Episode 12: Monday September 7

Drs. Salvatore Pacella, Sam Jejurikar, and Sam Rhee talk about one of the smallest, yet biggest operations patients may consider - a nose job (rhinoplasty). The three plastic surgeons go through a rhinoplasty case and discuss all aspects about what to think about in a nose job. If you ever thought you needed a nose job, you need to watch this episode. Do not miss!

Full transcript (download the PDF)

Dr. Sam Rhee: [00:00:00] Welcome to Three Plastic Surgeons and a Microphone. This is our 12th show. And today we are going to be talking about rhinoplasty. We have as always Dr. Sam Jejurikar from Dallas, Texas. His Instagram handle is @samjejurikar. Dr. Salvatore Pacella from La Jolla, California. His Instagram handle is @SanDiegoplasticsurgeon.
And 
Dr. Salvatore Pacella: [00:00:26] West Coast baby 
Dr. Sam Rhee: [00:00:30] that's what all the surfers do when they're out there. 
And then a 
Dr. Salvatore Pacella: [00:00:35] locals only, bro. That's right. 
Dr. Sam Rhee: [00:00:37] That's how you recognize the locals. They do that to each other. 
and then I am Sam Rhee from Paramus, New Jersey. And my Instagram handle is @Bergencosmetic. Remember, this show is not a substitute for professional medical advice, diagnosis, or treatment that shows for informational purposes, only treatment and results may vary based on circumstances, situation, and medical judgment after appropriate discussion, always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care and never, never disregard professional medical advice or delay seeking advice because of something in that in the show. So with that today, we are going to be talking about rhinoplasty and I will give it up to Dr. Sal Pacella to begin talking. 
Dr. Salvatore Pacella: [00:01:21] Good morning, gents, how are you both?
Dr. Sam Jejurikar: [00:01:24] Doing wonderful. Dr. Pacella. How about yourself? 
Dr. Salvatore Pacella: [00:01:27] Fantastic. It's it's been a usual sunny and hot weather. How's how's everything going? Did you guys get, did you get hit by any a hurricane there? Texas Sam? 
Dr. Sam Jejurikar: [00:01:36] We got, we got very, very lucky here in Dallas. the hurricane veered off to the East before we even got any remnants of it.
I think I got about three drops of rain on a, on my grill, on the backyard. And that's all that I noticed from the whole thing. Yeah, we got very lucky. 
Dr. Salvatore Pacella: [00:01:54] Yeah. And, Dr. Rhee from New Jersey, you, how's the Jersey Shaw. 
Dr. Sam Rhee: [00:02:00] Everything's good here on the East coast. nothing unusual. We're just getting geared up to get back to school and with the kids and sorta deal on with, With that right now.
Dr. Salvatore Pacella: [00:02:10] Yeah. Good. Good. All right. Well welcome gents.  so today's podcast, we're going to talk about something a little bit different that we haven't spoken about previously. And that's about rhinoplasty also kn own as nose jobs to the general community. And, you know, this, this is an area of the face and of the body where arguably function interacts with, with form and cosmetics, more than any other place in the body. I mean, it is a exceptionally challenging operation and, and I would say that most surgeons that I know have given up rhinoplasty in their practice early on were w Texas, Sam, or Jersey, Sam, you, any comments on that?
Dr. Sam Jejurikar: [00:02:54] You know, I'm I definitely haven't given it up. I think there are people that specialize in rhinoplasty. So in most large cities, there are rhinoplasty surgeons that are that's really all that they do. In fact, one of my partners is a internationally famous rhinoplasty surgeon. but it's true of the, of the 11 guys that are sort of affiliated with my group, probably five of them perform rhinoplasty.
The other ones that just gotten far away from it. Cause it's such a different skill set than other things we do in surgery. 
Dr. Sam Rhee: [00:03:21] Absolutely. I think it's one of the most dramatic changes that you can make to the face. It's one that as a Sal in San Diego has said is so functional also as well as aesthetic.
And for me, I still do rhinoplasties but I have. I know what I can do, and I know what I can't do if there's a complicated redo, or, a multiple, you know, redo you know, someone who's had multiple operations on their nose, I will send them to one of the specialists that Dr. Jejurikar mentioned someone who has a lot of experience.
if it's something I feel very capable about and that I know I can achieve a result with, I will do it, but I definitely pick and choose, I know, is within my my skillset 
Dr. Salvatore Pacella: [00:04:03] in, in Manhattan or in Northern New Jersey. Do you see a, this is a very popular operation. 
Dr. Sam Rhee: [00:04:10] Yes. There are a lot of people who, It's funny.
There are, there are probably more people interested in rhinoplasty than actually get rhinoplasties. I see so many patients who are interested in it, not sure whether they should proceed with it. And then, you know, at some point, do do it, it's something that they circle around for a real long time sometimes before they actually do it.
Yeah. 
Dr. Salvatore Pacella: [00:04:32] And, and, you know, the thing I find practice in San Diego and the Hoya is, you know, we, we have a huge population of patients that have both functional and cosmetic concerns. And you know, what I, what I tell patients is. You know, I give him this simple analogy. Anything you do to change the function of your nose can obviously change the aesthetics of your nose.
For example, let's imagine you, he had the biggest nose in the world with massive nostrils. And if we wanted to reduce the size of that, not it could easily see, you can easily see how that would affect the, the airflow through the nostril. Obviously you're breathing through something this big compared to something that big, consequently, let's say you.
You had a very small nose that we wanted to expand the nose. If your nose was just simply removed and you're breathing through a hole in your nose, obviously, so you could see how that would affect the cosmetics. So it's just absolutely critical to, to not underplay this concept of function versus cosmetics.
And those are two fundamentally different things. Sam and Dallas, would your thoughts? 
Dr. Sam Jejurikar: [00:05:38] I think that is a beautiful analogy. I've actually never heard that before, but I think that's a very apropos. It's very true. You know, I think, this operation more often than not the people that come into my practice, I'm gonna imagine the same.
It's going to be true in San Diego for you, with Dr. Pacella and, and, in New Jersey for you. Dr. Rhee is. People want their noses in general, they're coming to us for the aesthetic aspect of it. And they're not thinking so much about the potential consequences in regards to their breathing. and it's not just the nostril is like, like you mentioned, there's the septum, which is an area people don't traditionally see, there's a thing called the internal nasal valve, which I'm sure we'll touch upon later on, which is higher up in the nose, which can be a source of issues and trying to create that balance.
very much can sometimes go against their primary reason for being with us, which is to improve the, the reason, to improve the appearance of their notes. Just out of curiosity, before we move on, do you guys see in your practice, a large demand for now surgical rhinoplasty, Dr. Pacella. San Diego, is that a popular thing?
Dr. Salvatore Pacella: [00:06:37] I do actually as part of my affiliation with MD Anderson and, and also being part of a large, multi specialty group with, head and neck surgeons and otolaryngologist, I, I work with at least. 10 to 15, ear nose and throat doctors. And just for our listeners out there in ear nose and throat doctor is a, is a physician specifically, trained in diseases of the nasal cavity or airway or, or throat.
And so these, these types of docs oftentimes get, referrals for nasal airway obstruction. And when patients come in, they ask him questions. Hey, well, what about this hump on my nose? And many of them don't feel comfortable addressing the cosmetic yeah. Aspects. So I get those, I do, you know, serve, those patients for both functional and cosmetic reasons, but on the consequences.
Well, you know, being part of, being a cancer reconstructive doctor as well, I, I do, Take care of a fair amount of patients that have, really bad noses from the functional standpoint, either from trauma or nasal reconstruction. So that is a fairly large chunk of the, of the rhinoplasty patients.
I see no cleft lip, cleft lip, patients, rhinoplasty, et cetera. So, yeah. Well, why don't we, why don't we dive in here to, to the case here. So I'm going to, I'm going to share my screen here. Okay. Oh, you got it. Okay, great. Hmm, hold on a second. Sorry, gents. No problem.
Dr. Sam Rhee: [00:08:04] I was doing that. I was just going to comment on nonsurgical rhinoplasty as well. Sam. Yeah, that's been a growing. part of my practice too, for people who are looking for relatively minor changes, it can be a very powerful tool. you know, they hear a lot about liquid rhinoplasty or, you know, terms similar to that.
And that's a pretty easy noninvasive or not easy, but a relatively noninvasive way for people to change their appearance and see. Whether changing their nasal appearance is something that really liked to do. 
Dr. Sam Jejurikar: [00:08:39] Yeah. I I'm. The reason I brought that up is I've seen a huge increase in demand for liquid rhinoplasty and for relatively minor touch ups.
Like in the last month I've had no, no less than a half a dozen, young women who were getting ready to go to college who wanted a little, a little change before they went to, before they went to school. So just curious if you guys are seeing that same trend in other portions of the country 
Dr. Salvatore Pacella: [00:09:01] a little bit.
Yeah. Yeah. All right. Great. Well, okay. Let's you, you okay with sharing the screen there? Yes. Okay. Alright, so, we'd have our, you could see my first slide here. Yeah. Okay. So nasal surgery rhinoplasty. So, I want to show you a very challenging first case here. Okay.
Dr. Sam Jejurikar: [00:09:24] That's an oblique view of Dr. Pacella.
Dr. Salvatore Pacella: [00:09:31] So obviously, you know, we're with levity here. So this is a, this is an operation, obviously. That's okay. Is, you know, smack no, arguably no other area of the body is smack dab right in the middle of the face. And there is a reason why I love performing rhinoplasty so much. And it's, and the main reason is it's interplay with the, you know, and being a, being both the reconstructive and cosmetic eyelid surgeon.
you know, this goes part and parcel to the same thing. When we're talking with people at a conversational distance. Really when it comes to focusing on that person and speaking with that person, the eyes and the nose create a huge interplay. This is a, a attractive young lady here. And if you're, if you, if I just showed that slide to you, where are you going to focus your conversation on looking at this woman?
You're all going to focus right here. And that, that central triangle, the face is so critically important to, So communication to a human interaction and an any degree of deformity or, or shape disturbance in the nose can interplay with that human interaction. Jen, your thoughts? 
Dr. Sam Rhee: [00:10:43] I absolutely, I think that's one of the reasons why masks are 
Dr. Salvatore Pacella: [00:10:46] so. yes. 
Dr. Sam Rhee: [00:10:48] difficult in terms of human interaction, because you would think the eyes would be enough to react with someone, but no, you need that lower part of the central triangle to really feel like you're connecting us with something, buddy. 
Dr. Salvatore Pacella: [00:11:00] That's a great point about the masks. 
Dr. Sam Jejurikar: [00:11:02] Yeah, no, it's so true. And I like how it looks like it's an equal lateral triangle, the way you have it as well.
Cause that really are the ideal, the ideal proportions, the nose fits in nicely between the inner portion of each eyelid and, and if it's off and if that balance is off, the whole facial balance is off. Right. 
Dr. Salvatore Pacella: [00:11:20] So, so this is our, this is our patient here. So she is a, just as an intro here. This is, a very nice young lady, 23 years old, who came to see me, you've referred from her, otolaryngologists or her ear nose and throat doctor, had a significant amount of nasal airway obstruction.
Difficulty breathing. She was a bit of an athlete. when she ran, it was very challenging for her to take a deep breath. but clearly also did not like the cosmetic or aesthetic appearance of her nose. And, let's, hand it over to you guys. Tell me, you know, what you see here and what your thoughts are on, on her nose.
Dr. Sam Jejurikar: [00:11:58] I'm happy to go for. So, you know, this is very typical of many of the noses that we'll see. I basically will, will group rhinoplasties and there being two categories, rhinoplasties where you want to make the nose smaller and rhinoplasties where you want to add it and make it bigger. And in different the cities, you tend to have a predilection of one type versus.
Versus another. And this particular case, when you look at this young lady, the thing that you're drawn to more than anything is what we call the dorsal hump. So the portion of her nose, which is a portion of which is boney and a portion of which has cartilage, Doesn't have balance compared to the rest of her nose.
So I know this is something that she brought up to you when she first came in. The other thing that you look at when you look at this young lady is that overall her nose just appears long. when you look at where the tip of her nose is, and you think about the angles you want it to have with her face, the nose is plunging or going downward.
So the steps that we take during surgery are going to be geared largely towards. Raising the tip up and reshaping it and also reducing the size of the upper portion of her nose. 
Dr. Salvatore Pacella: [00:13:01] Absolutely. 
Dr. Sam Rhee: [00:13:01] Absolutely. One of the other things, one of the things that we did in training and that we all learned was how to do a facial analysis and how to evaluate the proportions of the nose.
And this is one of those things that we had a lot of training and we could go on, we could literally talk for an hour about the facial analysis and the nasal analysis and in a patient. it's super technical. It's not something that. I think patients would necessarily be interested in. but you could certainly talk a long time.
I'm about her, her about breaking down the technical aspects of it. But the only other thing I would want to comment on top of what Sam said though, is, it looks like she has a little bit of, a little bit of a C shaped deformity where the nasal bones are angled a little bit off to the, to her. Right.
but everything else Sam said was spot on. 
Dr. Salvatore Pacella: [00:13:53] Right. So, Jersey, Sam, that is, that is very correct. And a suit to view. So you can see here just the entire nasal platform is shifted off to the left here. And, you know, that's a, that's a challenging thing to fix. Oftentimes, you know, what I, what I tell patients is, In fact, let me go, let me go to the next slide here.
So this is, these are a couple of diagrams that appeared in my textbook aesthetic facial reconstruction after MOHS surgery for nasal reconstruction, but I think they're excellent excellent diagrams to talk about cosmetic nasal surgery. This gentleman who is in this photo is my good friend, Rob. Hi, great.
I brought him into the office one day. He's one of our reps for breast implants, and I said, you want to be in a textbook here, take a picture. And so, so we did this little overlay on his nose. So, what Jersey Sam is referring to here is there is a, there's an interplay here between the bony aspect of the nose and the cartilaginous aspect of the nose and a common misconception that I, I had when I first started studying nasal anatomy as well.
This area of the nose called the nasal ALA that the bottom or rim portion of the nose. Okay. You would think anatomically that there's cartilage down there. But there actually is no cartilage whatsoever down there. All this is is a, is a tube of fibrous tissue with fat surrounding it. It's, it's very much like a PVC pipe, PVC pipe underneath the sink.
And what I tell patients is when there is a break in that PVC, PVC pipe is very difficult to bend. You cannot flex it very much. If you take it and pull on it. Very difficult to change shape. But as soon as you cut a little tiny hole in that PVC pipe, all of a sudden, there's a, there's a fracture point of weakness and that can bend.
And that's why it's so critical to understand the anatomy of this area. Because if we start cutting into this area for, for functional or cosmetic reasons, and this fibrous tube is disturbed, all of a sudden that fibers tube can collapse and that can cause devastating nasal airway obstruction.
and you know, going back to this gal here, if you look at her, her skin, okay. So let's, let's just look at the base view. This is what we call the worm's eye view of the nose. If you look at the distance from her tip to this base of the ALA, which is a side of the nose, do you see, do you guys appreciate how this is smaller, shorter on the side?
Yeah. Right. So, so we can do everything we can to reconstruct this nasal cartilage right here and get it. Absolutely pencil. Perfect. Within. Fractions of a millimeter, but sometimes the issue is the soft tissue envelope of the skin. For 23 years, her nose has been re draped over this cartilage that has been short.
So it gets what happens to that skin. That skin is contracted. So the skin has some, an inherent memory to it. And when we put the, the nose back together or after reconstructing the cartilage framework, That skin wants to go exactly back to the, to the position that it was in. So we have to oftentimes do some maneuvers to mitigate that.
So, gents any comments on that? 
Dr. Sam Jejurikar: [00:17:05] You know, it's, one of the ways that we all learned to think about the nose, which is not as popular anymore, but I think is very apropos for this example is. So I think of the nose and particularly from the worms I'm view that you have, it will start to hear it as a tripod.
there's, there's essentially three legs of the tripod, one being the, the right ALR the right nostril room, one being the left nostril rim, and the other being the septum right here. And much like a tripod, if one leg is extended further than the other they'll whole nose will shift. And so Dr. Pacella is right in the sense that even though there is a fibro fatty framework, only along this outer portion sometimes to fix that, you have to add cartilage to actually give support to the skin where there wasn't any before.
And so it will be very interesting to see what he actually did to straighten the out, you know, going back to that, the fact that, or her overall nose is crooked. there's, there's a multitude of reasons why we see that it's not just the bones you see on the outside. I suspect that when dr. Buccella did her surgery, her septum was quite long as well.
And that curvature is contributing to that imbalance of the tripod. 
Dr. Sam Rhee: [00:18:08] It's funny. Cause a lot of patients, or if you just looked at her, the most people would say, Oh, she has a huge beak to her nose and you just got to shave down that big hump. But I know the minute I saw her and I saw it at worms, I said, How, how is dr.
Patella going to manage the tip? How is he going to support it? These are the sort of technical aspects. how is he going to shape it? Those are the technical aspects that make rhinoplasty so complex and. Very artistic because there are probably 15 different ways you could approach this. 10 of which would be perfect, five would be adequate and, you know, and that's something that is a constant, learning challenge. 
Dr. Salvatore Pacella: [00:18:50] That's a great point. And, and, you know, I just, the intricacy of rhinoplasty, it, it is truly an artistic. operation. I can literally, you know, I have, unfortunately many times I have a little short little attention span in life and in surgery and, and doing a long three or four hour case on the breast or the abdomen it's, you know, after the, the 3.5 hour Mark, it just gets a little, little taxing.
But I could literally look under the micros or look under my loops and in a, in a headlight at the same spot on a nose for, for four or five hours. And, and, you know, not, not, still be engaged. I mean, it's just a beautiful operation. I do. I truly enjoy it. now the other, the other important thing to talk about with this patient is, is the function, of course.
So clearly her initial. Issue with the otolaryngologist was breathing. Obviously you can see how our nose is fairly constricted with dr.  and Dallas referred to as the internal nasal valve. That was quite a obstructed. So hat on the inside of her nose, these fleshy little pieces of meat called the turbinates, which were quite large.
And so the combination of having large septal deviation, turbine and hypertrophy. Internal nasal valve obstruction really made her, her breeding very challenging. So our goals with this operation are not only to make this, this beautiful young gal look better, but to help her breeding and help her athletics and overall help her life to life for breathing.
All right, so I'm okay. So why don't we now go into the post operative results here? So, so this is her and, you know, I, I truly believe in the fact that, you know, not to a, on many of our plastic surgery colleagues along the country, but you see, In Instagram, you know, a phenomenon of shooting on table results right afterwards, you know, Oh, here's, you know, I'm the expert in this breast surgery.
And you know, this is what the breast looked like on the table. But I think the true test of time is, is key. I, I really only want to shoot these results at a year, and this is a year. Okay. And, you know, I think that tells us what happens to the nasal tip afterwards. It tells us what happens to the shifting of the pressure of the skin on the nose, after, after a year.
So. So, what I did in her is, we made a little incision at the base of the nose right here. I lifted everything up to expose it and then basically straightened out the septum. I removed a substantial portion of the septum very safely, and we put that. Extra septum on the back table. They use for spare parts, if you will.
I also did a bilateral what's called a submucosal turbinectomy so we don't damage the function of the turbinates. We just simply make them smaller. and then I did a series of maneuvers where we, we cut the bones of the nose and break them to widen the base of the nose a bit and open up this nasal passage in addition to reworking.
All of this cartilage at the nasal tip here, and that involves putting a graft at the tip of the nose to, to maintain the legs of that tripod as dr. Jerker and Dallas mentioned, and then adding a little bit of cartilage along the nasal rib, just a smidge to help maintain this tripod periods. So why don't we just run through and I'll come back to these.
So this is her oblique view on the left side oblique view on the right side, and then side views. And then of course the worm's eye view to things here, 
Dr. Sam Jejurikar: [00:22:27] it's a very dramatic change. yeah. It's, I'm sure she loved the, that transformation. 
Dr. Sam Rhee: [00:22:32] Yeah. It really balances out her face. It's very harmonious and I, I think it also shows some of the things you wouldn't necessarily understand when you first look at a patient is that you actually have to widen the nasal bones in order to.
You think she has a huge nose, but you actually need to do that in order to, to achieve more cosmetic harmony. you see her tip and, you know, all of the tip shaping that you did there, to balance out her nose and to make it look, but you didn't over do the tip. So a lot of what, you see with bad rhinoplasties with celebrities or sort of, In Hollywood, are these, you know, crazy, the, snub tips. that look really tiny and are totally pushed up. And she has a very natural, tip shape, which is balanced and harmonious with her face. 
Dr. Sam Jejurikar: [00:23:28] And I'm sorry if I missed it. What did you say you did for her internal nasal valve? Did you do something for that? 
Dr. Salvatore Pacella: [00:23:33] just, out fractured the nose and then, with the, yeah, so basically out fractured the nose, did some osteotomies on the sides here and spread our graphs essentially to, 
Dr. Sam Jejurikar: [00:23:46] okay.
Yeah. And that's the thing. Well, one of the things dr. Patella did are things that you don't even see on this patient. You know, he put grafts between her septum and the cartilage up high. I bet her breathing is dramatically transformed even though her nose looks smaller. 
Dr. Salvatore Pacella: [00:24:00] Yeah. There's difference. 
Dr. Sam Jejurikar: [00:24:02] That's a, that's a huge change in both the functional and anesthetic manner for this patient.
Dr. Salvatore Pacella: [00:24:08] Right. And when one of the, one of the areas, one of the, the yard sticks we want to look at after surgery and, and on, on the table during surgery is, is this area right here. This is what we call the. The dorsal nasal aesthetic lines. And you can see in this patient here, and this should be a gentle, gentle slope from the tip of the, what we call the rate X here in between eyebrows to the deck, down to the tip of the nose.
And you could see her. She's got a pretty dramatic triangle sitting here, preoperatively here, and there's a break in that. In that contour of the nose. And then afterwards, this is a, just a gentle curvature of the nose sitting right here in a, in a relatively straightish line. and to me, that's a, that's a huge yard stick that I look at on the table, to make sure my everything is straight and to make sure that the aesthetics is perfect.
Dr. Sam Rhee: [00:24:55] A technical question. When you do your osteotomies, do you do them internally or do you do external audits? 
Dr. Salvatore Pacella: [00:25:01] Excellent. Excellent question. So, You know, I, I just want to hint at the pedigree that we, we had at the university of Michigan. So dr.  and dr. Ray both trained with me, obviously at Michigan, we, we had a tremendous amount of training and rhinoplasty are one of our, Our professors, dr.
Haskell Newman was one of the founding members of the rhinoplasty society. we also had some expertise yeah. By a gentleman named dr. Robert O'Neil, who was, one of the pioneers of rhinoplasty. And so this is a. This is an area of plastic surgery where we really have a fantastic, I think background and what, what you're referring to here is I'm sorry, what was the original question?
I just kind of went,
Dr. Sam Jejurikar: [00:25:51] you 
Dr. Salvatore Pacella: [00:25:52] are awesome. 
Dr. Sam Rhee: [00:25:54] External or internal nasal osteotomies. Do you do that? 
Dr. Salvatore Pacella: [00:25:58] Okay, so, so Dr. Newman. taught us, the technique of external osteotomies. Okay. And what, what these referring to is when you break the nose, how do you break the sides of the nose? Well, the external osteotomy is a procedure where you make a little cut in that and the extra portion of nose and use a little tiny little, tiny little plate.
I'm a sharp little chisel, if you will, to just gently fracture this area here under a control fashion. And I would say that for the first five years of my rhinoplasty practice in San Diego, I did external osteotomies and quite honestly, I just, you know, although we had great training in that, it's just something where my evolution has shifted substantially.
and. You know, I just don't feel like I got great control of fracturing that area. And it was very difficult for me to fracture out a little bit laterally. So now what I do is an internal lateral osteotomy. So I'm oftentimes right near the turbinates and where I do my submucosal resection of the turbinates on the inside.
I just basically pass an osteotome underneath here. And it really allows me to fracture quite laterally. I think w what this has really allowed me to do is when we had more medial or more central osteotomies, I would see this kind of box, like deformity to the nose. People oftentimes have this bony prominence here that is pretty aggressive when they have a large dorsum.
And so allowing me to do the internal osteotomies that could fracture that out a little wider and just get a better shape in this transition zone.
Dr. Sam Jejurikar: [00:27:36] what was the question again? 
Dr. Salvatore Pacella: [00:27:39] Yeah,
no, no, I know, 
Dr. Sam Jejurikar: [00:27:44] I 
Dr. Salvatore Pacella: [00:27:44] know. Yeah. I was fortunate. I 
Dr. Sam Jejurikar: [00:27:48] agree with all of your, your thoughts about the quality of our rhinoplasty education at Michigan. I was fortunate enough that when I went to New York, after Michigan, I trained with Nixon ball and Sharelle Aston who, Only did internal osteotomies and then why joined a practice that had Steve bird and Rorick in it?
Who, and so there's no consensus on this question. I, I, I do a combination of both, but probably 90 10 internal osteotomies over, over external. 
Dr. Sam Rhee: [00:28:15] It's funny. I, It's funny. Cause I trained the same way you guys did at Michigan. And then, when I was at UCLA, we did internal nasal osteotomies and then I, I did it both ways for awhile now it's 90 10 for me external.
And I just feel like, I, I know what Sal's saying about getting that control, especially if you have to like bring it out the nasal bone. Okay. But I just feel like, you know, different tools, whatever you feel comfortable with. There's like a sound Sam said, and there's no consensus and whatever feels good in your hands.
And as long as you achieve the results you want to achieve, that's why I asked because it's, there's no. Necessarily good answer for it. It's it's what you feel comfortable. Yeah. 
Dr. Salvatore Pacella: [00:28:57] You know, clearly I think one of the artistic acts aspects of plastic surgery, cosmetic surgery of the nose and faces, you know, you have to have different arrows in your quiver and not every arrow is going to accomplish what you need.
So, and, and that's the broader you're trained. The more tools you have in your toolkit. I think the better, 
Dr. Sam Rhee: [00:29:16] the other point that you made, I mean I'm as guilty as anyone else about posting on table results for certain types of procedures. But I I've admitted. It's a social thing. 
Dr. Sam Jejurikar: [00:29:26] I do it all the time.
It's just what's expected in the current age, 
Dr. Sam Rhee: [00:29:29] but for rhinoplasties you cannot. And I do counsel patients. It takes a long time for that swelling and for the final shape, especially for the tip to come into focus. And, it's one of those that take some patients, especially when you're doing. you know, a fairly big rhinoplasty as you did here too, you know, for the final postoperative result to, to show.
Dr. Salvatore Pacella: [00:29:54] Like, 
Dr. Sam Rhee: [00:29:54] I don't think anyone should show an on table result for rhinoplasty. I think most of those should really be reserved for, you know, long longterm results. Cause that's really, like you said, where you're going to see 
Dr. Salvatore Pacella: [00:30:04] it. 
Dr. Sam Jejurikar: [00:30:05] Yeah. I mean, I think it all depends on the purpose of showing that on table result.
Let's be honest half the time it's on Instagram. It's to say, look, I do rhinoplasty. That's true. That's really, that's really the purpose behind it. You know? 
Dr. Salvatore Pacella: [00:30:19] Hashtag Insta. Good. Exactly.

Dr. Sam Jejurikar: [00:30:26] why is that? that was an excellent result. Dr. Pacella and an excellent presentation as always. I always feel a little bit smarter after I talk to you, gentlemen. 
Dr. Sam Rhee: [00:30:36] Same. Absolutely. That was an awesome case and really, really fine result. I I'm sure that patient functionally and cosmetically was, was thrilled and the fact that she's young and was able to do it.
I'm at an age where I think she's going to benefit for decades. This is going to be something that was life changing for her in so many different ways, which is really what our goal is. Right. We really want to make such super positive changes in our patients lives. 
Dr. Salvatore Pacella: [00:31:04] Great. Well, 
Dr. Sam Jejurikar: [00:31:07] I think on that note, we'll just, let's call it a, let's call it a podcast gentleman.
Thank you as always and have a wonderful week. 
Dr. Salvatore Pacella: [00:31:13] Great. Thank you. Take care of yourself. Take care. Alright.