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.

“The Seven Fears Prior to Rhinoplasty – Easing Your Worry”

1. Fear of the unknown. Anesthesia and surgery
2. What will I look Like?
3. When will I return to work and the gym?
4. Will it be painful?
5. What will others think?
6. Can I afford the surgery?
7. Which surgeon?

1. Fear of the Unknown – Anesthesia and Surgery

Rhinoplasty, an elective procedure, is anatomically- superficial. It’s an operation that occurs is immediately under the skin upon the bone and cartilage. No major body cavity is entered, as in chest, abdominal or brain surgery. Patients are in and out of the surgery center in five hours or less. You must be healthy to have elective surgery. Your personal doctor is charged with examining you and ordering the tests to “clear you”. The confirmation that you are healthy to have this superficial surgery should comfort you and erase some of the anxiety.

Ease Your Worry About Anesthesia.

Beverly Hills Rhinoplasty Surgeon Dr. Robert Kotler says, “here is the key to anesthesia safety: “The surgery should be done in a licensed outpatient surgery center, and the anesthesiologist should be a superspecialist who works exclusively with the same staff, and surgeons. It should be a stable team, performing the same procedure, over and over, which brings consistency, efficiency and therefore safety.”

The surgery is one level above a dentist pulling one or more teeth. Not like open-heart surgery or a kidney transplant. You get a dose of propofol, you fall asleep and immediately we inject local anesthesia. Therefore, there’s no pain during surgery and you’ll just wake up from a nice sleep. One of the glories of Propofol is that there is no hangover, no nausea and vomiting as in the pre-Propofol days. Quick recovery. Lunch or dinner that day.

2. Will It Look Natural?  

The fear of looking strange from a bad surgery raises its ugly head. To guarantee great results, “choosing the right surgeon who is experienced, board certified and empathizes with the patients will contribute to attaining the desired results,” says Beverly Hills, Rhinoplasty Superspecialist Dr. Robert Kotler.

Ease Your Worry About the Natural Results of Rhinoplasty.

A common postoperative reaction is to question whether the right choice was made. Adjusting to the results in some cases may take time, but the primary concerns usually fall by the wayside once the swelling subsides, and bandages are removed. 

3. How Long Before I Return to Work?

The first ten days are the core period of recovery after rhinoplasty surgery. By the tenth day most of the bruising and swelling is gone and you’ll already look very decent. “When I had my Rhinoplasty, I was back to the office and operating in ten days. My appearance never drew any questions”, notes Dr. Kotler. At ten days, you can return to regular activities including gym and full athletics, except contact sports, such as soccer or rugby. Six weeks for those possible “nose crunchers”.

Ease Your Worry About Returning to Work After Rhinoplasty.

Dr. Kotler feels that seven to ten days is the usual return to work period. With better techniques and drugs to control swelling and bruising, no one should fear looking like they just went 10 rounds with a boxing champ”, comments Dr. Kotler, a former Major, Medical Corps, US Army.

After the tenth day there’s continuous ripening and refinement, such that the nose becomes, “Just like wine, better with time”, he notes… A 100- day process that nature controls.

4. Will it be Painful?

The pain level after rhinoplasty is variable and for most people it’s relatively minor. For others who have a low tolerance for pain, stronger medications will be employed. Pain must be controlled and that’s the first duty of a physician, to provide comfort and pain control. The secondary and important reason is that uncontrolled pain can raise blood pressure. Elevated blood pressure can cause bleeding.

Ease Your Worry About Rhinoplasty Pain.

Because Rhinoplasty is a minimally invasive, relatively superficial operation, most patients achieve pain relief with Tylenol with Codeine, Extra Strength Tylenol, or stronger versions of Aleve or Advil.

5. What Will Others Think? 



Today in our culture, Rhinoplasty is increasingly commonplace. It may even come as a surprise to you how many people you know have either had nose surgery or are considering it.  Either way, it is an individual decision, and the improvement is yours and nobody else’s. If you’re not happy with your nose it’s your choice. Don’t put the decision out for a vote!

Ease Your Worry About What Others Will Think After Rhinoplasty.

Most people say it’s one of the best decisions they’ve ever made. Other people won’t even remember what your nose looked like before our surgery. And, remember, most are worried about their own appearance.

6. Surgery Costs

The popularity of Rhinoplasty is a testimony to it affordability and value. It is no longer an indulgence of the rich and famous. While the cost is not insignificant, consider improvement in your appearance, your self-satisfaction and your confidence, an investment, not an expense. And, the procedure is yours for the rest of your life. It will far outlive nearly every other purchase you may make.

Ease Your Worry About Rhinoplasty Cost.

Most practices offer financing, accept credit cards and payment plans.

When appropriate, there are lower cost, non-invasive procedures. Permanent non-surgical rhinoplasty or permanent non-surgical nose job may be a better choice than surgery for reasons beyond costs. The comprehensive consultation with Computer Imaging will aid your decision-making.

7. Choosing the Right Surgeon for the Job

This is the single most important factor in achieving satisfaction.

Ease Your Worry About Finding the Right Surgeon.

1. Training: Review their training, and always lean towards a ‘superspecialist.’ A superspecialist is a surgeon who specializes in one or two procedures, rather than all procedures under the sun. 
2. Experience: Experience counts in life. It takes a lot of time to be very skilled in anything we do in life.
3. Superspecialists are the doctors at the top of the totem pole. Why not have the most specialized talent? You know the old aphorism: “Jack of all trades, master of none”. You want the master.
4. Results: What are the results? Look at a lot of before and after photographs and the doctor’s reviews. The more photos in the surgeon’s gallery and the most 5-Star reviews the better.
5. Good Consultation: The doctor needs to spend time with you, answer all your questions, and understand your expectations and concerns. A top-quality consultation has the doctor spending more time with you than anyone else in the office.  You don’t go to a consultation for a sales pitch. You go to be educated and have your questions answers.
6. Computer Imaging: A consultation without Computer Imaging has little value. After all, shouldn’t you see the predicted result of your Rhinoplasty or Permanent Non-surgical Rhinoplasty?  Would you purchase a piece of art without seeing it?

When all questions and concerns are addressed, anxiety melts away.

• Robert Kotler, MD, FACS

Hosts Trina Renea & Dr. Vicki are joined by Plastic Surgeon Robert Kotler, MD, FACS. Together they discuss the once highly sought-after Phenol Peel, which is considered the most profound and most effective type of chemical peel on the modern market. The Phenol Peel is a powerful chemical peel made for treating multiple fine wrinkles, sun spots, and discolored patches for specific skin types. In a series of questions, we break down candidacy, downtime, cost, compare and contrast with other laser procedures, and of course, the pain level. Not many new practicing doctors have taken the time to master this peel. Check out their podcast & Dr. Kotler’s episode here!

Two Failed Surgeries, But No Desire For Temporary Solution

LOS ANGELES, CA, UNITED STATES, August 10, 2023/EINPresswire.com/ Sarah Grace Lee, the reigning Mrs. California, recently revealed that she opted to have a permanent filler― not temporary ― revision nose job. “Who wants a life sentence of doctor visits to keep replacing the dissolved filler? My research led me to Dr. Robert Kotler Beverly Hills’s Rhinoplasty superspecialist.” https://www.einpresswire.com/article/648933779/mrs-california-reveals-permanent-non-surgical-revision-nose-job

LOS ANGELES, CA, UNITED STATES, July 12, 2023/EINPresswire.com/ — Dr. Robert Kotler, MD, FACS, a renowned Beverly Hills Rhinoplasty Superspecialist, wins the Best of Los Angeles Award- “Best Rhinoplasty Surgeon – 2023.”

The “Best of Los Angeles Award” community was formed nine years ago and consists of over 7,800 professional members living and working in Southern California. It celebrates the best people, places, and things in Los Angeles with the slogan “No Ads. No B.S. Only the Best.”https://world.einnews.com/pr_news/643936105/robert-kotler-rhinoplasty-superspecialist-wins-best-of-los-angeles-award-best-rhinoplasty-surgeon-2023

“INSIDER’S INFORMATION FROM THE NASAL SURGERY SUPERSPECIALIST”

I would like this report to be precious to you.  I want this to have value such that you will say to yourself, “It’s a good thing I read this, I sure didn’t know that.”

Today I want to discuss with you issues that other MDs may not necessarily be as forthright or open about.  I am going to tackle a somewhat controversial subject. But I do this from the vantage point of having been a board-certified specialist for 36 years and having over 4,000 nasal surgery cases under my belt. My career included serving a fellowship in cosmetic facial surgery following my residency as well as a military career which gave me enormous experience and depth. 

Is Every Plastic Surgeon Qualified to Do Nasal Cosmetic Plastic Surgery?

The issue that I want to share with you is that not all “plastic surgeons” or head and neck/ear, nose and throat surgeons are equipped by training, talent or experience to perform cosmetic and reconstructive nasal surgery.  It’s an inconvenient truth that needs to be told.

What I’m telling you is based on my observations and my involvement over the years in the academic community and in acting as a consultant to the Medical Board of California and to insurance companies and even the City and County of Los Angeles Medical Departments.  Nasal surgery is unquestionably the most complex and challenging of all the surgeries within the world of cosmetic plastic surgery.  You can understand why.  The operation is typically done through the nostrils.  While it can be done through an external incision, even that still yields a very limited opening through which surgery is done.  Contrast that with surgery inside the abdomen, chest or even skull where the exposure or opening is quite generous.  In abdominal surgery, three or four surgeons could put their hands inside.  You can barely put your little finger inside the opening of the nose when operating. 

The other issue is that the nose has complex anatomy and the structures each are interdependent on each other and the room for air is very minimal.  It won’t make much difference if there is a little bit of tightness or a little extra scar tissue inside your abdomen after you have your gallbladder removed or your hernia repaired but you sure don’t want to have any scar tissue that shows on the outside of your nose after having cosmetic nasal plastic surgery.  So the standards for excellence have to be high.  With little room for error in appearance and the need often to make sure that the patient breathes well, there is a lot of responsibility that comes with picking up the instruments to do cosmetic nasal surgery or rhinoplasty as well as the surgery to improve the airway known as nasal septoplasty and turbinate resection.  Sometimes, it is even necessary to do some limited sinus surgery if in fact the patient’s breathing problems are so bad as to impact upon sinus function.

My point is that just like in orthopedic surgery, where not all orthopedic surgeons are experts in arthroscopic knee surgery, you must make sure that you narrow your search beyond just having a board-certified specialist in either head and neck surgery or plastic surgery because both of those fields are huge.  In plastic surgery, for example there are 137 operations that the American Board of Plastic Surgery considers within its domain and expects its graduating residents to have familiarity with and be capable of performing.  But there is no way any plastic surgeon could master all those operations.  Certainly rhinoplasty, as difficult as it is technically to perform, cannot be fully mastered in just a couple years of residency.  It takes many more years.  But the route to excellence comes from great teaching, proper training and broad experience.

  Current Problems with Training and Education of Cosmetic Surgeons

Speaking of training, you need to understand the current state of American post-graduate medical education, the residency system.

Nearly 100 years ago, the U.S. established the world’s premier and most sophisticated postgraduate physician training system.  All this was the result of recognition of specialties which began in 1916 with the formation of the American Board of Ophthalmology.  My specialty, head and neck surgery, was the second certifying board founded several years later.  Since then, there have been 23 recognized specialties, each conducting its own residency programs leading to credentialing known as “board certification.”

In the golden era of medical education which in my opinion began at the end of World War II and continued into the early 1980s, surgeons in training, particularly, had ample opportunity to amplify their skills since there were many patients who would come to the university hospitals and be willing to have their surgical procedures done by the surgeons in training under supervision of the professors and other faculty members.  This was possible because universities had large budgets to allow teaching and would, in fact, absorb the cost of the operating room times.  And as you can imagine, residents in training take longer to do procedures than sophisticated faculty or other veteran specialists in practice.  The system worked very well for many, many years.  This large inflow of patients allowed young surgeons to feel quite comfortable with their skills when they graduated from the residency programs.  I know that teachers in our program felt that way. 

Further heightening the abilities and talents of today’s senior surgeons was that nearly all of us served in the military.  For many of us who were fully trained specialists, it was a rich and rewarding opportunity to hone our skills and at the same time, of course, serve the country in a meaningful manner.  Most of today’s young surgeons have not had the privilege and honor plus the benefits of the experience that come with military service.

In the 1980s, the complexion of medical practice changed as insurance companies began to alter their manner of payment.  The bottom line is that over a period of time, teaching hospitals – like all hospitals, became financially squeezed as insurance company payments were continually ratcheted down and as the expense of providing care went up.  What that meant was that budgets in university hospitals were under such a tight rein that the residency programs began to suffer from it.  Some hospitals even gave up training certain residents and fellows (fellows are post residency subspecialty trainees) because government stipends were diminishing parallel to the decline in insurance reimbursements. 

So how did this all affect the training of residents?  The answer is that the opportunities to perform elective surgery drastically diminished.  Residents today graduate form some training programs with a very poor background in cosmetic surgery.  They are stronger in reconstructive surgery, whether in the head and neck or the rest of the body.  The reason is that reconstructive surgery is medically necessary and patients come to the hospitals with some form of insurance and, therefore, the hospitals still keep the welcome wagon out for them.  But hospital administrators are loathe to tie up an operating room for an entire day for a young surgeon to learn how to do a facelift which would take him eight to ten hours as compared with an experienced surgeon taking five or so. 

As usual, economics trumps all.  The consequences for today’s patients are significant in that if residents graduate from a residency program with little experience in performing nasal surgery, for example, they have to learn it on their patients in private practice.   We hear of surgeons who go into practice and proclaim that they perform cosmetic nasal surgery and yet have done two or three in their residency.  Their web site shows one or two cases. 

You need to think about all these things when you make your decision particularly concerning nasal cosmetic surgery which is by far the most technically demanding and sophisticated of all the cosmetic surgery procedures. 

—

Dr. Kotler:  “This is dictating an addition to a previous piece that was entitled ‘A Dr. Kotler Special Report’, so we’ll just plug this in.  Let me see here, current state of American postgraduate and the residency system – paragraph”  . . .

America established the world’s premier and most sophisticated postgraduate physician training program.  All this was the result of recognition of specialties which began in 1916 with the formation of the American Board of Ophthalmology.  My specialty, head and neck surgery, was the second certifying board founded several years later.  Since then, there have been 23 recognized specialties, each conducting its own residency programs leading to credentialing known as “board certification.”

In the golden era of medical education which in my opinion began at the end of World War II and continued into the early 1980s, surgeons in training, particularly, had ample opportunity to amplify their skills since there were many patients who would come to the university hospitals and be willing to have their surgical procedures done by the surgeons in training under supervision of the professors and other faculty members.  This was possible because universities had large budgets to allow teaching and would, in fact, absorb the cost of the operating room times.  And as you can imagine, residents in training take longer to do procedures than sophisticated faculty or other veteran specialists in practice.  The system worked very well for many, many years.  This large inflow of patients allowed young surgeons to feel quite comfortable with their skills when they graduated from the residency programs.  I know that teachers in our program felt that way. 

Further heightening the abilities and talents of today’s senior surgeons was that nearly all of us served in the military.  For many of us who were fully trained specialists, it was a rich and rewarding opportunity to hone our skills and at the same time, of course, serve the country in a meaningful manner.  Most of today’s young surgeons have not had the privilege and honor plus the benefits of the experience that come with military service.

In the 1980s, the complexion of medical practice changed as insurance companies began to alter their manner of payment.  The bottom line is that over a period of time, teaching hospitals – like all hospitals, became financially squeezed as insurance company payments were continually ratcheted down and as the expense of providing care went up.  What that meant was that budgets in university hospitals were under such a tight rein that the residency programs began to suffer from it.  Some hospitals even gave up training certain residents and fellows (fellows are post residency subspecialty trainees) because government stipends were diminishing parallel to the decline in insurance reimbursements. 

So how did this all affect the training of residents?  The answer is that the opportunities to perform elective surgery drastically diminished.  Residents today graduate form some training programs with a very poor background in cosmetic surgery.  They are stronger in reconstructive surgery, whether in the head and neck or the rest of the body.  The reason is that reconstructive surgery is medically necessary and patients come to the hospitals with some form of insurance and, therefore, the hospitals still keep the welcome wagon out for them.  But hospital administrators are loathe to tie up an operating room for an entire day for a young surgeon to learn how to do a facelift which would take him eight to ten hours as compared with an experienced surgeon taking five or so. 

As usual, economics trumps all.  The consequences for today’s patients are significant in that if residents graduate from a residency program with little experience in performing nasal surgery, for example, they have to learn it on their patients in private practice.   We hear of surgeons who go into practice and proclaim that they perform cosmetic nasal surgery and yet have done two or three in their residency.  Their web site shows one or two cases. 

You need to think about all these things when you make your decision, particularly concerning nasal cosmetic surgery which is by far the most technically demanding and sophisticated of all the cosmetic surgery procedures. 

—

                        A  Word about Before and After Photographs. 

There is no better telescope into the nature of a cosmetic surgery practice than the volume and quality of the before and after photographs that are made available to prospective patients.  I almost giggle when I see some surgeons with such a limited number of rhinoplasty or neck sculpting cases on their website.  They may have more breast augmentations or liposuctions but even those numbers are very small.  So if a surgeon has such a small library of before and after pictures, doesn’t it seem that their surgical experience would also be limited?

I love websites that have hundreds of before and after photographs because it is much easier for the prospective patient to identify someone, somewhere on that site that had similar needs and aspirations that they have. So don’t forget to ask about before and after photographs when you go for consultation and if there are no photographs that can be shared with you, I would suggest that you say “Oops, I think I have a call. I must leave now,” and graciously head for the door.

Should You Go to a Teaching Hospital?

Thanks to the Internet, today’s patients are very sophisticated. They know a lot and they also know that perhaps the teaching hospital is not the place to go for their surgery because that is where the surgery is done by trainees. So that keeps people from going to the hospitals and that diminished inflow reduces the surgical load for the surgeons in training.  In addition, teaching hospitals offer little privacy and personalized service. Further, of course, there is a greater risk of infection and other complications that are such an anathema to the surgeons.  

So what I’m suggesting to you is that if you are considering having nasal surgery, you must search for the superspecialist.  A surgeon who has narrowed his practice down to a very limited number of procedures among which is nasal surgery and who has the focus such that he has excluded other procedures from his practice that he may have even once been quite capable of well- performing. The educational background that one seeks is to have graduated from a residency program and passed the board examination and then gone on for additional fellowship training in facial plastic surgery which will always have nasal surgery as a key component. That is what you look for on paper.   After you glean that from the doctor’s resume, you need to ask how long the doctor has been doing nasal surgery and how many cases he has done over a period of years and do the calculation that shows how many are performed each year. Any surgeon who is performing fewer than 100 nasal cases per year is probably not at the top of the totem pole.

Remember, you have the right to ask these questions, you have the means to do your homework. As you know from seeing patients who have had unsatisfactory nose surgery, the stakes are high. 

You want to do it right the first time.

I hope this helps you.

Robert Kotler, MD, FACS