So, all cosmetic plastic surgeons want their patients to be in the pink of physical and mental health before rejuvenation surgery. In many states, that’s why you must first have a physical and some blood tests before going undergoing cosmetic surgery.

Patients seeking a re-do of a botched rhinoplasty often look long and hard to make sure a master nasal surgeon with years – if not decades – of experience does the revision which is more involved due to the damage done in the first nose job surgery.

As you may have read, many more people are developing Type II diabetes, a condition which seems to spread as more people become overweight or obese. Thus, more nose job patients are also asking if they can have a first rhinoplasty or a revision rhinoplasty if they also have Type II diabetes.

The answer? Maybe. It depends on how well the condition is controlled.

In Type II, the cells of the body don’t work well with insulin. In Type I, the body just does not produce enough insulin. In both types, blood glucose is higher than normal.

And how does all that affect cosmetic surgery? Wound healing is where diabetes types 1 & II and cosmetic plastic surgery touch. While rhinoplasty does not involve major incisions, any cuts made by surgeons’ knives are considered wounds. (An exception in nose surgery is African-American nose job surgery when nostrils are slimmed; incisions are hidden in folds and creases of skin.)

To make sure surgery is O.K., the plastic surgeon will check your blood levels for something known as an A1c rate. That’s a measure of how well blood glucose has been controlled over the previous three to six months. Any reading should be under 7 percent. (The highest “normal” reading is 6 percent.)

Thus, if you have diabetes and your A1c rate is over 7, your surgeon is likely to say rhinoplasty revision surgery is O.K. in another six months, after another blood test and a lower A1c level.

You can do your part in going ahead with revision surgery by cutting out surgery foods and drink, losing weight and getting regular exercise.

In some cases, the plastic surgeon will coordinate with the patient’s physician who handles the diabetes.

Plastic surgeon Mark Constantian, M.D. of Saint Joseph Hospital in Nashua, New Hampshire, wondered the same thing and organized a study to find out. The results are printed in the 9-’12 issue of Plastic and Reconstructive Surgery, an official plastic surgery journal, read by cosmetic plastic surgeons worldwide.

So Dr. Constantian studied the medical records of 150 patients who sought and had revision nose jobs.

Until now, most plastic and cosmetic surgeons considered patients who wanted a revision rhinoplasty hard to get along with, demanding or difficult during the consultation and surgical process.

But that finding may not be accurate.

Dr. Constantian knows because he also performed revision surgery on the 150 patients during a year and one-half period stretching from 2007 to 2008.

During the study, the doctor carefully looked at the reasons given by the patients for wanting the do-over surgery, any personality management problems caused by the study group along with the surgeon’s and the patients’ happiness over the outcome of the surgeries as revealed by the nose job before and after pictures.

The doctor studied 121 women and 29 men; the study group was an average of 42 years old.

Remember we said that first rhinoplasties were often botched? Dr. Constantian found the patients had undergone one to eight previous nasal surgeries with an average of 3.6 nose jobs per patient.

His findings? Let him tell it: “The reasons for wanting a revision surgery are about the same as people who want a first rhinoplasty – to look good and to have a botched nose reconstructed.”

Added the plastic surgeon: “My experience as a surgeon doing surgery on these 150 patients really questions the idea that patients who want a revision surgery are hard to get along with.”

But not all the revision surgeries were due to fumble-thumb surgeons.

A full 41 percent who wanted a fix-it nose job was to straighten out a new deformity. For instance, a nose that was once straight had become crooked. In about one-third of the patients, a first nose job did not correct an original deformity.

Another 15 percent of the study group thought their noses had lost the personal, family or racial marks that so well defined them.

One percent had new or continuing woes with breathing and obstruction of healthy airflow through the nose.

Only 10 percent wanted more improvement in a nose that could not be improved any more by surgery.

The score for Dr. Constantian’s group of 150? 97 percent were happy with the way their noses looked after surgery.

All that underscores the concept that a first rhinoplasty is the most difficult of all plastic surgeries so a master rhinoplasty surgeon is required for a revision rhinoplasty.

Why? The noses’ insides look different after other surgeries. One study found the average rhinoplasty revision patient – among 150 revision patients — has had a whopping 3.6 previous nose surgeries.

Sometimes, the interior of the nose has been operated on so much, there is no cartilage left to rebuild a nose. Then, the nasal surgeon must take donations of cartilage from the patient’s ears or from between the ribs.

But, in some cases, the cosmetic surgeon and patient choose to go with a plastic implant.

Now, a recent study in the medical journal, Archives of Facial Surgery finds that some plastics used in nose job revisions can result in stubborn infections.

So far, choices for nasal implants have been Gore-Tex, surgically known as ePTFE or a plastic known as Medpor.

According to a new study, as many as one in five revision rhinoplasties using Medpor resulted in nasty infections. It wasn’t hard for the patients to see something was wrong – the Medpor implant started sticking out through the nasal incision!

The new study looked at 662 rhinoplasties performed between 1999 and 2008 and found 2.8 percent of the surgeries, or 19 patients, ended in infection. Tellingly, all 19 had one of the two types of plastic supports used in the nose. In all, plastics were used in 151 cases.

The researchers, led by Denver plastic surgeon Andrew Winkler, M.D., noted that an infected nose job or revision rhinoplasty is usually not cured by antibiotics. Rather, the situation often requires yet another surgery to remove the implant.

Leading the infected cases was the Medpor implant, with one in five nasal surgeries leading to infection. But people who received donations of cartilage from their own bodies reported no infections at all.

The Gore-Tex or ePTFE implants showed a lower rate of infection at 5.3 percent of surgeries. Unfortunately, Gore-Tex is soft, floppy and can’t be used in all aspects of nasal surgery. Its most common use in nose surgery is building up height on the bridge of the nose.

In a face with a nonremarkable nose, the eyes of the observer first notice facial balance and then the person’s eyes. But in a nose that has flaws, including:

• Humps and bumps
• Low bridges
• Bends of twists in the nose
• Grooves, moguls or divots in the nasal skin
• Low hanging tips

the eye of the observing person remains stuck on the flawed nose and does not really notice the lips, cheekbones, jaw line and other features of the person you are looking at. It’s even worse if the person has as receding chin.

Only patients whose breathing is completely normal and do not need surgery inside the nose can have nonsurgical rhinoplasty. That includes people who need surgical attention for:

• The Septum
• The Turbinates
• A broken nose

To start a nonsurgical rhinoplasty, the patent is given local anesthesia in the treatment area of the nos; the plastic surgeon uses a syringe and very thin hypodermic needle to inject the soft tissue filler under the nasal skin.

While Restylane, Juvederm, Radiesse and other hyaluronic acid-based fillers are often used, only Silikon 1000 provides a permanent change. Using Silikon, the cosmetic surgeon places micro drops  of the substance under the skin. It becomes permanent because the body walls off, or encapsulates, the tiny drops of Silikon

Such minute amounts of filler are used that the patient often must return in six weeks to see how the nose is reacting and to add more filler, if needed. But the time required is far less than having yet another surgical rhinoplasty with its substantial costs and time away from work and family for recovery.

The actual time needed for a plastic surgeon to inject and emplace the soft tissue fillers require about an hour or less in many cases to perform in the surgeon’s office. When the procedure is finished, the patient is free to resume his or her usual activities.

The filler injection technique makes possible corrections like the augmentation of a flat nasal bridge, or, technically, a depressed dorsum. The surgeon can also add some projection to a nasal tip or camouflage a hump on the nose by injecting material above and below the hump. Nasal sidewalls depressions, saddle noses and a few other traumatic injuries can be treated and enhanced. (A saddle nose is the typical “boxer’s nose” with the bridge of the nose highly depressed.)

The study, one of the many medical studies done that show how well injection rhinoplasty  works, was done in Australia in 2005 and printed in the Australasian Journal of Cosmetic Surgery. Titled, Rhinoplasty Using Injectable Polyacrylamide Gel (Aquamid) – A patient Study, the study looked at the noninjection rhinoplasty on 89 patients who were an average of 32 years old. All the test subjects were treated for a nasal dorsum defect. (The dorsum is the long spine of the nose, running from the tip of the nose to its end just between the eyes.)

The test showed that the area which was injected was usually 20 to 30 percent higher than the healed height of the final correction. A special ointment was applied to swollen areas four times daisy.

Results? After 12 months, the follow up exam showed that all 89 patients were pleased with the aesthetic look of their injections and had a nose that looked natural in appearance and feel.

A “saddle nose” is also known as a boxer’s nose or a pug nose

. For boxers, a saddle nose results after taking many years punishment to the nose in the ring. But a book publishing society figure? How did she suffer a saddle nose?

The police also wanted to know and soon found the high level publisher had been pummeling his wife over so many years that her nose had literally been battered into a typical boxer’s nose.

The same result can happen when a beginning or inexperienced rhinoplasty surgeon removes too much bone, tissue and cartilage in a nose reshaping operation. Sports injuries like a blow with baseball, soccer or basketball can cause the same injury. Some people are just born with a saddle nose but most happen during the patient’s life time.

Unfortunately, nose reshaping revision on a saddle nose is surgically very involved, requiring changes to the inside and outside of the nose by a master rhinoplasty surgeon.

The key element inside the nose is the septum, a thin wall of cartilage and bone which, in addition to separating the nostrils, is also support for an upright nose. It does that through natural supports and struts so when too much is taken out, the nose no longer has the enough support. Over eager cosmetic surgery on a nasal hump can also cause the condition.

Yet another nasal procedure can produce a saddle nose. Septoplasty, the internal nasal surgery procedure to restore the septum, if done incorrectly, may result in a collapsed septum and eventual saddle nose. Breathing blockages can also result.

(Read more about septoplasty.)

To restore a normal looking nose, the nasal surgeon first repairs the airway by using donations of cartilage from the patient’s own body. Once the internal support allowing normal breathing is re-created, the surgeon, again working from the inside of the nose, can use synthetic nasal implants to straight the nose from the bridge to the tip.

The implants are made from medical-grade silicon and crafted to fit the patient’s exact specifications.

Using a closed technique means the surgeon operates through the nostrils only, avoiding unnecessary incisions and dissection throughout the inside of the nose.

The other method — the “open” technique — means the skin of the nose is peeled back so the cosmetic surgeon can operate on the bony structure of the nose. The open method requires intubation and deep anesthesia which causes more bleeding, bruising and making a more rocky patient recovery.

The open method also disguises the usual anatomy of the nose and its connections to the skin,  bones and cartilage inside the nose. The closed technique helps the surgeon better see his way when correcting the deformities caused in the first rhinoplasty.

With everything in the nose in its usual place, the surgeon can more accurately place the donations of cartilage taken from the septum, ear or the ribs.

Of course, there is less room in which to work using the closed method but it’s easier to find the exact place inside the nose to insert tiny, millimeter thick grafts in the nasal tip, the dorsum (the nasal bridge) and sides of the nose.

Using the closed method means the patient can undergo surgery with only intravenous sedation, a local pain killer in the nose and skip any narcotic or anesthesia, all of which means faster recovery and with less facial bruising.

Additional advantages of the closed technique include:

• A shorter operation
• Not as much swelling in the tip
• No scarring on the outside of the nose
• Less bleeding

At the start of a closed rhinoplasty revision, the surgeon sits the patient up and marks the nose with surgical ink exactly where the grafts are to go. Otherwise, surgical improvements would only apply to reclining patients!

While marking the nose, surgeon and patient can talk and agree about what is to be changed and in which location.

Michelle G. from Studio City, California, is probably typical. She had a first rhinoplasty several years ago, but the final look did not please her. Moreover, the first surgery done elsewhere by another surgeon was so badly botched her nose could not be operated on again.  “I was left feeling dissatisfied,” she writes “but then heard of this amazing technique that Dr. Kotler uses because nose surgery on me was not an option.”

Michelle is writing about permanent, non-surgical rhinoplasty. The technique is also known as injection rhinoplasty.

Writes Michelle: “It (the surgery) was a gradual progression; Dr. Kotler makes sure the nose looks natural and that not too much filler is applied at once. This allows you to see where results are headed.”

If the only surgery needed is on the outside of the nose, an unhappy nose job patient can have injection rhinoplasty. It produces a natural looking nose by filling in divots, marks and gouges with a permanent filler. The technique can even mask a nose hump or make a twisted one look straight. Injections are done six weeks apart in short office appointments.

Writes Michelle: “There is very little discomfort and no down time at all. Dr. Kotler is a very caring and honest doctor and has an amazing gift that one else is performing.”

Patient K.E. tells how he had a first rhinoplasty three years ago that did not turn out well nor provide the natural nose he wanted. “I had apprehensions about a second procedure because the first did not live up to my expectations… I also had reservations about physical discomfort and pain. But after Dr. Kotler’s surgery, my pain was minimal with not as much bruising the first nose job gave me. Surgery was only two weeks ago, and I can already see that profile has improved, my bridge is higher and tip is more refined…My experience with Dr. Kotler and his office and surgical staff was extremely positive. I would recommend him to anyone wanting to improve his or her appearance.”

1. Rhinoplasty is the hardest cosmetic surgery to learn and perform. Only consider cosmetic plastic surgeons with decades of experience. Revision rhinoplasty is even more difficult.
2. Revision Rhinoplasty – when a first nose job has been botched – should only be considered when the nose is badly shaped, does not fit the face or if the nose has terrible breathing, often caused by a deviated septum or turbinates, sensitive structures farther up in the nose that can block breathing. (Read more about turbinate reduction .)
3. In both first and revision rhinoplasty, one yardstick applies – a natural looking nose.
4. The very best of hands do not guarantee a great nose. Bad genes, weak nasal cartilage and bad skin quality can undo the work of a master plastic surgeon.
5. Less is more. Removing too much tissue – most especially large amounts of the nasal tip cartilage – can lead to unpleasant appearance or even a deformed nose. The framework of the nose is enhanced by moving, building up or reshaping the cartilage in the tip of the nose, and not taking it out.
6. Revision surgery is often O.K. to touch-up a minor imperfection. An even better choice – providing the touch-up is only needed on the outside of the nose – is injection rhinoplasty. The plastic surgeon uses a syringe and a facial filler to fill dents and depressions. (Read more about permanent, non-surgical rhinoplasty.)
7. Modern rhinoplasty for first or revision nose jobs can do wonders for an unattractive nose, but even the best plastic surgeons can only work with what they are given in any particular nose. Be realistic about changes.
8. First or revision nose job patients can’t have somebody else’s nose. What looks great on Brad Pitt will probably not be a match to your particular face with your unique shape, type of skin and strength of bone and cartilage. In cosmetic nasal surgery, one size does not fit all.
9. Revision (and first) rhinoplasties take place among three entities – surgeon, patient and Mother Nature. For the first several months, swelling may disguise a newly reshaped nose. Final healing may not take place for a full year.
10. Revision rhinoplasty is more complicated, much more expensive and, sometimes, less effective than a first nose job. It’s well worth your time to do lots of homework and make sure your surgeon really know his or her stuff.

Reconstructivecosmetic surgerycan be extremely important for many reasons including:

• Birth defects
• Scarring
• Burns
• Accidents

Other factors which have done damage to a person’s nose — including previously botched nose jobs – done elsewhere by other surgeons can usually be helped by the reconstructive nasal surgeon.

Just about all plastic surgeons say that 80 percent of their patients come to them via the Internet. So, from the comfort of your home computer, you can literally let your fingers do the walking to narrow the search for the bestLos Angeles plastic surgery provider.

First, check the “about the doctor” section of the website. Make sure he or she is board certified.

But beware! All types of boards exists which have little to do with medicine or surgery and only offer some paper hanging services. Make sure anyrejuvenation surgeon you may visit is board certified in:

• Plastic surgery
• Head and neck surgery, or, otolaryngology

To make sure you are on the right track, go to www.abms.org. Log in, and type into the search box the name and city of thecosmetic surgeon you want to visit. The website technology will then return his or her certification, if any.

Next, check the doctor’s hospital privileges listed on his websiste; the more the better. Hospitals have the inside track on which doctors and surgeons have the best records and only allow them inside their doors.

After that, check the surgeon’s website for before and after plastic surgery pictures. There should be hundreds. If theplastic surgeon does not offer any or says the before and after pictures are private, he or she is probably new tocosmetic plastic surgery and does not have any.

Any medical office staff will respond to the public according to how well they themselves are treated in the office by higher ups. So when you first call the practice, pay attention to how your phone call is handled. Is the person with whom you are speaking professional, unhurried and willing to take the time to answer all your questions? Or, do you find yourself rushed, spoken to curtly or – worst of all – put on hold?

When going to see the surgeon, you should feel like you:

• Have the doctor’s full attention
• Are not being pushed into additional, unwanted procedures
• Are not being subjected to sales pressure
• Are, at that moment, the surgeon’s only patientand concern

However, red warning flags should go up if the doctor takes phone calls during your consultation or if staff members stick their heads in the door to ask quick questions. What if he operates in the same fashion?

(Read more about finding and visiting an excellent cosmetic plastic surgeon and the questions you should ask while there.)

Robert Kotler, MD, FACS, in addition to being a master of the rhinoplasty and revision rhinoplasty procedures is a world-renownedBeverly Hills head and neck cosmetic plastic surgeon.

Dr. Kotler is additionally:

• A best-selling author (“Secrets of a Beverly Hills Cosmetic Surgeon”)
• An instructoratUniversity of California, Los Angeles,(UCLA)and University of Southern California (USC).