Dr. Steven H. Dayan is a double boarded certified Facial Plastic Surgeon and a clinical assistant professor at the University of Illinois – Chicago. After medical school, he spent his residency years specializing in surgical training of the nose, head and neck (Otolaryngology). Following residency he did an extra fellowship year intensely training in plastic surgery focused on the face only. Dr. Steven H. Dayan does not do tummy tucks, liposuction or breast augmentation; rather, he devotes his time and skill to plastic surgery of the face, the nose in particular. This explains why he has such extensive and deep experience in both the appearance and function of the nose.
His school of thought involves combining skills learned from multiple approaches to the nose to develop his own minimally invasive style on how to create a natural, attractive and balanced nose. After performing nearly 1,300 rhinoplasties, he developed a specialized “closed approach” that uses the stability enhancing maneuvers common to the more invasive open approach but employs them through a closed approach. The closed method can be advantageous, as it is usually associated with shorter time under anesthesia, produces less swelling with little to no bruising and has a quicker recovery period. During your consultation, Dr. Steven H. Dayan will be able to discuss which options will be best for you. It is especially important to select a surgeon experienced in treating both the interior and the exterior of the nose.
His written publications and presentations has resulted in him being a frequent stop on the training circuit for many plastic surgeons in training and physicians from other countries wanting to learn these finer skills of rhinoplasty. His volume of rhinoplasty procedures per year speaks for itself. He is one of the most sought out rhinoplasty physicians in the country. According to the American Society of Aesthetic Plastic Surgeons, the average plastic surgeon does approximately 12 rhinoplasties a year where as Dr. Steven H. Dayan does approximately between 150- 200 over ten times what the average plastic surgeon does!
Combining his passion for art with his disciplined skills and devotion to the patient’s desires, Dr. Steven H. Dayan is a uniquely qualified, talented and proven rhinoplasty specialist.
What happened to Closed Rhinoplasty?
Modern cosmetic rhinoplasty is generally conceded to have its roots in sacred halls of the Charite Hospital in Berlin Germany propagated by the second son of an orthodox Rabbi initially trained in orthopedic surgery. Jacques Joseph, born Jakob Lewin Joseph, is recognized by many as the father of internal incision rhinoplasty, although others have also been credited to have done internal incision rhinoplasty around the same time John Orlando Roe in Rochester, New York and Robert Wier in New York City. But it was Joseph who was famed for developing the closed rhinoplasty procedure and teaching it to so many. Despite Professor “Joseph Noseph” first describing the external dorsal incision open approach in 1898 to the Medical Society of Berlin, for seventy years his rhinoplasty legacy was primarily a closed procedure. Joseph was very much aware that cosmetic surgery was centered on treating ones psyche. A concept that our forefathers recognized as the primary objective of cosmetic medicine, but one that today may be too frequently deemphasized when the enthusiasm for a new aggressively altering medical intervention is described. Joseph’s techniques while exciting, new and ground breaking always placed the patient’s interest at its forefront.
A few forward thinking surgeons including Sam Fomon from the U.S. pilgrimage to the German surgical Mecca to learn from Joseph. They brought back this knowledge, and honed their new skills but most of all they learned the importance of respecting the nose and its function. After working hard to perfect these techniques they then delivered them to their colleagues and students in masses. Following World War II with the improvement in anesthesia, the availability of antibiotics cosmetic surgery expanded. Additionally, it quietly became increasingly more acceptable to undergo elective surgery and cosmetic surgery in particular. Also a large wave of ethnic first and second generation Americans, now with disposable income for the first time in their history desired a more “American nose.” Nasal reshaping surgery was on the demand and a new wave of cosmetic experts, were set on meeting the demand. More doctors performed the most common cosmetic surgical procedure.
These medicine men and women met the calling with what they had absorbed. Whether it was an abbreviated course at a hospital, a lecture, a book chapter or a brief part of their residency curriculum they mimicked the gross maneuvers they had learned. But something was missing, a rash of rhinoplastys were performed, swiping out dorsal humps, fracturing nasal sidewalls and excising tip cartilage margins. Many patients seemed happy, at least initially but while these occasional rhinoplasty surgeons were inspired by their deceptively positive results the follow up may have been poor. Soon many of these noses started to deviate, twist and collapse. The revision rate for rhinoplasty grew and is recognized to be well above other facial plastic procedures even in the hands of an expert. The importance of surgical gentility, respect of nasal anatomy and proper patient selection wasn’t being effectively conferred. And as closed rhinoplasty was generally the only method taught patients with difficult deformed noses that were not good candidates for a limited access rhinoplasty were treated anyways and often with untoward outcomes. Along the same time a consumerism descended upon an American population. A more demanding generation wanted better results. No longer was just an improvement in a hump or boxy tip acceptable they wanted the perfect nose. Physicians eager to please selected more patients. Extending the criteria and attempting to achieve heroic results with cartilage reduction maneuvers along with a lack of appreciation for internal nasal anatomy many poor outcomes prevailed. A newly defined plague of post operative conditions heralded including: nasal collapse, alar notching, inverted “V” deformities and bossa formations.
The setting was ripe for the emergence of the open approach. Modern day open rhinoplasty began when Goodman, a Toronto doctor reported its benefits. By creating an external nasal incision and by de-gloving the skin envelope from its underlying cartilaginous and bony skeleton the cartilages could be seen in their entirety. Now difficult maneuvers were done out in the open. Isolated cartilaginous notches, curves and irregularities could be addressed under direct vision. For the occasional rhinoplasty surgeon and the novice surgeon the open approach is a welcome change. For the seasoned surgeon consultant, it allowed excellent visibility and a wonderful approach for fixing the severely twisted or deformed nose. The open approach was especially valuable when doing revision work and teaching. But there may be some inherent disadvantages of the open approach. Intra-operative swelling seems to be greater with the skin elevated. Additionally mild adjustments made to the cartilaginous skeleton intended to improve angles and proportions can be difficult to visualize in 3 dimensions with the skin elevated. Also, repeated elevating and replacing the skin accentuated the swelling, furthering the difficulty in seeing the changes. Additionally degloving the nasal skeleton meant that much of the nose was destabilized in the opening process. Minor delicate and maybe unappreciated attachments are disrupted. The nose starts to morph even further from its pre-operative condition. In order to respond structural grafting becomes necessary, fixating positions of the tip and bridge and nostril margins. Grafting and more grafting became synonymous with opening the nose. Maneuvers were done to make the nose stronger and tension resistant. However, structurally reinforced noses were at risk for not compromising when kissing, not moving with smiling and while looking better statically and in photos in real life the noses occasionally didn’t appear natural. The procedure time is almost always more than the closed approach. Post operatively the external scar is rarely an issue but much more concerning is the prolonged swelling. Patients’ noses are bigger for a longer period of time. Bruising and swelling may persist longer. A lot of hand holding is often necessary. And results while lasting require a longer healing period. A discontented patient is the expected norm in the early postoperative period. However, because of the advantages of direct visibility and the ability to treat complex cases, the open procedure is the most popular form of rhinoplasty being taught today in fellowship and residencies. While at times, the open approach rhinoplasty is the overwhelmingly favored entry, such as when treating the severely deviated middle vault and the distorted nasal tip, perhaps the pendulum has swung too far to the open approach. There are still a lot of noses that can benefit from the closed approach.
?So what happened to the closed approach? It is still in bloom or dying on the vine as a younger generation of surgeons has been steered away from it? Perhaps wandering was a necessary course in order for closed rhinoplasty to reemerge with the respect it deserves. Closed rhinoplasty while not indicated for all noses is probably underutilized for many qualified candidates. And when done well closed rhinoplasty is an experience of art that delivers fantastic results. The advantages are many including minimal intra-operative bruising and swelling. Minor but significant cartilaginous native attachments are left in place. Subtle shaving and modifications made in the bridge can be viewed in real time. Minor millimeters of change in the tip can be visualized accurately with the nasal skin intact. The procedure is generally expedient and recovery time is less than what is common with the open. When done appropriately and for the proper indications, the modified nose is still one that is natural and remains within the context face and not drastically different from the original nose. Patient sat isfaction is great and early referrals are common.
Perhaps closed rhinoplasty should not be relegated to the graveyard of teaching. In fact it could still be taught but only after one and learns to respect it first. Certain prerequisites are mandatory prior to entering into the studies of closed rhinoplasty. First and foremost, understanding the rhinoplasty patients psyche is paramount. Many patients requesting rhinoplasty are not interested in a totally different nose. Minor adjustments may be all that they desire. Perhaps a DaVinci designed proportionally ideal nose is not what they want crafted. It is not uncommon following intense listening to a prospective patient’s wishes to identify that a mild shave, slight volume reduction of the tip and subtle hint of upward rotation is all that is desired. If so then it may be easier and more appropriate to provide these results with a closed approach. Good candidates for closed rhinoplasty, usually start with thicker skin, general tip symmetry and a midline bridge. Severely twisted asymmetric deformed noses are rarely going to be adequately corrected with a closed approach. The closed rhinoplasty pupil should have extensive understanding and appreciation for nasal anatomy, cartilaginous and mucosal attachments and upper airway respiratory physiology. Aggressive dissections, macerated tissue planes, abused mucosal attachments will more likely lead to post operative deviation and nasal collapse. Incisions and dissections need to be done in appropriate bloodless planes and in a gentle manner. Aggressive maneuvers will traumatize tissues, attachments and weaken important delicate supporting fibrous attachments. Additionally using instruments that are precise, sharp and appropriate are helpful for gaining access to the appropriate planes. Respect of the nasal valves and where they are located is essential. Care has to be taken to not cut across these valves and to end the procedure by closing all intra nasal incisions meticulously so as to prevent scarring of nasal valves.
Closed rhinoplasty is not for everyone to learn, only those deemed ready for it can begin to undertake its study. Four years before his death in one of his last publication, Sam Fomon, who was reported to have done over 15,000 rhinoplasties commented on how the “Fine art of rhinoplasty requires a long apprenticeship” “It takes a long time to train the students eyes for what he is to look and his finger for what to feel. And to digest assimilate and give meaning to his sense perceptions.” “Another reason for the prolonged apprentice ship is to enable the student to substitute instantaneously one type of manual integration for another should an unforeseen situation unfold.”
If those who perform closed rhinoplasty are better equipped, prepared to understand its potent inner workings then they will likely do a better job, there will be less unfavorable outcomes and ultimately happier patients. Closed rhinoplasty is not indicated for all patients requesting nasal reshaping but neither is the open approach. There are many great candidates for closed rhinoplasty who probably are getting more surgery and downtime than necessary. Perhaps residents in training and interested emerging rhinoplasty experts should be reintroduced to the benefits of the closed approach. But more emphasis placed on the study of psychiatry, art, anatomy and philosophy before progressing to hands on. Although rhinoplasty apprenticeships can take years before one develops the appropriate skills, perhaps the preparatory process can be abridged with intense study and a greater respect for closed rhinoplasty. Below are some general mandates we have distilled from the forefathers teachings and suggest their emphasis as part of the prerequisite study for the closed rhinoplasty student.
Mandates of closed rhinoplasty
- Treat the patient not the nose, select patients appropriately, understand their desires
- Respect and understand the function, physiology and anatomy of the nose
- Be gentle with the nasal tissues, dissect carefully and purposefully
- Dissect within established tissue planes
- Use sharp and appropriate instruments
- Respect the and preserve as much of the nasal septum as possible
- Keep as many mucosal attachments in tact as possible.
- Do less fracturing of the nose
- Close all mucosal incisions meticulously
- Ice, tape and cast appropriately
We believe that an informed patient will have a better surgical experience. Download the closed rhinoplasty packet (here) to review before your consultation with Dr. Steven H. Dayan.
