Frequently Asked Questions

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General

hello dr kotler i have had 2 nose jobs and my nose still looks the same when i smile my nose hangs down and my nose makes me so insecure about myself and i thought my nose will look cute and up and my sides will look cute but it dosent and i was woundering how much would it cost to do my nose job again is it the same amount as.doing the first rhinoplasty or is it less money

Hi, sorry you have not good luck with prior surgeries.

It may be that you need relatively minor revision surgery. The drooping of the nose with smile is very common and is handily corrected by releasing a muscle that tugs onto the tip of the nose with smile. That cures that problem is it is done via a short internal incisioin just inside the nose.

I would have to see photos of how your nose looks now and before the surgeries to give you my best recommendation and if you can send those to me, I would be pleased to evaluate and then speak with you about it. No charge, of course.

Pleased to be of service to you.

How do you check out the safety issues?

You need to know about the anesthesia specialist and the surgical facility. The safety issues are dependent on the anesthesiologist first and foremost. A board- certified anesthesiologist will not work in a non-certified, non-licensed, non- credentialed facility. His safety standards are high. He cares about your safety. If the facility did not qualify, or did not pass the test, he will not work there. Each facility should be able to tell you whether they are certified by the United States Government, through the Medicare program, or whether they are licensed by the State, or whether they have met the qualifications of the four independent accrediting organizations, such as the Joint Committee on Accreditation of Healthcare Organizations, which also accredits and certifies hospitals.

I like to see a facility located in a medical center or on a medical campus. A surgery center that sits in a strip shopping mall, all by itself away from medical support, is a bit hazardous, in my opinion. In case there is an emergency or problem, it is nice to know that there is a heart specialist or lung specialist, either in the building where the surgery center is, or in the building next door. Close at hand is important. We have an agreement with these specialists, such that if an emergency exists, they will come at a moment's notice.

How does one “check out” the doctor?

I have several criteria that I use when seeking the services of other doctors. First, I want to know that they are board certified - that they passed the test. Then, depending on how specialized the problem is, I would like to know if they are fellowship trained. For example, my wife had difficulty with her thyroid when she had a condition known as Grave's Disease; whereby, the thyroid is hyperactive and causes a lot of trouble. The doctor that managed her care was an internist first then, was trained as an endocrinologist, and, finally, did additional training, such that his practice was limited only to care of the thyroid gland. That is a super specialist! That is the doctor I wanted. The more specialized the doctor is, the better.

I look at other qualifications, besides the board certification and the fellowship. I would like to know how long the doctor has been in practice. There is no question that experience gives wisdom and talent. I prefer doctors who have been in practice for at least 20 years. Maybe it is because I was a military surgeon. I have a warm feeling for those doctors who served the country and, who mostly likely, enhanced their skills through their military experience.

You can ask around the community if you know people who are active in the medical world. You could certainly ask a nurse who works at a surgery center where there is a lot of cosmetic surgery done. Do as much as snooping as possible. In the end, you are going to be wise enough to make a good decision when you consult with several doctors. It will not be that difficult to decide which is right for you because you have been able to address all the questions that I am posing to you.

Which doctor is best qualified for my particular case?

The most important question. That is a book by itself. You are going to sense when you leave the office, whether the doctor and his staff are right for you. You are going to feel if they are genuine, or whether they are a bit "salesy". You are going to have a sense of whether this doctor is confident in his ability to succeed or whether your procedure is not his strong suit. That is a very important issue, by the way. For example, if considering rhinoplasty, is the surgeon with whom you are consulting a superstar, or a super-specialist, in rhinoplasty?

If most of the people in the waiting room are there for breast implants, liposuction, tummy tucks, hair transplants, or reconstructive surgery, you are probably not in the right place. You want a super-specialist - someone who majors in rhinoplasty, who is doing several every week, and who has a long run of experience. Rhinoplasty is the most complex and most demanding of all the cosmetic surgery procedures. It is much more difficult to perform and achieve excellent results than, say, liposuction or breast augmentation. Think about it. The surgeon must do the entire operation through the nostrils, or through a limited external incision. The surgeon has to be comfortable that he can manage a crooked nose or a blocked airway at the same time. There are a lot of factors that come into play. Do your homework. Ask a lot of questions. Most importantly, ask the key questions: "Doctor, is rhinoplasty the most common procedure that you have performed in your practice?" If it is not the most frequent, or the second or third most frequent, keep looking for the right office. Employ the same process when consulting for any cosmetic procedure. Look for the most specialized, "six of fewer procedures" practice.

What will my family, friends, or even coworkers think about this?

Patients are sometimes concerned about what their family and friends may think about this decision. My answer to that is the following: What matters most is what you think. You cannot put this out for a vote. You cannot do this to make your mother or your spouse happy. Do not do it to satisfy your Uncle Louie in Chicago. It is all about you.

May I speak with one or more of Dr. Kotler’s patients?

Yes. We can match you with previous patients who underwent the same procedure(s) you are considering, a great way to learn even more.

Are you a candidate?

This is a very important question. Not everybody is a candidate for cosmetic surgery. First, you have to be in good health to have it. If you have major heart, liver, or lung problems, sorry, it is not for you. The other thing is whether you are very clear on what you want to achieve and what can be achieved. Only a detailed and proper consultation can answer that question. When considering rhinoplasty, the surgeon is going to have to consider a lot of factors - the physical structure of your nose, including strength of the cartilage, thickness of the skin, and the status of the airway. It is also important to know whether or not your desires are realistic and can be achieved. The surgeon needs to answer that question for you without equivocation. When you leave the consultation, you should know what is possible, what is probable, what is realistic, and what the negatives or downsides may be.

Is it helpful to speak with friends?

Of course, speaking with people who have had cosmetic surgery, whether they are friends or family, is very helpful. There is nothing like walking in the shoes of those who made the march. On this website, there are many letters and memos from patients and their families describing the experience. That is a wonderful learning experience.

The "review sites," such as Yelp, Vitals, RealSelf and Google Places, are also very helpful. Negative posts are to be eyed with suspicion. Beware of hostile negative because, often, they are peppered with unfair and libelous attacks on the doctors. Most posts are bonafide, candid and helpful.

How do you search for the right surgeon for you?

This is a process of learning, of education. The main resources are books and websites. I have written two books to help the process. The first, Secrets of a Beverly Hills Cosmetic Surgeon is an encyclopedia. It has lots of "before" and "after" photos, and covers nearly everything that you need to know.

The second book, The Essential Cosmetic Surgery Companion is a workbook that you take to the consultation. It is a wonderful way to keep the consultation focused, efficient, and most importantly, informative for your particular situation. On this website are links to the book sellers to facilitate you obtaining them.

Websites are very helpful, too. I would say visit as many websites as you can. Later, I will discuss website specifically, and what makes the most informative and educational websites. Those are the ones you want to visit.

The Consultation

Why is computer imaging so important at consultation?

In my opinion, the consultation without computer imaging is virtually worthless. It is guesswork. It is conjecture. It is guessing. Should you not have a sense of what you are going to look like? Or at last let this doctor believe he can deliver? If you do not like the image he portrays, then, you need to discuss that. Or, perhaps, this is not the right doctor.

If the doctor is confident in his ability, he ought to be able to demonstrate what he is going to do. Just like an architect can show you a rough sketch blueprint of the house you are going to commission him to build. Would you just tell him to "go build a house" and hope it comes out to your satisfaction?

I like to see a practice either email the "before" and the "computer image after" to the patient via email, or prepare a hard copy, so they can have it for their files and study it. That way, they can review it, show it to their family and get some input, if necessary. Then, let that imaging act as a central feature of any further discussions with the doctor.

What are the key features of the superior consultation?

The best offices will give you time. Most of the time with the doctor. After all, it is the doctor who needs to answer your specific question, make an evaluation, and advise you whether or not your desires are appropriate. The office should solicit a very complete medical history so that they know whether you are healthy enough to have the procedure, or whether there are some issues. That includes all the medications you are taking, including, incidentally, nonprescription medications. The questionnaires that are given to you should be very comprehensive, so very quickly the doctor can ascertain your health history, your experience with previous surgeries of any sort, including, perhaps other cosmetic procedures, and any other medical issues, such as drug sensitivities, or difficulties with anesthesia.

Next, the ideal meeting with the doctor should show you a doctor who is concerned, who listens, and who asks questions. He does not talk about himself, his golf game, or how many times he has been mentioned in PEOPLE magazine. What is more important is the focus on you. You are the main event. For nasal surgery, the examination should include a thorough examination of the inside of your nose. Even if you do not have a breathing problem, the doctor needs to ascertain the structure, so that he is confident that there will be no breathing problems after surgery. Further, he needs to evaluate for hidden potential problems, such as large blood vessels inside the nose that might cause bleeding, or nasal polyps, which are benign growths, which could cause blockage of the nose after surgery. The doctor needs to look, listen, and feel.

You need to have a very clear understanding of the "ramp up." Will you need a physical examination, including a doctor examination and lab tests? Will you have a chance to speak to the anesthesiologist ahead of time, instead of meeting him just prior to surgery? Will the doctor be available to you 24/7 before and after surgery? Who will take care of you after surgery, and how many office visits are predicted? Will the office help with the insurance forms if your surgery is also for the conditions where insurance is obliged to participate in payment?

Finally, you need to know that there is a contact person in the office for you to reach with for specific information. If it is about insurance billing, who would you contact for questions regarding that? If it is a medical question, will you be able to speak to the doctor?

If I have had previous surgeries, should I bring in photos, op reports, doctor’s records, etc.?

Yes. This would be very helpful to Dr. Kotler. Please fax, e-mail, or U.S. mail all previous records related to the surgery for which you are going to consult Dr. Kotler. It is best if we have the records prior to your consultation so that Dr. Kotler can review them and be best prepared for you. If, for any reason, you have trouble obtaining your records, call us. We can help.

If I want to come back for a reconsultation with Dr. Kotler, is there another consult fee?

No. Dr. Kotler does not consider the consultation complete until all your concerns are addressed and all your questions answered. He is anxious to teach you.

Will I meet with Dr. Kotler during the consultation?

Yes, of course! It is imperative to meet with the doctor who will be performing your procedure. Dr. Kotler believes in educating the patient and he is happy to answer all of your questions. And, if you wish to have another consultation after the initial consultation, fine with us. There is no charge for additional consultations.

If I see a picture in a magazine of a facial feature that I like, should I bring the photo to the consultation?

Yes, Dr. Kotler would be happy to review the photos with you. This can help us understand your desires. You will also have computer imaging so you can see the predicted result of your procedure. Imaging is the best way to determine what you like and what will look the most natural.

Out of Town Patients

How is the “pre-op” managed? Can I have my physical and lab work done “at home?”

Absolutely. It is ideal. We will provide all forms for your doctor to complete and then send to us.

What if, for some reason, I need attention and yet I am back home?

Dr. Kotler knows appropriate specialists in nearly every metropolitan area. He would make arrangements for you to be seen, and will communicate with the doctor. Generally, there is no additional expense incurred by you personally.

If not staying with friends or family, is it wise to bring a companion?

Yes, for many reasons. It makes good sense. The recovery time passes more quickly.

If I am coming from out of town, how long after my surgery will I need to stay in southern California?

Each surgery requires a different recovery timetable. We can give you the range for any single procedure or combination. Seven to 10 days is most common. Remember, you are not an invalid; you are not confined to bed. Some patients become part-time tourists.

Do you offer local hotel accommodation information?

Yes. Click here for a list of nearby hotels which offer our patients a discounted rate.

Insurance

If I am going to have cosmetic and functional nasal surgery, will my insurance cover any portion of the procedure?

Maybe. Depending on your health insurance, the functional portion of your surgery may be covered. Dr. Kotler is not an employee of any insurance company, but our office will do all the paperwork and submit your claim for processing and payment.  See if you qualify for insurance coverage here

Post Op

What will I look like? Will I be happy with the result? Will it look natural?

People are concerned about what they will look like, whether they will be happy with the result, and whether it will look natural. The answer to that is going to come from the doctor's discussion with you and, particularly, computer imaging, which I am going to discuss below.

How long before I can return to social activities, work or exercise?

You are going to have questions about returning to social activities, work, or exercise. This will depend on what procedure you have, and can range anywhere from one to two weeks.

Will it be painful?

People are always going to be concerned about pain; that is the easiest thing to manage. Today, there are many pain medications available. So, even if you have had trouble with, or an intolerance to, a given pain medication, there are plenty to take its place.

What can I expect to look like one day after the procedure I am considering?

Our teaching album has examples of our patients' appearances from one day to over one year after surgery. The swelling and bruising that MAY be temporarily present is generally less than prospective patients imagine. But seeing our patients' photos is what will help give you some comfort.

If I am going to have cosmetic and functional nasal surgery, will Dr. Kotler write my employer/school a note notifying them of my need to stay at home to recover.

Yes, he will. Functional nasal surgery is a non-elective, necessary medical procedure to improve breathing, relieve sinus congestion and often lessen nasal allergy symptoms . Your employer/school should give you medical leave to recover.

What’s the average “down-time” after surgery?

For cosmetic and/or functional nasal surgery, otoplasty, chin augmentation, blepharoplasty and neck sculpture, plan on 7-10 days. For a face and neck lift and the chemical skin peel, plan on 10-14 days. You are not bed-bound nor house-bound; just "not quite ready for prime-time". You can walk for exercise and are not prohibited from anything, consistent with you desires, except strenuous exercise.

Financing & Cost

Fees. How do you compare one doctor’s fees with another?

My sense is that fees get confusing when it is not explained to the patient that there are several different components in the delivery of the service. There is a fee for the doctor's services, which always includes the postoperative care at no cost. Then, there is fee for the doctor anesthesiologist. Finally, there is a fee for the outpatient surgery center, hospital, or the doctor's in-office surgical facility. What really counts most is the "bottom line number." Often, people get confused when they hear that someone paid $ __ for a procedure, but did not mention that there was a Y and Z charge. It is the total that matters. Get the quote "in writing" and ask if there are any additional charges.

Can I afford what I want?

Finances come into the picture, and you need to know whether you can afford the services. A proper consultation includes very specific fee quotations so that there are no surprises after the surgery. You also need to know whether your insurance will provide benefits for the breathing or functional surgery. All these things should be, and can be, determined well before you make any decision. This is elective surgery. There is no rush. There is no emergency. Get everything on the table before you make your decision.

Are there ever any special financial offers?

Sometimes there are, particularly from financing companies or from some of the companies that supply the manufactured Botox, Restylane, Juvéderm, etc. Such special offers will be posted on this web site and on our Facebook fan page.

What if I was denied by CareCredit?

Feel free to contact us and we will provide you with additional financing options.

I am interested in financing my procedure. How can this be done?

We accept all major credit cards. We also provide financing for cosmetic procedures through CareCredit, an excellent company.

Will my medical insurance cover the procedure I am interested in?

Maybe. It depends on your health insurance policy and the nature of the surgery. Only by Dr. Kotler's complete exam in consultation can the determination of possible insurance benefits be made. We would need to determine the diagnosis and the appropriate computer code numbers to submit to your insurance company. Generally, functional surgery, that is to correct nasal blockage, repair a deviated septum, trim the large turbinates, and improve sinus problems, are covered. Likewise, if your upper eyelids are interfering with your vision. Bring your insurance card to the consultation. Our office does the preauthorization with the insurance company and does all the billing for you.

I did not realize I needed several different procedures to accomplish what I hoped for. I may be exceeding my budget. Is there a way for me to reduce cost, but without compromising the result?

Yes there are. Dr. Kotler, in Chapter 11 of his book Secrets of a Beverly Hills Cosmetic Surgeon, shares some very practical strategies. For example, if you have flexibility in your schedule and can fill a surgery center opening when one arises, you can save a healthy percentage of the surgeon's fee. There are other ways too. No shame in asking.

Research

In addition to reviewing the hundreds of before/after photos on the website and in the photo albums in the office, would it be O.K. to speak with a patient who already had the procedure performed by Dr. Kotler?

Yes, we are happy to have you speak with a patient who has had the procedure you are considering. Even better is an opportunity to meet the patient. We will first ask permission, then put the two of you in touch.

Rhinoplasty

I want to do the non surgical rhinoplasty, I want to know can that be permanently?

Yes, depending on your desires, permanent non-surgical or injection rhinoplasty may be a possibility. The only recognized permanent filler, in use for over 50 years in the US is medical grade silicone, used for micro-droplet injection under the skin of the nose. The material, marketed by one company under the name, Silikon-1000, is FDA-approved for injection inside the eyeball so its safety is quite well accepted. The use under the skin is “ off label” but such use, like for other medications and products in Medicine, is accepted as safe and prudent.

Suggest consultation and particularly “ The Kotler Saline Demo” whereby sterile salt water or saline solution is injected to show you want can be accomplished. It disappears within two hours but you see, first-hand, what the result of the permanent filler injections look like. Photos are taken before and after for your study and review at home. Like test driving a car; if you don’t’ like it, no obligation to own it.

Call Dolla at our office if any questions. I have 36 year’s experience with the technique. I doubt any other doctor in the US has such a long run and experience with it.

Thanks for inquiring.

- Robert Kotler, MD, FACS

Are all rhinoplasties purely cosmetic?

A Rhinoplasty is a cosmetic nasal surgery. However, there is an overlap with a functional or medically-indicated procedure when the surgery also involves restoring the nose to its normal shape. Often, athletic injuries are the most frequent cause of such a change, but, purely speaking, the rhinoplasty, or cosmetic nasal surgery, is performed to improve upon what Nature gave us.

Do insurance companies pay for a rhinoplasty?

No, insurance policies cover medical problems and not cosmetic surgery. However, one exception is where the operation is being done to restore the nose to its former shape because of an accident. In that case, the doctor's terminology should be different. It is called a "reduction nasal fracture" or "nasal reconstruction." The doctor's office is familiar with insurance billing practices.

Another exception, which can be a point of confusion, is when insurance is involved when having both rhinoplasty and a deviated nasal septum, turbinate resection, or sinus surgery to improve breathing. That gets particularly tricky because, now, your insurance company becomes a participant, and one is never quite sure what allowances are going to be made to the doctor, the anesthesiologist, and to the surgery center. You should inquire.

The best offices will help answer those questions for you. Often, they can communicate directly with the insurer; although, depending on the policy, that may not be possible. Some insurance companies, particularly if that office does not contract or agree to work for them, do not allow the office to receive the fee information. The patient, or the insured, certainly, is entitled to that information. The best offices will help guide you through the maze.

Remember…if you are having that functional surgery, do not expect the insurance company to pay for the cosmetic portion. This should be a pro-rated charge. You should also benefit as much as possible from the insurance, such that the rhinoplasty or cosmetic portion becomes a less than full charge "add on."

How long before one returns to work and normal activities typically?

After a purely cosmetic rhinoplasty, most people will be back to work in seven to ten days. The packing is out and the splint is off by five days, and people typically need a couple more days before they go back to work. I returned to practicing full time seven days after my rhinoplasty.

Can a cosmetic rhinoplasty be combined with a functional surgery?

Yes, whenever possible, it is ideal to combine the rhinoplasty with an operation to improve breathing and help prevent sinus problems. The recovery period is approximately the same. It does not take very much more operating time. There is even economy of dollars.

If a filler or injection is a reasonable and proper substitute for revision rhinoplasty, when can that be done?

Generally, not sooner than that three- to four-month mark. Interesting, everywhere in the body, nature takes 100 days to heal. I have had my own experience with other surgeries, and it is absolutely fascinating to see that at 100 days, external scars are soft and mature, and all the areas are free of pain with mobility. It is the magic "100 days," and it is no different for nose surgery than for surgeries elsewhere on the body.

If I am not happy with my nose at three months and there is an indication for revision surgery, when is it done?

Typically, most surgeons like to wait at least six months before revision surgery is done, and sometimes up to nine months. The reason is that there is still a need for the nose to settle down and be free of any thick internal scar tissue, and typically, it is wise to wait six months. It may be that you have a breathing problem, and that needs to be corrected, and that can be done sooner than six months, but typically, for the purely cosmetic aspects, if you are comfortable waiting at least six months, that is wise.

If one plays contact sports such as basketball or other sports that might endanger the recently operated nose, how long does one have to wait?

Typically, the nose is as structurally stable and firm as it is going to be within five to six weeks. Remember that, if you break your arm, it is eight weeks; about the same for a leg. The nose heals a little quicker because the bones are the thinnest bones in the body. If you have any qualms about returning to contact sports sooner than that, you need to discuss with your doctor obtaining a facemask, as you have seen some athletes wearing.

I hear that it takes three to four months before the nose looks really great.

It looks good by seven to ten days and good enough to be back in public. It looks better at two weeks, even better at a month, even better at six weeks. You get the idea. Typically, by three to four months, as with any operation of the body, healing is pretty much complete. However, after three to four months there are some even further subtle improvements. So, generally by three to four months, you have a very stable and satisfactory nose, and that is the time the doctors take the postoperative "after photos."

What about returning to the gym and other work activities?

Whether your surgery has been a rhinoplasty or rhinoplasty with functional surgery such as correction of deviated septum and trimming the turbinates or enlarging the opening of the sinuses, typically, by the tenth day there is little chance of bleeding, which is the main concern. If you are very worried or engaged in very high-power workout, then wait two weeks.

What if the rhinoplasty has been accompanied by the nasal septoplasty and turbinate resection or other procedures to help bleeding?

It may be a day or two more. The reason for that is, typically, there may be more swelling and bruising. You have had two operations instead of one. Nonetheless, it is very rare for people to be away from work and normal activities for more than ten days. Typically, by ten days, incidentally, the swelling and bruising is pretty much gone.

I heard there is now a “nasal airway” that can be inserted during surgery, before the patient wakes up, which assures breathing after surgery.

Yes there is, and I am proud to say that the one that is most successful and becoming increasingly popular throughout the world is the Kotler Nasal Airway™. The airway is simple, practical and very popular with patients. Think of two small drinking straws that are placed in the nasal passages with one opening at the nostrils and the other in the back of the nose. The airflow now is not subject to obstruction by any of the packing or swelling or blood or mucus inside the nose. The concept is very simple. The air tube is removed anywhere from the first to seventh day after surgery in the office painlessly and quickly. Many practices dribble in a little bit of liquid anesthetic to make the removal procedure virtually undetectable.

What about “packing?”

Packing refers to the insertion of either an absorbable or nonabsorbable tampon inside the nose. There are good reasons to use packing. One is that when strategically placed inside the nose, packing will reduce postoperative bleeding. The second reason is that packing materials often contain chemicals that help reduce swelling. Antibiotics can be placed on packing to reduce the chance of infection, but the main reason is to reduce bleeding. The packing absorbs blood and also may exert a slight pressure benefit onto some of the healing tissues.

Another reason to use packing is to reduce the chance of "adhesions" or scar tissue which could interfere with breathing after surgery. Packing is unpopular, patients however since, often, is causes complete nasal blockage, whether that be for one or five to seven days. For that reason, it is an important consideration that needs to be discussed with your doctor.

How long does one have to wear bandages?

Most surgeons prefer to be in a plastic or metal splint or shield/protector over the nose to prevent any accidental injury. Typically, it stays in place for five to seven days. There may also be a little dressing underneath the nose to pick up some of the blood that oozes out for the first couple of days. These are pretty common and typical features of rhinoplasty throughout the world.

What about steroids to reduce swelling after rhinoplasty?

Some surgeons use it routinely. There are very few downsides. While reduction of swelling is certainly desirable, the few negatives include delayed healing and possibly lowered resistance to infection. These problems and complications as well as the speed of the swelling reduction are really functions of the dosage.

What about bruising? Does one always have it?

Bruising is common but not universal. Bruising depends on many factors: Duration of the procedure, the skill and tissue handling techniques of the surgeon, use or absence of medications which will reduce swelling and bruising, and one's natural tendency to bruise."

Today, most surgeons employ all the scientific aids that are available to reduce swelling and bruising. This includes cortisone given at the time of surgery and before and after, the herbal Arnica. Other medicines are used orally after surgery to reduce swelling and bruising and accelerate its disappearance. These would include products that contain an enzyme such as papase. Papase is an enzyme found in meat tenderizers, incidentally, that break down protein. After surgery, it is used to break down the red cells which are rich in protein. These are the red cells that leak into the tissues during and after surgery, causing the bruising, which are ultimately "mopped up" by the body's own scavenger system, but anything to accelerate it is appreciated.

I don’t understand why some surgeons perform an “open rhinoplasty” and others a “closed rhinoplasty.”

The open rhinoplasty is a technique whereby some of the incision to gain exposure to operate must be performed on the outside of the nose. Typically, this is a horizontal incision across the pillar or columella that separates the nostrils. The advocates of the open rhinoplasty approach submit that visualization is easier, and that is true. On the other hand, the closed rhinoplasty fans are those with longer experience and often more specialized training. They feel that the exposure or visualization necessary to do most rhinoplasties (I emphasize most) is adequate. One of the negatives of the external incision approach is that the incision has some potential for being visible, although that is not likely. Also, the open rhinoplasty takes longer to perform for many reasons, including extra time to "open" and stitch closed.

A closed rhinoplasty is done entirely within the nose, and the incisions are closed with absorbable stitches. The most common reason to perform an open rhinoplasty is either for a revision rhinoplasty or when dealing with someone who is born with a very deformed nose such as that which would accompany a cleft lip and/or palate.

Are there major differences in recovery if one combines two unrelated procedures?

No. Generally, the recovery period is about the same. The recovery period is obviously longer for the longer procedure. Generally, the recovery period is defined by that procedure which has a longer recovery. However, if the standard recovery period for rhinoplasty is seven to ten days, it maybe ten days to two weeks for a major body liposuction and/or breast reduction. Not much difference. The benefits of combining far outweigh the negatives.

If one wanted to have an unrelated additional cosmetic procedure, can that be done with rhinoplasty, or rhinoplasty with septoplasty and turbinate resection?

Generally yes. If the additional operation is a breast augmentation or a breast reduction, or local liposuction, it makes perfect sense. If the second procedure is a very, very long procedure, eight to ten hours, one may want to split them, but most of the elective cosmetic procedures do not take that long to perform, and it is very wise to combine them. Generally, that means two surgeons. The facial plastic surgeon and the body plastic surgeon work sequentially. Typically, the body surgery is done first, and then the facial surgeon comes in and does his surgery.

What are examples of temporary versus permanent fillers?

Restylane and Juvéderm are popular. Radiesse is thought to be very long lasting, although no one has more than a seven- to eight-year followup because it is relatively a new product. The one standby, and by most considered to be the most "state of the art" is medical-grade liquid silicone which is most commonly marked under the trade name of Silikon 1000. Medical-grade silicone has been used in the United States to correct dips or depressions and fill hollows for over 60 years. It is safe. While used to correct post- rhinoplasty nasal imperfections is considered "off-label," one may be comfortable knowing that the FDA-approved use is for inside the eyeball to reset a detached retina. If it is safe inside your eyeball, assume that a couple of micro-drops just under the skin carries little risk.

What about the “non-surgical revision rhinoplasty” or “injection” revision rhinoplasty?”

Since the advent of fillers such as Restylane, Juvéderm, Perlane, Sculptra, Artiss, and Radiesse, people have become familiar with the concept of "filling." In revision rhinoplasty surgery, often, the point of dissatisfaction is a dip, a groove, or a mogul with depression. If that is the case, a filler is very appropriate. One has the choice between temporary and permanent fillers.

If the first rhinoplasty is not successful and one wishes to have a revision rhinoplasty, does the risk of failure increase?

A revision rhinoplasty is a more difficult operation: often a bit less predictable. However, in most cases, the operation is successful. The key to success is really the talent and experience of the surgeon. Because revision rhinoplasty is much more challenging due to scar tissue and uncertain anatomy, the surgeons who are most comfortable with doing it and who are willing to take the case on will be those who are the most specialized and most experienced. If you are not happy with the first operation, you should want to consult with at least one other surgeon before you make the decision as to whether to use the original surgeon or move on to a new surgeon.

I have heard that for rhinoplasty it is not necessary to have an anesthetic. True or false?

"Necessary" is probably not the best term. I would use the word desirable. While it is not necessary to be asleep for a rhinoplasty, few patients, given the option, would opt for being awake. Many, many years ago, when anesthesia was not as sophisticated or safe as it is today, many surgeons felt that the risks should be reduced by doing the operation under local anesthesia with just a bit of sedation, but the evidence of newer and more successful drugs, such as propofol, have pretty much declared being awake for a rhinoplasty is obsolete. The procedure is identical regardless of the technique the anesthesia specialist provides.

Can one have functional surgery such as nasal septoplasty and turbinate reduction done independent of a rhinoplasty?

Yes. A patient that wants to breathe may be happy with the appearance of his nose. However, if one is unhappy with the appearance of his nose, and the primary reason is to have the breathing improved, the wise approach is to discuss with the doctor the possibility of performing a cosmetic nasal surgery at the same time as the breathing surgery.

If the nose is crooked, what is the reason?

In nasal cosmetic surgery, one of the favorite sayings is "as the septum goes, so goes the nose." What that means is that the septum, a vertical partition separating the two nasal passages, is not straight or is crooked or "deviated," then one may also suffer from an external deviation of the nose. If one is not happy with the appearance and shape of the nose, the rhinoplasty procedure should be accompanied by the nasal septoplasty. Generally, the best opportunities for success are when all necessary procedures are done at once.

What are the common functional procedures that may be done with rhinoplasty?

Correction of a deviated septum, known as a nasal septoplasty and reduction of the turbinates. The latter procedure is also known as a turbinoplasty. Correction of a deviated septum and reduction of the turbinates are performed to improve the nasal airway. People with sinus problems generally benefit, as well as those who snore, and it may be appropriate for people with bad nasal allergies to open the airway. Many patients wait too long to get these procedures done.

Non-Surgical Rhinoplasty

What about other “permanent” fillers like AlloDerm?

The other so-called permanent fillers do not have the 50-year track record that medical-grade liquid silicone (common trade name Silikon-1000) offers.

Moreover, these claims of permanence made by the manufacturer should not be made due to the FDA evaluation of their product.

Frankly, permanent is a strong word, and until some of these other products have a proven lifespan of 10, 15 or 20 years, we question even using the word.

Does Silikon 1000 move under the skin?

No. The essence of the procedure is using micro-droplets, placed just beneath the skin. The droplets are immediately walled off and trapped by nature' healing process. Nor is the effect like a solid implant in which some potential for movement exists.

What if it does moves? In 36 years, we have never seen movement or a reaction.

Additionally, the micro-droplets cannot be seen or felt.

Why should choose Dr. Kotler for this procedure?

Perhaps you want a cosmetic plastic surgeon with 36 years experience and total confidence in the product and technique.

We have such confidence, we used the procedure on own daughter who had an accident after a Dr. Kotler rhinoplasty. That accident caused the middle portion of her nose bridge to cave in, leaving the remainder of the nose intact. Nonsurgical rhinoplasty was the perfect solution.

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

If we have sufficient confidence in the safety and performance of a product and technique to be comfortable using it on our own family, patients can be comfortable in our recommending it to them.

Sounds too good to be true… What are the risks and side effects?

Yes, we know non-surgical rhinoplasty does sound too good to be true. But sometimes some too-good things in life are true. And this is one of them. It has been a fabulous product to be able to deliver to our patients. If there were complications, ill effects, untoward results or unhappy patients, we would not use it. We only perform surgical procedures and conduct injections that have an ultra high rate of safety, success, and patient satisfaction. We are duty-bound to reveal any potential or possible risks and unwanted side effects.

Could there be a patient who develops a reaction to it?

Yes, but I have not seen one in 36 years.

Is it possible that the body would somehow react in a strange way?

Yes once more. But I have not seen it in 36 years. We are not being coy or repetitious, but are sharing our personal experience. By the way, our teacher reported his patients had the same happiness with non-surgical rhinoplasty.

Is it possible that one could develop an infection from the injection?

Yes again. But I have never seen one in 36 years.

What are the long-term side effects?

There are no long-term side effects. The only long-term effects we have seen are long-term patient satisfaction. What you read in patient plastic surgery reviews, comments and testimonials tell the story.

I read online that silicone 1000 is not FDA approved. Fact?

Online reports are often misstated. Actually, medical-grade liquid silicone is FDA-approved for use inside the eyeball. Again, for use inside the eyeball. The most common brand is Silikon-1000, manufactured by Alcon, a major eye surgery vendor. Because medical-grade liquid silicone is a clear, colorless fluid, eye surgeons have long used it to push detached retinas back into proper position.

Liquid silicone is very similar to vitreous, the natural-occurring fluid the eye produces. When a retina detaches and pulls away from its attachments inside the eyeball, the liquid silicone -- injected into the eye -- pushes the retina back.

Certainly, common sense says if the FDA approves a substance for use inside the eye, then micro-droplets -- hundredths of a cubic centimeter -- deposited under the skin of the nose is a realistic and safe procedure. Therefore, it is legally used in an "off-label" use, as are many, many other drugs and products.

What are other off-label uses of other facial cosmetic products?

Juvéderm, a veteran, reliable, and economical answer to the problem of shrinkage face fat is only approved for correcting nasolabial folds, those lines of aging running from the corners of the nose to corners of the mouth.

Nonetheless very experienced injectors use it in other parts of the face. Generally, the FDA does not approve all possible uses. It tends to approve the most common use for the more challenging problems. The assumption is that, if it works for the most delicate or difficult condition, then it would be applicable for a less challenging use.

What is the saline demo in non-surgical rhinoplasty?

The saline injection rhinoplasty demonstration is an ingenious opportunity for patients to see the actual results of permanent non-surgical rhinoplasty… before having the procedure. (Sterile saline is also used in intravenous fluids, to dilute antibiotics and other drugs given intravenously.) In this use, saline is injected into the area of the nose that shows an undesirable shape or marks.

Using a three-way mirror, the patient sees the result. What could be better? And that is even better than computer imaging used to show the most likely results after cosmetic plastic surgery. You can see and feel the result.

The saline dissipates in two hours. We take before and after saline demo photos that are e-mailed to you so that you can study them in the tranquility of home. If you like what you see and feel, then you have the best possible opportunity to appraise the value of the permanent fillers.

Non-surgical rhinoplasty saline demonstration is not unlike trying on clothes or shoes. You see the fit, the look and if you’re happy with the items.

But if you’re unhappy with the appearance of your nose, you are not obliged to purchase.

It is safe, logical, and extraordinarily helpful, and we are pleased to offer it to our patients.

Without any self-congratulation, we are the "inventor" of the saline preview to non-surgical rhinoplasty and most likely the only cosmetic plastic surgery offering it.

Why don’t other doctors perform this procedure?

Not all doctors understand the importance to patients of providing a non-surgical option to an unsatisfactory rhinoplasty.

In 1977, not long after finishing military service and beginning private practice, we associated with a physician who was very progressive and innovative and had taken great effort to learn the non-surgical rhinoplasty technique from its New York City originators who did the primary research at New York University. That doctor became the mentor and tutor from whom we learned the technique.

Once we saw how successful the procedure was, we became convinced it was the right track and the procedure would be a wonderful option for patients suffering a bad nose job.

(Read more about the science of non-surgical rhinoplasty.)

Since that time, it has become an important part of our practice. As we see more and more patients who are dissatisfied with rhinoplasties done elsewhere (many of whom have had two, three, and even four nose surgeries!) we take great joy in offering a practical, economical solution to the problem.

(Watch a video of a woman having non-surgical rhinoplasty.)

I want to do the non surgical rhinoplasty, I want to know can that be permanently?

Yes, depending on your desires, permanent non-surgical or injection rhinoplasty may be a possibility. The only recognized permanent filler, in use for over 50 years in the US is medical grade silicone, used for micro-droplet injection under the skin of the nose. The material, marketed by one company under the name, Silikon-1000, is FDA-approved for injection inside the eyeball so its safety is quite well accepted. The use under the skin is “ off label” but such use, like for other medications and products in Medicine, is accepted as safe and prudent.

Suggest consultation and particularly “ The Kotler Saline Demo” whereby sterile salt water or saline solution is injected to show you want can be accomplished. It disappears within two hours but you see, first-hand, what the result of the permanent filler injections look like. Photos are taken before and after for your study and review at home. Like test driving a car; if you don’t’ like it, no obligation to own it.

Call Dolla at our office if any questions. I have 36 year’s experience with the technique. I doubt any other doctor in the US has such a long run and experience with it.

Thanks for inquiring.

- Robert Kotler, MD, FACS

Results

What if the operation does not turn out exactly as I had hoped?

Cosmetic operations are rarely failures. However, if some portions or areas are less than ideal and Dr. Kotler feels that some type of touch-up is needed, it will be done at no additional cost. A return visit to the operating room is very rare; most of the imperfections can be corrected in the office, some with just an injection or skin treatment.

Surgery

I want to do the non surgical rhinoplasty, I want to know can that be permanently?

Yes, depending on your desires, permanent non-surgical or injection rhinoplasty may be a possibility. The only recognized permanent filler, in use for over 50 years in the US is medical grade silicone, used for micro-droplet injection under the skin of the nose. The material, marketed by one company under the name, Silikon-1000, is FDA-approved for injection inside the eyeball so its safety is quite well accepted. The use under the skin is “ off label” but such use, like for other medications and products in Medicine, is accepted as safe and prudent.

Suggest consultation and particularly “ The Kotler Saline Demo” whereby sterile salt water or saline solution is injected to show you want can be accomplished. It disappears within two hours but you see, first-hand, what the result of the permanent filler injections look like. Photos are taken before and after for your study and review at home. Like test driving a car; if you don’t’ like it, no obligation to own it.

Call Dolla at our office if any questions. I have 36 year’s experience with the technique. I doubt any other doctor in the US has such a long run and experience with it.

Thanks for inquiring.

- Robert Kotler, MD, FACS

I did not realize I needed several different procedures to accomplish what I hoped for. I may be exceeding my budget. Is there a way for me to reduce cost, but without compromising the result?

Yes there are. Dr. Kotler, in Chapter 11 of his book Secrets of a Beverly Hills Cosmetic Surgeon, shares some very practical strategies. For example, if you have flexibility in your schedule and can fill a surgery center opening when one arises, you can save a healthy percentage of the surgeon's fee. There are other ways too. No shame in asking.

Are these procedures painful?

Any surgery will be accompanied by some pain-but only if untreated. If you can take a pill to prevent or stop pain, you will have no pain! Dr. Kotler is very keen on providing all medicines routinely needed. Not only to control pain, but to relieve anxiety and also provide sleep. As Dr. Kotler has frequently stated when speaking to the public, "If a doctor cannot control pain and nervousness and help a patient get necessary sleep, with the great assortment of medicines we currently have available, he needs to retire". As needed, we provide these medications -- at no additional cost to you. They are included in your post-operative care kit; no one need wait in a long line at a pharmacy late at night.

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