Dr. Kotler's Cosmetic Surgery Blog

The latest insights and ideas from Robert Kotler, MD

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Sep 22

Non-Surgical Rhinoplasty: How It’s Done

"A Chinese woman shows the results of non-surgical rhinoplasty in before and after pictures"

Non-Surgical Rhinoplasty, Before and After

Many patients who have had a failed nose job often wonder how a nose is corrected via non-surgical rhinoplasty.

In a handful of places in the United States, cosmetic plastic surgeons and a few dermatologists have mastered using a syringe and a permanent filler to correct defects on the outside of the nose.

A medical grade liquid silicone, an FDA-approval product, is used “off label”, to permanently plump nasal defects and mask irregular places on the nose’s surface, including:

  • Low places
  • Dips
  • Divots

Liquid silicone can also be used to correct nasal imperfections after one or more failed nose jobs, substituting for rhinoplasty surgery.

Trade names for medical grade liquid silicone include:

  • Adatosil
  • Silikon-1000

The substance’s original FDA-approval was for use inside the eyeball for detached retinas. A drug or product used inside the eye infers a high level of safety and duration.

Here is how liquid silicone helps the nose during non-surgical rhinoplasty: In the office, micro-droplets of liquid silicone are injected under the skin, using a short, extremely fine-gauge needle — as wide as five human hairs – just under the skin but over the bone or cartilage skeleton of the nose.

          (Look at some more before and after non-surgical rhinoplasty pictures.)

One micro-droplet injection deposits 1/8th the amount an eyedropper dispenses in a single drop. Before the injections used in non-surgical rhinoplasty, the skin is anesthetized.

The classic filler technique, used in the United States for 50 years, gradually builds up nasal depressions to a normal level. The silicone is layered in over time.

In a typical non-surgical rhinoplasty, a tiny amount is injected into the same location, at a minimum of six-weeks apart until the defect is plumped out and corrected. After three to five visits, the nose then will look natural, without any other marks or scars.

The nose is considered an ideal location because hardly any movement takes place.

With a 50-year, highly successful track record, liquid silicone remains one of modern medical chemistry’s great achievements.

          (Read more about the science of liquid silicone in non-surgical rhinoplasty during the last 50 years.)

"A woman holds some herbs which can not be used in facial surgery"

Sep 11

Facial Surgery Patients: Too Many Herb Supplements?

"A woman holds some herbs which can not be used in facial surgery"

Fresh Herbs

Before facial surgery, patients are asked to remove some things and habits from their lives to yield the best, most healthy results from facial surgery.

                    (Look at some facial surgery before & after pictures.)

Foremost on the list: any tobacco use because nicotine injures the blood vessels and interferes with good facial surgery healing. Usually, aspirin and aspirin-containing products are next because they promote bleeding.

But because herbs are promoted as being extremely healthy and available without a prescription, many patients fail to disclosure herbs and herbal preparations – unless pressed on that point by their cosmetic plastic surgeon.

Herbs vary in strength, depending on the time of year they are harvested and what part of the herb – leaves, stems or roots – are taken.

So Bahman Guyuron, M.D. and colleagues looked over the medication lists of 200 cosmetic facial surgery patients to get an idea of how many herbs and other supplements typical cosmetic plastic surgery patients use. Eighty percent of the study group was women; the average age was 45.

Results? About half the facial surgery study group takes herbs and other supplements, some of which are known to increase undesirable events during surgery.

Writing in an issue of Plastic and Reconstructive Surgery, a publication for cosmetic plastic surgeons, Dr. Guyuron found 35 patients were taking supplements linked to increased bleeding, including:

  • Bromelain
  • Fish oil
  • Flaxseed oil
  • Vitamin E

Scanning the records, the researchers also found that other supplements popular with patients include:

  • Ephedra
  • Ginkgo
  • Kava
  • St. John’s worth
  • Feverfew
  • Ginger
  • Echinacea
                    (Read the facial surgery & herb study)

We have also studied popular herbs and supplements used among our own patients and found the most popular that should not be taken two to three weeks before cosmetic or facial surgery – are  “The 4 G’s”: Garlic, Gingko (Asian), Ginseng and Ginger.

                    (Read more about herb use & cosmetic surgery.)

That’s not to say all herbal preparations are bad for facial surgery patients.

We frequently recommend taking Arnica, a homeopathic drug, before facial surgery to reduce bruising.

We also find that fresh papaya and pineapple — which contain the enzyme papase — reduces bruising and swelling.

"A woman on the operating table has scar treatment"

Sep 10

Scar Treatment & Micro-Needling

"A woman on the operating table has scar treatment"


A millimeter is very small; but in a land ruled by inches and fractions of inches, most people are happy to learn that a millimeter is about the size of the period at the end of this sentence.

But a scar treatment technique punctures the skin just that much – and in some cases, twice as deep – to improve the look of facial skin.

             (Read more about facial fillers.)

And how does a facial plastic surgeon or dermatologist puncture the skin ever so slightly for scar treatment? With a device that looks like it’s intended for torture? It’s actually known as micro-needling; the tool, pictured in above, is known as a dermaroller and really does not hurt, according to patients who have used it for scar treatment like in acne scars.

The dermaroller needles produce a very slight and not very deep puncture which later causes the body’s defenses to fill the tiny wound with collagen and elastin, some very necessary ingredients for creating new skin in scar treatment. That action also reduces:

  • Scars
  • The size of pores
  • Improves skin texture and firmness

We now know this – at least about acne scar treatment – because dermatologists at the Northwestern University organized a small study comparing dermarollers with laser treatment for problem scar treatment.

Groups of 15 facial scar treatment patients had half their faces treated by micro-needling and the other half not treated at all. The patients had three dermaroller scar treatments at three weeks apart. Despite the devilish look of a dermaroller, patients said there was very little or no pain.

Three and six months later, independent dermatologists rated both sides of the subjects’ faces.

Results? There was some improvement at three months, but six months later, comparing the treated and untreated areas of the face, the dermatologists figured the dermaroller side had improved by 41 percent.

            (Read the scar removal and scar treatment study.)

In addition, the scar treatment via dermaroller costs very little, much less than lasers, and is easily done, often by assistants to the cosmetic plastic surgeon or dermatologists.

“Acne scars are highly resistant to treatment,” said the study organizer, Murrad Alam, M.D. of Northwestern University.

Dr. Alam also said another study is underway comparing laser scar treatment against micro-needling.

"Joan Rivers shows a book about anesthesia"

Sep 09

Anesthesia Fear & Joan Rivers

"Joan Rivers shows a book about anesthesia"

Joan Rivers, R.I.P.

According to her final interview only days before her untimely death, Joan Rivers told an interviewer she had never been afraid of going under the cosmetic surgery knife but that she was very, very wary of anesthesia and anesthesiologists.

She once cracked wise about getting anesthesia just before a cosmetic plastic surgery procedure and said to the anesthesiologist: “Who are you and when did you last have a glass of wine?”

She enjoyed baiting, teasing and confusing all type of doctors and surgeons, “asking them everything” and hounding them with endless questions about anesthesia.

The best educated guestimate of Joan Rivers’ total cosmetic surgeries is about two dozen including eyelid lifts, two facelifts and neck lifts, a nose job, liposuction and Botox every five or six months.

She once told another interviewer that she needed so much plastic surgery because she was “ugly.”

She then quipped: “I was so ugly I sent my picture to Ripley’s Believe It or Not but they sent it back saying: ‘I don’t believe it!’”

All the cosmetic surgery and the many cosmetic plastic surgeons also gave Joan material for a TV shtick, Fashion Police in which she used clever one-liners to run down what other celebs looked and acted like. (“So-and-so is so dumb, she has to study for her pap test!”)

Rivers once told a British interviewer in 2010 that she thinks about death constantly, but “I don’t fear it. With plastic surgery, the general anesthetic is like a black-velvety sleep, and that’s what death is – only without waking up to someone clapping and saying ‘Joan wake up, it’s all over and you’re looking pretty’.”

An investigation is being launched and the family has opened a lawsuit against the clinic where she died.

Several key questions have to be answered like the type of anesthesia used. General anesthesia can be a bit riskier because of age.

We need to know if an M.D.-anesthesiologist or nurse anesthetist was doing the anesthesia for Joan. We need to know if she was healthy enough for any surgery and if the Yorkville Clinic was prepared to handle emergencies like cardiac arrest.

(Read more about modern anesthesia in cosmetic surgery.)

"Three dimensional rhinoplasty masks are shown"

Sep 08

Rhinoplasty Results: Your New Look in 3-D

"Three dimensional rhinoplasty masks are shown"

Rhinoplasty 3-D Masks

One of the most popular services offered by cosmetic plastic surgeons is photo imaging. A computer artist, taking directions from a cosmetic surgeon about the changes that will be made in surgery, creates a picture of your most likely, after-surgery look, all on a computer screen.

          (Read more about computer imaging.)

In many cases, the actual after surgery result is better than the predicted results.

           (Look at some predicted photos & actual after cometic surgery pictures.)

Patients like comuter imaging because it puts patient and surgeon on the same page about what to expect from rhinoplasty and other surgery.

There’s now a new wrinkle in technology that will provide a new way to picture the most likely after surgery results – 3D scanning and printing.

The new technology – along with a 3D printer – scans an object into its memory and then layer by layer, reproduces the scanned object via the special printer. 3D printers are already being used – many in private homes — and may revolutionize the way products are made by changing the concept of a factory.

Plastic surgeon Yakub Avsar, M.D., in Turkey claims to be the only cosmetic plastic surgeon worldwide offering patients 3-D masks showing their current appearance and what they will most likely look like after rhinoplasty surgery and healing.

          (Look at some rhinoplasty before and after pictures.)

Dr. Avsar – like virtually every other nose job surgeon worldwide – is aware that a human nose, to look attractive, must be in balance with the face upon which it sits.

And, while the nose is the most prominent feature on a face, the nose draws virtually zero attention unless it is badly shaped, broken, twisted or just too large for the face.

First visit rhinoplasty patients have their faces scanned at Dr. Avsar’s office. The surgeon then uses a 3-D editing device to make the same changes that will be done in surgery. Then the actual before and predicted after surgery masks are created.

The 3-D masks are realistic because various coloring agents reproduce the patients’ skin tones.

One rhinoplasty patient from Stockholm, Sweden, described the 3-D masks as “magical.”

"Joan Rivers, plastic surgery queen is shown as a pretty woman"

Sep 05

Plastic Surgery & Joan Rivers’ Passing

"Joan Rivers, plastic surgery queen is shown as a pretty woman"

“Can We talk?”

In Joan Rivers, we’ve lost a classic.

As you doubtless know by now, comedienne Joan Rivers died on September 5th after a supposedly minor throat procedure, causing the New York State Health Department to open a full investigation into the center where she was treated.

There will never, ever be another Joan Rivers. She and Phyllis Diller invented a new form of comedy and social commentary that cannot be replicated. Both were fearless groundbreakers and paved the way for other female comics.

We knew Joan Rivers and she was the “real deal”.  No pretense, funny and very smart. She was not haughty or dismissive, but genuine and the type of person in whose company you are comfortable.

Others agree: Barbara Walters found Rivers’ humor often raunchy but, but in the privacy of the Rivers’ home, found her elegant and classy.

Joan was a fan of cosmetic plastic surgery, often using quips about it in her act. She once said she had her first plastic surgery at age 31 and went on to have several dozen more procedures.

She advised other performers the secret of having good plastic surgery results was to get rejuvenation surgery before anybody noticed that you need it.

Herewith, we remember Joan for some of her  beloved self-deprecating humor about herself and plastic surgery.

“I wish I had a twin, so I could know what I’d look like without plastic surgery.”

“Fashion magazines suggest that women should wear clothes that are ‘age appropriate.’  For me, that would be a shroud.”

“I now consider it a good day when I don’t step on my boobs.”

“I’ve had so much plastic surgery, when I die they will donate my body to Tupperware.”

“I said to my husband, ‘my boobs are gone, my stomach’s gone, say something nice about my legs.’ He said: ‘Blue goes with everything.’”

But Joan, you left us far, far too early.

'A lo;vely woman in all white recovers from cosmetic plastic surgery"

Sep 04

Cosmetic Plastic Surgery & Seasons

'A lo;vely woman in all white recovers from cosmetic plastic surgery"

Cosmetic Surgery Recovery?

To every thing, there is a season, and that especially includes cosmetic plastic surgery.

Surgery schedules are often dictated by school schedules so when the kids go back to school cosmetic plastic surgery providers become busier.

Here are the annual trends:

Fall to December:

Many people schedule their facial plastic surgery like upper and lower eyelid lifts for Fall because they want to be fully recovered in time for the holiday season that starts with Thanksgiving and continues on through Christmas, Hanukah, New Year’s and, for many, the Super Bowl.

Winter: December through March

The colder weather is also a great time for cosmetic plastic surgery because many people have the option of wearing heavy scarves, hats and turtleneck sweaters to disguise any swelling and bruising left from a:

Additionally, many people have time off in December and combine it with vacation days to complete a cosmetic plastic surgery recovery period which is shortened by the most modern anesthesia and efficient surgical hands that disturb less flesh while working, creating far less bruising and swelling.

Surgical makeup to disguise any remaining giveaway signs of cosmetic plastic surgery is always available.

Spring, April to June:

This season is another popular time for going under the knife due to those June weddings and the arrival of summer with its vacations and many activities. Many mothers of brides seek face lifts for June weddings. Many young people, finishing high school and looking toward college are considering rhinoplasty, along with those who have already graduated from college and want a leg up for that first professional job hunt.

Summer, June through Labor Day:

Cosmetic plastic surgery schedules tend to wind down during the summer months while family vacation plans are afoot. Teachers who have the summer off often use the summer months for all types of cosmetic plastic surgery.

In any event, surgical scars must be kept out of strong summer sunlight least the marks turn unnatural colors. Summer often sees Botox and injectable facial fillers, thanks to their non-surgical nature.

"A lovely woman gets ready for a face lift"

Sep 02

Face Lift: How Much Younger Will You Look?

"A lovely woman gets ready for a face lift"

Getting Ready for a Face Lift

Given the cost and time away from work for recovery, it’s a reasonable question.

Plastic surgeons have done a handful of studies, trying to nail down a specific number that currently seems to go from a high of 12 years to a low of three.

Probably the best yardstick is the actual surgeon who does your face lift. Ask:

  • How often he performs the face lift procedure
  • What past plastic surgery reviews say about their own face lift procedures
  • To see his before and after face lift pictures

          (See some excellent before and after face lift photos)

As for the face lift science and looking younger:

A study done in 2011 and printed in the medical journal, Plastic and Reconstructive Surgery asked 82 women and 11 men to rate their own changes seven months after a face lift.

Results? While most also had some other cosmetic plastic surgery like forehead and eyelid lifts, the average age reduction was found to be 12 years.

           (Read more about the face lift study.)

In 2012, the medical journal, Archives of Facial Plastic Surgery reported a survey of 54 women and six men who had facial cosmetic surgery.

Researchers took before and after photos of each patient, jumbled them and then ask 40 medical students to guess the age of the person in each photo.

The average age loss was 7.2 years. Just guessing the person’s age in the after photos only, the average age was about nine years lower than the patient’s real age.

Patients who had only a neck and face lift were judged to be 5.7 years younger when looking at both before and after pictures. An eyelid lift knocked off another two years, while if a person had forehead lift, face lift, neck lift and eyelid lifts, the perceived change was 8.4 years younger after healing.

Yet another study in the JAMA Facial Plastic Surgery found only three years difference.

Other factors affecting perceived age would be sun exposure, smoking, late hours and other bad health habits.

          (Read more about causes of face lifts)

"A lovely young girl learns about teen cosmetic surgery"

Aug 28

Teen Cosmetic Surgery: Yes or No?

"A lovely young girl learns about teen cosmetic surgery"

Understanding Cosmetic Surgery

Many people are aghast at the thought of teen cosmetic surgery.

But there are some cases in which the teen’s progression into adulthood is enhanced by cosmetic surgery, especially when the youngstger has an unattractive body part like an unsightly, misshapen or overly large nose. Or large, protruding ears.

           (See some youngsters’ before and after ear pinning pictures.)

The teen years are a time when the most important thing in life is fitting in with peers. If a young person is teased, ridiculed or harassed about his or her looks, the normal path to adulthood with healthy emotional and social development is interrupted.

But are Botox, facial fillers, breast augmentation and lip augmentation over the line in teen cosmetic surgery?

So how is a cosmetic plastic surgeon to know if teen cosmetic surgery is right for a particular youngster?

First, the body part in question has to be physically developed. Girls mature quicker so they can have nose jobs at 15 while most boys must wait until 17 for teen cosmetic surgery when the nose is fully grown.

          (Look at some before and after nose job pictures.)

Some teens may have unattractive scars from major trauma or skin conditions that need medical and cosmetic help. Perhaps microdermabrasion or a light chemical peel is indicated.

Second, is the teen emotionally mature enough to know all that surgery entails and that not all of life’s concerns will evaporate after teen cosmetic surgery like, rhinoplasty or pinning back of protruding ears? (Medically, Otoplasty.) Does the youngster understand that having a celebrity’s nose is neither possible nor desirable?

The payoff for teen cosmetic surgery? The youngster has more self-confidence just when it’s needed most for going out into the world.

For girls, a request to reduce overly large, cumbersome and painful breasts may be reasonable. But for another girl, who wants larger breasts to be more attractive in a bathing suit, the request may be a red flag for other issues.

A prime line of questioning asked by most cosmetic plastic surgeons: does the adolescent want the surgery for him or herself? Many times, a parent is embarrassed by a child with a large nose or protruding ears and wants the surgery as a status symbol.

Also, is it clear to parent and youngster that any surgery entails small but well understood risks?

"A woman shows the result of a migraine headache"

Aug 27

Cosmetic Eyelid Procedure: Eases Migraine

"A woman shows the result of a migraine headache"


We once told of lucky findings doctors have made, discovering something very useful although one they were not searching for at the time. Botox is an excellent example.

          (Read more about serendipitous discoveries like Botox in cosmetic plastic surgery.)

Doctors now think the stabbing pain of Migraine headaches has something to do with “trigger nerves” that become pinched, trapped or otherwise irritated.

The above sleuthing and intelligence came to light a decade ago when the patients of an Ohio plastic surgeon reported in after an upper eyelid lift, medically known as a blepharoplasty.

More and more of the surgeon’s patients said their migraine headache attacks had:

  • Gone away
  • Struck less
  • Delivered much less pain when striking

Later, the surgeon used Botox (which stops nerves from sending contraction messages) to find the bugbear muscle causing migraine.

Now, according to the professional magazine, Plastic and Reconstructive Surgery, Oren Tessler, M.D., an assistant professor of clinical surgery and director of plastic surgery at Louisiana State University in New Orleans, has found a new method to treat Migraine: first, he gives his patients an upper eyelid lift!

          (Look at some eyelid lift before and after pictures.)

Testing 35 migraine sufferers, Dr. Tessler found that 90 percent of the 35 patients had at least 50 percent improvement in the migraines. After a year passed, 51 percent no longer had migraines.

The average number of migraine attacks declined from 18.5 episodes monthly to less than four a month one year after cosmetic surgery.

Another plastic surgery study in Cleveland, Ohio, on migraine victims studied 246 sufferers and found 85 percent were greatly improved after cosmetic eyelid surgery while 55 percent lost the blinding headaches altogether.

Other doctors criticized the Tessler study because no “sham” comparison group was used.

To test for the placebo effect, a group of patients are told they were having surgery, put to sleep and then went home thinking the surgery had been real. Many “sham” patients actually think they feel better because they received treatment.

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