Introduction
The American and European Academies of Facial Plastic and Reconstructive Surgery have both had a significant role to play in the growth of facial plastic surgery in recent times.Reference Thomas and Graboyes1 Besides offering a certification of quality, both bodies were founded to provide support and training to all individuals interested in the area. In the United States, this interest has resulted in more attention to training during residency programmes, a certified fellowship in facial plastic surgery and a new subspecialty within the field of otorhinolaryngology.Reference Thomas and Graboyes2
Within the field of otorhinolaryngology (ORL), interest in facial plastic surgery has grown rapidly. Van Pinxteren et al. assessed Dutch otorhinolaryngologists' interest in facial plastic surgery.Reference Van Pinxteren, Lohuis, Ingels and Trenite3 They found that facial plastic surgery accounted for one-third of the daily practice of otorhinolaryngologists in Holland. They also found that 70 per cent of respondents regarded their training in the area as insufficient. The most common cosmetic operations performed by their cohort of otorhinolaryngologists were rhinoplasty (63 per cent) and otoplasty (51 per cent).
There is a lack of evidence in the literature documenting otorhinolaryngologists' interest in facial plastic surgery within the British Isles. Therefore the aims of the present study were to assess, within the British Isles, the work practices of otorhinolaryngologists in facial plastic surgery, and to compare these findings to those in mainland Europe.
Materials and methods
In January 2006, we mailed questionnaires to members of the Irish Otolaryngological Society and to all members of the British Association of Otolaryngologists, Head and Neck Surgeons (Appendix I). All replies received by 1 May 2006 were included in the survey.
The 14-question survey concerned experience with, and interest in, facial plastic surgery. The questionnaire was subdivided into four areas. The first part dealt with the respondent's work history i.e. number of years experience as a consultant in otorhinolaryngology, appointment type and focal area of practice. Secondly, a series of questions were asked on current facial plastic surgery practice, asking, among other things, about the share of facial plastic surgery in current practice and the number and kind of facial plastic procedures being performed. Thirdly, education and training in facial plastic surgery was assessed. This covered areas such as training during residency and supplementary courses. The final part of the survey dealt with the respondent's attitude towards facial plastic surgery and whether or not they were satisfied with their share of facial plastic surgery in daily practice.
Results
Of the 572 questionnaires mailed, 389 completed questionnaires were returned, a response rate of 68 per cent. We analysed the answers to all replies and described the results under four headings: (Reference Thomas and Graboyes1) experience and work setting in otorhinolaryngology; (Reference Thomas and Graboyes2) share of facial plastic surgery in current practice; (Reference Van Pinxteren, Lohuis, Ingels and Trenite3) education and training in facial plastic surgery; and (4) attitude towards facial plastic surgery within otorhinolaryngology.
(1) Experience and work setting of respondents
In terms of experience as a consultant in otorhinolaryngology, 202 (51 per cent) had more than 15 years experience, 141 (36 per cent) had between five and 15 years, while 49 (13 per cent) had only taken up their post within the last five years (Figure 1).
Number of years working as an ORL consultant.
When asked about the type of appointment, 218 (55 per cent) were working in the public and the private sector, 132 (34 per cent) were in full-time public posts, while the remainder, 23 (6 per cent) were in private practice only and 19 (5 per cent) were in academic posts (Figure 2).
Respondents' appointment type as an ORL consultant.
When asked about their main focal area of practice, 46 per cent said they were in general otorhinolaryngology, 32 per cent mentioned otology, 26 per cent rhinology, 22 per cent head and neck surgery, 14 per cent paediatrics, 14 per cent facial plastic surgery, while a small percentage mentioned cochlear implantation, phoniatrics and laryngology (6 per cent). Table I shows the types of cosmetic operations performed by each group.
Types of cosmetic operations performed by main focal area of practice groups
(2) Share of facial plastic surgery in current practice
The most common facial plastic surgery procedures performed included otoplasty (80 per cent; n = 311), rhinoplasty (74 per cent; n = 288), and facial flaps (28 per cent; n = 117). The remaining procedures described are shown in Table II. These results would correlate with figures published by the British Association of Aesthetic Plastic Surgeons for 2005 showing rhinoplasty (n = 2268), otoplasty (n = 1176) and blepharoplasty (n = 3415) as the most common procedures carried out by their members.Reference Asch and Jedrziewski5 The number of facial plastic surgery procedures performed annually was then assessed. Sixty-six per cent were doing less than 50 procedures a year, 20 per cent were performing between 50 and 100 procedures a year, while 14 per cent were performing more than 100 procedures on an annual basis.
Types of facial plastic surgery procedures being carried out by ORL consultants and the number of consultants performing each operation
The final part of this section dealt with the source of facial plastic surgery referrals, and asked if respondents were not going to operate on these patients, to whom would they refer them. Ninety per cent of respondents were receiving referrals from general practitioners (GP), 36 per cent from other otorhinolaryngologists, while 20 per cent and 18 per cent were receiving referrals from plastic surgeons and dermatologists, respectively. Seventy-eight per cent of respondents referred patients on to plastic surgeons, 48 per cent to other otorhinolaryngologists, 26 per cent to maxillofacial surgeons and 22 per cent to dermatologists, if they chose not to operate on them.
(3) Education and training in facial plastic surgery
Seventy-nine per cent of respondents were formally trained in facial plastic surgery during their residency, while 21 per cent felt they were not. We then asked whether they felt sufficiently trained to be performing facial plastic surgery procedures. Eighty per cent felt they were, while 20 per cent did not. Lastly, we asked whether respondents had attended supplementary courses to further their training in the area. A high number (72 per cent) had sought further training at supplementary courses and the most frequently cited of these are shown in Table III.
Courses in facial plastic surgery attended by respondents
EAFPS = European Academy of Facial Plastic Surgery; FPS = Facial Plastic Surgery; BAPS = British Academy Plastic Surgery
(4) Attitude towards facial plastic surgery within otorhinolaryngology
Regarding the perception of their share of facial plastic surgery in daily practice, 61 per cent considered this as sufficient, while 39 per cent did not (Table IV). The percentage of facial plastic surgery that daily practice would ideally comprise was zero for 15 per cent of respondents, whereas 65 per cent believed that facial plastic surgery should comprise up to one-third of their daily practice and 20 per cent put the ideal level at more than one third.
Perceived share of facial plastic surgery in daily practice by focal area of practice groups
Of all respondents, 97 per cent (n = 376) believed that facial plastic surgery should remain part of otorhinolaryngologists' practice.
Discussion
We believe ours is the first survey, within the British Isles, to document otorhinolaryngologists' interest in facial plastic surgery. We had a significant reply rate of 68 per cent, well above the expected reply rate of 50 per cent to postal surveys.Reference Asch and Jedrziewski5 This may reflect the keen interest in the subspecialty among those surveyed.
Although facial plastic and reconstructive surgery has traditionally been seen as the realm of general plastic surgeons this is no longer the case.Reference Rosenthal, Clark, Wax and Cook6 Van Pinxteren et al., documented Dutch otorhinolaryngologists' interest in facial plastic surgery.Reference Van Pinxteren, Lohuis, Ingels and Trenite3 They showed a significant number of respondents (24 per cent, n = 84) were performing facial plastic procedures regularly, and that the variety of procedures offered by otorhinolaryngologists was vast. Our results would mirror these findings and suggest that throughout Europe, facial plastic surgery is no longer the ‘realm’ of general plastic surgeons, but shared with other specialties, including otorhinolaryngology. This would seem a natural extension to the intensive training an otorhinolaryngologist receives, specifically dedicated to the anatomy, pathophysiology, diagnosis and treatment of diseases involving the head and neck.
• Within the field of otorhinolaryngology, interest in facial plastic surgery has grown significantly in recent years
• There is a lack of evidence in the literature documenting this interest in the British Isles. This paper aims to address this by means of a survey of United Kingdom and Irish otorhinolaryngologists
• One-third of respondents were performing facial plastic procedures regularly, most commonly otoplasty (80 per cent), rhinoplasty (74 per cent) and facial flaps (28 per cent)
• Facial plastic surgery has become a significant part of the otorhinolaryngologist's practice in the United Kingdom and Ireland
Van PinxterenReference Van Pinxteren, Lohuis, Ingels and Trenite3 also showed that only 13 per cent (n = 42) of respondents felt they were sufficiently trained in facial plastic surgery after their residency. Our results did not agree with these findings. Seventy-nine per cent (n = 312) of those surveyed in our cohort felt that they had been sufficiently trained in the subspecialty during their residency. However, similar numbers in both studies had attended supplementary courses in the area. These findings may suggest an increased desire for further training in the area of facial plastic surgery, possibly reflected by today's increasingly litiginous environment.
A similar survey to ours was carried out in the United States in 1985.Reference Adamson and Rubin7 It showed similar advances by otorhinolaryngologists within the field of facial plastic surgery at that time. Within North America and Canada, facial plastic surgery has grown into one of the more important areas within otorhinolaryngology.Reference Miller8 At present, the most popular area for postgraduate training in the United States is the programme in facial plastic surgery.Reference Van Pinxteren, Lohuis, Ingels and Trenite3 As a result of this, most academic centres have appointed one or more consultants who work full time in facial plastic surgery, which means that residents are increasingly exposed to the specialty. ThomasReference Thomas and Graboyes2 noted that such an appointment resulted in a sharp increase in the number of resident procedures in facial plastic surgery and a greater exposure to the specialty as a whole. In the United Kingdom and Ireland, such appointments should be considered. Trainees here require more exposure to facial plastic surgery as an increased emphasis in the intercollegiate examination becomes more apparent. As it stands, this increased exposure must be sought through supplementary courses and fellowship programmes.
APPENDIX I. THE QUESTIONNAIRE
1. (a) How many years experience as a consultant in ORL have you had?
<5,5–15,>15.
(b) How would you best describe your appointment?
Public, Private, Public/Private, Academic.
(c) What is your focal area of practice within ORL.
2. (a) What facial plastic procedures do you perform?
Otoplasty, Rhinoplasty, Blepharoplasty, Face Lifts, Facial Flaps, Chin augmentation, Trauma, Cleft surgery, Facial Reanimation, Laser resurfacing, Others – please specify:
(b) How many facial plastic procedures would you perform annually?
<50,50–100,>100.
(c) Which of the following would refer facial plastic patients to you?
GP,Other ORL,Plastic Surgeon, Dermatologist.
(d) Which of the following would you refer facial plastic patients to?
Other ORL, Plastic surgeon, Dermatologist, Maxillofacial surgeon.
3. (a) Were you formally trained in facial plastic surgery during your residency?
Yes,No.
(b) Do you feel you were sufficiently trained in this area during residency?
Yes,No.
(c) Have you attended supplementary courses in facial plastic surgery?
Yes,No.
(d) Which courses did you attend?
4. (a) Is your share of facial plastic surgery perceived as sufficient?
Yes,No.
(b) What proportion of your daily practice would facial plastic surgery ideally compose?
Zero,33%,>33%.
(c) Do you feel that facial plastic surgery should continue to be recognised as part of ORL?
Yes,No.
