Tag Archives: top surgeons.

Botched Nose Jobs

"A Rugby player shows his thrice broken nose in a close up"
Twisted outside = Twisted Inside

The most recent episode of Botched, the E! Channel’s latest offering of plastic surgery tales in the “Golden Ghetto,” (Beverly Hills) introduced Paul, a late 20 or 30-something married guy who had suffered, not one, but two botched nose jobs.

The most recent left his nose twisted to the left; moreover, he had a noticeable hump on his nose. So he was in for a revision nose job.

          (See some before and after revision nose job pictures.)

Among plastic surgeons, a common saying is: “A nose twisted on the outside is almost always twisted inside, too.”

Besides looking a tad strange, it means that Paul’s breathing is also affected. Additionally, he suffered chronic migraine headaches that left him tired and unable to play with his children as much as he would like. Functional surgery straightens out the breathing channels

          (Read more about functional surgery.)

But aren’t two botched nose jobs unusual?

Actually, one of the major professional societies for facial plastic and cosmetic surgeons estimates that 20 to 25 percent of all nose jobs are botched. Rhinoplasty is immensely difficult and not a job for beginning surgeons.

          (Read more about the high rate of botched nose jobs.)

So many botched nose jobs creates a huge need for revision (medicalese for a surgical re-do) nose jobs, which are harder yet. And even some of the revisions are revised. Top Beverly Hills nasal surgeons often see patients with anywhere from three to seven previous failed nose jobs.

         (Learn more about revision rhinoplasty.)

Sure enough, when the plastic surgeon duo stars of Botched peered into Paul’s nose, they found his septum leaning far into a breathing channel.


On the first  picture panel  Paul shows his crooked nose. The second before  and after profile panel  shows the hump removal. (E! Channel Photos)










Paul thought the surgery was going a little far because the surgeons needed some rib-donated cartilage to straighten Paul’s nose. It’s commonly done in rhinoplasty surgery, but Paul’s wife was a bit alarmed.

Said one of the Beverly Hills plastic surgeons: “Paul is a handsome guy, but his nose is basically on the left side of his face!”

True enough to the half hour T.V. segment, Paul’s cosmetic and functional nose surgery features were all resolved in thirty minutes.

In real life, a patient like that can go out in public again in, say, five days after a nose job while your revised nose should be pretty presentable within eight days including bruise remediation, if any. Still more healing goes on for a year.

Nose Jobs Gone Wrong

"A lovely woman has her face and nose bandaged after surgery"
Nose Job Gone Wrong?

Most of the media love bad news. Most T.V. stations play on humans’ ancient fears of bad news by using a “If it bleeds, it leads” philosophy for which news stories are selected for airing.

Thus, the sad, sad story of the Oklahoma patient who emerged from nose surgery with no nose at all seemed to lead medical news everywhere.

But a close reading of the story reveals the patient already had 21 nose jobs before going in for yet another. That’s probably more nose job work than singer Michael Jackson ever had!

But there is always a lesson to be learned when a rhinoplasty surgery goes wrong. The lesson here? Probably poor choice of cosmetic plastic surgeon for the first nose job.

Unspoken truth: any rhinoplasty is very involved surgery that becomes increasingly more difficult by leaps and bounds after a first or second nose job.

Nose surgery involves different types of the body’s tissue – most notably bone, flesh, fat, nasal skin and cartilage, all wrapped tighter than the innards of a fine Swiss watch.

Surgeons adept at the procedure think in terms of less-is-more because the tiniest changes in millimeters inside the nose can make a huge difference in how a nose looks after surgery and healing.

So what does that mean to the consumer?

While missing an entire nose – due to an infection — is a larger than life mistake, somewhere between 20 and 25 percent of all first nose jobs leave patients unhappy with the results while many more set out looking for a Master Nose Surgeon to repair the damage in a revision rhinoplasty.

But by the time 21 surgeries had already been performed, skilled, knowledgeable nasal surgeons would probably turn down the opportunity to operate.

After all, only so many revision surgeries can be done on one nose.

(Read what happens before and after rhinoplasty.)

Why? They knew things would not turn out well.

It’s no secret among top nose surgeons that, after a certain, point Michael Jackson went from one nose surgeon to another until he found somebody, anybody who would do yet another rhinoplasty.

Do you suppose that final cosmetic surgeon had the best qualifications and the most skilled hands?

Before Surgery: Extra Training Pays Big

"Two doctors warmlly shake hands"
Welcome to Fellowship Training!

We’ve always said extra training in cosmetic plastic surgery pays, and pays big.

We knew that when, as a younger surgeon, we signed onto a fellowship with a highly experienced plastic surgeon for a year of hands-on training at the side of a Master Surgeon.

Consider it on-the-job training writ in super-scrip.

Results? As a super-specialist, (that’s not a boast, but an actual medical description of a skill level ) we have specialized in surgeries of the nose, performing over 4,000 procedures of the nose, including:

  • Rhinoplasty
  • Revision rhinoplasty (after a first nose job done elsewhere failed.)
  • Ethnic nose surgery
  • Surgery to repair breathing difficulties
  • Non-surgical rhinoplasty

To illustrate, a new study compares the results of general surgeons with surgeries done by board-certified plastic surgeons who spent an extra three to seven years after the M.D. degree training in rejuvenation surgery only.

Printed in the current Plastic & Reconstructive Surgery, a medical journal, the study looked at the complication rates of 954 panniculectomy surgeries, the procedure to remove sheets of loose skin and fat, hanging from the stomach to the pubis after morbidly obese patients have dropped large amounts of weight.

A panniculectomy requires long incisions on the abdomen to remove the huge aprons of skin that hang down to the thighs in some cases.

(Read more about the paniculectomy cosmetic surgery.)

The American College of Surgeons conducted the survey and crunched the numbers.

The overall complication rate for non-plastic surgeons measured 23.08 percent while the board-certified plastic surgeons turned in a rate of 8.65 percent.

In infections, the non-plastic surgeon group showed a rate of 12.69 percent while the rate for board-certified plastic surgeons was 5.33 percent.

The study also figured the odds of having any complication after surgery done by a non-plastic surgeon at 3.23 percent while a patient had 1.25 percent chance of complications after a board-certified plastic surgeon’s procedure.

Concluded the study authors: “..data showed that panniculectomy performed by plastic surgeons results in a lower rate of overall post-op complications compared with that performed by non-plastic surgeons.”

Which surgeon would you choose?

Now, we don’t perform cosmetic surgery of the body, but the principal of specialized training holds true in all of cosmetic plastic surgery, including surgeries of the head and neck.

Performing one surgery over and over for years can only make a surgeon more efficient and lead to better outcomes, be they body surgery, eyelid lifts or nose jobs.

(Read more about the study on the cosmetic surgery procedure, panniculectomy.)

Nose Surgery and Operating Room Safety

"A clean, well-lighted modern operating room is shown"Before nose surgeons and other cosmetic plastic doctors worry about creating a better appearance in the operating room, they turn their collective minds to one, important bottom line principle: patient safety.

Recently, USA Today ran a long article about patients who reported for what they thought were minor cosmetic procedures but ended up disfigured, disabled or worse. (Read more about USA Today’s take on supposed “minor” cosmetic surgery procedures.)

After making sure your surgeon is board-certified in the area of his or her practice, ask where his or her hospital privileges are. (That means patients can be quickly admitted if suddenly needed.) Also ask a few questions about where the nose surgery will take place.

Several types of surgical center certifications are in use. Common to all are backup systems in case something goes wrong during nose surgery or any other procedure.

Start with the lights. In case electricity fails, a certified operating room has a backup emergency generator. Many have a battery backup system that provides electricity in case the generator fails.

Everybody involved in a certified surgical center takes part in fire drills twice yearly. (Continued below.)


In the patient below and right, a nasal hump has been removed via surgery through the nostrils only while an invisible incision was placed under her chin for chin augmentation. (Robert Kotler, MD, photo.)

"One picture shows the patient before surgery, a middle panel shows a computer-predicted photo while a third shows the actual surgery result"
(L to R) Before Surgery, Computer Predicted Photo, Actual After Surgery Picture


(Continued.) One, rare condition bedevils plastic surgeons and anesthesiologists because patients themselves don’t know about the allergy. Known as malignant hyperthermia, the condition strikes when a patient violently reacts to general anesthesia. Although the reaction happens perhaps once yearly somewhere in the United States, all certified surgical centers must keep on hand an expensive drug, Dantrolene, to counteract the effects of malignant hyperthermia. The vast majority of Dantrolene stocks expire unused and must be replaced.

Dozens of other backups are required and subject to surprise inspections.

The gold standard of O.R. certifications to many medical professionals of  is known as JCAHO (Joint Commission Accreditation Health Organizations) or more often just “The Joint Commission” which also certifies hospitals.

Yet another common O.R. certification is known as AAAHC (American Accreditation for Ambulatory Surgical Facilities.)

Still another, alphabet soup certification organization, AAAASF (American Association for Accreditation of Ambulatory Surgical Facilities) inspects surgery centers with a watchful eye on patient safety.

Another common practice common to certified operating rooms: the existing life-saving equipment is checked daily, with the checking staff person signing his name, date and time.

After you know you are as safe as science can make it, you can look forward to the completion of nose surgery.

Cosmetic Plastic Surgeons: Finding the Very Best

"A master surgeon operates with an apprentice at his side"
Master Surgeon and Apprentice

When searching for a plastic surgeon, most potential patients look at the usual markers of excellence, including:

  • Before and after plastic surgery pictures
  • University training
  • Board certification in plastic surgery or head & neck surgery

But, due to a quirk in the way today’s plastic surgeons are trained, there is a key in surgeons’ credentials which, when found, unlocks access to master plastic surgeons. (Continued below.)_________________________________________________________________________________________

The middle aged patient below had the bump on the left photo removed along with refinement in her bulbous tip that brought her nose closer to her face. Result on right? A near perfect profile. (Robert Kotler MD, photo)

"Middle-aged woman shows results of rhinoplasty and a new nose"





(Continued.) It’s the fellowship. Here’s why it’s so special:

University training of a plastic surgeon takes place in a residency program at leading universities for anywhere from three to five years. But in almost all programs, the emphasis is on reconstruction surgery where surgeons learn techniques like:

  • Burn treatment
  • Repairing cleft lip and palate
  • Other procedures restoring normal function to non-normal, damaged anatomy

Due to slim university budgets, however, universities must train plastic surgeons and receive medical insurance payments, too. But cosmetic patients are wont to see surgeons-in-training for rejuvenation surgery (medically known as making the unhappy, normal happy with their appearance) because patients want top results.

So the question is how can a university trained plastic surgeon also master cosmetic surgeries like:

  • Rhinoplasty
  • Other nasal surgery
  • The popular cosmetic procedures like face lift?

Here’s where the fellowship enters the picture, even if the newbie surgeon is already board-certified in plastic surgery.

The fledgling plastic surgeon agrees to work at the side of an older, much more experienced cosmetic plastic surgeon who has decades of experience performing four to seven rejuvenation procedures that make a person look better. In short, the fellowship is a hands-on apprenticeship.

Most fellowships last a year while some others go on for two years. (Read more about plastic surgery fellowships.)

The apprentice plastic surgeon, in addition to doing surgery at the side of the master surgeon, may also do some medical research tasks, using the older surgeon’s patient base.

Typically, the younger surgeon will sift through all the data on the master surgeon’s nose job patients to, say, compare the healing rates of open rhinoplasties against closed rhinoplasties. When the research appears, the apprentice will have his or her name listed as a co-author on prestigious medical journals.

It’s a time-honored way for apprentices to learn skills and practical knowledge to become yet another master surgeon after a decade or so of experience is under the belt.

That’s yet another reason for selecting a plastic surgeon who specializes or super-specializes in just a handful of cosmetic plastic surgery procedures.

Nose Job Costs in Beverly Hills

"A stethoscope sits atop a pile of dollars"When computer searching for a nasal surgeon to perform rhinoplasty, some people click off when they see a Beverly Hills cosmetic plastic surgeon pop up in the search results.

The common fear? That much of the cost of surgical fees is only due to the location and the cheek-by-jowl proximity to Hollywood’s rich and famous.

But there’s more than meets the eye. Sure, business overheads in Beverly Hills – most particularly in the so-called “Golden Triangle” – are higher.

(By the way, our “Golden Triangle” has nothing to do with basketball, but is the 90210 area that is extremely dense in some of the most sophisticated surgical specialists known worldwide; basically, the “Golden Triangle” is a private practice medical campus with no hospital.)

Plastic surgery patients also find many outpatient centers for cosmetic surgery here so surgeons’ fees may be a bit higher but nowhere close to double or triple compared to other areas. Fees for Beverly Hills cosmetic surgery do not vary that much compared to, say, what a surgeon in San Diego or San Francisco charges.

Advantages to seeing these super-specialists who tend to congregate include:

  • Each is highly proficient in the handful of procedures he performs

Medicine today is highly specialized so the plastic surgeon who only does five to seven procedures does them faster, better and has seen every possible complication that can crop up; that surgeon disturbs less tissue so patients have less bruising and heal faster.

  • It’s easy to make a referral

While out-of-town patients come to us for rhinoplasty, cosmetic nasal surgery, repair of deviated septums and turbinate reduction (to allow for better breathing) they also want, say, breast lift, breast augmentation or breast reduction. While we are super-specialists above the collar bone, we know the surgeons – indeed, a handful are right next door! – who are top specialists in the procedures below the collar bone.

  • The closeness of major teaching hospitals

Many Beverly Hills cosmetic plastic surgeons also teach or lecture at the world-class medical schools at USC (University of Southern California) or UCLA (University of California, Los Angeles) as do we. Thus, we very quickly learn about new surgical techniques, medical tools, medicines and other technologies that can benefit our patients.

According to 832 rhinoplasty patients reporting on RealSelf.com, the average cost of a nose job is $6200. Of those patients, 78 percent said the procedure was worth it.

Our best guesstimate: while it may cost somewhat more to have a procedure done in Beverly Hills, you receive the best the world has to offer.

Cosmetic Surgery: Top 5 for Your Age Group

"People of all ages line up, one behind the other"
Cosmetic Surgery line to see the Doctor

Cosmetic plastic surgery procedures are picking up steam, with more people going under the knife, but did you ever wonder what – and how many — facial cosmetic surgery procedures your particular age group is having?

Teens want more than anything to fit in with their friends. According to the 2010 American Society of Plastic Surgeons (ASPS), people 13 to 19  consider the following their most favorite facial plastic surgeries:

  • Nose reshaping (rhinoplasty) –35,005
  • Ear Surgery (Otoplasty) 8,763
  • Dermabrasion – 2,907
  • Eyelid surgery (Blepharplasty) – 1,922
  • Chin augmentation –1,070

In the 20s, men and women want to make a big splash as they move into the world of work and adult social whirls. So the top 5 facial rejuvenations 20-somethings crave are:

  • Nose jobs – 75,546
  • Ear surgery – 8,717
  • Eyelid surgery (blepharoplasty) – 3,820
  • Dermabrasion – 4,556
  • Chin augmentation – 1,637

People in their 30s are really starting to roll, raising children and swinging for the fences on the job. The top 5 cosmetic procedures they want are:

  • Rhinoplasty –62,447
  • Eyelid surgery – 14,143
  • Ear surgery – 5,190
  • Face Lift  (Rhytidectomy) -1,717
  • Cheek implants (malar augmentation) 1,611

When the 40s and early 50s roll around, people are still involved with family and career but are becoming ever more aware of health and appearance. These good folk want to look rested, refreshed and full of energy on the job.

Thanks to the changes we see in our mirrors, the top 5 plastic surgeries that group wants are:

  • Eyelid surgery  – 88,501
  • Rhinoplasty – 54,822
  • Face lift –36,533
  • Dermabrasion – 26139
  • Forehead lift – 17,477

Among the 55 and over set, many are still working, putting kids through college and probably concerned more than ever about looking haggard, tired and listless in the workplace due to normal aging. Their top 5 facial procedures are:

  • Eyelid surgery – 100,378
  • Facelift – 74,382
  • Dermabrasion – 27,407
  • Nose reshaping – 24,441
  • Forehead lift – 23,228

Having waded through a long set of dry statistics, what’s your guess for the top facial plastic surgery for both men and women?

Answer? Nose reshaping! 253,000 nasal surgeries were done in 2010.

Overall, in 2010 (the most current year for which we have statistics) women of all age groups had 189,000 nose jobs while men during the same year went to rhinoplasty surgeons 64,000 times.

Next most popular: Women of all ages had 177,000 eyelid surgeries while men had 31,000 procedures to trim sagging eyelids from their peepers and loose the bags from under their eyes.

Is it any wonder people blog so much about finding a qualified, experienced rhinoplasty surgeon?

Rhinoplasty & Snoring

"A wife is wide awake and angry over her husband's snoring"
Before Rhinoplasty?

Snoring is often the stuff of which cartoons are made.

How many times have you seen an artist’s clever vision of snoring, including:

  • Window shades flapping in and out
  • A bedroom filled with giant Z-Z-Z-Z-Z-Z’S
  • A care-worn wife dashing screaming from the room, her hands clamped over her ears

But there’s nothing funny about snoring — it’s actually some very loud bad health in progress.

We note that because, in our practice, about half the patients coming in for cosmetic plastic surgery have breathing problems

Causes of snoring can be many, but you must be wondering what has snoring to do with the nose job procedure?

Simple answer: many snoring cases are abated or cured in connection with rhinoplasty.

Deeper answer: Before rhinoplasty,  the savvy nasal surgeon will examine the nose’s insides for blockages if the patient (or patient’s wife!) reports habitual snoring. The exam is a thorough look-see by a surgeon trained and experienced in head and neck surgery.

The surgeon best qualified to perform that inside the nose exam is also usually board-certified in otolargyngology.

(Read our post about plastic surgery’s board certifications.)

That surgeon thoroughly checks the inside of the nose because some conditions could exist which require a separate surgery before the patient can proceed on to the cosmetic rhinoplasty.

Internal nose passages include:

  • The septum – that thin wall of cartilage separating the nostrils. A septum could be bent, twisted or blocked
  • The turbinates, larger structures farther up in the nose, could require reduction because they sometimes swell
  • Untreated broken noses that healed on their own

Turbinates humidify, filter and warm air before it reaches the lungs. If you snore, you become a mouth breather and get second choice air. Lungs are healthier with nose breathing.

Another answer to snoring may also be found in the sinuses, throat or neck when polyps or allergies are discovered.

In some cases, the patient’s uvula, that dangling structure in the very back of the throat, hangs too far down into the throat and flaps back and forth, causing the sleep robbing Z-z-z-z-zs.

An enlarged adenoid can be the bugbear, especially in children.

But, of those many adult patients who come in with snoring problems, most are totally cured or significantly reduced.

Bottom line: healthy breathing is quiet breathing!

Cosmetic Surgery Discounts

"A stethoscope is seen laying on a stack of medical bills"
Cosmetic Surgery Costs

While Fox Business is reporting on the top 10 ways to pay for cosmetic surgery, they don’t mention any ways to trim the total costs of plastic surgery. (Read the top 10 ways to pony up for cosmetic surgery.)

If you know the natural up and down business cycles of rejuvenation surgery, you can arrange the procedure you want when cosmetic plastic surgeons will be very glad to hear from you and may consider trimming not only some sagging flesh, but the tab for it as well.

Some insurance-covered procedures produce a better function and a more pleasing appearance, including:

  • Nasal procedures inside the nose for people complaining of sinus-like symptoms. (Read more about breathing woe due to internal nasal structures.)

From November through the New Year, most facial surgeons are booked solid for patients requesting:

  • Eyelid lifts
  • Face lifts or rejuvenation by facial fillers like Restylane
  • Wrinkle removal

But the first two months of the New Year see fewer patients. Arrange your surgery then and ask about a discount of 20 percent.

Summer, however, is not a time to seek bargains, with many high school grads, before heading off to college, booking:

  • Rhinoplasty
  • Other facial procedures like ear pinning, or otoplasty

College grads are also in the mix, wanting an improved appearance before a serious job hunt.

Another excellent – and financially sound – way to spring for cosmetic surgery is to save up and pay by check or cash. Credit card companies charge the surgeon anywhere from three to five percent of the procedure.  Likewise a three to five percent discount from the surgeon is reasonable for full cash payment.

Smart consumers can also ask for surgery on a standby basis, with seven to 14 days notice before surgery.

Plastic surgeons arrange their surgery dates in advance. And the staff in an operating room must be paid, even if a patient cancels the surgery. But if a patient on the standby list can replace the cancellation, the operating room remains busy. A 20 to 25 percent discount for standby surgery has been granted by some surgeons.

A word about shopping for plastic surgery bargains: confine price comparisons to board-certified cosmetic plastic surgeons.


If a lesser-trained surgeon botches the job, your costs to repair the damage can be two to four times greater than the price of the first surgery!