Episode 60: Friday November 25

One of the most challenging operations in plastic surgery is a revision rhinoplasty, or nose job. Think of the prominent celebrities who had to wrestle with bad outcomes after surgery.

Today we talk to special guest Dr. Yash Avashia @dryash, board certified plastic surgeon in Dallas Texas, who specializes in revision rhinoplasties. He shares his tips and tricks with Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Sam Jejurikar @samjejurikar, and Dr. Sam Rhee @bergencosmetic on how he manages the difficult technical challenges that a "botched" nose job can pose.

A board certified plastic surgeon, Dr. Yash earned his undergraduate degree at the University of Miami. He then attended the University of Miami Miller School of Medicine. After graduating from medical school, he completed a plastic and reconstructive surgery residency at Duke University Medical Center and an aesthetic surgery fellowship at Dallas Plastic Surgery Institute.

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

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[00:00:04] Dr. Sam Jejurikar: Welcome everyone to yet another episode of Three Plastic Surgeons and a microphone. As always, I'm joined by my two cohost, Dr. Salvato Pacella in La Jolla, California. He's, you can find him at, at San Diego Plastic Surgeon and Dr. Sam Re from Paramus, New Jersey at Bergen Cosmetic. And as always, I am Sam's Jejurikar.

Today we have a very exciting topic where we are gonna talk about vision rhinoplasty. We've talked about rhinoplasty on a few occasions, but we're gonna talk about what to do when rhinoplasty has gone wrong. Before we get into our guest who you see sitting in the bottom right hand corner. We're gonna just go over our usual laundry list of Matters, Sam.

[00:00:42] Dr. Sam Rhee: Thanks. This show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. Treatments 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 disregard professional medical advice or delay seeking advice because of something in this show.

Back to you.

[00:01:08] Dr. Sam Jejurikar: So, today we're joined by Dr. Ya Aasha, who is known throughout the Dallas community as Dr. Ya. I have been fortunate enough to know ya for about five years both during his aesthetic surgery fellowship and as he's very quickly built, built a Kind of a booming rhinoplasty practice here in Dallas.

Yas makes no secret that his his passion is rhinoplasty surgery and facial aesthetics. And and he has already sort of built up a following of revision rhinoplasty. So today we're gonna talk about revision rhinoplasty. So welcome to the podcast, ya.

[00:01:40] Dr. Yash Avashia: Thanks Sam, really appreciate you guys having me on the podcast.

A huge privilege. Really excited about the discussion. Rhinoplasty is a huge headline. I love primary rhinoplasties and I think revision rhinoplasty is kind of like next level in rhinoplasty. It's everything that is about complex, about our primary rhinoplasty. I think revision rhinoplasty is even more complex and I'm excited about the discussion we're gonna have today.

[00:02:05] Dr. Sam Jejurikar: So, yeah. So what are the reasons why patients come to you saying, I need some, my, you know, I've had my nose done, I'm unhappy with it. Like what are common scenarios that you.

[00:02:14] Dr. Yash Avashia: You know, the most frequent ones I think is why they wanna come in for a revision. Class C is one is a functional problem. I think people, people can quit sometimes a cosmetic deformity, but when you have a functional obstruction, that's a hard stop for a lot of patients and that's one of the more common reasons she's come in for revision rhinoplasty.

And reason I think other than function would be cosmetic reason. I think it can. Either a, a dorsal deformity, atty, or they just wanted more of what they originally went in to have done. The problem is that rhinoplasties can be done in so many different ways. We closed, we have open rhinoplasty. There's a new idea philosophy in rhinoplasty called the preservation rhinoplasty, and then there's a couple differences between one surgeon and another surgeon.

So even. Overall the plan is about the same. The end result is always gonna be different. And so I feel bad for patients who sometimes may not have what they're looking for after their first rhinoplasty that kind of leads them to seek out a revision rhinoplasty for that matter.

[00:03:21] Dr. Sam Jejurikar: So, you know, for our listeners revision rhinoplasty is substantially more complicated than traditional rhinoplasty.

You've, like you said, as a surgeon, you don't necessarily know what the surgeon before you has done. You don't know. You know, you, you, you may have an operative note to refer to, but it's, but it's hard to know what you're left with. So, when you see someone for a revision rhinoplasty, do you have specific things that you'll always do or things that you'll tell?

We're gonna do this open, we're gonna do this close. Like what's your, what's your, what's your te

[00:03:55] Dr. Yash Avashia: your approach to that? That's a, that's a great point. I think, you know, in the three phases of taking care of a, a revision line of patient, the first one being the pre-op, the second one being intra-op, and the last one being post-op.

I probably spend a lot of energy in my pre-op and certain things that I really say to them, first thing I really need to understand is why they're coming in to see me. And I really have to try to redirect that patient. Being upset or focusing on the surgeon in the past, or surgeons in the past to more or less of their notes.

And that's, that's a challenge in many cases with revision patients. I always tell the patient that if I don't see it and if I can deliver what you're looking for, probably not the right surgeon for you. And I think that's really important for revision patients is being very honest. It's. It's almost the most important thing in my opinion, is being as clear and honest with your patient upfront.

And, and I think they appreciate that too. Ultimately, they're looking for the person to do their revision. They've gone through this and be 1, 2, 3 times and they don't want it again. I think Rhino. Rhinoplasty Bolt is a tough enough operation experience as a patient. One time around, they're doing it again a few times.

You don't want it to get out with them. You wanna make sure you can deliver it. So I tell 'em, if I can't see it, if I don't appreciate the difference that I can give you, then I'll not the right surgeon for you. Or more importantly, I'll tell patients sometimes that if I don't think it's a bad enough problem, I'll also tell 'em that honestly.

Cause I think it's important to hear that from another plastic. They probably heard it from their first surgeon, which is why they're coming to you. But I think it's important for them to hear that if it's genuinely what you believe and what you feel. That's one thing I always tell patients. Second thing I always tell patients is I always will do an open approach for your revision rhinoplasty.

Well, the more common reasons why I see patients coming in for provision, it's had a close rhinoplasty, and I'm, I'm not dogging on pose rhinoplasties. I think in the ripe gent, it's a great operat. The only problem with close rhinoplasty in my opinion, is you have a really good surgeon to do close rhinoplasty.

Take a, take it. For example, you got a field goal to win the game and you put a blindfold on. If you've kicked a thousand plus field goals, you'll probably sink. If you've only done a few, you'll probably miss it. And that's what I think about close rhinoplasty. There's so many complexities to the nose.

The benefit of doing an open approach is you see the anatomy right there and then, and when, when surgeons or prior surgeons have done a close rhinoplasty, sometimes they're not seeing everything and you see that when you open the nose the second time around for revision rhinoplasty, and there's nothing wrong with that.

But ultimately, I think you can reduce the number of revisions needed for a patient if you do an open approach starting off. So that's, that's just my opinion and I know that's really crucial. But I told the patient I'm gonna do an open approach. So,

[00:06:47] Dr. Sam Jejurikar: Dr. Pacella, you do a lot of, a lot of revision rhinoplasty.

Do you always do open for your revisions as well? A hundred percent

[00:06:54] Dr. Salvatore Pacella: all the time. You know, I you know, what I sometimes tell my patients is you know, I think about. I think about the bone and cartilage as a hand, and the, the skin is a glove, you know, so if you, if you're borrowing somebody else's gloves and you try to put them on many times that doesn't fit right.

So it's like, You must've quit. You do whatever. No. , , .

[00:07:17] Dr. Yash Avashia: That's what I'm thinking. . All right. It's is. Its too long.

[00:07:22] Dr. Salvatore Pacella: iss too . It's, that's not, I

[00:07:26] Dr. Sam Jejurikar: I was, I got confused. I'm sorry. Continue. . So

[00:07:29] Dr. Yash Avashia: we're, mine's blast . The, the

[00:07:32] Dr. Salvatore Pacella: wants to do what it wants to do. And I, and I feel like the, the challenge many times in clothes rhinoplasty is when you're seeing some of these external cosmetic deformities of the skin.

The skin has already been trained to, to sort of adapt to that cartilaginous structure. So one of the most challenging things is if you try to do it closed again, you're going back into the same skin envelope. So you, you really need to structurally have much better support. Which brings me to my question, yash.

So what role do you see for preoperative imaging ahead of time? Do you get CT scans, et cetera? And I, I have found, A lot of times with functional issues if I don't get any imaging, I'll oftentimes uncover a big, large septal spur that I couldn't really identify on the preoperative exam. And then I'm gonna have a follow up question for you after that.

Go ahead.

[00:08:18] Dr. Yash Avashia: Yeah, sure. So preoperative I'll only really do is the patient's had private trauma or there's such a severe deformity that I can palpate with them. I do an anterior endoscopy with kind of like the spectrum. I don't normally do an endoscope. That's the difference between plastic surgery and emt.

So I'm not really visualizing posterior. For me, operative cts really only will tell me if, if they've had chronic infections and whether or not my functional rhinoplasty with the, with the COD combination is really gonna treat it or not. But for a revision patient, I rarely will do a CT preoperatively.

I do standardized photographs in the office like, like most people would. But I don't seemly go to CT imaging. Yeah,

[00:08:58] Dr. Salvatore Pacella: I, I I, you know, I, I tend to use CT quite a bit for a couple reasons. So in in revisional patients, number one, it's, you know, a lot of these patients, as you mentioned epli, they, they oftentimes have functional issues.

And, and sometimes in, in my evaluation, it's very difficult to, to see what the difference. The role of a crooked septum or nasal spur is compared to large turbinates. And you know, I think it's very challenging sometimes from anterior rhino to really understand how the, the turbinate are affecting airflow.

The second reason is, you know, I see a lot of referral patients who may have had an E N T based septoplasty. And, you know, as you, you may agree, You know, the septum is, is the premier donor site for, for cartilaginous support that we use. And, and I, you know, I think the CT helps me quite a bit ahead of time to understand what kind of cartilage bank I can work with.

Because oftentimes in, when I'm doing a case like this, I'm using a call STRT graft, I'm using spreader graphs, I'm using aler, batten graphs tip graphs, et cetera. So, your thoughts.

[00:10:04] Dr. Yash Avashia: No, I think, I think if that's, I think ultimately there are some endpoints that we need to get before we operate, and I think that's what you're highlighting is you don't step into the operator without having all the information, all the data you can really get.

And I think understanding how much could you have in a septum is a really big important thing. Like you said, even a ENT base, septoplasty, you'll still see a lot of septums in there, believe it or not, like you probably implied. I think that's good to know before you start, you know, going after rib or already you're getting cat rib bras for the patient.

So I CT scanning I tend to use I tend to use the anoscopy with the light to kind of visualize where the septum was taken. I'll palpate that as well. I personally haven't used cts to actually. Give me more detail as far as that, because in most, I also, that's the third thing I always tell the patient is I'm gonna prepare you for using or getting a rib graft for your rib.

You know, I don't typically go after their autologous rib. I, I tend to always use ric rib grafts, but I always tell patient, if you're coming in for a secondary or tertiary, whatever it is, rhinoplasty prepare yourself for a rip breath because I don't want to do a three where I don't have all my tools available to give you the result you're looking.

[00:11:18] Dr. Sam Jejurikar: So I wanna make this just a little bit more basic just for a second because you guys are using a lot of terms that our viewers have no idea what you're talking about. But, but ya, earlier you used the term preservation rhinoplasty Sal named a named a bunch of different cartilage graphs that are, that are that you would potentially use.

And I think you both are saying that when you're doing a revision rhinoplasty, so a secondary tertiary er rhinoplasty, There is a need to add structural support to the nose. A lot of times what you guys seem to both be thinking is we need to add cartilaginous support to the nose to build a framework back up.

Could you just sort of explain to the viewers, either or both of you guys why that's important and, and what's the rationale behind doing that?

[00:12:03] Dr. Yash Avashia: Sure. I, it's a simple, I think we talk about two things, form and function, revision rhinoplasty, right? So function, whether. Breathe properly or not, can you get a properly through your nose?

So that's function. And then form the aesthetics, the shape, the appearance. And in my opinion, I think structures, function and form more importantly in a revision microplasty. And that's why really mature. You have the right structure you know, during your r around a class. Now one of the frameworks or part of the frameworks for a nose is cartilage.

It's a bone and cartilage. Realistically, there's different types of glitch. They have the upper lateral cartilage. The lower out cartilages have different purposes from a functional and akinetic perspective, but it's part of the framework for the nose in addition to the bone. And when you do revision, oftentimes that cartilage is not in Its Atomic position quality, it's been violated from prior surgery.

And so you need to use cartilage to kind of support it and restore it. And then technically goes to where are you gonna get the cartilage from. And I think Sal had mentioned, you know, the septum is definitely the, the largest workhorse for rhinoplasty. And sometimes if you don't have cartilage there, where else do you owe?

And I think that leads us to what I mentioned before about using rib cartilage.

[00:13:29] Dr. Salvatore Pacella: You know, it's, it's interesting ya. You know, I, I really love and enjoy challenging rhinoplasties and you're clearly the same way. And it, it just kind of opened up the gates and we started diving into eating, right. So it's like, it's a, it's a discipline in and of itself, of, of plastic surgery that is, you know, you, you really have to, to kind of jump in full steam and be engaged with couple points.

I think you know, I For years I was doing rib cartilaginous graphs and what, you know, a few years ago there was kind of a push towards using fresh frozen rib cartilage. And, and honestly I think that's been a game changer. It, it seems to act a lot differently than, than The patient's inherent rib cartilage.

You know, when you, you know as well as I do, when you harvest rib cartilage and you're cutting it in fine little slits and, and structure, it oftentimes can warp. And, and the frozen cartilage doesn't necessarily do that. It oftentimes can really say stay super, super straight. And so that, that is really, I think, been a huge impact, has had a huge impact on my practice.

[00:14:33] Dr. Yash Avashia: Your thoughts on that? I totally agree. I think a, a lot can be said of that. I think just reducing the donor site morbidity alone is a huge benefit to the patient, female or male for that matter. Pain associated with that. And then, you know, if it's a patient, you're, you're not gonna get exactly like you said, Carly, that you may want, it may work over time, it may bend and then, but you're dealing with that secondary, you know, consequence after spending, you know, 30, 40 minutes, you know, harvesting and preparing a rip BRAF from their.

So I think that's a huge benefit. And then time, time and is also saved quite a bit in this operation by not having to go after the patient's rib. So I think those two benefits alone is one of the reasons why I always go for fresh, frozen allograph essentially. Now, I like the sheet crafts in general.

I think it's already cutting. Taking away a step that you're gonna have to do anyways. And so you have a nice prepared shape for you and you can kind of, you know, carve that and shape that to whatever use you may want. For patients that need a lot of cartilage, I'll actually get the segment and, and use it in ways for whatever I need for.

But in most cases, I'm using a sheet. Again, I think that has revolutionized revolution rhinoplasty. I don't think you just have to go after getting a autologous rib. Let me

ask

[00:15:54] Dr. Sam Rhee: this. Both you and Sal have a, a real interest in rhinoplasty, but I don't think people really understand. If you, if you're not a plastic surgeon, what it means to do a lot of second time operations on a nose or a third time operation on a nose, it's, it's a whole d.

Kettle of fish. I mean, people call themselves rhinoplasty surgeons, and they are very allergic to going back into a nose or maybe a third time back into a nose because it's so difficult. You have to be so precise The first time you, you, you open up a nose and you're, and you're opening up that surgical field, and then the second time it takes like, 10 times longer to get through all of that scar tissue to get to figure out what's going on.

And I can't even imagine. I think maybe I've done like one three time revision or, or on my own, or maybe twice, because you can't figure out where anything is. It's just the unholy mess in that nose. There's a reason why Michael Jackson's nose looked the way it did, because every time you go in, it just complicates things.

Tenfold. So what made you decide, this is something I wanna do, I wanna sit here for hours, and, you know, opening up this nose and trying to figure out what's going on with it. , like what made, what made that something that appealed to you?

[00:17:08] Dr. Yash Avashia: I think it's a great question actually. I go to sleep dreaming about riding Posses, honestly.

But to be honest, to be frank it's, it's way more challenging to probably ran APLA because the things you said, you know, you're dealing. Abnormal anatomy at this point. There's a lot of unknowns. I think it's, it's with the primary rhinoplasty, you see the, be the nose, you examine it, you have a very good understanding of what you're probably gonna deal with because there are certain trends in ethnicities and anatomy.

Your physical exam, you have a lot of information at your, at your disposal in the preoperative phase. So when you go in the operating room, there's not many surprises for the most. In a revision case, I'd say that there is a lot of discovery in the actual surgery and that is not abnormal. That is not wrong to say that, you know, you shouldn't scare the patient, but that's the truth.

You gotta have all your tools in your toolbox and available when you go in the operating room, I basically do an inop time out. I elevate the skin. Try to get through all the scar tissue preserve soft tissue envelope, and then you do like a mental timeout and you see, what do I have here? What's going on?

What was done in the past. It's a lot of like, cerebral work that you're doing. You're trying to think of what was done in the past and what does the patient want, and what do I need to do to get that patient there, and then what do I owe to do that? And so personally, I love that. I love that whole technical and mental c.

I think a four hour revision rhino is the most mentally exhausting operation that I do. But I love it. It's not physically taxing. You know, if I do like a four hour, 360 lippo, I'll probably be physically exhausted from that. If it's revision ladder, sure. But a four hour revision rhino, I'm probably not physically exhausted, but I'm mentally exhausted.

I, I personally just enjoy that. I think everybody's, everybody gets turned on by different things and that's something that works. Yeah,

[00:18:57] Dr. Salvatore Pacella: I, I, I think that's, that's, that's a fantastic insight, ya, it's I, I feel exactly the same way. I could literally spend hours picking away at a nose and kind of looking at, you know, the structure and understanding what I'm gonna use and what I'm not gonna use and, you know, trying one maneuver, flapping the skin over, seeing how it looks, et cetera.

You know, one. One of our former professors, Steve Buckman, used to say, you know, about, about facelifts. He said, you know, facelifts are a great operation after the first side. When you do when you do the second side, it's exhausting. Right? So it's trying to get everything symmetric. And that's, that's the one thing I love about rhinoplasty.

It's this one operation on one side or 1 1 1 single operation. So that's, that's a, that's a fantastic that. It's

[00:19:41] Dr. Sam Jejurikar: very true. So, ya, I know you have some some cases that you were gonna share with us. Now seem to be a great time.

[00:19:48] Dr. Yash Avashia: I see that. Absolutely. So, you know, I think the big common trends or themes that I'm, that I'm can you guys see this now?

Yep, sure can. Okay. So the more themes that I'm seeing in my are inadequate. Structural support like we talked about and then not adequate closure of dead space. And so what that kind of leads to is a lot of scar formation. And you know, what's, what's unfortunate about Rhino is you, the patient could have had a perfect operation and then they have a bunch of scar tissue development that has completely blunted their definition and they're unhappy.

So this is one. Patients, she had a primary rhinoplasty about two years ago and what you can appreciate here is says a loss of definition or tip. She actually got a hanging colella as well, you can see on lateral viewpoint, and she didn't find, she found her nose to still be very large. . And so we know her exam.

She actually has a co septal deviation. She's got a hanging column. Me, she's got a very boldest as well. And this just comes to show what scar can actually look like when you opened the nose. And this was an example we had. And so what we did for her is really tried to restructure her. Set her tip to give her good tip support.

I think that's another, a huge topic that we can root into to really get more into the nitty gritty and granual details of rhinoplasty. But for what, what she really needed was restructuring tip port and then closure of debt space. And so I actually will do some that actually helps tack down the skin in three different area.

And I don't want to get into too much detail. I know we talked about, you know, making it understandable for, for our listeners, but preservation of rhinoplasty is a great philosophy, a newer philosophy in, in rhinoplasty that I personally have started to really like and take more and more into my own techniques.

It basically says you want to preserve certain anatomy, you have to appreciate the anatomy, preserve it so you can get a long lasting. One of the things that they really talk about is preserving ligaments that connect the framework and the skin. And there are 2, 2, 2 groups of that. The, the tange ligament, which is kind of right up here in the super tip area, and then the scroll ligament right out, out here.

And what you see oftentimes after a primary rhinoplasty is just this blunting and fullness here. And so what I'll actually do in the revision case is I'll, I'll go through and I'll. Six oh Vis to help tack that down and pull that skin down together so you get a little bit more definition and prevent this kind of tissue formation.

[00:22:40] Dr. Sam Jejurikar: Now, did you add any additional structural support to her triage?

[00:22:43] Dr. Yash Avashia: I did. So in addition to moving, so she had a, she had a, had a large colonial strut that I had to move and, and I use obviously for her to create a septal extension graph in my hands. I found that to be a very consistent technique in setting tip rotation, which is, you know, where your tip falls up or down, and then tip projection without adding any fullness to, to LA or the Col Miller region.

And so that was probably the biggest thing that I, for her, in addition to refining h. Slightly redoing her. Austin needs to help kind of give her a little bit more smoothness in her door. So

[00:23:21] Dr. Sam Rhee: how long do you usually wait in between their primary, their first rhinoplasty versus what you do for them?

[00:23:27] Dr. Yash Avashia: One, so great question. I, I recommend patients waiting a full year, year. One year. I've had patients come in, unfortunately, a week after they're first serving. They're not. or sometimes at six months. And I, I think there's, there's value in having the patient wait one year. I think they start to appreciate their, their nose and I think they, they tend to forget the trauma, the emotional trauma that they've experienced from that first surgery, and they start kind of creating a slate and they're mentally ready for the revision by apla.

I said, I think there's, I think getting a rhinoplasty, whether it be your first, second, or third, hopefully only your first, but you know what I mean, is a big, is it rollercoaster? It's an emotional rollercoaster. It could be a happy rollercoaster or it could be an unhappy rollercoaster. And I, I think I really want pace to separate the rides.

I don't want them to make it one big ride. That makes, does that make sense? Absolutely. Yep. This is another example. This patient had two prior rhinoplasties, actually the first one was alo. The second was, was an open, but only around the tip. Nothing was done to the dosome. And then she, for her third with me, essentially.

And I had to piece a lot this, the history to understand what had happened. Like I said, one of the things. I really enjoy about revision writing classes is understanding what was done in the past. And so I had enough to understand that the whole bony dorson was completely active. Actually, it was not grasp, it was not reduced, not in fractured.

And that's, that's what was done. There was very thin skin. The tip actually and that's probably from a combination of the clothes and the revision. Limited open tip rhino. When I opened the nose and I'm sure if any of you have done the revision rhinoplasty, you've seen this, but the lower lader cartilages were completely transected.

There was absolutely no integrity or, or structure to it. And and then the whole, the mid vault actually was open, so there's communication between the mucosa and the actual nasal. I think that led to operative infection and which led to a lot of scar tissue development in this patient cuz obviously infection is inflammatory and scar tissue develops.

After her surgery, I did end up talking to her and, and piece together that that's exactly what had happened to her. And so the big thing for her was kind of doing a lot of damage control and closing off that communication. Trying to restructure her tip. Again, using a Sublux Sension graft to help support her tip, wanted more definition to her tip.

And then in doing the things that we would normally do in a primary rhinoplasty reducing her bony dosome in fracturing her nasal bones to get a bit more narrowing her upper third. And then obviously her case, I use. I actually use this like a unilateral spreader graph to help support mid vault because in my opinion, I felt that because of the prior violation of the mid, she needed some of inte support for long term success for her.

Do you

[00:26:44] Dr. Sam Rhee: use digital? Yeah. Awesome. Do you use digital simulation with your patients in your consult?

[00:26:51] Dr. Yash Avashia: I do. So in addition to these standardized photographs, I actually will use a square and I sit down and do it myself. And I actually kind of, morph those to what I understand the patient wants. And it's actually a great exercise and for the patient because for me, I am doing that I probably would do in the operating room and I know how far I can put and what I can.

And I give it back to patient and the patient. This is obviously not the same day of the consultation, but the patient normally will thumb them down or they'll give me their, their feedback saying, you know, I like it, but I was hoping for a little bit more slope or more tip projection. I don't want my tip to go off that high.

And then you get into this conversation about what I deliver, what I can't deliver, what's realistic, what's not realistic. I think that's really important in a revision patient. . And sometimes I'll tell the patient, I just don't think this a, a, this is, I don't think what they're asking for something can provide them.

And in some cases they're like, I'm okay, but at least I have this conversation. Like I said before, I think with revision patient, a lot of it's about the preoperative discussion that you have with them. You don't wanna have a moment in the post-op where you and them are saying, oh, we never talked about this, or, I wish I had said this to you before.

[00:28:09] Dr. Sam Jejurikar: Looks like you have one more case for us, Josh.

[00:28:11] Dr. Yash Avashia: Yeah, do, do we have time for one more case? Yeah, I think we can do one more. Okay. Yeah. So this one is a great, you know, example of where clothes rhinoplasty was done about 10 years ago, and she just didn't have any tip support. And so what is happening was without proper structure, The form was deformed over the course of the years.

And so you can imagine her tip, her soft tissue just contracted and pulled her tip up and came to me saying that I feel like I look like a pig. I feel like I can see way to my nostrils. And, and, and she had, she, I mean, that is something that I definitely saw. So it made sense. She had weakness, had herself triangles, and that just comes from lack of support, lack structure, not able to hold the form that she.

So in her case, again, we did an open approach round fee, and I had to, I ended up using, again, my workhorse was the SEP attention graft. In addition to other thing we had to do for her to help restore her dress lines and kind of set the tip to where we want it to be. So she has that definition, she has that rotation, and in case she needed a little bit of projection as well she had prior aler flare reductions that were visible.

We attempted to revise that. So it's a little bit more less, less noticeable where I kind of leave the scars and, you know, she's about two years post-op and she's pleased with the result. But I think the most important thing is verbal to her to bring her tip down, bring it out a little bit, and then kind of more of a profile.

She felt she didn't have that pre opportunity.

[00:29:54] Dr. Sam Jejurikar: Yeah. Well, you've done a really nice job with her, with her taking someone who looked very operated on and someone who looked much more natural, so to be commended. Thank you. Well, you know, you know, thank you so much, Josh, for that discussion. I think hopefully the viewers.

Have an idea of just how much more complicated secondary rhinoplasty is than primary rhinoplasty, which is in and of itself pretty complicated. And if you, you pay, you know, and I think that sort of the underlying theme amongst all your cases is you pay attention to the underlying form, the underlying structure.

You can oftentimes give patient the aesthetics they want. Thank you so much for, for your time and taking us down that journey. Do you guys have anything else you want to add?

[00:30:32] Dr. Sam Rhee: I think it's just amazing that the, one of the key points is just, you know, the preoperative. Melding of minds between you and the patient and making sure that you guys are on the same page and that you can achieve the results that both of you want.

And that's, that it seems like is so important for all plastic surgeons for any procedure, but particularly in a revision rhinoplasty case. Case.

[00:30:58] Dr. Yash Avashia: So true. Yeah. Well, thank you for having me. Really enjoyed it really. Thanks, Josh.

[00:31:05] Dr. Sam Jejurikar: Thanks Ash. For sure.