What is an Otolaryngologist? What does an ENT surgeon do? Part 5: Facial Plastics

Did you think that the practice of medicine and surgery was a science? Not exactly. Although it is founded on strong scientific basis, like the science of the primary colours, it’s actual practice is more of an art rather than science (some doctors would even go as far as saying medicine is neither art or science, it is business. And that’s another blogpost altogether). The practice of this art of medicine and surgery, I believe, is most evident in the art of Facial Plastic Surgery. I can find no other specialty where creativity, artistry, skills, imagination and science collide. It is by far the most artistically beautiful branch of surgery. A true craftsmanship.

It is also a shared space between ENT surgeons and plastic surgeons. Where competition occurred in the past, I think we’ve grown past that and we’ve decided that collaboration is the better way to move forward for our patients. So it matters not if a facial plastic surgeon was of the ENT breed or the plastic surgery breed. What matters is that he/she loves the art and is well trained in it.

So how do you beautify a face? Beauty is more than skin deep they say. It is true. Beauty involves muscle, fascia, bone and cartilages too. This question is much like asking how do you turn a Picasso into a Rembrandt using only the canvas and colours that are already there. As surgeons we need to work our magic to employ all the available tissues to turn a face into one where form and function match like a masterpiece. We think of the functional face. A face is not a face unless it can convey emotions, personality, character and even memories. There is no point in creating a beautiful face that can’t move. That’s called photoshopping. As facial plastic surgeons we think of the way the eyebrows move when elated, the forehead frowns when upset, the nose moves when speaking, the lips separate when laughing.

We do our nose jobs with nasal aerodynamics in mind. We think of the ethnic face and culturally-specific indications of beauty. We do our chin operations with sleep quality in mind. Facial plastic surgery separates the craftsmen and craftswomen from the ground crew. Lots of surgeons can do nose jobs or brow lifts. But to do it well, to create a masterpiece, now that demands artistry that I’m beginning to think is a God-given gift rather than a mastered-skillset.

I’ve been fortunate enough in my training to have attended a course in Facial Plastics and been involved in multiple facial plastics procedures. Where else in medicine can you express your artistic creativity? Here are a few operations that made my heart sing:

Rhinoplasty (“nose job”). There are 6 billion ways of doing it, because there are 6 billion different noses out there. Each nose is different and they grace different faces. No two rhinoplasties are ever alike. They way a nose is approached is unique for every patient depending on the concerns. We can restructure the cartilages beneath, remove soft tissues, or add soft tissues. We can do minimal work, or we can go the distance. I’ve taken cartilages from the ear and moved it into the nose. I’ve taken fascia layer from the scalp to sculpt the nose. I’ve even taken out a rib (probably the oldest surgery ever documented, done by God as written in the Book of Genesis) to be put into the nose. We rearrange the furniture in the nose and do a bit of architectural refinement work. All these were done to help patients breathe better, and look better. It’s not easy to reach perfection in the nose. When it happens, I need to hold myself back from jumping around theatre in songs of euphoria.

Otoplasty has a special place in my heart. I remember undoing the headdress of my first otoplasty on a gorgeous 12 year old girl. I can never forget the sparkle in her eyes and how she called me a magician. It’s almost criminal that I get so much pleasure for doing something so simple that would make someone else so happy. I also remember harvesting a rib and watching a master surgeon carve out an ear skeleton to be implanted into a young teen born without ears. Creating a beautifully sculpted ear out of nothing. Now that’s magic. Don’t tell me that’s just vanity. Think of how you would be treated if you were born with deformed rudimentary ears.

Blepharoplasty gets rid of eyebags. Brow lifts utilises endoscopic cameras through small cuts behind the hairline help to rejuvenate weary foreheads. Facelift, necklift, chin augmentation and reduction, lip fillers, Botox, etc. As you know, in our appearance-crazed society, there’s a whole industry out there to make people look better, younger, healthier, fitter.

That’s just vanity, you say. Well, it’s more than that. Only a small amount of our work in facial plastics is purely cosmetic or aesthetic. Most of our work is functional and reconstructive. It’s not about ridding the world of ugliness. It’s remodeling, reconstruction, and restoration. We surgeons know not to fall into the trap of operating on someone with body dysmorphic disorder. Our primary goal is function, with additional excellence in form.

Think of the following patient situations and think of how facial plastics would change their lives. A child born with deformity of the ears. A child with cleft lip and palate with deformity of the nose. Syndromic children with craniofacial dysmorphism. A child heartlessly bullied at school due to their prominent ears or congenital facial scars. A retired professional rugby player or boxer who can’t breathe through his traumatised nose. A mother whose nose has been broken after an accidental head-butting by her toddler jumping on her lap. A burns contracture to neck and face after thermal injury. A woman who had been violated and left with unsightly facial scars and nasal deformities to remind her of her insult and assault. Think of how facial plastics could change the lives of these people.

To be given the chance to reconstruct a face is an awesome privilege. Would you entrust your face to someone else to cut into?

The collision of art and science in ENT is most amazing. One day you can be operating on a child who can’t breathe, the next day you are implanting a bionic ear, the next you are operating on the vocal cords of a singer, then the nose of a politician, then relaxing on a beach. You know, they say ENT stands for Early Nights and Tennis.

There’s more to come…

NOTE: I will continue this series, while my mind is interrupted by other things. I already have another 3 posts drafted. I need time to tweak them. You’ll see them soon enough. Sorry.