Park Avenue facial plastic surgeon Norman J. Pastorek, M.D., has performed some 7,000 rhinoplasties using an endonasal approach that he says isn’t traditionally taught in residencies. Yet, his technique, which he documents fully on a patient in this video, rivals traditional open rhinoplasty in outcomes, without the long, potentially painful, recovery.
“Some surgeons think the open approach is the only way you should do rhinoplasty. As a teaching tool, I did the video to show that endonasal rhinoplasty is still very much alive,” Dr. Pastorek says. “It’s still an excellent technique. You can get gorgeous results. I like it because the patient looks good right away and, especially in New York, people want to have things done surgically and go back to looking really good right away.”
Dr. Pastorek tells Cosmetic Surgery Times that he uses the endonasal approach almost exclusively because there are no limits to what he can achieve using the closed technique. He says one indication for open rhinoplasty is the patient who needs an autogenous rib graft.
In the video, he uses endonasal rhinoplasty to address an under projection of the nasal tip, remove a bony hump and correct a deviated septum. He begins by excising the cephalic margin of the lower lateral cartilage. After removal of the cartilaginous and bony hump, correction of the deviated septum and completion of lateral and medial osteotomies, he shares an important aspect of his technique, placement of the dome-binding suture. He explains how he uses the suture’s placement to achieve three goals, according to the video: reformation of the lower lateral cartilage, from convex to slightly concave; an increase in tip projection and dome symmetry.
Dr. Pastoerk illustrates how the excision of a triangle of the anterior caudal margin allows the tip to rotate upward. The dome-binding suture alone, according to Dr. Pastorek, may not achieve adequate projection. As a result, he also places a cartilage strut through a mid-columella incision.
In This Article
Local vs General Aesthetic
Dr. Pastorek uses local anesthesia and intravenous analgesia in 95% of his endonasal rhinoplasty cases. Most surgeons, he says, have their patients go under with a general anesthetic because they believe it minimizes the risks of bleeding, choking and breathing problems.
He disagrees. With minimal intravenous analgesia and gentle anesthesia using acupressure techniques at the time of injection, he says he can do an entire operation with 4 mL of local anesthesia injected.
“I can see everything very clearly and all through the operation, if I sense the patient needs a little more intravenous analgesia, I just take a look at the anesthesiologist and give a little more,” he says.
Patients have some consciousness, but don't feel pain or discomfort and have little memory of the procedure. They are able to move to a mobile lounge chair from the operating table, recover for about an hour and then go home.
Dr. Pastorek says he performed four endonasal rhinoplasty cases the day before the interview with Cosmetic Surgery Times.
“I called them all last night. There was no bleeding, and they felt fine and had no pain. So, it’s actually a really nice experience,” he says. "I can't explain why they don't have much pain, but eight out 10 of my rhinoplasty patients do take any pain medication.”
Rapid Recovery Nuances
Dr. Pastorek uses a light-wave frequency technology, with a 660 nm red light, after removing patients’ splints to speed healing. For patients he suspects might bleed or bruise, he has them use Arnica montana three or four times after surgery, the day of and the day following surgery. He doesn’t use Arnica montana prior to surgery because he says that he has found the homeopathic remedy can cause bleeding when used before surgery.
Take a look at the video again. Dr. Pastorek shows his rhinoplasty patient six days postop. She has no signs of bruising.
Dr. Pastorek says he doesn’t proselytize his approach to endonasal rhinoplasty or the use of local anesthesia. Rather, he made the video to share his technique and experience with fellow surgeons and patients. Patients, he says, have embraced the video and don’t seem uncomfortable with its content.
“I think the open technique is still popular among surgeons today because many have been told that they can see better with the incision across the columella and with the skin lifted up. What I tried to show in that video is that I looked at everything. I looked at the cartilage from below; I looked at the top of the nose. You can see everything in the same way that you can with the nose open, but it cuts down tremendously on the swelling, edema and ecchymosis. Postoperatively, people can get back to their lives quickly,” Dr. Pastorek says.
Watch the Video
Disclosure: None
