Rhinoplasty Diaries #2: Overcoming bias
As promised last Sunday I am writing the second part of my series of articles covering interactions I have had during my 30 years in Rhinoplasty. This focuses on my journey as a Rhinoplasty at a time when the specialty was developing in India.
Nowadays with all the audio-visual aids and experienced surgeons learning Rhinoplasty is much simpler in India. But when I started, there was no authority on Rhinoplasty, at least in Mumbai. At the time there were some famous plastic surgeons but they were so secretive that they never allowed juniors to watch their surgery or just showed from a distance what a good Rhinoplasty result should be on the table. Especially if you weren’t a plastic surgeon - I would go so far as to say it was considered a sin for an ENT surgeon to even think of Rhinoplasty, all that was expected from us was to divert cases like traffic policemen.
As with all careers luck played a part, I was working as Lecturer at the B.Y.L Nair Hospital, the professor was very friendly with a German plastic surgeon and ordered a full Karl storz Rhinoplasty instrument set. But, it takes time in the Municipal Corporation Hospitals for purchasing any instruments and by the time the instruments were delivered the professor retired. So I got a brand new instrument set but with no training or role model to follow. The professor who took over was interested in Otology and told me, “Do Rhinoplasty if you can but I should not get any complaint that you spoiled a Nose.”
I decided to self-train myself. I read all the available books (all from western authors) and practised on cadavers. Interestingly I once went to a mortuary and found an orthopaedic surgeon trying to insert a bone graft in a cadavers nose. I thought, “Oh my god there is some serious competition, I thought I was the only ENT in Mumbai interested in Rhinoplasty, but there is serious competition.” I asked him what he was doing and he embarrassedly said “Brajendra, a lot of bone grafts are used in Rhinoplasty so orthopaedic surgeons should learn Rhinoplasty as well”. Anyway he left the mortuary as he was not expecting a visitor at the mortuary at 6.00 PM. Later he told me he was just experimenting and not keen to continue (He is now a renowned spine surgeon in Mumbai).
External Rhinoplasty in India
Now External Rhinoplasty is so widely practised and is a norm in India, but when I started was the era of Closed Rhinoplasty, and, all my initial cases were operated by the closed approach. It was believed that it gave good results in white skin but could be a disaster in dark skin.
I went to the Royal National ENT hospital in London as an observer to see the legendary Tony Bull (he was the most popular Rhinoplasty surgeon in England). I asked him if can we do External Rhinoplasty on Indian noses and he replied, “I don’t know, I only do closed Rhinoplasty but I did a externship for 18 months in an African country and didn’t see a single case of Keloid in the columella. You can try it, with care.”
I came back and tried External Rhinoplasty in a few cases, all healed well with no hypertrophic scar or Keloid in the columella. There was a plastic surgery meeting at the Grant Medical College and Sir J.J Hospital, Mumbai where I presented my cases. One of the senior plastic surgeons got up and scolded me badly. He said, “You are an ENT and don’t have any knowledge of Rhinoplasty who gave you authority to experiment on poor patients? Have you taken permission from the ethical committee (I didn’t know what that was) and we must report it to your Dean.” I was extremely nervous and felt like I'd committed a crime, I sent all the pre and post-operative pictures to Tony Bull and his reply was extremely encouraging, he asked me to make a paper and submit it for publication.
I followed his advice and this was the first publication on External Rhinoplasty from the Indian subcontinent on External Rhinoplasty
External Rhinoplasty in the Tropics. Brajendra Baser , Navin Hiranandani and D. S. Grewal. The Journal of Laryngology & Otology/ Volume 103 / Issue 12 / December 1989, pp 1198-1201
Wonderful case to do Augmentation Rhinoplasty, saddle nose deformity great pictures come in profile view
I attended a lecture on Augmentation Rhinoplasty by a professor of plastic surgery in a clinical meeting at the Sion hospital, where he was advocating over-correction by bone graft as part of it will be absorbed and after a few months, the nose will look great.
I started doing Augmentation Rhinoplasty as there were plenty of cases, post SMR, atrophic Rhinitis, Leprosy. Even though Rhinoplasty did not have mass appeal but a depressed nose was considered to be a stigma and even poor villagers did not want to return to their villages with a depressed nose. Additionally, Treatment in the Municipal Hospital at that time was absolutely free so in our earlier days most of the Rhinoplasty cases were augmentation Rhinoplasty.
We were struggling with a large iliac crest bone graft, Olecranon process of ulna and graft for tibial shin. By now the word was spreading in ENT circles in Mumbai specially amongst residents that there is a junior lecturer in Nair doing Rhinoplasty so I was getting cases from other government hospitals as well. The initial success went on my head and I started talking to everyone like I was an expert in Rhinoplasty.
But then came the day I was humbled. The new OPD building had just started and was located a little away from the college building. One day early in the Morning I was walking to the outpatient clinic with my Registrar (3rd year PG who is now a skull base surgeon in Mumbai). There was a patient who was sitting in the waiting room with a Gross Saddle Nose Deformity - I was excited and told him, “This is such an interesting case it is, we will use large Iliac crest bone graft and it will look great in pictures maybe we can present it in our next clinical meeting.”
The register whispered quietly in my ear, “Sir it is your operated patient, the bone graft is completely absorbed and he is waiting to see you.” This was really embarrassing and the first jolt in my fast moving Rhinoplasty career.
It was a case of atrophic rhinitis and the iliac crest bone graft I used in previous Rhinoplasty was completely absorbed (despite over augmenting ) and the patient was back to square one. I was depressed ,went to the library and tried to look for augmentation techniques in Atrophic Rhinitis, but there was no reference as Atrophic Rhinitis was a condition rarely seen in the western world .
I decided to change my technique and started using cartilage instead of bone in cases of Atrophic Rhinitis - I started using rib cartilage and found that there was no absorption of cartilage graft and proposed my hypothesis that Alkaline phosphatase secreted in Atrophic Rhinitis, was responsible for absorption of bone graft. The study was later published in the well-known Journal the JLO
Management of saddle nose deformity in atrophic rhinitis, Brajendra Baser (a1), D. S. Grewal (a1) and N. L. Hiranandani (, The Journal of Laryngology & Otology ,May 1990, pp 404-407
Jack Sheen from the USA published a 2 volume book on Rhinoplasty and it was the best book available on Rhinoplasty at that time, he introduced several revolutionary concepts including the spreader grafts (now so widely practised). I was deeply impressed with the book and even though it was very expensive for my salary as a lecturer in a municipal hospital I bought it and used to read it like a bible. It taught me use of spreader grafts in Rhinoplasty and use of Conchal cartilage for dorsal augmentation, both techniques worked very well and I used them in a large number of cases.
Rhinoplasty patient from Muscat: One of the senior practising ENT surgeons referred me to a patient from Muscat (Indian working in Muscat). I used conchal cartilage, and to my and his bad luck he developed perichondritis. I had a tough time in managing his perichondritis - with i.v antibiotics and local dressings it took 2 weeks. The patient, understandably, was not very happy with this complication. Later on he went back to Muscat, 6 months later I wrote him to send his pictures, he obliged me sent his pictures but wrote a note, “Doctor I am happy with my nose, but cannot pardon you the way you screwed my ear” (This was my first and last case of Perichondritis as after that in every case I took extra precautions.
Lastly we end it on a happy note and a reminder to Rhinoplasty surgeons about cultural sensitivity.
All the stories we told you are old but this is only about 3 years ago - I saw a patient from Qatar in my Baharin clinic with a large hump with a crooked nose. We posted him for surgery the next day but his father called me outside and in broken English he told me, “I know you will do a good nose job, but just a request don’t make his nose too flat, please don’t take out the Arab from his nose.” I understood that he wanted to preserve his ethinic identity, did a septo-rhinoplasty, but did not remove the hump aggressively preserving a small prominence of the dorsum.
3 months ago the patient came for follow-up. He was very happy and brought a cousin for Rhinoplasty whose operation we scheduled for my next visit. While I was coming back to Mumbai, he met me in the lounge looking very elegant in the white Arabic dress, he came to me and presented a small gift when I told him why he said, “This is for preserving my ethnicity.”
That’s all for now some more stories in the 3rd Blog post