Episode 54: Thursday October 13

What is the smallest, yet biggest plastic surgery operation? Certainly a nose job (rhinoplasty) qualifies! Dr. Salvatore Pacella @sandiegoplasticsurgeon takes point today and discusses the finer points of rhinoplasty with Dr. Sam Jejurikar @samjejurikar and Dr. Sam Rhee @bergencosmetic as they delve into an area of the face where form and function are both critical to a successful surgical result.

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#podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic #3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery #breastreduction #transformation ⁠#rhinoplasty

S03 E53 RHINOPLASTY AKA NOSE JOBS

[00:00:00] Dr. Sam Rhee: All right. Welcome back to another episode of Three Plastic Surgery sorry. Three plastic surgeons and a microphone. I'm here with Sam Jejurikar at Sam Jejurikar out of Dallas, Texas. And Dr. Sal Pacella at San Diego, Plastic surgeon out of La Joa, California, and today we are going to be talking about rhinoplasty.

This is the champagne of plastic surgery procedures. This is the, the one that you know, really defines. What kind of plastic surgeon you are. And with that I'm

[00:00:37] Dr. Salvatore Pacella: looking, that's a

[00:00:39] Dr. Sam Jejurikar: lot of, ok. What about, what about, what about those plastic surgeons who don't do rhino plastic?

[00:00:44] Dr. Sam Rhee: Well, honestly, you're losers. No, I'm not.

I actually you know what, I actually have pretty much given up doing rhinoplasties at this point. I focus a lot on the other procedures, so, I will put myself into that category, but if you're gonna do rhinoplasty, you better do a really, really, really, really good job with them. And that's why we have Dr.

Sal Pacella, who's going to be talking to us today about rhinoplasty and, and showing us a couple cases and maybe some insider tips on, you know, how to get a really good rhinoplasty result. So with that, I leave it to Dr. Jejurikar to give us our disclaimer.

[00:01:20] Dr. Sam Jejurikar: Well, before I get into disclaimer, I feel like only a minute and a half into this, I've learned that Dr.

Re has a lot of self-loathing. He considers himself to be a, he considers himself to be a loser plastic surgeon. Just, you know, we don't view you that way. Dr. Re, I still respect you quite a bit. Oh, thanks. Appreciate though. I do though. I do perform rhinoplasty and I think so, you know. Fair enough. . So this show is not a substitute for professional medical advice, diagnosis, or treatment.

This show is for informational purposes only. Treatment and results may vary based upon the 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 disregard professional medical advice or delay seeking advice because of something you may see in this show.

With that, I'll turn it over, Dr. Pacella to lead this discussion on rhinoplasty.

[00:02:11] Dr. Sam Rhee: I just love you guys. This is why I have so much. Good feelings. Every time I come with you guys, you guys just gimme the love. No judgment. .

[00:02:19] Dr. Salvatore Pacella: You're the

[00:02:20] Dr. Sam Jejurikar: one that called yourself a loser. I love you. Love yourself. Like I think you're a fantastic plastic surgeon.

Yeah, Thank you. Anyways,

[00:02:29] Dr. Salvatore Pacella: So the world has changed. The world has changed. So Jen so talking about rhinoplasty, so, you know, I, I agree with you, Sam from Jersey. I consider rhinoplasty to be the, one of the holy grails of, of plastic surgery, if not facial plastic surgery. And, and, and I gotta say, I think you know, most of the surgeons I speak to or communicate with, they, they feel very similar.

They, they have not they do not want to continue to do rhinoplasty. They find it very challenging. Very difficult to get good results. And, and to be quite honest with you, I've found the opposite. I've I find that the, that doing a rhinoplasty is, is very common. , believe it or not. I mean, we're really doing what, really dealing with two aspects of tissue, the skin and the, the structural component of the of the cartilage and bone.

And, and I've just, I could sit there for hours in doing these, this procedure and tweaking little millimeters and I, I've just found it very therapeutic. How do, how do you feel about it, Sam? Do you, do you find it challenging on the table when you're operating?

[00:03:34] Dr. Sam Jejurikar: So, I, I love doing rhinoplasty just like you.

But the, the reason I think why many plastic surgeons have sort of. Or many decide they don't want to do it. It's a very different skillset than some of the other procedures that we do. It's an operation of millimeters, you know, where literally you are moving at a very slow pace, just fine tuning things.

So I think for for those that are very detail oriented, it's very satisfying for those who. Wanna be done quickly, it's not necessarily as satisfying. I think the, I think the other issue is, and it's really interesting, you know, when I look at what you're really well known for, it's for eyelid surgery, it's for rhinoplasty, it's for operations that are operations and millimeters.

And it takes about a year for the swelling to go away post-op. And so sometimes it's challenging dealing with patients during that perioperative period. Which I think is another reason why sometimes people just think. You know, I'd rather do the body stuff because, you know, when a patient has some postoperative swelling in their nose and it, and it you know, it's going on for a few months afterwards, it can be frustrating for them.

And in turn they try to make it frustrating for the

[00:04:36] Dr. Salvatore Pacella: surgeon.

[00:04:37] Dr. Sam Rhee: I mean, for me, the reason why I stopped doing rhinoplasty about a year, about a year and a half ago was just because, and, and I'm a cranially trained guy. I mean, I know my way around a nose. I, I, some of those cases are very long that, that I trained with and that.

I know what Sal's talking about. I love the precision and the care that that is taken with the rhinoplasty. But when the other aspects of my practice were taking off aesthetically, I was maybe doing five, maybe six rhinoplasty a year, which I just never felt was enough for me to really feel. Up to speed to feel really comfortable.

And at that point I felt like I wanted, you know, again, you're right, it is a very precise operation. I felt that if I was only gonna do five a year, that really wasn't gonna be enough for me to get the best that I wanted for my patients. And honestly, from a financial standpoint, when I'm doing all this other stuff, it made sense for me to focus on the stuff that I'm doing every.

Several times a day all the time. And trust me, it wasn't an easy decision. I still love myself for, you know, and I still think I am a good plastic surgeon, , but I, there's no doubt that if you're gonna do rhinoplasty, you have to do a lot of them. And you have to be able to feel very comfortable. The minute you step into the minute you step out.

And, and if you're not doing a ton of 'em, You're not gonna be as sharp as you could be with those. That's, that's what

[00:06:09] Dr. Salvatore Pacella: I'm saying. Right, Right. I, And you know, one thing I would say is, you know, by nature of my practice being very unique, because I do quite a bit of reconstructive surgery you know, my skin cancer practice.

Is very highly, you know, mid-face oriented. So I, I tend to do a tremendous amount of nasal reconstructions for skin cancer, where that are multi-stage operations, 3, 4, 5 operations, you know, that are planned. And so, You know, when you do these kind of disaster cases where some, quite honestly, somebody's had their nose completely removed, You know, I, I find that doing a nice cosmetic rhinoplasty is, is, is very relaxing to me, believe it or not.

The other thing I'd say is, you know, I I tend to see a lot of patients who have not only cosmetic issues, but also functional issues because I, I do take insurance, I do do functional rhinoplasty as. I sort of look at this as, as kind of one package. So, with that intro here, let me let me share my screen here.

One second here. Let me just pull up my presentation. So Sam, when you were doing rhinoplasty routinely how, how often would you do it? Would you. I,

[00:07:19] Dr. Sam Rhee: you know, I felt comfortable if I was doing maybe 15 a year, Like I felt like that was a good number. I was doing more than that in when I first started, cuz I was coming at a, I was doing a lot of, like you said, functional rhinoplasty.

In addition to that, I was taking insurances, but, my last two years I was doing like six or five a year and I just said, you know, this is just not enough for me to, to feel really solid with it all the time.

[00:07:45] Dr. Salvatore Pacella: Okay. Do you guys see my screen here? Yes, sir. Okay. All right. So cases and write applies here.

. So, um, so to me, when I think about the concept of, or the conceptualizing rhinoplasty it, it's really melding appearance versus function. And, and one of the things I, I tell patients that come in many times they refer from, say, an otolaryngologist or an e t surgeon, head, neck surgeon who came to see that particular surgeon for nasal nasal.

They may have a deviated septum or something called turbinate hypertrophy. And when the patient's going through that evaluation with the head and neck surgeon, they may say, Well, you know, I don't like this hump. And so then, you know, the, the head and neck surgeon may not feel comfortable doing something so they, so I, you know, I was referred the case.

And so when I evaluate patients, I say to them, You. We have to blend. We have to work together, appearance and function. For example, let's say you had a very small nose and breathing was a problem. And if we're just concentrating on function, if we just removed your nose, there'd be a hole in the center of your face that you're breathing through

And clearly that there's gonna be no nasal obstruction, but that's gonna look horrific, obviously. Right. And on the same token, if you got the, the biggest nose, you know, a Pinocchio nose, And we try to reduce that and reduce the size of the nostrils, you can clearly see how that's gonna affect your function.

So, so we really gotta think about both of these. And I tell patients you want one nasal surgery in your entire lifetime. So this is a good time to, to adjust both of these because if you go back later on and you say, Well, I don't like this hump after I had a septoplasty or turbinectomy, we could potentially be damaging things.

So, sorry, the slide advancement is, Slow here. Okay. All right. So here's a little short video here of a, of a patient of mine, and this is a CT scan. So routinely when I'm doing a functional rhinoplasty, I oftentimes ask patients to undergo a CT scan. And so, so imagine we're looking straight on at the patient and we're taking.

Vertical cuts through their face with the imaging. And so what we see here is we're looking at the, so we're, we're sort of a little bit towards the back of the face and in the middle portion here, we're seeing the septum and we see these two fleshy pieces of tissue here. Called the turbinate. And the important thing about the turbinate is they oftentimes, when someone has nasal obstruction or allergies or some other issue, these turbinates are huge.

So you may ask, well, what is the function of the turbinate? Well, the turbinate is designed to warm air and increase the surface area as you breathe it in. And so all of these little eddies back and forth that are, that are that are in the nose, Sorry, we're not the slide isn't advancing here.

Hold on a second. Oh, there it is. Okay. All right. Okay, so now we're going through the nose here and look at this top portion of the septum here. You can see here this septum is we're gonna have a big deviation coming right here. If you see that right there, you see how that septum kind of grows into the side here.

So that's what's called a nasal spur. So you could clearly see how that may affect the breathing component. This is the turbinate that I'm talking to, talking about right here. You see how thick and heavy that is, so it's clear how that can affect somebody's. Any comments on that chance?

[00:11:15] Dr. Sam Jejurikar: Yeah, I, I think that's a really good illustration.

Turbinate, those, those are giant turbinates, those fleshy balls in the airway, giant turbinates, and usually a reaction to things. Oftentimes, not necessarily the primary issue, but if you don't address it during surgery patients still will have difficulty

[00:11:29] Dr. Salvatore Pacella: breathing. Absolutely. Right. And, and the other component of this too is let's say this particular patient went to see somebody who's just gonna play on doing cosmetic rhinoplasty.

And they, they don't go deeper into the septum and take that little, that little septal spur out. That patient is gonna be plagued by nasal airway obstruction. The rest of their life is, if that's not taken, taken. So we wanna think about this as a package. So, here's a little shameless plug for my textbook on MOS construction.

These are some imaging, these are some images from that textbook, but I think they do a very good idea of kind of illustrating exactly where the structure of the nose is. So when we look at the top of the nose, near the eyes, we you know, that component is bone. Okay? Now, somewhere around the middle portion of the nose, When we're going down inferiorly, there are really two sets of cartilages that we're looking at.

There's the upper lateral cartilage and the lower lateral cartilage. And what I wanna draw attention to here is this area right here on the side of the the nose here. This is called the nasal ala, and what we're referring to here is the fibro aerial or cartilage. If you were to take your finger and put that on the same side of your face here, I think there's a misconception in the world.

Cartilage exists on this portion of the nasal ala, but that's actually not true. There's no cartilage on the side of the nose, on the side of the nostril. What that is, is it's fibrous tissue and fatty tissue that create this kind of tube of, of flesh and. The issue is, is when that, that area here, if it's been untouched, it creates a nice arch to tissue.

Okay? What I like to think about is this is a PVC pipe that's underneath the sink. You know, that's a big round piece of tissue or big round pipe. But if you, if you weaken that pipe, you take a bite out of that pipe, oftentimes there can be collapse of that, of that structure. And, and that's the key component here, I think when we're talking about balance.

Form and function. If we go in there and muck up that fibro aerial or tissue during a cosmetic rhinoplasty without taking advantage or understanding how we're gonna change the, the, the breathing component, that could be a devastating problem for rhinoplasty.

Any comments? Jens

[00:13:50] Dr. Sam Jejurikar: y you know. So I think it's a really interesting conundrum that surgeons face because that fibro alar tissue that you're talking about doesn't have any cartilage in it. But yet I think what you're telling the viewers, at least that's what I got of it, is sometimes when you're doing the reconstruction on it, because it could collapse, you do have to add some structure to it in the form of car, which to try to provide that support.

So doesn't have that in its native structure, but sometimes you need to add it to it after you do a surgery in order to preserve. Function and even form.

[00:14:20] Dr. Sam Rhee: Right. A lot of times when you're first examining a patient, you, you check for that external valve and you see how much support it natively has.

And then in a lot of cases, and I'm sure you you'll describe it in terms of adding that support to that rim, to prevent it from buckling or Boeing or.

[00:14:39] Dr. Salvatore Pacella: Right, Exactly. And this is why I find it so, so, enjoyable is to sort of, it's thinking about this in three dimensions and structure. So let, let's kind of jump into a few cases here.

So this is a nice young lady in her twenties who Very, very unhappy with the appearance of her nose and, and her facial profile and, and really had some issues related to breathing. She was snoring at night. Lot of allergies, lot of Rudy noses and, and so, you know, we, we really wanna address these, these issues.

So maybe for the one other plastic surgeon that does rhinoplasty and on this podcast, , how. So Sam from Dallas, how would you, how would you approach this, or what do you tell Actually, first start, tell me what you.

[00:15:24] Dr. Sam Jejurikar: Sure. And I just see a lateral view. I assume there's no other view for me to look at.

Yep. Correct. Yep. But, but on this, on this lateral view, you basically see a woman that has what we call a dorsal hump, or basically there's a combination of both upper lateral cartilage and nasal bone hypertrophy that's giving her a Not the most feminine appearance to her nose. When you also sort of assess how projected the nasal tip is or how follower the nasal tip is, if you were to imagine you had sort of shaved down that hump, I think you would actually see that her nasal tip is either close to normal or maybe just a little bit projected too far.

And it's something that you would have to sort of make a decision intraoperatively about whether or not you were gonna bring that tip back. Typically when you do an extensive reduction of the dorsal hump you can create what's called an open roof deformity. So, when you shave that down, you can sometimes see the edges of the nasal bone.

So this is someone I would talk to about doing some, some relatively common and basic maneuvers. We do an all rhinoplasty, which is moving bone and cartilage from the upper two thirds of the nose, breaking the bones along the side called nasal bone o osteotomy, to reduce the overall size. And then, I'm assuming when we see her tip, there'll be some modifications of her tip that are required as well.

[00:16:36] Dr. Salvatore Pacella: I,

[00:16:36] Dr. Sam Rhee: I think the other thing to look at is her overall facial proportion. So I remember when we were residents, they forced us to do a facial analysis for every rhinoplasty patient we did. And I would look and see, you know, yeah, her menton sitting where, you know, what are her overall facial proportions and take that into account in the rhinoplasty.

[00:16:59] Dr. Salvatore Pacella: And that's, that's a, that's a cran facial word. What's a Menon ? Well,

[00:17:07] Dr. Sam Rhee: only a few people could really talk about that. You know, maybe some of my mentors,

[00:17:11] Dr. Sam Jejurikar: Well, yeah, Yeah. Henry could, I think Steve could too. Henry. Henry. But that's actually a great point, like an amazing point that, that Dr. Rhee, who. For some reason has given up Rhino apla yet is still good at doing the analysis on it.

It's, it's probably the only operation that I do where I actually suggest another procedure to someone. And so what Sam is getting at in this patient is this patient has a very under projected chin and it's someone who even when you reduce, reduce the nose, it's someone that you might talk to you about either doing, at least in my hands, a chin implant, but in Dr.

Re's hands, probably a genioplasty or an operation where you actually. Bring the bone forward, but amazing point that, that that, that Dr. Reeb brings up. Maybe you should think about getting back into rhinoplasty .

[00:17:57] Dr. Salvatore Pacella: So, excellent points, Jen. So you're, you're, you're sort of dead on with my analysis as well.

Now we did discuss performing a chin implant but it's something she didn't want to do, obviously. For various reasons. And so, so my, and, and the whole other side of this was the, the functional component of her nose. So she had really substantial nasal airway obstruction. And so we wanna address both of those.

So I so here's her result afterwards. Okay. And I, I think what, what I found myself in this case doing is really dealing with an over projected tip. Well, so let's start from the top to the bottom here. So, So this area of the nose here is called the radi. And many times when someone has a big, heavy hump here, they have this sort of app, what we call the Appian profile, or Greek or Mediterranean profile.

And that's when the radis of the nose is flush with the forehead. And so, In order to create a little bit better slope, you oftentimes have to take the bony resection up in this region here. And sometimes I use a combination of chisels, sometimes a combination of drills to get down this bony radi. And so, so I also did an an osteotomy where we took off the dorsal hump and brought the nasal the nasal tips together or the nasal bones together, but also worked extensively on this tip here.

The other thing I, I wanted to see, or wanted to point out here too is oftentimes when you have a very over projected nose and you set that nose back, what happens is the nostrils tend to. Okay. And so that's something we have to pay attention to. So if we're not paying attention to that, somebody could have a really good profile of their nose, but then the nostrils will flare and it'll look like a big wide nose at the bottom.

So I did something here called Aler Aler excisions, or we excisions at the corner. And what that does is it reduces the overall dimension of the bottom of the nose. Now going down at the upper lip here. So when I did take this, this nose back, and you could see I took it back, probably a good half a centimeter.

In order to make proportion here, this patient had quite a bit of bony excess in this area right here at the junction of the the nasal bone here. And the upper lip. And so what I did in this scenario here is I actually went ahead and drilled out a little bit of bone right here in order to create a much better lip profile.

And magically what that's done is it's changed her entire nose. It's changed her entire facial profile. I did this all without a chin implant. Okay, So no additional tissue. Was added to the chin. And so this simple act of taking out some bone right here, set her mouth down in such a way that it added additional support and additional volume to her chin.

And, and that was a, that was a surprising appearance for me. After the surgery, I didn't think I could, This could be achieved with just simple excision up here and without a chin. Did someone

[00:20:51] Dr. Sam Jejurikar: put filler in her chin? There's no way. There's no way.

[00:20:55] Dr. Salvatore Pacella: I asked. I swear to God. I asked her that. Did. Did you get anything done to your chin after our surgery?

No. Not one thing.

[00:21:02] Dr. Sam Rhee: I would put money. I would've put money. You did something to the chin on that one? I did. I did not. And, and with the amount of bony work you did, are you sure you're not a cranial surgeon? Cuz again, only a few of my mentors could really have gotten a result like this. I think it's pretty amazing.

That's pretty amazing. Who, who would you think Maybe

[00:21:23] Dr. Salvatore Pacella: Steve, maybe Henry. I mean, maybe Henry. Yeah,

[00:21:25] Dr. Sam Jejurikar: maybe Henry.

[00:21:29] Dr. Salvatore Pacella: All right, so let's go down to another case here. So we have a nice young lady here. She was a softball player in college, and you could see here she's got this kind of bony hump on her dosome here.

She's got kind of a wide tip. And so what, Jen, what do you think about that here?

[00:21:42] Dr. Sam Jejurikar: Do you want, do you wanna start with this one, Sam?

[00:21:44] Dr. Sam Rhee: She definitely appears to have wide nasal bones. Not seeing the lateral I would guess she has,

[00:21:51] Dr. Salvatore Pacella: Let's skip through the result here for real quick here.

[00:21:53] Dr. Sam Rhee: All right, there you go.

I would say, Sam, if you wanna jump in, I'm happy to let you in.

[00:21:59] Dr. Sam Jejurikar: Yeah, she, she's got sort of a complicated lower lateral cartilage situation. She's got what we call you know, a r mal position where her her tip looked just relatively pinched. So this is one of those, the, you know, when Dr.

Patella was talking earlier about the. The how the, the fibro fatty portion or the outer portion of the ala doesn't have cartilage. She's someone that actually could probably use a little bit more cartilage there to, to make the tip look a little less pinched. You know, but beyond that, the usual things that we had sort of talked about are dorsen, Tell us what you did Drella.

[00:22:30] Dr. Salvatore Pacella: All right, so we did the same kind of approach, an open rhinoplasty, and one of the things I placed in her, also, somebody again, who's had functional concerns with her nose. So in order to achieve a nice rectangular appearance to the dorsum, I, I did a maneuver called spreader graphs. And what these are is when we take cartilage out of the nose at the nasal septum.

We can add in some additional cartilage in order to recreate the, these dorsal aesthetic lines. And that has really helped her nasal tip quite a bit. And so you could see here, That tip has a nice kind of super tip break that we see. And she's got some nice tip defining points now at the tip of the nose.

You made an excellent point here on that fibro ariola cartilage. So I did do a little bit of augmentation to this area in order to drop the ALA down and add a little bit more structural support. So this is what's called an aler rim graft, and so very, very happy with the result here.

[00:23:26] Dr. Sam Rhee: What percentage of patients would you say you do spreader grafts?

[00:23:28] Dr. Salvatore Pacella: Probably a good 70%. Again, most of these patients are, are dual patients that have both cosmetic and functional concerns. So usually if there's a functional concern, I'll add a spreader graft. But I've been kind of backing off of it a little bit more at the, at the sort of mid end of my career.

[00:23:47] Dr. Sam Rhee: I mean, when I was doing them, I was using that technique where you kind of take that upper lateral and you kind of turn it into mm-hmm.

you know, you know, turn it into the septum and just sort of use those as spreader grafts.

[00:23:59] Dr. Salvatore Pacella: Spreader flaps. Yeah. Spreader flaps. Yeah.

[00:24:02] Dr. Sam Rhee: And I always, I thought that that was super helpful and, and saved me time from screwing around with the photographs.

[00:24:10] Dr. Salvatore Pacella: Great. All right, so now let's get into the more cranio facial realm here.

So maybe, maybe Sam Rhee will have a lot to say on this one. So here's a gen who was born with a unilateral cleft. Lip. And one thing we commonly see in patients with clef lip deformities is they have a lot of destruction in the, in the nose. He, he had a bony deficit to his cleft lip as well. So the maxillary bone had an area of bone that had a bad platform to things.

Let's see here. Yeah, let. I just wanna show you this picture here. Okay. So if you look at the, the worms eye view of things here, you see how these kind of tips are separated right here. And this nostril area is almost half the size of the opposite side. But the important thing here is this kind of bony aspect of the, of the nose here, the maxilla.

This area here of the maxilla is called the paraform aperture, and, and that area is recessed substantially. So whatever you do to that tip of the nose, Unless you're adding some additional platform here, it's just not, It's as, as our mentor, Kevin Chung used to say, it's not going to

[00:25:20] Dr. Sam Rhee: This is very classic cleft nasal deformity that you would always see in patients because when two things, the, the nostril is tight because when you do your clef lip repair, you're cheating and pulling the tissue together to do the repair, but that. Generally leaves the nostril tight unless you do some maneuvers like preoperative, you know, clef treatment to expand that area.

And then the second thing is, is there's by definition a maxilla bony defect. Or, you know, the upper jaw has a, has a. Has an absence where the cleft lip is, and generally speaking, you'll go in around, you know, nine, 12 years of age and you will bone graft that area to correct that. But a lot of kids never get that.

And so they're left with a permanent bone deficit there, which you can see is basically the collapse. There's a lack of foundation and, and the nose collapses into that area. So you are basically doing cleft work here, Sal, which. My mentors would tip their hats off to you because this is you know, this is what's, you know, you recognized it and you identified it, and, and you're taking care

[00:26:25] Dr. Salvatore Pacella: of.

Right. So that's exactly what I did. So, he, he actually did have what's called an avilar bone graft in the past, but it, it was not really, it's resorbed a bit over the years and kind of it, And so one, one thing I did was I got a, a 3d cranial ct and. So I ended up adding a bit of iliac crest bone graft to this area here in order to build up the base of the nose.

And so you could see here, this is his worms eye view. And what I did was we added a substantial amount of projection here. I utilized some cadaver cartilage to really help build up the tip substantially. An ad some structure to his. To the tip of his nose. You can see here, if you look, that nose is essentially curled down.

And the, and the reason for that is really that scarring and that pull and that loss of tissue support at the maxilla. And so adding that, Cartilage graft, a cadaver cartilage graft, as well as his own bony graft. It really helped with his lip, it helped with his nasal projection and just overall has a better appearance to his nose.

And, and the, the beautiful thing about a case like this is, look at his lip here. Okay, so. I did very little to the lip. I maybe added a little bit of fat to the, to the lip here to add into that scar. But when your nose looks great, it takes away from your lip. It kind of goes into that classic teaching that this is the area of the face that people focus on, this central triangle, the eyes and the nose.

And so adding, making this nose as perfect as it can be really takes the onus away from that. This such, such

[00:28:07] Dr. Sam Jejurikar: a ch, such a challenging case. Did you, you know, one of the things that I don't think the viewers necessarily recognize is how hard it is to close the soft tissue After a case like this patient who's had contracted tight skin envelope for, for years, you added a bone graft, which really helped that depressed scar.

And then you put in a large strut or coul strut using you know, using cadaver cartilage. It's hard to close that incision because it's tight and contracted for years. That's a fantastic

[00:28:35] Dr. Sam Rhee: result. I, I don't think I've seen a better adult cleft secondary nasal repair than this. It's kudos to you. That is amazing.

How, did you do this in one stage or was this multiple stages for you? One stage. Wow. Up. Blown away. Absolutely blown away on this one.

[00:28:53] Dr. Salvatore Pacella: Took a, took a bit, took about, you know, my average rhinoplasty time is probably about three hours. This, this probably took about five hours with the bone graft component.

The other nasal cadaver graft, things like that. So, one final quick case here. I know we're running out of time. Another patient with a wide nasal tip, wide base of the ala. So we did all these kind of maneuvers like we talked about. We I did a bony resection, we did osteotomies and did a substantial amount of tip work here.

Also did those weird excisions at the nasal ala to prevent nasal aler flaring. And you know, cosmetically. Varis patients very happy with the result. You know, Good super tip break. So, so, you know, these cases of rhinoplasty, I just find these exceptionally satisfying. I, you know, in the operating room, like I said, I'm a, I'm a surgeon who, who really, I kind of get, I get my rush out of dealing with things that are millimeters each.

And so that's, that's I think where I'm in my comfort zone with things. So, so that, yeah, that's about it for the cases, Jen.

[00:29:54] Dr. Sam Jejurikar: Great cases. I think they really did a nice job of illustrating to all of our viewers, just the, the various components of the nose that we're looking at during these cases. I mean, you talked about graphs to improve breathing and change the way the dosome look.

You talked about graphs to improve the tip and the, the, the ala There's a complex relationship between all of these areas and it's nice for the viewers just to see how, how someone like you approaches it.

[00:30:16] Dr. Sam Rhee: Yeah. It, it justifies my reason for not doing them anymore, and I'll just send them all allowed to.

La Joa. I mean, why not? Like, Or

[00:30:25] Dr. Sam Jejurikar: Dallas. Or Dallas. I did one of these to

[00:30:31] Dr. Sam Rhee: like amazing, amazing results. And it's it's like you said, those refinements, everyone can see it. But you know, we know technically achieving that is, is it takes a tremendous amount of skill and experience.