So I know most of you at this conference are not doing rhinoplasty and its not a significant part of your practice So this talk is really dedicated to knowledge because your patients are going to ask you about it whether you do rhinoplasty or not, your patients are getting it done. So, its mostly just to kind of give you an oversight on the options that are out there. I would like to thank my mentors because with rhinoplasty you don’t get anywhere without your mentors. So Dr. Raj Kanodia who is also my partner and practice As well as Dr. Norman Pastorek and Eugene Tardy who is everyone’s mentor technically. Without these guys you kind of don’t have a career in rhinoplasty so I would like to really thank my mentors. So you may not perform rhinoplasty, but your patients are getting it done So in 2016, this is data from ASPS, 223,000 rhinoplasties were performed Of those, 75% were females and it is important to flip that number That means 25% are males so 1 out of every 4 rhinoplasties are being performed on males. It’s the number 1 surgical procedure for patients aged 13 to 19 So if you have younger patients coming in for any reason they are definitely thinking about and mentally contemplating getting rhinoplasty or having one. It’s the number 2 procedure, surgical procedure, performed for patients 20-29 So anyone, 30 and under are thinking about it whether they have done it, not done it, never going to do it, it is something on their mind. So as a provider, whether you are an aesthetician, or a nurse, or a doctor, whatever you are It is important to at least understand that this is something your patients may be wondering about and it is good for you to have an idea of who you might refer them to in your local area Because who you refer them to in your local area will also feed back based on the results they get It is the number 3 procedure for ages 30-39 and the number 5 procedure aged 40-54 so of course as you get older other procedures like facelifts, lipo, tummy tuck, and breast start to pick up, but it’s still the number 5 procedure being performed all the way up to age 54. So it’s pretty impressive and something that everyone is talking about it and it’s happening a lot so it is just something to be aware of So the only reason I even bring up this topic is because the people who do closed rhinoplasty, their is a lot of them who still do it, but every surgery is the world is moving toward Minimally Invasive except for Rhinoplasty heart surgery, we all try to do minimally invasive heart surgery Spine surgery, we used to do huge traditional open surgeries and now we are doing minimally invasive spine surgeries. Abdominal, OBGYN, used to be done open and now its all being done with scopes laparoscopically. Skull base, pituitary tumors, used to be all done open with craniotomies and now what we are doing is skull base scopes and endoscopic fesses through the sphenoid sinus But with rhinoplasty, I would estimate, I’m guesstimating, I would say that 90-95% something around there is being done open And there is probably 100 to 150 surgeons who do a high volume of closed rhinoplasties left in America in each major city probably has 5 to 10 really good surgeons who do really exceptional closed rhinoplasty work But I think the importance is most people don’t even know that there is a difference So what it comes down to is this really a small difference in terms of the anatomy Open rhinoplasty just means that you are making a little cut at the columella You are lifting up the hood of the nose and you are doing all the stuff you need to do Closed rhinoplasty, the only difference, is that you do not make that little cut at the base of the nose That’s the only difference. Closed rhinoplasty, everything is done through tiny incisions on the inside the nose and you are able to do almost the same maneuvers without causing the little cut at the base of the nose What I want to show you is 6 days after closed rhinoplasty Minimal to any bruising Wow it looks so good! I love it! Blown away! It’s amazing! So happy! It’s still me, but like better We tell patients day 6 or 7 they can plan to literally go out for dinner that evening with a little makeup and they shouldn’t have any problems No one should even know that they had anything done, so I am just going to show you some patients the day their casts came off Just so you can see how minimal a rhinoplasty can be, it doesn’t have to be a huge dramatic thing And again I’m talking about primary cosmetic rhinoplasty and so I’ll talk about the importance and need of open rhinoplasty First peak.. Wow! Oh my God! It looks so great, it’s exactly what I wanted I am blown away! It’s amazing! Oooh! That is so cool! So cool! Yay! Oh it looks so good! Oh my God! I love it! It’s me just better, just refined. I can’t even stop looking at myself Was it painful? No not at all! Patient-I love it! Dr. Dugar-You like It? Patient-I do! I’m so happy! Ok, I have to take pictures now, everyone is telling me to take pictures before it swells up Yea, like, it doesn’t look done Oh my Gosh! It looks so good! And it is still me, but like better! It’s still me, but better. So that is the whole concept of the rhinoplasty. So open rhinoplasty is very necessary. Of course, everyone does it and it is very important for revision surgery, reconstructive surgery, difficult anatomy there is no question It is an important part of our practice But the key is to understand there are different types of rhinoplasty and I think the average provider when they are referring patients they don’t realize that and that is all this talk is about just to give everyone the education that there are multiple types of rhinoplasty So not everyone is a candidate for closed or “scarless nose” So is the little tiny incision at the base of the nose really what we are all talking about No, not at all that has nothing to do with it. That little incision usually heals totally fine, it’s usually not the concept What’s the difference is really it comes down to the philosophy Open rhinoplasty, you do view the structures much better so you have an ability to change and alter the nose to a significant degree and that is completely necessary for a lot of patients but for your patients who come in and want simple finesse refinement just a little bit taken off their bridge, a little refinement to the tip, scarless rhinoplasty, scarless nose you get a much better view of the face during the procedure You’re not just looking at just the upper level or lower level or the cartilage you are looking at the entire face so you can finesse and enhance the nose without changing it so it’s about refinement, not change and you preserve the character and integrity of the nose by doing finesse minimal rhinoplasty and not everyone can use this, but those patients that can should get this operation So how does it work? You make little tiny incisions inside the nose. Visualization is a huge thing everyone talks about. For most patients I would say visualization is not a problem you get adequate visualization of the upper and middle third of the nose You can deliver the tip out of the nose to see almost everything. There is value in doing traditional open rhinoplasty because things are still in sight too you’re not pulling the tip out of the nose but in general, you can see almost everything Fixing the breathing is pretty much mandatory, usually we will always accompany septoplasty with our surgeries And we use that for two reasons. One to fix the septum to make sure it’s totally straight if needed not always and then two, because we use the cartilage to do grafting So, one thing that almost every surgeon who does rhinoplasty does is called spreader grafts and this is a very common procedure that almost every surgeon does when they do rhinoplasty What a spreader graft is, is basically it’s a small piece of cartilage that we usually take from the septum carve it into little pieces, and stick it inside the nasal valve area and what that does is it acts like a spreader graft just in the way a BreatheRight strip does So when you use a BreatheRight strip at night it’s lifting, trampolining your lateral nasal passages open That’s the internal nasal valve that is collapsing that is now opening, same concept that we are doing with cartilage grafts for a permanent “BreatheRight” strip and that is something that something that is used ubiquitously across rhinoplasty surgeons but my hope, and the issue and the dilemma is when you see a face like this, someone like her comes in beautiful face, doesn’t really need much of anything, she might be in your clinic for injections, for botox, she might go in for her breast, she may go for lasers and she says ,”hey, you know I want to get my nose done.” What should she get done? and my whole point is that I don’t think she needs a lot done. I think she has a great face to the point where she almost doesn’t even need to have her nose done So, if you are going to do something to her nose, it has to be so minimal and it has to be done without inflicting a permanent scar for no reason Open rhinoplasty, very important, it should be done when necessary, but it should not be done unnecessarily So this is her six months later, just a little finesse to her bridge This is her from the front, we did a little bit of finessing to her tip, straightening the profile and narrowing her bones just a touch and that’s the point, she doesn’t look different, nobody knows She told me that she went home and nobody, none of her friends and none of her family knows. and so time after time, we are just going through a few cases just to understand the concept a girl like this walks in, same thing, beautiful face, definitely could use a rhinoplasty. We could all agree from her profile view but again, it is not something that has to be done this is her immediately after the cast came off, a little swollen, but you see much smaller deep projected, softer bridge, and this is her texting me pictures about six months later loving her profile, bragging about it, telling all her friends. She is obviously not shy about it but, the concept is that it can be done, without making the external incision which it should, the way heart surgery, brain surgery, abdominal surgery, OBGYN surgeries, spine surgeries all going to the minimally invasive. Why our noses? So, people argue well what about very difficult noses? You are showing much easy noses What about hard noses where you have a really tough tip that is asymmetric, bulbous, left side smaller than the right side, it’s really wide, the domes are not together I think these can also be done closed, so this is what she looks like before the surgery, You take the domes, you take the tip out of the nose, this is called a delivery technique and you notice the tips are very asymmetric they have nothing to do with each other almost and you do some procedures to kind of finesse and refine the tip you can do cartilage shortening techniques, you can do cartilage lengthening you can put grafts to construct and help build the side walls you can do columellar graft to help lift the tip of the nose, there is all types of techniques What we did for her is basically a shortening technique to help pull the tip back and give her a little extra rotation we basically split the cartilage, lift it up, and then you are going to overlap it and you’re going to suture it and what that does is you create the great on the inside? you create a much more refined tip that you then put together and then when you have it done you have a much more delicate balance and then these are her photos 6 weeks later where you have just a much more refined tip not a major change, most people wouldn’t even notice she had anything done to be completely honest but, a much more refined looking nose from all views much more fine, smaller, more delicate it just looks like it fits her face much better and the ability to do that without inflicting a permanent scar at the base of her nose I think is extremely beneficial If it’s possible to do, it’s not always possible but when it is it’s a good thing to be able to have in your back of your head as an option for your patients if they ever ask you What about crooked noses? Sometimes noses can be extremely crooked can you fix that with a closed scarless rhinoplasty? The answer is yes you can do mobilization of the nasal bone mobilization of the septum with asymmetric spreader grafts that you can straighten the nose as well What about someone who has a big bulbous tip? and that is the only complaint. Otherwise, a beautiful nose doesn’t need anything else done You can de bulk the tip of the nose just to give them a little bit of definition. You see on the right hand side just a little bit of definition of the tip and sometimes that is all it takes. Yes, could we have done more to the nose? Of course? But why? It wouldn’t have necessarily given her a better result, it wouldn’t necessarily make her any happier So the key sometimes is less is more and that’s the whole concept behind a scarless nose and the minimal philosophy You take this nose for example, beautiful nose just a little bit of a bump on the bridge Otherwise, she has a very pretty nose almost to the point where you would say “Don’t do it” What we did is very minimal surgery where we use osteotomes just to lift that little piece of bone out That’s that little piece of bone we removed, that’s literally almost all we did we did a little cartilage shaving, that’s it This is her after the surgery, and this is her the day the cast came off such a minimum finesse change you should be able to do this with 6 days of a cast, no significant down time, no significant pain no nasal packing and she doesn’t have to have any significant scarring or risk of scarring at the base of the nose for something so easy So, it’s not always possible, but when it is a patient like this You would say, hey you’re beautiful please get out of my clinic, and she comes back and you say it again Hey listen you shouldn’t do anything please go, she comes back again, and she says listen I just don’t like how my nose droops. Ok! So finally you are put in a corner, and you say ok listen I would rather do it than have you go out and get butchered You take her in and you lift it just a little bit and that’s all we did on her nose just a subtle small lift of the nose, and by doing it you’re able to give her what she views as purposeful without making significant change to her nose The front of her nose is more or less the same we straightened it just a little bit and then from the Three-Quarters you really see how we shortened the nose just so it fits her face a little better and she doesn’t feel like her nose is almost leading her face Beautiful girl by any means necessary. So then you do get difficult noses, noses like this, that potentially should be better, could be better corrected with open rhinoplasty, but again you can even do noses like this She naturally was born like this, this is not a revision case, she was naturally born with almost no dorsal bridge, almost an asian nose, and then this tip that swoops up So, we did the same kind of concept with her except instead of doing shortening laterally, we did shortening medially So we dropped the tip down by shortening it medially and we were able from the bottom picture, which is her pre-op, we did take it on a table You can see how we created a much more normal contour for her nose Six months later we straightened her breathing and corrected her septum deviations and we were able to get a much more natural looking profile It is not a significant change because we are not doing any significant alterations to her nose but it is a finesse minimalistic change that makes her feel more comfortable with her nose without the risk of external scarring Wide bones, it can be done in 6 minutes, it’s a very simple thing Any rhinoplasty surgeon can do this, this is not something that is special to me but the point is all of this can be done without any external scars everything can be done from inside the nose Nasal tip that are boxy and wide can be finessed from all views You can have tips like this that you can finesse You can have little small indents in the nose that you can fix with small grafts All of this can be done from the scarless technique Sometimes, the smallest taking, out just a tiny little piece of cartilage out just to finesse the nose without making any major alterations or changes to the nose This is another example, a patient who is two weeks post-op beautiful face, beautiful nose, she was actually getting married at the end of the month and she just wanted a simple change. She said, will my dad notice? I don’t want my dad to notice and we did it, and her dad doesn’t notice, her mom does of course because mom’s are hard to fool, but the dad didn’t notice and so you see, it’s not major change we are just doing a finesse, minimalistic change in the nose To give her that appreciation that she should already have for her face without doing any major complex work to it and that’s the key, I think a lot of noses can be done complicated or they can be done simple. Some need complicated, but the ones that need to be treated simply should be and that is something that you as a provider should know as their options So this is a nose I told her no twice and unfortunately she works in my building upstairs so at some time I had to give in and we did her nose, and literally this is what we did, You can’t even tell almost unless you are really staring at the photo We just shaved it down half a millimeter and she could not be more thrilled about the results Literally half a millimeter maybe a millimeter of shading of her profile and we did just a little tweaking to her tip, which I will show you on another view and just by doing minimal tiny alterations the finesse rhinoplasty skill that’s what gives you these results without any major changes they still look exactly like themselves Another beautiful model who came to see me recently, and I don’t even want to touch her nose I think she looks beautiful, I think she looks great, I like strong profiles in general I’m a naturalist, but again, it’s because of social media, because of selfies, this that They want something done, and the key is to preserve this to make this into a pointy tip, and to totally change her nose just because you can, I think is totally wrong The key is to do as little as you can and that is all we did with her just mildly finesse the image? just to give her a little result So I am out of time, but the whole concept of today’s point is just to say that things that should be done, should be done, and things don’t have to be done, don’t have to be done. Think about finesse, closed, scarless rhinoplasty, for your patients if needed.