Open Rhinoplasty vs. Closed Rhinoplasty

Open rhinoplasty vs. closed rhinoplasty - there is a lot of bandying about of these terms by perspective patients. The "open rhinoplasty" describes an operative technique by which an external incision is made to gain access to the interior of the nose. This is in distinction to the "closed rhinoplasty" in which all incisions are made entirely within the nasal interior.

There are disciples, defendants and proponents of each within the nasal cosmetic plastic surgery community. It is a matter of the surgeon's preference as to which technique he is most comfortable with for a given case. The nasal cosmetic surgery super-specialist will be adept at both techniques. He or she will choose a technique that seems appropriate for the case at hand.

Generally, younger surgeons appear to prefer the open technique because that is the way they have been trained. In the last twenty years that technique gained popularity, initially as a teaching device since it is easier for a student or trainee to see the nasal contour through the open approach. The more veteran nasal cosmetic surgeons were trained using the closed technique and generally were comfortable with it. But, it is not difficult for the highly experienced and specialized nasal surgeon to master the open rhinoplasty technique.

If you have never seen a photograph or a sketch of the open rhinoplasty, understand that using a horizontal incision connecting the two nostrils just below the tip, the skin is lifted as one would lift the hood of a car. Then one gets access to see the tip cartilages and when a certain instrument is placed through that opening, one can even see up to the bridge of the nose. No question that, for the novice and inexperienced surgeon or occasional rhinoplasty surgeon, this exposure is advantageous.

The open rhinoplasty tradeoff is the external scar which, while generally heals well, in some patients doesn't. Also, there is the uncertainty of how much tightening or contracture could take place during the healing.

The closed rhinoplasty, done entirely within the nose, does take greater manual dexterity and the technical facility to perform an operation "through a keyhole". Experienced surgeons will tell you that their visualization is not impaired, and in fact, this approach of course has been used for nearly 100 years with great success.




Of ultimate importance is that the surgeon be comfortable with his or her favorite technique. If you have confidence in the surgeon, have confidence in his or her judgment. Most likely, you will also be comfortable with the results that the chosen technique delivers.

If you are concerned about the visibility of the open rhinoplasty's incision, ask to see many before and after open rhinoplasty photographs, particularly close-ups. Then, you can evaluate for yourself the visibility or lack of visibility of the external incision.

- Robert Kotler, MD, FACS

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Fake Doctors and Real Doctors - Who is Injecting You?

Marie Claire Magazine Reports On Fake Doctors Taking Advantage of Patients

A recent special report in Marie Claire, a magazine that covers beauty and fashion quite nicely, reported several incidents of patients having injections and even surgical procedures by lay people - not licensed MD's. There have been reports of this in the past. The most common offenses tend to be patients having injections by these "pseudo-doctors" of non-medical grade silicone to pump up butts, breasts and other areas. It is hard to believe that people would submit to these treatments without understanding the background and qualifications of the person holding the syringe and needle, but it happens. The complications that were described were really quite bothersome and somehow it is hard for law enforcement to keep up with many of these self-styled practitioners who enter the United States, make a quick bundle of money and then leave a trail of unhappy, maimed and disfigured patients behind.

The "take away lesson" from this article is that one needs to do their homework. Here are some points that are worth remembering.

First, if a "doctor" doesn't have an office and sees you in your home or a friend's home, be suspicious that the "doctor" isn't. These bogus doctors are clever scam artists. Often they will even set up shop in a neighborhood or store front clinic but typically they are not allowed to practice in a bonafide medical facility such as a hospital or surgery center.

The best way to protect yourself is to ask for the doctor's resume, see what hospital and surgi-center staff he is on, and where he was educated and trained. It never hurts to check with the state medical board to see if indeed the person's name appears on the roster of licensed physicians.

In my book, The Essential Cosmetic Surgery Companion - Don't Consult a Cosmetic Surgeon without This Book!, I list the Federation of State Medical Boards of the United States website and phone number whereby you can make contact with the Medical Board in your state to verify credentials.

Finally, if the price seems too cheap, it probably is. Typically, these fakes attract patients not by qualification, experience or talent, but strictly because there are cheap. Caveat emptor! Buyer beware.

- Robert Kotler, MD, FACS

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Second Chances for Your Nose

The recent Elle Magazine had a feature article written by an experienced medical writer in which she discussed the issue of a second nose job - the so called "secondary rhinoplasty." The operation is always challenging and there are as many ways to do these operations as there are surgeons to perform them.

A few weeks ago, I participated in a seminar where several lecturers and panel discussions dealt with the issue of the "nose job re-do's." Everyone agrees that it is difficult, less predictable and this often translates to a lower level of patient satisfaction. There are procedures employed, including transplanting portions of rib, cartilage and even skull bone in order to reconstruct a nose that has not fared well with the first operation. This is why the procedure becomes unpredictable; the fate of these tissues when implanted into the nose is often unpredictable.

I was a bit disappointed that hardly any attention was given to the alternatives to grafting and transplanting tissues, that is the use of injectable "fillers." The mission is the same, to replace tissue that has been over sculpted, over-removed leaving dips, depressions, pinches and scooped out bridges. There is a place for these filling injections, some of which are permanent. I think patients owe it to themselves to check out all of the alternatives, surgical and nonsurgical before committing to a second major nasal reconstructive surgery.

-Robert Kotler, MD, FACS

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Today's Cosmetic Surgery Anesthesia Techniques

Photo: Robert Kotler, MD, FACS

Today's cosmetic anesthesia techniques and medications are extraordinary! The above photographs tell it all. The photo on the left taken at 2:26 pm shows a patient who has just completed a five-hour face and neck lift. The dressings are in place and the patient is about to be taken to the recovery room.

The second photo taken 3 minutes later at 2:29 pm shows the patient at her station in the recovery room fully responsive and when asked, "How are you feeling?" gives the thumbs up sign. That is a strong indication that the patient's faculties and brain function are intact.

The third photo is taken at 3:48 pm, approximately one and a half hours after the patient emerged from the anesthetic. She is alert, pleased, and particularly joyful because she had a history of having nausea and vomiting with a previous surgery. The patient will now be transported to a professional recovery facility where she will be observed overnight before she sees her surgeon the next day.

What is significant is that the patient had a particular cutting edge anesthesia technique. This technique is known as "PK" anesthesia. The "P" stands for propofol and the "K" stands for ketamine. Now propofol, which is the chemical name for the medication marked as Diprivan, has gotten a lot of attention recently because it has been implicated in the improper prescribing of medications for Michael Jackson. However, that should not at all dissuade anyone from availing themselves of this marvelous anesthetic which has a very quick onset and a very quick "wakeup." The "K" medication, ketamine, is a perfect partner for the propofol. The medication places the patient in a detached state whereby they are conscious but are totally isolated from any stimulation and, therefore, pain is not registered in the brain. While the patient is maintained on the propofol medication throughout the case, the ketamine is used only in anticipation of when local anesthesia is injected. Understand that the operation relies on local anesthesia - administered after the propofol-ketamine has been given intravenously - to render the tissues pain free.

It is remarkable that the patient required no oxygen, did not have a mask or tubes on her face or in her nose. She received no narcotics or any other medication that might be apt to make her nauseous and delay the emergence from anesthesia.

This technique has been popularized, worldwide, by anesthesiologist Barry Friedberg, MD. Dr. Friedberg, who is on the faculty of University of California, Irvine, is author of a very specialized medical textbook for cosmetic surgeons and anesthesiologists entitled, Anesthesia in Cosmetic Surgery.

- Robert Kotler, MD, FACS

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What Are Talent, Experience and Superspecialization Worth?

Recently, I reminded myself that one of the consistent business truths of life is that there are three variables in every purchase we make. The first is cost, the second is quality and the third is service.

What reminded me of this was when I visited my shoe repair shop with an urgent repair need. The shop has done very good work, and their turn-around time - the measure of service - is always short. However, their charges are higher than average. But, I don't mind paying the extra amount because I am getting quality and service.

The converse would be any low-priced service. If the price is low, then either the quality and/or service must also be low. What comes to mind is the typical fast food operation. The service is quick, the prices are low but the quality is not fantastic. So, you only get two out of three.

So how does this parallel the subject of talent, experience and superspecialization?

The most gifted cosmetic plastic surgeons with long experience and narrow focus - the superspecialists - generally deliver high-quality results. That is why they are at the top of the totem pole among other doctors. Typically, their offices render top service because they have developed efficiencies in both their surgery and practice operation. Rarely the lowest price.

You do get what you pay for.

- Robert Kotler, MD, FACS

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