Well, good afternoon. We'd like to thank the American Society of Plastic Surgery. It is a wonderful time to share these medical education programs together. We are going to start these sharing webinars that we expect that is going to be the first one of many others. We are going to start with the topic of rhinoplasty. We have three important doctors in Colombia, Dr. Rolando Prada. He lives in Bogota, Dr. Diego Caicedo that lives in Cali, and Dr. Eduardo Vallejo that lives in a very southern city of the country that is Pasto. I am very proud to introduce you, everyone, these professors. We are going to have first Dr. Rolando Prada's speech that is going to be in English. Then Dr. Diego Caicedo and Eduardo Vallejo that is going to be in Spanish but with English slides. And then after we are going to have the questions either in English or in Spanish. We are going to start with the presentation of Dr. Rolando Prada. We will continue with Dr. Diego Caicedo and finally Dr. Eduardo Vallejo. Welcome and thank you very much for this wonderful opportunity, Dr. Rolando Prada. Good afternoon. I'm Rolando Prada from Bogota, Colombia, and I'm going to talk about a very complex problem, the secondary rhinoplasty. It's important to define what is a secondary rhinoplasty. It's a static or functional surgery in patients who have already been operated and require another intervention to correct and solve anomalies or ones that were produced by the initial surgery. And resolve problems have two reasons. It was ignored at the first surgery because of wrong diagnosis or it wasn't resolved with the technique used. We can also have the atrophenic problems with scars, retraction, collapse, asymmetries. Also we will have serious problems with poorly executed surgeries. We need to have a complete medical history, know the initial program, and the surgery performed in order to understand the patient's need. If it's our own patient, easier. But if he has been operated by another surgeon and with lack of information, we need to proceed very carefully. It's crucial to have the initial photos in order to analyze the problems generated with the first surgery. Many times the diagnosis and what the patient thinks to have do not concur. A good way to clear this problem is the use of photos and videos. Planning is very important. We have to be precise in the diagnosis, decide the type of technique to be utilized with no limit time spent in the OR. Surgeons have to have good skills in this type of surgery because sometimes you have to change the technique depending on the interoperative findings. In this kind of surgery, we can take advantage of multiple grafts depending on each particular case. We have to be trained in taking the graft and using in all of the different ways. Execution means to fulfill a project with special skills. But to make it happen, we also need special instruments, well-trained assistants, perfect anesthesia, and facilities with all the requirements. The approach is planned depending on each case. We have to prevent complications and consider the scar tissue created in the previous surgery. Patient expectations are very important and must be sweetened. Bad expectations lead to more errors and dissatisfaction. Well, because of the time, we're going to see some few cases, the most active cases. This lady has two previous rhinoplasty and she has an obstruction due to bowel collapse. I inverted the E and asymmetries. Here we see the asymmetries, a poorly projected nasal tip asymmetry in the basal area. In surgery, we observe a cadaveric cartilage graft that was partially absorbed in the dorsum. That's why we don't use this kind of graft. And with no support in the internal bowel and deformities in both our cartilage. So we placed a stronger spreader graft and a temporal fascia graft in the dorsum. For the tip of the nose, we use a strong cartilage to gain a projection and definition. To prevent the scar retraction, we use a nasal shaper for three months in non-working hours. Here we see the correction of the inverted V with good dorsal shape. In the lateral view, we can see the projection of the tip was restored with good definition. And in the basal view, we can see improvement of asymmetry in a good shape and projection of the tip. This second case is another kind of problem. He had a previous rhino septoplasty and with no good results. He has a residual osseous hump with loss of tip projection, but also he had a large septal perforation. We decided to improve the nasal dorsum and projection of the tip. Because of the septal perforation, we have to be very careful to maintain good supporting of the septal frame. For that reason, we limited the osseous hump resection, bilateral strong spreader graft to reinforce the septal frame, and a tip graft and an intercrural strut, the shin type graft. Here we can see a better nasal dorsum with good tip projection. In the lateral view, we see a straight dorsum with a good projection of the tip and good lobe relations. The septal perforation was treated with a silicone shutter. This third case is another kind of problem also, but sometimes we have to treat. He had a successful initial rhinoplasty. He was very happy with his nose and with the result of the surgery. He also had obstructive sleep apnea. To solve the apnea, an orthognathic maxillary surgery was performed in another center. So after the surgery, she acquired nasal obstruction, loss of tip projection, and widening of the nasal base. The vertical impactation of the maxilla shortened the middle third and reduced the peripheral area, also creating nasal obstruction. She had pain in the left peripheral area and her lips projection changed. We plan an open rhinoplasty application of spreader grafts, columnella, a strip graft, a subdomal graft, and a deep graft. Here we see the very bad skeletal relationship, flattening of the profile. The vertical impactation shortened the dimension of the, and they reduced the peripheral area. We also plan extraction of the plates and screws and widening of this peripheral area. Here we place the stronger spreader grafts and fixate the upper lateral cartilage. We then later we applied intercranial extrude and a subdomal graft, which was used to strengthen the domal area. And then last, a deep graft, a pec-tip type graft. And also for narrowing the nasal base, we use a large stitching stitch, that's back in this picture. Here we see the removal of the plates and screws in this area, and the peripheral area was expanded by mining. So, in the frontal view, we see a better balance of structures and the base thinning. The patient reported that the nasal protrusion improved significantly. In the lateral view, we can see improvement in the nasal shape and projection. And in the basal view, we can appreciate the improvement in the nasal pyramid. There's another kind of cases that we're going to analyze now. It's the alloplastic materials of bupolymer injection. This is a serious problem. This lady was injected with an unknown solution in a previous operated nose. The nasal tip and dorsal was white and rigid. At surgery, we identify a rigid material with a lot of scarring. We resected this and apply inter-domal and inter-curl stitches to improve widening. So, as expected, there was an important scar retraction in the super tip in the dorsal area. Anyway, significant improvement was obtained. In the nasal base, it was more harmonious and thin, but despite the inter-curl resection in resection of the material, the inter-curl stitches, we still see some widening of the columnella. In the lateral view, we see the improvement in the dorsal tip relationship. We also see here the retraction of the skin. Another kind of problems, this lady underwent a rhinoplasty after surgery. She notes a thickening of the nose at the early postoperative period. The patient notes a dropping of the nasal tip that increased in smile and a hanging columnella. She refers after surgery the nasal lobe thickening and has a depression in the left alar edge that obstructs the external valve when she inspires. We perform a reduction of the dorsal hump, minimal reduction of the dorsal hump, reconstruction of the nasal crura, lateral crura of the left alar cartilage with a septal cartilage as we see here. She had a big defect here and a section of the depressor septinasi and we also did a lateral osteotomy. Here we see how the thinning of the width of the nose was achieved. Correction of the position of the tip and columnella was achieved, eliminating the depressor septi nasal muscle activity. We see the correction of the alar columnella relationship here. And the most important thing is that the lateral crux of the left alar cartilage was reconstructed and solving the collapse of the nasal edge and correction of the obstruction. So in conclusion, we can conclude that these surgeries are very demanding and procedures that require special attention. Accurate diagnosis is needed. They are best solved by experienced surgeons and the expectation of the patient must be well analyzed and must have a clear understanding of the plan and the expected results. Here we see Leonel Messi in Barcelona is the best team, best player, all the resources they have, multi-champions and team Barcelona lost to Bayern Munich 2 to 8 in the Champions League. So consider secondary rhinoplasty as a great opponent like Bayern Munich. So thank you very much and we're gonna be in the discussion. Thank you. Dr. Prado, thank you very much. We are going to follow with Dr. Diego Caicedo, his species, the nose and the plastic surgery. Dr. Caicedo. I would like to thank the Colombian Association of Plastic Surgery and the American Association for this invitation. And basically what we want in this presentation is to show what is the position of the plastic surgeon in the face of nose surgery. Dr. Caicedo, we cannot see your presentation. Please share your presentation. Okay. Okay, now it looks like it's perfect, so we're going to put it in action mode, now yes. Good. Well, I wanted to thank you for the invitation and we are going to give our position of what the plastic surgeon should do in the surgery of the anus. Over time, the nose has given the opportunity and the possibility of creating multiple surgical techniques that have transcended throughout history, giving rise to the aesthetic and reconstructive principles of nose surgery. That possibility even allowed to develop many techniques that were even against the canons that governed humanity at that time. However, the creative capacity of the nasal region has allowed different times and different authors to devise the surgical and basic principles of nose surgery. Even great surgeons like Eiffel Bass and Jack Joseph gave the opportunity to create their own techniques and instruments that were transcending their studies, as in the case of intranasal surgeries like that of Gustav Kilian, which today has the opportunity to carry out an integral procedure, both internal and external, of nasal surgery. I believe that versatility is something very important for the surgeon who faces a surgical procedure and it is understood as the ability to adapt quickly and easily to different situations that occur according to each patient. And I consider that this versatility must always be possessed by the plastic surgeon. Therefore, when we face a patient, we must have the capacity of an aesthetic and reconstructive approach to try to achieve what we want and what our patient wants in nose surgery. For this, it is also important to know what the anatomical and functional part of the nose is and to know what is normal and what is abnormal to be able to face a nose surgery. But what happens is that the facial proportions of each patient are different and this has allowed the different structures of the face to have harmonious relationships, always within an accepted social framework. Modernity has allowed us to identify exact points of the proportions of each person, which are unique and unrepeatable. And one of the things that affects us the most is race and customs, because there is a great variety of surgical approaches, with the need for that versatility that the plastic surgeon must have is its main quality when facing nose surgery. Because this way we can avoid the stereotypes that will not give the best results that we have in these surgeries. One of the problems is age. That is a problem that we have to solve. The development of each individual is different. And this development is the one that will give us the guideline for a surgery that can transcend time and avoid complications in the future. That is why the natural changes of the nose are the dynamic evolution of tissues with respect to their development. And we must always take into account this dynamic of growth and development. How does the plastic surgeon face nose surgery? The evolution of surgery must be dynamic, it should not be rigid, unrepeatable, the same in every patient. It must allow each technique to be applied to the patient according to their needs. So we see which are the patients that the plastic surgeon operates on the nose. Surgeons or noses with a commitment to congenital evolution, acquired evolution, or aesthetic rhinoplasty. Or patients with severe nose traumas. Patients who have alterations only at the level of white tissues. Or patients who have a commitment to the entire nasal structure and structure of white tissues. I think that the plastic surgeon does not operate noses. The true plastic surgeon must operate patients. And this is an integral concept that must be had to obtain the best results. We simply start with the aesthetic units of the nose. And these are the starting point for the anatomical and functional understanding of nose surgery. And this allows the versatility that can be obtained for the management of the different structures. And to be able, many times, to take advantage of what exists. And use different techniques for the development and result of a nose. Faced with this situation, we must take into account some fundamental principles. The principle of preservation. The principle of reconstruction. And the principle of reorientation. Always taking into account that all this will lead us to an ability to achieve a remodeling. If we have the three fundamental principles. Let's start then with the principle of preservation. The principle of preservation can be applied to the noses of the fractured patient. In which we will try to preserve all tissues. And the only thing we have to do is reorganize them. To achieve a symetrization and a naturalness. Including complex cases where we need to reorganize tissues. So basic to give the characteristic of a nose. As is the tip and the spine. Or perform that preservation of all tissues. To form an aesthetic unit. As in this case, the nasolabial aesthetic unit. With the use and structural preservation. That is very important. Supported by the placement of anti-injections. Both in the roof of the nose. As in the base of the nose. And to give it shape. As we generally do in the secondary rhinoplasty. By fracture of the biopalatine. Or get an anatomical relationship. In totally severe nasal deformities. In which we have to have the ability. To face and have all our surgical equipment. To perform procedures with an acceptable result. Always preserving all tissues. As in the case of facial traumas. To achieve what is most possible of a premium appearance. In the case of the fundamental principle of reconstruction. It is important that the plastic surgeon. Has the ability to reconstruct structures. Even as in this case of a reconstruction. Of the nasal dorsum. By intracranial and extracranial. To achieve the most normal aspect. In these severe malformations. Or the use of soft tissue coverings. In previous nasal processes. Where everything that is soft tissue has been injured. And we use as in this case. Expanded tissues for a nasal reconstruction. Or acute reconstructions. In which the patient with a trauma. We can do it in an acute way. The initial reconstruction. To avoid subsequent consequences. Or subsequent deformations. Or the late use. Nearby hangings. Or neighborhood. For reconstructions. As in this case of the nasal dorsum. We also often need the reconstruction. Of bone tissues. And soft tissues. So that these bone tissues have a coverage. We have in our hand. As a periosteum hanging. For that coverage. Of that cartilaginous injection. To try to achieve. This severe effect. And achieve both soft tissues. As bone tissues. Achieve that coverage. And that normal appearance. In complex reconstructions. Structural and functional. Do them totally with injections and hangings. And the utilization of that versatility. That the plastic surgeon must have. To achieve a reconstruction. At least acceptable. Of a patient who was totally affected. By an oncological commitment. And make a reconstruction. As close as possible to normal. And this result acceptable. Or patients in which. We have all the soft tissues. But we do not have bone structures. We find. Absolutely nothing of the support. Bone structural. Then we must have the capacity. So that with the tissues we have. Existing. We can reconstruct. In full form. The entire nasal cavity. And above all. And it is important. Do it firmly. With an internal coverage. And an external coverage. To achieve a subsequent reconstruction. As in this case of a periosteum hanging. And a frontal hanging. At the same time. To achieve. A successful result. In the nasal reconstruction. Many times. We are going to have the impossibility. Either by the comorbidities. That the patients present. Then we must also be aware. That at some point. We will not be able to use. The soft tissues. And we must resort to prostheses. For this we use. What is anatomoplasty. And achieving. From this effect. Another fundamental principle. That is even present. In all other principles. It is remodeling. Remodeling today. That is in fashion. Especially with the use. Of permissible injectable substances. But in this case. Like that of a fibrous dysplasia. We can simply. With a remodeling. Of the entire part. Of the nasal aesthetic unit. It is a much more pleasant aspect. Of the patient. And the other remodeling. As in the case of hyaluronic acid. Which I do not use. That can give. Many times appearance. But generally. They are temporary results. If they are not definitive results. And I think. That plastic surgery. Is the ideal. Is to achieve a definitive result. Whether closed or open. Structural. With preservation. The secondary rhinoplasty. The sequence I do. It is an open rhinoplasty. With a trans-columnal incision. With marginal lateral incisions. The dissection. And the skeletalization. Of the saline cartilages. The nasal dissection. Of the back of the septum. And if I have the need. It is for the septum. And always keep in mind. That I never. I never did it again. The medial osteotomy. I prefer to do. The scraping of the nasal dorsum. And with that I get. Better results. External lateral osteotomies. The resection. Of the saline cartilages. The conformation. Of a good nasal tip. The cartilages. Of the cartilaginous injections. And the fibrillation. Then we are going to see some. From the aesthetic point of view. Depending on the reorientation. Of the structures present. Of what we are going to achieve. Then as a sample. I make a step incision. At the level of the column. To which I continue. With a marginal incision. Subsequently I do the dissection. And depending on the projections. Then we are going to do. That cephalic resection. To in this way. Achieve an anterior-posterior orientation. To a superior-inferior. That many times. Helped. By an intradomal or interdomal application. Depending on each case. I'm going to give an appearance. To that aesthetic tip. With an elevation. As natural as possible. The regularization of the back. Without performing. A central osteotomy. Simply with a scraping of the back. And then with some. External lateral osteotomies. I'm going to achieve a better appearance. This in the profile view. To achieve this result. Without altering. The nasolabial angle. The same as in this case. When we find a tip that is. Fallen. To achieve. A fall more. Down. From this nose. We achieve a better projection. Of the nasal tip. This is evident in the profile. But if we see it in the back. In the front view. We can see that this relationship. Of the vertex of the base. With the nasal pyramid. It is very wide. So we must perform. A more natural tip. More harmonious. And that in a later result. It will stay in time. What do we generally achieve with this? With osteotomies. And a sharpening of the nose. A finer projection of the nose. When we perform the osteotomies. And the relationship of the tip. With the torso. We see it here. Achieving this symmetry. This better regularization. Of the back. With the projection. And the placement of the salars. We achieve that this spine. That is not present. We achieve a better anatomical relationship. Of the spine. Many times. This projection of the spine. Makes this back bigger. As in this case. A secondary rhinoplasty. With an open nose. With osteotomies. And a better. Intracranial cartilaginosis. To achieve. A better projection of the tip. In the base. We try to do. That symmetrization of the base. Of the equilateral triangle. With the different parts of the tip. And the base of the nose. To achieve. A very good scar. That symmetrization. And equal distance. Of the points. Of the nasal base. In some cases. We manage to do it. Trying to refine those wavy points. Achieving a more natural nose. And with a better projection. But also many times. As in this case of patients. With long-faced syndrome. In which it is important. To maintain this distance. From the nose to the chin. We need. To make a nose. That looks more harmonious. And more natural. And compensated with the face. And in this way. We achieve a much better result. Without. The mobilization of the nose. Simply with a reorientation. Of the salarial cartilages. A scratch of the back. And lateral osteotomies. That we are going to achieve. Harmony of the nasal angle. And the nasal tip. Or also the correction. In this case of the drooping tip. With the same technique. We give a better orientation to the spine. The relationship of the wing. With the back and the tip. We are going to achieve. In a more natural way. Always trying to maintain. That relationship. Between the back and the nasal tip. Having the difference. Of the nasal angle. Between the woman and the man. Which is totally different. To achieve a more natural projection. More harmonious. Related to the face. And at the same time. Trying to correct. This spine. Which is that spine that is shown. So much in the distances. More than 50%. To achieve. A more harmonious profile. And more natural. Also taking into account. That there is a direct relationship. Between the nose and the chin. And we must do this in a natural way. To achieve a successful result. And in the cases. In which we often need. To do other procedures. Like parpa. Or dentoplasty. To achieve a more harmonious result. More natural. With respect to the profile. And the chin. Among the conclusions. Well. For us to face. As plastic surgeons. We must have. An anatomical and functional knowledge. We must have that versatility. To face each case. In a different way. Knowing well the principles. Of nasal surgery. We must avoid. The offering of magical results. We must think. That the nose is part of the face. And not just the nose. We must achieve. A harmonious and natural result. To have the knowledge. Of facial anthropometry. The measures and their relationship. With the different structures of the face. To use. That aesthetic and reconstructive focus. That each surgeon must have. To recognize and know. And manage. The different bone structures of the nose. The coverage of the white tissues. And above all. To make an individual analysis. In each case of each patient. Thank you very much. Dr. Vallejo, can you please share your presentation? First of all, I would like to thank Dr. Ernesto Barbosa, President of the Plastic Surgery Society of Colombia, for inviting me, as well as the American society, to participate. We are doing this from the city of Pasto, which is the surprise city of Colombia, at the foot of the Galeras Volcano. Rhinoplasty is really a possibility that this surgery gives us the opportunity to demonstrate our skills, and I think it really unites science with art. Because alterations as small as 1 or 2 millimeters really make a difference in the result. To achieve these results, the most important thing is to have a panoramic view of the structures of the nose that we are going to correct. And that is why I think the open technique has become so popular, because it allows us to handle this situation in this way. I want to talk about a technique that is semi-open, without spine scar, which can also give us the same possibility to be able to handle all the structures of the nose and be able to have good results. When we do the analysis of a nose, we must do an integral nasofacial analysis, where we observe the nasolabial angle, nasofrontal angle, chin projection, cervical-mandibular angle. Why? Because many times the result is not solitary, that is, the nose not only gives the final result of the aesthetics of the face, but we have to intervene in other areas to achieve these results. At the level of the nose, the analysis of the tip is very important. Really, the position of the tip is what defines the aesthetics of the nose and defines the nose, the aesthetics of the face. A professor once told me, there are beautiful faces with ugly noses, but not ugly noses with beautiful faces, giving to understand the determining importance of the nose in the beauty of the face. For that we have to analyze the nasal tip, all the structures, salar cartilages, if the tip is down, if it has a support, how is the nasolabial angle, how is the dorsal bone, the jaw depends on the bone part, the cartilaginous part, if it is centralized, all the details of which depend on the aesthetics of the nose. But a very important part, as we all know, is the skin. We know that a thin skin will show us the result easily. But the challenge is when the skin is thick. Our population, fortunately or unfortunately, which is mestizo, the skins always have a mixed tendency, that is, a mixed tendency, greasy, thick, and then that makes us dedicate ourselves very, very, especially to those details of the tip to be able to notice a nose, a beautiful tip. The bifidiculated technique is based on two concepts, basically that it is a marginal incision and an inter cartilaginous incision. That will allow us to expose all the structures of the nose. I think that one of the advantages of this technique is that there is no columnar scar. I know that the white person, the scar is almost imperceptible, but in the dark skin, many times the scar is visible and many times when the patient is told that he is going to leave a scar, sometimes the patient thinks about operating, knowing, as I tell you, that it is an almost imperceptible scar. That option gives me a direct visualization and an exposure of the saline cartilages. It allows me to make comfortable maneuvers to place the injections, suture the tip and reposition all the structures of the nose. Additionally, it has been seen that it has less risk of residual edema on the tip when this technique is adopted. The treatment of the tip is decisive for the beauty of the nose. We have to locate it at its right point in terms of projection and in terms of definition. This implies that we must treat in a very judicious way all the aspects that at a given moment are alterations that do not allow a beautiful nose tip. This implies that we have to expose the saline cartilages, we have to remodel and we have to place the respective injections. In this video I am going to show my sequence of what I do. I generally make a marginal incision initially, then I make the inter cartilaginous incision. This allows me to leave a double pedicle to be sure that the saline cartilage is viable. This also allows me to dissect the entire saline cartilage and be able to expose it in a way that allows me to make the respective changes. Because it is very easy after having dissected the saline cartilages to expose them and be able to basically have the possibility to reform them if necessary. The points that are placed in the domus are made to finish the domus, which is generally done most of the time. This increases more or less 1 or 2 millimeters of projection and the definition of the tip. I think this is a very important aspect that I do in all my surgeries, I think 100%. It is very rare that I do not do it when the tip is defined. And then place the intertidal injection that will allow me to change the position of the nasolabial angle. Subsequently, fix the injection of the tip, generally a transverse injection, a PEC injection, where I always make them double, as I say, and it is because our population is a mestizo population that has a skin more or less tending to thickness, and that allows me to achieve a better definition of the tip. Basically, then I proceed to the treatment of the torso, where basically the nasal dorsum is lowered, the nasal dorsum is removed, generally with a scrape, for greater security. The recession of the cartilaginous dorsum and the external lateral fracture, which sometimes also requires it. As for the alignment of the torso, I always use a scrape, I never use a scope, because I am always afraid that it will go down too much. That allows me greater security and greater precision. And the recession of the cartilaginous dorsum, I do it with a scalpel, with direct vision, with an optical fiber, which also allows me to determine and remove the excess cartilage at the level of the dorsum, and that allows me to leave a practically straight dorsum. Later, I do an external lateral fracture, generally to be able to achieve, especially when the roof is open, or I suspect of having it open. The injection I always use is the cartilaginous dorsum at 90% and only at 10% the septum cartilage. I think that the cartilaginous dorsum is very important, because the pericondrium allows me greater integration. That implies, here is more or less the procedure as I do it. I always draw the injections on the dorsum, and then I do the incision and the respective recession. Later, as this is a curved injection, I rectify the curve for the intercurved cartilage, especially with a suture. That allows me to leave a totally linear injection to avoid a deviation. Later, I also remodel the cartilages that I am going to put on the tip. Generally, I use double cartilage in the umbilical cord. I remodel it because you know that any irregularity can be visible, especially in the skin, which tends to be thin. And that allows me to define the tip tip. Of the complications that I have seen, they are mainly related to the displacement or asymmetry of the injection of the tip. Fortunately, our skin is a little thick, so we don't have as much of that problem as it happens in thin skin, in white people. The other is the intercurved injection on the edge of the anterior septum, when the septum is a little long, which gives a click that the patient claims. Then, if you have to examine intraoperatively to make a resection of that septal cartilage, of the marginal edge. And sometimes, due to the inadequate use of the scraper, a residual cartilage may remain. I am going to present some cases. Generally, my protocol is, first, I correct the nasal tip. This is a patient with a 90-degree nasolabial angle, a tip that looks down, it is not defined, a practically almost straight back. The tip was treated, the intercurved injection was placed, the double nasolabial injection was placed, and the nasal back was rectified. This is a patient who has a slightly higher jaw, a 90-degree nasolabial angle, an intercurved injection was placed, the salar cartilages were remodeled, and a lateral fracture was made, observing an improvement in the nasolabial angle and a definition of the tip. One always tries to make the tip one or two millimeters more projected than the back. And with the double injection, it is possible to correct. When one does salar cartilage remodeling, which gives it one or two millimeters of projection, and places an intercurved injection, it is almost gaining around 3-4 millimeters, which is what the nose sometimes needs to have an adequate projection. This is a patient who had her back high, almost at the expense of the cartilage. An intercurved injection was placed, I mean, the intercurved injections that I place, I divide them depending on the nasolabial angle. In that patient, I place an intercurved injection of 3 millimeters, just to maintain the projection of the tip a little, and I define the salar cartilages very well with sutures and with the double injection, achieving a better projection. This is a patient with a very high back, of the cartilaginous union mainly. The tip is not very defined, it has a nasolabial angle a little more than 90 degrees. The back is treated the same as everything else, the salar cartilages are treated the same, the double injection is placed in sombrilla, and also an intercurved injection of 3-4 millimeters, achieving an improvement of its appearance. This is a patient with a pronounced hive, it has a slightly wide and slightly drooping tip, but it has a connotation, it has a slightly high spine. What is the plan of this patient? It is to lower the nasal hive, remodel the salar cartilages, place an intercurved injection, which one would say, but why do I place it even if it is left over, but I also do another treatment and it is that I dry the marginal edge up to the nasal spine to improve that curvature of the spine. In the side photo, you can see a better projection of the tip, the back is regularized and you see a much more balanced and aesthetic face. It is a patient who still has a little hive, has a slightly defined tip, has thin skin, however it has a spine. The scheme that I have always said, salar cartilages are remodeled, the double intercurved injection, but at the level of the spine, to improve that, I do the marginal resection of the septum up to the nasal spine and there is also bone spinal resection. This is another patient with the same characteristics, because I see that people, that is, one has to correct what the patient asks and what the patient asks for and what comes is because the tip is down, has the hive, and wants to keep a very natural nose. So I think that when one does a surgical planning, corrects the back, but I believe that the most important challenge is the placement of the tip in the right place. So I think that the intercurved injection and the double injection in shadow allows me that projection that I always want, giving an appearance, as I say, very, very natural. It is a patient who only had a drooping tip, the salar cartilages were wide, the nostrils were horizontalized because it was a nose that had no support. The injection was placed and then in the frontal projection you can see how the alignment of the tip greatly improves the appearance of his nose, the back was not treated, the one he had was left, the nostrils were closed, achieving a much more aesthetic result. This is a patient who, in addition to having the hive and the drooping tip, has a very important action in the depressive muscles of the septum, he intervened, an intercurved injection was placed, injected in the tip, double in the tip and the dorsal cartilage of the back was remodeled and additionally, when she smiled, the depressive muscles were released, the depressive muscles intervened to achieve a better result. It is a patient that in the analysis of the entire face, one sees that in addition to treating the nose, you also have to treat the chin and you also have to do a liposuction. So, when one treats those alterations that one has, one manages to balance the face, giving a much more natural appearance. It is a patient who had a very pronounced nasal hive, a little projected tip, however, he has a very high lipid angle, this patient intervened at the level of the back and at the level of the tip, but no intercurved injection was placed because he had a very high nasal hive angle and additionally, a chin prosthesis was placed that gave a very accurate balance to his face. This is his name, he has a drooping tip. These patients, as I told you, the scheme that you have already noticed, it is very important when these patients have a nasolabial angle less than 90 degrees, I generally put an interclural injection of more or less 7 millimeters in the base to be able to achieve a better projection and to improve even more that nasolabial angle that sometimes has an obtuse angle. The definition of the tip is given by the injection in the eyebrow, giving a very natural appearance. In the same way, a similar case, SEIDS proceeded to do the same procedure, lower the jaw, lateral fracture, definition of the tip with double injection, also achieving a good result. There is an important thing that I think happens to all of us and it is the final decision to place or not to inject in the tip. According to my experience, I have been more or less 20 years, I have always injected in the tip. I have regretted many times not having done it, but never having done it. In this case, it is a patient who, as you can see, has an almost rectilinear back, has a drooping tip, a nasolabial angle of 90 degrees. I proceeded to my scheme, interclural injection, definition of the tip, regularization of the face, but I was surprised that the patient did not like the nose. She thinks it was too long, too projected, and that forced me to intervene and remove the injection in the tip, not the interclural injection. When I removed the injection in the tip, look what happened. The projection went down, it shows as if I had left some Supratip in the tip, but in reality, if we go to the result, I think the result in the second photograph is much better. Surely now I will have to intervene and probably I will remove a little Supratip to improve, but her nose will not look as beautiful as it looked with the injection in the tip. So I think that the injection in the tip is decisive for the projection and for the rotation of the tip, as you can see. Another important issue is the issue of thick skin. As you know, we treat many teenage girls, teenage men who come to surgery, and most of them have acne and thick skin like her. This patient intervened, she did the plan that I always do, the interclural injection, the injection in the shadow, she did not have a lateral fracture, she removed the fat from the subcutaneous cell tissue to improve the appearance of the skin, to achieve a better result. However, in reality, one does everything, but the result is not seen. This patient had acne, I referred her to dermatology, she underwent treatment for eight months, complying with the entire dose, and what one observes is the improvement of the sebaceous glands in the tip of the nose, and it also refines the nose, and you can see what one really did. She also put on chin protection. You can clearly see that the nasal tip improved her appearance, but I think it is the help we receive from isotretinoin during her treatment months, achieving a very good result. Of the conclusions we can make is that the semi-open technique is a possibility that also gives us the open technique because it provides us with a direct vision, control and precision of all the steps we do, and it is easily reproducible. The position of the tip is decisive in the aesthetics of the nose, and I think that injections are an alternative that we should always consider to be able to modify it. Thank you very much for your attention. Dr. Vallejo, thank you very much. We are going to start with some questions that we have here. First for Dr. Prada, there's a question that in cases like you show, with external substance, there is any diagnosis method that you use before the surgery? I mean, for example, like MRI or sonogram or anything that may help you to understand how you are going to find her? Yes. Thank you, Ernesto. And thank you for the invitation. I'm very happy with this. Well, there's a lot of types of different materials that have been used for modeling the nose. Some of them are very dangerous. And when there are injections all over the face, in the nasal, labial angle, and in the chin, I usually ask for an MRI because there's a lot of inflammation in the tissues, and you really need to know where the material is located. But if it's like some material used like acrylic, and that they stay in the same position. And in those cases, I go directly to excise that material and see directly what's going on with the different structures. But when you use like biopolymers that are making some inflammation, you really need to do some testing before surgery. Thank you for all three guys. What kind of graft do you prefer in a secondary cases? I mean, for example, a graft of the ribs, or maybe a bank, a graft of the cadaver, or any other one? Well, it depends. It depends on the cases. In some cases, hard cases, when you don't have a septum or another kind of graft, I use costal graft. It's rigid, you have a lot, and it goes very well. But in the small cases, a regular graft is okay. Dr. Caicedo? The question is, and for Dr. Vallejo, the same question for Dr. Prada, in secondary cases, what donor sites or areas do you prefer? I mean, donor areas for cartilages. Or if you prefer to use bank grafts, or some kind of allogenic material? Well, personally, it also depends on each patient. In my case, for the need to collect small grafts, I use the first option, which is the cartilaginous septum. I don't use the ear graft, unless it's for the formation of a wing, to improve it, because the cartilage memory, despite the points, can always come back, so it doesn't make the incisions. The Gibson law is still essential. But after the septum, when I need a cartilage, I think the best bank is the costal graft. And I even use it, many times, in primary endoplasties, which I know I have, in the clinical environment, to make an injection. I prefer to mold a cartilaginous injection, which does not remove all the thickness of the rib, but I am doing a partial absorption of the entire rib, without going to the posterior part of the rib. I simply dissect the anterior pericosteum and I take it out of the same rib, especially in that part of the sixth, seventh and eighth, which are so united, it is the best bank, and I always mold it with an incision, which, if it is well structured, will not have any problem, always removing the patient. And I don't have pain, because I don't take out all the thickness of the rib, I just do a partial absorption of the rib. Dr. Vallejo. For the primary endoplasty, I generally, as I was saying, use cartilage of the ear, because it has adapted to me, and it seems very sensitive, easy and fast to me. And for the secondary nostrils, especially depending on the volume, if I am going to the posterior pericosteum, I prefer septal cartilage to place the spleen, which are much easier, because molding those cartilages is much more difficult, and the back is very sensitive to deformity. So, there I prefer septal cartilage. I don't use rib cartilage, really, unless I see the possibility that I will need a very large volume, then I would probably use rib cartilage. For Dr. Vallejo, you say that you always use PEG injections. Have you ever used chain-type injections? Why does PEG always seem that there is not a very good definition sometimes of the tip? I think that my initial experience used PEG injections, not double, but simple, and in reality, what you say, you didn't notice the definition of the tip. But when you do the suture of the domus, plus a double cartilage of PEG, in reality, you do achieve a definition. It also logically depends on the type of skin you have. I actually use very little chain-type injections. Dr. Prada, Dr. Caicedo, what type of injections do you use on the nasal tip? What kind of graft do you use on the nasal tip? In my case, I always use a chain-type injection. I generally use a cartilaginous septum, and it gives me a better definition than PEG. In the primary rhinoplasty, if you do an open approach, most of the time, I don't use a graft in the tip, because I use stitches to model the cartilage. When I use it, sometimes I use a PEG-type graft. But when you need a strong support, it will be, in my election, it will be a chain-type graft, because you need to have a good relation between the lobe and the supratip, so a chain is good for that. Well, in the very last years, there have been new techniques, like ultrasound osteotomies, and ultrasound nose jobs, or rhinoplasty. What do you think about it? Do you have any experiences? In the last years, there has been a lot of talk about ultrasonic rhinoplasty, ultrasonic fractures, and minimally invasive rhinoplasty with ultrasound. Do you have any experience with this? No, I don't have experience. I don't have experience either. The piezoelectric, the piezo is used, but I really don't think it's useful. You really can do it with a normal rasp and osteotome, so I wouldn't use it. Well... I think it's an advertising issue that has arisen from rhinoplasty, and I don't think it's a superior benefit. I don't have experience, but thinking logically, I think the nose should be done as it's traditionally done. And a device with a rotation, where you put more revolutions, maybe it lowers the back more, and well, it doesn't have much control, I think. Yes, I think the part of the body that is like to work like in sculpture, every step must be done very carefully to have a very good result. Well, this is all the questions. I want to thank you to the American Society of Plastic Surgery, Romina, to listen to you. And it worked, but it was really wonderful to start these educational things together. Most of the Columbia members have some troubles to connect. I think that they're both used to be in a webinar platforms that is more easily for everyone. But well, we have to have a resilience and to adapt to any kind of platform that helps to prevent Alzheimer's. So, it's a very good time for all of us to share all the knowledge. Romina. Thank you very much, everyone. Thank you. Thank you for sharing the knowledge. Very kind.

rhinoplasty

plastic surgery

secondary rhinoplasty

cartilage grafts

aesthetic approaches

reconstructive techniques

semi-open rhinoplasty

nasal structures

isotretinoin

ultrasonic rhinoplasty

personalized patient analysis