Searching for Surgeons

The stories of bad plastic surgery seem to always have a common beginning; either somebody does not like the appearance of his or her nose or needs internal nasal surgery to:

• Fix a once broken nose
• Repair a deviated septum
• Reduce turbinates

But then, things go wrong. Patients often quickly choose the closest plastic surgeon, the doctor who charges the least or the cosmetic surgeons they heard about through Aunt Sally’s boyfriend’s cousin.

However, a recent patient, 34-year-old J.G., at least made a stab at researching a qualified, trained, certified and experienced nasal surgeon near his Texas home to correct his deviated septum.

Although the Texas surgeon that J.G. found and used is:

• A book author
• Won awards for his work
• Was well respected in his medical community

the procedure did not turn out well at all and made J.G’s breathing even worse. A deviated septum that twists and turns inside the nose creates additional blockages to healthy breathing.

J.G. then widened his search for nasal surgeons worldwide to correct the damage  before landing in our Beverly Hills office. (Read more functional and cosmetic surgery patient stories.)

Finding corrective, or revision nasal surgery, requires much more research than finding a good surgeon for a first nose job.

Why? Revision nasal surgery is so much harder for many cosmetic plastic surgeons who routinely turn out first rhinoplasties day after day, they shy away from corrective surgery.

His corrective surgery went well with the breathing problem normalized.

Then, J.G. found that marks on the outside of his nose could be corrected without yet another trip to the operating room. He opted for permanent nonsurgical rhinoplasty which involves a series of quick injections in the office, separated by ten to 12 weeks.

(Read more about “Rescue” rhinoplasty, another moniker for permanent, nonsurgical rhinoplasty.)

So, for a while, J.G. traveled from his Texas home to Beverly Hills every three months to complete a corrective, non-surgical rhinoplasty that yielded a handsome nose which flattered his profile.

 Recently, a press release from one of the plastic surgery trade organizations reported that there was an increase in activity in the plastic surgery community.  That was said to be harbinger of better economic times to come. 

Frankly, I am not so sure of that.  The growth in cosmetic procedures is not in the surgical arena.  It is in the non-surgical office treatment arena.  So, as I see it, the increase in the “ plastic surgery business” is not in the plastic surgery but in the syringe and needle department.

Botox Cosmetic, Dysport, Restylane, Juvederm, Sculptra, and Radiesse, Artifill and medical-grade liquid silicone are all good and valuable treatments that patients are flocking to. 

We cosmetic surgeons are glad to have these excellent products available to us, but the reality is, alone, they cannot do the job.

Today’s patients, watching their budgets, are apt to opt for the non-surgical treatments before the more major treatments, such as face and neck lift, neck sculpture, upper and lower eyelid surgery, brow lift, chemical skin peel, or laser skin treatments.  It is understandable. Office treatments require no time off, are virtually painless, and are far less expensive. 

It may be that we never reach the numbers of surgical procedures that were done before the current Great Recession.  While the cutting and sewing procedures are available for patients, the utilization may be less because of economics, primarily.  Understanding that, many practices are offering reasonable discounts to aid people who might otherwise not be able to afford the procedures.

When consulting with doctors, be sure to ask about all treatments available, both surgical and non-surgical. And, ask how you can shave some dollars from the cost without sacrificing quality.

I have some hints on that for you on a future blog post.

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.

Discussion of Revision Nasal Surgery

Nasal surgery is an art based on a science, but it is not magic.  As a surgeon, I can only work with what I have been given with respect to tissue characteristics following previous surgery.  The aim is often to improve both appearance and function, and; therefore, there is a challenge introduced when the operation is not the first visit to the tissue.

I want to urge a sense of realism on the part of what the expectations could be.  We always attempt to yield the very best result possible with respect to both breathing and appearance.  So, while maximum improvement is always the surgical goal, and is, indeed, very often attainable, improvement is not the same as perfection.  The reasonable aim is to deliver a nose that is natural in appearance and functions well.

Please understand that in contrast with both primary nasal surgery, or original nasal surgery, the final result takes a bit longer to present itself.  Not that you will look terrible.  It is just that the swelling, although not necessarily highly visible to anyone, just takes a bit longer to subside.  Some noses look very good in 3-4 weeks, and others need more time for maturation.  As one patient said, “I guess it’s sort of like fine wine.  It takes a little time to get to its best.” That is true. 

After Surgery

After the surgical session, it may be important to undergo minor improvements at the postoperative office visits.  We have long experience in the use of medications that can be used to “smooth out” any irregularities or imperfections.  Another class of medication is used to help reduce internal scar tissue and unwelcomed thickening of the skin.  These are the medications that are called “shrinkers.” 

You and I make the decisions, jointly, before committing to any of these treatments.

For more information, please consult our website dedicated to revision nasal surgery at http://www.revisionrhinoplastydoctor.com/.

The Dr. Kotler Nose

Patients always kid me that they want a “Dr. Kotler Nose.”  When I ask them what they think a “Dr. Kotler nose” is, they usually reply “Well, one that looks natural.  It seems that you have the knack of producing natural noses.”

I am flattered by that.  I also take pride in those observations, because that has always been my aim.  I want to deliver a nose that looks natural, as if the patient had never had nose surgery. As if the patient were born with it.

The opposite of a “Dr. Kotler nose”, or a natural, un-done nose, is one that looks unnatural, fake, and over-done.  The nose that is too scooped out, that is too narrow, that has a pinched tip that has an overturned tip such that one is looking directly into the patient’s nostrils.  No one wants the unnatural nose.  We all understand that.

Incidentally, “The Dr. Kotler Nose” is worn by Dr. Kotler.  I had my nose done.  It was done by the world- renowned, and first rhinoplasty superspecialist, Dr. Howard Diamond, in New York City, in 1980.  Dr. Diamond was the unquestioned heavyweight champion of the world when it came to doing cosmetic nasal plastic surgery. He was one of my principal teachers and mentors.

I have a set of my pre-operative photos in the office, and I am always willing to share them with patients so they can see what I looked like “before”.  I like my nose because it looks natural, fits my face, and it is a better nose than I had.  That is the definition of success.

Rhinoplasty Revision – Is Simpler Better Than Complex?

Recently we saw a patient who was a student at a local university.  One year ago he had rhinoplasty performed and was very unhappy with the results.  He certainly had ample reason to be dissatisfied.  The nose was just terribly unsightly.  It was crooked, asymmetrical.  There was a gouge on the left side.  It had been over-shortened, overdone, and had entirely changed his ethnic appearance.  He brought in photographs to show me what he looked like prior and it was shocking how radical the change. Very poor judgment and substandard craftsmanship by the surgeon

I told the patient it was my opinion that much of what he disliked could, in fact, be improved without surgery.  By using a combination of filling injections and perhaps some shrinking injections, that he would have a much improved nose which would have a better “fit” with his ethnicity.  The common denominator was that, at his surgery, too much was done.  And when too much is done, often the most practical answer is to use filling injections under the skin to essentially plump up the skin. To replace the over-removed portions of bone or cartilage underneath the skin. The results of the injections resemble the results of having  surgical procedures which would involving grafting or transfer of tissue from one part of the body to the other. Often, in such complicated revision rhinoplasty cases, there may be more than one operation necessary to achieve a satisfactory result.

The patient was a little incredulous that I thought that I could achieve a satisfactory result –without any surgery – so I then did a “saline demo.”  We inject sterile saline, the same solution in intravenous fluids, underneath the skin that mimics the result of the final permanent filler injections. It made an amazing difference.  The nose was not perfect.  I would have liked to have seen some minor changes otherwise but they would require surgery.  But to achieve an 80% or 90% improvement without having surgery is impressive. And, practical and inexpensive compared to one or more trips to the operating room.

The patient related to me that he had seen another surgeon who told him he would require a seven-hour reconstructive surgery and that cartilage or bone would have to be taken from his chest and transplanted or grafted to the inside of the nose.  Disregarding the cost and the duration of surgery and all the other inconveniences and burdens, the question is whether or not the end result would be satisfactory.  Often, transplanted tissue can shrink or twist or partially disappear and this adds another level of complication and the need for even further surgery.

I think there is a place for simplicity that when an office procedure can do the work of surgery, it should certainly be considered. It’s not always the only treatment that is needed, but injections can do much of the work.

Before the operating time is reserved, the patient’s common sense might say: “Why not?”. Because there is great value to simplicity, economy and predictability.

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.

Men’s Nose Jobs

I have been thinking a lot about men’s rhinoplasty or cosmetic plastic surgery of the nose, the last several days.  In the last two days we performed nasal cosmetic and reconstructive surgery on two gentlemen.

The first was a middle-aged businessman who had difficulty breathing, but who also was motivated by the fact that he felt his “nose was growing”.   The nose, in fact, doesn’t grow, but the tissues within the nose, the loosen, the tip drops and the nose appears more bulbous and longer.  The gentleman’s motivation for that cosmetic enhancement was proper.  Likewise, the desire to breathe was very reasonable and the patient’s deviated septum and enlarged turbinates were causing blockage such that snoring and poor sleep quality was the result.  So it all made sense. 

In the case of that middle-aged gentleman it was very important to fully understand the man’s wishes.  He expressed on several consultation visits the need to have a natural looking nose that would not look artificial, “done” or drastically different from that which his face had carried for many years.  A surgeon needs to listen carefully to these words and understand the mission.  Any miscommunication could result in an unsatisfactory result and an unhappy patient.  That is not what a conscientious and competent cosmetic facial surgeon wants.

The second nasal case involved a young man who had had two prior nasal surgeries, one for breathing and one for appearance.  The former, the nasal septoplasty, was accompanied by reduction of the turbinates.  The turbinate reduction was quite satisfactory but the septum was still deviated to one side, meaning he had internal nasal blockage because of the shift of the septum which is the vertical partition that separates the two nasal passages.  Those “ revision septoplasty operations are not easy because typically some of the cartilage has been taken out of the septum and there is quite a bit of scar tissue underneath the internal lining of the nose.  It does call for considerable experience, expertise and judgment.

The young man’s other wish was to have his nose appear less long.  Indeed the nose was too long for his face and, as he ages, the length would have only increased.  Apparently the original operating surgeon did not heed the patient’s advice and the result did not match the patient’s wishes.

At this young man’s surgery, very conservative elevation of the nose was done such that it no longer looked too long as if it would touch his lip when he smiled.  And indeed, regarding smile, part of the problem was that he had a very strong muscle which, upon smiling, would depress the tip of the nose further.  The breathing problem was corrected by straightening the septum and some other relatively routine internal procedures, and we were able to lift the nose off the lip, release the muscle which had been exerting its downward force on the lip and give him a natural looking nose which was not radically different from what he had before. But certainly better and in keeping with his desires.

It is very important for surgeons to listen to patients, to get a good sense of what they want.  Also, in my opinion, it’s important have computer imaging available so that the perspective patients can see the predicted results of the procedure that the surgeon deems achievable and reasonable.  A meeting of the minds should take place at the computer imaging session such that the patient and the doctor are on the same page based on that computer visualization of the end result of the cosmetic rhinoplasty.

We have used computer imaging in our practice since 1989. It is helpful and important to patients who need the comfort of seeing the projected outcome.

Sinus Infections And Septoplasty

Unfortunately, the sinuses are the much maligned and much blamed subjects of advertisements for decongestant and allergic nose sprays, pills and an assortment of over-the-counter medications.  The reality is that the sinuses are dependent on the nose function. They need to be filled with air that flows into them from the nose. So it is the nose that really deserves our attention.  Consider the sinuses as anterooms that sit astride the nasal passage as a hallway.  You cannot get into your room if the hallway is blocked.   So if the nasal passages are blocked, you cannot expect the sinuses to function normally.

What happens in the case of abnormal nasal architecture such as the presence of a deviated septum (the vertical partition that separates the right and left nasal passage) is that the airflow is inadequate.  When the airflow is inadequate, then the sinuses do not aerate properly.  They may begin to fill with fluid and ultimately cause symptoms.  The symptoms of true sinus infections are hard to ignore:  headache or facial and tooth pain.  The signs are thick and often pus-like drainage from the nose into the throat. Sometimes bleeding.  Patients have a temperature and even nausea and vomiting. A sickness far worse than a “head cold”.

The best way to keep the sinuses healthy and out of trouble is to not smoke and make sure that your air passages are functioning well.  This calls for an examination by a specialist.  It may be that only allergies need treatment with a prescription steroid or cortisone nasal spray.  But for some patients, surgery is necessary.  The surgery takes less than an hour, has been done for over 100 years and is very well established.  The definitive operation is nasal septoplasty to correct the deviated, crooked or broken nasal septum as well as trimming of the inferior turbinates which are normal outpouchings inside the nasal cavity subject to enlargement either from allergy or other stimulations.

Finally, when patients tell me that they have “three to four sinus infections every year” I know they need help. That is not a normal condition.  True sinus infections should be very rare.

Three Wise and Practical Reasons For Cosmetic Surgeons
To Reduce Fees in a Tough Economy

A very savvy business friend of mine said to me several months ago: “I don’t know of anybody who has not been adversely affected by the very difficult economic times now facing the United States.”

Certainly, when the economy is tight, people have less money available for nonessential services such as cosmetic surgery.  Therefore, plastic surgery practices will see decreasing patronage.  For that reason, practices have to be realistic and ask themselves if there is not a way that they can contribute to helping ease the discomfort of a slow economy and at the same time benefit their practice.

I hereby submit that there are three good reasons why a cosmetic plastic surgery practice is wise to lower its fees: 

1. Physicians have a responsibility to help patients.  If economic difficulties present themselves, there is no reason why we cannot soften the blow by reducing our fees.   After all, physicians who treat illness such as internists, pediatricians, surgeons have treated the needy in exchange for diminished fees.  It is a tradition in medical practice that all be served.  Even though our work is not medically necessary, it is still a valuable and important service to patients.  Therefore, it is perfectly consistent with medical ethics that we lower the economic barrier for the sake of our patients.

2. To be most proficient, surgeons need to be busy.  “Beware of the surgeon who operates infrequently” is an ancient and well-respected axiom in the world of surgery.   My experience and that of other superspecialist surgeons is that in fact, the most gifted and proficient surgeons are busy.  They are busy because they attract patients through their talents.  They are also busy because they will accommodate themselves to the needs of the patients including the economic realities.

3. From a purely business standpoint, it is still better for the practice to do a case at a significant courtesy discount than not to do the case at all.  Medical practices have large fixed expenses including rent and staff salaries.  Accountants have long held that for elective surgery, a practice would be foolish not to discount its fees and continue to keep the operating schedule busy rather than take an aloof and distant stance and pass on surgical cases that would otherwise help the practice and the business’s bottom line.