Category Archives: Rhinoplasty

Rhinoplasty Training and Specialization

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 “Dr. Kotler, You Really Are Old School!”

That is what a patient said to me after we performed rhinoplasty, or cosmetic nasal plastic surgery, upon her teenage daughter.

Perhaps what she saw as setting us apart was that in our practice, it is 24/7 coverage for the patient.  Our patients receive my home phone and my cell phone numbers.  They are free to call me at any time.  If I am not out of town, I am on call 24/7 every day.  Of course, when I am out of town I have coverage from not only our office staff but two doctors as backup.

Yes, we do practice the old fashioned way.  We stay in close touch with our patients.  We see them often after surgery to check and make sure all is going well; we don’t like surprises.  And, Saturdays and Sundays are just another work day for us when patients need to be seen for either routine or special post-operative care.

The mother appreciated that we brought to the table many years of experience and a high degree of specialization in cosmetic facial surgery of the face and neck. Particularly in rhinoplasty, with over 4,000 nasal procedures having been performed. Such a track record comes with having been in the trenches of practice for many years and becoming a master surgeon, the highest accolade the world of surgeons can bestow.

Since I trained in the golden era of medical education, the 1960’s and 70’s, that should help one understand the value old school holds. In those grand days before teaching hospitals became weakened by all the changes in medical care delivery, we had terrific training and experience. The hours were long –but fascinating. We had demanding and strict teachers. That explains why it was expected of us to conduct ourselves in a manner that today is known as old school.

I am not sure what the new school is like, but I do know one thing, that the old school was the right school to attend. And, that, friends, is always appreciated by patients and their families.

Rhinoplasty For Men

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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.

Using Skype for Cosmetic Surgery Consultations

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Our Faith In Skype –

Consulting Affirmed

We have been big fans of consulting with patients long distance by using Skype.  We have used it to consult with patients both in the United States and overseas.  It gives us a chance to get a good sense of the patient’s request and problem if a new patient and also the ability to follow the progress of our postoperative patients. 

There was an article in The New York Times on Sunday, May 30, entitled, The Doctor Will See You Now, Please Log On.

The article discussed the advances in technology and the increasing popularity of what has now been labeled “telemedicine.”  The paper noted “spurred by health care trends and technological advances, telemedicine is growing into a mainstream industry.”

The article further stated “the technology has improved to the point where the experience of both the doctor and the patient are close to the same as in-person visits and in some cases better.”

I don’t agree with that statement because nothing beats a face-to-face meeting.  However, we have to accept some imperfections in indirect communication. If we do not have the chance to see the patient in the office to look, to feel and evaluate, certainly consultation via Skype is a second best.

The article brought to my mind the fact that three days prior to this article, on Thursday, May 27, we operated on a 15-year-old girl who came to us from Texas to have both rhinoplasty and functional nasal surgery including septoplasty and turbinate resection.  She also had placement of our post-operative nasal airway system to ensure breathing post-operatively. 

We had originally been contacted by the patient after she had visited our web site to learn more about the nasal surgery.  Following exchange of e-mails and phone conversations with our patient consultant, a Skype consultation was arranged. We had a good session the teen and her mother.  We also had the opportunity to provide, for the patient’s benefit, computer imaging to show the predicted result of the surgery since the patient was able to supply us with digital front and profile photos.

That Skype consultation went into very deep detail as much as we would in the office with regard to the patient history including the difficulty breathing, clogged ears and some of the medical issues.  We always ask about allergies, medications being taken, past history, so there is no short-cutting in the history and there is no reason not to address all issues past and present.  The only faculty we don’t have available is touch. 

Based on our long-distance consultation, computer imaging and Skype session, the patient came here prepared for surgery.  Her history and physical and all laboratories were done at home in Texas and she arrived the day before.

At the “pre-surgery” visit, I had a chance to examine the patient’s nasal airway and affirm that which I had learned from the history and also from reviewing the x-rays that were taken of the nasal passages and sinuses in her home town.   I also took further digital photographs that I could use to study before surgery and all questions were answered that had been posed by the patient and her mother.

As is routine for all our patients, whether local or national or international, all arrangements had been made for the patient to have her post-operative medications filled by our local pharmacy.  The patient’s post-operative kit was at hand so that she could start some of the medications that night prior to surgery.  The office had also assisted the patient’s mom in making hotel arrangements.

Certainly, technology is giving us a leg up on better pre and post-operative care and allows patients from afar to make contact with us and have meaningful conversations and consultations from nearly anywhere in the world. 

Cosmetic Surgery Office Procedures

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Why Patients Love “Demo” Office Procedures

1. Computer imaging.   On a computer screen, you can see the predicted result of the procedure. If your nose has a bump or is too long or the tip is too wide, all of the changes that the surgeon proposed can be seen after the “before” is morphed to the “after”.  Our practice, among others, conducts remote computer imaging.  If patients e-mail us photographs taken in proper views, we will perform the imaging in the office and e-mail back the results. Very cool.

2. Saline demo.  Using saline to inject into the deep nasolabial creases or into a previously operated over-scooped , narrowly-pinched nose to show the result is a wonderful way for the patient to see three dimensionally “live” what can be achieved using filling injections.  The filler will dissipate in two hours and photographs were taken before and after, of course, so that the patient can review them before making a decision about having either a temporary or permanent fillers.

3.  Photo archives. The most comprehensive and detailed web sites will have such a large collection of before and after photos, typically numbering in the hundreds, that you will be able to identify a patient who had a situation to yours.   You need to judge the “after” photos to see if you would be satisfied with the type of result shown

4. Meeting actual patients who have had similar procedures.  There is nothing that beats being able to stand in someone else’s shoes to understand the process and results. Many patients act as volunteer consultants for practices and make themselves available to speak with patients who are considering the surgical procedures or injections or nonsurgical processes that they had.  A wonderful way to learn and even to be able to assess the incision location and quality, etc. 

 

Blocked Air Passages

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How Do You Correct Blocked Air Passages?

Blocked air passages are extremely common.  Common causes include deviated septum, nasal allergy, enlarged turbinates (turbinates are normal, shelf-like structures within the nasal passages).  Some blocked noses are permanent due to abnormal architecture.  For example, after a broken nose, the bones and cartilages may be shifted out of position and, therefore, compromise the airway.

Sometimes nasal blockage is temporary such as during a common cold or an allergy attack.

Regardless of whether the problem is intermittent or constant or whether or not it is caused by allergy or architectural issues, blocked noses can be helped.  For nearly 100 years, a very successful operation has been performed totally within the nasal interior to straighten the deviated septum which is the most prominent player in causing the blockage and reducing the size of enlarged turbinates. 

Septoplasty Specialist

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Specialist in Septoplasty Surgery

Internal nasal surgery to correct a deviated septum is called septoplasty.  The root words are “septum” which means partition and “plasty” which means changing form or shape.

The object of a nasal septoplasty is to correct a deformed, crooked or perhaps broken nasal septum which is blocking the airway.  The end game is to make it straighter with fewer curves, baffles, angles, all of which contribute to blocking the airflow. 

It takes considerable skill and dexterity to do an operation entirely through the nostrils.  One has to conduct the operation with the same steps that are done in any operation:  There is an incision, there is work that has to be done, then the wound has to be closed and stitches placed to assure satisfactory healing.  Yet all this must be done through the nostrils; as if the surgeon is operating through a keyhole.  Often the nasal septoplasty is accompanied by reduction of the turbinates.  The turbinates, numbering three within each nasal passage, add to the surface area of the nasal interior and, therefore, multiply the humidification, purification, and warming functions of the inside of the nose.  Some turbinates become too large, particularly the inferior turbinate, or lowest turbinate, and when the turbinate becomes enlarged from allergy or even other unknown stimuli, it is necessary to reduce the size.  This can be done by many means, including standard surgical excision or laser treatment or other means to reduce the bulk. 

Since airflow through the nose is related to the fourth power of the radius of the air passage (Poiseuille’s law, well known to students of physics), a slight increase in the functional diameter of the nose by relieving the blockages yields a huge differential increase in air flow.

It behooves the patient who is consulting for cosmetic nasal surgery to ask the surgeon to evaluate the breathing.  It makes sense to correct the blocked nose at the same time that one is having cosmetic nasal surgery or rhinoplasty.   Why not have two operations at the same sitting with one anesthetic and have the economy of one recovery period and, often, you can save considerable money since the second and third procedures when added on to the primary procedure are generally significantly discounted by the surgeon’s office.

 

 

Sinus Infections and Septoplasty

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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.

Rhinoplasty or Septoplasty?

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Complete Nose Blockage

There are some people who almost have no need for their nose.  They are not using it to breathe.  But if so, something is wrong.  Nature gave us a nose for a reason.  We are not supposed to bring air into our bodies through the mouth; the nose is the preferred route.  Long ago, it was established in laboratory experiments, that lung function improves when the air is delivered to the lungs through the nose rather than through the mouth. 

So what are the reasons for this complete nose blockage?  There are a limited number of reasons why the nose does not allow enough air through it.  The first is that the passages are blocked from a previous injury.  When the nose is injured, the support structures cave in, become crooked and become an impediment to airflow. The nasal septum is broken, crooked, deviated. Often the injuries occur when we are young and so the adult patient has no knowledge of “normal breathing.”  They have only known complete nasal obstruction.

Another common reason is nasal allergy, particularly when it is superimposed upon an architectural deformity such as uncorrected broken nose.  The lining of the nose is very sensitive to certain allergens in the air.  For some people in springtime it is grass and trees.  For others it is indoor mold.   Others have very specific sensitivity to ragweed pollen which only grows in certain parts of the country.  But whatever the offending allergens, the nose blocks up because the lining swells.  Two normal structures within the nasal passages called the inferior turbinates are particularly subject to this.   The two inferior turbinates are larger than the four other turbinates can expand to nearly twice normal size.  Such a blockage within the nasal passages has dire consequences for breathing.

If you combine a deviated nasal septum as part of an uncorrected nasal fracture or just because one was born with it, with nasal allergies causing swelling of the lining and particularly thickening of the inferior turbinates, you have the setting for very poor breathing.

There is good new about this sad story, however.  Modern techniques of surgical correction sometimes in concert with certain simple medications can make a huge difference.  One of the most rewarding things for a surgeon is to give a patient his breathing back.  And, incidentally, when you give the breathing back, you also give the sense of smell back.  Because if air does not enter the nose, the smell receptors high in the nasal passages are not activated and the sense of smell is non-functional.  People think that taste comes from the tongue in the mouth but the reality is that the tongue has very primitive sensors that detect only salt, sweet and bitter.  But the actual aroma of food, for example, comes when air passes through the nose and stimulates the olfactory nerve which carries the sensation of smell to the brain.  Now you know why “food does not taste very good” when you have a cold.  Colds are temporary.  Think about those people who have permanent blockage and never have the pleasure of smelling a blooming rose or even a great dinner dish.

 

Dr. Kotler Featured in American Way

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The American Airlines Magazine, American Way, Features Dr. Robert Kotler and Dr. Stuart Linder

We all read the in-flight airline magazines while traveling.  Personally, I find them always interesting and I particularly enjoy American Airlines’ American Way mainly because of the Mensa quiz.   Those are real brain-teasing questions and I always try to pit myself against the smartest people in the world.

I also enjoy the feature articles. In the February 15 issue, for an article entitled Vacationing for a New You, Dr. Stuart Linder and I were honored to be resources. The well-written piece describes the influx of patients, from throughout the world, to Beverly Hills for their cosmetic surgery.  I won’t steal the thunder of the article’s content but rather suggest that you follow the link to it.  I think you will find it interesting and enlightening.

Incidentally, Dr. Linder and I represent somewhat of a new wave or new trend in cosmetic surgery.  I see it as a very positive trend for the specialty.  Each of us is a superspecialist.  I operate only on the face and neck; Dr. Linder only operates on the body. While I perform facelifts, eyelid surgery, nose surgery — both for appearance and function — and procedures chin augmentation, neck sculpting and ear pinning, that’s the limit of my procedures.  No reconstructive surgery.  No cancer surgery, no accident surgery, no major reconstruction.

Likewise, Dr. Linder performs only breast augmentation and reduction, breast lifting, tummy tucks and body liposuction.

None of us can be experts in everything and typically the best results always come from those specialists who further refine their practice within a given specialty. Only via such narrowing of practice scope can they become what we in the medical profession refer to as master surgeons. That should be the goal of every surgeon in practice.

 

Beverly Hills Cosmetic Surgery Fees

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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.