses of Black South Africans and compare this to data from studies on noses from Caucasian, Asian, Korean, and African-American populations. Ninety lower lateral cartilages of 45 cadavers of Black South Africans who did not have previous surgery or trauma to the nose were dissected. The morphological shapes and 12 standard anatomical measurements were recorded. The results were analyzed and compared to data in the literature from studies on lower lateral cartilages of Caucasian, Asian, Korean, and African-American populations. A statistically significant difference was found in terms of overall cartilage dimensions, distance from nasal rim, and morphological shapes, compared to all previously studied groups, including the African-American population. There were significant differences in cartilage dimensions between males and females. This translates to clinically significant data that is useful during reconstructive and aesthetic nasal surgery on patients with a Southern African background. This study sets norms for alar cartilages in Black Southern Africans.

Surgical Management of Obstructive Sleep Apnea.

Surgical management of snoring and obstructive sleep apnea is indicated when a surgically correctable abnormality is believed to be the source of the problem. Many patients opt for surgical treatment after noninvasive forms of treatment have been proven ineffective or difficult to tolerate. With increasing frequency, functional rhinoplasty, septoplasty, turbinoplasty, palatal surgery, and orthognathic surgery are being used in the management of snoring and obstructive sleep apnea. Plastic surgeons' experience with aesthetic nasal surgery, nasal reconstruction, palatal surgery, and craniofacial surgery puts them at the forefront of performing surgery for snoring and sleep apnea. The role of functional septorhinoplasty, turbinoplasty, palatal surgery, genioglossal advancement, and orthognathic surgery is indispensable in the surgical management of obstructive sleep apnea. Multidisciplinary management of these patients is critical, and plastic surgeons are encouraged to work collaboratively with sleep medicine clinicians and centers.

Does the Nose Have a Function Beyond Breathing?

This article examines how functional nasal surgery can result in aesthetic improvement to the nose. We performed a literature search examining functional rhinoplasty with resultant aesthetic benefits. We also conducted a review of various techniques that can be used to correct functional nasal obstruction that also achieve aesthetic improvement(s).Although there are data demonstrating improvements to quality of life after functional and aesthetic nasal surgery, there is limited work linking the close relationship between functional nasal surgery with resultant aesthetic improvements.Functional rhinoplasty to correct nasal obstruction can also result in aesthetic improvements. Perhaps reconsideration of separating these closely tied issues is needed. A formal study looking at the degree of worsened, unchanged, and improved nasal aesthetics that occurs after true functional rhinoplasty, from both objective and subjective viewpoints, should be considered.

Development and validation of the Functional Rhinoplasty Outcome Inventory 17 (FROI-17).

Quality of life aspects become more and more important in all fields of medicine. There is a lack of such instruments for septorhinoplasty that cover sufficiently both functional and aesthetic aspects. In Phase 1, a group of experts identified 22 questions that represent the symptoms of patients with nasal deformities, which undergo a functional and aesthetic nasal surgery. Forty-one patients filled out the questionnaires before septorhinoplasty. The item assessment and item reduction was performed by a sequential statistical analysis, which included a single item analysis, an assessment of internal consistency, construct validity, the divergence validity and a factor analysis. The resulting 17-item questionnaire was used in a prospective validation study (Phase 2) in which 103 patients were enrolled. Statistical analysis included testing of validity, reliability and responsiveness. In Phase 2 data analysis revealed a good internal consistency and significant test-retest reliability. A literature survey confirmed that the relevant items were included in the questionnaire. We found significant item-score-correlations. Furthermore, the existence of concurrent validity was confirmed. Standardized Response Mean (SRM) as a measure for sensitivity to change indicated moderate to large effects. FROI-17 is a valid quality of life instrument for use in septorhinoplasty patients. The instrument is now available for prospective data collection in future septorhinoplasty outcome studies.

Dentistry in nasal reconstruction

Introduction: Popularity of aesthetic nasal surgery is testament to the importance patients place on the cosmetic appearance of the nose. Some nasal defects following tumour surgery require a Rhinectomy or partial Rhinectomy. Nasal defects can have significant psychological and functional morbidity. There are various surgical options for reconstruction of nasal defects. There a variety of reconstructive methods including prosthetic. Dentists are used to taking intra oral impressions. We used this expertise to reconstruct patient specific splints.

Development and validation of the Functional Rhinoplasty Outcome Inventory 17 (FROI-17)

Quality of life aspects become more and more important in all fields of medicine. There is a lack of such instruments for septorhinoplasty that cover sufficiently both functional and aesthetic aspects. In Phase 1, a group of experts identified 22 questions that represent the symptoms of patients with nasal deformities, which undergo a functional and aesthetic nasal surgery. Forty-one patients filled out the questionnaires before septorhinoplasty. The item assessment and item reduction was performed by a sequential statistical analysis, which included a single item analysis, an assessment of internal consistency, construct validity, the divergence validity and a factor analysis. The resulting 17-item questionnaire was used in a prospective validation study (Phase 2) in which 103 patients were enrolled. Statistical analysis included testing of validity, reliability and responsiveness. In Phase 2 data analysis revealed a good internal consistency and significant test-retest reliability. A literature survey confirmed that the relevant items were included in the questionnaire. We found significant item-score-correlations. Furthermore, the existence of concurrent validity was confirmed. Standardized Response Mean (SRM) as a measure for sensitivity to change indicated moderate to large effects. FROI-17 is a valid quality of life instrument for use in septorhinoplasty patients. The instrument is now available for prospective data collection in future septorhinoplasty outcome studies.

Identical Twins Rhinoplasty: Challenges &amp; Psychological Aspects

Identical Twins Rhinoplasty: Challenges & Psychological Aspects Being part of a "twin unit" presents a unique experience for twins. It is also an unique experience and a true challenge for the rhinoplasty surgeon to operate on such an exceptional group of patients because of the complex interplay of psychological and social influences on" these two parts of a set". This article attempts to show the authors' experience in rhinoplasty in identical twins, demonstrating the questions that must be answered and the major challenges that must be considered before performing such surgeries. The authors present their experiences with a series of cases involving six pairs of twins (12 patients); five of these pairs of twins were phenotypically identical and underwent aesthetic nasal surgery between 2009 and 2013.

The Role of Upper Lateral Cartilage in Correcting Dorsal Irregularities: Section 2. The Suture Bridging Cephalic Extension of Upper Lateral Cartilages

Dorsal irregularity after hump reduction is one of the most annoying problems in aesthetic nasal surgery. Spreader grafts, cartilaginous autogenous thin (CATS) grafts, Skoog-type dorsal grafts, cartilage grafts, bone grafts, fascia grafts, dermal grafts and nonbiologic products such as silicon and polytetrafluoroethylene are used to overcome this problem. In cases managed with spreader flaps rather than graft procedures, problems may persist in the area of the nasal bones, whereas irregularities in the cartilage dorsum can be minimized. More specifically, the surgically treated surface of the dorsum's upper third and the rhinion area [nasal bone and upper lateral cartilage (ULC) junction], which has the thinnest nasal soft tissue, present the greatest challenge for hiding irregularities and call for special attention. The ULC has a cephalic extension with varying lengths under the nasal bone. When these pieces of cartilage are protected during hump excision and sutured to each other, a strong, smooth, and a single-unit structure can be obtained. This technique was applied to 76 patients between 2009 and 2010. Manual examination during the postoperative period showed no irregularities in 60 patients. In the remaining 16 patients, minimal irregularities in the bony region were encountered. In 4 of these patients, the irregularities were visible in the profile view, and in the remaining 12 patients, they were felt only by manual examination. The bridging suture technique using cephalic extensions of the ULC is an improvement of the spreader flap technique to obtain a straight, smooth, and single-unit dorsum in rhinoplasty patients. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The use of titanium clips in septal surgery for correction and strengthening

Permanent correction of septal deformities is one of the most difficult and controversial subjects in aesthetic nasal surgery. The main reasons for failure in most of the corrective procedures are either not to weaken the septal cartilage enough to straighten it, or to treat the septum too radically causing iatrogenic deformities or predisposing it to new deformities postoperatively. Our approach to correct septal deformities relies on the principle of strengthening/reinforcing the septal cartilage (with or without some weakening maneuvers to correct the deformities beforehand) with application of titanium hemoclips at some critical locations inseptum. Eighty-seven patients operated on between 2007 and 2009 are included in this study. Thirty-six of these patients had combined septo-nasal deformities while the remaining 51 had solely septal deformities. In 30 patients with septo-nasal deformity the technique was proven to be successful. The remaining 6 patients of this group had axial nasal deformity (rather than intrinsic septal problems) and did not respond to our technique successfully. Within four years of follow up, we did not encounter any recurrences, infections, ulcerations or exposure in the mucosa covering the titanium clips. None of the titanium clips were required to be removed for any reasons.

REVIEW: The role of anthropometric measurements in nasal surgery and research: a systematic review

Anthropometric measurements of the nose provide objective data about the size and shape of the nose. Data of average nasal anthropometric values for various ethnic groups is promoted to be of great importance in planning aesthetic nasal surgery, but there may be fundamental problems with this approach. To collate existing knowledge on nasal anthropometry and, determine its value to the nasal surgeon, in planning aesthetic nasal surgery and in research. A structured search of PubMed was performed from 1 January 1973 to 31 December 2009 focussing on nasal anthropometry. The MeSH keywords used were nasal/nose, anthropometry/history/methods/measurements, aesthetic, surgery, nose, otorhinolaryngologic surgical procedures. There is published literature on the average values of the nasal dimensions for various ethnic groups, to aid surgeons in planning improvements of the face. However the large overlap of anthropometric data between racial groups and the lack of any scientific basis for the concept of race means that the published data for racial groups is of little use in planning nasal surgery. Nasal anthropometry, however, helps to answer important clinical questions in research. It has established the role of primary rhinoplasty in patients with cleft lip nasal deformity. It serves as an objective tool to investigate whether reconstructive nasal septoplasty in the paediatric population has any deleterious effect on nasal growth. Anthropometry also helps in the characterisation of dysmorphic syndromes. The published anthropometric data for racial groups is of little use in planning nasal surgery. Anthropometric measurements of the nose may help to answer important clinical questions in research on the effects of surgery on nasal and facial development.

Adolescent Rhinoplasty: Challenges and Psychosocial and Clinical Outcomes

The adolescent patient subset represents a challenging demographic for the rhinoplasty surgeon due to the complex interplay of psychological, social, and physiologic influences. This study aimed to assess the authors' experience dealing with the adolescent patient demographic using a defined set of decision-making criteria and to evaluate outcomes using validated methods with this patient population. The patient population comprised a consecutive series of 30 patients who underwent aesthetic nasal surgery at the ages of 13 to 19 years between 2005 and 2008. In addition to the standard indications for aesthetic rhinoplasty, including patient desire and surgical appropriateness, the following criteria also were required for this age group before surgery: 1-year postmenarche status, stable growth for at least 1 year as reported by parents, and parental support. The main outcome measure was the 18-item Glasgow Benefit Inventory (GBI), a validated and reliable postinterventional questionnaire aimed at detecting changes in health status produced by surgical interventions. The potential GBI score ranges from -100 (maximal harm) through 0 (no change) to +100 (maximal benefit). Enhanced quality of life and patient benefit after rhinoplasty were evident in this patient population. Positive benefit is evident in the General subscale (mean GBI score, 68.2), the Physical Health scale (mean GBI score, 18.3), the Social Support scale (mean GBI score, 32.2), and the Total scale (mean GBI score, 53.8). Although no statistically significant difference in satisfaction was observed between the early postoperative period (<30 months) and the later postoperative period (>30 months), the means were higher for the Social Support and Physical Health scales among the patients surveyed later, trending toward significance. The patient population showed no evidence of a gender- or age-based effect. Quality of life was enhanced by aesthetic and functional rhinoplasty in this patient population according to the authors' defined set of preoperative criteria and evaluation. The adolescent subgroup represents a unique demographic to treat based on a combination of social, cultural, and psychological variables. Aesthetic rhinoplasty is an undeniably effective tool for correcting psychologically impairing features that adolescents perceive as undesirable. Postoperatively, these patients demonstrate positive changes in behavior and interpersonal relations. With proper preoperative assessment and selection, excellent aesthetic and psychosocial outcomes can be expected.

Shuttle Lifting of the Nose: A Minimally Invasive Approach for Nose Reshaping

Suspension sutures are commonly used in numerous cosmetic surgical procedures. Several authors have described the use of such sutures as a part of classical rhinoplasty. On the other hand, it is not uncommon to see patients seeking nasal surgery for only a minimal hump deformity combined with an underrotated, underprojecting tip, which does not necessarily require all components of rhinoplasty. With the benefit of the suture suspension technique described here, such simple tip deformities can be reshaped percutaneously via minimal incisions. In this study, the author describes an original technique based on the philosophy of vertical suspension lifts, achieving the suspension of the nasal tip with a percutaneous purse-string suture applied through small access punctures. Between December 2005 and December 2008, 86 patients were selected to undergo rhinoplasty using the author's shuttle lifting technique. The procedure was performed with a double-sided needle or shuttle, smoothly anchoring the lower lateral cartilages in a vertical direction to the glabellar periosteum, excluding the skin envelope. Mean follow-up was 13 months, with a range of eight to 24 months. Outcomes were satisfactory in all but 12 cases, of which seven found the result inadequate; two of those patients underwent a definitive rhinoplasty operation. Five patients requested that the suture be detached because of an overexaggerated appearance. Operative time was less than 15 minutes in all patients, with an uneventful rapid recovery. As a minimally invasive nasal reshaping procedure, shuttle lifting is a good choice to achieve long-lasting, satisfactory results in selected patients with minimal hump deformity and an underrotated tip. The significance of this technique lies in the fact that it is one of very few office-based minimally invasive alternatives for aesthetic nasal surgery, with a recovery period of two to three days.

So you want to be … an otorhinolaryngologist

Ear, nose and throat surgery (ENT), now referred to as otorhinolaryngology, head and neck surgery, offers a multitude of opportunities and has been described as having all surgical skills under one umbrella. Open surgery of the salivary and thyroid glands, reconstructive surgery and free flap surgery following excision of head and neck cancer, skull base surgery, microsurgery of the middle ear, endoscopic sinus surgery, facial plastics, functional and aesthetic nasal surgery, phonosurgery and the advances of lasers and navigational surgery are all included within otorhinolaryngology, head and neck surgery. There are approximately 565 consultants and 337 specialist registrars in the UK.