Category Archives: Septoplasty

Care Package After Cosmetic Surgery in Beverly Hills

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     Care Package After Cosmetic Surgery in Beverly Hills

“Care Package” is a term very familiar to many Americans regardless of interest in cosmetic surgery.  The original Care Packages were donations of food and supplies to the poor of war-ravaged Europe, beginning in 1945.  Americans, the most generous people in the world, not only helped prop up devastated Europe through the economy-boosting Marshall Plan, but individual Americans sent care packages to share with the less fortunate in England, France, and even to our former enemies, Germany and Italy.

Today, 60 years later, in the world of cosmetic surgery, the term Care Package has now become common parlance for a kit that contains all the supplies and medications necessary for home care after cosmetic plastic surgery.  Since cosmetic facial surgery including rhinoplasty, with or without septoplasty and turbinate resection to improve nasal obstruction, face and neck lifting, eyelid surgery, chin augmentation, neck sculpting, liposuction and chemical skin peel, are outpatient procedures – not hospital procedures.  It is important that patients have all the needed supplies and medications, at hand, at home.

I have always felt that it is incumbent upon the cosmetic plastic surgeon’s office to provide as much guidance and support for the post-operative care as possible, regardless of where the surgery took place: hospital, outpatient surgery center or office operating facility. I stressed that in both my books, SECRETS OF A BEVERLY HILLS COSMETIC SURGEON and THE ESSENTIAL COSMETIC SURGERY COMPANION.  For that reason, our home care package includes pain medication, antibiotics as appropriate, and all routine wound care supplies.  Such home care supplies would consist of nose sprays, both decongestant and refreshing saline or salt water. These are important after cosmetic plastic nasal surgery or functional nasal surgery including septoplasty and turbinate resection.  The kit has vitamin A&D ointment to be placed inside the nose to prevent crusting as well as small dressing pads placed under the nostrils to collect any drainage from the nose.

Dr. Kotler's post-op care kit given to his patients to take home after surgery

Dr. Kotler's post-op care kit given to his patients to take home after surgery

The Care Package for facelifting, eyelid surgery, chin augmentation and neck sculpture would include Q-Tips and ointment for application of the ointment to the incisions.   For chemical skin peel patients, there are additional supplies including special eye drops and large amounts of antibiotic ointment to be placed on the healing facial skin.

Procedure-specific written instructions are provided for each operation performed and are also placed in the bag.  Further, the patient has a listing of my home telephone and cell phone numbers so they can reach me immediately.

As I have always stressed to the young doctors I teach at UCLA and USC, the care of a surgical patient does not end with placement of the last stitch.

Beverly Hills Rhinoplasty Surgeon's Correction of the Pinched Nose Deformity

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Beverly Hills Rhinoplasty Surgeon’s Correction of the Pinched Nose Deformity

There are two means of correcting the pinched nose deformity.  Noses looked pinched or overdone because two much cartilage was taken out of the tip at the original surgery.  And, there are a few people who are born with this deformity.  In the case of the latter, the cartilages at the tip of the nose instead of being convex are concave. 

The solution is identical. Either cartilage is grafted or transplanted from either inside the nose or from the ear and placed underneath the skin over the existing cartilage or the pinch is corrected by incremental filling injections.

The decision whether or not to have surgery performed or use filling injections, which is an office procedure, must be made after a thorough analysis. If breathing is an issue and there are other deformities of the nose which cannot be corrected by filling injections, then surgery is indicated although often even after surgery, the filling injections are helpful to achieve an optimal result. 

I am very pleased with liquid silicone which is the permanent filling injection material.  On the cover of my book, SECRETS OF A BEVERLY HILLS COSMETIC SURGEON, you will see a young man who had very severe pinching on the left side of the nose.  While part of this overall unsatisfactory look was a deviated septum and poorly performed rhinoplasty previously, it was necessary to use filling injections on the left side.  The result speaks for itself.  Liquid silicone is permanent but must be injected gradually over a period of several months because it cannot be easily removed.

How This Beverly Hills Rhinoplasty Surgeon Corrects Asymmetric Nostrils

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How This Beverly Hills Rhinoplasty Surgeon Corrects Asymmetric Nostrils

Asymmetrical nostrils may present themselves before surgery.  That is why it is very important for the surgeon to conduct a very thorough evaluation and examine for asymmetries. More often than not, nostril assymetry is caused by a deviated nasal septum.  The septum, which attaches between the two nostrils, may be off-center and, therefore, influencing the size and shape of the nostrils. 

If the nostril asymmetry is caused by the deviated septum, then at surgery, correction of the deviated septum should correct the problem.  However, some people may have been born with asymmetrical nostrils.  Also, some people as a result of unpredictable healing after rhinoplasty, will have a difference in the nostril shape and size.

I believe the most practical, economical, expeditious and reliable technique to correct asymmetrical nostrils is to use a filling injection. The filling injection can be temporary such as Juvederm or Restylane or permanent such as medical grade liquid silicone.  The nostril that has the highest peak and largest size is filled to match the other side.

Interestingly, the eye recognizes asymmetries more than gross dimensions.  Therefore, it is very important that even though the nostrils may not be the perfect configuration then at least they can be made symmetrical to avoid detection.

Avoiding the Beverly Hills Rhinoplasty Saddle Nose

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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

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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.

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.

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.