As a patient, it can be hard to know who to see when your nose is giving you trouble. If the issue is seemingly cosmetic, a plastic surgeon would be the logical choice; however, if you can’t smell normally, breathe through your nose properly, or get recurring sinus infections with abnormal mucus, then it’s clearly off to the ENT you’ll go. But it’s not entirely cut and dry. Dr Mark Torres-Holmes explains how a combination of these two disciplines produces the best results when nasal reconstruction is required.
The reality is that the efforts of both of these surgical specialists may be the key to achieving the best outcomes for nasal reconstruction. In my professional capacity, I have worked with three different plastic surgeons for over 10 years and have seen the immense benefit of good teamwork first-hand.
The ins and outs of nasal anatomy
The inside anatomy of the nose (primarily the nasal septum) affects the outside anatomy and vice versa. Unfortunately, in the past, the medical profession unwisely divided up the nose – with plastic surgeons not being trained on the inside and the ENT specialisation neglecting the outside. We now know this is important because many nose problems are often only partially corrected by one surgeon. This frequently requires repeat surgery. You can imagine how frustrating and costly this can be.
Ideally, experienced ENTs and plastic surgeons working together from the beginning – to comprehensively assess all the problems with the nose – will likely produce the best outcome, decreasing the chance of revision surgery.
What causes nose problems?
The external nose is a pyramid that requires the proper alignment of forces to be central and stable. Any number of reasons could destabilise this pyramid, with the most common being trauma.
Trauma can occur as early as in the womb. Even later in life, the injury doesn’t have to be memorable to be significant. Cartilage can crack with minor injury and cause buckling due to changes in forces over time.
Other reasons for internal or external nasal asymmetry are mouth-related. Thumb sucking as a baby or toddler and the prolonged use of pacifiers push the hard palate upwards, preventing the nose from growing properly. Another reason is teeth crowding and abnormal maxillary development, which sometimes requires braces or maxillofacial surgery.
The assessment of nasal problems involves photographic documentation, nasal endoscopy, and cone beam CT scan imaging. As an ENT, the primary focus is identifying the causes of your symptoms, which may be structural or inflammatory – or both. Structural abnormalities of the nasal septum and turbinates can result in turbulent airflow, often presenting as nasal congestion or rhinorrhoea (a posterior nasal drip, if it goes backwards). The septum may be deviated for the reasons already mentioned, but the turbinates may become abnormally enlarged to compensate for this deviation or in response to the air we breathe.
It’s up in the air
The nose responds to five major factors in the air: atmospheric pressure, humidity, temperature, allergens, and pollution/irritants. Inflammation of the turbinates and sinuses can be significant as a result of sensitivity to the above factors, but can also originate from an abnormal immune response to them. Primary sinus disease can be both structural and inflammatory. Secondary sinus disease means that the sinus problem begins elsewhere, such as in the teeth.
What are the treatment options?
Whether the symptoms a patient experiences are purely due to inflammation or from a structural problem like the septum can be difficult to determine. Trialling a nasal steroid or decongestant spray/drops to treat inflammation is often advised, but structural problems cannot be cured with medications.
When the other medical options have been exhausted (or there’s a significant structural problem), surgery is the next logical step. If both the external and internal nasal anatomy is abnormal, then a combined approach with both ENT and plastic surgeon is the way forward. After reviewing all the information, surgery is planned and the role of each surgeon is defined.
The role of the ENT
In principle, the ENT surgeon’s goal is to align the forces on the inside so that the septum is both straight and central for the best cosmetic and functional outcome. Turbinate surgery involves reducing the size of the inferior turbinates either by moving them out of the way, shrinking them with an electrical device, or partially removing them. In some cases, people simply have an anatomical variation that causes an enlarged middle turbinate. Sometimes, this also needs to be dealt with surgically. The combination of a straight septum and smaller turbinates results in laminar airflow, which improves symptoms.
Another valuable part of what an ENT does during nasal reconstruction is safely harvesting the nasal septal cartilage to use in the reconstruction of the external nose and septum. Cartilage grafts are precisely placed and sutured in place to ensure maximum, long-term stability.
Sinus surgery is sometimes required at the time of nasal surgery if there is a significant history of associated chronic sinusitis. This surgery, called endoscopic sinus surgery, involves using small cameras and instruments through the nostrils to remove bone at the natural openings of the sinuses to allow for better air ventilation and mucus drainage.
The final cut
No one wants to regret going ahead with surgery without thinking it through very carefully and being aware of all the implications… but the converse is also true. If you cannot breathe, sleep, or exercise properly – all because of nasal problems – this can have a significant negative impact on your health as you get older. In this case, it’s highly likely you’ll regret not having surgery!
It is with deep sadness to inform that Dr Mark Torres-Holmes sadly passed away in August 2024. Dr Torres-Holmes contributed his clinical skills as well as was committed to improving the quality of life for all his patients. We extend our thoughts and sympathy to the family, friends and colleagues of Dr Torres-Holmes.
MBChB, FCORL(SA), GOLF(IFHNOS)
Dr Mark Torres-Holmes completed his undergraduate medical degree at the University of Pretoria in 2001. He qualified as an ENT surgeon with FCORL(SA) in 2009 and subsequently served as a consultant at the University of Witwatersrand Charlotte Maxeke Johannesburg Academic Hospital for four years, focusing primarily on head and neck surgery.
In 2014, Dr Torres-Holmes joined the Private Head and Neck Multidisciplinary team at Mediclinic Morningside in Sandton, Johannesburg. In 2016, he completed a two-year Head and Neck Surgery and Oncology Fellowship through the International Federation of Head and Neck Oncologic Societies. Additionally, he serves as a sessional employee and lecturer at Steve Biko Academic Hospital within the University of Pretoria's Department of ENT.
Currently, Dr Torres-Holmes is the secretary and treasurer of the South African Head and Neck Oncologic Society (SAHNOS) and an executive committee member of the South African Society of Otorhinolaryngology Head and Neck Surgery. His special interests lie in head and neck oncology and septal/nasal surgery.