Surgeon’s Review of Dr. Dean Toriumi’s Surgical Techniques: 3

Testimonial on Dr. Toriumi's Surgical Techniques 
 -Dr. Leandro Pellarin   

Dear Dr. Toriumi,

First of all, I would like to thanks for the opportunity to visit you. Rhinoplasty surgery is the most challenging surgery for the plastic surgeon. Every surgery I learn, I realize the difficulties and especially i realize how hard it is to achieve the result we envision . With the learning process, every difficulty solved countless others appear. Each surgery is done by the perception of the surgeon, by art, by perfectionism , relentless pursuit of perfect and ability to put such features into practice.

Watching countless times your classes , learning from your lectures , articles and books , I noticed that all the important points to a nose surgeon are made by you in an extremely refined way and a higher level than any other. These gifts , combined with the dedication, study, and a great respect for the patient did you the best nose surgeon . My visit and the opportunity to attend your surgeries , discussing cases, teaching all your experience, confirmed all this and infinitely mainly increased my respect and admiration for you. I learned more than numerous conferences and hours of study.

I would like to thank you immensely for this great experience , the teachings and help me to improve my thinking and especially improve the care of my patients.

All The Best,
Leandro Pellarin

Dean Toriumi: Facelift Surgery

If you are unhappy with the lower two-thirds of your face, Dr. Toriumi may suggest you undergo a rhytidectomy procedure. A rhytidectomy, or facelift, is designed to correct conditions associated with an aging face. Visible indicators include saggy or loose skin and loss of facial muscle tone. A facelift can correct these indicators by removing excess skin from the face and neck, and sculpting the underlying tissues and muscles in your jaw, cheek, and neck area.

A facelift can be combined with other procedures to strengthen your chin and improve your brow or eye area. These include brow, chin, or eyelid surgery. 

Pre-Operative Instructions: Before Surgery:

This information is designed to answer questions about your pre-operative care. To achieve the most satisfactory results, you should follow these instructions closely and familiarize yourself with these instructions. Please attempt to follow these instructions faithfully.

1. Do not take any aspirin, compounds containing aspirin, or non-steroidal anti-inflammatory medications (Motrin, Ibuprofen, Advil, Aleve, Vioxx, Celebrex, Naprosyn, etc.) for four weeks prior to and four weeks after your surgery.

2. If you require pain medications, you may safely take Tylenol products in the period from surgery preparation until you return home. If you require stronger pain management, consult Dr. Thomas.

3. Do not take Vitamin E or herbal supplements such as gingko, ginseng, fish oil, garlic, St. John's wort, etc. for four weeks prior to your surgery and four weeks after your surgery.

4. Avoid alcoholic beverages 48 hours prior to surgery.

5. If you smoke tobacco or use smokeless tobacco products, stop using them at least four weeks prior to surgery and refrain from them for at least four weeks after surgery. Smoking is directly related to poor wound healing and possible skin loss.

Post Surgery:

To expedite healing and minimize discomfort, please follow Dr. Toriumi's explicit directions. Dr. Toriumi will advise you to avoid strenuous activities right after surgery.

Surgeon’s Review of Dr. Dean Toriumi’s Surgical Techniques: 2

Testimonial on Dr. Toriumi's Surgical Techniques 
 -Mauricio Buitrago, MD.   

Dean M. Toriumi MD. came to San Jose Costa Rica on a probono mission trip to help patients with complex nasal deformities from April 22 to April 28 2013. Dr. Toriumi used complex surgical techniques that are not commonly used in Costa Rica. He harvested rib cartilage and performed complex cartilage grafting on a young man with a bilateral cleft lip nasal deformity . This patient underwent several previous surgeries and had severely deficient nasal tip projection and a very wide nasal tip with nasal obstruction. Dr. Toriumi performed a very successful operation and the patient has done very well since surgery and is very happy with his outcome both from an appearance point of view and from a functional standpoint. Dr. Toriumi also operated on a patient with a severely deviated nose with nasal obstruction who underwent a couple of previous surgeries. He performed rib cartilage harvest and cartilage grafting to correct the patients breathing problems. Dr. Toriumi performed the surgeries at the Clinica Biblica Hospital and the public children's hospital in San Jose. Other patients had severe functional problems and complex nasal deformities.

In addition to performing the surgeries on the patients Dr. Toriumi also taught Costa Rican surgeons in the operating room. He provided a very concise didactic experience explaining all of the maneuvers so the observing surgeons could understand the surgeries . He also gave an 80 minute presentation to the Costa Rican surgeons to augment the teaching points made in surgery.

This was a very special mission trip donated by Dr. Torium i and we are very grateful for his generosity and donated time and expense.

Mauricio Buitrago, MD.
Otolaryngology Department Hospital Clinica Biblica
Costa Rica

Dean Toriumi: Anti-inflammatory Diet

Many prominent physicians –including Dr. Barry Sears, Andrew Weil, and “Dr. Oz” – and dozens of books have advocated healthier, anti-inflammatory diets for improved health and weight loss. A few have addressed the connection between diets and allergy. But Dean M. Toriumi, M.D., a noted facial plastic surgeon and Professor of Otolaryngology-Head and Neck Surgery at UIC, has adapted the antiinflammatory diet trend to his facial plastic surgery patients – with significant results, results that help improve healing and quality of life for many patients post-surgery.

Many Americans consume diets high in pro-inflammatory foods – processed fats and meats, hydrogenated oils, trans fats, and refined grains and sugars. These ingredients can radically affect how we respond to food ingredients that can induce allergic reactions, often instantly. On average, the more inflammatory substances we put into our body, Dr. Toriumi noted, the greater the allergic response. Symptoms - from congestion and sneezing to watery eyes and skin irritation - can result. For Dr. Toriumi, a world-renowned facial plastic surgeon, the effects of inflammation on his patients’ nasal symptoms, especially among those recovering from surgery, were of particular concern. Nasal congestion, breathing difficulties, and related inflammation problems can be amplified in surgical patients, causing significant discomfort and slowing recovery –an important factor for patient outcomes.

So Dr. Toriumi began prescribing his anti-inflammatory diet – developed over many years and has some similarities to the Sears “Zone Diet” and the proven Mediterranean diet – to surgical patients. “Some facial plastic surgery patients have expectations about how quickly they’ll get the look they’re seeking from surgery,” he noted. “While some patients clearly have unrealistic expectations that everything will look great instantaneously, clearly diet can make a difference, expediting people’s recovery by contributing to a reduction of swelling,” he noted.

Dr. Toriumi’s clinical studies found that the diet, when adhered to in a highly disciplined way, contributed to many patients’ health and recovery. He would prescribe his diet – including a lot of leafy green and vegetables, minimal animal fat (unless it’s from grass-fed animals who don’t consume a lot of corn – corn ingested either directly through their body or through an animal that ate corn is highly inflammatory, he noted), green tea, and olive/fish oils – to patients for three months and asked them to record their symptoms. “Among those who were really disciplined and committed to the diet, the results were astounding,” Dr. Toriumi noted. “Regardless of their nasal problem before the antiinflammatory diet – congestion, swelling, breathing difficulties, etc. – the symptoms were significantly reduced and quality of life improved demonstrably with the diet,” he said.

Patients felt better, noticed speedier recovery from surgery, and were better able based on the symptoms they had to understand and gauge those foods that particularly contributed to their allergic conditions. From there, Dr. Toriumi noted, they were better able to dictate and control their own intake of the most inflammatory foods to help manage their diet and allergies going forward, he said. And there were other benefits – aside from the weight loss that typically occurs when people adopt an antiinflammatory diet: patients needed fewer or no medications to manage their allergies. “Because the body through food and nutrition is naturally preventing allergic reactions, many patients don’t need any more pharmaceuticals to do the job for them,” Dr. Toriumi said.

His focus on nasal symptoms, diet, and how it these relate to surgical patients applies to patients both pre- and post-surgery, even years after their initial surgery. In short, with the right diet, anything inflammatory gets better. This is the case for any allergy, he added, whether food-based or not. “It all has to do with the body’s response to the allergen and its connection to anti-inflammatory agents,” he noted.

As a facial plastic surgeon, Dr. Toriumi’s work is unique among the tomes of diet books and TV shows we see today. “It is a bit out of left field for a surgeon to look into these issues, but it feeds well into my practice and patients,” he noted.

“Most patients really want to take care of themselves and be in control of their health. Particularly among surgical patients, who tend to be well educated and sophisticated – not to mention very much in tune with any nasal symptom that gets in the way of their recovery and outcomes, this is right up their alley,” Dr. Toriumi noted.

Dean Toriumi Gives You Balanced Features

Dr. Toriumi Gives You Balanced Features

This patient presented with an under-projected chin.

To help balance her nose with her other facial features, Dr. Toriumi augmented her chin and increased the projection of her her nasal tip.

The photographs represent a two year postoperative outcome.

Pre-Operative Photos	Post-Operative Photos

Dean Toriumi: In News

Dr. Toriumi Coordinates Global Meeting on Rhinoplasty

CHICAGO (December, 2012):  Dean M. Toriumi, M.D., Professor of Otolaryngology – Head and Neck Surgery and Head of the Division of Facial Plastic & Reconstructive Surgery at the University of Illinois at Chicago, served as co-organizer of the “Cutting Edge 2012 Aesthetic Surgery Symposium Advanced Sculpting of the Nose” meeting in New York City, November 29 to December 1 in New York City.

Along with colleagues Dr. Sherrell Aston and Dan Baker, Dr. Toriumi organized the interdisciplinary symposium, which drew more than 600 surgeons from 55 countries, including some of the most highly regarded international experts in rhinoplasty.   Major topics addressed in panels included new and more established rhinoplasty techniques in areas such as nasal tip surgery, osteotomies, dorsal augmentation, nasal function, the deviated nose, revision rhinoplasty, ethnic rhinoplasty, and others.

“The meeting was a smashing success, given its overwhelming attendance,” Dr. Toriumi said.  “Many of the attendees said it was the best rhinoplasty meeting that they had ever attended, telling us that the focused presentations, panels of top rhinoplasty surgeons from all over the world, and use of video made the symposium highly educational and useful.”

M. Eugene Tardy, M.D., former Chair of the Department, gave a keynote presentation, as did Dr. Toriumi, who spoke on his new methods of managing nasal tip contour and tip position.

Dean Toriumi: Replacing the Nasal Septum

Does Dr. Toriumi take out and replace the nasal septum, and, if so, under what circumstances ? 

Dean Toriumi:

Rarely do I remove the nasal septum and replace it. The vast majority of patients will undergo a conventional septoplasty to straighten their septal deviation. In the conventional septoplasty operation, deviated portions of the septal cartilage are removed leaving an intact L-shaped septal strut (see figures 1 and 2). It is important to preserve this L-shaped septal strut to avoid loss of support and possible collapse of the nose. 

Perhaps some of the confusion arises from the name of a graft that I commonly use, called a caudal septal extension graft. In many cases I will place a caudal septal extension graft, which is a cartilage graft that is positioned end to end or may overlap the existing caudal nasal septum (see figure 3). 

A caudal septal extension graft is similar to a columellar strut except it is more stable, as it is connected to the existing caudal septum. This graft provides excellent support to the nasal tip without changing the existing septum. The caudal septal extension graft prevents postoperative loss of tip projection and sets nasal length as well as other parameters. I find this graft very helpful to avoid common rhinoplasty complications, such as postoperative loss of tip projection (resulting in a polybeak deformity), short nose deformity, overrotated nose ("turned up nose"), etc. However, use of this graft is clearly not equivalent to replacing the nasal septum, as it is a cartilage graft that is added to the existing nasal septum to provide support. 

Patient A.S. underwent a primary rhinoplasty after suffering trauma to her nose leaving her with a deviated nose, nasal obstruction and nasal deformity. She requested that her nose be straightened, her nasal tip shape be improved, and her airway corrected. She also requested to keep her nose on the shorter side. Her surgery required straightening the nasal septum, and a caudal septal extension graft was used to stabilize and straighten her nasal tip. Her caudal septum was not replaced, but, rather, the extension graft was added to provide tip support and move her tip back to the midline. This is the method used in the majority of primary cases. Rarely do I remove and replace the septum. Postoperatively, her nose is noted to be straight, and her airway is dramatically improved. 

Patient J.F. underwent a primary rhinoplasty to correct an overprojected nose and large dorsal hump. In her operation her nasal septum was straightened. Only the deviated portion of the nasal septum was removed, leaving an L-shaped septal strut behind. This is typical and does not require replacing the nasal septum. Postoperatively, her nose is noted to be straighter, and her dorsal hump was reduced. 

This patient underwent a fairly typical primary rhinoplasty using the open rhinoplasty approach, dorsal hump reduction, placement of spreader grafts, and tip work to reshape her tip. She had plenty of her own septal cartilage to perform the necessary grafts and provide her with excellent structure to better insure a long term outcome.

On rare occasions I do replace the caudal portion of the septum. The primary indications include the severely deviated caudal septum, unstable caudal septum, or a previously over-resected caudal septum. In the case of the severely deviated nasal septum, removal and replacement of the deviation is the best method in my hands to create a straight nose with a good airway. Many surgeons will leave the deviated septum or try to manipulate it, which can be successful but also has a high incidence of failure or partial correction. Failure to straighten the septum may leave the patient with a deviated nasal septum and nasal obstruction. Many surgeons try to resect the deviated portions of the deviated caudal septum without replacing it, leaving the patient with a potential loss of tip support. These patients will frequently be left with a residual septal deviation, inadequate tip projection, turned up short nose, retraction of the columella, etc. To prevent these deformities I prefer to replace the deviated septal cartilage that is removed in order to reestablish appropriate tip support and prevent complications.

Patient S.L. had a crooked nose deformity and severely deviated caudal septum that was blocking her airway on the right side. Correction required removal of the existing caudal septum and replacing it with another piece of her own cartilage to recreate a stable nasal septal structure. Using this technique her nose could be reconstructed around this new midline caudal septum. The postoperative result shows correction of the deviation of her nose, excellent symmetry to the base of the nose with an open nasal airway. 

This patient is very happy with her outcome and has excellent nasal function with no consequences of replacing her deviated caudal septum.The patients who undergo this type of operation do well, and what is accomplished is the reconstruction of the caudal septum to a state that would be considered normal instead of deviated. In my opinion it is better to reconstruct a new straight caudal septum that will support the tip and create an excellent airway instead of doing a less stable operation potentially leaving deviation and obstruction. Over the past 20 years, I have had great success with this approach to correct severe septal deviations. I published this technique in 1994 in an article entitled, "Subtotal septal reconstruction of the nasal septum," (Toriumi DM, Laryngoscope Vol. 104, 7, July 2004). Since then many other surgeons have adopted this technique for correction of the deviated caudal septum, overresection of the septum, lengthening the nose, etc.

One of the most common steps in a typical reductive rhinoplasty is to trim the existing caudal septum to shorten the nose or rotate the nasal tip. This frequently leaves patients with a severely deficient caudal septum. When these patients come to me for revision, I often find that the caudal septum is essentially gone or severely damaged. I prefer to place a new caudal septum in these cases to replace the normal anatomy and regain tip support. Patient C.F. underwent a previous rhinoplasty in which an excessive amount of caudal septum was resected in a previous operation. This resulted in a severe loss of tip support, loss of tip projection, and drooping of the nasal tip. Replacement of the deficient caudal septum allowed replacement of support and improved tip contour 

This is the type of patient that requires structural grafting to insure a good outcome. To overview, surgical management of the nasal base involves either placement of a columellar strut, caudal extension graft, or rarely replacement of the caudal septum. Patients undergo placement of a caudal septal extension graft that does not involve replacement of the caudal septum. The caudal septal extension graft actually involves placement of a graft that acts as an extension off of the existing caudal septum. This is a very powerful graft, enables stabilization of the base of the nose, and helps prevent postoperative loss of tip projection, drooping of the tip and shortening of the nose. The caudal septal extension graft or caudal septal replacement can result in stiffness of the nasal tip or change in upper lip feel and position.. We discuss these potential sequellae with patients if such grafting maneuvers may be used. Over the past 20 years, I have noted that the vast majority of patients have no negative consequences from such grafts and do well with a good, long-lasting outcome.