Making Revision Rhinoplasty Too Complicated

Posted on February 19, 2010 by admin

Are We Making Revision Rhinoplasty Too Complicated?

Today a patient came to see me in consultation. He was a young adult who had a history of sustaining a broken nose and having delayed in having it repaired. Finally, unhappy with the appearance and the breathing, he had reconstructive surgery done by a plastic surgeon who was not specialized enough to render the result that might have been achieved. He waited for one year and then had a second surgery by a more specialized surgeon. This “first revision rhinoplasty” according to the operative report was quite complex and intricate. It involved transplanting tissue from the scalp and cartilage from the ear into the nose. Apparently the surgery took five hours. The patient said that it took nearly “two years” for all the swelling to go away. I was somewhat astonished by that initially, but then after reviewing the operative report, and seeing all the maneuvers, techniques and manipulations that were performed, it made sense the operation would take that long.

Before and after photo of another patient of Dr. Kotler who in another state, sustained two prior, yet unsuccessful operations to improve appearance and breathing. Dr. Kotler was able to create a natural nose that worked normally and relieved the patient of her blocked nose and sinus headaches.

Unfortunately for this patient, it did not render satisfaction and thus we are going to have to perform another operation on him. If it were not reasonably predictable that the outcome will be better, I would not consent to perform the surgery. I think it is very important that the “odds” of success be taken into account when performing yet another revisional rhinoplasty surgery.

My assessment is that the operation can be done more simply, efficiently and that this in itself will allow faster healing.

The issue of healing is of major concern for the patient. Because he works with the public he cannot afford to be away from work for weeks and months because the nose and face are so swollen.

Interestingly, and coincidentally, his experience is not unique. Later in the day as I was reviewing a medical magazine, I noticed an article on a young woman who required two revision rhinoplasty operations. Her surgeon noted that “one year post procedure she will be about 30% healed, and only 40% healed after two years.” That is a long time line. Most patients are not happy with the prospect of healing that takes so long.

My point is that it may be that when the operations are done, the techniques involved are just too complicated, too complex and too prone to take so much time to heal that the patient sits in a state of suspended animation for a period far longer than they would like.

Los Angeles Rhinoplasty

Posted on January 27, 2010 by admin

What’s With the Five Hour Rhinoplasty?

I am hearing some amazing stories from patients. While we always learn from listening to our patients, I am not only learning but becoming a bit dismayed with respect to what I am hearing about nasal cosmetic plastic surgery. Patients report operations taking three, four and even five hours that ultimately were unsatisfactory for the patient. It seems the operations become longer as more grafting and transplantation of tissue takes place. Now certainly there are indications for adding on tissue into the nose, particularly if there has been previous surgery or if there has been an accident that has destroyed some of the tissue. But, even if that is the case, why are these operations taking so long? I am not sure of the answer, except, my sense is that some surgeons are making the operation much more complicated and complex than need be. For many of the grafting or transplanting needs, there is adequate tissue inside the nose itself. This of course makes it very economical and efficient to be able to harvest the tissue since it is coming right from the area that we are working on. Often, we use cartilage and bone from the nasal septum because we are taking it out anyway to correct the deviated nasal septum and improve the airway, and correct problems that might lead to sinusitis and other serious complications. While only very rarely is it necessary to take cartilage from the ear, I am now hearing stories of almost routine harvesting of rib cartilage and even rib bone to be place inside the nose, and of course, that makes for a very involved, complicated and long duration operation since other surgical sites besides the nose must be operated upon. I guess I am just from the old school. We do nearly all our surgeries from inside the nose using completely hidden incisions, closed with absorbable stitches. That is called a “closed rhinoplasty“. The “open rhinoplasty” requires an external incision, and I just don’t see the need for that very often. And I have done over 4,000 cases in my career which now spans nearly forty years. The other issue is that some surgeons are not efficient. It just takes them too long to get the job done. I would attribute that to less-than-optimal training in the residency programs as well as inexperience. Generally, inexperienced surgeons are slower than veteran surgeons. The “occasional nasal surgeon”, the doctor who spends more time doing other cosmetic plastic surgeries such as breast augmentation, tummy tuck, breast reduction and liposuction just doesn’t develop the facility for rhinoplasty because he doesn’t operate on the nose often enough. He cannot become a master nasal surgeon. In my experience, most cosmetic nasal surgery or rhinoplasty procedures could be done within an hour. If you need to add on the functional or breathing operation, that adds another 20-30 minutes. The total time in the operating room, including going to sleep and waking up from the anesthetic, should rarely be more than two hours.

Beverly Hills Cosmetic Surgery, Not Like Dropping-In For a Haircut

Posted on December 23, 2009 by admin

Having Cosmetic Surgery is Not Like Dropping-In For a Haircut

Today our patient correspondent and consultant, mentioned a conversation with a patient from Europe. The patient was coming to us to have nose surgery done and seemed a bit put off when told that it was necessary to make all the arrangements ahead of time. Ideally, the arrangements would include having a Skype consultation with Dr. Kotler so any questions or issues that the patient wanted to present to him could be done before the patient gets on an airplane and travels thousands of miles to come here. Secondly, after the Skype session, if the decision has been made to have the surgery, it is very important that the patient have a physical exam and the appropriate laboratory and x-ray work done well before surgery. After all, if there is a medical problem, surgery cannot be performed. Cosmetic plastic surgery is only done when the patient’s general health condition is excellent. There can be no compromises. So if there is a problem, you surely want to know well ahead of time so that schedules can be amended and most importantly the medical problem could be attended to before flying across the pond.

It seemed that the patient thought he could come in on a Monday, have a consultation and go to the operating room on Tuesday. And maybe that is because he, as others, tend to minimize the importance of a proper pre-operative evaluation and workup and that everything be put in proper order.

There are logistical issues that have to be considered. We have to reserve the operating room. We also have to reserve the doctor-anesthesiologist so that everything is properly anticipated and done properly. Depending on the procedure, necessary supplies and equipment have to be available and that cannot always be done on a one-day’s notice.

Most importantly, Dr. Kotler and the patient must have time together to discuss the patient’s desires either via Skype or, of course, person-to-person when the patient is here. Our preference, for patient safety and comfort, is that all possible communications and arrangements be made well ahead of time. And the patient just doesn’t get off the plane and go to the operating room. There is always a visit with me in the office one or two days before the procedure. It is important for me to do a complete examination and determine those things that are not possible to determine via Skype and computer imaging, of course. I want to explain in detail, face to face, how the procedure will be conducted. I explain to the patient that the anesthesiologist will call the night before, that the patient will see me in the morning, that the patient will have my home phone and cell phone number so that he knows we are ready and prepared to give the patient the care that he or she deserves.

It may be a tribute to cosmetic surgery that people feel that it is a “minor undertaking.” If it is a tribute, it is because we have been able to handle all the issues such as discomfort and provide for rapid recovery. But the truth is, we do not treat it with any less importance than a neurosurgeon treats a patient upon whom he will be doing brain surgery. After all, we trained as long to do our work as the neurosurgeon trained to do his.

Cocaine and Rhinoplasty in Beverly Hills

Posted on December 15, 2009 by admin

Cocaine and Rhinoplasty in Beverly Hills

Unfortunately, cocaine use is still with us. There are significant consequences to cocaine abuse. The worst complication is its effect on the heart and blood vessels which causes high blood pressure that can possibly lead to a stroke – or even death.

Cocaine and Rhinoplasty Surgery Do Not Mix!

With respect to nose surgery in Beverly Hills, patients who have been abusing cocaine present significant surgical problems. First, the lining of the nose is terribly inflamed and irritated and it is impossible to conduct a proper operation under those circumstances. Secondly, the abuse of cocaine can lead to creation of a hole within the internal partition of the nose. This is known as a nasal septal perforation. The hole can be anywhere from the size of the tip of a fountain pen to the size of a nickel.

There are problems that come with septal perforations: crusting, whistling and bleeding. It is a real hassle. And once that hole is created, it is very difficult to surgically close it. While there are some appliances that can be inserted to act as a “stopper,” just be aware that one is asking for considerable problems with long-term cocaine abuse.

The other issue is that one should never consider having any cocaine in their body at the time of surgery. This sets the stage for a possible anesthetic catastrophe! There can be an unfavorable interaction with the anesthetic drugs as well as the local anesthetics that must be injected.

Remember, doctors are not judges. We are not an arm of the legal system. Our conversations and records are private and cannot be shared with anyone without your permission. We don’t have an editorial position on personal choice issues. Our only job is to serve you. However, you need to be frank and honest with your doctor whose only aim is to have a safe surgery and a satisfactory outcome for his patient.

Correcting A Short Nose Is A Common Beverly Hills Nose Surgery

Posted on September 25, 2009 by admin

Correcting A Short Nose Is A Common Beverly Hills Nose Surgery

Revision rhinoplasty is common in Beverly Hills because there is a certain percentage of patients who are unhappy with their surgery previously performed elsewhere. Here in Beverly Hills, where we have several surgeons with a long track record of experience and superspecialization, patients congregate to have the more the difficult nasal surgeries performed.

One of the more common consequences of an overzealous or overdone rhinoplasty is that the nose is “too short.” The nose tips up and the angle between the nose and the lip is so great that sometimes it looks like the nostrils may fall prey to a thunderstorm. Perhaps there was inadequate surgery done at the junction between the nose and the lip. This can be improved. The nasal spine and the caudal septum, whether straight or deviated, may be altered and that sharpens the nose-lip angle. This makes the nose look much less pug or upturned. If that is not an option, cartilage can be transplanted just behind the tip to push it forward. Another technique is to use a filler to plump the skin of the tip just between the opening to the nostrils and this again leads to a more satisfactory nose-lip angle. Also remember that a nose looks overly-short if the bridge has been taken down too much. If the nose has that overdone ski-slope look, filling this defect either with a cartilage graft or even with office-performed filling injections will raise the bridge and make the nose look much less short.

Understand that much of what we do has to do with illusions and appearances – small differences can make a big difference.

Avoiding the Beverly Hills Rhinoplasty Saddle Nose

Posted on September 18, 2009 by admin

Avoiding the Beverly Hills Rhinoplasty Saddle Nose

A rhinoplasty saddle nose occurs because the internal supports have been weakened or removed. The upper bridge of the nose is bone but the lower portion of the bridge of the nose is cartilage. If too much of the septum underneath either is removed, there will be a collapse of the bones and/or collapse of the upper lateral cartilages which rests upon the septum and when they “fall” into the nose, the outside appearance looks like a saddle.

Assuming that the breathing has not been impaired, the correction is by insertion of the patient’s own or transplanted tissue. Some surgeons prefer bone. Others prefer cartilage and some use another material, from under the skin, called fascia. Or one can insert a custom-made or custom-trimmed prosthetic part. Generally these are solid medical-grade silicone, the same material that is used in artificial heart valves and artificial joints. It can be sculpted to the size of the saddle-depression and then tucked underneath the skin through internal nasal incisions. Afterwards, there is no saddle and the profile is straight. But an alternative is filling injections. Temporary injections are fine but most patients coming to Beverly Hills for revision rhinoplasty certainly are also offered the possibility of a permanent filling injection. Medical grade liquid silicone which has been used in the United States for over 50 years, in droplet form, is a very practical solution to correcting a saddle nose post-rhinoplasty.

Beverly Hills Closed Rhinoplasty

Posted on September 11, 2009 by admin

Beverly Hills Closed Rhinoplasty

Closed rhinoplasty refers to the standard and classical technique of making all the incisions necessary to perform cosmetic nasal surgery within the nostrils and confines of the nose. Many surgeons, particularly those rhinoplasty superspecialists with long experience cosmetic plastic nasal surgery, feel that they can accomplish what needs to be done entirely through those internal incisions. There is no question that it requires more skill and manual dexterity.

A recognized advantage of the closed rhinoplasty technique is that, by avoiding an external incision below the nose tip, there is a reduction the chance of compromised circulation to the tip of the nose. Should there be poor tip skin circulation in the post-operative period, there is some risk of loss of the skin and underlying tissues, which is catastrophic. Likewise, using the closed rhinoplasty approach, generally, there is a lesser chance of infection and wound breakdown with scarring. That is also related to circulation, the currency of good healing. Infection tends to take hold where circulation has been compromised. These are risks that one should want to avoid if possible.

Personally, I like the closed approach since I was raised on it. Very comfortable with my consistent technique.

I have performed over 4,000 nasal surgeries, most including a cosmetic component and I used the closed rhinoplasty technique for nearly all. Only two or three operations utilizing the open rhinoplasty or external approach. I wasn’t unhappy with the external approach, and it was not difficult, but I do feel that if I am capable of delivering satisfactory results through an internal, scar-free procedure, that’s better for patients.

A Balance And Natural Look Is The Desire Of Every Beverly Hills Rhinoplasty Surgeon

Posted on September 8, 2009 by admin

A Balance And Natural Look Is The Desire Of Every Beverly Hills Rhinoplasty Surgeon

It is very important that a nose look natural. This includes balance. Balance is defined as appropriate relationship between the tip and the bridge. If at rhinoplasty, the bridge is created too low, there becomes a ski-slope appearance which actually makes the nose look more protuberant from the face. This is never satisfactory. Also, if the tip drops and looks round after surgery, then the bridge looks higher and the nose has a very unsatisfactory look. This lack of balance can be corrected, of course, but it is best to have the original surgery avoid this problem.

The other issue, which I discuss in my book, Secrets of a Bevelry Hills Cosmetic Surgeon, is how the nose looks from the front with respect to the tip versus the bridge. If the tip is too wide for the bridge, particularly if the bridge has been overly narrowed by previous surgery, then the answer lies in correcting the bridge and not the tip. On the other hand, sometimes if the bridge looks quite satisfactory, the tip of the nose is too bulbous, too wide, too bulky, then the tip must be addressed to bring it in harmony with the bridge.

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

Posted on August 31, 2009 by admin

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.

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

Posted on August 24, 2009 by admin

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.