Tag Archives: top surgeons.

Botched Nose Jobs

"A Rugby player shows his thrice broken nose in a close up"
Twisted outside = Twisted Inside

The most recent episode of Botched, the E! Channel’s latest offering of plastic surgery tales in the “Golden Ghetto,” (Beverly Hills) introduced Paul, a late 20 or 30-something married guy who had suffered, not one, but two botched nose jobs.

The most recent left his nose twisted to the left; moreover, he had a noticeable hump on his nose. So he was in for a revision nose job.

          (See some before and after revision nose job pictures.)

Among plastic surgeons, a common saying is: “A nose twisted on the outside is almost always twisted inside, too.”

Besides looking a tad strange, it means that Paul’s breathing is also affected. Additionally, he suffered chronic migraine headaches that left him tired and unable to play with his children as much as he would like. Functional surgery straightens out the breathing channels

          (Read more about functional surgery.)

But aren’t two botched nose jobs unusual?

Actually, one of the major professional societies for facial plastic and cosmetic surgeons estimates that 20 to 25 percent of all nose jobs are botched. Rhinoplasty is immensely difficult and not a job for beginning surgeons.

          (Read more about the high rate of botched nose jobs.)

So many botched nose jobs creates a huge need for revision (medicalese for a surgical re-do) nose jobs, which are harder yet. And even some of the revisions are revised. Top Beverly Hills nasal surgeons often see patients with anywhere from three to seven previous failed nose jobs.

         (Learn more about revision rhinoplasty.)

Sure enough, when the plastic surgeon duo stars of Botched peered into Paul’s nose, they found his septum leaning far into a breathing channel.


On the first  picture panel  Paul shows his crooked nose. The second before  and after profile panel  shows the hump removal. (E! Channel Photos)










Paul thought the surgery was going a little far because the surgeons needed some rib-donated cartilage to straighten Paul’s nose. It’s commonly done in rhinoplasty surgery, but Paul’s wife was a bit alarmed.

Said one of the Beverly Hills plastic surgeons: “Paul is a handsome guy, but his nose is basically on the left side of his face!”

True enough to the half hour T.V. segment, Paul’s cosmetic and functional nose surgery features were all resolved in thirty minutes.

In real life, a patient like that can go out in public again in, say, five days after a nose job while your revised nose should be pretty presentable within eight days including bruise remediation, if any. Still more healing goes on for a year.

Nose Jobs Gone Wrong

"A lovely woman has her face and nose bandaged after surgery"
Nose Job Gone Wrong?

Most of the media love bad news. Most T.V. stations play on humans’ ancient fears of bad news by using a “If it bleeds, it leads” philosophy for which news stories are selected for airing.

Thus, the sad, sad story of the Oklahoma patient who emerged from nose surgery with no nose at all seemed to lead medical news everywhere.

But a close reading of the story reveals the patient already had 21 nose jobs before going in for yet another. That’s probably more nose job work than singer Michael Jackson ever had!

But there is always a lesson to be learned when a rhinoplasty surgery goes wrong. The lesson here? Probably poor choice of cosmetic plastic surgeon for the first nose job.

Unspoken truth: any rhinoplasty is very involved surgery that becomes increasingly more difficult by leaps and bounds after a first or second nose job.

Nose surgery involves different types of the body’s tissue – most notably bone, flesh, fat, nasal skin and cartilage, all wrapped tighter than the innards of a fine Swiss watch.

Surgeons adept at the procedure think in terms of less-is-more because the tiniest changes in millimeters inside the nose can make a huge difference in how a nose looks after surgery and healing.

So what does that mean to the consumer?

While missing an entire nose – due to an infection — is a larger than life mistake, somewhere between 20 and 25 percent of all first nose jobs leave patients unhappy with the results while many more set out looking for a Master Nose Surgeon to repair the damage in a revision rhinoplasty.

But by the time 21 surgeries had already been performed, skilled, knowledgeable nasal surgeons would probably turn down the opportunity to operate.

After all, only so many revision surgeries can be done on one nose.

(Read what happens before and after rhinoplasty.)

Why? They knew things would not turn out well.

It’s no secret among top nose surgeons that, after a certain, point Michael Jackson went from one nose surgeon to another until he found somebody, anybody who would do yet another rhinoplasty.

Do you suppose that final cosmetic surgeon had the best qualifications and the most skilled hands?

Before Surgery: Extra Training Pays Big

"Two doctors warmlly shake hands"
Welcome to Fellowship Training!

We’ve always said extra training in cosmetic plastic surgery pays, and pays big.

We knew that when, as a younger surgeon, we signed onto a fellowship with a highly experienced plastic surgeon for a year of hands-on training at the side of a Master Surgeon.

Consider it on-the-job training writ in super-scrip.

Results? As a super-specialist, (that’s not a boast, but an actual medical description of a skill level ) we have specialized in surgeries of the nose, performing over 4,000 procedures of the nose, including:

  • Rhinoplasty
  • Revision rhinoplasty (after a first nose job done elsewhere failed.)
  • Ethnic nose surgery
  • Surgery to repair breathing difficulties
  • Non-surgical rhinoplasty

To illustrate, a new study compares the results of general surgeons with surgeries done by board-certified plastic surgeons who spent an extra three to seven years after the M.D. degree training in rejuvenation surgery only.

Printed in the current Plastic & Reconstructive Surgery, a medical journal, the study looked at the complication rates of 954 panniculectomy surgeries, the procedure to remove sheets of loose skin and fat, hanging from the stomach to the pubis after morbidly obese patients have dropped large amounts of weight.

A panniculectomy requires long incisions on the abdomen to remove the huge aprons of skin that hang down to the thighs in some cases.

(Read more about the paniculectomy cosmetic surgery.)

The American College of Surgeons conducted the survey and crunched the numbers.

The overall complication rate for non-plastic surgeons measured 23.08 percent while the board-certified plastic surgeons turned in a rate of 8.65 percent.

In infections, the non-plastic surgeon group showed a rate of 12.69 percent while the rate for board-certified plastic surgeons was 5.33 percent.

The study also figured the odds of having any complication after surgery done by a non-plastic surgeon at 3.23 percent while a patient had 1.25 percent chance of complications after a board-certified plastic surgeon’s procedure.

Concluded the study authors: “..data showed that panniculectomy performed by plastic surgeons results in a lower rate of overall post-op complications compared with that performed by non-plastic surgeons.”

Which surgeon would you choose?

Now, we don’t perform cosmetic surgery of the body, but the principal of specialized training holds true in all of cosmetic plastic surgery, including surgeries of the head and neck.

Performing one surgery over and over for years can only make a surgeon more efficient and lead to better outcomes, be they body surgery, eyelid lifts or nose jobs.

(Read more about the study on the cosmetic surgery procedure, panniculectomy.)

Nose Surgery and Operating Room Safety

"A clean, well-lighted modern operating room is shown"Before nose surgeons and other cosmetic plastic doctors worry about creating a better appearance in the operating room, they turn their collective minds to one, important bottom line principle: patient safety.

Recently, USA Today ran a long article about patients who reported for what they thought were minor cosmetic procedures but ended up disfigured, disabled or worse. (Read more about USA Today’s take on supposed “minor” cosmetic surgery procedures.)

After making sure your surgeon is board-certified in the area of his or her practice, ask where his or her hospital privileges are. (That means patients can be quickly admitted if suddenly needed.) Also ask a few questions about where the nose surgery will take place.

Several types of surgical center certifications are in use. Common to all are backup systems in case something goes wrong during nose surgery or any other procedure.

Start with the lights. In case electricity fails, a certified operating room has a backup emergency generator. Many have a battery backup system that provides electricity in case the generator fails.

Everybody involved in a certified surgical center takes part in fire drills twice yearly. (Continued below.)


In the patient below and right, a nasal hump has been removed via surgery through the nostrils only while an invisible incision was placed under her chin for chin augmentation. (Robert Kotler, MD, photo.)

"One picture shows the patient before surgery, a middle panel shows a computer-predicted photo while a third shows the actual surgery result"
(L to R) Before Surgery, Computer Predicted Photo, Actual After Surgery Picture


(Continued.) One, rare condition bedevils plastic surgeons and anesthesiologists because patients themselves don’t know about the allergy. Known as malignant hyperthermia, the condition strikes when a patient violently reacts to general anesthesia. Although the reaction happens perhaps once yearly somewhere in the United States, all certified surgical centers must keep on hand an expensive drug, Dantrolene, to counteract the effects of malignant hyperthermia. The vast majority of Dantrolene stocks expire unused and must be replaced.

Dozens of other backups are required and subject to surprise inspections.

The gold standard of O.R. certifications to many medical professionals of  is known as JCAHO (Joint Commission Accreditation Health Organizations) or more often just “The Joint Commission” which also certifies hospitals.

Yet another common O.R. certification is known as AAAHC (American Accreditation for Ambulatory Surgical Facilities.)

Still another, alphabet soup certification organization, AAAASF (American Association for Accreditation of Ambulatory Surgical Facilities) inspects surgery centers with a watchful eye on patient safety.

Another common practice common to certified operating rooms: the existing life-saving equipment is checked daily, with the checking staff person signing his name, date and time.

After you know you are as safe as science can make it, you can look forward to the completion of nose surgery.

Cosmetic Plastic Surgeons: Finding the Very Best

"A master surgeon operates with an apprentice at his side"
Master Surgeon and Apprentice

When searching for a plastic surgeon, most potential patients look at the usual markers of excellence, including:

  • Before and after plastic surgery pictures
  • University training
  • Board certification in plastic surgery or head & neck surgery

But, due to a quirk in the way today’s plastic surgeons are trained, there is a key in surgeons’ credentials which, when found, unlocks access to master plastic surgeons. (Continued below.)_________________________________________________________________________________________

The middle aged patient below had the bump on the left photo removed along with refinement in her bulbous tip that brought her nose closer to her face. Result on right? A near perfect profile. (Robert Kotler MD, photo)

"Middle-aged woman shows results of rhinoplasty and a new nose"





(Continued.) It’s the fellowship. Here’s why it’s so special:

University training of a plastic surgeon takes place in a residency program at leading universities for anywhere from three to five years. But in almost all programs, the emphasis is on reconstruction surgery where surgeons learn techniques like:

  • Burn treatment
  • Repairing cleft lip and palate
  • Other procedures restoring normal function to non-normal, damaged anatomy

Due to slim university budgets, however, universities must train plastic surgeons and receive medical insurance payments, too. But cosmetic patients are wont to see surgeons-in-training for rejuvenation surgery (medically known as making the unhappy, normal happy with their appearance) because patients want top results.

So the question is how can a university trained plastic surgeon also master cosmetic surgeries like:

  • Rhinoplasty
  • Other nasal surgery
  • The popular cosmetic procedures like face lift?

Here’s where the fellowship enters the picture, even if the newbie surgeon is already board-certified in plastic surgery.

The fledgling plastic surgeon agrees to work at the side of an older, much more experienced cosmetic plastic surgeon who has decades of experience performing four to seven rejuvenation procedures that make a person look better. In short, the fellowship is a hands-on apprenticeship.

Most fellowships last a year while some others go on for two years. (Read more about plastic surgery fellowships.)

The apprentice plastic surgeon, in addition to doing surgery at the side of the master surgeon, may also do some medical research tasks, using the older surgeon’s patient base.

Typically, the younger surgeon will sift through all the data on the master surgeon’s nose job patients to, say, compare the healing rates of open rhinoplasties against closed rhinoplasties. When the research appears, the apprentice will have his or her name listed as a co-author on prestigious medical journals.

It’s a time-honored way for apprentices to learn skills and practical knowledge to become yet another master surgeon after a decade or so of experience is under the belt.

That’s yet another reason for selecting a plastic surgeon who specializes or super-specializes in just a handful of cosmetic plastic surgery procedures.