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Adventures in Amsterdam Part 3.

Friday was the final day of the course, a day devoted to revision rhinoplasty. I gave the featured lecture, titled: “Lessons learned in revision rhinoplasty, how to avoid it in the first place.” This lecture evolved from a study I performed and published reviewing the reasons patients seek revision rhinoplasty. Since over almost half of my rhinoplasty practice is fixing problems, I presented the most common reasons patients seek revision rhinoplasty, what likely went wrong, how I fixed it, and most importantly, how to avoid it in the first place. As in all of medicine, the best treatment for a problem is prevention. 

 

That night we had an elegant dinner with our hosts Drs. Gilbert Nolste-Trenite and Dirk Jan Menger and their wives. Not only was the dinner wonderful, but Gilbert is a wine aficionado, so the wines were spectacular. Friday afternoon, Saturday and Saturday night, Ali and I were on our own to further explore Amsterdam. Included was the newly renovated Riiksmuseum, just recently re-opened after 10 years of renovation. 

 

My wife and friends sometimes ask me why I travel so far and often to lecture. My travel and hotel were covered by the meeting but I’m taking days off from my practice without pay. Academic medicine is about teaching others, giving back and the opportunity to share ideas with other experts from around the world. It’s an immeasurable experience to lecture around the world, an excuse to travel and an unmatched opportunity to share ideas with others. 

Adventures in Amsterdam Part 2

The second of the course included a live televised rhinoplasty that I performed. This was a stressful, yet exhilarating experience. The patient was recruited by one of the faculty members. She had a deviated septum and was given the option for a cosmetic rhinoplasty by a visiting Professor from the U.S., namely me. I treated her just like one of my own patients. I received the photos by email a few weeks prior. I uploaded the photos into my computer and performed computer imaging on the photos. I then saw the patient the afternoon before for a personal examination and to discuss our plan. Most importantly, to make sure that the patient was comfortable with me and the surgical plan. When the consultation was complete, she was quite excited at the prospect of a new nose. She had a crooked nose and a very wide twisted nasal tip that was over-projected (stuck out too far from her face).

I maintained my routine of doing what Dr. Robert Simons and my mentors always taught: a rhinoplasty is performed 5 times. The first time is when you meet the patient, discuss their desires and perform a thorough nasal examination. The surgery is already being planned in the surgeon’s mind. The second time is reviewing the photos and imaging, often with the patient at a second consult. The third time is the morning of surgery. I review the photos, the written surgical plan and the imaging. The fourth time is actually performing the surgery. For a primary rhinoplasty, surgery rarely deviates from the plan given a careful evaluation and intimate knowledge of nasal anatomy. The fifth time is a year later, comparing the before and after photos to see how the nose actually came out. We critique our own results to help affirm or look to further refine our personal technique. For this young lady, the first two steps were reversed, but the rest adhered to. I had gone over this plan many times in my head before her surgery.

 Back to the surgery, I went to the operating room on Thursday morning, a beautiful newly renovated facility. I was even given bright yellow surgical O.R. clogs to wear. They have them in every size, and are cleaned after every surgery just like the surgical scrubs. I was then wired for sound and off to the surgery. There were three video cameras, one above the patient, a second from the side and a third with a close up view from below the nose. I was quite comfortable narrating my rhinoplasty since I am usually accompanied in surgery by ether a fellow in Facial Plastic Surgery or a resident from the New York Presbyterian, Columbia, Cornell program.  The moderator back in the lecture hall was Prof. Gilbert Nolst-Trenite, a recognized international leader in rhinoplasty education and author of numerous textbooks and hundreds of articles on rhinoplasty.  He asked questions throughout the surgery and related questions from the audience. By the time I started surgery, my butterflies were gone. With a scalpel in my hand, I felt quite at home. Surgery went very well. The feedback during surgery from the other faculty in the lecture hall and attendees was quite positive. 

Thursday afternoon was a relief. Despite having performed thousands of rhinoplasies, this was an exception; the pressure of a live rhinoplasty in front of the symposium as well as a dozen faculty of established rhinoplasty surgeons was now over. I had one more lecture that afternoon.  But first there was a cadaver dissection lab. This is quite routine for me since I have participated in and taught in many of these lab sessions. There is a room with fresh frozen cadaver heads on trays. These are from people who have donated their bodies for medical study. The cadaver heads are always treated with respect and will be used by a number of specialties in pursuit of medical educations. The faculty members helped the attendees perform dissections and surgical techniques on these specimens according to a planned lab manual.

My afternoon lecture was,  “Intra-nasal Rhinoplasty, a dying art?” Another name for intra-nasal rhinoplasty is closed rhinoplasty. This is a topic for another series of blogs. In a nutshell, most young surgeons only taught the open rhinoplasty approach. There are a number of contributing factors for this. However, for most patients, I feel that a skilled, experienced surgeon can get equal results with closed intra-nasal rhinoplasty without an external incision across the bottom of the nose. A better view of the tip cartilages doesn’t automatically make for a better surgeon or better results. It’s as stated prior: precise analysis, understanding nasal anatomy and an armamentarium of sufficient rhinoplasty techniques is what it takes to obtain quality results. This is with or without an incision across the bottom of the nose. 

That night was a banquet dinner for the entire meeting, including faculty and attendees. There were a few speeches and I was honored and surprised with a crystal cut glass wine decanter. At dinner, another faculty member had just arrived for his talks the next day, Prof. Tony Bull from Great Britain. Dr. Bull is recognized as one of the most well respected rhinoplasty surgeons in the world. He also has a tremendous sense of humor that comes out in conversation at dinner plus throughout his lectures.

 

Adventures in Amsterdam

A photo of my wife Ali taken while we were out exploring the city.

I was invited to be the featured guest speaker at the Amsterdam Rhinoplasty course about a year ago. Officially entitled “20th International Course in Modern Rhinoplasty Techniques”, the course was run for most of the past two decades by Prof. Gilbert Nolst-Trenite. It has recently been taken over by one of his very accomplished students, a well-established rhinoplasty surgeon and teacher in his own right, Dr. Dirk Jan Menger. I brought my wife, Ali, with me on this trip. I submitted a number of topics to lecture on. Among the five talks I was to give, they chose one of my favorite subjects, Revision Rhinoplasty, to be the “Lecture of Honor” for the final day of the symposium. That would become the subject for all lectures that day.

We arrived on Tuesday and had the entire day off to tour and catch up on our jet lag. Right after checking in at our hotel we immediately proceeded to the Van Gogh Museum. This is a spectacular museum, with four floors of Van Gogh masterpieces arranged to mirror his life and the evolution of his work.  I heeded the advice I received from my Uncle from when I was backpacking in Europe as a student: that the one thing not to skimp on fees is the audio program. These programs offer insights on the art that only a student of the subject can appreciate. After a nice stroll around Amsterdam we went back to our hotel for a power nap. Dinner was with our host Dr. Menger and his lovely wife at a beautiful brick-walled restaurant.

On Wednesday I was picked up at 7:45 a.m. by Dr. Menger to go to the meeting at the University Hospital of Amsterdam. This is a huge, modern hospital with a soaring roof that housed not only the hospital, but stores, restaurants, and kiosks for the benefit of hospital staff, patients, and their families. Most attendees at this course were practicing surgeons looking to hone their techniques and learn about new innovations in rhinoplasty. There were surgeons from Europe, Asia, and the Middle East. I had two lectures to give later that day. These were preceded in the morning by a live televised surgery by Dr. Menger. I got a preview of what was expected of me for the following day, my own live surgery. Dr. Menger did a beautiful job.

My first lecture was on “Graduated Tip-plasty.” Surgery for the nasal tip is the most challenging part of rhinoplasty. Each patient needs to be assessed and treated as an individual. Volume, length, strength, and the shape of the nasal tip cartilages are all evaluated, as well as the relationship of the nasal tip to the rest of the nose and the patient’s face. Treatments range from simple to complex and may involve trimming some cartilage and/or rearranging parts of the tip cartilage. Sutures and grafts of the patient’s own cartilage are also often used to obtain the desired result.

I gave my second lecture that afternoon, “3-D Imaging, a New Dimension in Consultations, Evaluation and Planning.” I have been using computer imaging for rhinoplasty since the beginning of my practice 25 years ago. Like surgical techniques, this technology has evolved from black and white video capture, to color cameras, to digital photography, and now to 3-Dimensional imaging. Computer imaging is not just for showing potential results, it helps stimulate a dialogue with patients about potential changes, mutual goals, and what can and can’t be achieved in rhinoplasty. Vectra 3-D imaging takes this to the next level. It is also excellent for an academic rhinoplasty practice such as mine, since precise measurements can be made of each nose and compared to both projected as well as actual outcome. These can be recorded and used for medical studies on rhinoplasty.

My last presentation for that day consisted of a few case presentations. I projected the “before” photos of a patient and a panel of experts from the faculty discussed how they would treat these patients. This was followed by a discussion of my results. It’s quite interesting to see how other experts on rhinoplasty think and plan for surgery, sometimes quite differently. This underscores the fact that there is rarely one solution to rhinoplasty. It’s not a cookbook approach of learning, a series of techniques, but more the art of evaluation and planning.

Dinner that night was with the course faculty. This was a chance to get to know my European colleagues in a more cordial atmosphere. Two of the distinguished faculty included Dr. Miriam Bonish from Austria and Dr. Peter Hellings from Belgium.

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