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Dr. Steinbacher: To not just zoom in a hundred percent on the nose, but to zoom out a little bit and look to see is this the right thing to do the rhinoplasty at this point in time? Or should I do this in conjunction with a genioplasty? Are there things that we can do to alter the balance of the face?
Dr. Cameron: Ladies and gentlemen, welcome to another episode of the Rhinoplasty podcast with me, Dr. Cameron Macintosh. I’m super excited for this month, which is brought to us by Allergan. Thank you. Shout out to them for enabling the podcast for the month of March. The theme is the influences, the reason I’ve named it the influences or the people that are guests on this month have really had a great and a massive influence in the world of rhinoplasty, both from a professional but also from a lay side of things. And kicking this month off all the way from the US of A is no other than Derek Steinbacher. Derek, thank you so much for being on the show with us today.
Dr. Steinbacher: Thank you so much, Cameron. Thanks for having me, and excited to chat a little bit this morning.
Dr. Cameron: So Derek, off air, we were saying how different our geographies at the moment. I’m sitting in South Africa, 30 degrees Celsius, not a cloud in the sky. Tell the listeners where in the world are you at the moment?
Dr. Steinbacher: Yeah, so I’m in Connecticut, which is kind of New England, part of the United States near New York, and it’s snowing. It just snowed this week and so it’s cold and we’re in the thick of winter and I’m definitely envious of your temperature and looking forward to that happening here over the next few months. Cool.
Dr. Cameron: So Derek, we’ve got a really interesting topic that we’re going to chat about is really orthognathic surgery and not just being so focused on the nodes but realizing that there’s so much more involved in the facial skeleton, et cetera, et cetera. But before we climb into that topic, and I know we spoke about it, that you’ll be able to share both for the listeners who are not necessarily surgeons, but also really some key take home messages for the surgeons. Give us a little bit about your history. How did you end up, where you at now? Yeah, for interest’s sake.
Dr. Steinbacher: Yeah, thanks. Yeah, so I started my training began actually going to dental school and I trained in some of the best centers in the US. I think I went to Penn for dental school and then I went on to do some maxillofacial training and I went to Harvard Medical School, finished oral maxillofacial surgery training there. That was at Mass General and Boston Children’s as well. And then went on to plastic surgery, plastic and reconstructive surgery at Johns Hopkins. And there had really the full gamut of learning and training about plastic surgery, not only the face, but breast and body as well. And then finished that off with training in craniofacial and cleft surgery back at 10 and at chop. And then since then I’ve been at Yale for the past 10 or 11 years and have been a full professor here as well. And rhinoplasty I think really has interdigitated with all of these interests and it’s something as a lot of your other guests have shared that you really have to have a passion for and you have to teach yourself in part as well. And so I started getting exposed to rhinoplasty really during my plastic surgery training and just started picking it up and running with it.
Dr. Cameron: Wow, sure. I know two of your colleagues from the Rhinoplasty Society are actually queued up to be for their podcast to go out later this month. Paul Nassif and Jay Calvert, you guys understand, are quite a small society, but goodness me, you guys punch above your weight.
Dr. Steinbacher: Yeah, so it’s the main society in the US plastic surgery sphere that focuses on rhinoplasty and it does incorporate people from ENT otolaryngology, head and neck specialty and facial plastic specialty and also plastic surgery. And it’s really a nice niche group that just gets together and focuses on rhinoplasty research and techniques and ways of furthering the field and specialty.
Dr. Cameron: So one of my best mates is one of the top maxillofacial surgeons in South Africa, Cyrus the virus, I won’t mention his name, but many guys know who I’m talking about. And he trained under one of the profs who was quite instrumental with a sagittal split technique as I understand. And I think that’s quite something that’s come out of South Africa. I know the South African maxillofacial surgeons do a huge amount of work and they’re super skilled in what they do. It’s really nice for me to hear that with your background with that and plastics and rhinoplasty that I hope that for the listeners from a maxillofacial site to realize that they can actually step up to the plate and do the work because they are exceptionally talented surgeons. But sometimes I kind of feel that they don’t quite feel that’s in their field of having to work. I don’t know what your thoughts are on that.
Dr. Steinbacher: Yeah, no, no, I agree. And they’re so interrelated, and firstly, they’re very similar in that it’s kind of modifying bony or cartilaginous skeleton. You’re changing the bones of something to influence the aesthetics or the cosmesis and the function of something. So when you move the jaws around, you’re certainly going to change aspects of the face and function related to the face and breathing and airway. And the same with rhinoplasty, you’re taking down bone or adding grafts and changing the structure underneath to have an influence. The other interesting thing is that one influences the other. So if you’re doing LeFort osteotomies, that’s going to have a major influence on the nose because we’re moving the pyriform and we’re changing septum and it can change how the nose looks. So we have to be able to anticipate that and be able to do things to modify the nose at a later date.
But interestingly, like you’re saying too, I think I’ll go to some maxillofacial meetings or where the focus is heavy on orthognathic surgery and there’s great results that are shown, but there’s such a little influence. There’s sort of less of an emphasis on the nose and how the nose looks and these great results are being shown, but the nose is kind of being ignored. And then conversely to that, I’ll go to rhinoplasty and plastic surgery and facial plastic surgery meetings and present there, and there’s so much emphasis on the nose, but people start forgetting a little bit about the face and miss VME and retrognathia and microgenia and those kinds of things. So they’re really interrelated and I think both of these things together are extremely powerful.
Dr. Cameron: So Derek, you’re kind of in a unique position between the two. What do you think is the way to try and marry them or bring them closer to each other?
Dr. Steinbacher: Yeah, I mean, I don’t know if every specialist wants to get involved in both of them necessarily. I don’t think that’s necessarily the goal. But I think just starting with education and a recognition that somebody’s coming with an airway concern, that to look beyond maybe your own sphere and make sure that you’re at least asking the questions related to how sleep apnea is coming about from maxillofacial discrepancies. And if you’re doing maxillofacial things, making sure you’re focusing on the nose and ensuring that if they have septal deviation or things like that. And from an aesthetic perspective, which is more and more of what I’m kind of focusing on, they’re really very married together. But again, I don’t know if every provider needs to necessarily do both procedures, but just having an awareness or education of them I think is paramount.
Dr. Cameron: Okay. So another question I have for you, which might almost be uncomfortable to answer, but I mean you’re an academic, I mean Yale, you can’t argue that maxillofacial and plastics, where does liquid rhinoplasty fit into the picture?
Dr. Steinbacher: So I still see the whole gamut of cosmetic patients and some patients that want to come with very little intervention and have very little downtime and have a mild deformity. There’s certainly an advantage to doing that, and we certainly offer that. I think one thing I’ve done a lot in my practice too, and we’ve written papers about this, is fat grafting and crushed cartilage and fat for the nose and for some of my primaries or revision rhinoplasties that we’re doing subtle asymmetries or depressions or those kinds of things are certainly can be amenable to aspects of filler based liquid rhinoplasty or sometimes fat injections as well.
Dr. Cameron: Okay, I had a really interesting chat with Alvin de Souza, the president of the EAFPS earlier this week, and he told me that he uses a large amount of Botox during rhinoplasty because he feels that especially on deviated noses or if you’re working in the radix et cetera, the muscles around the nose can have a big impact on the outcome of the rhinoplasty. I found that very interesting.
Dr. Steinbacher: Yeah, no, that’s a great point. I haven’t actually done that in rhinoplasty. I’ve done it for cleft lip for scar, helping mitigate the scar, and I do it in orthognathic to try to help prevent the masseter and temporalis muscle pull at the jaws. But it does make sense. And most of the time I’ll do orthognathic and then rhinoplasty stage, but sometimes we’ll do it together and maybe that’s an advantage because the muscles and the facial drape has all been inserted, which sometimes I think is a disadvantage, but from this perspective of the muscles and the muscles pull, maybe that’s an advantage to a deviated nose and removing some of that muscle pull on the nose. So that’s very interesting. But yeah, I think Botox has more and more applications all across aesthetics, not just aesthetic brow aging and forehead aging. So that’s very interesting.
Dr. Cameron: Oh, maybe there’s a study there, you can get some of your fellows to look into something like that. So obviously it’s been a long road for you to get where you’re at. What is the resilience that you’ve had to rely on to get where you are at, and paired with that is what do you do to be able to survive your off time? Because you can’t be just grafting as a prof at one of the Ivy League universities and working like you do. What do you do when you need the break?
Dr. Steinbacher: Yeah, no, sounds good. So in terms of resilience, I think just having this personal drive or having the interest in the topics and subjects that we’re doing, and a lot of it comes from the patients and we learn so much from the patients. I think we never just want to come in and be cookie cutter in terms of what we’re trying to do. I think especially when you’re combining new and different fields together and you’re trying to push the boundaries and push the envelope of what we’re trying to do and some of the results we’re trying to achieve, I think looking to our patients and really studying our before and afters, and I do a lot of 3D morpho metrics where you could really study results down the line and be critical and try to see what are things we can do or what techniques we’re using to make things better.
So I think I gain a lot of the things that we’re thinking about for the future based on patients and patient results and really just trying to be as good as we can be and better and push the envelope related to rhinoplasty and research related to that as well. And then yeah, certainly downtime is critical and you can’t work 24/7, 7 days a week and expect to not be veering towards burnout at all. So around here in New England, getting outside is good when possible this time of year, obviously skiing and in the summer months, out on the water and boating and out hiking in the spring and fall and those kinds of things. I think similar to you guys, you need to get outdoors and spend time with family and think about things outside of plastic surgery, just try to help refresh us as well and come up with new ideas.
Dr. Cameron: Okay, so before we get into more on the orthognathic side of things, one question in terms of the listeners that for, because actually quite a few lay people listen to the podcast all over the world now. What would your words of caution be to somebody who’s considering a rhinoplasty in terms of what they should be, their homework, they should be thinking about why they want it or who they should have it through, et cetera, for the listeners out there?
Dr. Steinbacher: Yeah, I mean I think one of the things that I’m commonly seeing or have seen to some extent is somebody will come and they’ve had either an incomplete rhinoplasty or they’ve had a full rhinoplasty but still have dysmorphology in their face or they’re unhappy with the cosmetics related to their face. And then it turns out that they’re really a candidate for orthognathic surgery and it’s possible and we have to do it all the time where we do the orthognathic after the rhinoplasty, but then the nose is going to change again and they may need a revision rhinoplasty. So in an ideal world, we would see a patient upfront and you would do the orthognathic surgery first if they’re a candidate for that, then the rhinoplasty as a second stage. So sometimes we’ll do it concurrently, but it’s the second part of the surgery. But most of the time, I’d say 80, 85% of the time I’ll do the rhinoplasty three or four months later.
And not everybody’s a candidate for both of these procedures certainly, but you’d be surprised how interrelated they are. A lot of the jaw deformities come about because of nasal obstruction. There’s a lot of studies from the early eighties and seventies where if there’s nasal obstruction, it leads to this vertical maxillary excess and mandibular lack of growth and those kinds of things. And people have had experience with trauma that have caused their nose to deviate or congenital deviation and they’re really fixated on one element of these things and not always recognizing how interrelated they are. So I would just say just be aware that these are interrelated, it’s all part of your face and that we want to be able to address everything and if it’s an ideal world, we’ll do the jaw surgery and then the rhinoplasty.
Dr. Cameron: Awesome. Okay. Really basic question. What exactly is orthognathic surgery and why would a patient need to have orthognathic surgery?
Dr. Steinbacher: Yeah, so orthognathic surgery, it’s basically movement of the jaws. It’s kind of cuts in the jaws where we reposition them in one place or another in space. And many of the times it’s the upper jaw, lower jaw and chin genioplasty together. And there’s all types of reasons that people want to do it. Most of the time it has to do with their jaw misalignment leads to some malocclusion. But we have some patients with perfect occlusion that want this procedure for strictly aesthetic reasons. And we have some patients that have a perfect occlusion that have both jaws are back and their airway is closed off and they have significant sleep apnea. So the fourth component really is the TMJs and you can have some TMJ issues that can either predispose you to jaw issues or they’re interrelated as well. So it’s those four things that we’re kind of addressing by orthognathic surgery.
Dr. Cameron: Awesome. Okay. So now moving on a little bit more towards our colleagues. Obviously various other people will be listening, but my first kickoff is a cone beam CT scan. So almost every single rhinoplasty I do, I’d insist on a cone beam CT scan. And to me, it’s interesting because a lot of people who say, no, you don’t need a scan, but what you pick up on it is massive. And the majority of my scans, I’ve also asked the maxillofacial just to look if there’s stuff that I might be missing at the same time, I think it’s an essential part of rhinoplasty, what do you think?
Dr. Steinbacher: Yeah, I mean I’m obviously biased towards cone beams as well, and I don’t know if I get it for every single rhinoplasty, cosmetic rhinoplasty, but we have a cone beam kind of in our center, so it makes it very straightforward and easy in the radiation dose is much, much lower and it’s not sending them across somewhere to a radiation or a radiology center for a full CT. It’s very easy. It takes 30 seconds. And I agree if there’s ever any doubt of some issues with their sinuses or if I’m looking at their jaws anyway, we definitely get a lot of cone beam CTs definitely before and after every orthognathic case. And we use this for 3D planning and it’s helpful there to be able to look at their nose and say, look, we’re going to change the position of your LeFort, but you have septal deviation that’s above where we’re going to be operating it. That’s not going to be fixed in this surgery. And that’s something we can do later with a rhinoplasty.
I think the other advantage of cone beam CTs is the research component. If you have before and afters, you can show how the septum is straight, you can show the volume of the nasal cavity, you can show the sinus change in sinus position and all those kinds of things. So I agree, I think there’s great research potential. There’s ability for algorithm construction and things like that when we’re talking about computers and looking at ways that we can predict soft tissue changes and airway changes. So I think it’s a great technology and ancillary really to our procedures.
Dr. Cameron: Yeah, I think you touched on that research. So one of the things that there’s a couple of us doing like international collaboration with Miguel Ferreira on looking at the differences from his side. It’s more in terms of the hump, but we don’t necessarily in South Africa, African humps isn’t really something that we see much of. But to try and look at the relations between the cartilages and the bony septum and how much there’s, because if we are doing an African nose, we need septum and there’s often not enough and the cone beams giving that ability to actually carefully measure that, which I find very interesting. Having said that, I think that there’s possibly, there’s such a discrepancy in reporting on CT scans of the nose with our radiology colleagues. Some guys will give a sentence and some guys can give you a page and I think there needs to possibly be a standardization of this is how a CT should be reported on, I don’t know what you think about that.
Dr. Steinbacher: Yeah, I know, absolutely. I usually don’t even look at the report, I’m just looking at it myself and they focus on the run. They just say the sinuses are aerated or something like that. So don’t, the septum has some deviation or they see a spur, but they don’t really comment on the areas that most of the time we’re really looking at. It’s interesting sometimes I find that it’s hard to distinguish between where the cartilaginous and the bony, where I think we can see the cartilaginous and the bony septum, but in some of these revision rhinoplasties, it’s hard to tell are they going to have any septum, any cartilaginous septum left or is that all just scar tissue there? And they have supposedly a septoplasty in the past and the septum is just so thick and inflamed looking on the cone beam. So sometimes I find it difficult from that perspective to be able to assess if there’s going to be any septum left or not.
Dr. Cameron: Okay. So here’s an interesting question for you. Imagine you’ve got two groups of people listening to you on this podcast. Now there are a whole lot of rhinoplasty surgeons be that plastics or ENT, and then there’s a whole lot of maxillofacial surgeons, the orthognathic side and the rhinoplasty side to try and get these guys to talk to each other. What would your main advice be towards the maxillofacial and then your main advice towards what are call the non-maxillofacial and incorporating some type of orthognathic principles into their surgery?
Dr. Steinbacher: Yeah, no, that’s great. So I think it starts with really if a patient’s presenting for orthognathic at whoever’s providing that a plastic surgeon, maxillofacial surgeon for them to understand what the movements are going to be and how that’s going to change the nose. So many of my patients these days, they want to know exactly how they’re going to look and there’s not really great algorithms related to that yet, but they come for aesthetic optimization and they want these procedures for cosmetic reasons and to look better and to function better. I know some of my colleagues, they’ll see these kinds of patients and they focus just on the occlusion or they don’t really think about the face as a whole. Not everybody obviously, but some people or some providers may do that. And I think it’s incumbent upon them and to give their patients some estimation of how their nose is going to be influenced by this.
And patients always appreciate it if you say, we’re going to do this, your nose is going to look worse and you’re going to need a procedure as opposed to doing the procedure. And then it’s kind of a surprise to everybody. So as much as we can anticipate how that’s going to change and if they’re going to need that procedure in the future, I think would be ideal. And then before even doing any surgery at all, making sure that that provider has seen the patient and says, yes, we’ll be able to take care of any untoward change in your nasal shape or appearance or function. We know with certain movements the alar base is going to widen, the nasal tip might turn up more. There might be worse in septal deviation. The terminates might become close to the maxillary floor and cause more obstruction. So as much as we can or whoever’s doing orthognathic can predict that the better.
And then conversely, on the side of the rhinoplasty side, and we just had a symposium on this, a further rhinoplasty society about genioplasty and facial profile to not just zoom in a hundred percent on the nose, but to zoom out a little bit and look to see is this the right thing to do the rhinoplasty at this point in time or should I do this in conjunction with a genioplasty? Are there things that we can do to alter the balance of the face and if there’s a malocclusion, maybe before jumping into the rhinoplasty, let’s have you see this specialist to at least talk to you about the pros and cons and benefits and risks of undergoing orthognathic surgery first before the rhinoplasty. I think if there’s good communication and with all of our colleagues like this, I think that’ll be the best for the patients.
Dr. Cameron: Sure. Okay. So rule of thumb would be first get the orthognathic surgery sorted out, wait for three or four months and then get the rhinoplasty. You wouldn’t consider doing them both in the same setting?
Dr. Steinbacher: I do do them at the same setting. We wrote a paper about this a few years ago, but I find for a few reasons I prefer to do them staged in about 80% of the cases. The first reason is terms of anesthesia. When you’re undergoing these procedures, you have a nasal ray tube placed by anesthesia to do the jaw surgery. Then on your freshly operated jaws, the anesthesia team needs to come and turn that tube, take that tube out and convert it to an oral tube to do the rhinoplasty. And then secondly, the patients, you’re a little bit, we don’t wire anybody together, but they have pretty tight rubber bands holding their jaws closed. So it can be a little difficult to breathe through the mouth. And I use Doyle splints. I don’t use any packing, but most of the time I’ll use Doyle splints for the rhinoplasty and you can breathe through there, but maybe not as well as you would otherwise.
So I think from a patient comfort perspective too, it’s not always good to do them at the same time. And then really the main reason is when you’re de-gloving the facial tissues and changing the Pyriform and you’re putting plates around where you’re going to be doing your nasal osteotomies are close to that, that can change how you’re going to predict what the nasal form is going to be. We make some osteotomies underneath the anterior nasal spine so that we try to preserve the nasal base, but the nasal base is really weakened when you do a LeFort osteotomy because you don’t have that anterior nasal spine to maxilla to the posterior septal angle connection quite as robust or sturdy. Additionally, all the muscles and the periosteum has been pretty much dissected free, so the nose can be a little bit more difficult to predict what you want to do. So for those three reasons, primarily I like to do it in a staged fashion 80% of the time.
Dr. Cameron: Yeah, you just answered my next question. I want to know what to be careful of if you’re going to be doing a rhinoplasty in someone who’s had orthognathic surgery.
Dr. Steinbacher: Yeah, yeah. So that’s great. And we’ve tried to predict that. And if we think we’re going to need to do a rhinoplasty in this person, I try to make sure that the plates that we place along the pyriform are not quite right up on the nose because if you’re trying to osteotomies or even use a Piezotome to do your osteotomies and you have a titanium plate there, you can’t go through that unless you’re planning to remove those plates at the same time. But repositioning those plates is one thing. Making sure that we save the anterior nasal spine. I mean the conventional way that people do before osteotomies is you totally separate the posterior septal angle from the anterior nasal spine, and then that septum is just kind of flopping in the wind and you reposition the maxilla and maybe the ANS is now over here compared to the septum, and you can end up with septal deviation.
And some colleagues in Europe have written about coming under the anterior nasal spine, leaving that bone preservation. And then I kind of bone graft underneath there. So by the time you come back to the rhinoplasty, this is nice and it’s never been detached. And as you and others and Toriumi have talked about the nasal base is really where it all starts. So that in any way is not stable or it’s deflected. That can be an issue. So the other area would be when we do some impaction, we want to predict how much impaction that’s going to be and if it’s going to come too close to the terminates, usually I don’t like doing full turbinectomy, but we will do maybe some submucosal resection and maybe we’ll take down some of the bone and the nasal floor so that there’s room between the nasal floor and the terminates. Sometimes we’ll widen the nasal cavity as well, that lateral nasal wall will be able to contour that away to help the sinuses drain. But considering all these things for a potential future rhinoplasty. But I think the critical ones are really the plates at the pyriform and the anterior nasal spine.
Dr. Cameron: Okay. So Derek, this is fascinating. It’s so interesting. What I want to ask is what resources are available for the listeners? I mean, obviously you can go and you can do searches and get journal articles and stuff, but there’s not a go-to book on this or perhaps a course or some type of fellowship or something like that that people can try and reach out to increase their knowledge.
Dr. Steinbacher: So we actually have a book that came out that does discuss a lot of these things, nasal considerations in rhinoplasty and rhinoplasty and orthognathic surgery. It’s called Aesthetic Orthognathic Surgery and Rhinoplasty, which really touches on a lot of these types of things. So that’s one resource. And initially when I was starting practice, I was really interested in how the nose changes with jaw surgery. So we wrote about three or four papers about that. I can send you links to those. But I think predicting how the nose is going to change is critical. And then lastly, we wrote a paper where we looked at my experience with doing jaw surgery and rhinoplasty and when to do it concurrently, like we said, and when to do it in a staged fashion. So those are some resources, and I don’t think there’s any particular course. I think it would be a very interesting course though to consider all of these things together. But yeah, I think a course and fellowships and additional resources, maybe I’ll put out some additional YouTube videos as well. But yeah, those journal articles and book I think are great resources.
Dr. Cameron: Just remind listeners how can they get hold of that book
Dr. Steinbacher: Just on Amazon aesthetic with an AES – aesthetic orthognathic surgery and rhinoplasty is probably the easiest way.
Dr. Cameron: Fantastic. And I guess what I’m saying is we’re going to have to come and run that course in South Africa.
Dr. Steinbacher: Yeah, that’d be great. Yeah, see some rugby. And do you play rugby too?
Dr. Cameron: I used to play rugby, but that was when I was a young man. Not anymore, but we can get you to play rugby if you want to. They might even funny enough talking about that. We recently looked at the last 50 nasal injuries, trauma injuries, autonomy as an otolaryngologist, I don’t see the same amount of facial fractures as the maxillofacial surgeon friends in town here. But of the last 50 we looked at that and obviously rugby was the most common injury, but what do you think the second most common sporting injury was? Of the nose that I saw over the last few years?
Dr. Steinbacher: There’s not much basketball there, huh?
Dr. Cameron: No, not much basketball.
Dr. Steinbacher: Maybe surfing or soccer.
Dr. Cameron: Surfing.
Dr. Steinbacher: What is it? Surfing. Okay. Yeah,
Dr. Cameron: We just a near Jay Bay where the Billabong Pro is every year. So people love surfing a lot here in South Africa.
Dr. Steinbacher: And they fall onto their board?
Dr. Cameron: Fall onto the board, back to their nose. These laid back surfers get pissed at each other. They, she stole my wave and they punch each other, whatever. Wow. Sure.
Dr. Steinbacher: That’s great.
Dr. Cameron: Derek, this is a fascinating conversation with you. I think this is an area that is so poorly spoken about at congresses and online and things. So I mean, on behalf of all the listeners around the world, I just want to say thank you so much for sharing this. I mean, what you’re doing is fantastic and guys go out, they find those articles, find the book, and befriend each other. The days of us trying to be in our ivory towers and not working together as different kinds of specialists are over, we’ve got to be working together. So be that the plastic surgeon, the otolaryngologist, the maxillofacial surgeon, we all got to at the end of the day, get the best result for our patient. And it’s not about you anymore, it’s about getting that patient the best result. So that’s why, I mean, being able to sit here and speak to Derek and hear what he has to say is just so inspiring. So thank you very much.
Dr. Steinbacher: Thank you. No, this is great.
Dr. Cameron: Great. Yeah. And finally, just shout out to Allegan again for enabling us to have this podcast. And guys, please come back again next week. Same place, same time for another speaker.

Hey everyone. So today I’m excited to start unpackaging and reviewing the instruments in my Steinbacher rhinoplasty set. The first thing we’re looking at here is what’s called the double guarded nasal osteotome. This helps smooth the bump, so we’ve got a small single skin hook, and now we’re moving to a beautiful slender speculum to help us access the septum and inside the nose. For rhinoplasty, you need a very fine, small, a traumatic needle holder, which we have here, which is beautiful. Very nice. The next thing I’m opening is what’s called a coddle elevator. It has a spoon like end, as well as a blunter end that helps us with dissection and along the septum. This next instrument is Ron jour, which allows us to nibble away at things. And now another speculum enabling us to get inside the nose and along the nostrils. The next things here we’re going to open are called nasal rasp, and this is a surface that’s like a nail file and it helps us to smooth the bone of the bridge of the nose and the grits on the surface here are graduated to help smooth these in a progressive manner.
This next item is a very fine guarded osteotome. This next instrument is a long contra angle scissor that helps us or enables us to trim cartilage. This is a wire loop retractor called an Eva retractor that works beautifully. Here’s another dissector or elevator. This is a freer elevator with a significant curve, and now another coddle elevator. This next instrument enables us to get to the back of the septum and remove spurs. It’s called a Takahashi. Here’s what we refer to as a baby Ron Jaw with a fine tip in another Takahashi like instrument that enables us to get to the back of the septum. This is a baby fine, two-millimeter osteotome. This next instrument I’m really excited about, it’s the Steinbacher version of the Converse scissor, which is a contra angle sharp tipped scissor, helping us with rhinoplasty dissection. See those tips closely here, and this will have a black handle. Here’s the pair of different sized, double guarded osteotomes, and now a Joseph elevator. Now this is an awesome Ferrari, red guarded bipolar, and now finishing with that smooth Webster needle driver that helps us suture. So, this gives you a sneak peek at this awesome Steinbacher rhinoplasty septoplasty set. Now check out some case examples where we achieve these results using my rhinoplasty set. Thanks again. This is Derek Steinbacher.

This 24-year-old woman presents for rhinoplasty. You can appreciate the dorsal hump blending with the tip. On lateral view, you can see a deep nasal frontal recess with good projection and rotation. The submental view, the hump looks more obvious than the tip and the zoomed in you can see a broad boxy tip with irregularities. Frontal view shows a C-shaped deformity with the light reflex irregularities of the alar, especially on the right-hand side. This rotating image is useful to communicate with the patient and determine problems and goals. Here you can see that prominent dorsal hump and no super tip break. We use 3D analysis and planning using the rhinoplasty tool. Again, a CS shaped deformity, a prominent dorsal hump, deep nasal frontal recess. We can adjust the tip position, create a super tip break, bring down the dorsum, augment the radix area here too we’re adjusting the alar. On frontal view we can narrow the tip. We can simulate placing a spreader graft to widen the mid vault and address this C-shape in irregular light reflex. Next, we can look at the before and after simulated view. Communicate this with the patient and ensure that we’re on the same page for goals. This is the rhinoplasty diagram showing the spreader graft, septal extension, graft, fat rafting. Here you see correction on frontal of the C shaped deformity. Better tip definition in a better equilateral triangle. Better support at the alar base.
Gentle dorsal lines, blending to the tip with a very subtle and gentle super tip. Break on the lateral view. Again, good dorsal definition smoothing to a super tip break. 3D image shows correction of that C-shaped deformity, smoothing of the dorsum, correction of the deep nasal frontal recess, better tip projection definition, and a small super tip break.

Hey, how’s it going? This is Derek Steinbacher and I’d like to discuss your postoperative rhinoplasty course today. So first off, you will have a splint in place that we put on postoperatively. There will be no packing and there will be a couple tubes inside the nose that keep the septum straight, but you’ll be able to breathe through these if you can keep them clean. There can be a variable amount of bruising postoperatively and we take steps to try to minimize or avoid these steps so that there’s no nausea and vomiting, but we want you to avoid strenuous lifting or exercise. No hanging the head low. Also, applying ice, especially to the lower eyelids is helpful. We like and recommend using green tea bags, steeping these, and then keeping several in the freezer, placing them to the lower eyelids. There’s also a few dietary and topical considerations.
Pineapple juice has an enzyme bromelain that seems to block and lessen bruising. Arnicare as well is an herbal supplement that you can place topically in the lower eyelids as well as dissolve a tablet under the tongue and doing all these things leading up to and after surgery has a positive effect. Vitamin K ointment on the lower eyelids after surgery too will help limit or lessen bruising. In terms of medications and keeping the area clean, we want no water on or underneath the splint because we want this to stay in place. We would like for you to clean the nostrils in the area of blue sutures. In doing this, we’d like for you to use a Q-tip with hydrogen peroxide or soap and water and gently curl this back and forth to clean any debris as shown here on this gag gift pillow with my rendering.
We also will give you nasal sprays. We’ll give you either Afrin or Neo-Synephrine and would like for you to use two sprays per nostril, three to four times per day, stopping after the third day. Additionally, we’ll give you a saline nasal spray. Frequently, Ocean spray nasal spray for this, please use it four times per day and each nostril and continue this until we see you. A few other things to consider. Please keep your head elevated while sleeping on two to three pillows. Take it easy. As mentioned, no exercise. Glasses are okay while the splint is in place, but once we remove the splint, no glasses for at least four to five weeks and this includes sunglasses. Flying is okay if you’re traveling for surgery, you may want to stay nearby for one day postoperatively, depending on the time we finish the case. If you were more local or regional and flying at some point postoperatively, that’s fine too. We may just want to give you some Sudafed to help with any ear or sinus pressure before and during the flight. We typically will see you back at about seven to ten days following surgery at which point we will remove the splint tubes and sutures.
This image shows a young woman at about the eight-day post-op mark just having those things removed. We actually studied over a hundred of my own patients and showed looking at edema or swelling, that 70% of it goes down by about four to six weeks postoperative, but the remaining 30% takes the better part of a year to completely go away. And these images are from our study showing at various time points how the nose takes shape as the edema comes down with time. So, we’ll finish off this short video just showing a couple postoperative results. This is about one year postoperative and showing that when you adhere to the recommendations that we describe, this will help your recovery go smoothly and we can both look forward to your final results. Remember, every case is different, and please discuss with us in person for any specific situation and contact us anytime during your recovery phase. See you soon and looking forward to your results in your rhinoplasty. This is Derek Steinbacher.

So, this is the 3D rhinoplasty tool that we use. First, we look at your nose together and we can make changes that adhere to your goals and our goals. We want to try to do this in the confines of what we can really achieve and what is biologically possible. Here you can see we’re adjusting the tip in the profile of the nose on the lateral view. We can then compare with your preoperative or your preexisting nose to see how close this looks. We can rotate this in multiple directions. Again, this is a 3D image, and this gives us an idea of what we’re shooting for and trying to achieve with your rhinoplasty. So, on the bottom panel here in the middle is the simulated result, and on the far right is the actual result. Here is the before and the actual after result, and we’ll finish up with the rotating 3D view of the before and the actual after result. Thanks for watching. This is Derek Steinbacher.

This is a neonate with rod band sequence. You can see the micro retrognathia. The baby has a cleft palate and requires feeding supplementation. CT scan reveals the small position of the jaw. Sagal image shows gloss ptosis with constriction of the airway. We utilize 3D planning and use an inverted L osteotomy coming above and beyond the nerve. We also can look at the position of the nerve and roots and understand the thickness of the cortex of the mandible. In planning the cut, we also look at the projection magnitude and vector of the distraction consolidation phase. And with removal of the device, we can see the improved projection of the mandibular body length. No tracheostomy has been required. These images show on removal of the device, the new projection of the chin, and you can see the mandibular gum pad is now anterior to the maxillary gum pad showing this progno appearance. This is after removal of the devices. We were successfully able to improve the patient’s feeding, avoiding a trach, allowing him to gain weight undergoing the cleft palate repair at a later stage. Thank you very much.

Access to the temporomandibular joint. Condyle and arch is required for numerous purposes. Trauma access to pathology to perform high ectomies in cases of condylar hyperplasia for internal derangement, arthritis, or disc displacement to name a few. These images show examples of mandibular asymmetry from condylar hyperplasia, which required treatment. See the 3D plan and the need for the condylectomy or high condylectomy on the effect side. This CT now shows erosion loss of cortico of the condylar head and a deep eminence. These cases now show exposure for high ectomies. In this case, on the right hand side can see the condylar head and exposure. Here’s the condylar head as a specimen and the NeoCon prior to closure. And this shows the before and after on lateral view. And here in a closeup, you can see how well the scar heals in its barely appreciable. Another similar example, after raising the skin flap, the S smash flap is being repositioned. On this closeup view, you can see both the condyle, the disc itself, and the eminence. High condylectomy is performed. You can see the trough on the left image and the condylar specimen that’s removed. And this is her scar postoperatively before and after, again, nearly imperceptible. So regardless of the indication for exposure to the condyle, temporomandibular joint, eminence, oid, this exposure is effective. Thank you.