Editorial note: This is a lightly edited transcript of the episode. Minor edits have been made for readability, grammar, and clarity while keeping Dr. Garcia’s conversational voice, phrasing, and substance. This episode features Dr. Garcia as the sole primary speaker.
Dr. Roberto Garcia: You’re listening to The Confident Choice podcast with me, Dr. Roberto Garcia, a double board-certified facial plastic and reconstructive surgeon. Honest conversations and expert advice about the decisions that make you feel your best.
Welcome, everybody, to Season 2, Episode 5 of The Confident Choice. I’m your host, Dr. Roberto Garcia. Today we’re going to talk about something that truly impassions me. I wanted to get into some of the procedures that we mostly do in a little bit more detail—not to get too granular because it’s not supposed to be a scientific podcast—but I do want to get into the parts of rhinoplasty that I feel are important as you’re gaining information in order to eventually make it to a consult and then eventually have surgery, hopefully with a double board-certified facial plastic surgeon.
Dr. Roberto Garcia: There is something very important when we talk about facial plastic surgery. When the American Board of Facial Plastic Surgery was being created, there was a big lawsuit—I think we talked about that in one of the podcasts with my brother, briefly—about the “Skin Mill” case.
One of the reasons otolaryngologists, or ENTs, won that landmark case against the general plastic surgeons who were trying to limit their practice of facial plastic surgery was because it was really shown that otolaryngologists had more focus and attention in facial issues than the general plastic surgeon.
For instance, otolaryngologists, or head and neck surgeons, had more knowledge about brow lifting and eyelid surgery because of their work with craniofacial flaps and osteoplastic flaps, and with access to orbital rim fractures and trauma in the periocular area.
Then, when the discussion came about the nose, we were doing nasal surgery all through residency. It may have been straightening a septum, which is that central partition between the sides of the nose, or it might have been sinus surgery, where you have to have an absolute, very intricate fund of knowledge about nasal anatomy and physiology in order to perform sinus surgery.
It’s a very complicated surgery, and we did probably a thousand of those cases in our residency. When I graduated from my residency in Syracuse, I had to tally up how many cases I had done. I did 4,900 surgeries in four years of just ENT—ENT, facial plastics, otology, pediatric ENT, sinus surgery, laryngology, and head and neck surgery.
That was a lot of time in one area. When I graduated and went to do my fellowship, I was so used to working in the deepest, darkest parts of the human skull that all of a sudden I thought, ‘Wait a minute, I’m just working underneath the muscles here of the face. This is pretty cool. I can do this.’
Dr. Roberto Garcia: Programs around the country started entrusting facial plastics fellowships, as part of otolaryngology residencies, to do all the plastics of the face. So now, in today’s world, you can go to see a general plastic surgeon and maybe they’re doing breast surgery, abdominal plastic surgery, or liposuction. More than likely, they’re not doing enough faces.
I do more faces in a week than most of these surgeons do in a couple of months. There comes that level of years of repeatable execution and experience that really plays a factor in how you become a good rhinoplasty surgeon.
Dr. Roberto Garcia: I remember a guy named Howie Simons. Howie Simons was a trauma surgeon in Syracuse. For those of you from Syracuse who are listening to this, you’ll remember him. The guy was a genius. He was a great trauma surgeon. He had written a book about life in residency.
During my chief year, when I was already matched for fellowship in facial plastics, he said, ‘Hey, so I heard you’re going into facial plastics.’ I said, ‘Yeah.’ And he goes, ‘You like rhinoplasty?’ I said, ‘I love rhinoplasty.’ He goes, ‘Good, because you’re not going to understand it for 15 years.’
I thought, ‘What does this guy know?’ But, lo and behold, as time goes on and I’ve gone to these meetings over the years, you hear these older, seasoned rhinoplasty surgeons, guys who are on the front lines of rhinoplasty, and they all say the same thing: rhinoplasty is one of these thinking surgeries.
You have to have seen the ramifications of what that move you’re about to do can have, how it can affect the nose ten different ways in different types of skin and cartilage. That only comes with time and experience.
Over the years, I’ve developed techniques based upon how my hands can execute a result. I can’t get another surgeon to come in here and look at my technique and say, ‘Oh, I’m going to do the same thing that Roberto did.’ You’re probably going to get a different result because my hands will create a different technique than yours will. That’s just the way rhinoplasty is.
Rhinoplasty, or nasal surgery, is really confined to such a small part of the face. It’s so intricate that any little twist or tweak that doesn’t go right is very visible.
Dr. Roberto Garcia: We look at these noses from a functional versus a cosmetic route. There are two ways that you can address the nose.
The nose is basically composed of two paired nasal bones. There are two cartilages called your upper lateral cartilages, which, together with the septum, make a V. They control airway flow. Then there are two cartilages on the tip of the nose called your lower lateral cartilages.
The septum divides the nose into left and right. The front of the septum is cartilage; the back of it is bone.
Ninety percent of people over the age of 50 are going to have some kind of a deviated septum. Because the bone is so thin, at some point you’ve bumped it or cracked it. I can almost always find a deviated or crooked septum, even in a person who is completely asymptomatic and is not having trouble breathing.
Those are the things that a specialist in my field looks for. I can straighten out the functional component as well as the cosmetic component.
Dr. Roberto Garcia: I’m constantly looking at the give and take within the surgery. I want to make sure that I’m giving this patient an aesthetically balanced nose that fits their face, and that’s a critical thing.
A properly done rhinoplasty—you should never see the rhinoplasty. A properly done rhinoplasty means that you see other features of the face except the nose. Everything just kind of falls in.
That’s kind of what we were talking about with Lisa a few weeks ago: facial balance and harmony. You want everything to just kind of blend in as if it’s supposed to be together. What you’re doing is taking that negative attention off of that ill-appearing nose and balancing it with everything else so that other features of the face are able to stand out and draw more attraction.
Dr. Roberto Garcia: When we talk about the results our patients are able to achieve, I feel like realistic expectations are a big part of my consultation process.
Even though I sit with a patient, talk to them, go over the details of the surgery, and then use our VECTRA three-dimensional analysis program to kind of draw out a nose that would fit that patient, I still feel that a big part of it is establishing real expectations.
You have patients that come to me from all over the place. They look at our before-and-afters and say, ‘I want that nose.’
Well, you can’t have that nose because that nose is made for that face. I can balance your nose with your face, but if I put that nose on your face, it’s going to look completely unnatural.
So I’ve got to kind of talk patients down a lot of times and say, ‘Hey, listen. That’s not what’s best for you.’
Dr. Roberto Garcia: I just saw a consult about 20 minutes ago before we started this podcast. A guy came in and said, ‘I’m having a significant problem breathing. I got in a lot of bar fights. I used to be a boxer in the Marines. I was a firefighter. I broke my nose a hundred times.’
He said, ‘While I’m here, I’m thinking about maybe fixing the outside of my nose.’
I said, ‘Well, really, does it bother you, the outside?’
He goes, ‘No, I think it looks fine.’
I said, ‘So do I.’
And he goes, ‘Can we fix the inside?’
I said, ‘Yeah, we can fix the inside, but don’t mess with things that aren’t really impacting your life.’
That’s a critical part of this specialty overall. Surgeons spend their lives recommending surgeries to people that are necessary—excuse me, that are not necessary. And so I spend more time talking people off the ledge.
As I’ve gotten older, I talk more people off the ledge than I encourage them to do surgery. Isn’t that crazy?
Sometimes I go overboard a little bit. I get it. I’m sorry.
Dr. Roberto Garcia: The last thing I want to get to is the process.
Everybody hears the phrase, ‘Trust the process.’ Trust the process. As I get older, I understand more what ‘trust the process’ means. You’ve heard that before, haven’t you?
The phrase really falls true in rhinoplasty more than any other surgery because you can’t fathom how long it takes for a nose to heal.
I will take my first set of pictures at two months. Don’t get me wrong, when we take the cast or the splints off in a week, you already see a big difference. It already looks great.
But then, man, the nose takes many more months to really get into this place where it’s settled. It just takes a long time because the lymphatic drainage of the nose is poor, and so it takes so long for it to really get into the normality of the face.
It’s so important, particularly with this surgery, that you really trust the process and you have that level of patience.
Dr. Roberto Garcia: I want to close today with a very important, I think very moving, story.
My dad died last year. My dad came from Cuba, but there’s a very interesting story of how he got here. I feel like we’ve been talking about him all this time, telling all these stories, but no one really knows who he is.
In 1958, my dad was on the Cuban National Rowing Team. They were invited to the Pan-American Games in Chicago to row prior to the Olympic Games. They were slated to go to the 1960 Olympic Games in Rome.
The way my father told me the story, they got back from the Pan-American Games and the Cuban Revolution was beginning in the mountains of eastern Cuba, an area called Oriente.
This was Castro’s revolution, which was going to bring independence from the dictatorship of Fulgencio Batista, the dictator of Cuba. There was a police state, basically, and they started this revolution in the mountains.
My father and his friends, his rowing buddies, were coming back. They were back in Cuba and doing an exhibition. My father goes up to one of the women paramilitaries for the revolutionary battalion, and they all had AK-47s issued by the Soviet army.
My dad said something to her as a joke. The joke turned sour. They got him and the other guys, and they ended up putting them up on a firing squad.
He was 17 at this point. As they were about to be shot, the colonel who knew the coach and knew my dad actually saw what was going on and stopped it. My father was let go.
He went back home and started in university. He always kind of knew what the revolutionary movement was about, so he fought fervently against it. He got thrown in jail, got beaten up, and they let him back out.
Finally, my grandfather, who had been an ex-police officer in Batista’s police force, told my father, ‘If they catch you again, they’re going to kill you.’
This was in the summer of 1960. Castro had now been in power for a year and a half.
My father was six-foot-three, blonde with blue eyes, and had a flat top. He was an athlete, and he stood out like a sore thumb.
My grandfather said, ‘I want you to go to the embassy in Havana. You can take this airplane ticket that I have for you. Here’s $100, and I want you to go to the embassy. Go fly to New York City. I have family there, and this revolution is not going to last. You’ll be able to come back.’
My father said fine. He went to a van and was sitting outside the American embassy, which is a block—a square block. He was sitting at a little outside tent area having a drink, and he noticed that the revolutionary police, or Castro’s police, were walking around picking people out of line because they were still on Cuban soil. They weren’t yet in the embassy.
My father did the calculation. He said, ‘They know what I look like. If I stand in line, they’re going to pluck me like that.’
So he decided not to do that. He saw Americans wearing black suits and sunglasses with briefcases walking up the side of the building. They would just nod to the security guard and walk right up.
My dad said, ‘I’m going to try that out.’
He went to a secondhand shop. He bought a black suit, sunglasses, a suitcase—everything he had except $7. He put $7 into the toe of his shoe and walked right up, hoping they wouldn’t say a word to him because he didn’t know any English.
He walked up, nodded his head, they nodded, and he got into the American embassy. Now he was on American soil, but he still had to get off the island.
The next day he went to the airport, and the Cuban revolutionaries started questioning him as to why he was going to the United States. He said, ‘I’m going to study engineering so I can defeat those imperialist bastards,’ and they said, ‘Okay, perfect.’
They took him into this room called the “Bera,” which means fishbowl. It’s a giant room that’s all glass-enclosed. They took all his clothes off, all the way down to his shoes and socks.
The tactic they used was to put you in such a level of angst and anxiety that you were willing to talk more. They kept asking the same question, and he kept saying the same thing.
Meanwhile, he was sitting there watching the plane with the propellers cranking up, and he was saying to himself, ‘If I don’t get on that plane, by the time the next plane is to leave tomorrow, they’re going to put two and two together. They’re going to know who I am and I’m dead.’
The whole time he was praying. Remember, he wasn’t a very religious person. He was spiritual, but he wasn’t religious.
Somehow, they let him go. He got on the plane and got to the United States with nothing but $7 in his shoe.
Dr. Roberto Garcia: He started that way. He studied English in Georgia—Douglas, Georgia. He learned English from a lady, Mrs. Lott. He then went to the University of Florida to study engineering. Eventually, he got married to my mom there. He met my mom, went to Puerto Rico, my brother and sister were born there, he worked as an engineer there, and then he went to study medicine in Spain. I was born there. And the rest is history.
Dr. Roberto Garcia: One thing I wanted to say is quiet discipline. That was one of the things my dad always practiced.
He never really said, ‘Do this, do this, do this.’ He was almost always, ‘Watch me, watch me, watch me.’
He had this quiet discipline. Nothing really phased him. He always could solve the problem.
For you young men who are listening to this, become fearless, disciplined problem-solvers. Become individuals that people can come to when they’re in a pickle and they don’t know anywhere else to go, and you’re their solution.
The only way that you can acquire that talent is if you have that quiet discipline. When a problem comes to you, you’re pensive about it. You think about it, you digest it, and then you come up with a proper solution.
I think that’s a good lesson that we need to take today from my dad. I hope some of you will take that story home and maybe begin to appreciate a little bit more the beauties of this country.
We’re not perfect. We’re far from being perfect. But, like a guy in medical school told me, we’re the least screwed up in the world.
Dr. Roberto Garcia: Next week we have a very special guest, Catherine Turner, a very dear friend of mine. I’ve known her for many years. In fact, I met her when Eva, my youngest, was a month old, and I have a picture of her carrying her. Isn’t that crazy?
Her and her husband Ron will be here. They’re fantastic people. We’re going to be talking about some of the myths associated with facelift surgery—when’s the right time to do something, when’s the right time to get involved.
She was one of those classic examples of an individual who did something a little bit earlier in life—not too young, but young enough to where it just gave it that distance of results.
Dr. Roberto Garcia: So I’m going to end our fifth episode of Season 2. This is so exciting. We’ll end with our sign-off.
Good decisions come from good information, guys.
Thank you very much. God bless you, and we’ll see you next week.
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