Rhinoplasty at the Global Crossroads

In Turkey, rhinoplasty is the most common operation in the field of facial plastic surgery and has gained increasing popularity especially within the past decade. There are many reasons for this increase. First, traditional Turkish noses are usually big, with humps of varying degrees. Second, image has become very important, especially among younger adults (those aged 18 to 25 years). Third, the number of surgeons performing this operation in Turkey has increased exponentially within the past decade. Fourth, the costs of the operation have also decreased, so rhinoplasty is no longer an operation only for rich people in Turkey.

Turkey has about 72 million inhabitants, and it is estimated that there are an additional 5 million Turks living outside the country. Throughout history, this region has been a cradle of many civilizations and a melting pot for people from many countries. Therefore, although it is almost impossible to speak about one type of nose in Turkey, in general it can be said that the main complaints of our patients are their nose humps and big noses. When one walks on the street, these findings can easily be detected. In my own practice, in more than 90% of patients this is the case as well. There are 7 different geographical regions in Turkey, and the climate changes from mild Mediterranean weather to a colder climate when one goes from west to east. The skin thickness of the population increases according to the climate. It can be said that the noses seen in the Eastern provinces are similar to the average Middle Eastern nose, whereas in the Western provinces noses are more Mediterranean in appearance.

Until the late 1990s, the endonasal approach was the main approach used in rhinoplasty in Turkey. Within the past decade, however, the pendulum has swung to the external approach. Most senior and junior surgeons use the external approach in 80% to 90% of their cases. At the beginning of this century, the use of grafts became more common, whereas within the past 4 to 5 years the popularity of the suture technique has increased.

Image has become a very important issue, not only among teenagers and young adults aged 18 to 25 years, but also among older patients. In my opinion, the main reason for this change is the power of the media—television, radio, magazines, and movies. Aesthetic surgery is always one of the major topics that is covered on a daily basis, and often celebrities are shown as examples. Some documentaries and entertainment programs on television even show all kinds of aesthetic procedures being discussed and/or performed. The net effect of the media's interest in beauty has considerably increased the number of patients seeking facial plastic surgery.

In the 1960s, facial plastic surgery practices, especially those performing rhinoplasty, blossomed in İstanbul because of the influence of an ear, nose, and throat (ENT) surgeon, Erdogan Konuk, MD, who spent 3 years studying facial plastic surgery in Paris, France. Since then, rhinoplasty has become part of the surgical armamentarium of the university ENT clinics. Starting in the late 1990s, a second powerful wave of change reached Turkey with the international courses on rhinoplasty organized by Metin Önerci, MD, from Hacettepe University. We also owe a lot to surgeons like Gerhard Rettinger, MD, Egbert H. Huizing, MD, PhD, Eugene Kern, MD, Ted A. Cook, MD, Wayne F. Larrabee Jr, MD, Charles J. Krause, MD, E. Gaylon McCollough, MD, Stephen S. Park, MD, Vito C. Quatela, MD, Stephen W. Perkins, MD, Peter A. Adamson, MD, Jonathan Sykes, MD, Minas Constantinides, MD, Norman J. Pastorek, MD, Gilbert Nolst-Trénite, MD, PhD, Pietro Palma, MD, and Abel-Jan Tasman, MD, who put a lot of effort into teaching rhinoplasty to us. I would like to express my special thanks to the Chicago group (Eugene M. Tardy, MD, Regan J. Thomas, MD, and Dean M. Toriumi, MD, from the University of Illinois at Chicago) and Tony Bull, MD, FRCS, from London, England, because they support our efforts to organize joint meetings on rhinoplasty and facial plastic surgery in Izmir (since 2000, there have been 4 meetings, and the number of participants has increased from 350 to 550). These highly informative meetings have inspired many young Turkish surgeons to concentrate more on rhinoplasty. In 2001, the Facial Plastic Surgery Workgroup, under the auspices of the Turkish Society of Otorhinolaryngology and Head and Neck Surgery, was established. In 2005, this work group became a society of its own and has acted under the umbrella organization of the European Academy of Facial Plastic Surgery. Each year, the university clinics have organized 4 to 5 courses solely on rhinoplasty in various parts of Turkey. The Facial Plastic Surgery Society in Turkey convenes an annual meeting in different cities. The rhinologic society has put a lot of effort into teaching rhinoplasty in Turkey as well. This enormous effort of education has increased the interest in rhinoplasty on both the surgeons' side and on the patients' side. Articles on computerized medical record keeping and facial analysis, camouflage with bruised and diced cartilage, nasal valve surgery, and crooked noses have been published by our colleagues.^{1 - 13} Within the past decade, many books on rhinoplasty have been published in Turkish.

In 1960s and 1970s, one could find only a handful of surgeons who performed rhinoplasty in Turkey, whereas within the past decade the number of surgeons has increased considerably because of the educational efforts mentioned herein. In fact, this increase was also the result of supply and demand, that is, the increasing number of patients seeking rhinoplasty. Without exception, within the last 30 years the government in Turkey has tried to lower the costs of medical services and procedures. The current government has gone 1 step further and tried to encourage surgeons to work full time in hospitals. In the meantime, the costs for medical services decreased even more. The government passed a new regulation for physicians that says, in effect, “the more you examine and operate, the more you earn.” This regulation caused a migration toward hospital-based practices, and the number of physicians having private offices dropped tremendously. The net effect of this regulation is that there are many rhinoplasty patients who want to undergo surgery while paying less money. Meanwhile, Turkey is becoming an important tourist destination for Europe and for the rest of the world as well, and in recent years health tourism has made Turkey a popular destination for ophthalmic surgery, dentistry, and aesthetic surgery owing to the low cost and qualified surgeons available.

In conclusion, rhinoplasty has become a very highly demanded operation in Turkey. Within the past decade, ENT colleagues have become very well educated in rhinoplasty procedures because of the well-structured courses given by the masters in the field. In coming years, our close relationship with colleagues in Europe, North America, and Asia will increase even more to keep up with education and training.

Correspondence: Dr Apaydin, Faculty of Medicine, Department of Otorhinolargyngoly, Ege University, Bornova-Izmir 35100, Turkey (fazil.apaydin@ege.edu.tr).

Financial Disclosure: None reported.