FPSAM - Roundtable 2022 - 8

EXPERT PANEL DISCUSSION
adding large caudal-septum extension grafts, dorsal
grafts as well, because many ofmy patients are African
American, Asian and Latina. The goals of their rhinoplasty
are different because they want to have a stronger
profile and smaller nasal tip and improved rotation
which can be lacking. However, the nasal tip skin can
be thicker some individuals. I have been doing many
African American rhinoplasties and it's a little bit less
predictable in terms of the nasal skin because sometimes
I have to thin out the skin, which can lead to a lot
of swelling. Without thinning out the skin it is difficult
to see any nasal tip rhinoplasty changes. Immediately
following the rhinoplasty, I'll put the nasal thermasplint.
Following cast removal I'll have them do a nasal
massages to their nose after surgery, sleeping at a 30
incline for a few weeks after surgery as well. I always
counsel them, and tell them that swelling can take
months for you to see significant changes.
Dr. Spiegel: Absolutely. Dr. Rodman, any thoughts
on rhinoplasty? and manage swelling?
Dr. Rodman: I am open to suggestions! This is not
just in trans women, but this is the bane of my existence.
I feel like they are OK at first. You tell them, it's
going to be swollen. At 2 weeks, they are like, ''I know
it's swollen.'' Then at 6 weeks, they are like, ''it's still
too big. This is not what I wanted.'' I explain that it's
still swollen. I find that right at the 6-week point,
people lose patience with waiting for it to go down,
especially at the tip. I put people on a Medrol DosePak,
and I think that helps. I started using TXA in all of my
injections, which is helping with bleeding and helping
with swelling. Trying to stay in the right planes and be
minimally traumatic. In trans patients these are big
reductions with a large soft tissue envelope that has to
contract. I also hired a nurse practitioner to help hold
hands, and pat backs, and tell them it's going to go
down, and that's normal, and it looks great.
Dr. Spiegel: Are people removing SMAS in the
nose, reduction of soft tissue? Dr. Garcia is raising
her hand.
Dr. Garcia: Yes, at the nasal tip. I have had patients
whose skin was maybe 6 to 8mm thick and no matter
what I did, you were not going to see any changes
unless you remove SMAS, which can lead to a lot of
swelling because then you're obstructing some of the
lymphatics. Over time, you can actually see some of
the changes, and a little bit of Kenalog in these really
thick noses goes a long way postoperatively.
Dr. Spiegel: I will throw out there that I have been
experimenting with radio frequency in the nose.
Morpheus, Profound, Pixel 8, whatever brand you
8
want, the radiofrequency microneedling, I think
contracts soft tissue, and might speed things up,
and is an intervention that can help.
Dr. Schechter: No healing problems? When do you
do that, Jeff?
Dr. Spiegel: Postoperatively.
Dr. Schechter: Pre- or postoperatively, OK.
Dr. Spiegel: Yes, postoperatively. That is challenging
because not everybody is local, of course, for all
of us. For people who are coming back with persistent
swelling, I've got Kenalog. Some people are
using Accutane, retinoids, perioperatively. Of
course, you need to monitor liver functions and
other enzymes if you're going to do that, but that
has been something we have been considering.
I also will reduce the soft tissue, which I know has
always been a little bit of a technique that people
don't encourage necessarily and doesn't necessarily
reduce swelling immediately, but I found in the
long term it can help quite a bit.
Dr. Schechter: When do you stop your Accutane? We
have always been concerned about healing.
Dr.Spiegel: Yes, Ihaven't beendoing it yet personally.
I know out there, people are doing it and they are
starting it perioperatively. They'll start a few weeks
before and operate throughout that period. It's kind
of the reverse, this whole retinoids-in-surgery teaching
is changing. I think even in the dermatology field,
there are some articles on lasers with retinoids, and
they're changing how they're feeling about it.
Dr. Rodman:How far out postoperatively do you wait
before you do the radio frequency?
Dr. Spiegel: I would do it as soon as 3 weeks later.
We are very lucky in the head and neck with our
blood supply, in that you can do things that you
would not be able to do on the trunk and lower
extremities and get away with it.
Dr. Schechter: Jeff, that's with an open approach and
defatting?
Dr. Spiegel: Yes, all the above, and it has been fine.
I'm not doing it on everybody, but that's something
we are trying now. I think we are getting pretty
good encouraging results so far.
How are people handling rhinoplasty with lip lift
and alar base simultaneously? Are people staging
that, doing it all together, combined in one incision?
ª 2022 American Academy of Facial Plastic and Reconstructive Surgery, Inc.
FPSAM - Roundtable 2022

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