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                   Dr. Azizzadeh Primary

Dr. Denenberg Interview - Chat      

Chat - Start

CJ7 > Dr Denenberg, how to ENT's differ from surgeons certified in plastic surgery?

DrDenenberg > Hi, CJ7. ENT's generally have much more experience in rhinoplasty *when they graduate their residencies.* After then, all bets are off, because anyone can get more training in rhinoplasty later. What you learn during your residency shouldn't hold you back for your entire career.

Baseema > DrDenenberg: Can you give me a pretty good idea what my nose will look like after the surgery?

DrDenenberg > Baseema, predicting what the nose will look like after surgery is the most crucial part of the consultation, because... on just what we would like to change and the surgical history of the nose.

Baseema > That makes sense.

Marielee > Dr. Denenberb do you turn people away and if so why?

DrDenenberg > Marielee, I turn people away if I don't think I can help them. That might be because I don't know how to fix the feature they complain about, or if they need more of a correction than I think I can achieve. During the consultation we try to predict how much improvement the operation can achieve, and whether that amount of realistic improvement will make the patient happy with the results.

CJ7 > Whats is the hardest part of the nose to correct in a revision rhinoplasty in your opinion Dr. Denenberg?

DrDenenberg > CJ, the hardest part is often the tip, as it is in primary rhinoplasty, although any part of the nose can become the hardest part, depending on what was done in the previous operation. When I am looking at a revision candidate, I love it if most of the cartilage in the tip of the nose is still present, because that gives us more options, more to work with.

Dean > Dr Denenberg what do you do to improve the chances of having a smooth tip when you do tip grafting?

DrDenenberg > Dean, when I do tip grafting, if I'm using a shield-type graft, I like to have the top of the graft *not* be edge that the skin rests against, because that can cause a sharp edge. I like, if I can, to have the shield graft give the tip strength and support, but have some curve of the patient's normal tip cartilages project slightly beyond the tip graft, so the skin is resting on a curved cartilage surface.

DrDenenberg > Did I explain that understandably enough?

Dean > yes,Dr. D,thank you

Baseema > DrDenenberg: Is it okay if I bring a couple of pictures with me to let you know what I want my nose to look like?

DrDenenberg > Baseema, I do like it when someone brings pictures, though not when someone brings a couple hundred, as has happened to me. The pictures help me because they show me what the patient thinks is ideal. Then, I have to make sure the patient knows that I cannot necessarily make a nose like in the pictures, but the pictures can often direct our efforts.

Baseema > DrDenenberg: lol..I will keep that in mind. Have you done a lot of ethnic noses?

DrDenenberg > Baseema, I have done ethnic noses, although they are not the majority of my practice, obviously. The techniques used in a black or asian nose, for example, are the same as those used in caucasian noses, it's just that a black person typically has different requests than the typical caucasian request.

Baseema >What about a middle eastern nose? a long projected nose, I mean.

CJ7 > Dr Denenberg, was there any surgeon(s) who were instrumental in your success at becoming a rhinoplasty expert?

DrDenenberg > CJ, the doctor I did my fellowship with, Gaylon McCollough, was extremely instrumental. Even though many of the techniques I now use are different than those I learned during my fellowship, he did an incredible job of teaching me how to keep the operation under control, so that I have time to try everything that a nose needs during surgery. Many surgeons get into too much bleeding or other problems, and have to cut the operation short. If the rhinoplasty is kept under control, you have time to think, time to try different techniques if the nose is very difficult. Dr. McCollough is now in Gulf Shores, Alabama.
Baseema > that's scary

Marielee > Dr Denenbery what type of annesthesia do you usually use for rhinoplasties

DrDenenberg > Marielee, I almost exclusively use intravenous sedation. I give the patient IV drugs to let her drift off to sleep, then anesthetize the nose with Lidocaine, which is what we use instead of Novocaine, and then do the operation. Since the patient's nose is completely numb, she needs only a tiny amount of sedation to keep her asleep. I don't like general anesthesia, because I don't like to fight the tube that protrudes from the patient's mouth, and I don't like how the patient coughs when the tube is removed, and it's much more likely to cause someone to be nauseated.

CJ7 > Dr Denenberg, The techniques that you use now, did you invent them yourself?

a.z. > Dr. Denenberg I learned A LOT from your site and I like your resulting style of noses. Can you achieve same results with thick skin?

DrDenenberg > a.z., thick skin can keep us from getting all of the improvement we sometimes want in a nose. During the rhinoplasty, we change the size and position and shape of the cartilages and bones. If someone has soft cartilages and very thick skin, you can imagine that the thick blanket of skin can cover and obscure the changes that we made in the cartilages. If someone has thick skin, I try hard to see just what we can accomplish, and make sure I don't overstate how much change the rhinoplasty can give.

Baseema > good thing i have thin skin then

Baseema > thank you for your thorough explanation

a.z. > thanks Dr. D. I really do like your noses Would it be worth a try with thick skin?

DrDenenberg > a.z., It might be worth a try. It never hurts to get an evaluation. If you wish, you can send me some photos, and I'll see if I can tell you anything smart based just on the pictures.
a.z. > thanks Dr. Denenberg:) I will send you my photos.

Elaine > Dr.Denenberg can you tell me in your experience with gore-tex what is the long term effect with it in the nose?

DrDenenberg > Elaine, I haven't ever had a problem with Gore-Tex. It's my favorite implant material for building up the bridge of a nose, because it can be tailored to the right size, and, since it's soft, unlike grafted cartilage, it won't leave a visible sharp edge under the skin as a cartilage graft can if it's not designed exactly or if it moves. Of course, we need to use cartilage for grafting if the graft needs to have *strength,* as when we put a graft in the tip of the nose.

CJ7 > Dr Denenberg, what is the differnce between am umbrella tip graft (crushed) and a tip shield graft?

DrDenenberg > CJ, if I understand the umbrella graft correctly (different doctors sometimes use different terms), the umberlla is just placed on top of the tip cartilages to increase the definition of the tip of the nose and a little to increase projection, whereas the tip shield graft is sewn to the tip cartilages in the columella, to help the columella be stronger and more projecting, and to allow the tip to be wider. I've only used an umbrella graft once. The columella, by the way, is the 'little column' of skin and cartilage that separates the nostrils on the base view of the nose.

CJ7 > so the umbrella graft isnt sewn to the lower lateral cartiliges? how is it put in place?

DrDenenberg > CJ, yes, the umbrella graft typically *is* sewn, like most cartilage grafts are, just to keep it from slipping after surgery. I'll put it on my list to describe umbrella and tip grafts better on my site when I'm updating the tutorials.

CJ7 > thanks Dr D

Dean > Dr. Denenberg,do you believe in or use spreader grafts at all and what for? Thanks

DrDenenberg > Dean, I do use spreader grafts. They are useful for increasing the width of the cartilaginous portion of the bridge of the nose. The upper third of the nose (approx) is made of bone, the middle third is cartilage, and the lower third is the tip. Sometimes, for various reasons, the cartilages of the middle third collapse against the septum, and that middle portion looks unnaturally narrow, like a knife edge along the dorsum (the bridge). Spreader grafts are little rectangular pieces of cartilage that can be sewn adjacent to the narrow briidge cartilage to widen it slightly. They work great in the right nose.

Elaine > Dr.Denenberg I am with Dr.Conrad in Canada and I am having gore-tex placed in the nose. I have had 9 surgeries will that make a difference? My bones are OK, just my columella needs lifting

DrDenenberg > Elaine, say hi to Cris for me. I don't know how to answer your question. Nine operations sounds awful to me. If you are getting a Gore-Tex implant, it sounds as though he is trying to build up some area, either in height or width. Is that what's happening. You should know, as he certainly does, that the scar tissue that forms after that many operations puts great limits on the amount of improvement that can be achieved.

Elaine > yes that is what he is doing..

Marielee > Dr Denenberg how do you narrow nostrils

DrDenenberg > Marielee, usually we narrow nostrils by making a small incision and removing a wedge of skin, then sewing up the defect. Narrowing nostrils isn't an exact science, because many times it's not just the width of the nostril but also the curve that the skin of the nostril takes that is the concern, and we don't have the ability to tailor those results like we do in some other areas of the nose. Typically, I won't narrow the nostrils unless they *realllly* look as though they would benefit from the procedure.

Kate > My tip graft is visible as two knobs on the end of my nose...can it be adjusted without major surgery again or am I stuck with the graft showing?

DrDenenberg > Kate, any time someone tries to make a change in the tip of the nose, it's major sugery. The task would be to see if the edges of the graft can be trimmed down, smoothed out, maybe, as I mentioned earlier in this chat, moving the graft so that the natural curve of your natural tip cartilages rest against the skin, with the tip graft providing the necessary support to place the tip cartilages in an aesthetic position. It's a problem that requires lots of thinking before acting, but often there are satisfactory ways of addressing it.

DrDenenberg > I'll make another comment to the person who was asking what kind of anesthesia I use. Don't try to micro-manage your experience. For example, don't go to a doctor because he uses this or that kind of anesthesia. Don't go to a doctor because he performs open rhinoplasty or closed rhinoplasty, or because he likes this graft material or that graft material. If you succeed in finding a doctor who can see and understand what you complain about and who has excellent photos to show you, don't go elsewhere because of minor complaints you have with how he likes to proceed.

jenn > Hello Dr. Denenberg, so glad you are here. Can I ask a question?

Dean > of course Jenn

jenn > The main problem I have with my nose is its bulbous (& slight hump). Do you have alot of experience making bulbous noses smaller??

DrDenenberg > Hi, Jenn, Yes, bulbous tips is one of the most common complaints I get. It's one of the hardest parts of the rhinoplasty, but usually we can make nice improvements. My site, www.FacialSurgery.com, has a section of before and after photos of patients who had bulbous noses. I call them 'wide tips.'

CJ7 > Dr. Denenberg, since you work with noses all the time do you ever think about how you could improve the way your friends, family or your nose when you look at a them? I always wondered if plastic surgoens thought about that.

DrDenenberg > CJ, actually, I don't look at a nose outside the office unless it absolutely stands out, either as a huge or unfortunate nose, or as a breathtakingly beautiful nose. I'll often be at some gathering, and someone will walk away from the group I'm talking with, and someone else will say, 'Boy, did you see *her* nose?' And I won't have even noticed it.

Baseema > LOL that is heck of funny

CJ7 > wow that’s interesting

Karley > Dr.D, I have had 2 unsuccessful revisions to restore projection and definition to my tip but my nose is still too short & too rounded. How can I fix this problem?

DrDenenberg > Karley, that depends so much on what your nose looks like now, and what was done to the cartilages during the previous operation.

Karley > I had septal grafting to my tip via the open method

DrDenenberg > There are ways of addressing that problem, but I guess I don't know what to say about it without seeing your pictures because there are sooooo many options there. One thing you might want to do is go to my site and read some of the tutorials on nose surgery, especially surgery of the tip. You might get some good insight into what you have. Of course, if you want to post or email me your photos, I'll try to help.

Karley > my tip is a dome-like shape without definition

DrDenenberg > Karley, is it the size and/or shape of the graft that you see in the tip of the nose? Sometimes it's not the graft, but the whole tip gets surrounded by scar tissue, and that's where the problem resides.

Ruth > Can I still use a surgeon who didn't show me pictures? He has an /excellent/ reputation.

Ruth > What about my surgeon? he showed no pics but has a GREAT rep.

DrDenenberg > Ruth, you just can't go to someone if you haven't seen his photos. A reputation can be based on many factors *other* than the quality of results. Your nose is too important. Readers of this site know how much trouble can ensue if the operation doesn't go well. I tell my email correspondents that if they go to a world-famous rhinoplasty surgeon (how do you define that?), and the doctor won't show any photos, they simply have to cross him off the list and continue their research elsewhere. You're buying a pig in a poke, no matter how big the doctor's reputation. Also, don't be intimidated during your consultation. *You* are the employer, and *the surgeon* is applying to be your employee. Get all of your questions answered. If the doctor won't address your concerns now, forget about getting them addressed *after* surgery!

Dean > Great advice Dr. D,thanks for saying that

kline > very true Dr. denenberg

CJ7 > Dr Denenberg, who, in your opinion, were some of the pioneers in rhinoplasty over the years who helped advance the operation into what it is today?

Elaine > Dr.Denenberg if you felt you could not inprove a nose...would you refer a patient to another doctor and if yes who?

DrDenenberg > Elaine, I send people to other doctors all the time. I do that if they need a technique I am less experienced with, such as rib grafting. I also send someone elsewhere if I think I can improve the nose, but I don't think I can make the patient happy, either because he needs more improvement than the operation can give, or because we aren't communicating effectively enough. If I *know* that the nose cannot be improved, I'll recommend that the patient stop looking, but who's to say that another doctor can't connect with the patient better than I can, and ferret out something reasonable and safe to do. The doctors I like (and this is not an exhaustive list) include Dr. Toriumi in Chicago, Dr. Kridel in Houston, Dr. Quatela in Rochester, NY.

Elaine > Dr.Denenberg that is good to hear...and very honest of you.

jenn > I keep hearing about people getting pinched tips and having excess skin after getting bulbous tips reduced. HOw does that happen ?

DrDenenberg > Jenn, I don't think excess skin is ever much of a problem. I haven't seen it. Whether a nose gets a pinched tip depends almost entirely on what the surgeon does with the tip cartilages. The surgeon needs to keep track of what he's doing so that he doesn't do too much in any area of the operation.
jenn > So the nose should not get pinched if the doctor knows what they are doing with the cartiledges

Kate > I have to go but thank you Dr. Denenberg for talking with us-I know everyone really appreciates you taking your time-Thanks again.

campy > Dr. Deneberg, I have thick nasal skin and have had 2 rhinoplasty to reduce my tip. I still dont really have tip refinement. Is it impossible to get a small thin tip with thick nasal skin.

DrDenenberg > campy, it probably is impossible to get a small thin tip with thick skin, but the correct question would be *how* much thinner could your tip get, realistically, and would that amount of narrowing be enough to make you think the operation was worthwhile. Of course, we always have to work with the patients individual anatomy, but that doesn't mean that we can't make some improvements.

campy > Thank you DR. D

margy > - DR D - ILOVE your noses - it is possible to shortened a long bulby tip - 2 ops already

DrDenenberg > Margy, since the tip is the hardest part of the nose to operate on, I often find that revision patients complain that their noses are too long after a first operation, even if the surgeon did remove a hump. Most rhinoplasty surgeons do a poor job addressing the tip of the nose, so shortening a nose is often possible because the previous techniques used to shorten the nose were doomed to failure.

jenn > Why were the doomed to failture?

DrDenenberg > That often means that there are still changes that can be made in another operation to get the nose to an attractive length. Of course, that doesn't mean that's what happened to *you,* but that's the generality that I see most often in my office.

DrDenenberg > Jenn, when I said 'doomed to failure,' I meant that the previous surgeon selected a surgical technique to use that couldn't have made an adequate correction of the problem at hand. For example, a surgeon who might have wanted to shorten a nose, but just didn't know how to do it. A better rhinoplasty surgeon who was a fly on the OR wall might have commented that the nose couldn't have shortened adequately because the techniques that were used just wouldn't allow it.
jenn > Thank you - I'll bet they would have been better if they had gone to your site or spoke w/ you .
margy > thanks dr d


DrDenenberg > Jayy, howsabout calling my office manager and asking her =).

Marielee > Dr Denenbery if a nose can't be improved is it because it is a minor problem or a major problem

DrDenenberg > Marielee, your question about minor or major problems is a *great* question. Often it's because the problem is minor. Not minor because it is unimportant in the eyes of the nose's owner, but small when measured in millimeters. In a revision, just getting up into the nose to get to the location of the problem can be risky, taking the chance of altering something that we don't want to alter. That's all part of the calculation we do to compare the risk of a revision to the amount of improvement that we think we might achieve.

Elaine > Dr.Denenberg any in Canada you would send a patient to?

DrDenenberg > Elaine, how about contacting me by email about that. In general, I know doctors all over, but it's different to know a doctor's work and to have seen it first hand enough to *know.*

campy > Dr. D, are there limitations to how short a long nose can be shortened.

CJ7 > Dr Denenberg, how much does healing affect the final outcome?...

DrDenenberg > CJ, healing can change the outcome, but it's not verrrry common. If the surgeon puts the nose where it belongs, it will usually stay there, or stay close to there. The dressing is important to help hold things in place. It's true that a patient may have an unusual amount of scarring under the skin, or there may be some other unusual healing factor, but in general when I see a revision patient, the problems stemmed from decisions made during the previous operation and not from excellent surgery and poor healing.

Lee > Hi, Dr. D.

Lee > Dr. Denenberg, hello. My question is: is it possible to change the shape of the nostrils without cutting them at all at the alar base.

Lee > I believe my depressor septi muscle has been cut or something, and am wondering if my nostrils can be restored to their original shape.
Lee > How can this be done?

DrDenenberg > Lee, sometimes it is possible to change the shape of the nostrils by putting cartilage grafts along the nostrils or along the cartilages that normally sit adjacent to the nostrils. It's not unknown, but its not hugely common. I may get in trouble with my colleagues here, but I really don't think that the depressor nasi septi muscle has much effect on the shape of the nose. Remember that we try to change the shape of the nose when it is *at rest.*

Lee > I just see that my nostril went from being oval to being round with my surgery and my nose was more sophisticated with oval nostrils and wondering if that can be restored . Lee > How about lengthening a nose and changing the shape of the nostrils to make them a little longer?

DrDenenberg > Lee, a nose can be lenghened by using cartilage grafts, but your question is one of those where I'd have to see a picture to comment well. In general, we are not good at subtle shape changing of the nostrils. We try to place the nose in a better position, such as lengthening it if possible, and cross our fingers and see if the nostril shape change is what the patient wanted.

Lee > thank you, dr. D.

CJ7 > when you take your gloves off, do you know what the final, result will look like? or can it change dramatically?

star > Dr. denenberg how much do you charge for a primary??

margy > I have cartilage sown into a diamond shape for a tip - can you change that it is a new technique apparently

Karley > I'd like to know taht too

DrDenenberg > Margy, most cartilage shape problems in the tip can be addressed. Sorry, but I'd have to see some pics. I don't mean to cop out occasionally.
margy > thank you Dr d - do you use ear or rib cartilage when needed - any prefernce?

DrDenenberg > Margy, I like primarily to use septal cartilage, cartilage from the nasal septum, if I can get it. If there isn't enough, then I go to the ear, and ear cartilage can be very good, although you have to work with the fact that the cartilage pieces you harvest to put in the nose are curved, and that can present a problem. I don't take rib from the patient. Rib cartilage taken from motorcycle riders (donor cartilage) can be used sometimes, but if the patient needs a graft of his own rib, I'll often send the patient to someone else who works with it with frequency.
margy > so you use alloderm

Karley > how can a nose be lengethened?

DrDenenberg > When we talk about lengthening a nose, I think about the length from where the nose begins between the eyes down to the tip of the nose. A nose needs to be lengthened in this dimension if it was overly shortened in another operation. Lengthening a nose like that is extremely difficult. Some people refer to the distance from the tip of the nose back to the upper lip. I don't call that 'length,' I call that 'projection.' Increasing the projection of the nose is much more doable than increasing its length.

CJ7 > Dr D, how does projection differ from length of a nose?

jenn > I have heard that open rhino is better for many reasons, it that especially true for working on bulbous noses?

DrDenenberg > Jenn, In *my* hands, open rhinoplasty is infinitely better for working on a bulbous nose. It certainly can be done closed, but I frankly see huge advantages to the open technique and no real disadvantages.

Chad > Does any particular nose problem that you have encountered stand out as being your most challenging?

DrDenenberg > Chad, yes, in general, revisions are the most challenging (I would use even stronger terms) and the hardest revisions are those where the previous surgeon took out too much cartilage, leaving the patient with a bag of skin covering scar tissue. It can be downright impossible to find enough graft material and enough techniques to get some shape and form to the nose.

Chad > Thanks Dr. D - have you ever been in a situation where you were already inside and there is not enough cartilage anywhere to use? what do you do then?

DrDenenberg > Chad, I've really not been in that situation. If I suspect it might arise, I'll be thinking about it before I agree to operate. Besides the septum, you can harvest lots of cartilage from an ear, and then from the other ear. If you're still in trouble, you can use banked donor cartilage for some places in the nose, or you can steal a piece of cartilage that was already in the nose and move it where you need it more. Still, it is possible that you would just run out. I'd probably cry, and then I'd think of something to do that involved some compromises.

Baseema > I have to go. Dr. Denenberg, thank you. This chat session has definitely been very educating and your noses look great.

CJ7 > just read what you said

Dean > Dr. D,have you ever used a glue like substance to minimize the columella scar like Toriumi supposedly uses?

DrDenenberg > Dean, I haven't used glue on the columellar scar. It's possible to sew it so tightly and nicely that it heals well without the glue. I usually don't take on a new technique unless someone proves to me that its better than what I'm currently using. If Dean does a study and shows something good, I'll get right in line. I think his work is excellent.

CJ7 > Dr. D, which surgeon would you recommend for working with rib grafts?
DrDenenberg > CJ, Vito Quatela in Rochester, NY, has extensive experience with rib grafts in the nose.

campy > Do you decide what nose shape and size will look good on your patients or do you find out what type nose your patients had in mind and try and give it to them.

DrDenenberg > Campy, I do the latter. I try to find out, by looking at pictures, by listening to the patient, by using the video imager, what the patient is looking for. If he is looking for something that I think won't look good, or if he hasn't considered something I think he needs to consider, I'll discuss it, but in general the patient rules as far a goals of the operation.
campy > Thank you, I ran into trouble by letting my surgeon choose what he thought was best and it wasnt what I had in mind. I guess that was huge lack of communication on my part. Thank you for your time Dr. D.

Chad > Can you explain cartilage buckling? Thank you

DrDenenberg > Chad, some of the cartilages in the nose need to have strength, to withstand the pulls and weight of the skin and its elasticity. If a cartilage is too weak to stand the stress, (it might have been carved too narrow by the surgeon), it will buckle just like a beam in a building will buckle if too much weight is placed on the beam. That buckling can cause *lots* of problems. We try to train rhinoplasty surgeons not to take out too much cartilages in areas where strength is important to support the structure and shape of the nose.

Chad > can you be more specific about what problems that buckling causes

Karley > Dr D - have you ever heard of the Medpor Nasal Shell that Dr. Paul O'Keeffe has designed? Apparently, it's yielding excellent results

DrDenenberg > Karly, I'm familiar with the Medpor material, but I haven't looked to see the shape that Dr. OKeeffe has designed it in, or where he places it. Sorry.

Karley > he places it on the dorsum to mimic the anatomy of the nose

Karley > it looks very natural

margy > have you ever used medpor anywhere in the face?

Elaine > Dr.Denenberg I guess what I wanted to ask is if you would recomend Dr.Conrad for revision nasal surgery?

DrDenenberg > Elaine, I know Dr. Conrad, but I've never seen his work first hand. I know him to be a clear thinker, for which I respect him greatly. When it comes to revisions, it's hard to say someone will be great, or will be the best. Different excellent surgeons will have different approaches, trying to see what route will get the most benefit for the least risk. I like Dr. Conrad a lot, but you always should shop a difficult revision around a little bit, just to see what the field thinks about your nose.

Elaine > Thank you very much Dr.Denenberg.

DrDenenberg > Ok, my fingers are cramping. Any last pressssssing questions? Remember, you can email me questions off of my site.

margy > do you take ininternational clients?

DrDenenberg > Margy, yes, after I put up my Web site, people started coming from all over. Finland, China, Japan, New Zealand, Alabama, you name it.

Dean > Would you like to Headline here every Wednesday night? lol
margy > australia?

DrDenenberg > I couldn't swear to Australia, but maybe I have had someone from there. .
margy > do you do 3rd and 4th time noses

Dean > Thank you so much Dr. Denenberg,you were extremely helpful

kline > thank you Dr. denenberg
Elaine > thank you.

margy > thank you very very much Dr d

Sim > Thank you too

Chad > Thank you very much Dr. Denenberg

DrDenenberg > You are all very welcome. The questions were excellent. I'm signing off. Thank you all for coming. -Steve

Chat - End





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