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Can Computer imaging predict rhinoplasty results?

The usefulness of computer imaging to predict rhinoplasty is a frequent topic of conversation amongst plastic surgeons. There are essentially two camps of thought, the first being that it is generally a good thing and the second is that using this technology unrealistically raises expectations of patients and leads to disappointment.

California plastic surgeon Umang Mehta tested the accuracy of computer prediction in 38 patients who underwent rhinoplasty. The predictive images and actual photos taken six months after surgery were sent to two panels of judges, surgeons and non-surgeons, to assess how similar they were. On a scale of one to five, one being not accurate and five being very accurate, the surgeons gave the computer images an average score of three—moderately accurate. The non-surgeons were a little more impressed, giving an average score of 3.55.

These findings match my own experience. I have been using computer aided prediction for rhinoplasty for the last 7 years and my impression is that people’s noses end up looking quite like the computer prediction (i.e. it is moderately accurate).

“So why use computer prediction if it isn’t that accurate?” the sceptics would say. I think this misses the point. Many people who come for a rhinoplasty consultation are fairly sure they want to change the shape of their nose and have a rough idea about the change they want. Their wishes are often difficult to describe in words and so many people bring pictures of noses they like or refer to pictures of relatives with noses they consider better than theirs.  These aids to discussion in the consultation are helpful, but don’t get around the fact that a nose that looks good on someone else’s face may look good on yours.

In my practice, the great value of computer prediction is that it allows the surgeon to establish the shape of a nose that fits harmoniously with the general shape of the face. There are often many possibilities and which to choose is a matter of personal choice. I think the real value of computer prediction is that it gives the surgeon and patient the chance to discuss visual representations of the possibilities and decide together on the desired outcome. Ultimately, computer prediction results in an outcome that is much closer to the patient’s wishes.

For more information visit http://www.daviddunaway.co.uk/rhinoplasty/

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RSM Medical Innovations Programme

Last week, I spoke at the Royal Society of Medicine Medical Innovations meeting about the separation of the Sudanese conjoined twins Rital and Ritag. It was an opportunity to share the thinking and organisation behind the separation.

Preparing for the lecture gave me some time to reflect and organise my thoughts about the whole process. Although the surgery was quite complex, I think main reason for such a successful separation lay in the meticulous pre operative planning and the wide range of expertise that the team at Great Ormond Street Hospital was able to offer.

You can read about the separation at http://www.independent.co.uk/life-style/health-and-families/features/separate-lives-conjoined-twins-2357401.html

The Medical Innovations Programme was a very informative and enjoyable day. Subjects ranged from latest updates in biotechnology to innovations in deep brain stimulation to treat movement disorders to the architecture of Maggie’s cancer centres.

It was a thoroughly inspiring day and a great venue to exchange ideas with medical innovators from a wide range of disciplines.

I am looking forward to next year’s event.

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Facing Africa Mission to Addis Ababa

I have just returned from a surgical mission to Ethiopia with Facing Africa a British charity set up to treat children with noma.  Every year, I travel with a team of surgeons, anaesthetists and nurses from Great Ormond Street Hospital and other leading British hospitals to treat children and young adults with this condition.

Noma is a condition that results in severe facial disfigurement.  It is caused by a gum infection that rapidly spreads into the cheeks and lips. It only occurs in malnourished people that have no access to medical care. Today it is only commonly seen in sub Saharan Africa.

Facing Africa organises two missions a year to Ethiopia and undertakes about 100 complex reconstructions a year.

You can find out more about the work of Facing Africa at www.facingafrica.org

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Facelift update at the Royal Society of Medicine

I recently spoke at the Royal Society of Medicine on a day devoted to a comprehensive overview of surgical techniques for rejuvenation in the face and neck. The day was organised by Barbara Jemec, president of the plastic surgery section of the Royal Society of Medicine. Speakers included Patrick Tonnard who developed the MACS lift, Roberto Pizzamigli, known for the Silhouette lift, Alain Fogl, Lucian Ion and myself. The day was extremely informative and especially valuable because each of the speakers has carefully documented their work and audited their results.

As one would expect from such leaders in the field, the results shown were quite spectacular and I really don’t think that in terms of final outcome, that there was much difference between the techniques and treatment philosophies described. One thing did strike me though, and that was that more extensive and complicated the surgical techniques resulted in longer the recovery times and higher adverse event rates. Part of my remit for the day was to review pitfalls and complications in the literature and after a comprehensive review the same message evolved. – Minimally invasive facelifts produce results that are just as good as more complicated techniques and the recovery time for these more modern minimal procedures is much less.

These thoughts have very much reflected my own practice in recent years. It is now very uncommon for me to undertake an extended SMAS lift and my most commonly performed lift is the Lateral SMASectomy with quite minimal undermining of the skin. The procedure can often be performed as a day case procedure and in situations where a dramatic lift isn’t needed, sedation rather than general anaesthetic can be used.

The Royal Society of Medicine day on facial rejuvenation was a great success and it was a real pleasure to be involved in an event dedicated to cosmetic surgery that was truly based on surgical science and audit.

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152 Harley Street welcome Professor John Harper, Consultant Paediatric Dermatologist

152 Harley Street is about to enter its second year of being fully open. During the year, the community of clinicians practicing there has grown into an effective group providing complimentary skills. There are dermatologists, maxillofacial surgeons, plastic surgeons and ENT surgeons. In the New Year specialists in aesthetic medicine will join us.

My own private practice has benefitted enormously from having ready access to respected clinicians who have skills that compliment my own plastic surgical experience.

I am very pleased that Professor John Harper, consultant paediatric dermatologist has joined us. I have a close working relationship with him in our NHS practices at Great Ormond Street where we treat children with pigmented skin lesions, vascular anomalies and unusual skin conditions that require a joint dermatological and plastic surgery approach.

We are establishing a joint private paediatric dermatology and plastic surgery clinic at 152 Harley Street to treat difficult conditions or where decision making requires a multidisciplinary approach.

152 Harley Street is one of the very few independent private facilities licensed to treat children. The facilities include a child friendly local anaesthetic theatre. This means that older children willing to undergo minor procedures such as removal of moles under local anaesthesia with the support of their parents and our staff can have treatment without the need for an admission to hospital or general anaesthesia. This form of treatment isn’t suitable for all children, but can be a great benefit in selected cases.

Professor Harper can be contacted on 020 7390 8308  or portjh@tiscali.co.uk

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Listed in the Times as one of the top British Surgeons

The Times on Saturday 10/12/11 published its top British Surgeons list and I was thrilled and honoured to be included in the list alongside my friend and colleague Owase Jeelani, consultant neurosurgeon. The article about us was centred on our recent successful separation of the Sudanese conjoined twins Rital and Ritag. The separation of the twins, was a tremendous success and represents one of the very few successful separations of craniopagus (joined at the head) twins in the world.

In reality, extraordinary events like this are built on the experience of others and the existence of dedicated teams of clinicians and professionals in the healthcare sector.

Our craniofacial team is situated at Great Ormond Street Hospital for Children, which I think is probably one of the few institutions in the world that is able to support a team able to plan and carry out complex procedures such as these.

The road to separation was long and involved. The first task involved working out how they were joined together which involved some quite complex radiology. By the time the twins had had MRI’s,  CT scans and angiograms the team was able to establish that Rital and Ritag’s brains were separate but that they shared some important veins. The information provided, allowed us to make a detailed plan for a staged separation, which in the end turned out to be based on very accurate information.

Sharing major blood vessels in the head led to many other unexpected consequences. The circulating blood was flowing predominantly through Ritag which meant that her heart and kidneys were overloaded. In effect, she was doing the work needed to survive for both twins. This caused heart failure and renal problems needing expert cardiological and renal intervention. The fact that both twins shared a blood supply caused problems for anaesthesia, because anaesthetic drugs given to one twin would affect the other in unpredictable ways.

Without experts in all of these fields who were used to dealing with unusual situations, it would not have been possible to safely separate the twins.

Another great advantage we had as a team was that a number of us had been involved in a similar separation a few years before. At the time, we had been advised and guided by two New York Surgeons, Jim Goodrich and David Staffenberg who had really established the principle of staged separation.

The separation would not have been possible without charitable funding. Facing the World, a London based charity raised the funds and organised the transfer of the twins to the UK. You can read more about the separation and other cases on their website www.facingtheworld.net

It has been an extraordinary experience leading the team that separated the twins which leaves me very proud to be part of Great Ormond Street Hospital and Facing the World.

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New website goes live

My new website went live today 16th December 2011

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