Objectives: To describe the main forces that shape the world of plastic surgery in Israel including the three most significant diseases that we treat: skin cancer, breast cancer and morbid obesity and the modulation of these forces by a national society - The Israeli Society of Plastic and Aesthetic Surgery - ISPAS.

Introduction: The world of Plastic and Aesthetic Surgery in Israel has changed significantly in the last twenty years from a public based practice to an equally important private practice profession; from a face to a breast and body contouring practice and also from a practice of tens to a practice of hundreds board certified and thousands non board certified caregivers.

Materials / method: An evaluation of the balance between private and public, face and body, board certified and non board certified caregivers was done and will be presented.

Results: The practice of plastic and aesthetic surgery is rapidly changing and not always in a favourable direction.

Conclusion: National societies of plastic and aesthetic surgery need to monitor the rapid changes in our profession and try to modulate those changes using medical, legislative, PR and political tactics.

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Objectives: The Author will present his own way to manage almost the totality of primary rhinoplasty deformities via endonasal approaches without use of structural grafts.

Introduction: Currently, the vast majority of surgeons use external structural approach for their primary cases.
The intentional destabilisation of major and minor support structures of the nose lead to an almost compulsory use of reconstructive techniques and obligatory grafting. This has led to many patients receiving too much surgery for small problems. On the contrary, patients are moving towards less invasive procedures that request shorter operating times and, hence

Materials / method: Patients are moving towards less invasive procedures that request shorter operating times and, hence, reduced costs for patients.
Faced with such a rapidly changing trend in cosmetic surgery patients’ behaviours and considering the many potential problems with the external structural approach, it seems clear that rhinoplasty surgeons need to rethink this approach and include the endonasal techniques in their armamentarium of skills.

Results: A wide variety of approaches and techniques can be selected on the individual goals to be achieved: transcartilaginous, transcartilaginous extended, delivery, infracartilaginous, partial (“slot” incision) or complete; and mixed.
Regarding tip surgery, the endonasal rhinoplasty surgeon may select within a vast choice of non-structural techniques, including precise sculpturing of the nasal tip cartilages, tip cartilages suture, micrografting (autologous cartilage flakes or paste of septal cartilage) and gentle zonal defatting.

Conclusion: A vast array of endonasal approaches and techniques does provide the astute rhinoplasty surgeon with excellent technical tools to improve surfaces and contours of the nose. Deconstruction of the nose is not necessary in most primary cases. This obviates the need for structural reconstruction and shortens the operative time.

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Objectives: The middle third of the nose is an area less explored. The use of spreader grafts, spreader flaps and onlay grafts has been suggested in this area.

Introduction: The aim of this study was to retrospectively look at my rhinoplasties since I have started working as an independent surgeon in 2001 and to describe the lessons I have learned about care of the middle third in primary and secondary rhinoplasty.

Materials / method: Retrospective analysis of the records, including photographs of my work as independent surgeon in Israel since 2001 in a pediatric hospital (Schneider Children’s Medical Center in Petach Tikva) and in a private adult aesthetic clinic (City Gate Medical Center in Ramat Gan).

Results: Six hundred and eighty four (684) patients had rhinoplasty. The typical local anatomy included thick skin, elongated caudal septum, dorsal hump and boxy tip. 504 were primary rhinoplasties and 180 were secondary rhinoplasties. 202 were children or teenagers. 482 were adults. 645 surgeries were done using open rhinoplasty and 39 using closed rhinoplasty. Of the primary rhinoplasties, only 5% had focused middle third treatment in addition to routine hump reduction. Of the secondary rhinoplasties, 82% had middle third treatment with onlay or spreader grafts.

Conclusion: When looking at the rate of request for refund (2/684) and lawsuits (1/684), which is lower than other surgeries I have done, it seems that overall the lessons I have learned about the nose have some value and are worth sharing. I do not focus on the middle third during my primary rhinoplasties but it is a routine part of many of my secondary surgeries. The indications for middle third surgery and my technique will be presented. I believe that middle third nasal care is not required in my primary surgeries, due to the typical local "thick skin" nose.

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