Awake Patients & Cosmetic Plastic Surgery

38041781 - doctors in scrubs and surgical masks scanning patient lying on hospital operating table
…….So my two kitties play together and unspool yarn and any rolls of toilette paper left out while my two grown kitties just worry about getting fed and you should see them play with the three kitties next door, but this dog…..

According to the American Journal of Surgery, a professional magazine for surgeons, more awake patients are being seen; those patients are having surgeries with only a local anesthetic to block sensations in the area being operated on.

Some surgeons like awake patients in surgery because the surgeon can ask the patient to move this way or that or answer questions during the operation.

But consider: if you are a surgeon with an awake patient who can hear all the sounds – and perhaps see some sights — around him in a typical operating room, it’s not too bad an idea to dismiss the phrase “oops!” from your vocabulary.

You might also want to find another way to ask surgical trainees to step over and take a gander at how your surgical work is going.

Studies have shown that awake patients want trainees and newbie surgeons nowhere near them.

Moreover, studies reveal that awake patients under the knife in operations – like biopsies, abortions, cataract surgery as well as some cosmetic plastic surgery procedures – tend to have shorter recovery times.

Awake patients for cosmetic surgeries often include:

Cosmetic plastic surgeons using local anesthesia usually also provide intravenous sedation medications to awake patients.

            (See some Chemical Wrinkle Remover before & after photos)

However, buyer beware: “awake” cosmetic surgery can also be an attempt at cutting corners by doing without an anesthesiologist. To cope, check thoroughly on your surgeon’s qualifications and surgical training.

For instance, Miami plastic surgeon Constantino Mendieta, M.D. avoids awake patients for buttocks and breast augmentation because he does not want the patient to move at a critical moment.

                   (Learn more about face & neck lift)

Alexander Langerman, M.D., Assistant professor of otolaryngology at Vanderbuilt University Medical Center in Nashville, Tennessee and team interviewed 23 surgeons in various specialties about operating on awake patients.

On the plus side, Dr. Langerman said most of the surgeons reported awake surgery was more efficient and satisfying overall. But downsides included talking about patients’ pain during surgery and the chance a patient would make a risky movement.  Patients generally are so put off by trainee surgeons, the group of surgeons said it was harder to teach surgical newcomers.

          (See some neck sculpture before & after pictures.)

So most surgeons in the study were less likely to allow beginning surgeons to take part in procedures. Surgeons reported trying to make things more comfortable for patients on the operating table by playing music and limiting others from entering and leaving the room.

Some surgeons offered alert patients sedatives to help them relax or fall asleep.

          (Look at some permanent, non-surgical nose before & after photos.)

Botched Nose Jobs —What to Do

" A waiter in a classy joint copes with a Botched nose job"
Coping with a Botched Nose Job

Nose Jobs are the second most often performed cosmetic surgery in the United States, according to the American Society of Plastic Surgeons (ASPS.) For instance, of the 1.7 million cosmetic surgery procedures performed in 2015, 217,979 were nose jobs, says the ASPS.

And why not? The nose is the largest and most visible feature on the face. If a nose is twisted, has a hump, turned up nostrils or is otherwise strangely shaped, it usually affects the person’s self-image and confidence because that nose just does not fit that face.

          (Look at some first nose job before & after pictures.)

Virtually all plastic surgeons say nose shaping has the highest degree of difficulty because a nose is a complex, three-dimensional structure and usually responds to the principle of “less is more.” That is, remove too much tissue and you’re likely to create an even stranger nose.

Solution? Find a cosmetic plastic surgeon with the most experience who does nose jobs at least weekly and has done so for a decade. Make sure he or she is board-certified in a facial specialty.

But, alas, according to one professional organization of facial plastic surgeons, anywhere from 15 to 25 percent of first nose jobs are botched.

Which brings us to revision rhinoplasty and its particular problems. In some cases, breathing is retarded, the nasal tip droops or, conversely, turned up so you look into the person’s nostrils instead of his or her eyes.

         (Read more about revision rhinoplasty)

 Now, you really need a super-specialist, a cosmetic facial surgeon who has performed mostly nose surgery for many decades. It’s because the challenges in revision rhinoplasty are substantial. In some cases, that nose has had six or seven prior operations. Due to past inadequate surgical skill, the patient presents a nose that has been the victim of:

  • Poor planning before surgery
  • Carelessly placed incisions
  • Too much cartilage and, sometimes, bone removed
  • Damage to delicate, convoluted nasal tip cartilage
  • Too much cartilage removed from the septum, the wall between the nostrils
  • Poor use of skin grafts

Some cases require a new nasal framework under the nasal skin.

Not to brag, but if you select a nasal surgeon with a cosmetic surgery resume like this, your chances of a successful revision are much, much higher. The recovery and healing, however, takes no longer – about 100 days – than a well done first rhinoplasty.

          (Look at some before & after revision rhinoplasty photos.)

And – be realistic. Angela Jolie’s nose only looks good on her. Your revision rhinoplasty should add aesthetic harmony to your face and profile.

Another option: ask if your botched nose job can be fixed via permanent, non-surgical rhinoplasty.

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

Non-Surgical Nose Jobs? Happy Patients!

'A happy Asian woman is thrilled after a non-surgical nose job."
Happy after a Non-Surgical Nose Job

According to the Aesthetic Surgery Journal, a professional magazine for dermatologists who do cosmetic plastic surgery, rhinoplasty is the most frequently performed cosmetic procedure in all Asia, outranked only by double eyelid surgery.

Asian rhinoplasty is so frequently requested in the Far East because Asians often have short nasal bones plus a depressed dorsum bridge.

Comparing Asian rhinoplasty to the Western version, the difference is usually augmentation for Asian noses and reduction in the West.

Asian rhinoplasty is also marked by:

  • Short noses
  • Wide nasal tips that usually point up. (Medically, “over-rotated.”)
  • Thicker skin
  • Weaker cartilage
  • Not much septal cartilage for grafting
  • Inadequate columella (the area between the nostrils.)

Virtually all Asian patients are proud of their heritage and the traditional features marking that background. Like Western patients, most merely want the nose – the largest facial feature – to fit in with and flatter their other features.

          (Learn more about ethnic rhinoplasty)

Because surgical rhinoplasty is so often done, researchers in Seoul, South Korea, studied the medical records of 242 local patients who had non-surgical nose jobs.

          (Look at some non-surgical nose job before & after photos.)

Writing in the October, 2016 issue of Dermatological Surgery, a professional magazine for dermatologists who do cosmetic facial surgery, Sung Hwan Youn, MD, in the Department of Dermatology and pathology, Hallym University Scared Heart Hospital, Hallym University College of Medicine in Anyang, Korea, and colleagues studied the surgical records of 242 patients who had a non-surgical nose job, using a hyaluronic acid filler.

One hundred twelve had nasal dorsum augmentation, eight had tip rotation and 122 had nose augmenation.

After studying all aspects of the non-surgical nose jobs, including before and after pictures, the surgeons-authors wrote:

Filler rhinoplasty offers a compelling alternative to surgical augmentation rhinoplasty in terms of:

  • Absence of social downtime (recovery.)
  • Surgical complications like contracture or thinning of the nasal tip
  • Showing the expected results of surgery to patients afraid of surgery

It turned out all 242 non-surgical nose job patients were delighted with the look of their augmented noses.

         (Read the non-surgical nose job article.)

While we hate to rain on anybody’s parade, hyaluronic acid fillers dissolve within months.

Our suggestion? Offer a permanent, non-surgical nose job by using Silikon 1000 in the micro-injection technique.

That filler and technique have a 50-year record of safety and effectiveness.

           (Learn more about Silikon 1000’s half century safety record in non-surgical nose jobs.)


Nose Job Cartilage for Aching Knees

"A doctor carefully measures the angles of a pretty woman's face"
Starting Nose Cartilage Donation

Whenever you’re having a nose job, your surgeon may have to snatch a small bit of nasal cartilage to make repairs elsewhere.

Sometimes, the septal cartilage blocks or bends (medically, deviates) into a breathing channel so the doctor moves that cartilage back to the center position.

If more cartilage donations are needed, some may be taken from the ear or from the costal cartilage between your ribs. (Sure, that’s another surgical site that needs post-surgical care.)

One thought in mid-stream before we get to the main point of this post about a new use for nose cartiladge: If the only changes are needed on the outside of the nose, you would  save:

  • Money– (80 percent less than a surgical nose job)
  • Time away from work for recovery
  • More time via short (10-minute) office appoints
  • Additional surgery
  • Three to five day recovery time

by opting for a non-surgical nose job.

(Read more about the benefits of a non-surgical nose job over rhinoplasty surgery and see some non-surgical nose job before and after pictures.)

So, nasal cartilage has one more use in research: as relief for aching knees. England’s Daily Mail reports that a pioneering new procedure takes  cartilage from a patient’s nose to grow and soothe knee  joint cartilage pain. The nose-to-knee cartilage implant isn’t being done in England yet, but 100 European patients at various centers have had the procedure which is said to be especially useful for osteoarthritis or those who are at risk for developing the disorder.

Said  Marcus Mumme, M.D. a surgeon doing the procedure: “Nasal cartilage is more resistant to inflammation; plus, nasal cartilage adapts itself to the knee joint environment.”

Donated nasal cartilage is grown in the lab for two weeks and then combined with collagen, a natural, bodily substance. The resulting patch is then  sewn into place over bad knee cartilage. Nose cartilage then meshes with knee cartilage, repairing existing damage.

The procedure may do away with metal knee transplants and could be useful in facial reconstruction after auto accidents said Ivan Martin, a tissue engineer at University Hospital Basel in Switzerland.

So far, nobody has complained about such a cartilage-enhance knee objecting to the odor of spoiled fish or burned toast.

Non-surgical Rhinoplasty: Join in!

'A soccer star shows his nose after a nose job"
Non-surgical rhinoplasty, before (left) and after

Non-surgical rhinoplasty patients often report that having permanent, injection rhinoplasty was so interesting because:

  • They were not put under anesthesia
  • They could take part in the procedure
  • They saved a lot of money versus having surgery

Patients write the checks for almost all cosmetic plastic surgery procedures. So they pay attention when they learn a permanent, non-surgical nose job usually costs 80 percent less than surgery.

  • It’s a noon time procedure.

Non-surgical rhinoplasty requires perhaps 10 to 15 minutes of your time in the surgeon’s office for three to five visits. When you leave, no tell-tale signs like bruises or swelling mar your face. You go right back to what you were doing before.

  • What You See: It’s What You Get

Before the permanent injections, the surgeon gives you a preview of a finished, non-surgical rhinoplasty; it’s known as a Salt Water Demonstration. While you watch – and direct – in a hand mirror, the doctor uses salt water to fill in the area(s) in your nose – like divots, gouges, twists or he can even hide a nasal hump. Salt water dissolves in a couple of hours, but that’s long enough to take before pictures.

  • Dread a syringe jab?

Fear not, the procedure is painless because a numbing cream is applied to your nose first.

(Watch a video showing a patient having permanent, injection rhinoplasty.)

  • Had a first, surgical nose job that failed? No problem.

As long as the needed corrections are on the outside of your nose, your nose can be treated via permanent, non-surgical rhinoplasty. (In surgical rhinoplasty, transplanted cartilage or bone can grow, twist or otherwise change.) Many patients needing a revision rhinoplasty have a permanent, non-surgical nose job instead.

  • Had functional nose surgery?

Say you’ve had surgery inside your nose to create clear breathing. But there are still some hollows, gouges, marks or even a twist in the middle of your nose. Perhaps your nostrils are unbalanced or your nasal tip needs help. Some prospective patients have had a broken nose heal in the broken position leaving a crooked nose while yet others need a heightened bridge.

Why take a chance on more surgery after that expensive functional surgery?

  • Easy Does it!

So the outcome produces a natural looking nose which the surgeon creates a little at a time. Non-surgical rhinoplasty is best done a little by little which usually means an injection followed by a wait of four or five weeks. Then, and only then, do doctor and patient decide if more is need.

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















Non-Surgical Nose Jobs: Patients’ Review Letters

"A lovely woman is shown in profile after a non-surgical nose job that removed a hump from her nose."
Non-surgical nose job, before (left) and after.

Provided the only changes needed are on the outside of the nose, patients can skip a surgical nose job and have a permanent, non-surgical nose job, even as a nose job revision.

(Read more about permanent, non-surgical nose jobs)

Not only does the no-knife rejuvenated nose look natural, but it usually costs 80 percent less than surgery.

A permanent, non-surgical nose job requires three to five short office appointments, separated by a wait of five to six weeks.

Sound too good to be true? Then, take a look at some of the nose surgery patient review letters sent to Dr. Kotler after their syringe-based surgery.

Patient Michelle G. wrote to say “…not too much filler is applied at once. That allows you to see where the results are headed. There is very little discomfort and no down time at all…..he (Dr. Kotler) has an amazing gift that no one else is performing.”

          (Watch a video of patient Jessica telling about her non-surgical rhinoplasty.)

 Patient T.K. had two previous nose surgeries that left the nose over-corrected and with a “conspicuous” dent that left her “a bit shy and self-conspicuous.” She writes further: “I was apprehensive about a third procedure and the possibility of complications. But three visits to your office for silicone injections and the appearance of my nose was corrected.”

T.K. loved the fact that the results of the permanent, non-surgical nose job were immediately noticeable. She concludes: “I kicked myself for not having done something sooner!”

          (Look at some permanent, non-surgical nose job before & after pictures.)

 A patient who signed himself “Better Now” suffered disfigured nostrils from a cancer operation a decade ago. Surgery left one nostril much higher than the other, leaving the patient with the feeling he was walking around with a giant fish hook pulling that one nostril up.

Wrote the patient: “Dr. Kotler, WITHOUT SURGERY, in two minutes fixed 75 percent of the problem I had lived with for 10 years.”

Dr. Kotler told the patient to come back in 45 days. “With another few injections, the problem was now 85% resolved. After my 3rd and final visit, the effects on the skin cancer marks and scars were undectable! It has now been a year since the final treatment…. It is as though I never had the cancer surgery.

“I can not say enough great things about Dr. Kotler’s competence and skill…”


Obsessed: Cosmetic Surgery Perfection

"An angry woman is pictured with a rolling pin"
Angry BDD Patient

Cosmetic plastic surgeons are trained to spot and turn away patients with an odd perfection syndrome known as Body Dysmorphic Syndrome (BDD.) The syndrome means no surgical outcome is ever good enough; some BDD patients turn violent, often sue cosmetic surgeons and file the worse reviews possible.

Now, new research is showing that many – if not most – BDD patients suffered some childhood trauma. Making matters worse, the latest research shows the BDD afflicted are attracted to cosmetic surgery.

(Our sister website offers a blog post showing that 81 percent of nose job patients suffered a childhood trauma.)

Plastic surgeon Mark B. Constantian, MD, FACS, in Nashua, New Hampshire describes typical events after BDD patient cosmetic surgery:

“Although the procedure went perfectly, the patient hates the result and hates you” Dr Constantian said. “After looking at the before surgery pictures, the patient says you are a liar and a crook and tells everybody on the Internet.”

          (Read more about nose jobs and revision rhinoplasty.)

Part of the BDD puzzle – trying to fix facial imperfections others can’t even see – started in abusive childhood situations.

Dr. Constantian and colleagues studied 100 patients after surgery. Eight-seven percent had cosmetic surgery while 13 percent had reconstructive procedures.

For a comparison, the researchers looked at the results of 17,433 general medical patients; 16 percent gave one positive answer about childhood trauma. But 54 percent of the cosmetic surgery group gave at least four positive answers to childhood trauma situations like:

  • Emotional abuse
  •    “        neglect
  • Living with alcohol/drug abuse
          (See some nose job before & after pictures.)

“Other research links BDD to trauma in childhood and teasing,” said Dr. Constantian. “Child trauma is also linked to adults who are perfectionists, obese, obsessive, untrusting, needy and dependent.”

One other study done by JAMA Plastic Surgery found – of 234 patients — – 13 percent of cosmetic surgery patients and two percent of reconstructive patients had BDD.

Katharine Phillips, MD at Warren Alpert Medical School at Brown University operates a BDD clinic.

Cosmetic surgery is rarely a fix for BDD patients,” says Dr. Phillips. “Plus, surgery can be risky; the patient might become suicidal. Plus, the patient usually harshly criticizes the surgeon, sues or even physically threatens the doctor.”

          (Look at some revision rhinoplasty before & after pictures.)

Adds Dr. Constantian: “If a BDD patient ends up in a cosmetic surgeon’s office, he or she is looking for self-esteem. When their wildest dreams aren’t realized, they flash back to childhood, reawakening their feelings of worthlessness. That’s why they get so irrational; you can’t reason with or calm them down.”













Tattoo Removal: Easier with New Patch

"A woman's neck is shown with an artistic tattoo"
“Body Art”

Any patient going through a tattoo removal procedure with a cosmetic plastic surgeon or dermatologist has twice gone through major regrets. Once for having “body art” and another for going thorough the often painful removal process.

But you can add tattoo removal to the burgeoning list of non-surgical procedures.

Tattoo removal dissolves the stubborn brightly colored ink deposited deeply under the skin without surgery.

 (Read about Chemical Wrinkle Remover.)

The popularity of tattoos has gone in just a few decades from the realm of sailors, jail inmates and other outcasts to perhaps half the western world’s populations. Police departments everywhere even keep pictures of known miscreants’ “tats” for quicker I.Ds.

Among non-law breakers, the likes of Carolyn Kennedy, Helen Mirren, Jenifer Aniston, Ben Affleck, Brad Pitt and other well known people bear tattoos.

Along with the acceptance of body art, came another trend: huge increases in the numbers of people requesting tattoo removal.

          (See some Chemical Wrinkle Remover before & after pictures.)

The removal pain level is something like getting a tattoo; others have described it as having drops of hot bacon grease splashed on your skin.

Some doctors tell patients to use non-aspirin products like Tylenol. Aspirin and other nonsteroidal anti-inflammatory products like Ibuprofen  can produce some serious bruising after treatment.

Black tattoo ink is easily removed while other colors – like green – absorb laser light. So the choice of laser depends on the color being removed. Plus, tattoo ink is down in the second layer of skin, the dermis.

                    (Read about permanent, non-surgical rhinoplasty.)

Now, a new patch – known by the tongue-twisting moniker of perfluorodecalin ( PFD for short) — is helping. The doctor now shines the laser light through a PFD-soaked patch. That results in faster tattoo ink removal and, not surprisingly, happier patients.

Writing in the October, 2015, issue of Lasers in Surgery and Medicine, Brian Biesman, M.D., a clinical assistant professor of dermatology, ophthalmology and ENT found when shining a laser through a PFD patch, he could do four passes at a higher energy level. Without the patch, the doctor was limited to one pass.

In a small study, 30 tattoo removal volunteers with blue or black tattoos were tested with the FDA-cleared patch.

(See some permanent, non-surgical rhinoplasty before & after pictures.)

One half of a tattoo was treated with either the patch (using four passes) or no patch, using only one pass. Treatments were given every four to six weeks.

Results? All 30 test subjects opted to continue tattoo removal with the PFD patch.

          (Read the tattoo removal article)

Top 8 Things to Know Before Cosmetic Surgery

" A cosmetic surgery patient uses a checklist"
Check, check and Check!

Cosmetic surgery is on the upswing, according to the latest statistics, with more – including younger – patients being seen by cosmetic surgeons.

Eight considerations about cosmetic surgery don’t immediately come to mind.

  1. Some surgeons are more skilled. You, of course, know to look for a board-certified cosmetic plastic surgeon, but did you think to look for one who often does the procedure you want? As in weekly? A look at the surgeon’s before and after pictures should tell you volumes.

               (Look at some Master Surgeon nose job before & after pictures.)

  1. Don’t expect perfection. Due to the unpredictable ways of a sometimes wily Mother Nature, a cosmetic procedure may turn out differently than first thought. But, be happy with improvements.
  1. On your consultation, the surgeon will want to know what cosmetic surgery changes you want. The whole idea is ending with a more refreshed version of you. Provided you’re in good hands, your friends will only notice there is something different about you, but they can’t put a finger on it.
  1. In the occasional case, a patient may prefer the pre-surgery appearance. That’s especially true with rhinoplasty in a world where 15 to 25 percent of patients are unhappy with a nose job. Why? Rhinoplasty is the most difficult cosmetic surgery to learn, perform and master.
  1. Know that some cosmetic surgeons try to boost their bottom lines by talking you into cosmetic surgery procedures you don’t necessarily need. Listen to what the doctor has to say, but listen critically. Ask for computer imaging if you are still unsure which way to go.

                          (Read more about computer imaging.)

  1. Hey, depression happens. Modern anesthesia allows you to wake from cosmetic surgery feeling fine, but the sight of your swollen and bruised face may be a downer. However, black and blue marks and swelling are temporary and are usually gone within five to 10 days.

                 (Look at three-part — as is, predicted after, actual after —   computer imaging photos.

  1. Cosmetic surgery results aren’t instant. In a rhinoplasty case, you may look presentable in 10 days, but actually the nose will fully heal over a year. And if something should be wrong with your rhinoplasty – and you decided you want it redone – you’ll still have to wait until the one-year mark.

          (Look at some permanent, non-surgical nose job before & after pictures.)

  1. Your plastic surgeon listens very carefully when you explain why you want cosmetic surgery. After all, there are risks and complications – like infections – to worry about. The surgeon does not want to hear that you need a pick-me-up. A more realistic reason for wanting surgery is because you were divorced and will  soon be dating again.

Rhinoplasty Surgeon Beverly Hills