Has the pendulum swung too far?: trends in the teaching of endonasal rhinoplasty.

M EDICINE, AND surgery in particular, is trending toward less invasive procedures, reduced morbidities, and quicker recovery times. Cholecystectomies that used to be performed through a large abdominal incision and required a 7-day hospital stay are now done laparoscopically, which allows patients to be home by that evening. As simpler, less invasive, more effective treatments have been developed, many procedures that were once common no longer exist. For better or worse, the patients of today expect minimally invasive procedures. This trend is not limited to general surgery but also exists in aesthetic medicine. The 15% decrease in cosmetic surgical procedures over the last 2 years may not be the sole result of the poor economy. The tremendous popularity of fillers and neurotoxins has resulted in many patients who expect all cosmetic procedures to be performed with effective and immediate results. Additionally, the popularity, although arguably a fad, of short scar facelifts, minilifts, and the like cannot be denied. So, with the trend in medicine toward a less invasive procedure that offers equivalent, if not superior, efficacy and quicker results, how does rhinoplasty fit in? Traditionally, patients are instructed that the healing period following rhinoplasty can last up to 1 year. However, over the past couple of decades, an emphasis on building structurally sound noses that stand the test of time has seen rhinoplasty evolve into a bigger procedure, with more surgery, operative time, and potential for prolonged edema. In the appropriate candidate, if the predictability and reliability of the endonasal approach can equal that of an external approach, is it time to revisit the endonasal approach? At one time, the endonasal approach to rhinoplasty was the one predominantly taught and performed. Generations of physicians were trained in transcartilaginous, intercartilaginous, and delivery approaches to rhinoplasty with only minor modifications from the teachings of our predecessors. In the late 1970s and early 1980s, the transcolumellar external rhinoplasty approach gained popularity. The openness of the procedure allowed a versatile approach to the nose with greater exposure of the nasal cartilages, which proved to be a superior method for complex revision work and a better teaching tool. The last decade has seen external rhinoplasty become the predominant method used in rhinoplasty. Additionally, as leaders in our field turned to the external approach, the training of facial plastic surgeons in this approach followed, and it appears that the endonasal approach is rarely taught today. It is likely that a generation of facial plastic surgeons may not be proportionally educated in the endonasal approach to rhinoplasty. Modern cosmetic rhinoplasty and internal incision rhinoplasty are traditionally attributed to German physician Jacques Joseph. Joseph was aware that cosmetic surgery was centered on treating the psyche of the patient. Many of Joseph’s patients were not accepted into German society owing largely to their ethnicity, so by having physical features that were identifiers of one particular ethnic group altered, individuals could come to more closely resemble an average person in that country at the time. Positive patient satisfaction as the outcome is a concept that our predecessors recognized as the primary objective of cosmetic medicine. Surgeons flocked to Berlin to learn from Joseph. While they absorbed his knowledge and sharpened their new skills, these early pioneering surgeons gained experience, became experts, and developed a modern procedure that would shape attitudes, careers, and, arguably, a generation. Perhaps the most recognized teacher of rhinoplasty in the United States, at least for the otolaryngologist, was Samuel Fomon, an anatomist who traveled to Joseph’s clinic in the 1920s. Fomon, a dedicated and determined explorer, reportedly persuaded Joseph’s nurse, by offering to pay her $50, to come in after hours and draw sketches of Joseph’s coveted tools. Fomon was an incredibly talented teacher who was known to explain difficult concepts in an easy-to-understand manner. To share his acquired knowledge, he set up courses around the country; he is responsible for bestowing the gift of rhinoplasty skills upon well-known physicians such as Morey Parkes, Irving Goldman, Jack Anderson, Maurice Cottle, and others. Rhinoplasty became part of the curriculum taught to young doctors in multiple specialties and to residents-in-training across the country. However, rhinoplasty was mostly based on theories of reduction and prediction. Precise cartilage excisional maneuvers were expected to result with predictability to a certain degree of rotation, narrowing, or projection. While surgeons were enthusiastic and full of theoretical knowledge, the intricate nuances of the operation perhaps were not being properly translated. Additionally, as endonasal rhinoplasty was generally the only method taught, eagerto-please physicians may have extended the criteria and attempted to achieve heroic results. Unfortunately, patients whose noses had a difficult degree of deformity, who would not be good candidates for a limited-access rhinoplasty by the standards of today, were often left with untoward outcomes. A new language began to take shape that was