Rhinoplasty Specialist Blog

Rhinoplasty specialist Dr. Kotler has performed over 4,000 nasal surgeries

Botox: Becoming a Spread-on Gel?

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'A middle aged woman rubs cream onto her crows' feet"

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.

Septoplasty & Turbinate Reduction Patients Speak

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"A beautiful woman shows only her nose and lips"

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:

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.)

Nonsurgical Chemical Wrinkle Removal

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"A woman about 60 shows her before and after chemical peel pictures"

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.

Nose Jobs of The Rich and Famous: Miss California

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"Miss California shows her nose job in before and after pictures

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 15th.  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:

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.

The January/February issue of Archives of Facial Plastic Surgery, a professional magazine for plastic surgeons is reporting additional benefits to a nose job that brings a face into better harmony. It may also make you look younger. A study of 53 patients found a rhinoplasty may make patients look 1.5 years younger.

(Read more about the nose job study.)

Cosmetic Surgery Myths: Top 6

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"A man is shown in front of a blackboard wondering if certains things are true"

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.

"A bogus picture purports to show plastic surgery in the womb"

Photoshopped Picture of in-the-womb Rhinoplasty

 

Cosmetic Surgery’s Most Quirky Patients

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"A very attractive woman checks her reflection in a mirror"

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.

(Read more about bogus cosmetic surgery patients in The Broken Mirror.)

Liposuction of the Neck — Enough?

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"A 40-ish woman shows the difference in her profile after a neck lift."

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.)

"A woman shows in her before and after pictures the huge difference a chin implant has made"

Before and After Chin Augmentation

Nose Job Costs in Beverly Hills

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"A stethoscope sits atop a pile of dollars"When computer searching for a nasal surgeon to perform rhinoplasty, some people click off when they see a Beverly Hills cosmetic plastic surgeon pop up in the search results.

The common fear? That much of the cost of surgical fees is only due to the location and the cheek-by-jowl proximity to Hollywood’s rich and famous.

But there’s more than meets the eye. Sure, business overheads in Beverly Hills – most particularly in the so-called “Golden Triangle” – are higher.

(By the way, our “Golden Triangle” has nothing to do with basketball, but is the 90210 area that is extremely dense in some of the most sophisticated surgical specialists known worldwide; basically, the “Golden Triangle” is a private practice medical campus with no hospital.)

Plastic surgery patients also find many outpatient centers for cosmetic surgery here so surgeons’ fees may be a bit higher but nowhere close to double or triple compared to other areas. Fees for Beverly Hills cosmetic surgery do not vary that much compared to, say, what a surgeon in San Diego or San Francisco charges.

Advantages to seeing these super-specialists who tend to congregate include:

  • Each is highly proficient in the handful of procedures he performs

Medicine today is highly specialized so the plastic surgeon who only does five to seven procedures does them faster, better and has seen every possible complication that can crop up; that surgeon disturbs less tissue so patients have less bruising and heal faster.

  • It’s easy to make a referral

While out-of-town patients come to us for rhinoplasty, cosmetic nasal surgery, repair of deviated septums and turbinate reduction (to allow for better breathing) they also want, say, breast lift, breast augmentation or breast reduction. While we are super-specialists above the collar bone, we know the surgeons – indeed, a handful are right next door! – who are top specialists in the procedures below the collar bone.

  • The closeness of major teaching hospitals

Many Beverly Hills cosmetic plastic surgeons also teach or lecture at the world-class medical schools at USC (University of Southern California) or UCLA (University of California, Los Angeles) as do we. Thus, we very quickly learn about new surgical techniques, medical tools, medicines and other technologies that can benefit our patients.

According to 832 rhinoplasty patients reporting on RealSelf.com, the average cost of a nose job is $6200. Of those patients, 78 percent said the procedure was worth it.

Our best guesstimate: while it may cost somewhat more to have a procedure done in Beverly Hills, you receive the best the world has to offer.

Nasal Surgery to Ditch a CPAP Machine

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"A haggard, sleep deprived man is shown wearing his CPAP mask with the tubing around his neck"

CPAP User

If your eye caught the headline on this post, you are probably either a CPAP (Continuous Positive Air Pressure) user or your bed mate is one.

Joked one 50-something CPAP user after having internal nose surgery: “Only my ex-wife thought the CPAP was great; she considered it an anti-adultery device!”

You must admit, the typical CPAP user going to bed, like the guy above, looks like he (or she, in fewer cases) is ready for high altitude flight or suffers from some strange breathing disorder.

For those who don’t know, a CPAP forces air through the nose into the lungs. The device is diagnosed when a person snores loudly, depriving the body’s organs of enough oxygen. (And we mean ALL the organs!)

But in the vast majority of cases, an internal nose blockage causes the snoring. Fix the block and ditch the CPAP machine.

Of course, snoring can be cause by other health woes, including:

  • Enlarged tongue
  • Short, receding lower jaw
  • Huge tonsils
  • Enlarged palate or uvula, that bit of worm-like flesh dangling in the back of the throat

A common blockage is a bent septum, the thin wall of cartilage separating the nostrils. A deviated septum often rambles from one side to the other, restricting airflow.

Another major red warning flag: enlarged turbinates, bony, flesh-covered structures higher in the nose that swell in reaction to allergies and other unknown reasons. Solution? Trim the turbinates to ensure good airflow.

If you:

  •    Snore
  •    Suffer frequent sinus infections
  •    Have allergy attacks or
  •    Use a CPAP

ask yourself: when is the last time a doctor looked up into your nose? It seems like an elementary course of action but it rarely happens for whatever reasons.

Here’s another hint: top nasal surgeons say that healthy breathing is quiet breathing. If you can close one or the other nostril and, with your lips firmly sealed, hear noise while breathing through that one nostril, you may be a candidate for internal nasal surgery.

A competent nasal surgeon (who is also usually a cosmetic plastic surgeon) can perform the internal nose surgery you need, with or without a cosmetic rhinoplasty.

Concluded our pal from above whose wife though he looked not-so-sexy in his CPAP mask:

“My new partner tells me I sleep quietly and soundly; the CPAP mask and machine now sit off-duty, in its bag in a dusty corner of the garage.”

"A man is shown before and after cosmetic rhinoplasty

Before and After Rhinoplasty and Internal Nasal Surgery for Better Breathing

Fat Injection? Facial Fillers? Which is best?

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"A closeup shows where a woman will have a facail filler to plump up signs of aging

Filling a Nasolabial Fold

So much is being written about fat transfer, (a cosmetic plastic surgery procedure that takes fat from where you don’t want it and applies it to where you do want it) that many are asking facial plastic surgeons:

  • Can fat injection be used to fill in grooves, folds and deep facial wrinkles?

The procedure is also known as fat grafting and fat transplantation.

Mostly, patients want the following filled:

  • The nasolabial lines, running from the corners of the nose to the corners of the mouth
  • The sardonically named “drool lines” that run from the outer edges of the lower lip down the chin

Also responsible for normal facial aging – and open to fat grafting — are sunken cheeks and hollow, under eye areas.

Fat transfer is extremely time-consuming: the surgeon must liposuction a donor area – usually the tummy or the buttocks – then filter and prepare the fat for injection.

The plastic surgeon then painstakingly places dozens, if not hundreds, of fat droplets through layers of tissue and muscle.

The key to lasting fat transfer is finding a blood supply. Top practitioners say droplets of fat no larger than a small pearl stand the best chance of surviving.

Long story short?  Sometimes fat transfer works as intended. At other times, transferred fat is absorbed into the body.

Cosmetic Surgery Times, recently interviewed two top cosmetic surgeons, one of whom is very pro-fat transfer while the second is decidedly not.

Observed the more skeptical cosmetic surgeon, Val Lambros, MD, about another rarely mentioned consideration: “Injected fat can also grow.”

Will that become a problem over time?

Meanwhile, the fat grafting advocate, J. William Little, MD, says that rejection does not take place because the transferred fat is your own natural tissue.

However, transferred fat can’t be removed. What happens if injected fat on one side of your face grows while the fat on the opposite side stays as is?

(Read more about the virtues and vices of facial fat grafting.)

Meanwhile, cosmetic plastic surgeons offer a handful of facial fillers that are proven to be reliable, predictable and, not least, wildly popular with consumers. Those fillers include:

  • Juvederm
  • Radiesse
  • Sculptra
  • Restylane

With the exception of Artefill, the fillers are absorbed into the body, but you know what you’re getting.

Sculptra can last up to five years in some cases although it requires several months for results to appear.