Dr. Sam Jejurikar: Welcome, everyone, to yet another episode of Three Plastic Surgeons And A Microphone. As always, I’m joined by my two co-hosts, Dr. Salvatore Pacella in La Jolla, California. You can find him @sandiegoplasticsurgeon, and Dr. Sam Rhee from Paramus, New Jersey, @bergencosmetic. And as always, I am Sam Jejurikar. Today, we have a very exciting topic where we are going to talk about revision rhinoplasty. We’ve talked about rhinoplasty on a few occasions, but we’re gonna talk about what to do when rhinoplasties go wrong. Before we get into our guest, who you see sitting in the bottom right corner, we’re gonna just go over our usual laundry list of matters. Sam?
Dr.Sam Rhee: Thanks. 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 healthcare provider with any questions you might have regarding medical care, and never disregard professional medical advice or delay seeking advice because of something you may have heard on this show. Back to you, Sam.
Dr. Sam Jejurikar: So, today we’re joined by Dr. Yash Avashia , who is known throughout the Dallas community as Dr. Yash. Now, I have been fortunate to know yash for about 5 years, both during his aesthetic surgery fellowship, and as he’s very quickly built a booming rhinoplasty practice here in Dallas. Yash makes no secret that his passion is rhinoplasty, surgery, and facial aesthetics, and he has already built a following of revision rhinoplasty. So, today we’re going to talk about revision rhinoplasty. So, welcome to the podcast, Yash.
What’s revision rhinoplasty?
Dr. Yash Avashia: Thanks, Sam. Really appreciate you guys having me on the podcast. It’s a privilege. I’m really excited about the discussion. Rhinoplasty is a huge
. I love rhinoplasties, and I think revision rhinoplasty is kind of the next level in rhinoplasty. Everything that is complex about rhinoplasty, I think revision rhinoplasty is even more complex, and I’m excited about the discussion we’re gonna have today.
Dr. Sam Jejurikar: So, what are the reasons patients come to you, saying, ‘I’ve had my nose done, I’m unhappy with it.’ What are common scenarios that you see?
Dr. Yash Avashia: You know, the most frequent ones, I think, is – one is a functional problem. People can come sometimes with a cosmetic deformity, but when you have a functional obstruction, that’s the hard stuff for a lot of patients. And that’s one of the more common reasons patients come in for revision rhinoplasty. And other than that, it would be a cosmetic reason. It could either be a dorsal deformity, , or they just want more of what they originally wanted to have done. The problem is that rhinoplasties can be done in so many different ways. We have open rhinoplasty, there’s a new idea or philosophy in rhinoplasty called preservation rhinoplasty, and then there’s a difference between one surgeon and another surgeon. So, even though overall the plan is about the same, the end result is always gonna be different. So, I feel bad for patients who sometimes may not have what they’re looking for after their first rhinoplasty, and it leads them to seek out a revision.
Dr. Sam Jejurikar: So, for our listeners, revision rhinoplasty is substantially more complicated than traditional rhinoplasty. 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 may have an operative note to refer to, 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 them? We’re gonna do this open, we’re gonna do this closed – what’s your technique and approach to this?
Three Stages of Revision Rhino Patient Care
Dr.Yash Avashia: That’s a great point. I think the three stages of taking care of a revision rhino patient, the first one being the pre-op, the second one being the inter-op and the third one being post-op, I spent 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 and redirect that patient from being upset, focusing on the surgeon or surgeons in the past, to more or less on their nose. And that’s a challenge in many cases with revision patients. I always tell the patient, if I don’t see it, and if I can’t deliver what you’re looking for, I’m probably not the right surgeon for you. And I think that’s really important for revision patients, to be very honest. It’s almost the most important thing, in my opinion, it’s being as clear and honest with your patient upfront.
And I think they appreciate that too, ultimately. They’re looking for the person to do their revision. They’ve gone through this maybe one, two, three times, and they don’t want it again. I think a rhinoplasty is a tough enough operation experience as a patient, and they’re doing it again a few times – you don’t want to skid out with them. You want to make sure you can deliver it. So, I tell them, if I can’t see it, if I don’t appreciate the difference that I can give you, then I’m 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 them that. Because I think it’s important to hear that from another plastic surgeon. 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 feel.
An Open Approach to Rhinoplasty
The second thing I always tell patients is, I will always do an open approach for revision rhinoplasty. The more common reasons why I see patients come in- originally they had a closed rhinoplasty. And I’m not dogged on closed rhinoplasty. I think, in the right patient, it’s a great operation. The only problem with closed rhinoplasty in my opinion is, you need a really good surgeon to do a closed rhinoplasty. Take for example, you’ve got a field goal to win the game, and you put a blindfold on. If you’ve kicked 1000 field goals, you’ll probably sink it. If you’ve only done a few, you’ll probably miss it. And that’s what I think about closed rhinoplasty. There’s so many complexities to the nose, the benefit of doing an open approach is that you see the anatomy right there and then. And when surgeons have done a closed rhinoplasty, sometimes they’re not seeing everything, and you see that when you open the nose the second time around for revision. 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. That’s just my opinion. I know that’s really , but I tell the patients I’m going to do an open approach.
Dr. Sam Jejurikar: Dr. Pacella, you do a lot of revision rhinoplasty. Do you always do open for your revisions as well?
Dr. Sal Pacella: 100%, all the time. What I tell my patients is- I think about the bone and cartilage as a hand, and the skin is a glove. So, if you’re borrowing somebody else’s gloves, you put them on, many times they don’t fit.
Dr.Sam Jejurikar: So you must acquit.
Dr.Sam Jejurikar: I got confused, I’m sorry.
Dr.Yash Avashia: We’re still talking about plastic…
The Challenges of Closed Rhinoplasty
Dr. Sal Pacella: The skin wants to do what it wants to do, and I feel like the challenge many times in closed rhinoplasty is when you’re seeing some of these external deformities of the skin, the skin has already been trained as sort of a 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 and gloves, you really need, structurally, much better support. Which brings me to the question: what role do you see for the imagining – CT scans, etc.? I’ve found, a lot of times, with functional issues, don’t get any imaging, I’ll oftentimes uncover a large septal spur that I couldn’t really identify on the pre-op exam. I’m gonna have a follow-up question.
Dr.Yash Avashia: So, pre-op I’ll only really do it if the patient has had prior trauma, or there’s such a severe deformity that I can palpate in an exam. I do an anterior rhinoscopy with the speculum. I don’t normally do an endoscope exam. That’s the difference between and ENT. So, I’m not really posterior. For me, for CTs, really all they will tell me is if they’ve had chronic infections, and whether or not my functional rhinoplasty with the treated or not. But for a revision patient, I rarely will do a CT pre-op. I do in the office like most people would, but I don’t usually do a CT or anything like that.
Dr.Sal Pacella: You know, I decided to use CT for a couple of reasons in revision patients. Number one, a lot of these patients, as you mentioned, they often have functional issues, and sometimes in my evaluation it’s very difficult to see what the difference of the role of a crooked septum or a nasal spur is, compared to large turbinates. I think it’s very challenging sometimes to really understand how the turbinates are affecting air flow. The second reason is, I see a lot of referral patients who may have had an ENT . You know, I agree, the septum is the premier donor site for cartilaginous support that we use. I think the CT helps me quite a bit ahead of time to understand what cartilage I can work with. Because oftentimes, when I’m doing something like this, I’m doing a columellar strut grafts, spreader grafts, alar batten grafts, tip grafts, etc. So, your thoughts on that.
Dr. Yash Avashia: I think, ultimately, there are some endpoints that we need to get before we operate. I think that’s what you’re highlighting. You don’t step into the operating room without having all the information, all the data that you can get. And I think understanding how much cartilage you have in the septum is a really big, important thing. Like you said, even an EMT-based septoplasty, you still see a lot of septum in there. Believe it or not, like you implied there. And I think it’s good to know before you start going after , or whether you’re getting cadaveric grafts for the patient. CT scanning, I tend to use the anterior rhinoscopy 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- that’s the third thing I always tell the patient. I’m gonna prepare you for using, or getting a graft for your . I don’t typically go after their rib, I tend to always use cadaveric rib grafts. But I always tell them, if they come for a secondary, or tertiary, or whatever it is rhinoplasty, prepare yourself for a rib graft, because I don’t wanna do a where I don’t have all my tools available to give you the results you’re looking for.
Dr. Sam Jejurikar: I wanna make this just a little 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. Earlier you used the term ‘preservation rhinoplasty’. Sal named a bunch of different cartilage grafts that you would use. You both are saying that when you’re doing revision rhinoplasty, so a secondary, tertiary, or whatever 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 the framework back up. Can you just explain to the viewers why that’s important, and what’s the rationale behind that?
Why proper foundation for the nose surgery is important?
Dr. Yash Avashia: To simplify, I think we’re talk about two things: form and function, revision rhinoplasty. So, function, whether you can breathe properly or not. Can you get air properly through your nose? That’s function. And then form, the aesthetics, the shape, the appearance. And in my opinion, I think structure precedes function and form, more importantly in a revision. And that’s why, really make sure you have the right structure during your original rhinoplasty report. Now, one of the frameworks, or part of the framework for a nose is cartilage. The bone and cartilage, realistically. There’s different types of cartilage. There’s the upper lateral cartilage, the lower lateral cartilages, they all have different purposes from a functional and cosmetic 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 common position quality. It’s been violated from prior surgery. And so, you need to use cartilage to support it and restore it. And then technically goes to, where are you going to get the cartilage from? And I think Sal had mentioned, the septum is definitely the largest workhorse for rhinoplasty. And sometimes, if you don’t have cartilage there, where else do you go? And I think that leads us to what I mentioned before, about using rib cartilage, essentially.
Dr. Sal Pacella: You know, it’s interesting, Yash. I really love and enjoy challenging rhinoplasties, and you’re clearly the same way. It just kinda opens up, and we start-
Dr. Sal Pacella: It’s a discipline in and of itself, of plastic surgery. You really have to jump in full steam. A couple of points. For years I was doing cartilaginous grafts. A few years ago there was kind of a push towards using frozen rib cartilage. And honestly, I think that’s been a game changer. It seems it acts a lot differently than the patient’s inherent rib cartilage. You know as well as I do, when you harvest rib cartilage, and cutting fine little slits and structure oftentimes can work. Frozen cartilage doesn’t necessarily do that. It oftentimes can really stay super, super straight. And so, that has really had a huge impact on my practice. Your thoughts on that.
Dr.Yash Avashia: I totally agree. I think a lot can be said about it. 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, you’re not going to get exactly, like you said, the cartilage you may want. It may warp over time, it may bend. And then, when you’re dealing with that secondary consequence after spending, you know, 30-40 minutes harvesting and preparing a rib graft. I think that’s a huge benefit. And time. Time 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 are the reasons why I always go for fresh frozen allografts, essential. Now, I like the sheet grafts, in general. I think it’s already cutting, taking away a step that you’re gonna have to do anyways.
And so, you can have a nice, prepared shape for you, and you can kind of, carve that and shape that to whatever you want. For patients that need a lot of cartilage, I’ll actually get the segment and use it for whatever I need it for. But in most cases, I’m using a sheet allograft. And I think that has revolutionized revision rhinoplasty. I don’t think you have to go after a rib.
Dr. Sam Rhee: Let me ask this: both you and Sal have a real interest in rhinoplasty, but I don’t think people understand, 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 a whole different 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 open up a nose and you’re opening up that surgical field, and then the second time it takes 10 times longer to get through all of that scar tissue to figure out what’s going on. And I can’t even imagine- I think maybe I’ve done one three-time revision on my own, or maybe twice, because you can’t figure out where anything is. It’s just an unholy mess in that nose.
There’s a reason my Michael Jackson’s nose looked the way it did, because everytime you go in, it just complicates things tenfold. So, what made you decide, this is something I want to do, I want to sit here for hours, opening up this nose and trying to figure out what’s going on with it? What made that something that appealed to you?
How Yash Avashia found solace in nose surgery
Dr. Yash Avashia: I think it’s a great question, actually. I go to sleep dreaming about rhinoplasty, honestly. To be frank, it’s way more challenging to plan a rhinoplasty because of the things you said. You know. you’re dealing with abnormal anatomy at this point, there’s a lot of unknowns. I think, with a primary rhinoplasty, you see the even nose, you examine it, you have a very good understanding of what you’re probably going to deal with, because there are certain trends in ethnicities and anatomy. You have a lot of information at your disposal in the preoperative phase. So, when you go in the operating room there’s not many surprises, for the most part. In a revision case, I’d say that there is a lot of discovery in the actual surgery. And that is not abnormal, and that is not wrong to say. It shouldn’t scare the patient.
That’s the truth. You gotta have all your tools in your toolbox and available when you go to the operating room. I basically do an inter-op time out. I elevate the skin, try to get through all the scar tissue , and then you do like a mental time out, and you see – what do I have here? What’s going on? What was done in the past? It’s a lot of 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 have available to do that? And so, personally I love that. I love that whole technical and mental challenge, 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 a four-hour 360 lipo, I’ll probably be physically exhausted from that. If it’s revision, for sure.
But for our revision rhino, I’m probably not physically exhausted, but I’m mentally exhausted. I personally just enjoy it. I think everybody gets turned on by different things, and that’s something that works for me.
Dr.Sal Pacella: I think that’s a fantastic insight, Yash. I feel the same way. I could literally spend hours picking away at a nose, and looking at the structure, and understanding what I’m going to use and what I’m not going to use, try one maneuver, flip the skin over, seeing how it looks. One of our former professors, Steve Buckman, about facelifts, he said, you know, facelifts are a great operation after the first side. When you do the second side, it’s exhausting. So, trying to get everything symmetric. And that’s the one thing I love about rhinoplasty – it’s one operation, one side. Or one single operation.
Dr. Yash Avashia: That’s true.
Dr. Sam Jejurikar: So, Yash, I know you have some cases that you were going to share with us, and that’s going to be a great time.
Why a perfect rhinoplasty operation can lead to scar tissue
Dr.Yash Avashia: Absolutely. So, I think the big common trends and themes that I’m- Can you guys see this now? Okay. The themes that I’m seeing in my revision rhinoplasties are inadequate support, like we talked about, and then not adequate closure of dead space. And so, what that leads to is a lot of scar formation. What’s unfortunate about rhinoplasties is, 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 of my patients. She had a primary rhinoplasty two years ago, and what you can appreciate here is, there’s a loss of definition on the top. She actually got a hanging as well. You can see on the lateral viewpoint. And she didn’t- she found her nose to still be very large.
And so, in her exam, she actually has a caudal septal deviation. She’s got a very bulbous tip as well. And this just comes to show what can actually look like when you open the nose, and this was an example we had. And so, what we did for her is really try to restructure her nose, set her tip to give her a good tip. I think that’s another huge topic that we can get into, to really get more into the nitty-gritty and granular details of rhinoplasty. But what she really needed was restructuring, tip board, and then closure of dead space. And so, I actually will do so that actually helps tack down the skin in three different areas. And I don’t want to get into too much detail – I know we talked about making it understandable for our listeners – but preservation rhinoplasty is a great newer philosophy 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 result. And one of the things that they really talk about is preserving ligaments that connect the framework and the skin. And there are two groups of that: the ligament, which is right up here in the super tip area, and then the scroll ligament right out here. And what you see oftentimes after a primary rhinoplasty is just this blunting and fullness here. So what I’ll actually do in the revision case is, I’ll go through and I’ll actually to help tack that down and hold that skin down together so you get a little bit more definition, and prevent this kind of tissue formation.
Dr. Sam Jejurikar: Did you add any additional structural support for her?
Dr. Yash Avashia: I did. So, in addition to moving- So, she had a large strut, and I used, obviously, for her, to create a septal extension graft. In my hands, I found that to be a very consistent [glitch] in setting tip rotation, which is where your tip falls, up or down, and then tip projection, without adding any fullness to the tip or the columellar region. And so that was probably the biggest thing that I did for her, in addition to refining or some slightly redoing her to help give her a little bit more smoothness.
What timeframe is good for a rhinoplasty revision?
Dr. Sam Rhee: How long do you usually wait between their primary rhinoplasty versus what you do for them?
Dr.Yash Avashia: So, great question. I recommend patients waiting the full year. One year. I’ve had patients come in, unfortunately, a week after their first serving, they’re not happy. Or sometimes at six months. I think there’s value in having the patient wait one year. I think they start to appreciate their nose, and I think they tend to forget the trauma, the emotional trauma that they’ve experienced from that first surgery, and they start creating a slate, and they’re mentally ready for the revision. 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 emotional roller coaster. It could be a happy roller coaster, or it could be an unhappy roller coaster. And I really want patients to separate the rides. I don’t want them to make it one big ride. Does that make sense?
This is another example. This patient had two prior rhinoplasties, actually. The first one was a closed, the second was an open, but only around the tip. Nothing was done to the dorsal. And she did her third with me, essentially. And I had to piece a lot of the history to understand what had happened. Like I said, one of the things I really enjoy about revision rhinoplasties is understanding what was done in the past. So, I had enough information to understand that the whole bony dorsum was completely- actually, it was not , it was not reduced, . That’s what was done. There was very thin skin at the tip, actually, and that was probably from a combination of the and the revision open tip. 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 and outer cartilages were completely transected.
There is absolutely no integrity or structure to it. And then, the whole the mid bulb actually was open, so there’s communication between the mucosa and the actual nasal framework. I think that led to the operative infection, and which led to a lot of scar tissue development in this patient. Because obviously, infection is inflammatory and scar tissue developed after her surgery, I did end up talking to her and pieced together that that’s exactly what had happened. So, the big thing for her was doing a lot of damage control and closing off that communication, trying to restructure her tip work, again, using a graft to help support her tip. We wanted more definition for her tip. And then, doing the things that we would normally do in a primary rhinoplasty, reducing her bony dorsum, her nasal bones to get a little bit more narrowing on her upper third, and then obviously, in her case I actually used a unilateral spreader graft to help support the mid bulb, because in my opinion, I felt that because of the prior violation of the mid bulb, she needed some support for long-term success for her.
Dr. Sam Rhee: Awesome. Do you use digital simulation with your patients in your consultations?
Dr. Yash Avashia: I do. So, in addition to these standardized photographs, I actually will use a software, 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 for me and for the patient, because for me, I am doing something that I probably would do in the operating room, and I know how far I can go and what I can deliver. And I give it back to the patient, and the patient – this is obviously not the same day of the consultation, but the patient normally will give me their feedback, saying, you know, ‘I like it, but I was hoping for a little bit more slope, or more tip. I don’t want my tip to go up that high. And then, get into this conversation about what I can and what I can’t deliver, what’s realistic, what’s not realistic. I think that’s really important for your revision patient.
And sometimes I’ll tell the patient I don’t think what they’re asking for is something I can provide them. And in some cases they’re like, ‘I’m okay’, but at least I had this conversation. Like I said before, I think with revision patients, a lot of it is about the preoperative discussion that you have with them. You don’t want to 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’.
Dr. Sam Jejurikar: Looks like you have one more case for us, Yash.
Dr. Yash Avashia: Yeah. Do we have time for one more case? So, this one is a great example of where closed rhinoplasty was done about 10 years ago, and she just didn’t have any tip support. And so, what ended up happening was, without proper structure, the form was deformed over the course of the years. And so, you can imagine, her soft tissue just contracted and pulled her tip up. She came to me saying, ‘I feel like I look like a pig, I feel like I can see way into my nostrils’. That is something that I definitely saw, it made sense. She had weakness at her triangles, and that just comes from lack of support, lack of structure, not being able to hold the form that she wanted. So, in her case, again, we did an open approach. Again, my workhorse was the graft, in addition to other things we had to do for her to help restore her , and set the tip to where we want it to be so she has that definition, and she has that rotation.
And the patient needed a little bit of projection as well. She had prior alar flare reductions that were visible, so we attempted to revise that so it’s a little bit less noticeable, where I the scars. And she’s about two years post-op and she’s pleased with the result, but I think the most important thing is, we were able to bring her tip down, bring it out a little bit, and then have more of a profile view that she felt she didn’t have.
Dr. Sam Jejurikar: You’ve done a really nice job with, making her go from someone who looked very operated-on to somebody who looks . Thank you so much, Yash, 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 I think this underlying theme amongst all your cases is, the underlying form, the underlying structure, you can oftentimes give patients Тhank you so much for your time, and taking us down that journey. Do you guys have anything else you want to add?
Dr. Sam Rhee: I think it’s just amazing that one of the key points is the pre-operative 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, it seems like, is so important, for all plastic surgeons, for any procedure, but particularly in a revision rhinoplasty case.
Dr.Yash Avashia: Well, thank you for having me. I really enjoyed it.
Dr.Dr.Sal Pacella: Thanks, Yash.