Monthly Archives: August 2009

Modifying The Tip Of The Nose Gives The Beverly Hills Rhinoplasty Look

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Modifying The Tip Of The Nose Gives The Beverly Hills Rhinoplasty Look

The classic Beverly Hills rhinoplasty look is a natural look.  The tip should never look unusual, asymmetrical, pinched, overdone or in any way suggesting that this nose is not the one that the owner was born with.

Now, there are several techniques that each surgeon should have in his toolbox to address the specific problems.  The most common problem is the tip is too bulbous or bulky or too plump.  Generally, this can be addressed by making the incision on the inside of the nostril along the dome of the cartilage which comprises the major portion of the tip and removing a portion of that cartilage along with the attached lining skin.  This will allow, as healing takes place, for the tip of the nose to refine and narrow.  As with all aspects of nasal surgery, but particularly in the tip, the process of narrowing, shrinking or tightening towards the ultimate results takes several months.  Not that one does not look good in 7 to 10 to 14 days, but one will look better with the passage of time.

For some people with very thick skin and an ultrabulbous tip, it is often necessary to perform a slightly different maneuver.  A surgeon executes what is know as the “delivery” technique by which through two parallel incisions within the nostril, the cartilage is actually brought out of the nose. While still attached, it is modified to make it thinner and less spring-like.  Then the smaller cartilages are returned back to their bed and the incisions closed.  This technique is commonly used if there also has been previous surgery and the surgeon is not certain exactly as to what maneuvers were performed in the original rhinoplasty procedure.

When all incisions are internal and invisible, the technique is called closed rhinoplasty. Some surgeons prefer to approach the tip of the nose using an open rhinoplasty method.  The open rhinoplasty involves in addition to the usual incisions inside the nostril, a horizontal incision connecting the two nostril openings halfway between the lip and the tip.  Typically this incision heals well wit minimal visibility.

What is a “Liquid Facelift” in Beverly Hills?

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What is a “Liquid Facelift” in Beverly Hills?

 

The advent of the various injectable filling products which began with collagen and evolved to Juvéderm, Restylane, Perlane, Artefill and Sculptra has spawned a change in concept of facial rejuvenation.  In addition to these FDA-improved skin fillers, there is Botox and now Dysport which are not fillers, but which have a place in rejuvenation of the face by reduction of wrinkles and even reversing the stippled appearance that some chins have because of continual muscle contraction.

Frankly, “liquid facelift” is somewhat of a misnomer because in fact there is no lifting or elevation of the sagging tissues which occurs with age, but rather a plumping.  Now, plumping is not bad.  We need plumping because as we age there is shrinkage of the fat underneath the skin which begins around the mouth and then later occurs around the eyes and cheeks.  Likewise, plumping is good for those who have a rather thin lip and wish to have the lip look a little fuller, which is generally desirable. 

Reduction of wrinkles, improvement of creases, folds and restoration of natural curved facial contours all do help provide improvement to the face.  However, one should not believe that these are substitutes for certain surgical procedures.  For example, one of the earliest signs of aging for most people is in the jaw and neck.  None of these “liquid facelift” substances can help the gravity-driven sag which creates jowls that hang down below the jaw bone and the double chin or vertical bands in the neck.  These will require surgery.  In fact, most of the photo examples that one sees on the manufacturer’s web sites are of younger people who are not old enough to show the ravages of the gravity induced jowling and neck sagging.

However, the nice thing about these products is they are low risk.  Because they are temporary, if one does not like the look or appearance, there is no cause for alarm because they will disappear within some period of time.

We recommend that patients consider fillers and Botox or Dysport often as an adjunct to blepharoplasty, either upper blepharoplasty or lower blepharoplasty.  Likewise, as the “frosting on the cake” after a neck sculpture or face and neck lift.

Why A Non Surgical Nose Job Is Often Preferred By Beverly Hills Rhinoplasty Patients

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Why Non Surgical Nose Job Is Often Preferred By Beverly Hills Rhinoplasty Patients

Oftentimes, a patient comes to Beverly Hills to have corrective surgery after an unhappy experience with one or more previous rhinoplasty surgeries.  Often part of the problem is a deviated septum.  Sometimes the septum is deviated causing crookedness and diminished airflow.  Or, the problem is that the tip is too bulbous or asymmetrical. The tip is too narrow and asymmetrical or the bridge may be too low or asymmetrical because the nasal bones were not properly corrected.   In any event, often while surgery is feasible, it is not always the optimal treatment. 

Surgery is sometimes necessary.  However, there are many circumstances where patients have had surgery and perhaps they might have been satisfied by non-surgical means.  The most practical answer for many patients is a series of filling injections.   Filling injections are using either temporary or permanent fillers in the office under a topical skin anesthetic.  Fillers raise depressed areas and correct asymmetries.  Some patients are amazed when they are told that they do not necessarily have to have another operation, particularly those who have had three or four previous rhinoplasty surgeries.  The prospect of having yet another surgery with again the possibility of an uncertain outcome is not very palatable.  But hearing that the office treatment can be done and that the patient can participate by judging the results of each of the series of injections is very attractive and practical.

The cost is less, there is no time off work, and that is why for many patients, filling injections – not surgery -  is preferable.

Deviated Septum in Beverly Hills

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Deviated Septum in Beverly Hills

We see many patients who come to us who are unhappy with their breathing.  Now, ours is not a typical “plastic surgery” practice.  First, of course, we only operate on the face and neck.  Secondly, 70% of the practice is devoted to nose surgery.  My background is a head and neck (ear, nose and throat) specialist and my additional formal training in cosmetic, plastic and reconstructive surgery of the nose plus my military experience gives me comfort in limiting my practice so narrowly and majoring in nasal surgery, including rhinoplasty, revision rhinoplasty, correction broken nose, nasal septoplasty and turbinate resection.

Patients do come to Beverly Hills because their sense, and it is usually correct, is that the most sophisticated superspecialists practice here.   We see patients with problems of a deviated septum because they have either had previously unsuccessful surgery or, in fact, had a rhinoplasty surgery and never had the problem of the crooked nose or the breathing addressed.  Typically when there is a deviated nasal septum, there will be in addition to a breathing difficulty, a high percentage of patients who also have crookedness to the nose.

The significance to the patient is that if you have trouble breathing and your nose is crooked, you will have to have surgery on that deviated nasal septum to achieve an optimal result.

Beverly Hills Before and After Photos Will Help You Decide On Rhinoplasty Surgery?

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Will Viewing Before and After Photos Help You Decide Whether Or Not You Should Have Your Revision Rhinoplasty in Beverly Hills?

The purpose of the consultation with the cosmetic surgeon is to learn more.  One of the most valuable components of that visit is the chance to view a large number of typical “before and after” examples.  The primary reason for some people’s post-surgical remorse and the need to come to Beverly Hills for revisional surgery is the original failure to study the first doctor’s work.   You need to get a sense of his art form, his style and his results.  Photographs offer an impression of that particular surgeon’s idea of reasonable improvement.   They also help give you, the patient, a grasp of the realistic results of your rhinoplasty.

I am often amazed when I learn of people who have been disappointed with their cosmetic surgery and when asked:  “Did you see the doctor’s work before?  Did you see a lot of before and after photographic examples of his work?”  They answer:  “No, I didn’t.  I asked the doctor for before and after pictures but the doctor said he didn’t have any for me to look at,” or the reply is:   “Well, he only had a couple to show me.”

That was a tip-off that they were not dealing with a rhinoplasty superspecialist.  A surgeon whose practice is focused on rhinoplasty will have dozens of examples to show you and you should be able to see within those examples a case study similar to yours.

What is the “Kotler Rhinoplasty” in Beverly Hills?

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What is the “Kotler Rhinoplasty” in Beverly Hills?

Interestingly, I never created the term “Kotler Rhinoplasty”. A patient did.
But, I like it.

The young woman, who did quite a bit of on-line research regarding the procedure and choice of surgeon, shared some thoughts with us:

“When I looked at your dozens of website photos of rhinoplasty patients, I came to the realization that there was a consistency. The consistency – a good one – was that there was NO CONSISTENCY of appearance. Each patient had very much a customized result. No cookie-cutter nose jobs there”, she wrote.

“When I visited other sites, I felt embarrassed for some of these doctors whose results were not very good and yet here they were being shown to prospective patients. For the most part, they looked
“done”, artificial and unnatural.
  
What I decided to term the ‘Kotler Rhinoplasty’ was a nose that looked as though the patient could have been born with it. That, to me, is what great rhinoplasty surgery is all about. The patients’ noses wore no sign or placard announcing a nose job.”

I appreciated reading this young lady’s comments. It does embody our approach to cosmetic nasal surgery that has been in effect for the 38 years I have been performing nasal surgery; over 4000 cases.

For the understanding of what patients want and for the education and training by which natural and satisfactory results can be delivered to happy patients, I thank my teachers.

Searching For Rhinoplasty Information in Beverly Hills?

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Searching For Rhinoplasty Information in Beverly Hills?

There are several ways that one can get up to speed about rhinoplasty or cosmetic plastic nasal surgery. One source, of course, is to read books on the subject. I am partial to SECRETS OF A BEVERLY HILLS COSMETIC SURGEON because I wrote it. I also like its sequel, THE ESSENTIAL COSMETIC SURGERY COMPANION, but there are other good books.

Among the best of the cosmetic surgery books are The Bevelry Hills Shape by another and mighty superspecialist, Stuart Linder, MD. The Smart Woman’s Guide to Plastic Surgery is quite good. Cosmetic Surgery Without Fear by Patricia Burgess and What Your Doctor Can’t Tell You About Cosmetic Surgery by Joyce Nash are both very consumer oriented and very “ matter of fact”.

The internet, of course, remains a very rich source of education. However, it takes quite a bit of time and effort to weed through much of the information since the sources of the information being posted vary in knowledge, experience and particularly degree of specialization. I always favor articles or blogs written by superspecialist cosmetic surgeons since these are the people at the top of the totem pole in terms of their education, training, experience and practice focus.

Now, I will share some advice with respect to how to get the most information from the internet. I would suggest that you use the following core search terms: rhinoplasty, septoplasty, secondary rhinoplasty, nonsurgical nose job.

If you have need for consultation regarding improving upon a previously performed rhinoplasty, use the following search terms: revision rhinoplasty specialist, secondary rhinoplasty, revision rhinoplasty doctor. Incidentally, I mentioned nasal septoplasty. A septoplasty is an internal nasal procedure which often but not necessarily accompanies cosmetic nasal surgery. The reason why it is important to understand the role of a septoplasty is that if one has a breathing problem, then undoubtedly, the examining doctor must look to determine if there is a deviated nasal septum. That may come from an accident or one may be born with it. The nasal septum is that vertical partition that separates the two nasal passages. If it is crooked or injured, it often assumes an S-shaped curvature and impedes the airflow.

Also study turbinates. Turbinates are normal structures within the nose that help to humidify, moisturize and filter the incoming air. Particularly in allergic patients they become large and contribute to a blocked nose.

The reason why I mention these terms is that often it is wise to have improvement in breathing done at the same time as a rhinoplasty. Therefore, having a nasal septoplasty and turbinate reduction in addition to the rhinoplasty makes sense in terms of economy of time and even dollars.

Addressing A Twisted Nose Is A Common Occurrence

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Addressing a Twisted Nose is a Common Occurrence
for this Beverly Hills Rhinoplasty Specialist

Addressing a twisted nose is a daily event for this Beverly Hills rhinoplasty specialist. Twisted noses are very common, particularly in men as a result of athletic injuries. A twisted nose is generally due to a deviation of the nasal septum. A deviated nasal septum is a consequence of an injury which has detached the septum from its normal internal attachments and made it bowed or crooked. Sometimes it is even S-shaped. This twisted look can exist whether or not the nasal bones have been broken. If they have, the twist will be even worse and that requires surgery on the nasal bones.

The major culprit in the twisted nose, including the tip leaning to one side or the nostrils appearing asymmetrical, is that deviated septum. The crookedness corrected by a strictly internal procedure that seeks to reattach the septum to its proper attachments or even remove a bent portion which is causing the crookedness. Sometimes it is difficult to make the nose perfectly straight because the cartilage has a “memory,” but in almost all cases, there is significant improvement in breathing. Typically at the same time, enlarged turbinates are also reduced further improving the airway.

If one wishes to have a cosmetic plastic surgery or rhinoplasty performed, that can be done also. Often, the best strategy is to have all the issues corrected at the same time rather than submit to two separate surgeries.

Collapsed Rhinoplasty Nose Is Avoidable, Also Fixable in Beverly Hills

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Collapsed Rhinoplasty Nose Is Avoidable,

Also Fixable in Beverly Hills 

Collapsed rhinoplasty is where the bridge has been lowered so much either by radical take-down. Or the internal support, the septum which was crooked, has been weakened so much that the buttress supporting the bridge has been inadequate and there is a large dip or “saddle” deformity.  It is avoidable if the surgeon does the operation carefully and incrementally.   Shaving down the bridge, a sliver at a time, helps prevent that problem.  Likewise, when performing correction of the deviated nasal septum, one needs to constantly assess how strong the upper margin of the septum is and be wary not to remove too much of the higher septum that supports the bridge of the nose.

If the patient has a result which demonstrates a collapsed nose, it can be fixed.  There are three techniques.  One is to place a preformed plastic part or prosthesis under the skin to fill the “dip.”  The second is using the patient’s own cartilage from the internal nose and external ear.   And third, to use filling injections to raise the bridge to the point that it is satisfactory for the patient.

I recommend the patient consult very carefully before making a final decision about the preferred technique.