The Expert Always Nose: Discovering The Right Options for Your Rhinoplasty w/ Dr. Jason Bloom

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Welcome to another episode of
Park Avenue Plastic Surgery Class,

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the podcast where we explore controversies
and breaking issues in plastic

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surgery. I'm your cohost Doreen Wu.

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I'm excited to be here with Dr. Lawrence
Bass Park Avenue plastic surgeon,

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educator, and technology innovator,
as well as our guest, Dr. Jason Bloom,

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a facial plastic surgeon
from Bryn Mawr, Pennsylvania.

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The title of today's episode
is "The Expert Always Knows:

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Discovering the Right Option
For Your Rhinoplasty."

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Today's episode is all about the
rhinoplasty. Also known as a nose job.

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Why is the surgery so popular?
What are the main techniques?

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What should I expect as
a patient experience?

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Is this something that
is only for teenagers,

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I'm going to find out about these issues
and more from our two experts. First,

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Dr. Bass, where does the procedure
come from? Tell us the history.

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Modern rhinoplasty really began
with a surgeon named Jacques Joseph,

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who was training in Berlin
in orthopedic surgery.

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Uh, but his training was abruptly
stopped when without authorization,

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he did a prominent ear
surgery on a young boy

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and his orthopedic professor,
uh, discharged him from training,

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but he pursued his interest
in beauty surgery and

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developed the modern techniques
that we use in rhinoplasty

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with endonasal incisions,
incisions inside the nose,

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and many of the instruments he
developed to enable surgeons to do

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rhinoplasty surgery are still
used when we operate today.

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Dr. Bloom,

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why is the rhinoplasty such a popular
procedure and what is it designed to do?

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So there are many different things
that we can do with rhinoplasty.

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I think it's popularized
really because, um,

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it's sitting right in the
middle of your face. And,

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certainly from an aesthetic standpoint,

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there are a few things that
patients come. At least to me,

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into me to see in my office,

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probably the most common is like
a bump, a dorsal or a bridge bump,

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or a, a hook on the side in the profile.
They want to change that profile,

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droopiness in the tip. They
want to lift that up with.

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So whether it's the tip being too
wide or the nostrils being too wide,

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we can do things with the bone,

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the cartilages and the soft
tissues in order to narrow

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the nose in order to improve
the profile in order to

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support the the

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tip in order to give it a more aesthetic.

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Look now the secondary thing
too. And in some cases,

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this would be the primary reason
why people come in is for breathing.

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Certainly the nasal airway
is really important.

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I trained before I did my
facial plastic fellowship.

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I did my ENT ear nose and throat
surgery at University of Pennsylvania.

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And I tell patients, I want to, I'm not
going to just make your nose look good,

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but I'm going to make your nose breathe
as good as it does now or better.

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And so it's important to understand the
function of the nose and how it works.

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And the nasal airway to make patients
either breathe better or the same that

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they came in.

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Let's move on to the
techniques that are involved.

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How is a rhinoplasty performed?

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There's this big split between an
open rhinoplasty versus a closed one?

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What is the difference?

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So the rhinoplasty is designed to adjust

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the cartilage and bone framework
over which the skin is draped to

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alter the appearance and position of
different parts of the nose. Classically,

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as I mentioned

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with Dr. Joseph in Berlin,

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this was done endonasal or
through incisions that were

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solely inside the nostrils.

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So there were no incisions
on the outside where

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anyone could see them techniques
were developed in the 1980s and

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beyond. And prior to that used
in cleft rhinoplasty surgery,

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rhinoplasty in children who had cleft

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lip and palate,

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but these were generalized to
open rhinoplasty techniques

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were cosmetic uses where
a small incision is made

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in the columella,

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the piece of skin in between
the two nostrils in the center.

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And that incision extends
up to the inside of the

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nostrils or rim incision inside the
nostrils to allow access to the nose.

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And that allows the surgeon
to visualize the anatomy

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inside the nose in ways that they can't in

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a closed or I rhinoplasty.

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So these are the two primary main
approaches that are used, uh,

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for rhinoplasty surgery today.

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In general, my practice,

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I do close to around 200
rhinoplasties a year.

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It is by far my most common surgery.

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And I would say my,

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for my primary first time,

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rhinoplasties I do about 95% of them

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through an endonasal or a closed
approach, as you were saying. 25%

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of all the rhinoplasties
I do are revisions.

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And I tend to do 95% of my

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revision rhinoplasty
through an open approach.

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And so that's the hard thing.

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And I'll explain the reasons
why I like the endonasals,

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and we can go into that
for a primary case with

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a few exceptions.

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And we can talk about what are some of
the things that I would open a primary

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nose in my hands,

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but there's not necessarily a
better or a worse, you know,

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a worse approach.

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It's what works well in the hands
of the surgeon and what they've been

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trained to do, and what throughout
the years, like my, uh, you know,

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I've been in practice now for 12 years,

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what I I've seen my results
and things that I used to do

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through an endonasal
approach are now I, you know,

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in looking back at my results,

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there are some things that I now do open
because I've seen this over the years.

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But the, the hardest thing we do,

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I think as you know,

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plastic surgeons and facial plastic
surgeons is revision rhinoplasty or

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secondary rhinoplasty. And I was
talking to my friend the other day,

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who happens to be, you were mentioning
orthopedics, he's an orthopedic surgeon.

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And he said to me, you know, what is
the most difficult surgery you do?

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And I said far and away, it's a
revision rhinoplasty, mainly because,

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so for example,

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if he's had a guy who comes
to him with has had an

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ACL repair, and now he needs a second one,

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and he really doesn't even need to
necessarily see that patient, you know,

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he comes with an MRI and the CT scan,
and he can see below the tissues.

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Now we're trained as plastic surgeons
to do a physical examination and get

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a good idea of what is going on
underneath the skin and soft tissue

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and kind of translate it in our
heads as to what's going on.

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But honestly,

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we really don't truly know what's
going on until we get in there.

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And that's one of the hardest
things about secondary

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rhinoplasty is, you know, we can have a,

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an idea of what's going on in our head,

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and then we open things up and
it's not till then that we really

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visualize the whole nose.

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And sometimes plans change
right in the middle of surgery.

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and that's,

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that's just the tip of the iceberg of why

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rhinoplasty is challenging,

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because there's so much
variation in what you can do

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to work on different portions of the nose.

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And what you might choose to
do is going to be modulated by

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what the rest of the
patient's face looks like,

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which is different in every individual.

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You want a nose that fits their
face and by what their aesthetic

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preferences are as an individual,
your orthopedic friend,

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if someone comes in with a bad hip,
we know what that patient wants.

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They want a pain free hip
that's strong and stable,

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and lets them go skiing or
whatever their favorite sport is.

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But everyone wants something, a
little different in a rhinoplasty.

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And so the number of
per mutations of options

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is so great that this is part of
the challenge in the procedure.

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So I have to agree with you
when I do a primary rhinoplasty,

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almost all of those are going
to be done endonasal or closed

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because I can usually perform
whatever maneuvers are

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planned,

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unless there's a particular
unusual kind of cartilage grafting.

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There are a few circumstances where
I'll open, but most of the time,

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those are going to be closed
in the secondary rhinoplasty.

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I still do a significant portion closed,

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but a high percentage of
those are going to be open.

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And often the original rhinoplasty
was done by somebody else,

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not me. And so, I don't know,

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even if I've read their operative note
exactly what I'm going to find in there,

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and that ability to look at the anatomy
with the open approach is a benefit,

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but Dr. Bloom,

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maybe you can outline what
some of the advantages are

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for a closed approach in
terms of recovery and,

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and otherwise.

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Yeah. So when I, when I do an endonasal,
or a closed approach rhinoplasty,

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I think there are some
definite benefits. Number one,

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it's obviously scarless, right?
There's no open incisions.

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And even when we do an open incision
and make an incision or a cut

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along that part called the
columella between the nostrils,

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I say only dogs and lovers can see it.

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It heals very well and it's kind
of on the underside of the nose,

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but not having that and
truly doing a scarless

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rhinoplasty is a benefit for patients
because you do have to heal that

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incision. I think
additionally, the benefits are,

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we're not totally devolving
all of the tissues of the nose

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and that leads to swelling.

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You can get scar tissue formation a little
bit more in these kind of cases when

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you open the nose. and

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just suturing the skin
soft tissue envelope back,

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you can get asymmetries and
things in the nostrils, um,

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which aren't there when you
do an endonasal approach.

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I do in every one of my
cases still deliver the

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tip.

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So I bring the tip cartilages
out through the nostrils,

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work on them and then place
them back in the nose.

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Some people make incisions inside the
nostrils and don't deliver the tip

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if there's no tip work needed. Uh,
even if I'm not doing a true tip work,

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you know, a tip modification,

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I still will deliver the cartilages to
take a look at them and see if I can

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modify them in any way.

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So I take a very similar approach
and I think that that extra swelling

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and, you know,

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the tip will tend to be somewhat
firm at first after a rhinoplasty

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and the number of months it's
going to take for the tip to soften

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unquestionably is going to be considerably
longer with an open approach totally

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than it is with an endonasal
or closed approach. So if,

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if we need the open approach,

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because something has to
be looked at or done or

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positioned or sutured in place, very
precisely that can't be done endonasals,

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it's fair to open, but to add that
extra recovery, if you don't need it,

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doesn't make a lot of sense to me.

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Yeah. I mean, I mean,
that is totally true.

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You're not getting a rock hard tip
like we do sometimes when we're adding

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a lot of cartilage grafting in
a secondary rhinoplasty even,

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I will just say the two main reasons for

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me to open a primary nose are number one,

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a caudal septal deflection. That
means the bottom of the septum.

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When you look up the nose
is off into one of the

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nostrils and I have done these
through endonasal or closed

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approaches and swinging the
septum back to the midline. I,

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but when I look at it,

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I think I have seen a few of these
patients back where the septum will

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just slowly migrate back to one side.

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So if I want to move the bottom
part of the septum over to the

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midline and lock it into position,
I tend to open those noses now.

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And the second one is if
the nose is very highly

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rotated up and I need to
rotate the nose down and give

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it additional length,

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and I need to add some kind
of septal extension graft or

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something to push the tip of the
nose in a counter rotated position.

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I need to add that cartilage on.

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It's easier for me to do that
through an open approach.

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And I will say those are the main two
reasons why I tend to open a primary nose

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at this point in my career.

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Yeah.

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I think anytime you need to suture a
cartilage graft and very precisely,

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you know,

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some surgeons will say they make a very
form fitting pocket and they can slide

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the cartilage graft in just
so exactly where they want it.

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But I think cartilage
spends its entire life

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scheming ways to warp and distort whether
it's during the initial healing or

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in the decades that
follow the rhinoplasty.

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And so anything I can do to
stabilize that positioning I think

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is worthwhile and you brought up
actually another subject I wanted to

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wanted to discuss,

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which is when you choose
to use a septal extension

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00:16:04,370 --> 00:16:09,240
graft versus alternatives
like columellar strut

233
00:16:09,300 --> 00:16:12,520
and spreader grafts,
things like that. So how,

234
00:16:12,860 --> 00:16:16,400
how has your practice evolved
and where have you landed on,

235
00:16:16,820 --> 00:16:18,400
on those options?

236
00:16:19,600 --> 00:16:24,200
Um, I tend to not use a lot of,
uh, columellar strut grafts.

237
00:16:24,920 --> 00:16:27,240
However I do, as I was saying,

238
00:16:28,040 --> 00:16:31,720
if there's an over-rotated
nose, either in a primary,

239
00:16:33,160 --> 00:16:36,800
or a revision case,

240
00:16:37,520 --> 00:16:40,320
I will use a septal extension graft.

241
00:16:41,080 --> 00:16:44,280
And that is by extending this part,

242
00:16:44,560 --> 00:16:48,080
the bottom or caudal portion of
the septum and pushing it forward,

243
00:16:49,040 --> 00:16:54,040
you can take a nose that's over
rotated or pushed up and give it more

244
00:16:55,920 --> 00:16:58,640
appropriate rotation. Now,
there is a modification

245
00:17:00,200 --> 00:17:04,680
of a septal extension graft that
has been popularized in Turkey, um,

246
00:17:05,040 --> 00:17:09,200
that a lot of people are doing recently
and that's something called an ANSA

247
00:17:09,520 --> 00:17:13,960
banner. And what it is
it's basically like a,

248
00:17:14,320 --> 00:17:19,200
it looks like a unicorn horn that
will come off the anterior septal

249
00:17:19,520 --> 00:17:22,400
angle and it comes at 45 degrees.

250
00:17:23,080 --> 00:17:25,480
And then you can suture the tip to that.

251
00:17:26,560 --> 00:17:31,080
And basically what that's doing
is helping to kind of extend the

252
00:17:31,680 --> 00:17:32,800
septum without with,

253
00:17:33,560 --> 00:17:38,520
in those cases where you might
not have enough cartilage to do a

254
00:17:38,680 --> 00:17:39,920
true septal extension graft.

255
00:17:40,560 --> 00:17:45,200
It's allowing for counter rotation of
the nose with stabilization at the same

256
00:17:45,520 --> 00:17:46,190
time.

257
00:17:46,190 --> 00:17:50,320
Yeah. And I think in a lot of
rhinoplasty that are secondary,

258
00:17:50,410 --> 00:17:55,160
where a lot of tissue has
been resected or removed

259
00:17:55,260 --> 00:17:59,680
at the first procedure and there's
contraction of the tip elements,

260
00:17:59,681 --> 00:18:01,320
you're trying to get projection,

261
00:18:01,321 --> 00:18:05,160
or you're trying to derotate the tip to a,

262
00:18:05,161 --> 00:18:07,720
to a more natural looking angle.

263
00:18:07,721 --> 00:18:10,650
You know,

264
00:18:10,651 --> 00:18:13,130
having trained and been brought up at,

265
00:18:13,150 --> 00:18:18,090
in the heyday of open rhinoplasty
that was always columellar

266
00:18:18,091 --> 00:18:22,210
strut, columellar strut, columellar strut.

267
00:18:22,870 --> 00:18:27,610
But I think we've come to recognize
that there's a lot of limitation

268
00:18:28,110 --> 00:18:29,050
in reality,

269
00:18:29,270 --> 00:18:34,090
to the ability of the columellar strut
to project the tip or derotate the

270
00:18:34,110 --> 00:18:34,943
tip.

271
00:18:34,990 --> 00:18:39,610
And so I've increasingly gone over to

272
00:18:39,790 --> 00:18:44,650
septal extension graft as
a more stable and stronger

273
00:18:45,680 --> 00:18:47,050
support if you will.

274
00:18:47,051 --> 00:18:51,650
But there are some
downsides and, you know,

275
00:18:51,910 --> 00:18:56,650
the tip will never be as
flexible and soft. So it's,

276
00:18:56,651 --> 00:19:00,290
it's a virtue, but it's also a
flaw. You get the support you want,

277
00:19:01,070 --> 00:19:05,650
but it's not as naturally soft as
an unoperated tip that's for sure.

278
00:19:06,600 --> 00:19:10,530
Totally. Yeah. I, I tend
to see that a lot. I mean,

279
00:19:10,950 --> 00:19:15,930
the other thing that I like
instead of a columellar strut graft

280
00:19:15,990 --> 00:19:18,730
when I'm using a septal extension graft,

281
00:19:19,580 --> 00:19:21,530
which I think is one of the,

282
00:19:22,550 --> 00:19:27,530
the strongest techniques in all
rhinoplasty is something called a tongue

283
00:19:27,531 --> 00:19:32,450
and groove where we
actually like imbricate the

284
00:19:32,790 --> 00:19:37,530
caudal aspect of the
septum in between the,

285
00:19:37,670 --> 00:19:42,170
the medial crura of the lower
lateral cartilages and create

286
00:19:42,520 --> 00:19:44,050
that stable support.

287
00:19:44,590 --> 00:19:49,090
So you get the septum straight
and then you put the caudal,

288
00:19:49,670 --> 00:19:54,210
the caudal septum between the medial
crura of the lower lateral cartilage

289
00:19:54,510 --> 00:19:59,410
and lock that into position
that is a very stable setup.

290
00:19:59,750 --> 00:20:03,890
And doesn't allow for, you know, like
you said, it doesn't allow for movement.

291
00:20:03,891 --> 00:20:06,130
It makes it a little bit more firm,

292
00:20:06,710 --> 00:20:09,570
but when we're looking for support,

293
00:20:09,670 --> 00:20:12,690
that really is one of my go-tos.

294
00:20:13,550 --> 00:20:14,280
And you know,

295
00:20:14,280 --> 00:20:19,090
that that's the location where the
columellar strut would've been placed in

296
00:20:20,730 --> 00:20:25,510
for surgeons who were using
that technique. So it makes
sense to put it there,

297
00:20:25,930 --> 00:20:29,510
but to do you typically suture
it there to stabilize it,

298
00:20:29,511 --> 00:20:32,710
or you just tuck it in and, and it holds.

299
00:20:33,610 --> 00:20:36,430
If I'm doing an endonasal approach.

300
00:20:37,310 --> 00:20:40,390
I do what I call a
modified tongue and groove,

301
00:20:40,760 --> 00:20:45,190
where I will retro dissect
a pocket through my

302
00:20:45,191 --> 00:20:49,960
inter cartilaginous
Hemitransfixon incision in between

303
00:20:50,420 --> 00:20:55,280
the two medial crura. And
then I will, I, I mean,

304
00:20:55,470 --> 00:20:58,440
when we're doing endonasal,
I use a dissolvable suture,

305
00:20:58,441 --> 00:21:02,920
like a 4-0 chromic to
lock the septum in between

306
00:21:04,130 --> 00:21:08,800
those medial crura, when I'm doing it
open and like a reconstructive nose

307
00:21:10,580 --> 00:21:15,440
to like lock it in, I will use a 5-0
Prolene. I will use a permanent suture.

308
00:21:16,660 --> 00:21:20,720
And as we look at cartilage
grafts, of course,

309
00:21:21,690 --> 00:21:24,720
often we borrow some
cartilage from the septum,

310
00:21:25,300 --> 00:21:28,680
the cartilage plate that's
in between the two nostrils,

311
00:21:28,681 --> 00:21:32,840
because it's nice and straight
where ideally is straight, not,

312
00:21:32,940 --> 00:21:36,240
not in all cases. But again,

313
00:21:36,300 --> 00:21:40,120
in patients who have had
a few previous surgeries,

314
00:21:40,121 --> 00:21:44,640
they may not have adequate cartilage
there. So what's your strategy currently,

315
00:21:45,420 --> 00:21:47,600
if you need additional cartilage,

316
00:21:48,140 --> 00:21:51,800
are you using rib from the patient?

317
00:21:52,020 --> 00:21:56,320
Are you using cadaveric rib
grafts or, or some other option?

318
00:21:56,950 --> 00:22:01,560
What I always say is it's important
to replace, like for like,

319
00:22:02,260 --> 00:22:06,800
and what I mean by that is the nose
is actually made up of two different

320
00:22:06,930 --> 00:22:11,560
types of cartilage. So you have soft,

321
00:22:12,240 --> 00:22:17,120
flexible cartilages in the tip
that are fibroelastic cartilage

322
00:22:17,470 --> 00:22:21,960
that are found only really in the
tip of your nose and in your ear,

323
00:22:22,330 --> 00:22:26,920
right. If you feel your ear, the ear
cartilage is similar to the tip cartilage,

324
00:22:27,420 --> 00:22:32,360
and then there's the hard structural
supportive cartilage that's found

325
00:22:32,460 --> 00:22:37,120
in the septum of your nose and
in the rib that's limb cartilage.

326
00:22:37,121 --> 00:22:41,360
It's harder to, and some people do it,

327
00:22:41,640 --> 00:22:46,200
but I have found that it doesn't
work as well to try to create support

328
00:22:46,960 --> 00:22:50,120
with a flexible fibroelastic
part of the cartilage.

329
00:22:50,880 --> 00:22:53,000
So if I'm looking for support,

330
00:22:54,000 --> 00:22:58,720
I will typically use rib cartilage,
well, septum being, if I,

331
00:22:58,920 --> 00:23:02,760
if the septum is there, I will use that
as my primary cartilage source. Sure.

332
00:23:03,060 --> 00:23:05,800
If it's not there, then I will go to rib.

333
00:23:06,760 --> 00:23:09,800
I have harvested tons
of ribs in my career.

334
00:23:09,801 --> 00:23:14,240
But now in the last five to seven years,

335
00:23:14,950 --> 00:23:18,480
I've gone almost exclusively
to cadaveric rib.

336
00:23:19,760 --> 00:23:24,560
I have found, and now some of the places,
it, it's still difficult to get these,

337
00:23:25,000 --> 00:23:28,680
and it's become more scarce
and recent, in the recent year.

338
00:23:28,681 --> 00:23:33,320
But I have found cadaveric rib to carve

339
00:23:33,321 --> 00:23:38,240
exceptionally well. It is, I
mean, now they're, they're fresh.

340
00:23:38,241 --> 00:23:40,160
They're not even frozen anymore.

341
00:23:40,161 --> 00:23:44,920
It works extremely well
for what I need and,

342
00:23:44,980 --> 00:23:49,120
and it saves the patient, the
pain of having a chest incision.

343
00:23:49,590 --> 00:23:54,080
Like once you harvest a rib, they're not
even thinking about their nose anymore.

344
00:23:54,190 --> 00:23:57,200
It's like the pain that's
coming from their chest. Yeah.

345
00:23:58,320 --> 00:24:02,800
And so I typically, if I'm
looking for structural cartilage,

346
00:24:03,280 --> 00:24:06,960
I will use cadaveric rib.
And then if I need like a,

347
00:24:07,080 --> 00:24:11,480
a tip deficit or a tip defect,
and I need to reconstruct the tip,

348
00:24:12,040 --> 00:24:15,720
I will typically use ear cartilage
and I harvest that from a patient.

349
00:24:16,540 --> 00:24:20,280
And what do you, what do you think
the long term fate of the cadaveric

350
00:24:22,400 --> 00:24:25,040
rib graft is or their downsides?

351
00:24:26,000 --> 00:24:30,400
I mean, it, uh,
theoretically the, the, um,

352
00:24:31,920 --> 00:24:36,600
they, they talk of more risk
of resorption and warping.

353
00:24:37,280 --> 00:24:38,320
I will tell you, uh,

354
00:24:38,560 --> 00:24:42,400
Russ Kridel wrote a great article
using thousands of rib grafts,

355
00:24:42,600 --> 00:24:46,000
and he saw thought it was
in, in this study, um,

356
00:24:46,800 --> 00:24:50,560
showed that there was no
higher risk of absorption, uh,

357
00:24:51,520 --> 00:24:56,280
no higher significantly statistically
significant risk of absorption or,

358
00:24:56,800 --> 00:25:01,440
um, or warping in a cadaveric
rib versus a, autologous rib.

359
00:25:02,690 --> 00:25:06,570
Yeah, I, I think especially
for the non frozen ones, uh,

360
00:25:07,410 --> 00:25:10,270
that they're, if you can get 'em,

361
00:25:10,590 --> 00:25:15,470
they're advantageous and they're taking
much more steps nowadays to ensure

362
00:25:15,750 --> 00:25:18,750
the flexibility of the cartilage,

363
00:25:19,430 --> 00:25:23,510
because a graft that comes from someone
who's very elderly might be a little

364
00:25:23,750 --> 00:25:24,583
more brittle.

365
00:25:25,230 --> 00:25:30,030
So they're now explicitly
factoring that into this selection

366
00:25:30,310 --> 00:25:32,470
and processing, which has been a big plus.

367
00:25:33,630 --> 00:25:35,430
The only downside of that is that it,

368
00:25:35,670 --> 00:25:40,150
they are very difficult to get at this
point. And the they're all back ordered.

369
00:25:40,150 --> 00:25:42,390
I, I waited
three and a half months

370
00:25:44,990 --> 00:25:49,670
recently to get one for a
complex secondary reconstruction.

371
00:25:50,090 --> 00:25:53,470
So I I've had that experience as well. Uh,

372
00:25:53,610 --> 00:25:58,510
do you have a favorite
approach or technique for the
patient who needs a lot of

373
00:25:58,690 --> 00:26:00,110
dorsal augmentation?

374
00:26:00,770 --> 00:26:04,070
Yes. That has changed. I think for me,

375
00:26:09,030 --> 00:26:13,870
I used to take a rib and
carve it like a single piece

376
00:26:13,970 --> 00:26:18,390
and slide it onto the bridge,
what I have done well,

377
00:26:18,410 --> 00:26:20,310
and then in my fellowship,

378
00:26:20,311 --> 00:26:25,310
I was doing a lot of
using diced cartilage and

379
00:26:25,710 --> 00:26:30,070
wrapping it in, uh, temporals
fascia and sliding that in.

380
00:26:30,250 --> 00:26:31,710
And that being a

381
00:26:34,850 --> 00:26:38,470
softer approach to this dorsal graft,

382
00:26:39,170 --> 00:26:43,760
but what I've done in the last
two to three years is I'm not even

383
00:26:44,050 --> 00:26:46,600
using the temporals fascia anymore.

384
00:26:47,340 --> 00:26:52,040
And I finally dice either me or my fellow

385
00:26:52,630 --> 00:26:56,960
will finally dice some cartilage
down to almost like, I mean,

386
00:26:56,961 --> 00:27:01,720
it is almost like sand it's
really, really small, small dicing,

387
00:27:02,420 --> 00:27:05,080
and then drips some fibrin sealant,

388
00:27:05,590 --> 00:27:10,400
some tisseel or artiss
onto it, have it set.

389
00:27:10,900 --> 00:27:12,880
And what it does is, well,

390
00:27:12,881 --> 00:27:16,640
I'll take a three CC syringe
and I'll cut it in half.

391
00:27:17,140 --> 00:27:19,760
And what it does is it makes like a canoe.

392
00:27:20,580 --> 00:27:22,480
We call it the glue canoe,

393
00:27:23,140 --> 00:27:26,720
and then I drip the fibrin sealant,

394
00:27:26,820 --> 00:27:30,200
the fibrin glue onto this diced cartilage.

395
00:27:30,660 --> 00:27:35,000
And it makes a perfect
dorsal augmentation graft

396
00:27:35,390 --> 00:27:40,160
that I'm able to slide up there.
You can actually carve it.

397
00:27:40,220 --> 00:27:44,200
And it's so much more flexible and easy,

398
00:27:44,300 --> 00:27:46,800
and it lasts, it's been phenomenal.

399
00:27:47,220 --> 00:27:51,400
So that's been my primary technique
for the last probably five years.

400
00:27:52,390 --> 00:27:56,720
Yeah, that's interesting because that
was going to be my next question.

401
00:27:56,721 --> 00:27:59,400
What your thought was on diced cartilage,

402
00:27:59,401 --> 00:28:03,080
fascia grafting also known
as the Turkish delight.

403
00:28:03,081 --> 00:28:07,400
But I can see where you come with that.

404
00:28:07,950 --> 00:28:09,600
I've, I've had the experience of,

405
00:28:09,601 --> 00:28:14,400
of having to revise those where I
can go back and remove the entire

406
00:28:14,650 --> 00:28:19,080
graft that went in as little
particles of cartilage,

407
00:28:19,081 --> 00:28:22,360
all chopped up as a single piece and

408
00:28:22,361 --> 00:28:27,280
recarve it, remold it and replace it, uh,

409
00:28:27,340 --> 00:28:31,320
as long as it's had enough healing
time to properly consolidate.

410
00:28:31,321 --> 00:28:36,080
There is recovery time though,

411
00:28:36,081 --> 00:28:38,440
with that approach, when
you put that graft in,

412
00:28:38,441 --> 00:28:41,280
there's going to be swelling
for a while. It's not a,

413
00:28:41,670 --> 00:28:45,920
it's not a splint off at five
days and go to the prom at,

414
00:28:45,980 --> 00:28:48,480
at 10 to 14 days kind of procedure.

415
00:28:49,030 --> 00:28:49,863
Totally.

416
00:28:50,500 --> 00:28:53,040
So last, last question on technique,

417
00:28:54,660 --> 00:28:57,000
dorsal preservation, rhinoplasty.

418
00:28:57,140 --> 00:29:00,840
So this is a technique where the dorsum is

419
00:29:00,841 --> 00:29:04,920
preserved while underlying elements are

420
00:29:05,850 --> 00:29:10,280
pared down or reduced to create less

421
00:29:10,290 --> 00:29:13,920
projection. We just talked about
making more projection in the dorsum,

422
00:29:14,400 --> 00:29:16,240
a stronger bridge to the nose.

423
00:29:16,900 --> 00:29:20,600
And now we're talking about taking it
down when maybe there's a bump or it's too

424
00:29:20,660 --> 00:29:21,060
big.

425
00:29:21,060 --> 00:29:26,000
So this has been a trendy
technique in the last few years.

426
00:29:26,830 --> 00:29:28,560
What are your thoughts, Dr. Bloom?

427
00:29:29,880 --> 00:29:33,370
Well, this is a technique
that was coming out of Turkey,

428
00:29:34,440 --> 00:29:37,650
that they were doing it. And, you know,

429
00:29:37,850 --> 00:29:42,560
I have never been on the
bandwagon for this yet.

430
00:29:42,760 --> 00:29:45,680
I mean, mainly because I don't have
the training. It's not something that

431
00:29:47,960 --> 00:29:50,240
I haven't, I mean, I
looked into some of this,

432
00:29:50,241 --> 00:29:54,600
their specific instrumentation
that they're using for it. The,

433
00:29:55,480 --> 00:29:59,960
I mean, it's certainly been a
hot topic. And interestingly,

434
00:30:00,400 --> 00:30:04,880
I think some of the Turkish surgeons
who originally talked about this

435
00:30:05,260 --> 00:30:09,840
are no longer doing this technique,
but where I worry about it is,

436
00:30:10,880 --> 00:30:15,560
uh, is for the breathing result because
what you're doing is you're basically

437
00:30:16,430 --> 00:30:20,400
telescoping the nasal
bones and tissues like

438
00:30:21,260 --> 00:30:26,200
inside themselves and dropping
the whole nose back the bridge of

439
00:30:26,201 --> 00:30:30,080
the nose back. And I would
say that if you do that,

440
00:30:30,130 --> 00:30:34,840
there has to be some detriment
to breathing in those cases

441
00:30:34,990 --> 00:30:39,080
because you're taking like an
open nasal airway and now you're,

442
00:30:39,180 --> 00:30:43,960
you're dropping nasal bones
back inside of the previous

443
00:30:44,240 --> 00:30:47,400
structure. But again,

444
00:30:47,920 --> 00:30:50,160
I haven't been doing that in my practice.

445
00:30:51,800 --> 00:30:54,040
I know it's super hot right now.

446
00:30:54,760 --> 00:30:59,640
There are some interesting aspects
of this surgery that I've been

447
00:30:59,920 --> 00:31:03,120
looking into. One of them being piezo,

448
00:31:03,640 --> 00:31:05,160
which is like an ultrasound device

449
00:31:07,600 --> 00:31:11,080
to help with more precise
bony cuts. Certainly

450
00:31:12,720 --> 00:31:16,240
I'm more interested in
that to try that out,

451
00:31:16,840 --> 00:31:20,640
but I haven't incorporated either of
those techniques into my practice.

452
00:31:21,720 --> 00:31:23,960
Yeah. It's interesting
because we we've taken

453
00:31:25,880 --> 00:31:27,880
despite somewhat different
training backgrounds,

454
00:31:28,600 --> 00:31:32,040
almost identical approaches
in how we do these things. I,

455
00:31:32,120 --> 00:31:37,080
I think initially part of the idea of
dorsal preservation was that you're

456
00:31:37,200 --> 00:31:41,600
not disrupting that, that hinge area
between the upper lateral cartilage and,

457
00:31:42,240 --> 00:31:43,160
and the septum.

458
00:31:43,920 --> 00:31:48,920
But as you point out the collapse in
of some of the structures that you

459
00:31:49,120 --> 00:31:53,320
are creating may actually
have more impact on breathing

460
00:31:54,240 --> 00:31:57,040
than what you're protecting. Uh,

461
00:31:57,760 --> 00:32:01,040
my aesthetic thought on the
technique, which is really,

462
00:32:02,960 --> 00:32:03,793
uh,

463
00:32:04,000 --> 00:32:09,000
why I haven't adopted it is that
you have to really be in love

464
00:32:09,360 --> 00:32:11,640
with the appearance of
the dorsum as it is,

465
00:32:12,120 --> 00:32:14,640
and just feel it's
somewhat over projected.

466
00:32:15,520 --> 00:32:20,000
And if you really want to modify the
appearance of the dorsum aside from just

467
00:32:21,760 --> 00:32:23,920
flattening it down somewhat, uh,

468
00:32:24,360 --> 00:32:28,040
then you're going to an
awful lot of work, uh,

469
00:32:28,720 --> 00:32:32,360
to achieve that, or you're going
to be unable to achieve that. So

470
00:32:33,920 --> 00:32:36,840
I don't think that represents
a lot of the noses that I see.

471
00:32:37,160 --> 00:32:38,520
So I haven't jumped on board.

472
00:32:39,440 --> 00:32:40,273
I agree.

473
00:32:40,300 --> 00:32:44,160
So Dr. Bass, after our extensive
discussion of rhinoplasties today,

474
00:32:44,430 --> 00:32:47,200
what are some important takeaways
for our listeners to remember?

475
00:32:48,320 --> 00:32:52,480
There's a bunch, actually, each
nose is unique, as I mentioned,

476
00:32:53,080 --> 00:32:54,680
and each face is unique.

477
00:32:55,040 --> 00:32:59,960
So blending the patient's aesthetics
with the other facial features is a big

478
00:33:00,360 --> 00:33:02,160
part of the job, uh,

479
00:33:02,440 --> 00:33:07,000
that the surgeon and patient have to
accomplish in conjunction with each other

480
00:33:08,720 --> 00:33:12,240
often, small changes will make a big
difference in the appearance of the nose,

481
00:33:12,500 --> 00:33:16,760
but recognize there's
some unpredictability to
the result that you get.

482
00:33:17,670 --> 00:33:22,320
Part of the challenge for rhinoplasty
surgeons is that what you see at the end

483
00:33:22,321 --> 00:33:26,120
of the operation is not what
you get when the nose is healed.

484
00:33:26,980 --> 00:33:31,800
And you have to recognize that that
expected recovery is a long time to see

485
00:33:31,801 --> 00:33:32,680
the final shape,

486
00:33:33,160 --> 00:33:37,560
probably around a year for a primary
rhinoplasty in two years for a

487
00:33:37,630 --> 00:33:41,000
secondary, but, you know, overall,

488
00:33:41,440 --> 00:33:45,360
I think it's important to pick a surgeon
who's listening carefully to your wants

489
00:33:45,420 --> 00:33:47,160
and needs, uh,

490
00:33:47,300 --> 00:33:52,080
be real about how much
predictability the operation

491
00:33:52,260 --> 00:33:53,440
has, uh,

492
00:33:53,460 --> 00:33:58,320
and look at the surgeons before and
afters and see if your aesthetics and the

493
00:33:58,480 --> 00:33:59,840
surgeons are similar.

494
00:34:00,660 --> 00:34:05,000
And that will be more
important than almost anything
else in getting a good fit.

495
00:34:05,000 --> 00:34:07,360
Dr. Bloom, any takeaways to add?

496
00:34:07,790 --> 00:34:11,600
Yeah. I mean, I will echo
what Dr. Bass said. I mean,

497
00:34:11,680 --> 00:34:15,080
I think it's so important. You know,

498
00:34:15,081 --> 00:34:18,880
when I'm consulting a
patient and talking to them,

499
00:34:18,960 --> 00:34:20,080
I think it's really important to,

500
00:34:20,260 --> 00:34:25,240
I'm so much more upfront with them
at this point in my career and

501
00:34:25,380 --> 00:34:29,000
explain that rhinoplasty is, you know,

502
00:34:29,001 --> 00:34:33,280
there are persistent asymmetries
and irregularities that happen in

503
00:34:33,820 --> 00:34:38,720
every single one of these cases
and noses aren't made of clay.

504
00:34:38,830 --> 00:34:43,400
They're made of bone and soft tissue and
cartilage and all of these interactions

505
00:34:43,401 --> 00:34:46,200
between and how they heal. Like,

506
00:34:46,201 --> 00:34:50,320
all of these interactions does
lead to some unpredictability.

507
00:34:51,440 --> 00:34:55,480
However, there's two things
I like to do in the consult.

508
00:34:55,720 --> 00:35:00,720
One is I do like to do some
computer imaging in that I

509
00:35:01,080 --> 00:35:05,640
always take the liberty of being the
first person to do the computer imaging,

510
00:35:06,200 --> 00:35:10,880
because I want to show them something
that I think would look good on their face

511
00:35:11,680 --> 00:35:14,600
and that I think I can
do. And it's mainly to,

512
00:35:15,080 --> 00:35:20,080
to visualize the dorsum or the
bridge and because they can kind of

513
00:35:21,240 --> 00:35:25,400
potentially say, oh, I, I want less of
a slope or what, whatever it may be,

514
00:35:25,640 --> 00:35:29,440
but if they like that,
and I think I can do that,

515
00:35:29,840 --> 00:35:32,400
then we're in aligned when
we go to the operating room.

516
00:35:33,080 --> 00:35:37,160
So that's the first thing I'd like to
get on the same page. As the patient,

517
00:35:37,560 --> 00:35:40,760
I think it's really important
to achieving a good result.

518
00:35:41,560 --> 00:35:46,040
And then I also kind of have to explain
to them that their nose is going to

519
00:35:46,520 --> 00:35:47,720
change. I want,

520
00:35:49,120 --> 00:35:53,360
it's going to take some
time and they have to be

521
00:35:54,200 --> 00:35:58,360
realistic. I tell them, I think
I can get your nose 90% better.

522
00:35:59,720 --> 00:36:03,880
And it's, this is like, if,

523
00:36:04,160 --> 00:36:09,080
if they're happy with that, 90% is a
huge difference in their, you know,

524
00:36:09,320 --> 00:36:11,760
in their outcome, then
they're a good candidate,

525
00:36:11,960 --> 00:36:13,640
but if they're going to sit and,

526
00:36:13,920 --> 00:36:18,320
and just agonize and really
take away this beautiful result

527
00:36:19,520 --> 00:36:24,200
from them over the, the remaining
five to 10% of their nose, you know,

528
00:36:24,640 --> 00:36:28,400
that's something we need to consider
prior to moving forward with any surgery.

529
00:36:29,510 --> 00:36:30,440
Well, Dr. Bloom,

530
00:36:30,620 --> 00:36:34,360
I'd like to thank you for joining
us on the podcast again today.

531
00:36:34,360 --> 00:36:38,920
And you are really a
master of rhinoplasty your

532
00:36:40,120 --> 00:36:45,120
anatomic and technical knowledge
right up to the cutting edge of what's

533
00:36:45,121 --> 00:36:49,920
being done today, along with, uh,
incredibly good clinical judgment.

534
00:36:50,220 --> 00:36:54,000
And not just because you take a lot
of the same approaches I do. ,

535
00:36:55,180 --> 00:37:00,120
but it's really a pleasure to have a
chance to talk these issues back and forth

536
00:37:00,320 --> 00:37:01,960
a little bit with, with you.

537
00:37:02,310 --> 00:37:03,800
Well, thank you so much for having me.

538
00:37:04,450 --> 00:37:05,760
Thank you, Dr. Bloom, again,

539
00:37:05,761 --> 00:37:08,760
for sharing all of your insight and
your wealth of knowledge with us today,

540
00:37:09,100 --> 00:37:12,600
and thank you to our listeners for
joining us to hear about this surprisingly

541
00:37:12,601 --> 00:37:13,520
complicated subject.

542
00:37:14,200 --> 00:37:18,040
I hope you found this episode as
informative and interesting as I did.

543
00:37:18,580 --> 00:37:21,880
If you think of other exciting
developments in plastic
surgery that you would

544
00:37:21,881 --> 00:37:24,120
like to see us discuss
in upcoming episodes,

545
00:37:24,121 --> 00:37:27,560
please reach out by email or
Instagram. We'll see you next time.

546
00:37:28,850 --> 00:37:31,900
This is Doreen Wu, thanking you
for joining Dr. Bass, Dr. Bloom,

547
00:37:31,900 --> 00:37:34,860
and me for this discussion
of rhinoplasty techniques.

548
00:37:35,320 --> 00:37:38,660
Be sure to tune in next time. And don't
forget to subscribe to our podcast,

549
00:37:39,000 --> 00:37:42,700
to stay up to date with all of the
exciting content that is coming your way.

550
00:37:43,870 --> 00:37:47,900
Thank you for joining us in this episode
of the Park Avenue plastic surgery

551
00:37:47,990 --> 00:37:52,500
class podcast with Dr. Lawrence
Bass Park Avenue plastic surgeon,

552
00:37:53,300 --> 00:37:55,180
educator, and technology innovator.

553
00:37:55,480 --> 00:37:57,980
The commentary in this
podcast represents opinion.

554
00:37:58,170 --> 00:38:00,700
This podcast does not
present medical advice,

555
00:38:01,040 --> 00:38:05,020
but rather general information about
plastic surgery that does not necessarily

556
00:38:05,080 --> 00:38:08,220
relate to the specific conditions
of any individual patient.

557
00:38:08,560 --> 00:38:13,260
No doctor-patient relationship
is established by listening
to or participating

558
00:38:13,360 --> 00:38:14,193
in this podcast,

559
00:38:14,450 --> 00:38:18,420
consult your physician to advise you
about your individual healthcare.

560
00:38:18,760 --> 00:38:20,300
If you enjoyed this episode,

561
00:38:20,480 --> 00:38:24,580
please share it with your friends and
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562
00:38:24,581 --> 00:38:28,500
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563
00:38:28,800 --> 00:38:31,060
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