Episode 22 – Bilateral Cleft Rhinoplasty: Rebuilding Nasal Projection

In this episode of Doctor Dan Behind the Scalpel, Dr Dan Robinson explores bilateral cleft rhinoplasty, one of the most technically challenging procedures in facial plastic surgery.

While bilateral cleft rhinoplasty is an extremely complex operation, Dr Dan explains why it can paradoxically be somewhat easier than unilateral cleft rhinoplasty.

The central challenge is restoring nasal projection. Understanding this fundamental issue is essential to achieving a successful reconstruction.

Dr Dan discusses his surgical approach, including the use of rib cartilage, extensive septal reconstruction and the challenges of establishing a stable structural foundation.

Topics covered:

• Why bilateral cleft rhinoplasty differs from unilateral cleft reconstruction
• The importance of restoring nasal tip projection
• The role of rib cartilage and complete septal reconstruction
• Extended spreader grafts and nasal bone osteotomies
• The challenge of finding a reliable anchoring point on the premaxilla
• Large septal replacement grafts, extension techniques and tensioning

Key takeaway: Successful bilateral cleft rhinoplasty depends on restoring adequate nasal projection through robust structural reconstruction. Understanding the anatomy, establishing stable support and using advanced grafting techniques are fundamental to achieving a successful result.

Show notes

Cleft palate rhinoplasty is one of the most technically demanding operations in rhinoplasty — and one of Dr Dan’s favourites. In this episode, he explains why these cases require extensive rhinoplasty experience, how unilateral and bilateral cleft deformities differ, and why reconstructing a stable septal framework is central to his approach.

The discussion focuses particularly on unilateral cleft rhinoplasty: the potential need for rib cartilage, complete removal of existing structural components where appropriate, osteotomies, and a substantial septal replacement graft rather than relying on a simple extension graft. Dr Dan also discusses the limitations of tensioning, his strong opposition to primary alar base reduction on the cleft side, and selective premaxillary augmentation.

These are the surgeon’s clinical views and operative preferences, rather than universal treatment rules. Individual anatomy and prior treatment determine surgical planning.

Key topics

Why cleft rhinoplasty is exceptionally difficult

Unilateral versus bilateral cleft nasal deformity

Rib cartilage and rebuilding structural support

Full explantation, osteotomies and the limitations of tensioning

Large septal replacement grafts versus extension grafts

Why Dr Dan avoids alar base reduction in primary unilateral cases

When cleft-side premaxillary augmentation may be considered

In this episode of Doctor Dan Behind the Scalpel, Dr Dan Robinson explores the relationship between nasal breathing, athletic performance and recovery.

Drawing on his experience treating elite athletes, including Troy Herfoss and Olympic swimmers, Dr Dan discusses how functional rhinoplasty may improve breathing, sleep quality and the ability to recover from demanding training sessions.

He also shares observations from a small, exploratory VO₂ max assessment, including why improvements in perceived performance don't always translate into measurable increases in aerobic capacity.

Topics covered:

· How nasal obstruction may affect exercise and recovery

· The potential benefits of improved nasal breathing during sleep

· Experiences of elite athletes following functional rhinoplasty

· Observations about VO₂ max and exercise tolerance

· Special considerations when operating on professional athletes

Key takeaway: Improved nasal breathing may offer meaningful benefits to sleep, recovery and perceived athletic performance, although stronger clinical evidence is needed to establish direct performance benefits.

Episode 19 – Podcast Show Notes

🎙️ Dr Dan Behind the Scalpel – Episode: The Roman Nose

The Roman nose is one of the classic nasal shapes that patients may seek rhinoplasty to address. Characterised by a prominent dorsal hump and a long, downward-pointing nasal tip, a Roman nose can make patients feel that their nose is too large or prominent for their face.

In this episode, Dr Dan explains what causes a Roman nose, why it often runs in families, and the structural changes that contribute to its distinctive appearance.

He also discusses the complexities involved in correcting a Roman nose, including hump reduction, nasal bone restructuring, rebuilding the middle third, managing tip position and addressing the nasal valve to ensure that both the appearance and function of the nose are considered.

🔎 What You’ll Learn in This Episode:

• What is meant by a “Roman nose”.

• The key features that characterise a Roman nose.

• Why a Roman nose can make the nose appear overly large or prominent.

• Why Roman noses often run in families.

• How overgrowth of the septal cartilage contributes to the appearance.

• How a large dorsal hump and tip ptosis develop.

• What columella show and a long alar can have to do with nasal growth.

• Why skin thickness is an important consideration when correcting a Roman nose.

• The role of hump reduction and nasal bone restructuring.

• Why rebuilding the middle third of the nose is important.

• How spreader grafts and septal grafting may be used.

• Why tip position and projection need to be carefully considered.

• Why some female patients may also require alar base reduction.

• How a Roman nose can be associated with nasal obstruction and nasal valve problems.

• Why addressing nasal function is an important part of Roman nose surgery.

• Why complex Roman nose surgery may benefit from an experienced rhinoplasty surgeon with a strong understanding of nasal valve anatomy.

🎙️ Dr Dan Behind the Scalpel – Episode: Saddle Nose Deformity After Previous Rhinoplasty

A saddle nose deformity doesn’t only occur following significant trauma. In some cases, it can develop after previous rhinoplasty surgery when too much structural support has been removed without adequate reconstruction.

In this episode, Dr Dan discusses saddle nose deformity following previous nasal surgery, including why the nose can gradually collapse months after an operation, the role of over-resection and inadequate structural support, and the less common complication of septal perforation.

Dr Dan also explains why timing can be critical when a saddle nose deformity is identified shortly after surgery, how early intervention may sometimes prevent a more complex reconstruction, and what happens when patients present months or years later with established scar tissue and skin contraction.

🔎 What You’ll Learn in This Episode:

• What causes a saddle nose deformity following previous rhinoplasty.

• How over-resection of the nasal dorsum can contribute to structural collapse.

• Why the middle third of the nose needs adequate structural support.

• Why a saddle nose deformity may not become obvious immediately after surgery.

• How septal perforation can contribute to loss of nasal support.

• Why the timing of revision surgery can be critical.

• When early intervention may be possible following a previous rhinoplasty.

• Why scar tissue and contracture can make delayed reconstruction more complex.

• How skin stretching may be used in selected patients.

• Why hydrodissection may sometimes be required in severe cases.

• When hyperbaric oxygen therapy may be considered.

• Why rib cartilage may be required for complex saddle nose reconstruction.

• How extended spreader grafts can restore support to the middle third.

• How fascia and crushed cartilage may be used for camouflage and contouring.

• Why complex revision rhinoplasty requires specialised experience.

Dr Dan Behind the Scalpel – Episode: Traumatic Saddle Nose Deformity

A saddle nose deformity is one of the more complex problems that can occur following significant trauma to the nose. In this episode, Dr Dan discusses what a traumatic saddle nose deformity is, how it develops, and the functional and cosmetic concerns it can cause.

From contact sports injuries to major accidents, severe trauma can disrupt the nasal septum and nasal bones, resulting in a loss of structural support and a characteristic collapse of the middle third of the nose.

Dr Dan explains when it may be appropriate to consider surgery, why ongoing participation in contact sports can influence the timing of reconstruction, and the complex techniques and grafting required to rebuild the structure and projection of the nose.

🔎 What You’ll Learn in This Episode:

• What a saddle nose deformity is.

• How trauma can cause collapse of the middle third of the nose.

• How severe trauma can also affect the nasal bones.

• Why traumatic saddle nose deformities can cause significant nasal obstruction.

• The cosmetic concerns patients may experience following a traumatic injury.

• How a saddle nose deformity can affect wearing glasses.

• Why participation in contact sports can influence the timing of surgery.

• The importance of risk mitigation following reconstruction.

• Why saddle nose reconstruction is a complex rhinoplasty procedure.

• Why rib cartilage grafting may be required to rebuild the nose.

• The role of fascia grafts in camouflage and reconstruction.

• How skin contraction can affect patients with previous compound fractures.

• Why patients may need to prepare the skin before surgery.

• How structural grafts are used to support and reconstruct the middle third of the nose.

• Why patients with traumatic saddle nose deformities should seek a surgeon with extensive rhinoplasty experience.

You’ve had your rhinoplasty—now what?

The post-operative period is one of the most important parts of the rhinoplasty journey, and it’s also when patients often have the most questions. In this episode, Dr Dan takes you through what to expect after surgery, from waking up in recovery and managing pain and congestion, through to your first post-operative appointment and the months that follow.

He explains the importance of pain relief, saline nasal washes, medications and proper wound care, as well as when patients can return to exercise and other activities. Dr Dan also discusses common concerns during recovery, including nasal congestion, unpleasant smells, dissolving sutures, nose taping and differential swelling.

🔎 What You’ll Learn in This Episode:

• What to expect immediately after waking up from rhinoplasty surgery.

• Why Dr Dan does not routinely use nasal packing.

• Why staying on top of your pain relief is important during early recovery.

• How and when to use saline nasal washes.

• The role of antibiotics, steroids and Clorsig ointment after surgery.

• How to sleep comfortably during the first week.

• What to expect between day 2 and your first post-operative appointment.

• What happens when your external and internal splints are removed.

• When you can safely return to exercise.

• What is normal during the first 8–10 weeks after surgery.

• What to do if you notice an unpleasant smell inside your nose.

• Dr Dan’s approach to nose taping.

• When you can return to Botox, laser and heavy microdermabrasion.

• When steroid injections may be considered.

• How nasal massage may help manage areas of differential swelling.

Episode 15 – Podcast Show Notes

🎙️ Dr Dan Behind the Scalpel – Episode: Understanding Rhinoplasty Splints

Splints are one of the most talked-about parts of rhinoplasty recovery and one of the most misunderstood. In this episode, Dr Dan explains the purpose of both external and internal splints, why they are essential for healing, and how his customised approach helps achieve the best possible surgical outcomes.

He also discusses why he no longer uses traditional plaster casts, how customised internal splints differ from standard off-the-shelf options, and what patients can expect during the first week after surgery.

🔎 What You’ll Learn in This Episode:

• The difference between external and internal rhinoplasty splints.

• Why external splints are used to reduce swelling and protect the nose - not change its shape.

• Why Dr Dan prefers mouldable plastic splints over plaster casts.

• How customised internal splints help control swelling inside the nose.

• What it feels like to wear splints during recovery.

• How to care for your splints and keep them clean after surgery.

• What to expect when your splints are removed.

• When splints may need to remain in place for longer than one week.

🗝️ Key Notes

• Rhinoplasty recovery typically involves two types of splints:

– External splints (over the nose)

– Internal splints (inside the nose)

• External splints:

– Help reduce post-operative swelling.

– Protect the nose from accidental bumps during the early healing phase.

– Do not reshape or structurally change the nose.

– Are typically worn for 5–10 days and may naturally fall off without affecting the surgical result.

• Dr Dan uses mouldable plastic splints rather than plaster of Paris because:

– They provide excellent protection and swelling control.

– They avoid the potential risks associated with plaster.

– They are easier to customise to each patient.