Interviewing a Surgeon

Before having rhinoplasty surgery, you’ll have a consultation with your cosmetic plastic surgeon. That is your chance to ask him or her anything, from where the cosmetic surgeon was trained to the last time he or she flubbed a procedure.

The top 10 best questions include:

• In what board are you certified?

There are many bogus boards but you should listen for the only two that train cosmetic plastic surgeons: American Board of Plastic Surgery or the American Board of Otolargyngology (head and neck surgery.) Extra points: ask where the surgeon’s fellowship was.

• How many nose jobs do you do in a typical week?

Look for two to three weekly over the last 10 years.

• What is your policy on revision rhinoplasty?

Even in the best of hands, things can go astray. Ask who covers what expenses and fees in case you need a re-do or more work after surgery.

• What is your percentage of satisfied patients?

Read patient reviews on the surgeon’s website and the Internet; there should be many.

• Where are your before and after rhinoplasty pictures?

Look for patients who had changes like what you want. You should see many dozens, if not hundreds.

• Do you have computer imaging?

Surgeon and patient really get on the same page when computer imaging shows what you will most probably look like after healing.

• How long does it take to perform a cosmetic rhinoplasty like I want?

• How did you handle your last infection?

The national average for infections in plastic surgery is one percent. If the surgeon says he never had one, he’s not being straight with you. A board-certified nasal surgeon has seen every possible, off-the-wall wrinkle that can crop up and knows what to do.

• What kind of anesthesia do you use and how long does it take to recover?
• Do you think what I’m asking for is realistic?

Some patients like a particular nose, say, Brat Pitt’s, and tell the surgeon that’s what they want. But Brad’s nose on your face may look goofy; part of the art of rhinoplasty is to perform the changes you want while creating a nose that fits your face and flatters your profile.

In Surgery

One of the most common questions asked by nose job patients is: “After rhinoplasty, what should I do, doctor?”

Overall, don’t put any pressure on the newly rejuvenated nose. Some patients have even found that industrial protection type eye glasses are too heavy to sit on the bridge of the nose.

Our patients can wear contacts one to two days after cosmetic surgery; for those who must wear eye glasses, we show them how to suspend their spectacles from the forehead so there is no pressure on the nasal bridge; that continues for five weeks.

Most cosmetic plastic surgeons have lists of recommendations on how to care for one’s self after nasal surgery so be sure and follow those instructions.

It’s obviously also a good idea to stay away from any sport, hobby, pastime or person which could involve a blow to the nose.

Many are curious when they can resume regular workouts and exercise. For the first seven to 10 days after nose job surgery, let your body concentrate on healing and catch up on your reading although slow walking and stretching can start the day after surgery.

But exercise that really gets the blood going is not a good idea because increased blood pressure can lead to a bleeding nose and a possible increase in swelling and bruising. Another caution about nose bleeds: don’t blow your nose for the first 10 days after rhinoplasty surgery.

If you have stopped smoking for some weeks before rhinoplasty surgery, let the smokes lay unlit for a while longer – the nicotine in tobacco injures veins and reduces the blood flow which is needed to promote healing.

If you are fond of herbs, beware the “Four Gs”: garlic, gingko, ginseng and ginger. Those substances can affect blood clotting and a good cosmetic surgery result.

Catch up on your Z’s because adequate sleep ensures quicker recoveries. Also, mild pain medications, if needed, are usually available to help you sleep. Most patients find the nose is dry after surgery. But you can keep it better humidified by using saline nasal sprays.

Following doctors’ instructions usually means you are good to go in seven to 10 days….. although it may require a month for your breathing to reach its optimal level.

The rhinoplasty patient below had the bump on her nose removed while the scoop above the tip of the nose was corrected. (Robert Kotler, MD photo)

Before and After Rhinoplasty

2012 Cosmetic Surgery Trends

A major plastic surgery organization for surgeons worldwide, the International Association for Physicians in Aesthetic Medicine (IAPAM) queried its global membership, medical professors and other experts in aesthetic medicine to predict some of the major trends you are likely to see among plastic surgeons during 2012.

• Nonsurgical and minimally invasive cosmetic surgery procedures will top the charts.

Some experts say the economies of the major nations still dictate that many patients must forgo more expensive surgical face lifts for less expensive facial fillers.

But that’s always the nature of a recession: people learn to cut, squeeze, trim and make do with less until the good times start to roll again.

Also look for:

• Combination packages.

More cosmetic surgeons will offer medical skin care, facial injectables and laser conditioning in a single treatment package.

More cosmetic injectables: Botox will have more competitors that create the same wrinkle removing effects. Already, a rub-on Botox cream is completing clinical trials. Plus, new fillers like Belotero and LaViv may come into wide use. (Read more about LaViv, a facial injectable  made from the patients’ own cells.)

• More uses for neurotoxins.

Botox, Dysport and Xeomin are in a class of medications known as “neurotoxins.” As time goes on, more uses are found for neurotoxins which are now used to treat migraine headaches, stop excessive sweating and halt other medical woes. Already, according to the IAPAM, one professor is using Botox and Dysport together to reshape the face, instead of just removing its wrinkles.

One nonsurgical procedure that is rising on more patients’ radar screens: permanent, non-surgical rhinoplasty.

Used in cases where only the outside of the nose needs correction, a needle replaces the scalpel to fill in humps, depressions and other unsightly nasal marks.  And, for the many budget-concerned patients who have learned to do more with less, a non-surgical, permanent nose job costs a fraction of surgical rhinoplasty in both money and time.

Many patients with botched nose jobs are candidates for the procedure.

(Read more about permanent non-surgical rhinoplasty.)

Plastic surgery

It’s because the human nose is a 3-D structure which has supports, supporting walls and is extremely interconnected.  It’s also a procedure where less is more; most flubbed nose jobs are due to newer surgeons removing too much cartilage, tissue and, sometimes, bone.

With an estimate of some 20 to 25 percent of first rhinoplasties being botched, many patients worldwide ask for revision or secondary rhinoplasty.

And if a first rhinoplasty is hard, a revision rhinoplasty requires extreme specialization; it’s also because:

• More scar tissue exists in a failed rhinoplasty
• The nose looks different and no longer looks like nose pictures in medical texts
• There may be no more nasal cartilage to work with

So why is Beverly Hills a Mecca for excellent rhinoplasty revision and other plastic surgery?

• Beverly Hills is close to major university medical schools and top-rated hospitals

Medical schools often contribute the latest techniques because many Beverly Hills plastic surgeons are also university instructors.

• Los Angeles International Airport is less than half an hour away

Many European and Asian patients arrive in Beverly Hills in just one flight.

• Numerous types of cosmetic plastic surgery providers are clustered together (offering face lifts, neck sculpting, chemical face peels and other procedures) so seeing other doctors is easy; often, the other doctor is in the same building.

• Beverly Hills is geared to visitors

That city offers an admirable selection of “hideaway” aftercare facilities that are staffed for the cosmetic surgery patient resting up before seeing the surgeon the next morning.

(Look at a list of plastic surgery after care hotel-like facilities.)

Moreover, after a day or two, many patients can go out and see the sites in the only North American region – Southern California — that offers a true, year-round Mediterranean climate.

• Alternatives to surgery

If you only need cosmetic correction on the outside of the nose, you can opt for nonsurgical rhinoplasty. Many Beverly Hills cosmetic surgeons offer facial fillers like Juvederm and Restylane for nasal corrections but those injections must be repeated periodically to maintain the look.

Read more about permanent, nonsurgical rhinoplasty.

Nose Correction via Permanent, Non-Surgical Rhinoplasty

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.