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

Doreen Wu (00:00):
Welcome to another episode of Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your cohost Doreen Wu. I'm excited to be here with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator, as well as our guest, Dr. Jason Bloom, a facial plastic surgeon from Bryn Mawr, Pennsylvania. The title of today's episode is "The Expert Always Knows: Discovering the Right Option For Your Rhinoplasty." Today's episode is all about the rhinoplasty. Also known as a nose job. Why is the surgery so popular? What are the main techniques? What should I expect as a patient experience? Is this something that is only for teenagers, I'm going to find out about these issues and more from our two experts. First, Dr. Bass, where does the procedure come from? Tell us the history.

Dr. Lawrence Bass (00:54):
Modern rhinoplasty really began with a surgeon named Jacques Joseph, who was training in Berlin in orthopedic surgery. Uh, but his training was abruptly stopped when without authorization, he did a prominent ear surgery on a young boy and his orthopedic professor, uh, discharged him from training, but he pursued his interest in beauty surgery and developed the modern techniques that we use in rhinoplasty with endonasal incisions, incisions inside the nose, and many of the instruments he developed to enable surgeons to do rhinoplasty surgery are still used when we operate today.

Doreen Wu (01:48):
Dr. Bloom, why is the rhinoplasty such a popular procedure and what is it designed to do?

Dr. Jason Bloom (01:54):
So there are many different things that we can do with rhinoplasty. I think it's popularized really because, um, it's sitting right in the middle of your face. And, certainly from an aesthetic standpoint, there are a few things that patients come. At least to me, into me to see in my office, probably the most common is like a bump, a dorsal or a bridge bump, or a, a hook on the side in the profile. They want to change that profile, droopiness in the tip. They want to lift that up with. So whether it's the tip being too wide or the nostrils being too wide, we can do things with the bone, the cartilages and the soft tissues in order to narrow the nose in order to improve the profile in order to support the the tip in order to give it a more aesthetic.

Dr. Jason Bloom (02:52):
Look now the secondary thing too. And in some cases, this would be the primary reason why people come in is for breathing. Certainly the nasal airway is really important. I trained before I did my facial plastic fellowship. I did my ENT ear nose and throat surgery at University of Pennsylvania. And I tell patients, I want to, I'm not going to just make your nose look good, but I'm going to make your nose breathe as good as it does now or better. And so it's important to understand the function of the nose and how it works. And the nasal airway to make patients either breathe better or the same that they came in.

Doreen Wu (03:33):
Let's move on to the techniques that are involved. How is a rhinoplasty performed? There's this big split between an open rhinoplasty versus a closed one? What is the difference?

Dr. Lawrence Bass (03:44):
So the rhinoplasty is designed to adjust the cartilage and bone framework over which the skin is draped to alter the appearance and position of different parts of the nose. Classically, as I mentioned with Dr. Joseph in Berlin, this was done endonasal or through incisions that were solely inside the nostrils. So there were no incisions on the outside where anyone could see them techniques were developed in the 1980s and beyond. And prior to that used in cleft rhinoplasty surgery, rhinoplasty in children who had cleft lip and palate, but these were generalized to open rhinoplasty techniques were cosmetic uses where a small incision is made in the columella, the piece of skin in between the two nostrils in the center. And that incision extends up to the inside of the nostrils or rim incision inside the nostrils to allow access to the nose. And that allows the surgeon to visualize the anatomy inside the nose in ways that they can't in a closed or I rhinoplasty. So these are the two primary main approaches that are used, uh, for rhinoplasty surgery today

Dr. Jason Bloom (05:59):
In general, my practice, I do close to around 200 rhinoplasties a year. It is by far my most common surgery. And I would say my, for my primary first time, rhinoplasties I do about 95% of them through an endonasal or a closed approach, as you were saying. 25% of all the rhinoplasties I do are revisions. And I tend to do 95% of my revision rhinoplasty through an open approach. And so that's the hard thing. And I'll explain the reasons why I like the endonasals, and we can go into that for a primary case with a few exceptions. And we can talk about what are some of the things that I would open a primary nose in my hands, but there's not necessarily a better or a worse, you know, a worse approach. It's what works well in the hands of the surgeon and what they've been trained to do, and what throughout the years, like my, uh, you know, I've been in practice now for 12 years, what I I've seen my results and things that I used to do through an endonasal approach are now I, you know, in looking back at my results, there are some things that I now do open because I've seen this over the years.

Dr. Jason Bloom (07:28):
But the, the hardest thing we do, I think as you know, plastic surgeons and facial plastic surgeons is revision rhinoplasty or secondary rhinoplasty. And I was talking to my friend the other day, who happens to be, you were mentioning orthopedics, he's an orthopedic surgeon. And he said to me, you know, what is the most difficult surgery you do? And I said far and away, it's a revision rhinoplasty, mainly because, so for example, if he's had a guy who comes to him with has had an ACL repair, and now he needs a second one, and he really doesn't even need to necessarily see that patient, you know, he comes with an MRI and the CT scan, and he can see below the tissues. Now we're trained as plastic surgeons to do a physical examination and get a good idea of what is going on underneath the skin and soft tissue and kind of translate it in our heads as to what's going on. But honestly, we really don't truly know what's going on until we get in there. And that's one of the hardest things about secondary rhinoplasty is, you know, we can have a, an idea of what's going on in our head, and then we open things up and it's not till then that we really visualize the whole nose. And sometimes plans change right in the middle of surgery.

Dr. Lawrence Bass (08:58):
<laugh> and that's, that's just the tip of the iceberg of why rhinoplasty is challenging, because there's so much variation in what you can do to work on different portions of the nose. And what you might choose to do is going to be modulated by what the rest of the patient's face looks like, which is different in every individual. You want a nose that fits their face and by what their aesthetic preferences are as an individual, your orthopedic friend, if someone comes in with a bad hip, we know what that patient wants. They want a pain free hip that's strong and stable, and lets them go skiing or whatever their favorite sport is. But everyone wants something, a little different in a rhinoplasty. And so the number of per mutations of options is so great that this is part of the challenge in the procedure.

Dr. Lawrence Bass (10:03):
So I have to agree with you when I do a primary rhinoplasty, almost all of those are going to be done endonasal or closed because I can usually perform whatever maneuvers are planned, unless there's a particular unusual kind of cartilage grafting. There are a few circumstances where I'll open, but most of the time, those are going to be closed in the secondary rhinoplasty. I still do a significant portion closed, but a high percentage of those are going to be open. And often the original rhinoplasty was done by somebody else, not me. And so, I don't know, even if I've read their operative note exactly what I'm going to find in there, and that ability to look at the anatomy with the open approach is a benefit, but Dr. Bloom, maybe you can outline what some of the advantages are for a closed approach in terms of recovery and, and otherwise.

Dr. Jason Bloom (11:13):
Yeah. So when I, when I do an endonasal, or a closed approach rhinoplasty, I think there are some definite benefits. Number one, it's obviously scarless, right? There's no open incisions. And even when we do an open incision and make an incision or a cut along that part called the columella between the nostrils, I say only dogs and lovers can see it. It heals very well and it's kind of on the underside of the nose, but not having that and truly doing a scarless rhinoplasty is a benefit for patients because you do have to heal that incision. I think additionally, the benefits are, we're not totally devolving all of the tissues of the nose and that leads to swelling. You can get scar tissue formation a little bit more in these kind of cases when you open the nose.

Dr. Jason Bloom (12:10):
and just suturing the skin soft tissue envelope back, you can get asymmetries and things in the nostrils, um, which aren't there when you do an endonasal approach. I do in every one of my cases still deliver the tip. So I bring the tip cartilages out through the nostrils, work on them and then place them back in the nose. Some people make incisions inside the nostrils and don't deliver the tip if there's no tip work needed. Uh, even if I'm not doing a true tip work, you know, a tip modification, I still will deliver the cartilages to take a look at them and see if I can modify them in any way.

Dr. Lawrence Bass (12:59):
So I take a very similar approach and I think that that extra swelling and, you know, the tip will tend to be somewhat firm at first after a rhinoplasty and the number of months it's going to take for the tip to soften unquestionably is going to be considerably longer with an open approach totally than it is with an endonasal or closed approach. So if, if we need the open approach, because something has to be looked at or done or positioned or sutured in place, very precisely that can't be done endonasals, it's fair to open, but to add that extra recovery, if you don't need it, doesn't make a lot of sense to me.

Dr. Jason Bloom (13:45):
Yeah. I mean, I mean, that is totally true. You're not getting a rock hard tip like we do sometimes when we're adding a lot of cartilage grafting in a secondary rhinoplasty even, I will just say the two main reasons for me to open a primary nose are number one, a caudal septal deflection. That means the bottom of the septum. When you look up the nose is off into one of the nostrils and I have done these through endonasal or closed approaches and swinging the septum back to the midline. I, but when I look at it, I think I have seen a few of these patients back where the septum will just slowly migrate back to one side. So if I want to move the bottom part of the septum over to the midline and lock it into position, I tend to open those noses now. And the second one is if the nose is very highly rotated up and I need to rotate the nose down and give it additional length, and I need to add some kind of septal extension graft or something to push the tip of the nose in a counter rotated position. I need to add that cartilage on. It's easier for me to do that through an open approach. And I will say those are the main two reasons why I tend to open a primary nose at this point in my career.

Dr. Lawrence Bass (15:18):
Yeah. I think anytime you need to suture a cartilage graft and very precisely, you know, some surgeons will say they make a very form fitting pocket and they can slide the cartilage graft in just so exactly where they want it. But I think cartilage spends its entire life scheming ways to warp and distort whether it's during the initial healing or in the decades that follow the rhinoplasty. And so anything I can do to stabilize that positioning I think is worthwhile and you brought up actually another subject I wanted to wanted to discuss, which is when you choose to use a septal extension graft versus alternatives like columellar strut and spreader grafts, things like that. So how, how has your practice evolved and where have you landed on, on those options?

Dr. Jason Bloom (16:19):
Um, I tend to not use a lot of, uh, columellar strut grafts. However I do, as I was saying, if there's an over-rotated nose, either in a primary, or a revision case, I will use a septal extension graft. And that is by extending this part, the bottom or caudal portion of the septum and pushing it forward, you can take a nose that's over rotated or pushed up and give it more appropriate rotation. Now, there is a modification of a septal extension graft that has been popularized in Turkey, um, that a lot of people are doing recently and that's something called an ANSA banner. And what it is it's basically like a, it looks like a unicorn horn that will come off the anterior septal angle and it comes at 45 degrees. And then you can suture the tip to that. And basically what that's doing is helping to kind of extend the septum without with, in those cases where you might not have enough cartilage to do a true septal extension graft. It's allowing for counter rotation of the nose with stabilization at the same time.

Dr. Lawrence Bass (17:46):
Yeah. And I think in a lot of rhinoplasty that are secondary, where a lot of tissue has been resected or removed at the first procedure and there's contraction of the tip elements, you're trying to get projection, or you're trying to derotate the tip to a, to a more natural looking angle. You know, having trained and been brought up at, in the heyday of open rhinoplasty that was always columellar strut, columellar strut, columellar strut. But I think we've come to recognize that there's a lot of limitation in reality, to the ability of the columellar strut to project the tip or derotate the tip. And so I've increasingly gone over to septal extension graft as a more stable and stronger support if you will. But there are some downsides and, you know, the tip will never be as flexible and soft. So it's, it's a virtue, but it's also a flaw. You get the support you want, but it's not as naturally soft as an unoperated tip that's for sure.

Dr. Jason Bloom (19:06):
Totally. Yeah. I, I tend to see that a lot. I mean, the other thing that I like instead of a columellar strut graft when I'm using a septal extension graft, which I think is one of the, the strongest techniques in all rhinoplasty is something called a tongue and groove where we actually like imbricate the caudal aspect of the septum in between the, the medial crura of the lower lateral cartilages and create that stable support. So you get the septum straight and then you put the caudal, the caudal septum between the medial crura of the lower lateral cartilage and lock that into position that is a very stable setup. And doesn't allow for, you know, like you said, it doesn't allow for movement. It makes it a little bit more firm, but when we're looking for support, that really is one of my go-tos

Dr. Lawrence Bass (20:13):
And you know, that that's the location where the columellar strut would've been placed in for surgeons who were using that technique. So it makes sense to put it there, but to do you typically suture it there to stabilize it, or you just tuck it in and, and it holds

Dr. Jason Bloom (20:33):
If I'm doing an endonasal approach. I do what I call a modified tongue and groove, where I will retro dissect a pocket through my inter cartilaginous Hemitransfixon incision in between the two medial crura. And then I will, I, I mean, when we're doing endonasal, I use a dissolvable suture, like a 4-0 chromic to lock the septum in between those medial crura, when I'm doing it open and like a reconstructive nose to like lock it in, I will use a 5-0 Prolene. I will use a permanent suture.

Dr. Lawrence Bass (21:16):
And as we look at cartilage grafts, of course, often we borrow some cartilage from the septum, the cartilage plate that's in between the two nostrils, because it's nice and straight where ideally is straight, not, not in all cases. But again, in patients who have had a few previous surgeries, they may not have adequate cartilage there. So what's your strategy currently, if you need additional cartilage, are you using rib from the patient? Are you using cadaveric rib grafts or, or some other option?

Dr. Jason Bloom (21:56):
What I always say is it's important to replace, like for like, and what I mean by that is the nose is actually made up of two different types of cartilage. So you have soft, flexible cartilages in the tip that are fibroelastic cartilage that are found only really in the tip of your nose and in your ear, right. If you feel your ear, the ear cartilage is similar to the tip cartilage, and then there's the hard structural supportive cartilage that's found in the septum of your nose and in the rib that's limb cartilage. It's harder to, and some people do it, but I have found that it doesn't work as well to try to create support with a flexible fibroelastic part of the cartilage. So if I'm looking for support, I will typically use rib cartilage, well, septum being, if I, if the septum is there, I will use that as my primary cartilage source.

Dr. Jason Bloom (23:02):
Sure. If it's not there, then I will go to rib. I have harvested tons of ribs in my career. But now in the last five to seven years, I've gone almost exclusively to cadaveric rib. I have found, and now some of the places, it, it's still difficult to get these, and it's become more scarce and recent, in the recent year. But I have found cadaveric rib to carve exceptionally well. It is, I mean, now they're, they're fresh. They're not even frozen anymore. It works extremely well for what I need and, and it saves the patient, the pain of having a chest incision. Like once you harvest a rib, they're not even thinking about their nose anymore. It's like the pain that's coming from their chest. Yeah. And so I typically, if I'm looking for structural cartilage, I will use cadaveric rib. And then if I need like a, a tip deficit or a tip defect, and I need to reconstruct the tip, I will typically use ear cartilage and I harvest that from a patient.

Dr. Lawrence Bass (24:16):
And what do you, what do you think the long term fate of the cadaveric rib graft is or their downsides?

Dr. Jason Bloom (24:26):
I mean, it, uh, theoretically the, the, um, they, they talk of more risk of resorption and warping. I will tell you, uh, Russ Kridel wrote a great article using thousands of rib grafts, and he saw thought it was in, in this study, um, showed that there was no higher risk of absorption, uh, no higher significantly statistically significant risk of absorption or, um, or warping in a cadaveric rib versus a, autologous rib.

Dr. Lawrence Bass (25:02):
Yeah, I, I think especially for the non frozen ones, uh, that they're, if you can get 'em, they're advantageous and they're taking much more steps nowadays to ensure the flexibility of the cartilage, because a graft that comes from someone who's very elderly might be a little more brittle. So they're now explicitly factoring that into this selection and processing, which has been a big plus.

Dr. Jason Bloom (25:33):
The only downside of that is that it, they are very difficult to get at this point. And the they're all back ordered.

Dr. Lawrence Bass (25:40):
<laugh> I, I waited three and a half months recently to get one for a complex secondary reconstruction. So I I've had that experience as well. Uh, do you have a favorite approach or technique for the patient who needs a lot of dorsal augmentation?

Dr. Jason Bloom (26:00):
Yes. That has changed. I think for me, I used to take a rib and carve it like a single piece and slide it onto the bridge, what I have done well, and then in my fellowship, I was doing a lot of using diced cartilage and wrapping it in, uh, temporals fascia and sliding that in. And that being a softer approach to this dorsal graft, but what I've done in the last two to three years is I'm not even using the temporals fascia anymore. And I finally dice either me or my fellow will finally dice some cartilage down to almost like, I mean, it is almost like sand it's really, really small, small dicing, and then drips some fibrin sealant, some tisseel or artiss onto it, have it set. And what it does is, well, I'll take a three CC syringe and I'll cut it in half. And what it does is it makes like a canoe. We call it the glue canoe, and then I drip the fibrin sealant, the fibrin glue onto this diced cartilage. And it makes a perfect dorsal augmentation graft that I'm able to slide up there. You can actually carve it. And it's so much more flexible and easy, and it lasts, it's been phenomenal. So that's been my primary technique for the last probably five years.

Dr. Lawrence Bass (27:52):
Yeah, that's interesting because that was going to be my next question. What your thought was on diced cartilage, fascia grafting also known as the Turkish delight. But I can see where you come with that. I've, I've had the experience of, of having to revise those where I can go back and remove the entire graft that went in as little particles of cartilage, all chopped up as a single piece and recarve it, remold it and replace it, uh, as long as it's had enough healing time to properly consolidate. There is recovery time though, with that approach, when you put that graft in, there's going to be swelling for a while. It's not a, it's not a splint off at five days and go to the prom at, at 10 to 14 days kind of procedure.

Dr. Jason Bloom (28:49):
Totally.

Dr. Lawrence Bass (28:50):
So last, last question on technique, dorsal preservation, rhinoplasty. So this is a technique where the dorsum is preserved while underlying elements are pared down or reduced to create less projection. We just talked about making more projection in the dorsum, a stronger bridge to the nose. And now we're talking about taking it down when maybe there's a bump or it's too big. So this has been a trendy technique in the last few years. What are your thoughts, Dr. Bloom?

Dr. Jason Bloom (29:29):
Well, this is a technique that was coming out of Turkey, that they were doing it. And, you know, I have never been on the bandwagon for this yet. I mean, mainly because I don't have the training. It's not something that I haven't, I mean, I looked into some of this, their specific instrumentation that they're using for it. The, I mean, it's certainly been a hot topic. And interestingly, I think some of the Turkish surgeons who originally talked about this are no longer doing this technique, but where I worry about it is, uh, is for the breathing result because what you're doing is you're basically telescoping the nasal bones and tissues like inside themselves and dropping the whole nose back the bridge of the nose back. And I would say that if you do that, there has to be some detriment to breathing in those cases because you're taking like an open nasal airway and now you're, you're dropping nasal bones back inside of the previous structure. But again, I haven't been doing that in my practice. I know it's super hot right now. There are some interesting aspects of this surgery that I've been looking into. One of them being piezo, which is like an ultrasound device to help with more precise bony cuts. Certainly I'm more interested in that to try that out, but I haven't incorporated either of those techniques into my practice.

Dr. Lawrence Bass (31:21):
Yeah. It's interesting because we we've taken despite somewhat different training backgrounds, almost identical approaches in how we do these things. I, I think initially part of the idea of dorsal preservation was that you're not disrupting that, that hinge area between the upper lateral cartilage and, and the septum. But as you point out the collapse in of some of the structures that you are creating may actually have more impact on breathing than what you're protecting. Uh, my aesthetic thought on the technique, which is really, uh, why I haven't adopted it is that you have to really be in love with the appearance of the dorsum as it is, and just feel it's somewhat over projected. And if you really want to modify the appearance of the dorsum aside from just flattening it down somewhat, uh, then you're going to an awful lot of work, uh, to achieve that, or you're going to be unable to achieve that. So I don't think that represents a lot of the noses that I see. So I haven't jumped on board.

Dr. Jason Bloom (32:39):
I agree.

Doreen Wu (32:40):
So Dr. Bass, after our extensive discussion of rhinoplasties today, what are some important takeaways for our listeners to remember?

Dr. Lawrence Bass (32:48):
There's a bunch, actually, each nose is unique, as I mentioned, and each face is unique. So blending the patient's aesthetics with the other facial features is a big part of the job, uh, that the surgeon and patient have to accomplish in conjunction with each other often, small changes will make a big difference in the appearance of the nose, but recognize there's some unpredictability to the result that you get. Part of the challenge for rhinoplasty surgeons is that what you see at the end of the operation is not what you get when the nose is healed. And you have to recognize that that expected recovery is a long time to see the final shape, probably around a year for a primary rhinoplasty in two years for a secondary, but, you know, overall, I think it's important to pick a surgeon who's listening carefully to your wants and needs, uh, be real about how much predictability the operation has, uh, and look at the surgeons before and afters and see if your aesthetics and the surgeons are similar. And that will be more important than almost anything else in getting a good fit.

Doreen Wu (34:05):
Dr. Bloom, any takeaways to add?

Dr. Jason Bloom (34:07):
Yeah. I mean, I will echo what Dr. Bass said. I mean, I think it's so important. You know, when I'm consulting a patient and talking to them, I think it's really important to, I'm so much more upfront with them at this point in my career and explain that rhinoplasty is, you know, there are persistent asymmetries and irregularities that happen in every single one of these cases and noses aren't made of clay. They're made of bone and soft tissue and cartilage and all of these interactions between and how they heal. Like, all of these interactions does lead to some unpredictability. However, there's two things I like to do in the consult. One is I do like to do some computer imaging in that I always take the liberty of being the first person to do the computer imaging, because I want to show them something that I think would look good on their face and that I think I can do.

Dr. Jason Bloom (35:13):
And it's mainly to, to visualize the dorsum or the bridge and because they can kind of potentially say, oh, I, I want less of a slope or what, whatever it may be, but if they like that, and I think I can do that, then we're in aligned when we go to the operating room. So that's the first thing I'd like to get on the same page. As the patient, I think it's really important to achieving a good result. And then I also kind of have to explain to them that their nose is going to change. I want, it's going to take some time and they have to be realistic. I tell them, I think I can get your nose 90% better. And it's, this is like, if, if they're happy with that, 90% is a huge difference in their, you know, in their outcome, then they're a good candidate, but if they're going to sit and, and just agonize and really take away this beautiful result from them over the, the remaining five to 10% of their nose, you know, that's something we need to consider prior to moving forward with any surgery.

Dr. Lawrence Bass (36:29):
Well, Dr. Bloom, I'd like to thank you for joining us on the podcast again today. And you are really a master of rhinoplasty your anatomic and technical knowledge right up to the cutting edge of what's being done today, along with, uh, incredibly good clinical judgment. And not just because you take a lot of the same approaches I do. <laugh>, but it's really a pleasure to have a chance to talk these issues back and forth a little bit with, with you.

Dr. Jason Bloom (37:02):
Well, thank you so much for having me.

Doreen Wu (37:04):
Thank you, Dr. Bloom, again, for sharing all of your insight and your wealth of knowledge with us today, and thank you to our listeners for joining us to hear about this surprisingly complicated subject. I hope you found this episode as informative and interesting as I did. If you think of other exciting developments in plastic surgery that you would like to see us discuss in upcoming episodes, please reach out by email or Instagram. We'll see you next time. This is Doreen Wu, thanking you for joining Dr. Bass, Dr. Bloom, and me for this discussion of rhinoplasty techniques. Be sure to tune in next time. And don't forget to subscribe to our podcast, to stay up to date with all of the exciting content that is coming your way.

Speaker 4 (37:43):
Thank you for joining us in this episode of the Park Avenue plastic surgery class podcast with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather general information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor-patient relationship is established by listening to or participating in this podcast, consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.