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.

Nasal Exam

Regular readers of our blog posts already know a CPAP is a face mask and machine for people who snore, often due to problems inside the nose that block healthy breathing.

But, as a curious cosmetic plastic surgeon, we also scan forums and bulletin boards for news about CPAP (which stands for “continuous positive air pressure,” a fancy way of saying “forcing air into your lungs through your nose”.)

So we note some users have found that nasal surgery makes their CPAP work even better.

The basic start of all this is raw snoring….ear-splitting, freight train decibel, nocturnal snoring that makes the bedroom curtains flap in the breeze and can be heard downstairs, if not the next house.  Pity the sleep-robbed mates of snorers.

Snoring can have many causes but some of the most common are:

• A deviated septum
• Swollen turbinates, structures higher up in the nose

A septum is the thin wall of cartilage that separates your two nostrils. When bent, twisted or otherwise deformed, they can block the breathing channels in the nose.

Turbinates warm and humidify the air you breathe. But they often react to allergies and other conditions by swelling, again blocking healthy, quiet breathing.

Curious about the numbers of healthy and blocked breathers, The University of Washington’s Sleep Disorders Center studied 306 CPAP users for two years. They wanted to find why some did not wear the CPAP mask regularly. (Read more about nose surgery and CPAP use.)

After exams, 108 patients showed abnormal nasal exams and were also the same group who did not use the mask correctly, if at all. The study authors concluded patients with abnormal nasal exams had decreased CPAP use and tolerance.

Concluded the authors: why not treat nasal conditions before prescribing a CPAP?

Yet another study at the Stanford Sleep Disorders and Research Center in Palo Alto, California, found that turbinate treatments, when appropriate, appear to benefit nasal obstruction and ease the breathing of CPAP users.

But before you say “yes” to a CPAP, ask yourself if any medical professional has actually looked up into your nose to see and diagnose the state of your nose and if its internal architecture allows for easy, quiet breathing.

Perhaps that would be the best first step possible!

Injection Rhinoplasty

Quite a few rhinoplasty surgeons offer non-surgical (or injection) rhinoplasty. But does it last?

Facial fillers like Sculptra, Radiesse, Juvederm and Restylane are often used. But they dissolve back into the body within six months to a year. That means more trips back for additional injections and more time lost from work.

But, permanent injectable fillers last as long as you do. To date, there are only two for the face:

• Artefill
• Silikon 1000

While Artefill is intended for the deep creases, lines and age-revealing folds in the face, Silikon 1000 is used for permanent nose jobs done by injection. And that’s only if you need correction on the outside of the nose.

With Silikon, you can get a preview of coming attractions.

If you have divots, marks, scars, pocks, a nasal hump, a low bridge or other marks on the surface skin of the nose, only a few U.S. rhinoplasty specialists offer Silikon 1000 corrections. The very best surgeons can show you what your nose will look afterwards by using sterilized saline – plain old salt water – to reveal what the Silikon 1000 injections will do for your nose.

Saline improvements last perhaps an hour, long enough to snap a few pictures. Compare the saline test shots with pictures showing the nose in its natural, unrepaired state and then decide if you want to make it permanent.

Silikon 1000, a medical grade silicone, is used in internal eye surgery. A standard, approved and legal part of any medical practice – including those of cosmetic plastic surgeons – is using a substance or technique “off-label”.

Meaning? While the substance has not been tested by the FDA for that particular use, it is the best treatment available to the doctor who has seen it work in many patients.

Some history:  Silikon 1000 for injection rhinoplasty has been used successfully in nasal skin improvements for the last 50 years. According to scientific literature, the secret is placing tiny micro droplets just under the skin to plump out and disguise hollow places.

(Read more about permanent, non-surgical rhinoplasty in Plastic and Reconstructive Surgery, a professional magazine for plastic surgeons.)

For instance, a nose with a large hump can be made to look straight again using no more than 1/8^th of a teaspoon of Silikon 1000 injected at many different locations on the nose.

The body walls off the tiny micro-droplets, creating a plumping action that fills in humps, scars, lines and other marks on the nose.

Before and After Non-surgical Rhinoplasty

The woman’s nose, left, caved in from a failed surgical rhinoplasty done elsewhere. Right, the results of permanent non-surgical injection rhinoplasty. No further surgery needed.

Crows' Feet, Begone!

Plastic surgery researchers are always looking for new and better ways of doing things cosmetic.

For instance, surveys show that many people dislike and avoid needles, although needles on surgical syringes have shrunk to virtually nothing and are even coated with special materials so that a puncture is barely felt.

Some plastic surgery researchers have even developed syringes that blow a blast of numbing frigid air just before the needle touches flesh. (Read more about cosmetic surgery ouchless needles.)

Plus, smaller, less painful needles can be used on all types facial fillers.

Other Botox, Dysport and Xeomin (the newest wrinkle fighter) users also say they don’t like needles anywhere near their eyes.

Plus, if unskilled practitioners inject too much Botox, the wrinkle killer can spread under the skin and make an eyelid droop, cause an eyebrow to sag or result in a partially drooping lip that might make you look like you’re pouting. Too much Botox, Dysport, or Xeomin injected into the crows’ feet in an overdose can result in dry eyes. And, bruising at the injection site is always a concern.

Now in stage II clinical trials, a California company is developing a gel that smooths crows’ feet very much like Botox, but without injections. Instead, the substance – now known only as RT001 — is spread on like night cream or sun block…. by a cosmetic plastic surgeon.

But don’t hold your breath just yet; it may be several years before the next, and final, round of clinical trials of topical Botox are finished.

According to the manufacturer, Revance Therapeutics in Mountain View, California, RT001 has been in 11 clinical trials that treated 550 research subjects.

Researchers found the active ingredient, the muscle-paralyzing botulinum toxin type A, does not cross through the skin. But, when combined with another substance – in this case a coating of something known as peptides – the wrinkle fighter penetrates the skin to stop muscle actions resulting in facial wrinkles.

In the latest RT001 tests, about half of patients and researchers saw a huge improvement (from severe to mild) in crows’ feet after a month. About 89 percent saw a modest improvement. Just to make sure they were on the right track, some researchers painted botulinum toxin right on the skin. But nothing happened.

When RT001 goes onto the market – under a more attractive name, of course – it will only be used by doctors and not available for home use.

The function of the nose: to breathe

If you read plastic surgery bulletin boards and forums dedicated to people who have trouble breathing, you’ll discover that the real cause of their breathing woe is usually a surprise.

For instance, Kilgore T. writes: “I just had too many episodes of Afrin addiction due to swollen turbinates.”

(Background: turbinates are bony, flesh-covered structures high inside the nose. Turbinates often react to allergies and other “insults” by swelling and blocking healthy breathing.)

Afrin shrinks nasal tissues but has bothersome side effects like keeping you up all night because it’s an upper and causing mens’ sensitive tissues to swell.

The proposed solution to bugbear breathing: turbinate reduction surgery. Kilgore asks fellow bad breathing sufferers to:

• Comment
• Commiserate
• Share experiences about lousy breathing and internal nasal surgery.

Kilgore’s headline was: “Nose Surgery – CPAP usage and effect on apneas?” He’s asking if he would breathe well.

(Yet more background: CPAP, short for Continuous Positive Air Pressure is a machine that forces air through the nose and into the lungs; a CPAP is worn in bed at night.

Read more about CPAP and nose surgery.

Squid13 tossed in his two cents worth: “I had the surgery…they packed my nose with gauze for a couple of days and then removed it…in four to six weeks (the nose) good as new and boy did my breathing improve…make sure you go to a doctor who knows what he is doing, as too much turbinate reduction can lead to very deleterious results, i.e. empty nose syndrome.”

Added SleepingUgly: “I had septoplasty and turbinate reduction. It had great benefits to me (sic) in terms of being able to breathe through my nose…I have even gotten less sinus infections since the surgery.”

Commented Kitatonic: “(my doctor) stated nasal surgery should be done if the goal is to improve your daytime breathing.”

But Dale92 put a nice cap on Kilgore T.’s question: Pens Dale: “I had turbinate reduction on my right side and my deviated septum fixed in 2004. Before this, I was unable to breathe through my nose for most of my life except for periods of Afrin use which caused even more problems. Finally, I was able to breathe!…Like I said, it was the best thing I had ever done to improve my health…I would gladly do the surgery again.”

You can also have a cosmetic nose job during the same procedure.

(Read the internal nose surgery comments in full.)

Chemical Peel for Wrinkle Removing;( Surgery for neck & jaw line sagging)

In one of the first episodes of Dr. 90210, we (cosmetic plastic surgeon Robert Kotler, MD) had a patient with a very low-tech procedure.

Despite a wonderful array of all type lasers, Fraxel machines, UltraSounds, radio frequency, Velosmooth and Intense Pulsed Light devices along with other high-tech wizardry, we were filmed applying a strong chemical peel solution on the woman’s face.

(Look at more Dr. 90210 episodes.)

The client was heading into – if not beyond – her late 50s, getting married and wanted to look good. But she did not want surgery.

Thanks to massive advertising and marketing of many wonderful and some not-so-wonderful machines in cosmetic plastic surgery, chemical peel has been done in the United States for over a half century.

But its popularity becomes evident if you glance at the annual statistics for the procedures done in 2010 and see that 1,144,865 patients opted for chemical peel, according to the American Society of Plastic Surgeons (ASPS.)

We once co-authored a medical study with a leading UCLA dermatologist comparing lasers and the Kotler technique of chemical peel. Published in the professional journal Dermatologic Surgery, the study found chemical peel superior to the most powerful laser. (Read more about the chemical peel v. laser study.)

We also authored a textbook, Chemical Rejuvenation of the Face which some have dubbed “the Bible” of chemical skin peeling.

Who needs chemical peel? Anybody who wants more youthful, refreshed-looking skin due to age and sun spots, wrinkles, deep lines and crows’ feet. (Look at some before and after chemical peel pictures.)

The best candidates for chemical peels include those with:

• Fair skin
• Blue or green eyes
• Natural red or blonde hair

Those people often have thin skin which crinkles easily, especially around the jaws, mouth and chin.

On the other hand, the darker the skin, the thicker the skin and less wrinkling.

While chemical peels are nonsurgical, they are not “instant”. Usually, the procedure takes about two hours under general anesthesia with another one to two hours are required for recovery.

Eight to 10 days may pass before going back to work is O.K. Patients’ faces may still be reddened at 10 days after surgery, but surgical makeup can mask the redness.

Healing continues over several months when new fresh, tightened, unwrinkled pink skin can be seen. Care must be taken about going into the sun afterwards, because too much sun probably caused the premature facial skin aging.

Miss California Before and After Rhinoplasty

When the new Miss California, Natalie Ann Pack, was a kid bouncing on a trampoline, her brother mistimed a bounce and smacked Natalie in the nose with a knee. The result: Natalie’s broken nose.

Nonetheless, Natalie went on to model and was named Miss California, January 15^th.  A broken nose leads to other medical problems as well, probably restricting her breathing. If a broken nose is not treated within about ten days, the broken bones heal as they are, often creating twisted nasal passages that restrict healthy breathing.

Other people in the same boat as Natalie are often those with:

• A deviated septum
• Enlarged turbinates
• Claims of four or five sinus infections a year
• A CPAP (continuous positive air pressure) machine
• Sensitivity to allergies

The plastic surgeon who performed the procedure blogged: “Natalie was concerned about the asymmetry of her nose as well as an overall feeling of visual heaviness.”

Last year, Natalie got a functional and cosmetic rhinoplasty, creating a better nose and taking care of some internal blockages that prevented healthy breathing.

Results? Natalie’s health profile improved. She told an interviewer about the effects of her nose job: “I can breathe, I don’t get headaches, I can sleep, the modeling pictures are better.”

Natalie’s plastic surgeon, quoted in the Orange County Register, said “she went from a nine to a 10” on the beauty scale

So why does a nose job make a person more beautiful? Or handsome? Because the nose is so prominent, it dictates how the eye takes in and “sees” a face.

When a nose is larger or swollen and thick as was Natalie’s, the eye mostly sees – and often gets stuck on – the person’s nose.

But when a nose is proportional, balanced and fits the face and profile, our eyes move up to take in the eyes and then the whole face. The person just looks better to us.

Many rhinoplasty patients opt for adding a little bulk to their receding chins, making their appearance go from never to constantly noticed and appreciated. However, Natalie’s chin needed no augmentation.

Bogus? True?

A few years ago, a Denver newspaper reported that a very large man with big hands had “whittling” plastic surgery on his thumbs so he could better text on his iPhone. The procedure, supposedly known as a “thumbioplasty” went viral and was reposted everywhere. For extra oomph! the doctor who developed it said “thumbioplasty” was improving workplace efficiency.

Results? The red-faced newspaper had to eat its own words; the story was a hoax. (Read more about the bogus plastic surgery thumb procedure.)

Non-existent cosmetic surgery procedures aren’t the only myths to become widely believed. Here are five more that still circulate.

• Cosmetic surgeons are also plastic surgeons

Nope. In the US, anyone with an MD degree can offer cosmetic surgery. A plastic surgeon must have four to seven years extra surgical training after the MD degree plus board certification by the American Board of Plastic Surgery or, for head and neck cosmetic plastic surgery, certification is issued by the American Board of Otolaryngology/Head and Neck Surgery.

•    Cosmetic surgery isn’t safe.

Actually, safe cosmetic surgery is routinely done. Countless measures have been put in place to make rejuvenation surgery as safe as medical science can make it. When things go south, it’s because somebody has cut corners or has not followed safety rules.

•    Plastic cosmetic surgery involves no scarring

Wrong. Any time a scalpel enters flesh, a scar will result. One of the arts of plastic surgery is putting scars where they are hidden or not noticed. For instance, is the typical neck sculpture, the surgeon does virtually all his work through an incision under the chin, one that faces your shoes.

•     Facial fillers are the same as a face lift

Not so. The vast majority of facial fillers (like Juvederm, Restylane, Radiesse) plump out folds, deep creases and lines but soon dissolve. However, a surgical face lift provides a more rested and youthful appearance for a much longer time.

•    Plastic surgery in the womb

One of the most outrageous myths circulating about plastic surgery supposedly told how a fetus had a nose job in the womb. A wag who was handy with Photoshop started the hoax with a sonogram of a fetus with a long nose in the womb. He or she then worked his pixel magic and created an after rhinoplasty picture, below, in which the fetus had a picture-perfect nose that flattered its profile.

Photoshopped Picture of in-the-womb Rhinoplasty

She Doesn't See What You See

We recall well the day a very attractive woman in her 50s came into our office complaining that:

• Her nose was too large
• Her skin too wrinkled
• She is just too unattractive

But we saw a completely different picture sitting across from us. Actually, her nose was proportional for her face and had very few imperfections. Her facial skin did bear a few wrinkles but she was by no means disproportionately aged.

It soon dawned on us that patient was suffering from an odd psychological affliction known as Body Dysmorphic Disorder (BDD). Regardless of my evaluation (which would have been no cosmetic facial surgery needed because her features cannot be improved upon) she would still see herself as unattractive.

BDD causes sufferers to perceive themselves as ugly even if they are beauty contest winners. The quirky condition also drives sufferers to visit many plastic surgeons and cosmetic dentists, requesting cosmetic procedures to rejuvenate body features that are already attractive.

But regardless of the changes or number of surgeries, they are never satisfied and continue to see themselves having a highly flawed, off-putting appearance.

The problem is widespread, not only in cosmetic plastic surgery but in dentistry. Researchers in Australia, for instance, studied the BDD syndrome and came up with a special test, The PreFACE, which will flag troublesome patients who are likely to view themselves as grotesque, regardless what others may see. (Read more about the test that screens out bogus cosmetic surgery patients).

A book, The Broken Mirror, is a result of many years study on BDD and reveals the common facial surgical rejuvenations most requested by this unfortunate lot:

• Rhinoplasty – 36 percent
• Skin refreshing like Botox, Chemical Peels or Juvederm – 73 percent
• Eyelid lifts – 20 percent

Of course, ever alert and on-their-toes plastic surgeons already know common questions to ask to get an insight into how the patient is thinking.

One of the most common: “What is goal of the surgery you are requesting?”

One OK answer might be: “I don’t want to look too haggard in the workplace.” Another might be: “I was divorced and am ready to start dating again.” Or: “My large nose has always bothered me.”

But if the patient responds he or she just wants to feel better, the only thing forthcoming from the wise plastic surgeon is a referral slip to a good psychologist.

Neck Sculpture, Conservative Rhinoplasty and Chin Implant

We frequently receive inquiries from budget conscience but appearance-minded readers about having neck liposuction.

Long story short: most patients, even including thin patients, are usually disappointed with the results of liposuction only on a naturally aging neck.

In virtually all cases, the platysma, (PLA-tis-muh) a long muscle that runs from the shoulders up to the chin, has stretched and is sagging.

The key to a more youthful and rested look is shortening that muscle to remove its:

• Laxity
• Sagging
• “Turkey gobbler” look

A neck sculpture also includes some liposuction and can be done alone or in connection with a face lift. (Read more about the neck lift procedure.)

First the liposuction: the cosmetic surgeon makes an incision under your chin so the scar can’t be seen later. Then, the shallow layer of fat in the neck is liposuctioned away except for a naturally occurring section of fat found deeper in the neck that does not respond to liposuction. That fatty area is removed with surgical tools.

After that, the cosmetic plastic surgeon turns his attention to that long platysma muscle which has been making you look older than you feel. The platysma is also a very broad muscle so it is heavy.

(You can feel your platysma stiffen if you forcefully draw down the corners of your mouth. The platysma also creates expressions of sadness or fright.)

Using surgical tools designed for the procedure, the surgeon shaves the excess from the platysma and then stitches the two edges together to form what is basically a sling or corset of muscle. That internal tightening is the key to a long-lasting result that gives you a more natural looking, smooth neck.

Plastic surgeons also have a great eye for balance; so if you have a receding chin, your facial profile will be out of balance as was the woma’s below. This would be the opportune time to have a chin augmentation (with a chin implant) to bring out the best in your features.

A neck sculpture procedure is more involved than liposuction alone but it does much more. We frequently see patients who only had neck liposuction but were very disappointed with the result.

What’s more, neck sculpture may even be good for you!

According to a recent article in Science Daily, researchers found that removing a portion of the platysma muscle may ease symptoms of chronic neck stiffness and a few other maladies.

(Read more about medical benefits of neck sculpture.)

Before and After Chin Augmentation