Episode 79: Preservation Rhinoplasty

Have you ever heard of a preservation Rhinoplasty? A preservation rhinoplasty preserves tissue and cartilage but changes the foundation of the nose. In a classic rhinoplasty, the dorsum is not preserved, but in a preservation rhino, we take little nibbles of bone and cartilage further toward the base of the nose, changing the support structure. The dorsum is gently repositioned to its support structures. In this procedure, the piezotome is a saw that decreases the amount of swelling and bruising and causes less trauma to the tissue. A good candidate for this procedure is someone who doesn’t need a lot of change to their nose; for example, they have subtle over projection or a slight hump. The goal is to preserve as much natural tissue as possible.  Listen to this podcast as Dr. Weinfeld, Dr. Franco, Dr. Micallef, and Dr. Arredondo discuss this fantastic procedure.


All right, welcome back team to Plastic Surgery Untold, greatest podcast in the world, is voted by us. Got our celebrity crew back again. So gonna talk about Preservation Rhino today and and we’ll walk you through some of the differences. But before we we get too much into it and Dr. Weinfeld takes over the the mic here. Let’s go around the room and kind of catch up with everybody, got Dr. Arredondo joining us today. Hey, good to be back. What’s going on in your life? Well, getting super busy in the OR. Clinic, it’s been super busy. Our skinny shot is keeping us, it’s keeping us moving with tons of new patients coming in. And so that’s been exciting because a lot of these patients are asking about surgery. They’re like, hey, we want to lose a few pounds. They do and now they’re ready for surgery. So it’s fantastic. Yeah, awesome.

Dr. Micallef, what’s going on with you down in the USA?

You know, we’re staying pretty busy, you know, with the with the invent of our, the implementation, I’m sorry, of the skinny shot in San Antonio, we’ve seen a huge influx of new consultations that we’ve really been able to optimize their body habitus before they go into body contouring, so, super exciting things to come.

Dr. Weinfeld, what what’s going on with you?

Yeah, I’ve been very busy as well. In fact, we had a Friday where we did three rhinoplasties, and they were really perfect, in terms of the way the surgery center functioned, all the help that I had, I was able to do as good a job on the last one as I was on the first one because we just like, seamless transition from patient to patient and patient. So I really love that because those three cases a day, I think, are gonna allow me to offer wonderful surgery to even more patients. It’s awesome. I even cleared out my schedule. So where I could spend some time and learn from the master. That’s, yeah, that was that was a lot of fun. Actually, I appreciate you being there. What’s always so impressive is how many other surgeons that you have come visualize, you know, and watch you perform surgery. So I know Dr. Arredondo joins you, but he’s not the only surgeon that’s come to observe you and and learn from you. So flashback that day, another plastic surgeon Sarah Fermer was here.

Just go. I mean, it’s it’s always flattering, because I mean, that’s that’s someone taking time out of their busy schedule to come learn for you. So super impressive. And I know you’re too modest to ever say it. But you know, congratulations, because that’s great. We did have a little discussion that day talking about what exactly Preservation Rhino is. And so we were just I don’t know, if you could fill our listeners into some of that. Yeah, and and we’re going to do our best job here to keep this at a level where where patients, you know, it’s really directed towards patients. So as I was driving in, I was thinking about this, you know, there’s so many things that could, we could talk about, right, but let’s start with one, let’s nibble away at that, and then kind of go on to other things. So you know, in essence, you know, just really basic, you know, think about the word preservation means to preserve, or to not disturb not to change. Now, of course, it’s a rhinoplasty. So we’re changing the shape of the nose.

So what is the word preservation referring to, what is the thing we’re not changing? And the way that preservation differs from other forms of rhinoplasty is such that it deserves the word preservation is how we address the dorsum of the nose, the bridge of the nose, right? Now, that’s an area that most people seeking a rhinoplasty want, right?

They have a hump or the dorsum, the bridge is too far from their face.

So how is it we can both simultaneously change that, meaning make the dorsum, the bridge less projecting, give patients that swoop that people always are asking for and, or get rid of a hump? How can we both leave it alone and change it?

And the way that we do that is to preserve the tissues, the bone and the cartilage that make up what we’re touching, but to change what is beneath it, the foundation. So to tackle the sidewalls of the nose, the bone and the cartilage that support the dorsum, that support the bridge, and then also the septum in the middle, which is also both bone and cartilage. And the way that you go about that is it, you approach those structures differently than we used to do, what we used to do is we wouldn’t preserve the dorsum, we would remove bone and cartilage from the top, from the bridge of the nose incrementally, little bit little bit little bit until we got the height, the projection, the reduction of the hump, that would satisfy the patient. And then we’d bring those structures back together. That’s not preserving it. But in preservation rhinoplasty, we’re taking little nibbles of bone and cartilage further down, further towards the base of the nose until the support structure has changed, the walls and the support beams in the center have been reduced. And then we just push down the dorsum of the bridge of the nose so that it essentially gently collapse or it lands, like hovers down to those support structures. And in the course of doing so, you can also push out the band that used to make up the hump.

So that’s the best example of how a preservation rhinoplasty is different from what we did in the past. It’s not the only thing. But I think it’s a way that we can explain it to patients so that they understand what the fundamental differences are. How do you decide who’s going to be a better candidate for one procedure or the other? Because I don’t think most people and even for me when I was arriving, it was hard to understand the concept of, there’s so many, rhinoplasty isn’t a rhinoplasty. I mean, there’s, there’s open, there’s closed, there’s, you know, using grafts and different things. How do you kind of decide what’s the best treatment for a patient?

Well, you know, that’s one of those questions where the answer is very similar for all types of procedures, it depends a little bit on the patient, but also depends on the physicians, the surgeons experience level, right. And so, you know, so for most surgeons who are experienced at rhinoplasty, and starting to introduce preservation rhinoplasty into their practice, the best candidate is going to be the candidate who doesn’t need a ton of change, the patient who may need little tweaks to the tip, and we’re gonna get to how the tip relates to the bridge in the context of preservation in just a second, but that patient who has a subtle projection, over projection of the dorsum, and or a subtle hump, because those are the patients where you don’t have to remove quite as much bone and cartilage in the septum. And where you don’t have to remove as much bone and cartilage in the sidewalls to gently let that that hump and that dorsum hover down to its new resting place to give that beautiful, sleek contour that they’re looking for. And so why, why that patient who has a subtle desire for change, because you don’t have to overdo it, much more controlled than trying that more aggressive hump, that more aggressive dorsal reduction.

And, Dr. Arredondo, talk to us a little bit because one of the things that has made this so much more available and probably possible for patients is the advent of the Piezotome, which is a super cool device that we have in our practice, oh yeah, that we use for other things, you use for your… procedures and other stuff like that as well. And I’ve used it in my training extensively when we did craniosynostosis.

So..  that have sutures that haven’t fused, you know, we’ve used that on the skull to reshape that. And so it’s it’s a fantastic tool, it’s so delicate. It’s designed so that way it only attacks really the bone that you want, and it leaves the underlying tissue preserved. And that’s changed the game because that lining of the nose underneath the bone is so delicate. And so to be able to precisely control where we’re going to put those cuts, and I got to see Dr. Weinfeld doing this expertly with his cases on Friday. It’s just amazing. And you just leave that layer protected and preserved. And that’s the most important thing about the Preservation Rhino, it’s protecting those surrounding structures, just changing what you want to change.

And in the past, I’ve always heard people say that rhinoplasty is, they’re worried about it, because when you’re changing these bone stuff, that they’re an extremely painful procedure. Can either of you comment, is that a true statement or not?

You know, I would argue that it’s more, that there’s so much less trauma to the surrounding tissue, because it’s so controlled that there’s less bruising, but Dr. Weinfeld’s used it a lot longer than I have. Yeah, no, I agree with you, you know, blood in and of itself is inflammatory. It’s in our it’s in our stomach because we swallow it, it makes us throw up. You know, bruises hurt because of the blood and in addition to other issues. So yes, if we are more gentle in the way that we handle the soft tissues, there’s less bleeding, less trauma to the soft tissues, which is where the nerves are. And so it can be a lot less uncomfortable. And then, of course, also a lot less, a lot less bruising. But rhinoplasties in general aren’t as painful as people think, you look a lot worse than you feel most of the time. Wouldn’t you say that’s true? Well, I always avoid using the P word anyway. I try to, I try to say discomfort. Now, I slip sometimes, but I try to use the word discomfort. Yeah, I agree. I think most patients complain more of a feeling of stuffiness, more pressure inside of their nose than they do about outright pain. Yeah, but I also don’t ask about pain, I talk about discomfort. *laughing*

Reframing the discussion. Yeah. I mean I think that’s the biggest key is that with the with the use of the Piezotome, and with the the

these novel techniques surrounding preservation rhinoplasty, we’ve really decreased the amount of swelling postoperatively that’s taking place, that, the amount of bruising that’s taking place that we used to see with these big open rhinoplasty cases and so which also ultimately does improve people’s not pain. Yeah, discomfort.

We should, we should we should mention or I should mention, briefly that a Piezotome with rhinoplasty, we call it Piezorhinoplasty and preservation rhinoplasty are not 100% synonymous, there’s not 100% overlap. You could do a preservation rhinoplasty without a Piezotome. And just like we did for the three cases on Friday, you can use a Piezotome to do rhinoplasty without it being preservation. Now here, we’re gonna put us a little bit into a tailspin here. But you can do a preservation rhinoplasty that is partially open. And you can also do a preservation rhinoplasty that’s entirely closed. And that’s where this starts to get really, really interesting. And another episode, we’ve talked about how interesting body contouring has become because of all of the amalgamation of the different techniques that we can use. The same thing is true if we look at only preservation rhinoplasty, so you know, an example of, of a preservation rhinoplasty, this kind of both closed and open, would be a preservation rhinoplasty where you address the dorsum of the nose and the way that I spoke of earlier where you’re kind of nibbling away a little bit at the bone, and the cartilage that is pushing that dorsal, pushing that dorsal. *laughing*

Dr. Weinfeld was raising the roof.

So that bone and the cartilage that was raised for a reason

Where it should be, we’re nibbling away at those walls of that foundation so that the roof can gently come to rest in a better position to give that sleeker contour to the upper part of the nose. So just real quick recap of that last couple of seconds before I interrupted myself. So closed and open Preservation Rhinoplasty together is, there would be closed for the upper two thirds of the nose for the dorsum. But you, then you open the tip of the nose to make finer perhaps more precise, or just more involved changes to the cartilage to give us a different shape tip. Right and I think a lot of that also depends on the patient’s goals. And so that’s where plastic surgery is so great is that we take your, the patient’s goals and desires into mind. Those wish pics are always so helpful and we kind of create a plan that’s unique to them. And it’s not the same. That’s why rhinoplasty is not a rhinoplasty. You know, it’s not a rhinoplasty. It’s not the same for any two patients. Yeah, the three we did on Friday, were all completely different. Yeah, it was awesome. Yeah. Fun.

So if I if I heard that correct, so you kind of decide in Preservation Rhinoplasty if you’re going to use a closed technique, open, partially open technique or combination of these, kind of based on what you’re going to do and based on whether or not you need to do tip work. Correct, yeah, well, it’s not tip work, per se. So in some Preservation Rhinoplasty is what I will do is it’ll be closed closed. So I can address both the dorsum and the tip in a closed fashion. But that’s different from closed rhinoplasties in the past, where it was totally closed, but you’re still subtracting from the dorsum of the nose, and then bringing the bone and the cartilage together at the top of the nose. And so why why avoid that, like what’s so cool about preservation. And what’s so cool about that is that that, that separating the tissues and then bringing back together can at times create irregularities to the nose. So someone has a beautiful dorsum, a beautiful bridge to their nose, but they still have a slight hump, or just over projecting, why undo and then redo that in a way you cannot control perhaps, just put it in the place that you want it. So so anyway, so closed close, closed for the dorsum, closed for the tip would be a patient where I can bring the dorsum down, but I can do the adjustments to the tip in a way where I don’t have to open the nose and the columella ,the most lower part of the nose, in order to make those adjustments, but I might do closed open for someone where going into it, I don’t think that I’m going to be able to make the adjustments I need to the tip by keeping the skin on top of it. Okay.

And I think this is a common theme and surgery overall but especially in plastic surgery where we’re trying to be the least invasive possible because we all know that scar tissue leads to you know, changes over the long term. And you know, the less trauma, traumatic we can be, you know, the faster the recovery, the less discomfort, you know those type of things. So it’s really cool to hear you kind of talk about this because similar to a lot of the other things we’re doing, we’re trying to make the changes we need, but also minimize that change because just like.. and other stuff. It’s amazing how much the nose can change after a rhinoplasty over the years. Yeah.

Although the technique of Preservation Preservation Rhinoplasty has evolved over the years, it’s really not a new technique. People were doing Preservation Rhinoplasty much before, or some version of Preservation Rhinoplasty before they really entered this realm of open rhinoplasty slash closed rhinoplasty. Yeah, yeah, that’s absolutely true. And to be honest with you, I don’t actually understand the history of why preservation rhinoplasty went to the wayside. I think part of it was that there were some really foundation lane books that came out about open structure rhinoplasty, and that there were also some really, really, really wonderful educators who spoke of open rhinoplasty in a way that made rhinoplasty something that really most plastic surgeons with, who really wanted to learn about it, could really get good at in a predictable way.

But as Dr. Arredondo said, that doesn’t mean that open rhinoplasty makes sense for everyone. And that it has to be the entree into rhinoplasty, gave a great analogy about laparoscopy, where you know, if you understand the techniques and the principles and the anatomy, you can go into preservation rhinoplasty, so long as you are, you know, really honest with yourself about what you can do without having to have necessarily done 100s of 1000s of rhinoplasties. Because, you know, open rhinoplasty is not necessarily an easy thing to do, either. This is just a different version of a challenging procedure that you you just want to make sure you understand all facets of what you’re actually doing for any particular patient. So, so I think, though, what happened, again to answer your question is that there was just so much about open structure rhinoplasty that the education sort of led the field, whereas there’s been a now there’s a little bit of a shift back to something that you’re right, that had been done, you know, 10s and 10s of years ago, not 100s but 10s.

And so for patients, like if I’m if I’m listening to you all, I, it would sound to me that, you know, for patients really when they do their consultation, you know, one if they’re interested in preservation right now, you should search someone like yourself or someone who has experience doing it, but but just because that’s what they want, may or may not be a candidate for it even if somebody performs that procedure. Kind of in the simplest, oh, yeah, absolutely. Yeah. For me, if I were to have someone come in who had a significant amount of deviation to their nose, or had a very, very large hump to their nose, that would be the patient who I would still feel like I can personally address… with an open rhinoplasty, you know, kind of open open.

But it was a patient who had a very unusual tip with a lot of changes they want, but a very subtle change that they needed or moderate change that they needed to their dorsum. So not too big, and not too deviated of a dorsum. That’s someone where I might do sort of Preservation Rhinoplasty closed, but then open to the tip, you know, and the, here’s another thing too, just to get a little bit more complex. If you’re doing a closed rhinoplasty to the tip at the same time as a closed preservation of the bridge, you can preserve the ligaments that support the tip. So then you’re talking about two layers of preservation, both preserve preserving the bone, and the cartilage of the bridge of the nose, but also the ligaments that hold all the cartilage together in the lower part of the nose of the tip. Right. For those who really want to geek out, that’s what a lot of the talk about Preservation Rhino has been. That was one of the criticisms of open rhinoplasty. But as we’ve learned, you know, preservation has its advantages and disadvantages. And that’s why it’s so important to have that discussion with your surgeon beforehand to know what’s going to work best for my nose, for my goals, my desires.

Yeah, I keep saying. You know, you guys had asked about, you know, recovery and discomfort. Yeah, you know, if you’re not disrupting those ligaments and the soft tissue envelope that carries the blood vessels, the lymphatic channels, and the nerves, then you’re going to have less pain because you’re not disturbing the nerves as much. But then you’re also going to have less swelling because the lymphatics go through, and the blood vessels, go through the ligaments through the skin, and all of those structures are going to be maintained or most of them. And so you can also have less bruising, and therefore easier, quicker recovery as well. And I was just gonna say, I think one of the, one of the concepts of Preservation Rhinoplasty is that if we’re preserving that soft tissue envelope in a closed close technique, it’s we get more predictable long term outcome as well. I think that’s right, because, and we get to that outcome quicker, get to that outcome quicker. I think that’s right, because one of the things that I know I find challenging and frustrating and patients do too, is that we can show wonderful pictures with the skin open and open rhinoplasty showing the structure of the bone of the cartilage that we’ve, the changes that we’ve made at the end of the surgery, and then even on table results with the skin re-draped and and it looks like that even when the splint comes off. But after you know a couple of days of the splint coming off, you do get some swelling that comes back and patients can get frustrating because they don’t really get a glimpse at that structure once again until all that soft tissue swelling has gone away, you know, months and months later. And when we’re, when we’re really being gentle. We’re preserving those ligaments, being less traumatic to the soft tissue, that timeframe when the splint comes off to when they see their final results, I think is going to slowly decrease.

Yeah. And don’t you think also some of the long term unpredictability because whether we’re talking about rhinoplasty, breast surgery, lipo, I mean, scar tissue can be so frustrating.

Yeah. And it’s super hard to predict who’s gonna have it. And sometimes it’s gonna make something that looked absolutely fabulous develop either a little pull, a little something, you know, and so the less trauma we can do to that, I mean, just seems like the better long term stuff because yeah, I know, even in a world of lipo, there’s times that people look great for the first couple of weeks and they develop a little scar tissue. And we’re massaging, we’re doing things to get that out just to try and avoid them having to do a little revision surgery.

Yeah, yeah. Well, on that note, again, just to keep it, you know, because we want to make sure that patients understand the real basics of this. That is that if the the bridge of the nose is just a little bit over projecting, the nose looks too big in the upper two thirds of the nose, and there’s a subtle hump, that, that reducing that can, with a Preservation Rhinoplasty leaves those structures in place. So you’re not dismantling, you’re not removing the bone, where the bone and the cartilage look so good, but it’s just a little bit off from what you want it to be. So if you’re not dismantling it, and having to put it back together, you’re going to have what you started with. And that going back to your predictability, and that’s the preserva, that’s the essence of the preservation. Leave the thing you like alone, only change what you don’t like.

What What would you, and I know this is a little bit general and not so much preservation right now. But I’d love, from, hear from you Dr. Arredondo. When somebody is looking to have a rhinoplasty, what are good questions to ask? Because I feel like it’s an area that that really concerns people, most people have thought about it a long time. So one, what should they look for? Two, there’s always a question of like, what’s a good age for this? Because for a lot of people, it’s bothered them for a long time. And another, some younger patients that that want to do this. And so can you maybe address those two questions? I know they’re a little broader. But I would love to get your feedback. And a lot of people slide into our DMs with those questions. Yeah. And maybe you can answer for people.

Shawn, please, you talk too much. *laughing*

I don’t know that there’s necessarily a bad age for a Rhinoplasty. I will say, you know, in the teen years, sometimes our nose is still developing, we’re still growing. And so those are times when you want to kind of maybe take a pause, let things finish developing, before you start jumping in to make some changes, because I think that leads into that unpredictability that we were talking about. So that’s one thing that I kind of caution people against. If some, if somebody is 18 though and, would you say that that’s fair or safe to do a Rhinoplasty at 18? Oh, yeah, yeah, yeah. And I think, you know, this, obviously, is really, really, you know, there’s so many ways to answer this. But as Dr. Arredondo was saying that, you want them, the face to be skeletally mature. So the bone and cartilage has to, you know, be the bone and cartilage of what their adult face is going to look like or at least close to it. You know, and girls that could be as early as 13 and 14, I’m sorry, as early as 12, 13. And for boys 13, 14. But the second and really important criteria, are they emotionally, intellectually mature enough? And I would argue that they may not be, it might be better to have a child who has gone through a little bit of high school, has a little bit better sense of who they are and where they fit into the, in the world for them to be happy with it in the long run. 18, I think, is getting, you know, in very safe zone, age wise. And it’s funny, because these are the little pearls that I think it’s sometimes hard for people to know that the deeper thought that goes into this because it’s the, we can physically do it, but should we and so not to go down the rabbits hole of philosophy here. But another big part of that which people don’t necessarily think about is social support, and kind of emotional well being like, are we going through major life changes? Are we, do we have somebody that we can rely on during a difficult time? I think those are all important questions that we forget to ask ourselves, anytime we’re going through a surgery because that’s a recovery. Regardless whether or not there’s any discomfort. You still want somebody to help you out. Yeah, you know, sometimes day to day, and I think those are important things too. It’s not just necessarily a physical point, standpoint, but emotional and social standpoint, too.

Yeah, it’s a roller coaster. Yeah, the excitement of it, the anxiety, the excitement right after, then the dog days of like.. *laughing*

This is a must do podcast to think for next section. The next session is like the psychology of cosmetic surgery in general. You know, going back to that age thing real quick, I don’t want to give the impression that you got to be 18 and that even though your skeletally, skeletally mature at, you know, sort of between 12 and 14, that you shouldn’t do it. You know, in those younger years. There, I have dealt with patients who were adolescents who were being teased so much because their, their nose just was very obviously different than the sort of societal norms and expectations that, that I’ve dealt with people who were like, like, really, like, they had to go to homeschooling and stuff like that, all because of their nose, you know. And, and so that’s the kind of patient where, where, to me, it seems like a no brainer, you know, you can, when you can make a really profound change, that’s going to give patients the confidence to know that, you know, these people around me are jerks. And you know, and I’m not who they’re going to say I am being defined by the appearance of my nose. That’s a really powerful thing. So I just think that’s a really good thing, cuz I’ve dealt with many, not many, but several patients like that, that it was like a life changing operation. I think this just comes down to the consultation, and it’s not, it’s determined on a case by case basis.

Yeah. And what about when we’re looking, because for a plastic surgeon, because we get a lot of DMs and stuff for people like who live out of state out of, you know, out of the area, and like, hey, what should I ask, what should I look for, for a plastic surgeon when performing either preservation or just a rhinoplasty? Is there…

You did ask that question. *laughing*

Circling back. Yeah, showing some bullet points. You know, I think age is an important thing. I think patients should be, should be asking about their physicians, their surgeons experience level. No, no, no.

Their, you know, their experience, it’s always good to ask to see some befores and afters. I think it’s good to have a really good, like a patient should ask, you know, what are you pretty confident you can provide? And what are the things that you think are, you know, a little bit up in the air? I always tell patients like, these are the kinds of things that I can’t entirely control, and that I both, I think both you, as a patient myself, as a surgeon may be slightly frustrated, you’re gonna love all of this. These are the things I can’t in any way guarantee. So I think it’s good for a patient to ask those kind of, you know, important questions. I think it’s good for a patient to ask about, you know, revision rates and revision policies, because that’s a reality within a rhinoplasty even among, you know, the world experts, they all acknowledge that it’s important to discuss that with patients because there are things that surgeons can’t control.

And then I think it’s important to ask about technique, and, you know, what, why a particular technique was chosen for me the patient, and I think it’s good for a patient to also, you know, tell the surgeon, you know, well, I’ve learned about this, I’m interested in this, another doctor told me this, what are your thoughts, you know, and I always love it when a patient is telling me what’s inside of their head. I mean, that’s the only way, that’s the only way, I will know how I can veer the result towards what they’re looking for. And and a lot of plastic surgeons will use either some morphs or some visualization tools for rhinoplasty. How do you feel about that? Because I know especially in like breast aug, for example, I love wish pictures, I love sizing, because sometimes what people are hoping or want to achieve is just not something I can physically do. And I rather that they they’re disappointed in the console then after the surgery. How do you feel with that? I have some thoughts, but I insist that Dr. Arredondo… *laughing*

Just cause I know that I can keep going on and on. Yeah, I have not used a ton of the morphing software for rhinoplasties. I’ve been trained by people that have. And I think, I probably for myself just need a little bit more experience and seeing sort of like where my results land. I’ve definitely been able to achieve the results I want. But like, to Dr. Weinfeld’s point, I’m always very honest with patients, like these are things that I can achieve. These are things that I, you know, that I’m not sure I can achieve. And these are things that I don’t think we can change, because I don’t think physically, like it’s going to happen with your nose. And so that’s what I like to do. I do like to take their pictures and use drawings to maintain some, to imitate what I’m going to change with the surgery so they understand, like from the structural point, how we’re going to make those changes to get the difference in appearance in their nose. And that’s sort of what I use right now.

Yeah. Yeah, I mean, to Dr. Arredondo’s point, that any sort of picture imaging sketches that we can use with a patient to make sure that we’re on the same page is really important. A picture paints 1000 words, I tell the patient that you know, that a combination of the morphs that I give them just using very simple Photoshop, and the inspirational photos they may have shown me that those allow us to do a little bit of a mind meld so that we can get inside of each other’s head and, and make sure that we are you know, kind of appropriately communicating with one another, making sure we’re on the same page. It’s like a good filter, you know, I can I can filter out whether a patient’s expectations really exceeded what I can deliver. And a patient can filter out whether I’m really hearing and understanding them. And so I like to do morphs. I don’t do it on everyone. I always tell patients, you know, obviously it’s not a guarantee of the results. And also, you know, don’t, if you don’t like the morphs, it doesn’t mean you’re not going to like the results of a rhinoplasty, but if you don’t like the morphs, it’s not that the morphs were not successful, they were actually really successful, because you’re telling me what you don’t like, and that’s what was in my head. And you may be asking, you, and then I also, it’s been successful for me because I can say, well, you know, and I usually provide two morphs of each, you know, front and side view, you know, and I’ll tell them, this is kind of a bracket of where we can be. And if you don’t feel like you’re gonna be happy, if you’re, you know, if you’re in that bracket, then we need to talk about what we can actually do. So it’s a really helpful process.. imperfect.

I think one of the important things I’ve learned from plastic surgery through my training and differs from general surgeries, I can, in general surgery, I could do a technically perfect procedure, take out a gallbladder, remove a colon cancer or something, and everybody’s happy because I’ve achieved my goals that I know I have to hit. In plastic surgery, I can do the same thing. I can achieve a technically perfect rhinoplasty, a technically perfect breast augmentation and I can be happy, but the patient’s not happy. And it’s because we just, that mind meld, like you say, didn’t happen on the right level. And that’s where pictures are so important, you know, their opinion of the surgery afterwards is almost the only thing that matters.

No, it’s the only thing. Yeah, and Dr. Micallef and I get this a lot in our breast surgeries, because terms like natural, subtle, bold can mean a lot of things. It’s amazing. Sometimes what people bring in is, this is natural, they’ll bring a picture, you know, as someone who has 800cc implants.

Sounds like those are great, maybe not what I would’ve pictured as natural. But I tell everybody, just as Dr. Weinfeld, Dr. Arredondo said is, you know, the ultimate is we want to get you what, you’re the one walking around with it, we want to get you to a good goal, we want to make sure it’s something we can achieve. And so some of those terms are a little bit loose. And we, it’s hard for us to get a great picture of, of what you want, so I think any tool you use… it’s just one quick more thing. These professional photos, like it’s such an important psychological screening tool too. Because you know, you can have a patient who shows you this lovely face of, of a woman, totally different ethnicity, totally different age, totally different skin type, totally different BMI with a really blurry nose where you can’t even see the nose. They’re like, I want my nose to look like this. And I say, I can’t even see the nose. Are you sure? *laughing*

And I’m like, let’s be honest about like, what you really like, what bothers you, doesn’t bother you, about your nose, about your face, maybe even your life. You know, I’m not saying that you’re not the right candidate for rhinoplasty. But this is telling me a lot more than you want to change your nose.

Right, that’s for another podcast. Yeah, that’s a huge can of worms that you kind of have to start exploring, though. We’re more than just surgeons. Yeah. And that inspirational photo has really narrowed that chasm between my understanding and what they’re telling. Yeah. Any last preservation or rhinoplasty nuggets that you guys would like to leave all your longtime viewers, some time DMers. I think just reiterate, it’s not a one size fits all. Not everybody’s gonna be a candidate to have a complete total preservation, like he was saying, of the dorsum or of the tip. And so keeping that in mind, listen to what the surgeon is saying. Ask questions. Definitely follow up later on. I think Dr. Weinfeld follows up with every single one of his patients that he talks to, to make sure that even after that consults ended, he still was able to answer questions and all those things. Yeah. Yeah, I think in a nutshell, it’s you know, keep what you like, keep what’s good, change what’s bad instead of undoing and redoing everything. Dr. Micallef, any last home nuggets for for everybody. I don’t have anything for preservation.

I’d like to thank everyone for tuning in. We got a lot more episodes coming up soon. So stay tuned, Plastic Surgery Untold, you can get us anywhere where you get your favorite podcasts. So iHeart iTunes, Spotify, Pandora, and if you want to see Dr. Weinfeld raising the roof, you can even check us out on YouTube or Instagram.

We’ll see you guys again. Alright, bye.