John M. Roesler, MD

Both Afrin and cocaine cause vasoconstriction of the nasal membranes, along with inflammation and rebound congestion.  It is not uncommon for septal mucosal and cartilaginous destruction to occur with regular cocaine abuse, resulting in a septal perforation.  Perforations larger than 1 cm are extremely difficult to close successfully, regardless of the surgeon's experience, skill, or technique.  It is critical to discontinue using Afrin and cocaine immediately, and to find a reputable ENT / Otolarygologist for a thorough examination and consultation.

Your best choice for a rhinoplasty surgeon should be someone who routinely addresses both breathing and cosmetic issues, is experienced with both open and closed surgical approaches, and is able to show you many of his or her before and after surgery photos of different noses.

This surgeon should be able to discuss in detail with you exactly how he or she is going to change your nose, in accordance with your goals. Make certain that you feel confident in your surgeon's aesthetic judgement, knowledge, experience, and skill.

Transconjunctival lower eyelid blepharoplasty is 100% the way to go, especially for a young person who has genetic (versus age-related) orbital fat pseudoherniation. I recommend this procedure for patients with lower eyelid 'fat bags' related to aging, as well. There are no visible scars and the results are excellent in experienced hands. While injectables are an effective means to recontour and smooth the transition between the lower eyelids and the cheek, they are temporary. Mesotherapy is not FDA-approved and has no U.S. studies to evaluate safety or efficacy; do not take a chance on this treatment around your eyes!

Overall, the most versatile, long lasting, and effective filler currently is Juvederm. I like it because it comes in two concentrations, Ultra and Ultra Plus, that can be used for finer or deeper lines. After injection, this product has excellent longevity (upwards of 6 months), is soft and supple, and causes minimal skin reaction. It can be used anywhere, including the lips, and, worst case scenario, it can be dissolved with hyaluronidase.

Radiesse is an excellent choice for deep nasolabial folds, for 'non-surgical' rhinoplasty, and for deep injection augmentation of the cheeks and chin. It is unpredictable in the infraorbital region and definitely should not be injected in the lips.

Restylane is equally as versatile as Juvederm, with great short-term results, but perhaps only 10% of my patients still have results after 4 - 6 months. It generally lasts only 1 - 2 months in the lips.

For permanent results, Artefill is the one and only choice. Presently, I am using it only in the nasolabial folds and marionette lines, but with excellent results.

Sculptra stimulates collagen production, resulting in filling and overall volume restoration / augmentation over time (and requiring 3 - 5 injection sessions spaced 4 - 6 weeks apart). It is not a traditional, 'what you inject is what you get', filler. It works best for patients with criss-cross crepey wrinkles and diffuse lower face hollowing.

Juvederm or Restylane in combination with a very low dose of Botox works well for fine vertical lines extending from the lips, although CO2 laser resurfacing really works best.

The mini-facelift is an old concept really - an idea that will always sound good, except that, unfortunately, it does not result in superior, or even good, lasting results.

The procedure differs from a traditional SMAS or deep-plane facelift in the following ways:

• It is performed under local anesthesia, usually with oral sedation
• The dissection (the 'lift' part of the procedure) is superficial, usually below the skin only
• Surgeons performing mini-facelifts usually have not undergone the training required to perform more complex facelift procedures
• Note, however, that the length and position of the resulting scar is actually nearly identical to a traditional facelift!