Episode 31: Rhinoplasty: What You Should Know About the Nose!

Johnny: Welcome back to “Plastic Surgery Untold,” the greatest podcast in the world as voted by us. We got our celebrity crew and a special guest that we have brought back, Dr. Adam Weinfeld, who also specializes in rhinoplasties and craniofacial surgery. So, before we get to him and our topic of rhinoplasty, knowing the nose, let’s catch up on what our celebrity cast is doing. We have Austin’s most beautiful man, G-Berto Saenz back with us. He missed an episode because he had a hair appointment, so I appreciate that you could squeeze us in today, new pocket square, and you’re ready to go today.

G-Berto: I am. Yeah. Thanks for having me back.

Johnny: We had missed you. We needed you in… You know, while you were gone, I did find out that I can mute you with this knob I have in front of me, so I’m pretty excited and worked up today.

G-Berto: I don’t know how to feel about that.

Johnny: So I hope you bring your A-game.

G-Berto: I don’t know how to feel about that.

Johnny: What’s going on in your life? What’s new? Anything exciting? New?

G-Berto: So, I’m actually getting ready to head out to Kansas City in a few weeks to attend this cadaver dissecting course where I’m going to learn some injectable techniques. I think you may know the physician who puts this together, his name is Dr. Chris Ciric. I think he said he may have been your med student at one time or something.

Johnny: He was a med student when I was a residency, so I don’t want to make myself sound old, but yeah, no, he’s incredible, he’s a super hard worker, a very gifted guy, so I think that’ll be great.

G-Berto: Yeah.

Johnny: And catch me up…and I don’t know if we’ve ever talked about this. You actually got invited to be on a dermatology podcast. Is that true? You’re cheating on us?

Travis: Who’s the mistress?

G-Berto: Yeah, no, it’s true. I got asked to be a cast member of the Society of Dermatology PA’s podcast. We haven’t really put together any podcasts yet. We have our big fall conference coming up in about a week and I think they’re going to wait until after the conference before we start putting any podcasts together, try to get the crew together and get everyone to meet each other because we’re all in different places across the country, and so it’s going to be a way for us to kind of just meet and then put a game plan together for some of these podcasts to come out.

Johnny: And they found you because you’re world-famous? Or how did this magic happen?

G-Berto: So, I actually submitted an audition tape, thanks to you, and thanks to Donald. He helped kind of put this together, and I submitted this audition tape of our podcasts and I guess they liked what they saw.

Travis: Oh, man, I thought you were going to say Tinder for sure.

Johnny: It was a match made in heaven, you know, his little Bumble. And what about you, Celebrity? I know you’ve had to take a little break from running and it’s messed up…

Travis: Oh, man. Had to bring it up.

Johnny: …you’ve had to wear a shirt, you’ve had an ankle injury, a lot of stuff going on in your life right now.

Travis: I don’t know if you all can tell, I’m like extra pale right now.

Johnny: I mean, you hit the age of 27 and boom, boom, boom, it started to fall apart.

Travis: I wish. Oh, yeah, man. I was running. I think I was overreaching, overtraining just a little bit and not taking my recovery seriously enough, ended up with a little bit of an Achilles injury and a knee problem that has persisted for the past couple weeks. So taking a little hiatus from running, and it’s actually been okay because I’ve been so busy doing other stuff with getting the house sold and all that stuff ready, but I’m dying. Not being able to run and not being able to work out every day is not easy for me, so.

Johnny: Adam, can I tell you a little nugget here? The difference between a tough week in the CRNA world and a tough week in a surgery world because him and I are working together and, one, he was being relieved at noon because he’d been there for five hours already, but he’s telling me as he’s about to leave at noon, he’s like, “This week has been so tough. The other day I worked till 10:00 a.m, and then I had to go to Home Depot and Bed Bath & Beyond.” I was like, “Travis, how do you do it? I mean, these three-hour workdays, it’s just…” I’m just amazed that you’re willing to make time for us, so thank you, Celebrity. I appreciate it.

Travis: Can’t forget the small people.

Johnny: And doctor, what about you? What’s going on new with your life?

Dr. Weinfeld: It just happened a couple hours ago when after seven…how many months into this are we? Seven?

Johnny: Yeah.

Dr. Weinfeld: Yeah. Seven months of COVID and putting on a little weight. I could still fit into this suit and it happens to match my Allbirds Dashers. You see that?

Travis: Yes.

Johnny: That’s awesome.

Travis: We got those.

Johnny: I love that.

G-Berto: He’s giving Travis some run for his money with those shoes.

Travis: You are giving me a run for the money.

Dr. Weinfeld: I’m still looking at…earlier today, I was sort of fishing for an Ozarka endorsement deal. This was my Allbirds attempt. I don’t know what we’re going to make of this.

Johnny: We’ve been fishing for endorsements for a long, long time, so.

Travis: I’m still waiting for FIGS. If you guys are listening, we’re ready.

Johnny: I’ll tell you. It’s almost humbling. I got a little Frenchie a couple weeks ago, and that little guy has already gotten two endorsement deals and I’ve got nothing. So, I was like, “I’ve been one up by a little dog.”

G-Berto: That’s…

Johnny: But let’s jump into it because I don’t want us to run short on time. This is a topic that we’ve been getting DMs. We’ve been having people message us to talk about, and so something I don’t do as much of and so glad that we could have a real expert on the field. So, today we’re talking about rhinoplasty, nose jobs, and so something that Dr. Weinfeld does a ton of. I actually refer all my revision rhinoplasties, not my revisions but people coming for a revision rhinoplasty, to him. And so, we’ll touch maybe a little bit on basic rhinoplasties, maybe some revision stuff, and then even the non-injectable, non-surgical liquid rhinoplasty, if you will, and get your thoughts on that. I know a lot of craniofacial people have either like it or hate it, and so maybe we will save that little nugget for… see what you and G-Berto think about.

Travis: We’re gonna have a battle royale.

Johnny: I hope you guys disagree.

G-Berto: No, but…

Johnny: I hope you do.

Travis: Me too. Me too.

G-Berto: I’m really interested to hear his insight.

Johnny: Well, let’s get started a little bit about rhinoplasties and maybe how you start the evaluation because I feel like noses is one of these that’s a very touchy subject because a little hard to predict. I feel like little changes make a big difference in the overall face and something that when it goes smoothly, it goes smoothly, but when a nose job goes wrong, it’s really hard to come back and fix later.

Dr. Weinfeld: Yeah. So, the way I start all consultations is I just walk into the room, not all consultations, but all consultations for rhinoplasty, I walk into the room and I don’t even use the word rhinoplasty at first, actually. I just say, “I understand you’re here because you want to talk to me about your nose,” and then I shut up, and I just let the patient talk, and talk, and talk, and talk until they’re exhausted. And I try not to interrupt them.

Johnny: You’re a patient man.

Dr. Weinfeld: Yeah. Well, you know, it’s interesting. It actually doesn’t take…

Johnny: Maybe this is where I struggle.

Dr. Weinfeld: No. You know, most patients don’t go beyond about three minutes or so, but two things happen. One is you really get a good sense for what they’re like, what the patient is like, whether you’re going to be a good match with that patient, and if their expectations are realistic, what they really are looking for, what kind of aesthetic is important to them. And you also learn things that you might not otherwise know, like if they breathe well or they don’t breathe well. So, it’s a really important process, but then also it’s therapeutic. You know, if you’ve given them a ton of time to explain things to you, no matter what the result is, and it’s always going to be, you know, some version of good, it may not be exactly what they were looking for, but if they started off that relationship with you feeling like they were heard, they are much more likely to be like, “Oh, yeah, he knew exactly what I wanted,” you know. That’s been really helpful for me. And again, you just really learn what the patient wants, and then I start to become a little bit more systematic about things, you know, and I’ll kind of do 180-degree observation of them. Have them sit, tell them to look into one corner, and I go from their left side to their right side, really paying attention to their nose and how the features of their nose interact with the other sub-features of their nose, and then how their nose, as a facial feature, relates to other parts of their body. In particular, it’s really important from the side, the profile view, to get a sense for how it relates to the forehead and to the chin, things that we can actually make some changes, and really the nature of the forehead. The nature of the chin really has an impact on how we perceive the nose. So, I’ll do that observation then I touch the nose, and I’m always real careful as like, you know, “Can I touch your nose?” And I think that’s helpful because patients…

Johnny: Especially in the day of COVID.

Dr. Weinfeld: Yeah. Without a doubt. Yeah. And I always say things like…you know, and of course they’re their to let me look at their nose, but I’ll say like, “Do you mind taking off your mask? Do you feel comfortable doing that?” And I wear N95 mask. And so, I say, “Hey, listen, you know, I’m wearing N95 mask. Not only does this protect me from you, but it protects you from me,” you know? And so, you’re right. There’s an additional layer of interaction that you have to introduce to this consultation process to make everybody feel comfortable nowadays.

Johnny: What do you think in terms of…because it was interesting for you to say this because on one of our previous episodes when we were talking about butt and other stuff how we talk about…you know, and even when I do breast augmentation and people sizing to look at your whole body, to make sure that it fits you, you know, your breasts match your butt and waist and that the whole form looks good. Very interesting that you take the same approach with the face because a lot of times if somebody has a weak chin or other stuff, that can make the nose look different, and sometimes their true concern isn’t even the nose or it’s only a part of the overall concern.

Dr. Weinfeld: Yeah. Yeah. You know, there’s a couple things to unpack there, and absolutely the chin is the classic example of the other facial feature that you have to consider when you’re thinking about a patient’s nose. If a patient’s chin is small, it’s going to make the nose look bigger than it might otherwise look, and a patient might have this sense that they want their nose to be smaller than it actually should be because they’re comparing it to a small chin. And this is one of the few examples where I’ll kind of bring up to a patient something that isn’t related to the primary feature that they’re asking me about because…I try to avoid the upsell because when I… You know, and so the upsell is kind of like introducing other procedures to a patient that they may sort of latch onto and want to have. And the reason that I do that is because, you know, I’m sure you see this too where a patient comes from another plastic surgeon, and fortunately that doesn’t happen that often in this town, but they’re unhappy. And often the thing that they’re unhappy about is the thing that they didn’t really want to have done but it was, like, introduced to them. So, I avoid the upsell whenever it’s appropriate, but with rhinoplasty, it actually is important to at least point out the fact that their chin is small or large and that it’s out of proportion with the rest of their facial features and thus has an effect on the way they are perceiving their nose. And so, I point that out and then I say, you know, “It is important for me for an educational completeness to let you know that and that there are procedures that can be done to change that. I’m not suggesting that you should want them or that you should feel like you have to have them, but it’s important for me to be complete to tell you this.”

Johnny: Because it’s the limitation of their results because when they look at that profile, they may still not have that strong feature or maybe too strong depending on what their specific goal is.

Dr. Weinfeld: Yeah, without a doubt. And for those patients, I’ll do more of simulations. And it’s really helpful in the profile view when you’re talking about the chin, and I’ll do a little simulation on the chin too and show them the chin being, you know, a little bit bigger or smaller if it needs to be so they get a sense for how that’s going to work with a rhinoplasty.

Johnny: Do you do simulations, because that was going to be my next question, for all your rhinoplasties to give them a little bit better idea?

Dr. Weinfeld: Yeah. Almost all of them. Yeah. Not all nasal surgeries, though. If a patient comes to see me only for, like, a septoplasty and some of the other things we do for breathing, I actually tell them I’m not going to do them because I don’t want you to get expectations that it’s going to change the shape of your nose in one way or another. That’s a really important partition that I create between those two types of surgeries if a patient is purely there for functional, but if they’re there for aesthetic surgery, for cosmetic rhinoplasty, I almost always do simulations with another exception, and that is if a patient brings me simulations they’ve done and I think they’re realistic and perfect, I say, “These are amazing.” Like, “Why would I want to redo what you’ve done? You’ve shown me what you want. I think you’ve done it in a very realistic way, and I think surgery can get you a very nice facsimile of what you’ve shown me. I don’t see any reason to cloud the picture by me trying to interpret that. I’m going to work from what you have.” And they love that. And it’s true. You know, I go from those images.

Johnny: Can I back up onto something? Because I think it’s super important you brought up the functional rhinoplasty because I think sometimes people get confused a little bit, you know, in terms of there’s the breathing aspect and then there’s the cosmetic aspect. They can both be done at the same time, but they’re very different kind of goals and sometimes can be a little bit competing goals, and I think that’s sometimes hard to explain to people.

Dr. Weinfeld: Oh, yeah. I mean, we can talk about that whole process, that whole interaction for an hour. But simply said, I like to break it down like this for patients, a rhinoplasty is the thing that changes the shape of your nose to get the appearance that you want to, and you and I and your insurance company, we all should, and all will consider that a cosmetic procedure. Things to improve your breathing are different from that, so that, your insurance company [inaudible 00:13:07] pay for it, not a cosmetic rhinoplasty. But the three things that many people need to undergo in order to improve their breathing are a septoplasty, the septums, the wall between one side of the nose and the other, and if it’s bent, crooked, has projections out of it, it’s going to create turbulent airflow and obstruct airflow and make a patient not be able to breathe well through their nose. The second thing that we address is something called nasal vestibular stenosis. That’s just a fancy way of saying that the sidewall of the nose is either weak and collapses in when you breathe or that the sidewall is too close to the septum and it’s just narrow from the very start and this doesn’t take a genius to understand how that would obstruct airflow. The final thing that we address when we address someone’s breathing is called turbinate hypertrophy. We have these filters in our nose that are called turbinates. They’re super important because they humidify air, they remove dust, but if they’re too large, and we won’t go into how they get too large, but if they’re too large, it obstructs airflow. And there’s a set of three on each side, the lower one that we call the inferior turbinate happens to be the biggest one and the culprit as it relates to how turbinates decreased airflow, and we can decrease the size of that without hindering its function surgically. So those three things, correcting nasal vestibular stenosis, septoplasty, turbinate reduction are often combined with a rhinoplasty. And in fact, there is some overlap, about 20%, 30% overlap between what we do for let’s say the correction nasal vestibular stenosis and what we do with the cosmetic rhinoplasty. But they are different things, and the insurance company is going to pay for those three things, septoplasty, correcting the nasal vestibular stenosis, and turbinate reduction, not the rhinoplasty. But it’s really important that if you’re going to ever have a cosmetic rhinoplasty and you don’t breathe well, or you don’t breathe well and you’re ever going to have a cosmetic rhinoplasty, you got to have those done together because once you’ve done one and not the other, it makes it very difficult to do it late… Well, very difficult is not really…it just makes it much more complex, more expensive, and it almost turns it into, like, a revision rhinoplasty situation.

Johnny: Can we jump into a different topic that we deal with a lot for me, butt and breasts? And I’d love to see what your thoughts are from a face and noses. I love social media, you know. We’ve done some things together on social media before, and hopefully, people like following us on Instagram, and your Instagram handle for those listening is…

Dr. Weinfeld: @happinessplasticsurgery.

Johnny: Oh, that’s cool. Not as good as…

Dr. Weinfeld: Or it’s @happinessplasticsurgery.

Johnny: Okay. I mean, not as great as @austinplasticsurgeon, but it’s good. It’s good. But what about that in terms of noses? Because for me, for like butt stuff, there’s a lot of reigning in of what people see on Instagram, Facebook, other stuff, TikTok in what they can or can’t achieve. Do you deal with some of that for noses as well?

Dr. Weinfeld: Absolutely. And it goes beyond just the issue of social media, but it’s really the whole idea of how the selfie lens, the selfie camera has impacted the way we see ourselves and that, you know, many people look at themselves in their camera more frequently than they see themselves in the mirror. And the problem with that, and there’s a study that shows this really well, a facial plastic surgeon did this, is that the selfie image increases the size of your nose by about 30%. And so, it kind of gives us, I’ve heard it described as like a doorknob view of your face, and it really…that change in the perception of the nose is bigger than it truly is has driven a lot of plastic surgery. So, that’s the whole selfie phenomenon. And then there’s the Instagram, the social media where everybody is trying to catch up to other people’s noses, which are often Photoshopped or seen through different filters or with different makeup to enhance it, and it does create expectations that are false. A classic example is someone who comes to me and they say, you know, “I want… I’m from this ethnicity. I want to have an ethnic rhinoplasty. I want it to fit my face,” and then they’ll show me a picture of someone’s nose that is like a different ethnicity and is a nose that would never make sense for their face, and you wonder if you’re having the same conversation, but gosh, I would love…I mean, it’s great to know that in advance. And so, I tell patients, you know, “Bring me as many photos as you can, clip them from my website, other people’s website, I don’t care. Get them from social media, magazines. Whatever you want to do, show me as much as you need to show me to let me know what you’re thinking, and then let’s have this conversation again.” It is extremely helpful. And again, it’s about them knowing that I’m hearing them, and I’ll take a ton of those photos into the operating room so I really am reminded of the vision that they had. But if they show me something that doesn’t make sense, you know, social media image that doesn’t make sense I’m like, “Uh-uh, that just…” Like we need to say that that is not something I can achieve.

Travis: I think you and Dr. Franco do a really good job of kind of tampering those expectations. And sometimes when you have a patient who comes to you with unrealistic expectations and things that cannot be done safely or with a good outcome, you guys have that conversation upfront and in the beginning of that relationship.

Dr. Weinfeld: Yeah. It’s…

Johnny: I’d rather them be disappointed at the consultation pre-op, not have a surgery, than be disappointed after a surgery to their face, butt, breasts, $10,000, $15,000 later, whatever it is depending on what they had.

Travis: Yeah, 100%.

Johnny: And then they’re really upset. And some of the things that’s hard is in…it’d be interesting if you get it. I know, G-Berto, we’ve talked in the past has it with even injectables where it’s terms like natural, subtle, different things, really mean a lot of things to a lot of people.

Dr. Weinfeld: [inaudible 00:18:43], without a doubt.

Johnny: And there’s times I’m like, “Oh, that’s subtle.”

Travis: Subtle.

Johnny: Okay. Cool, that’s…and it’s just…you know, at least gives us…I tell people at least we have a reference point that we’re both starting with when we’re using these terms to describe the change.

Dr. Weinfeld: Yeah. I mean, touching back on something that you had mentioned is it’s so hard to say no to a patient, but I’m kind of a little bit early with the quote of the day, which isn’t even really my responsibility.

Johnny: But I’m glad somebody took it upon themselves.

Dr. Weinfeld: Yeah. But there’s a good saying, and you probably have heard this, but you’d rather have someone be mad at you for not operating on them than for operating on them.

Johnny: Oh, for sure.

Dr. Weinfeld: Yeah. And so, yeah, sometimes you just have to say no or no I’m not going to be able to do that, or, you know, a real classy way of doing that is say, “I don’t know if I can deliver what’s going to make you happy.” Sometimes you need to do that.

Johnny: My nurse gets mad at me because sometimes they’ll just show me a picture and I’ll be like, “No.” And then it’s the awkward silence. My nurse is like, “Why did you just say that?” I want the point to come across very clear, like, “Hey, I can’t do that,” you know? And sometimes you just need to let them sit for a little bit and be like, “Hey, let’s be crystal clear. I don’t want to have any mixed terms. Like, I can’t do that.” Unfortunately, people don’t realize, you know, filters, angles, Photoshop, I mean, so many things get changed and it’s just like…because…and we haven’t even scratched the surface with some of the limitations of noses. And you talked about ethnicity and lots of factors, but how thick the skin is, the bone structures, what’s in your face, whether you’ve had a surgery before, there’s so many factors that we can’t necessarily change or control.

Dr. Weinfeld: Control. Yeah. And that’s hard. I mean, you want to have a patient have confidence in you, but you also…and, you know, say, “I’ll do…” It’s hard to say things like, “I’m going to do everything I can do, but the way your body heals may take in a direction that both you and I wish were different,” you know, but it’s important to have those conversations upfront because here’s another quote that I’m sure you’re familiar with. Like, everything that you tell a patient in advance is education. Everything you tell them after surgery is an excuse, right? So, it’s really important to go through all of those limitations that exist in a surgery as complex as rhinoplasty, without a doubt.

Johnny: Can I just say I hope right now that Celebrity Anesthesia and Austin’s most beautiful man is taking some notes on…

Travis: Taking notes on that.

G-Berto: I like that one.

Johnny: And maybe you can help them with some future quotes of the day because those are on point, damn.

Dr. Weinfeld: I have one more for a hat trick. I just…

Johnny: Yeah [crosstalk 00:21:10]. That’s good.

Dr. Weinfeld: No, no, no. I’m saving it for later. I don’t remember where exactly.

Johnny: Okay.

Dr. Weinfeld: Like saying it kind of pushed it back down, but I’m going to let it…I’m not going to think about it, it’s going to come back up.

Travis: There we go.

Johnny: Well, especially if somebody belly flops the quote of the day, maybe you can come in and save the day at the end of the episode here. But let’s talk about a couple other specific topics. One, maybe kind of work our way up from complexity to not and get G-Berto in here. We talked a little bit off the air about this whole non-surgical or liquid rhinoplasty. What are your thoughts on that? And I’d then love to get G-Berto’s rebuttal to whatever your statement is.

Dr. Weinfeld: Yeah. I mean, I know you guys were looking for a little controversy.

Travis: I hope so.

Dr. Weinfeld: I don’t know that I’m going to say anything that’s controversial. I mean, truth be told, by the time a patient comes to see me, like, they know what I do, you know. I don’t promote liquid rhinoplasty a lot. I do talk about, you know, rhinoplasty, cleft rhinoplasty, revision rhinoplasty that when people are searching me out they know what I do. And so, I’m mostly seeing patients who want to have surgical rhinoplasty. I think that with social media and the way people advertise, they’re, like, fantastic, people who are doing liquid rhinoplasties, people who don’t want surgery end up going to see… I do have some experience with it. I don’t have a lot of experience. So, let me tell you, though, couple of things that I think are true and I think that he’s going to say are true as well, but one is, I think patients need to understand that, at least in my understanding, liquid rhinoplasty means adding to the nose, right? So, if you want your nose to look smaller, that’s going to be really hard to achieve by adding a filler to it. Now, the way that adding filler to a nose can be really powerful, beneficial, and of value and that I have no…take no issue with whatsoever is if someone has a very subtle hump and you add a little bit of filler above it and below it, you can make a nose look straight. You are actually adding to the nose. You’re making it bigger, but in some ways, it may change the perception of the nose. They may feel like their nose looks smaller because they no longer see the hump or, at a minimum, at least you’ve camouflaged the hump. So, I think there’s a lot of value to it.

Another couple other things is that, you know, again, I always shoot for perfection, but there are times that I don’t get a patient to where they want to be or where I want to be, and I do use fillers to try to rescue those situations. And it’s really interesting. Fillers are temporary, but in many patients, especially in the nose, there’s something about it that if you put a little bit of a filler in an area where there’s a little bit of, like, a divot, it fills it in and they look great for a year. And maybe you need to repeat it once, and then often it just…you know, I don’t know if it’s filling in with collagen, or scar tissue, or what, or just created a space that the body filled in somehow, but that can be a really powerful [inaudible 00:23:56]. And I do that and I don’t do it. You know, I don’t charge my patients for it if I think it’s indicated. And then one final thought on fillers is that in the nose is you definitely have to be careful. And I know skilled practitioners always are, but fillers anywhere can increase the risk of vascular compromise to the tissue so you can have skin dye and it can even from the nose can go into the vessels that supply the eye and cause blindness is a very rare thing. I don’t mean to scare away patients from that because as I said, I think there’s a ton of value with it, but those are the kind of things I think about even when I’m in my few experiences injecting fillers in the nose. I’m always thinking about that and being mindful, and I’m sure that he’s going to have some great comments about how to keep people safe.

Johnny: G, I feel like there’s so many things to talk about here because there were some good nuggets there.

Travis: Yeah.

Johnny: Some, I agree, some maybe I have some different thoughts on.

G-Berto: No, I think Dr. Weinfeld hit it on the head with that.

Johnny: You folded like a wet noodle.

G-Berto: I mean, I can’t compete with a man who does this every day. I will say that, you know, when I do liquid rhinoplasties, which I can’t say I do a lot of them, but the ones that I do, it’s kind of like what Dr. Weinfeld said. It’s mostly to correct like a little nasal hump, just to kind of camouflage it a little bit. I’m not doing anything that’s crazy. I know my limitations. If I feel that the patient is, you know, really a surgical candidate, I can help them to maybe defer that surgery for a while, but ultimately, if they need surgery, then that’s what they need, and I’m going to refer them. I actually do refer a lot of patients to Dr. Weinfeld. I don’t know if you knew this or not, but…

Johnny: Oh, I thought you referred them to me. That’s cool. Now the truth comes out. The truth comes out.

G-Berto: No, actually I’ve…

Johnny: Changing like the winds.

G-Berto: I’ve sent a lot of patients to Dr. Weinfeld in the past.

Dr. Weinfeld: Well, thank you.

G-Berto: I’ve known of him for quite some time since I moved to Austin and heard he was a great facial plastic surgeon, so anyone needing facial plastic surgery, I always do mention him to those patients.

Dr. Weinfeld: I appreciate, guys.

Johnny: I think a couple thing about the liquid [inaudible 00:26:01] just my thoughts, and I’d love to hear both of you guys is that, one, I think there’s very specific spots that it helps. I tell people for, like, a nasal tip standpoint, I don’t think it’s helpful in that area, and I think that does put you a little bit more risk for some vascular injuries because to your point about that, we try to be right on either the periosteum, perichondrium, right on the bone, right on the cartilage because that tends to be a safer place. I do think for the dorsal hump stuff, I think it’s absolutely fabulous. The one place I guess I would disagree a little bit is this plastic surgery illusion, so people that have a very broad nasal dorsum. I feel because then you turn it from like a square roof to very angular. You can give the illusion of a more narrow nose, even though you’re adding volume. So, I think that’s one specific spot where maybe you can create an illusion of a more narrow nose, even though you’re adding volume. And it’s a very particular style of nose but I do think there’s a spot that can help. We have people that come in to see me who have had a rhinoplasty. There’s just, to your point, a little something that they want to tweak, and you know better than I do. Some of these tiny little defects, it’s a long run for a tiny little gain to try and reopen the nose and redo stuff, and sometimes much, much better with just doing a little touch-up. And it’s interesting because I’ve had the same experience with filler and I guess great for the patients, maybe not great for our practice that they will do, like, something like Voluma and they’ll take years to come back because they’re like, “It just lasted.” And I think some of it, there’s not a lot of motion in the nose.

Dr. Weinfeld: I think that’s what it is, yeah.

Johnny: So, the product doesn’t really get beaten up, not like lips, which is the opposite and the product gets very, very quick. So, I think those are some great spots where we’ve had success. So, love to hear either of you guys’ thoughts on those things.

Dr. Weinfeld: Yeah, you know, the three things you mentioned, I mean, I agree with you 100% that if you make that the roof of the nose go from square to thinner, even though you’re adding on that front view, that portrait view of the patient and the one that they’re probably looking themselves the most, it’s going to make the nose look thinner and thus small. I agree with that. I just don’t have a lot of experience doing that, but I totally agree with that. And then you mentioned the tip, and the tip is a dangerous place to inject, especially if it’s already had surgery because it’s just sort of a dense…the skin is more adherent to the underlying structures and try to get a little bit of product as people call it between the cartilage and the skin can create the risk of vascular compromise. I think it can be done safely, but you got to work in small amounts and tell the patient, you know, maybe we add a little bit and you come back, add a little bit and you come back. And I think that’s one way to do it safely. And then definitely, I think you’re absolutely right because it’s not a highly mobile structure, the anatomy is not moving around a lot, if you get that product down on the bone, it can last for a long, long time. I think it defies the recommendations of the manufacturer by how long it actually lasts, by two, maybe, twofold.

Johnny: I agree. And I think one of the things that’s kind of cool and I try to…love to hear your thoughts about this, but direct people like G-Berto is saying, if somebody is like, “Hey,” coming in for a liquid rhinoplasty and they’re like, “Hey, I’m thinking about having my nose done in six months,” I will [inaudible 00:29:10] fight them to do a liquid rhino because I was like, “Hey, then if you’re going to go see somebody such as yourself, they’re going to get a distorted view of where you’re at, so don’t do that if you are thinking about getting this soon. If you just know that it’s years down the road and it’s just…” Because we get people who are just they’re scared of surgery. They just don’t want to do it. They just want something to make it look a little better. You know, they’re trying to dip their toes. I think those are good candidates. If you’re already down the pipeline and you’re like, “Hey, I’m going to get this done within the next year,” I’m like Gilbert. I’ll fight them a little bit to do this because I think it then sometimes makes your job a little harder if you don’t know what you’re really dealing with.

Dr. Weinfeld: Yeah. You know, I haven’t knowingly…You bring up a really good point that I probably need to do a better job about asking because I don’t actually, come to think of it, I don’t know that I ask patients if they have filler in their nose. I think sometimes you can tell, and often patients actually are pretty…you know, we do ask them about procedures on their nose, so I’m hopeful they’re understanding that as at least a procedure, but we don’t ask about that directly. I think I’m gonna start to do that. I’m trying to work out a way for you to still give those patients filler and then have them come see me later. We can melt it away with the hyaluronidase.

Johnny: Yeah.

Dr. Weinfeld: So, you can even work that in, you know, is that you can try this on for size, see what you think. And then later, if you do decide to have surgery, even if it’s in six months, you can use the hyaluronidase to melt it away and you can kind of get back to baseline so Dr. Weinfeld can really see what’s up.

Johnny: And the hyaluronidase is something that everybody who does injectable should have in their office readily available because that is one of the treatments if you were to ever get obviously extraordinarily rare intravascular injection.

Dr. Weinfeld: Yeah. Without a doubt. I mean, that’s part of your rescue kit. Yeah, that, the nitro paste, the aspirin, the hyaluronidase, all really important things.

Travis: Sure.

Johnny: G, any other comments about liquid rhino, other fillers, stuff that you like to use in terms of products? My go-to is typically like a Juvederm Voluma. I’ll do a Restylane Lyft, but those are my favorites because they’re reversible, so that’s why I love them. They tend to be a little bit softer because sometimes when people have really thin skin, you can feel every bony segment, but if the product is too firm, sometimes they can feel a little bit of that hardness too.

Dr. Weinfeld: Yeah.

G-Berto: I like a variety of different HA fillers. I’ve never used Voluma in the nose.

Johnny: You’re so politically correct.

G-Berto: But I like Restylane Refyne. I like just plain Restylane-L, maybe some Juvederm XC, maybe even some Juvederm Ultra, but I don’t know. I feel like Voluma, for me, maybe it’s a little too robust, a little too, like, bold. I don’t know. That’s just me.

Johnny: You got such a kit. I got a [inaudible 00:31:47]. That’s cool.

Travis: Not to get too off-topic, I do want to go back to rhinoplasty if we can because I have a couple of questions for Dr. Weinfeld. And I know we’re running short on time a little bit, but open or closed technique.

Johnny: Oh, that’s a good one. That’s a good one. Is that still a controversy or no?

Dr. Weinfeld: Well, I mean, I think it’s a great controversy, and it’s not really a controversy. It’s just two different ways to skin a cat.

Travis: Sure.

Dr. Weinfeld: I do most of my…

Johnny: I mean, we love cats, but yeah.

Travis: Sorry, Peter.

Dr. Weinfeld: No cats were injured in the making of this podcast or my rhinoplasties for that matter. Yeah. You know, so an open rhinoplasty for those who are listening, hopefully a lot of people, right? It is the world’s best podcast after all, according to us or as voted by us. But open rhinoplasty is where you make incisions, small ones, on the skin, very difficult to see, to be able to lift the skin off of the structures and really see them well. It’s kind of like lifting the hood up off of a car engine to be able to see down from above. A closed rhinoplasty is where you make the incisions on the inside of the nose and reveal the structures like that. You can’t see them quite as well, but with experience and skill, you can certainly modify them in appropriate ways. I was taught open rhinoplasty. It serves me and my patients very well. I will do closed rhinoplasties in specific situations, in particular, if someone has the need for an augmentation rhinoplasty, so they have a small nose that they want to be bigger, and it’s kind of bigger in a specific area, usually the dorsum. That, I can do really well through a closed technique and there’s a lot of benefits to it. That’s probably the best example of when I do a closed rhinoplasty. But there’s a lot of shift going on in rhinoplasty towards what’s called preservation rhinoplasty, and there are a lot of ways that people are using preservation rhinoplasty in a closed rhinoplasty format that I find very intriguing. I don’t think the pendulum has really shifted all the way towards that part of the rhinoplasty spectrum yet, but it’s something that I’m keeping my eye on and that I’m going to start to attend some of these courses and get some information. So we might see in my practice a…

Johnny: You mean the courses that you chair? Because you’re actually the chairman of the Rhinoplasty Symposium.

Dr. Weinfeld: Yeah. Myself and this guy by the name of Sam Most, he’s a facial plastic surgeon at Stanford, we’re co-chairs of the Rhinoplasty Symposium/ASAPS meeting called the… It’s a half-day course on rhinoplasty that occurs before the rhinoplasty meeting every year.

Johnny: Just so you guys know how modest he is being right now.

Dr. Weinfeld: Yeah. At least one of us has to be.

Johnny: Somebody on this show has to be because it’s not Celebrity who’s trying to change his name to Average Anesthesia for a while and it hasn’t caught on, so.

Travis: I do want…

Dr. Weinfeld: It was already taken, I think, right?

Travis: I did want to touch on one more thing. Dr. Weinfeld and I have worked together quite a bit, and I wanted to ask you about other things that you add cartilage-wise from different parts of the body to the nose to change the shape.

Dr. Weinfeld: Yeah. So, you know, primary rhinoplasty, so first rhinoplasty, we have to move structures or tissue around, and it’s cartilage from the septum in order to really freeze that framework so that the skin overlying it maintains the shape that we want for a long period of time. But if someone has already had a rhinoplasty and they’re to see me for a secondary rhinoplasty, that cartilage from the septum has most often been used. So, to achieve the goals of the secondary rhinoplasty, we need to get cartilage from other parts of the body, and the two parts of the body that are really the main sources for that are either the ears or the rib. Now, when I tell that to patients, can you guess what they always say they want? The ears, right? Because it just seems less invasive, which it is. Well, sort of is. But they’re very different types of cartilage. Cartilage from the ear, it’s thin, it’s flexible, it’s not strong. But because it’s flexible and it’s thin, it’s really good for kind of…I call it like as an ornament, so if you need to add a little bit to the tip but have it still retain the natural softness of a tip, ear cartilage is good for that. Whereas if you need to add some real structure to maintain the shape of a nose that you’re rebuilding because let’s say it was over resected in the primary rhinoplasty, your cartilage is not going to do it. You need to have rib cartilage. It’s available in greater abundance. You could make longer pieces out of it, and it’s firm, and it’s not flexible. It really can maintain the shape. So two different types of cartilage. Usually, for a revision rhinoplasty, we’re using rib because that’s what we need. It’s available in that abundance and it’s the stronger, more durable cartilage of the two.

Johnny: And this is why I think that not everybody does revision rhinoplasties because you really have to have a lot of tools in your kit to do revision because number one, if you didn’t do the first one, you never know exactly what you’re going to find when you’re in there. You know, sometimes if you’re kind of doing a redo all over and truly trying to support that nose, I mean, you need more material than people think. You’ll take a big piece to get down to something that’s shaped just right.

Dr. Weinfeld: Yeah. From the beginning to the end, the entire enterprise, if you will, of a revision rhinoplasty, it’s just more taxing. It’s more trying. It requires a greater attention to detail in comparison to a procedure that already is kind of taxing and requires a greater attention to detail, you know, than many things. And so, I mean, it starts from the interaction with the patient because you’re already interacting with a patient who’s experienced disappointment, and so try to kind of unwind that to gain trust, to have them trust in the process, yet all the while recognizing that there’s only so much we can control. I mean, that in and of itself is very difficult to do. Fortunately, we’re able to do that well, and we’re able to attract really reasonable patients most often and be able to [inaudible 00:37:44] the surgery. But yeah, I mean, I post most of my primary rhinoplasties for about three hours. Sometimes it takes two and a half hours. Sometimes it takes three and a half hours. Never rush. But when I’m doing a revision rhinoplasty and it’s going to require rib, I’m usually saying four and a half to five hours because, again, you never want to feel rushed, and you need that extra time to safely get that rib out. You know you’re going to be dealing with scarred tissue, scarred skin, scarred cartilage. Takes longer, there’s more bleeding associated with it, so you just got to go slower and really pace yourself.

Johnny: Maybe one of these days, if you wouldn’t mind sharing with us, we’d love to post just you because I’ve seen you do this where you’re just at the back table, you know, there’s the main table, obviously, where the patient is, but then we have kind of a backward table where you typically keep instruments. But a lot of times you’ll just sit for a little while shaping and carving this, and I think people…I don’t want to steal your Behind the Bovie nugget, but just sit there, you know, just sculpting this just perfectly, which is really, really cool to see sometimes.

Dr. Weinfeld: Yeah. I mean, it’s a lot of fun, you know, and like you said, a fair amount of the really precise work actually is not occurring in the patient. It’s preparing those pieces of cartilage for grafting. It’s a lot of fun, takes a lot of patience, and there’s a lot of art to it.

Johnny: And then because we are running a little short on time, but I don’t want to skip this because I think it’s super important, recovery for rhinoplasty. Because we’re not cutting out a ton of skin, so if you’re making the nose smaller, that skin is got to shrink down, and then two, it seems like the nose just holds on to swelling and this takes a while, and there’s just only so much you can do other than time.

Dr. Weinfeld: Yeah. I tell patients, you know, one, they should plan to definitely look like they had surgery for at least a week, and the reason they should look like they…or they will look like they had surgery is because they’re going to have a metal cast or splint on the outside of their nose. They’re going to sound like they had surgery because they’re going to have plastic tube-like splints on the inside of the nose, which will make them sound congested, and they may have bruising or probably will have bruising underneath their eyes. Those splints are removed at a week. They still probably will be, you know, somewhat swollen such to the extent that people will know that they had surgery, pretty obviously. They’ll still have some bruising underneath their eyes. Now, depending on the patient and how well things went intraoperatively in terms of minimizing the conditions that lead to swelling and bruising, and some of it is up to people like Travis, and when it’s executed really well, some of our patients at a week can almost look as if they did not have surgery. Sometimes they may need just a little bit of coverup makeup underneath the eyes. But I tell patients, you know, “You may be able to go back to work or school at a week and with a little bit of touch up makeup or just kind of not caring what people think, be able to, like, move about your world feeling pretty normal.”

Johnny: Or turn off your Zoom camera.

Dr. Weinfeld: Yeah. It can be helpful too, or just have a still image of before the surgery, or just use my morphs as your still image on Zoom. Yeah. So, I like patients to stay away from extreme physical exercise for two to three weeks, and then I tell patients to avoid anything that is a contact sport or could be accidentally a contact sport for at least two months.

Johnny: But correct me if I’m wrong. Patients typically don’t have too much pain with, like, a primary rhinoplasty.

Dr. Weinfeld: That’s mostly true. The thing that patients really complain about is the pressure on the inside of their nose and that sense of stuffiness that occurs because of those silicone. They’re soft plastic splints we put inside the nose, but they do press on the tissues to prevent the internal swelling. And that’s really what patients complain about, that and then kind of having those removed as well.

Johnny: But all the swelling to be 100% gone from the nose takes months.

Dr. Weinfeld: Yeah. It takes months. So, 3D image studies done by a plastic surgeon out at Yale demonstrated that at 3 months, 60% of the swelling has gone.

Johnny: Wow.

Dr. Weinfeld: And then it takes…

Johnny: But that means there is still 40% at 3 months.

Dr. Weinfeld: Exactly. Yeah. And so, you got to tell patients that upfront. Patients come to us very well-educated nowadays anyhow, so a lot of them kind of know that, and that’s a good…you know, reminding of them of that is really helpful in interacting with the patient who a week or two out is like, “Well, what about this? What about that?” And they’re all legitimate questions, like my tip is bigger than I wanted to be. Well, yeah, of course, it is, you know. I mean, it’s just been a week or two since surgery. Remember that even at 3 months, even at a month, I think you’re going to be really happy, but even at 3 months, you’re still going to have 40% of your swelling. That’s a really important sort of card that we have to be like, “Hey, you know, you got to be patient with this.” And what’s really interesting is that there’ll be times that I’ll see a patient even at my six-month follow-up. So, they’re beyond that 60% swelling reduction time, and there’s a little something that’s bothering them, a little something that’s bothering me, and I’ll tell them, you know, “I see what you’re talking about. It’s there and it bothers me, but let’s just wait until we get to a year.” And it’s amazing what happens in that last six months. You know, so much of what bothers the patient and it’s usually little things, but they’re real and it’s their face, and even bothers me because I’m really honest with myself and the patients if there’s something I’m a little discouraged about. It’s amazing how things really shake out in a really nice direction when you get to a full year. So you got to be patient.

Johnny: Because you can set yourself up for problems chasing your tail.

Dr. Weinfeld: Oh, without a doubt. I’ve done that once before where a patient was really…they were kind of really distressed about having more swelling than they want on the side of their tip, and I injected steroids, which is a good technique for accelerating that process of the swelling go away, but I did it at, like, two or three weeks, and yeah, that area hollowed out and then the rest of it looked sort of bloated in comparison to that. And then we were, like, trying to…like you said, you know. I think on that patient I was even injecting fillers to try to fill that area in. At a year their nose looked great, but like you said, you can totally chase your tail. I won’t inject steroids usually until we get to about three months.

Johnny: Any last nuggets you’d like to leave people before we jump into Behind the Bovie here?

Dr. Weinfeld: Yeah. I mean, I think that one, a lot of patients come and see me and they say, you know, “Well, I’ve met with other doctors who say they can do it in one to two hours. I personally think it takes longer than that, at least for me to do a really nice job. And I think, yeah, if you’re going to be having a revision rhinoplasty, you want to go and see someone who has a lot of experience, and if they’re not talking about some type of rib graft or there’s even sort of out of the package kind of [inaudible 00:44:00]. If they’re not talking about something like that, you need to ask about it because that really should be a part of the plan.

Johnny: And I don’t think whether it’s nose, butt, breast, time I don’t know should ever really be a factor. I mean, there’s obviously the time, like surgery going 12, 16 hours for an elective surgery. You know, that’s a problem. But I tell people all the time it takes what it takes. If I’m going to sit you up four times for a breast aug, then I’ll sit you up four times. You don’t want to come back six months later because I was trying to do the world’s fastest breast aug.

Dr. Weinfeld: I totally agree. I always, or at least I try to, Travis might call me out on this, I try to overpost my rhinoplasty times just so I…you know, if there’s couple of stitches at the end that I feel like I need to go back and undo, redo, I don’t feel like I’m going to be holding myself or someone else up for that.

Johnny: Agree 100%. What little Behind the Bovie nugget would you like to let us know? I feel like you’ve dropped a few of these, like waiting a year in some of these, but any you haven’t shared with us?

Dr. Weinfeld: I try to be modest when I do this. So, I devised a technique that I think is extremely helpful for revision rhinoplasty where you need to add cartilage to remake a dorsum. And so, you know, using rib, in the past what people would do is they would take a chunk of rib and they would carve it to look like the dorsum and then stick it underneath the skin. Well, the problem with that is it kind of shifts. It can shift and it can warp, and that can affect the results of the rhinoplasty. So, then a lot of people shifted to dicing up little pieces of cartilage with blades and shoving them in some fascia, which is like the covering over our muscles and sticking it underneath the nose. And if you have a bunch of little pieces, it’s not going to warp, but that chopping it up part, it takes so long, like people can spend 20, 30 minutes doing that. So, just a couple years ago, I came up with this process where I take basically a surgical grade steel grater and I use that to grate cartilages into little tiny pieces and then I glue it together with fiber and glue, or sometimes I wrap it up with fascia and I use that to do my dorsal augmentations. And that has been a really, really nice addition to my practice. I think it’s wonderful.

Johnny: That’s really cool. Maybe someone else will have to get on the ground one of these days.

Travis: It’s pretty cool to see live.

Johnny: Do we got a quote of the day or does Dr. Weinfeld have to take that home too?

G-Berto: I don’t know. I’ve got one, but I feel like Dr. Weinfeld has been hitting them out of the park all episode.

Dr. Weinfeld: I think the one that I said was the second one was the third one. I just thought of it twice, so I don’t have another one.

Johnny: All right. Well, we appreciate you giving this back to G-Berto because he needs it. Go ahead, G.

G-Berto: All right. I got one from Jimmy Dean. I think…

Johnny: Sausage guy?

G-Berto: The sausage guy. Yeah.

Johnny: Oh, cool. I mean, that’s cool.

G-Berto: Yeah. It says, “I can’t change the direction of the wind, but I can adjust my sails to always reach my destination.”

Travis: All right.

Johnny: Wow.

Travis: Okay.

Johnny: That’s a good one.

G-Berto: Yeah.

Johnny: That’s a good one. Yeah, I like it. Yeah.

Dr. Weinfeld: I like it. Yeah.

G-Berto: I thought it was [inaudible 00:46:57].

Johnny: Well, let’s adjust our sails to bring this podcast home for the day.

G-Berto: Yes. Let’s get it to our destination.

Johnny: Well, I can’t thank Dr. Weinfeld and our cast for everyone being here and giving up their free time to share a little knowledge. I would love to have you back talking about noses some more because I feel like we’ve only scratched the surface of some of these issues. This was fabulous.

Dr. Weinfeld: Yeah. Anytime. Yeah. I feel like we talked about 10% of what we could talk about.

Johnny: And maybe…because I know you’ve talked to me on other episodes, you even do a lot of ears. I would love to talk otoplasties one of these days. That’s one of my favorite procedures that I don’t do that often that is so cool.

Dr. Weinfeld: Oh, yeah, equally complex as rhinoplasty. I’d love to.

Johnny: But thank you for being here, Celebrity. Appreciate it as always. Austin’s most beautiful man, G-Berto, appreciate it.

G-Berto: Thank you, Dr. Weinfeld.

Dr. Weinfeld: Yeah, thank you.

Johnny: Thanks for listening to “Plastic Surgery Untold,” greatest podcast in the world as voted by us. Download anywhere you get your favorite podcasts, iTunes, iHeart, Pandora, Spotify. See you guys soon. Bye.

Dr. Weinfeld: All right. Bye-bye.

Travis: See you.

About The Author

Dr. Johnny Franco
Episode 30: Everything Butt…Episode 32: Breast Reduction – The Art of Lifting and Shaping the Breast!


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