In the Pursuit of Nasal Form and Function

InFocus Issue 22, January 2022

Otolaryngology Head & Neck surgeon Dr Marty Hanson outlines the causes and impact of nasal obstruction and shares his fresh surgical approaches to deliver form and function to patients with nasal conditions, driven by his elite skill as one of Australia’s few surgeons to undertake formal fellowship training in Facial Plastic Surgery in the United States.

Nasal obstruction is one of the most individual of symptoms that the human body experiences and has been associated with reduced exercise ability, sleep disorders, poor cardiovascular health, snoring and OSA (obstructive sleep apnoea). As a common presenting complaint in the primary care setting, both on its own and with its sequelae, nasal obstruction bears a significant burden on the health economy.

Basically, the causes of (non-cancerous) nasal obstruction are either inflammatory or structural.  Inflammatory conditions can be addressed with oral and/or topical preparations but there is no pill or spray that will correct issues with the nasal superstructure causing symptomatic obstruction, and surgery is the only real option.

Fresh Surgical Approach

As an Otolaryngology Head & Neck surgeon with advanced training and subspecialty interests in Thyroid & Parathyroid Surgery, Head & Neck Cancer Surgery, and Facial Plastic Surgery, I am also one of small group of Australian surgeons to have undertaken formal fellowship training in dual sub-specialties in the United States – in Head & Neck and Thyroid Cancer Surgery and also in Facial Plastic Surgery.

After working at Memorial Sloan Kettering Cancer Center in chaotic bustle of New York City, I moved to the country tranquility of Charlottesville and the University of Virginia. Here, under the guidance of Dr Stephen Park, past president of the American Academy of Facial Plastic & Reconstructive Surgeons, I was taught an array of skills we are not routinely exposed to during surgical training in Australia. Dr Park has trained fellows from all over the world for nearly 25 years, but I had the fortune of being the first to be subsequently offered a full-time faculty appointment to work on his clinical team at the completion of my fellowship training.

This training and faculty practice has led to my experience that despite the general success of basic interventions such as septoplasty and turbinate reduction, the nose is a complex 3-dimensional structure with intricately related tissue dynamics that may not be wholly addressed by this simple first-line paradigm. The nasal valve, the positioning of the lateral and dorsal cartilaginous elements, the distribution of tension in the nasal soft tissue envelope and the dynamic collapse of the nasal structure during respiration are components requiring thorough consideration for the optimal surgical treatment of nasal obstruction. These potential areas of pathological concern can be addressed through structured septorhinoplasty.

Throughout my years in the United States, I focused on the entire spectrum of structure rhinoplasty. From rebuilding the nose of the total-rhinectomy patient (who no longer has one courtesy of cancer), through to challenging revision cosmetic rhinoplasty for the patient left dissatisfied with previous plastic surgery, the primary theme in my practice has been the marriage of form and function.  

Revolutionising Form and Function

One of my mentors used to say ‘for a nose to work well, it usually has to look pretty darn good too’. While I can only give that statement a degree of qualified support, it really speaks to a seismic shift in the American rhinoplasty landscape. Patients are no longer accepting of recurrent cosmetic procedures resulting in the “Michael Jackson nose” and will not tolerate the negative quality of life outcomes of a dysfunctional or obstructed nose following aesthetic plastic surgery. It is becoming less common for rhinoplasty procedures to be considered as exclusively cosmetic or exclusively functional undertakings. There is also an increasing body of evidence supporting the role of structured septorhinoplasty in the multi-disciplinary and multi-phased treatment of OSA.

During my time overseas, I was fortunate to be on faculty at international meetings and teach dissection courses alongside rhinoplasty luminaries from around the world such as Dr Dean Toriumi from the US and Korea’s Dr Hong-Ryul Jin. Some of these specialists are amazing – Dr Toriumi was telling us that he collects approximately 500 pieces of data from every rhinoplasty procedure he performs (I still can’t work out how) – and have led a new wave of thinking about the approach to rhinoplasty. While traditionally quantities of cartilage and tissue were removed during rhinoplasty surgeries, increasingly the contemporary trend is towards actually added cartilage to the nose, including through non-anatomic grafting, allowing for the redistribution of tissue forces and vectors of tension that ultimately result in a more natural appearance coupled with a strong robust breathing apparatus.

This revolutionary approach to incorporating an optimal aesthetic outcome with a durable functional result also influences my work performing reconstruction of complex skin cancer defects after operations performed by other specialists. As one of the few Australian surgeons to be formally trained in the art of facelift and who performs blepharoplasty, brow-lift and other oculoplastic surgeries for aesthetic concerns and functional issues arising from cancer, this thinking is about optimizing quality of life outcomes for patients who have already experienced high levels of stress associated with their medical journey.

The pursuit of exceptional form and function in the treatment of complex nasal conditions, through meticulous and structured surgery, is an important and growing perspective that ultimately acts to deliver the best solutions for our patients.