Correction of imperfect rhinoplasty using cortisone injections to shrink the bulbous tip. No surgery.
What is a bulbous tip?
A bulbous tip is an enlargement of the lower third of the nose that is inconsistent with the other components of the nasal structure. This is often the result of cosmetic surgery. It can be related to the reshaping of the nose during plastic surgery performed on the nose. It can be a reflection of the inherent features of the nose.
What causes a bulbous nose to develop?
The typical causes of a bulbous nose to develop are natural circumstances as the nose shape evolves over the years. This is a reflection of the skin’s tendency to thicken. This bulbous tip is not necessarily because of lifestyle or any other social or medical issue. Likewise, the use of dermal fillers may be a cause. Of course, these can be subject to reshaping using enzymes that are capable of dissolving the temporary filler, such as hyaluronic acid. The nose tip has often been exaggerated in the course of plastic surgery on the nose because the adjacent upper lateral cartilages may be minimally sized, and the nasal bones are small and narrow.
Can you get rid of a bulbous nose without surgery?
If the bulbous nose is caused by thickening of the skin, which can occur as a consequence of cosmetic surgery on the nose, it can be improved. The anatomic issue is that the space between the outer skin and the underlying framework has been thickened since nature abhors a vacuum, and when too much cartilage has been brought out, it forms this soft scar tissue, thus causing somewhat of an inflation of the nasal tip. The answer to this dilemma is a non-surgical nose job, not using a dermal filler but rather using a medication that will shrink this layer of fatty-like tissue, causing the bulbous tip. Think of this as another liquid nose job, but the liquid is different from the filler.
Understanding liquid rhinoplasty and its limitations for bulbous nose shape?
The classic liquid rhinoplasty is an exercise in filler. This process may be compensating for overzealous cartilage resection during the original rhinoplasty surgery. Further, the classical non-surgical nose job is often used to raise the bridge, such as in Asian non-surgical rhinoplasty. It is also used to correct asymmetries that develop as a result of cosmetic surgery on the nose. The non-surgical nose job is an excellent remedy for a crooked nose, whereby one side is narrower than the other. While plastic surgery can correct this with grafts and other filler material, the reality is that the technique of non-surgical rhinoplasty is an excellent and more practical and predictable alternative.
What is discovered following 5,000 non-surgical nose shaping procedures?
After a large volume of non-surgical nose jobs, particularly the permanent variety using Silikon-1000, the take-away message and teaching is that there are more patients who benefit from this service by a plastic surgeon than one would imagine. There are many imperfections of the nose which, when treated with the non-surgical nose job, are quite satisfactory to the patient. There is a certain percentage of people who have an unyielding disposition against cosmetic surgery of the nose. For whatever reason, including concerns about anesthesia and worries about the ultimate outcome, they do not want to have surgery. Often, while the result of the non-surgical nose job may not be ideal, they are satisfied, and that is the most important issue. Is the patient satisfied by a procedure that is certainly less expensive, less time-consuming, and more predictable than a standard cosmetic surgery on the nose or surgical rhinoplasty? The most important feature is the satisfaction of the patient states. Several modalities may be offered, but the aim is the patient who feels the undertaking of the non-surgical rhinoplasty was worthwhile and satisfying.
Why Choose Non-surgical Nose Reshaping?
Non-surgical nose reshaping should be chosen when there are defects and imperfections after an unsatisfactory cosmetic surgery on the nose. If the filler can correct those problems, the patient benefits from cost savings and time savings and has the benefit of predictability and precision that only the non-surgical technique, whether it be a permanent non-surgical rhinoplasty or temporary non-surgical rhinoplasty, can provide.
Reduce a bump on your nose.
The appearance of a bump on your nose can be significantly minimized by employing the non-surgical nose job. If the bump is not too large, by adding the filler above and below, you are technically reshaping the bridge and obscuring the bump. This takes several sessions to accomplish, particularly when using Silikon-1000 as a permanent non-surgical nose job vehicle.
Reshape the tip of your nose.
Reshaping the tip of the nose can be done as part of plastic surgery on the nose or surgical rhinoplasty. There is a role for the non-surgical nose job. There may be a cleft or vertical crease between the two tip cartilages, left and right, and using the dermal filler, the so-called butt crease can be eliminated. It can be eliminated by either temporary or permanent filler. Often, people have a round and slightly lower tip, which lacks strength. It is usually because the natural cartilage is too small. The nasal tip can be augmented very handily by employing the non-surgical rhinoplasty technique, building up the tip so that it is lower than the bridge of the nose. This is a very practical means of improving the appearance without surgery.
Straighten your nose
Some people have an asymmetry of their nose such that it does not look straight. It may be that the nose sits on an asymmetrical face whereby the left and right embryonic parts are not mirror images of each other, with the nose being a “compromise.” It may be asymmetrical or off-center. That often can be improved with a non-surgical nose job. While there are some limitations, it may be an excellent alternative to yet another plastic surgery on the nose if one has already been performed.
Minimize scarring on your nose.
Non-surgical rhinoplasty is an injected technique that involves the use of dermal fillers, whether temporary or permanent, to create certain changes. Many surgeons use the open rhinoplasty technique, whereby a horizontal incision is made between the two nostrils. This provides access to the framework of the nose as that incision allows the skin to be literally rolled back to gain exposure to the tip cartilages and upper lateral cartilages that comprise the central third of the nose. Typically, the other scars are more internal and, therefore, hidden. The so-called “open rhinoplasty” or “transcolumellar” (literally across the columella) incision may be visible at some point and, therefore, somewhat of a liability. Having a non-surgical nose job alternative available is often very important to the prospective patient.
Who Is A Good Candidate For A Non-Surgical Rhinoplasty?
A good candidate for non-surgical rhinoplasty is a patient who may have minimal imperfections of the nose. The nose tip may be a little low and flat. The nose bridge may be a bit low and, therefore, would benefit from some raising. There may be a very minimal dorsal hump that can be obscured or eliminated by the non-surgical nose job techniques of filling under the skin to give the appearance as though the architectural infrastructure is perfectly even. Other candidates are those who have had unsuccessful surgical rhinoplasties, one or more. We see patients who have had up to five, and yet it seems, based on their recollection, that after the first unsuccessful rhinoplasty, they may have been very satisfied with a permanent or temporary non-surgical nose job and thus avoided a chain of further unsuccessful procedures.
Who Is NOT A Good Candidate For A Non-Surgical Rhinoplasty?
A significant number of people seeking to change the appearance of their nose may not be good candidates for a non-surgical nose job. First, someone who has a very large nose that requires reduction to blend in with the facial features would not be a good candidate for a non-surgical or liquid rhinoplasty. Another reason not to have a non-surgical rhinoplasty would be if the tip depresses significantly with a smile and changes the architecture of the nose. Another issue would be a very crooked nose that also has compromised breathing. A crooked nose with compromised breathing does call for plastic surgery upon the nose to render the abnormalities much less visible and to reduce the general volume of the nose. Other people who are not good candidates for non-surgical rhinoplasty are those who are actually quite pleased to have a large nose.
How can a liquid rhinoplasty or non-surgical rhinoplasty enhance the appearance of your nose?
Liquid rhinoplasty or non-surgical rhinoplasty can enhance the appearance of your nose because it creates a reshaping without an operative intervention. Should there be an asymmetry, a dip, a divot, or even congenital underdevelopment of cartilage, the non-surgical nose job is an excellent alternative to cosmetic surgery.
Low bridge
A low bridge is an excellent opportunity, particularly for Asian patients who have raised the nose bridge without surgery. The non-surgical nose job literally raises the bridge, as would grafting with cartilage or bone or other material, but it is much more accurate and efficient. There is no downtime except for the office visit. While Silikon-1000 is a permanent solution to the problem, some surgeons prefer hyaluronic acid as a liquid nose job vehicle. The problem is that there is the need for eternal “refilling” as that filler material is dissolved naturally by the body.
Revisions
In some cases, a bulbous nose is a result of inadequate cartilage removal during the course of the rhinoplasty. If that is the case, then treatment with shrinkers or fillers would not be adequate. The patient would require relatively minor revision rhinoplasty. It should be done in an operating room, of course, with proper anesthesia and staffing. Revision usually makes the bulbous tip cartilages visible, either by delivering them or operating on them through internal approaches, creating more symmetry and reducing the domes of the tip cartilages.
Irregularities
Irregularities of the nasal architecture may be properly and efficiently corrected by the non-surgical nose job. Correcting dips, divots, and dents and concealing sharp edges is the mission of non-surgical rhinoplasty. It is excellent when there has been an unanticipated “settling” of the framework after the surgical rhinoplasty.
Dip in the nose bridge.
A dip in the nose bridge usually implies that as a result of the plastic surgery on the nose, there has been sagging, typically at the junction of the upper septum and nasal bones. It is the opposite of the development of a dorsal hump where there is too much cartilage causing a convexity. This dip in the nose bridge is a concavity and lends itself very well to a non-surgical nose job. The idea is to use the dermal filler to literally fill the concavity until the filler has created essentially a straight-line profile.
Nose bump
A nose bump can be concealed or obviated by a non-surgical rhinoplasty. If one fills “above” and “below” in the region of the nose bridge, the nose bump will disappear. This assumes that the volume of the nose is not such that any additional dermal fillers will make the nose look unnatural and unsatisfactory to the patient. The practical way to understand how employing the liquid nose job minimizes the appearance of the nose bump is to create an analogy between filling a valley next to a mountain. If the valley is filled, the mountain no longer stands above the surrounding terrain.
What Problems Can Not Be Fixed With Non-surgical Rhinoplasty?
There are some problems that cannot be fixed with non-surgical rhinoplasty.
Drooping nose tip
A drooping nose tip is typically due to either the underdevelopment of the tip cartilage or occasionally due to some trauma that has visited the nose. That plunging, drooping nose tip, which only worsens with a smile, presents a circumstance that may not be ideal for the non-surgical rhinoplasty or non-surgical nose job. One of the reasons is that the depressor septi muscle exerts a constant downward pull on the tip while smiling, and over a period of years, the stretching of the tissues makes the tip drop even further.
Wide nostrils
Wide nostrils are another anatomic variation that cannot be fixed with non-surgical rhinoplasty. There is no role for a dermal filler here. There must be a surgical excision at the base of the nostrils called a Weir’s procedure, which essentially will allow the outer walls of the ala or wings to be positioned more medially and, thus, diminishing the size of the nostril opening. This is an important component of correcting an unsatisfactory nose tip among certain ethnic groups, such as Asians.
Bump
If there is a massive bump on the nose, then a non-surgical nose job is not an ideal remedy since it will increase the volume of the nose. It will raise the entire nose bridge, and this reshaping may not be satisfactory to the patient whose nose is disproportionally large to the face. Nose shape and size are very important in developing a plan for dealing with an unsatisfactory appearance. A plastic surgeon should analyze all elements of the nose, including the height, the width, the distance between the nose and the lip, and the distance between the root of the nose and the top of the forehead.
What Type Of Filler Is Utilized To Perform Non-surgical Nose Jobs?
There are two classes of fillers: permanent and temporary. Hyaluronic acid and variations are very common since the public knows of these as fillers that are used for lips and cheeks. Hyaluronic acid is a chemical name for a material that is compatible with the body but which will be degraded by the body. The most common products are named Juvéderm® and Restylane®. The variations upon the theme of those two may last longer, but they are still considered temporary liquid rhinoplasties. There is only one substance that provides a permanent non-surgical rhinoplasty, and that is medical-grade liquid silicone. This product was first developed in the 1960s. It was approved by the FDA at that time and has never had any retraction of the FDA’s approval. It is a clear, colorless liquid that is injected under the skin, just as the hyaluronic acid temporary fillers are, but it is permanent because the body encases it and maintains it in its position, and there is no degradation. While less commonly known, the permanent filler marketed under the name Silikon-1000 or AdatoSil-5000 is considered very successful and much appreciated by the patient since they are not anxious to have a lifetime of temporary injections, which, of course, must be renewed.
Role Of Hyaluronic Acid Fillers
The bulbous tip is rarely appropriate for additional fillers. It requires “subtraction” instead of addition. All fillers, temporary or permanent, such as Silikon-1000, which is medical-grade silicone, are additive. When hyaluronic acid fillers are placed, the tip will only become bulbous. While liquid rhinoplasty is a legitimate vehicle to correct some deformities, it is typically not used in the tip. However, if there is a bulbous tip that is the result of excess hyaluronic acid filler placed prior, that filler can be dissolved. The patient has a choice: either wait for it to dissipate spontaneously or have it injected with an enzyme called hyaluronidase, which will quickly, basically, eliminate the temporary filler. At that point, the patient may opt to have further evaluation as to whether or not a rhinoplasty approach is necessary.
What Is The Cost Of A Non-surgical Rhinoplasty?
The cost of a non-surgical rhinoplasty depends primarily on the vehicle being used. Considering that there are two classes, temporary and permanent. Within the temporary are the varieties of hyaluronic acid. The cost is indeterminant since it is a lifetime cost. Each session may be $900 or $1000 and may last up to 6 months or a year or perhaps longer, but ultimately, all temporary fillers become degraded and need to be renewed. Therefore, as one person put it, they found themselves in “filler prison.” There is no release date. On the contrary, permanent silicone injections, whether Silikon-1000 or AdatoSil-5000, are administered in a few sessions typically. The value of sequential filling is that one gets to see the illusion and may further participate with the doctor in deciding “how much to put.” The importance of the permanent filler is that it brings finality and closure, particularly to those patients who have not had great success with one or more surgical rhinoplasties. The cost of the permanent filler typically depends on how many sessions are expected. Typically, three sessions are the most common format for this liquid-nose job. Occasionally, one or two additional sessions may be necessary, but there is a finite number. The number of sessions always depends on the complexity of the nose’s architecture when presenting to the plastic surgeon.
The Procedure Of Non-surgical Rhinoplasty
The procedure for non-surgical rhinoplasty is injection underneath the skin using a small trocar or cannula for temporary or an ultra-fine needle for permanent non-surgical rhinoplasty or permanent non-surgical revision nose job. The nose may be numbed ahead of time with a topical anesthetic. When done under magnification, accuracy is enhanced. These injections are simple. There is very little downtime and little chance of problems after injection.
Technique Used
The technique used for non-surgical rhinoplasty is placing the cannula or needle under the skin. Where possible, the syringe is drawn back to make sure that the tip of the instrument is not within the hollow of a blood vessel, and then, very slowly, the material is injected. When the permanent filler, medical-grade liquid silicone, is used, a series of micro-droplet injections are used. When the temporary filler is employed, the cannula can be moved underneath the skin to deposit the filler in various areas. That is a significant difference. In other words, multiple micro-droplet injections through the skin into the space between the skin and the underlying bony architecture of the nose is one technique, and the other places a cannula and lets it run the course of the nose and deposits the temporary filler.
What To Expect Before Treatment?
Before a non-surgical nose job, there is no preparation other than to wash one’s face with an antiseptic soap, ideally. One should be aware that one cannot have an injection when there is active pustular acne. The numbing medicine is typically placed 30 to 45 minutes before the anticipated treatment. There is nothing really to anticipate other than to be prepared to have the session.
Dos And Don’ts Before The Procedure:
The main thing is to be aware of any incipient infection on the nose. Pustular acne would be a reason not to have either a temporary or permanent non-surgical nose job. One should not apply any harsh chemicals, such as skin peeling agents, to the skin, which would tend to irritate it. One should not vigorously massage the nose, which would increase the redness and blood supply and, therefore, possibly generate bleeding during or after the procedure.
What To Expect After Treatment?
After treatment, one should expect no particular problems or complications. Typically, there is no significant swelling or bruising. What you see is what you get. That is why there is no “downtime.” There are no obvious side effects, such as major swelling and bruising, as can occur with a surgical rhinoplasty. Aftercare is nonexistent. One should just be careful not to massage the nose or have a facialist perform any manipulation on the nose. One can have a facial, but all manual manipulations on the face should be done apart from the nose.
Post-Procedure Precautions And Aftercare:
A non-surgical correction of a bulbous tip usually relies on steroids as “shrinkers” instead of fillers; there is no issue of any particular risk afterward with respect to precautions. Obviously, one should avoid any injury to the nose, but it would be very rare for there to be any deleterious effect of minor trauma to the nose. The usual aftercare is appropriate for cleansing the skin and avoiding any chance of skin infection after the injection.
How Long Does The Recovery Take After A Non-surgical Nose Job?
There is no recovery. It is an office treatment. You leave, and then it is back to work or back to normal duties.
Can A Non-surgical Nose Job Go Wrong?
A non-surgical nose job can go wrong, and that is usually a matter of technique. What if too much of the dermal filler is placed? What if the nose bridge is raised too high when we are trying to create a small bridge or fill a concavity on the profile? This would not be ideal. This is why the permanent filler is done in layers and step-by-step with separate sessions. Sequential filling avoids the chance of overfilling, and that is the main complication of undesirable side effects of using permanent filler. Temporary filler is more forgiving because it can be dissolved with a specific enzyme called hyaluronidase. Infection is very rare with either a temporary or permanent filler. Significant bleeding is very rare. Any damage to the skin is extremely rare. Some cases of skin necrosis have been reported, which means a portion of the skin died, but it is extremely rare considering the large volume of filler sessions.
Risks And Side Effects Of Non-surgical Rhinoplasty?
The major risk is the breakdown of the skin. Infection is a risk but rare. Side effects would tend to mean perhaps some irritation of the skin from the procedure, but that is generally temporary and not a strong enough reason not to have a liquid nose job.
Is A Non-surgical Nose Job Permanent? How Long Does Non-surgical Does It Last?
If the non-surgical nose job vehicle is medical-grade liquid silicone, Silikon-1000, or AdatoSil-5000, then indeed, it is permanent. It is the only FDA-approved permanent filler. If the filler is hyaluronic acid or one of its variations, then the lifespan of the filler is months. The duration depends on the filler material used.
Exploring the Capabilities of Rhinoplasty Treatments?
People are free to explore the possibility of various rhinoplasty treatments. They should consider non-surgical rhinoplasty as well as surgical rhinoplasty. Whether one has a problem with the nasal tip, nose bridge, asymmetry, or even a bulbous tip, the first question that one should ask themselves is: “Could I be satisfied with a non-surgical rhinoplasty, temporary or permanent?”
Our practice offers a way to assess the satisfaction that would come from a permanent non-surgical nose job. We provide the Kotler saline demo whereby a sterile saline solution, the same as that used in intravenous fluids, is injected into the sites that the patient would like to have improved by filler. They can immediately see the results in a mirror, and now there is no abstract conception of what permanent filler can or cannot provide. It is excellent, particularly for people who have had several unsuccessful rhinoplasties since often they are very skeptical that there is a remedy to their chronic dissatisfaction. The reshaping can be done without yet another operation, which would include the grafting of bone or, cartilage, or other body tissue into the nose, with uncertainty of the outcome.
Comparative Analysis: Bulbous Nose Rhinoplasty vs. Standard Rhinoplasty Procedures
Bulbous nose rhinoplasty often requires a combination of both the delivery technique as part of a surgical rhinoplasty and later using non-surgical means to shrink the tip. As explained above, that implies the use of silicone, not a filler such as Silikon-1000 or hyaluronic acid. It is hard to compare the results of a bulbous nose rhinoplasty versus a standard rhinoplasty procedure because there are so many variables in the equation. One has to understand that when the skin is thick, there is less contraction available to nature to best define the nose tip and provide reshaping that yields a very satisfactory and harmonious result.
Safety and efficacy considerations in bulbous nose tip rhinoplasty
Where there is a bulbous nose tip, and it is deemed that surgical rhinoplasty is the most appropriate modality, then one has to take into account the thickness of the skin, the strength of the cartilage, and whether or not that nasal tip can maintain its strength after reduction of the cartilaginous architecture. Remember that one cannot excise skin. It is totally unwise and impractical. One has to rely on the contraction of the skin and perhaps later use the steroid shrinkage of the skin to help accommodate a smaller frame. The core procedure in the case of the bulbous tip is that there be some reduction in the nose tip. Typically, one practical means for a surgeon to do that is to use the “delivery” technique. The delivery technique allows the surgeon to bring forth the alar or tip cartilage, trim it, and also remove some of the excess fat. This is a practical way of gaining exposure to as much of the nose tip as possible and operating on the component parts so that there is not only refinement of the tip but also avoiding asymmetry. The plastic surgeon who is capable of performing the Joseph technique of delivering the tip as part of a closed rhinoplasty has a very important skill to offer the patient.
Rhinoplasty Expectations: A Focus on Men with Bulbous Noses?
Rhinoplasty expectations should be reasonable and rational. This is why, in our practice, computer imaging has been so important and available to patients for over 30 years. One needs to have clarity in what they can expect, particularly men who have had several injuries to the nose and desire improvement and yet have a “natural nose.” Nothing beats computer imaging when seeing what subtraction techniques, such as refining a bulbous tip or shaving down a bump on the bridge, can do.
If the bulbosity of the nose is caused by thickening of the skin after one or more unsuccessful rhinoplasties where too much cartilage and bone have been removed, then there should be consideration for the steroid or cortisone “shrinking” non-surgical nose job. The polar opposite of using a temporary or permanent filler. Men’s skin tends to be a little thicker, and often, that can be a remedy for their problem. Even men who have never had a surgical rhinoplasty may benefit from the “shrinker” non-surgical nose job process. Typically, several injections are required. The injection is conducted exactly the same way as that of a permanent filler. The nose is numb, and serial injections are placed.
Ethnic Considerations in Rhinoplasty for Bulbous Noses?
Some ethnic groups have a very bulbous tip of the nose, as well as a wide base. This is not uncommon in patients of Asian ancestry. Often, they will require a surgical reduction of the rather ball-like, round, sphere-like tip, as well as the narrowing of the base of the nostrils. While the walls of the nostrils or ala are thick and cannot be thinned, what can be affected is sliding those walls toward each other in the midline. This process is called a wedge resection of the base or the Weir’s procedure. It involves taking out a section of the skin and soft tissue from the sill or base of the nostrils and then migrating the lateral walls toward each other, therefore narrowing the dimensions of the width of the base of the nose. Some Black and Hispanic patients may suffer the same genetic imperfection.
Why Should You Consult With Dr. Robert Kotler?
What we hear from patients is that they are anxious to consult with Dr. Kotler for several reasons. First is his ultra-long experience. Secondly is his fine focus and hyper-specialization in that he performs only noses. He is not a “jack of all trades” but is considered a master of nasal surgery. He also has unusual experience and capability in the sphere of permanent non-surgical rhinoplasty or permanent non-surgical revision liquid rhinoplasty. Experience and specialization are sought after.
Another reason is that the consultation includes computer imaging and may also include the Kotler saline demo. These are very helpful in patients deciding whether to proceed with either a non-surgical or surgical option based on the particulars of their nose. The office examination includes a thorough internal examination of the nose to determine whether there are any structural abnormalities that would compromise a surgical rhinoplasty. One should have the airway assessed and make sure there are no issues that might well be corrected at the same time as cosmetic surgery. This would include deviated nasal septum or enlarged turbinates, which are particularly common in people with allergies. It is wise to combine any and all surgical procedures in the same setting, and that decision should be based on a thorough examination of the nasal interior. The nasal exterior, of course, is readily examined, and then computer imaging is the key to seeing the anticipated result of the surgical rhinoplasty and sometimes even the permanent non-surgical rhinoplasty or permanent non-surgical revision rhinoplasty. All technology should be employed so that the concepts discussed are not abstract but visible and realistic using modern technology.
About Dr. Robert Kotler
Dr. Robert Kotler has had unique training and experience. He is fully qualified in all aspects of head and neck surgery, with an emphasis on facial plastic and reconstructive surgery. He served a fellowship in facial cosmetic surgery following the completion of his two years of active military duty, which was extremely valuable in refining his skills and adding to his book of experience. Experience and practice is very important. Focus and super-specialization are very important, and Dr. Kotler embodies those most important qualifications. He has been creative in his work, as well as creative in his support of the specialty. He is the inventor/patent holder of the Kotler Nasal Airway. These are two small, soft silicone tubes inserted onto the floor of the nose after the completion of any nasal surgery, whether it be cosmetic and/or reconstructive. This assures the patient of clear breathing after surgery, whether the nose is packed or not. He has written many journal articles on nasal cosmetic surgery and has taught at the local universities. He epitomizes the moderate super-specialist with ultra experience to draw upon. All of these work to the benefit of the patient. He is also well known for creating a technique of creating a natural nose, a rhinoplasty that does not look like any surgery was done. He performs closed rhinoplasties exclusively and thereby avoids the external scar. All incisions are internal, and all are closed with dissolvable stitches. Typically, this is preferred by patients as opposed to open rhinoplasty with an external scar, which typically heals very well, but in some patients, it may not and becomes a point of dissatisfaction. The other feature of Dr. Kotler’s practice is his availability to his patients 24-7/365. Patients have his two landline phone numbers plus his cell phone number, and therefore, he is available at any time. Another feature of Dr. Kotler’s practice is that rhinoplasty surgeries are performed in a private, small, outpatient surgery center that is highly specialized. Super-specialization is the key to safety and success. Likewise, almost all of his anesthetics are given by one of the two anesthesiologists who have worked for him for over 20 years. Dr. Kotler’s office staff is also ultra-focused, ultra-specialized, and ultra-experienced. The office manager, Mary Jake, has been with the practice for over 20 years and is well-recognized in the cosmetic surgery community as a superior practice manager with long experience and deep knowledge that benefits the patients.
