Category Archives: Nose Surgery

Nose Jobs for Teens: Summer is The Time

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"A happy teen boy sits with his school books and chats on his cell phone"

After Rhinoplasty

While many teens are now high school grads, some are saying “no more school, no more books, no more teachers’ dirty looks.”

Others are saying: “Doctor, can rhinoplasty make my nose look better?”

Many college grads also join in, thinking a better appearance can’t hurt chances of landing a choice job.

With the approach of summer vacation – and time for recovery from surgery – many older teens feel the time may be nigh for a procedure they have long wanted.

One recent patient recovering from a Beverly Hills rhinoplasty recalled that she was called “Miss Piggy” during  high school and requested, not a car for her 16th birthday, but a nose job.

But, alas, her facial growth was found to be incomplete so she had to wait a few years.

After she did have rhinoplasty, she wrote her plastic surgeon, profusely thanking him saying: “Dear Doctor; I still look like me, only much better!… My only regret is I did not do the surgery sooner… Much love, Ex-Miss Piggy!”

(Look at some  nose job before and after pictures.)

Unfortunately, there is no one formula for when teen rhinoplasty is appropriate. Cosmetic plastic surgeons must evaluate the teen’s state of physical and emotion growth and make sure the surgery is wanted for him-or-herself, not a social-climbing parent embarrassed by a child with an overly large or unattractive nose.

Hint: Even if your teen is not quite ready for surgery, ask your surgeon to take photos, anyhow. Another set of photos a year later will show how much the teen’s facial structure has changed.

According to the American Society for Aesthetic Plastic Surgery (ASAPS), rhinoplasty is O.K. when a nose has completed 90 percent of its growth. For girls, that can happen as early as 13 or 14; in boys, 15 or 16 in some cases.

The American Society of Plastic Surgeons (ASPS) reports 35,005 nose reshaping procedures performed on patients 13 to 19 during 2010.  It’s a procedure parents want done correctly the first time or else the patient will have to see a revision rhinoplasty specialist to repair the first procedure and make sure breathing is O.K.

Thus, it pays huge dividends in time, money and convenience to find a board-certified cosmetic plastic surgeon with many years of experience.

Sleep Apnea on the Rise

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Recently, the Health & Wellness section of the Los Angeles Times had two excellent articles that dealt with the problem of sleep apnea and snoring

According to the Los Angeles Times, “2% of women, or at least 4% of men, suffer from obstructive sleep apnea.”  If you are not familiar with sleep apnea, it is a condition “in which the airway collapses and blocks breathing for 30 seconds, or even up to a minute or two.  The brain senses that it isn’t receiving enough oxygen and sends a signal to the patient to wake.”

People with sleep apnea (apnea is translated as “without breath”), find themselves in an unsatisfactory and untenable situation because their sleep quality is poor.  Poor sleep quality can generate  a myriad of problems including sleepiness at work and leisure, and even possible elevations of blood pressure, and other imperfections in your normal bodily function.

Maybe there is a connection between the rise in obesity in the United States and sleep apnea.  The paper says, “the incident rises with age: experts estimate that it affects about 40% of people age 65 and older.”  What we are seeing in the United States is that older people tend to be heavier.  That is not good news on many fronts. 

The articles also points out that it’s not just about age.  The overweight issue is very significant.  Overweight patients have double the risk of sleep apnea according to Dr. Lawrence Epstein, of a sleep center chain in Massachusetts.  Incidentally, if you have ever seen kids with large tonsils and adenoids struggling to get breath when they are sleeping at night, which is not that uncommon, you have a clue as to what sleep apnea is like. 

The article pointed out that there are mechanical remedies available including the infamous CPAP (“Continuous Positive Airway Pressure”) device, which is a spaceman-like mask which affixes tightly and to the face, akin to a scuba mask.  An external electrical power source drives the air into the lungs under pressure at night.  It is not too pretty; but, it does provide relief for people. 

Other technical aids are dental mouth pieces, and even some of these external nasal breathing strips. 

I was a bit disappointed that the article did not discuss management of one of the key causes of sleep apnea – that is a blocked nose. Nasal obstruction.

More on that to follow because there is a huge pool of patients in the United States, and worldwide, whose problems can be helped with a veteran, venerable, and reliable one-hour surgical procedure – nasal septoplasty and turbinate resection, with or without rhinoplasty. 

~Robert Kotler, MD, FACS

 

 

Considering Rhinoplasty?

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CONSIDERING RHINOPLASTY?  BE SURE TO CHECK OUT YOUR CHIN ALSO.

Many people have rhinoplasty because they are not satisfied with their profile.  There might be a hump or the nose may project too far from the face.  The nose may be too long ; even  “so long” that it nearly touches your lip when you smile.  Most people do not see their profile and, rarely, can make the same objective judgment about their nose that they can about the width, which is visible from the front.  Often, photographs are what drive people to see us for consultation concerning their nose because, “Whoa, I saw what I look like from a side view, and I sure don’t like what I see.”

A complete consultation will include evaluation of the appearance of your nose in all views.  The wise cosmetic surgeon, or plastic surgeon, or facial plastic surgeon will also take into account the dimensions and position of the chin.  It is very important because often the nose appears unduly large because the rest of the face is not large enough.  In other words, there is a disproportion between the nose and the face based on how the other facial structures are formed and what their dimensions are.

The chin often needs to be augmented.  In other words, the profile is improved if the nose is made smaller, and the chin is made larger on the profile.  I am not talking about looking like Jay Leno.   But, I am suggesting, and in some people, just a very small increase in the forward projection of their chin will compliment the improvement in the nose and make the profile as good as possible.  At consultation, it is very important that all aspects of your appearance be considered.  Do not go in with a narrow-minded view of “I need a rhinoplasty.”  The point of consultation is for you to learn and understand what the anatomic issues are.  If the surgeon suggests that you consider a chin implant, do not take it as an insult, but, rather, that the surgeon is thinking about your entire face, and that is exactly what his mission should be.

 

Rhinoplasty Packing Anxiety

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After nasal surgery, cosmetic or reconstructive to improve nasal breathing, there is generally some sort of “packing” placed inside the nose.  The same process for people having a nasal and sinus surgery.  Whether it be a cotton pad or Telfa, or cloth-like material, the purpose is to maintain the reconstructed parts in the proper anatomic position, reduce the chance of bleeding, and to deliver important medications into the tissues, such as antibiotics and even medications to speed healing.  So, packing has always been a traditional part of rhinoplasty, nasal septoplasty, and turbinate resection, but not necessarily welcomed by patients. 

Patients, understandably, dislike the complete blockage, the feeling as though “there is a clothes pin put on my nose.”  They do not like it because it produces a dry mouth and, worse, a sense of anxiety that they cannot catch their breath.  One patient likened his experience to being “waterboarded.”  Another said it was one of the worst experiences of his life because he was very anxious, he could not sleep, and was “generally miserable.”

Interestingly, the specialties of facial plastic surgery, head and neck surgery, ear, nose and throat and general plastic surgery have not paid enough attention to  patient satisfaction with the post-operative experience. While the results of the rhinoplasty and other procedures generally been good, patients rarely give high grades to the experience.

With that in mind, recently, I have developed a new medical device that allows patients to breathe completely freely and normally during the entire postoperative period, including right after surgery.  This Kotler Nasal Airway is placed by the surgeon at the operation, and then the packing is placed.  So, the airway is guaranteed, and the comfort and security of being able to breathe is assured. 

More to follow on this later.

Rhinoplasty Cost

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Beverly Hills Rhinoplasty Cost

Patients always wonder whether or not there is a “excise tax” placed upon surgical fees in Beverly Hills.  In other words, are people paying for the location, perhaps, without any correlation with quality.

The hard economic reality is that the costs of doing business are higher in Beverly Hills.  Particularly, the so-called “Golden Triangle,” where there is an extremely high concentration of some of the most sophisticated specialists – in all areas of Medicine – residing.  It is a medical campus without a hospital.  But, there are many outpatient surgery centers for the types of elective surgery that we perform, for example.  So, yes, the cost of doing business is higher in Beverly Hills, and, therefore, the surgeon’s fees may be a bit higher.  But, they are not double or triple what they are elsewhere. 

There are advantages to seeing doctors who are at the top of the list of super specialists because they tend to be the most proficient in the procedures they perform, and they tend to congregate together.  The reasons why the highest quality physicians and cosmetic plastic surgeons tend to congregate is that there is ease of consultation and referral.  These translate into significant benefits for patients.  Some of our patients come from out of town and appreciate the fact that we can make arrangements with the other specialists whom they may want to see for other services.  For example, patients often come to see us to have rhinoplasty, cosmetic nasal surgery, and also septoplasty and turbinate resection for breathing.  They may also want to have breast augmentation.  We have a very close working relationship with some of our plastic surgery colleagues who specialize in body plastic surgery, and; therefore, are super specialists “below the neck,” as we are super specialists “above the neck.” 

Typically, fees for cosmetic procedures do not have that wide a variation.  Therefore, while it may cost perhaps 10% or 20% more to have the procedure done in Beverly Hills, most patients feel that, indeed, “you get what you pay for,” and if the most highly skilled, most super specialized doctors are in Beverly Hills, because they are there in a central location surrounded by other top specialists then, it is not unreasonable to pay a bit more. 

 

Middle Eastern Rhinoplasty

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Noses are different within the varied ethnic groups that populate the planet.   An Asian nose has certain features which distinguishes it from the Northern or Central European nose which is different than the Middle Eastern nose which is different than the Central American nose.  One’s color which is a reflection of racial ancestry has an influence also irrespective of the geographic location.  For example, Asian patients regardless of where they dwell in the world, typically have a broad nose with a low bridge and wide nostrils with thick nostril walls.  These are racial characteristics.  Due to intermarriage, often certain features are improved or worsened depending on the genetic match.

Rhinoplasty or cosmetic nasal surgery for Middle Eastern patients must take into account the following typical features of the nose:  There is usually a bump or hump.  The nose tends to be long and somewhat curled down.  When smiling, the tip of the nose drops down even further.  The nose may be wide with very broad lower cartilages causing large nostrils.

The management of such noses has to be very judicious.  It is important to remove the bump without causing a scooped-out appearance.  The nose should be narrowed but never pinched.  The tip needs to be raised up such that the nose no longer seems like it is going to touch the lip when smiling.  And, speaking of smiling, the little muscle that causes the tip to depress with smile generally has to be severed.

The ideal result would be a nose that has not been made too small, is not turned up too much and, as noted earlier, does not have a scooped bridge or a pinched tip. Improvement with preservation of ethnic identity is the key to success. 

Dr. 90210 Rhinoplasty Specialist

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Dr. 90210 Rhinoplasty Specialist

Here, in Zip code 90210, there are some of the world’s most sophisticated cosmetic surgeons. “ The Golden Triangle of Beverly Hills, Zip 90210” has eye doctors who specialize in cosmetic surgery of the eyelids and brow and dermatologists who specialize in chemical skin peels and filler injections such as Juvéderm, Restylane, Perlane and of course, Botox  and Dysport.  We have other cosmetic plastic surgery specialists that have particular expertise in cosmetic breast surgery, both primary and revision breast augmentation.  There is one surgeon whose practice is nearly only breast surgery and he does revision breast augmentation for patients who have had work done elsewhere and are dissatisfied.

Other cosmetic plastic surgeons specialize in tummy tuck and liposuction.

I have always felt that the most specialized and highly focused talents should be the choices for patients.  Patients often don’t recognize or are unaware of the degree to which all medicine has become specialized, sub-specialized and superspecialized.  A superspecialist is a doctor who practices a very boutique practice, focusing on six or fewer procedures. Typically, he has taken additional training beyond a long residency and even after passing the rigorous board exam to become “board certified”.

As one of the doctors who appeared on Dr. 90210 and as a rhinoplasty superspecialist, I can attest to the fact that, unfortunately, there are patients who come to see us who have had substandard work done by surgeons who have had very little training in cosmetic and functional nasal surgery, and who have no focus in that area.  These surgeons may do everything from hair transplants to thigh implants and everything in between.  Rarely will they be the most experienced and proficient practitioners.

What prospective patients need to know is that if they put themselves in the hands of those surgeons who have long experience and a fine degree of specialization, they are more likely to have a satisfactory outcome.

Computer Imaging and Hollywood

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Computer Imaging and Hollywood

There is something magical about computer imaging.  The uniqueness is that the prospective patient can see their predicted result on a computer screen and immediately understand “what it is all about.”

The discussion of cosmetic procedures is often very abstract without some visuals.  The most powerful graphic they can have would be a computerized prediction of the outcome of whatever procedure they are considering, whether it is rhinoplasty, blepharoplasty, face and neck lift, chemical skin peel or neck sculpturing with or without chin augmentation. 

Previously all we had available to demonstrate to patients would be a magic marker to “erase” the bump on the nose.  We have used computer imaging in our practice since 1989.  Today’s technology, of course, is far advanced over those rudimentary computer systems we had and patients very much appreciate the chance to have that as an important part of their consultation.

In Hollywood, the home of the stars, we sometimes kid our patients who come from out of state to see us that “Welcome to Hollywood, now we will show your transformation to a Hollywood star!”

Rhinoplasty Costs in Hollywood

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Rhinoplasty Costs in Hollywood

Do rhinoplasties cost more in Hollywood than in other parts of the country?  I suspect they do.  There are several reasons for this.  One is that we do have more superspecialists here performing cosmetic procedures, including rhinoplasty.  Superspecialists tend to command slightly greater fees because of their prominence, their excellence lower rate of re-do or revision surgery.

The cost of doing business is higher in Hollywood than it is in Lincoln, Nebraska or Appleton, Wisconsin.  The labor costs are higher; nurses and surgical assistants command higher wages, all of which are a factor of the higher cost of living in California. Ditto for New York and other centers of excellence.

If one had blepharoplasty and chin augmentation he or she would expect to pay a bit more than you would elsewhere, although not greatly more than in other large cities that have very sophisticated practitioners of cosmetic plastic surgery including New York City, Miami and Houston.

When looking at costs in Hollywood or anywhere else, always be mindful to ask about “the entire cost.”  You need to know what additional costs there would be for the outpatient surgery center, and anesthesia specialists, medications and perhaps even a postoperative recovery facility in which to stay for one or two nights.

Rhinoplasty Surgery in Hollywood

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Rhinoplasty Surgery in Hollywood

Rhinoplasty, which is cosmetic plastic surgery of the nose, has long been staple in Hollywood.
The reason is that Hollywood thrives on showing the world beautiful faces and it is impossible to have a truly beautiful face without a satisfactorily-shaped nose.

Some people are lucky and are born with a nose that is proportional and is pleasing to the eye.  Elizabeth Taylor comes to mind.  Likewise Grace Kelly and Catherine Deneuve. 

Those who have not had luck on their side with respect to receiving a “good nose”, have always had the option of having the rhinoplasty surgery. Of all the procedures that a younger person can do to improve their appearance, rhinoplasty ranks number one.  It is more important and more commonly requested than chin augmentation or blepharoplasty.

Remember, also, that many people have the rhinoplasty surgery at the same time as they have nasal septoplasty and turbinate resection to improve the airway or correct a sinus problem. This “double need” is more common in men than women, of course.

Marilyn Monroe had rhinoplasty.  Comedian Milton Berle and actor Dean Martin also had rhinoplasty.  

Years ago when I was researching for my book, Secrets of a Beverly Hills Cosmetic Surgeon, I visisted a photo archives facility in Venice, California.  It was fascinating to leaf through the drawers and recognize that many familiar faces had indeed had rhinoplasty surgery at some point in their life. 

Incidentally, some people go to great lengths to conceal the fact that they are having such surgery.  If you ever saw Barbara Streisand in the movie Funny Girl, you would know that it was the story of comedienne Fanny Brice.   In the 1930s, Fanny had a rhinoplasty performed in a hotel suite.  She felt that was the best way of keeping it a secret.

Today, rhinoplasties are not performed in hotel suites and, frankly, they are rarely performed in hospitals.  It is appropriate to perform such a procedure in a credentialed outpatient surgery center or a duly qualified physician’s office surgical suite.