POSTED UNDER Rhinoplasty REVIEWS
Costly Revision Needed 6 Years After Primary Rhinoplasty
ORIGINAL POST
Costly Revision Needed 6 Years After Primary Rhinoplasty
flamingocactusMay 13, 2021
$8,000
I hate to write this review because he's a really nice guy, but the more important thing is that people get the results they want from their surgeon so here goes:
I'm very unhappy with my nose job 12 years out and I've been unhappy for about 6 years. For the first 5 years it looked great - then, for whatever reason, the tip/bottom of the nose drifted to the left and retracted and caused other facial asymmetries. It's by no means awful, but I do angle my face in pictures to strategically hide it.
The movement had the effect of making the nostril on the right too high and retracted, and the upper lip pulled up with it, so I avoid that side view, and the nostril on the left pushes down on the lip, my understanding is that it's because the nasal base is being pushed on that side, so not only is my nose asymmetrical and jutting to the left, but my face is more asymmetrical with the lip, nasolabial fold, and cheek in general sitting differently because the nostril is pushed on the left. The movement also had the effect of separating the foot plate (forgive me if that's not the right terminology) - meaning the cartilage in between the two nostrils looks separated. This started to appear in ~year 8. The tip retraction also contributed to the nostrils showing too much, particularly the nostril on the right.
It's not entirely clear to me what happened, but as I understand that a decent chunk of nose jobs are revised (some 20%), and it's quite common for a nose to look good and do what it's supposed to for 5 years then start to heal in funny ways from there. My best guess is that he shaved a little more off the right than the left, and that he corrected a deviated septum that deviated back to where it wanted to be over time, pulling the nostrils/base of nose more asymmetrical. Before I had the nose job, I had a bump on my nose and a bulbous tip and he narrowed tip and got rid of the bump. It was also slightly deviated and he fixed that. The deviation was imperceptible to me going in and he mentioned he fixed it after (not complaining about this, just a note)
It's still better than pre nose job nose, and I still prefer to have gotten it, but he implied that the nose would be in its final position by year 1 and stay there (barring movement/growth related to aging), and I wasn't properly informed of the risk of revision/that noses don't really settle into a permanent place like he said. I would have asked questions differently and looked for different things had I known how high the chance of a revision would be and that I should expect it to look good for 5 years.
I started looking for revision surgeons 5 or so years ago, and have met with 5 or 6 and it seems the consensus is that the deviated septum needs to be fixed and rib or ear cartilage would need to be taken to improve the alar rim retraction and the tip turning up. Problem is, there don't seem to be a lot of surgeons willing to take on revision rhinoplasties due to complexity, risk, and skill needed, and the quotes I've gotten for it have ranged from $18-27k. I don't have $18-$27k to make this correction so I just have to live with it (I paid $8k in 2007 for the original surgery) and I'm frustrated.
I tried getting the surgery notes from Kotler's office to help inform my consults for revision and his office lost them so that kinda sucks for guiding a new surgeon around the scar tissue. I tried doing a "nonsurgical nose job" - aka fillers in the nose - it cost $1800 and made a maybe 10-20% improvement and lasts 18 months or so - overall not worth it at all. I tried visiting Kotler to see if he would recognize an error and do a revision less expensively - he said he'd offer a "big discount" - which was $1k off of $15k for a septoplasty, and he didn't seem to want to do it at all (Not great when it's your work I'm correcting). I don't think he saw it as a big enough error - which indicates to me that this isn't uncommon - which indicates to me I should have known this at time of original surgery and makes me concerned how common it actually is for a so-called minor revision (aka it's not horrifying; you can live with it) to be needed years later.
Again, he's a nice guy and I'd venture to say a trustworthy human being in general and I hesitated to write him a negative review. In the period before I became unhappy with my nose, I even referred him business. But I think there should have been more responsibility for correcting it and I should have been informed clearly that this was likely to happen before moving forward.
I'm very unhappy with my nose job 12 years out and I've been unhappy for about 6 years. For the first 5 years it looked great - then, for whatever reason, the tip/bottom of the nose drifted to the left and retracted and caused other facial asymmetries. It's by no means awful, but I do angle my face in pictures to strategically hide it.
The movement had the effect of making the nostril on the right too high and retracted, and the upper lip pulled up with it, so I avoid that side view, and the nostril on the left pushes down on the lip, my understanding is that it's because the nasal base is being pushed on that side, so not only is my nose asymmetrical and jutting to the left, but my face is more asymmetrical with the lip, nasolabial fold, and cheek in general sitting differently because the nostril is pushed on the left. The movement also had the effect of separating the foot plate (forgive me if that's not the right terminology) - meaning the cartilage in between the two nostrils looks separated. This started to appear in ~year 8. The tip retraction also contributed to the nostrils showing too much, particularly the nostril on the right.
It's not entirely clear to me what happened, but as I understand that a decent chunk of nose jobs are revised (some 20%), and it's quite common for a nose to look good and do what it's supposed to for 5 years then start to heal in funny ways from there. My best guess is that he shaved a little more off the right than the left, and that he corrected a deviated septum that deviated back to where it wanted to be over time, pulling the nostrils/base of nose more asymmetrical. Before I had the nose job, I had a bump on my nose and a bulbous tip and he narrowed tip and got rid of the bump. It was also slightly deviated and he fixed that. The deviation was imperceptible to me going in and he mentioned he fixed it after (not complaining about this, just a note)
It's still better than pre nose job nose, and I still prefer to have gotten it, but he implied that the nose would be in its final position by year 1 and stay there (barring movement/growth related to aging), and I wasn't properly informed of the risk of revision/that noses don't really settle into a permanent place like he said. I would have asked questions differently and looked for different things had I known how high the chance of a revision would be and that I should expect it to look good for 5 years.
I started looking for revision surgeons 5 or so years ago, and have met with 5 or 6 and it seems the consensus is that the deviated septum needs to be fixed and rib or ear cartilage would need to be taken to improve the alar rim retraction and the tip turning up. Problem is, there don't seem to be a lot of surgeons willing to take on revision rhinoplasties due to complexity, risk, and skill needed, and the quotes I've gotten for it have ranged from $18-27k. I don't have $18-$27k to make this correction so I just have to live with it (I paid $8k in 2007 for the original surgery) and I'm frustrated.
I tried getting the surgery notes from Kotler's office to help inform my consults for revision and his office lost them so that kinda sucks for guiding a new surgeon around the scar tissue. I tried doing a "nonsurgical nose job" - aka fillers in the nose - it cost $1800 and made a maybe 10-20% improvement and lasts 18 months or so - overall not worth it at all. I tried visiting Kotler to see if he would recognize an error and do a revision less expensively - he said he'd offer a "big discount" - which was $1k off of $15k for a septoplasty, and he didn't seem to want to do it at all (Not great when it's your work I'm correcting). I don't think he saw it as a big enough error - which indicates to me that this isn't uncommon - which indicates to me I should have known this at time of original surgery and makes me concerned how common it actually is for a so-called minor revision (aka it's not horrifying; you can live with it) to be needed years later.
Again, he's a nice guy and I'd venture to say a trustworthy human being in general and I hesitated to write him a negative review. In the period before I became unhappy with my nose, I even referred him business. But I think there should have been more responsibility for correcting it and I should have been informed clearly that this was likely to happen before moving forward.
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Replies (4)
Now, some explanation regarding your unhappiness regarding this unexplained change. The chances of such a spontaneous change after rhinoplasty, five years or more after surgery, is extremely low, in my experience. Impossible to know about it unless patients come to see us about it. I have been practicing here for decades and if this were a common problem, I would know about it since patients certainly could contact me; I am not hard to find. Most noses are indeed “ stable and final” after one year. My rhinoplasty done 40 years ago has not changed a bit. The good news is that for many patients, we can correct those mysterious consequences of time without surgery; using a permanent non-surgical office injection process. No doctor in the US has more experience with that superb process than I do.
You said you started “ looking for revisions” 5 or so years ago; 12 years after our surgery. Various solutions and remedies were suggested by other doctors and you have shared the costs and even the techniques proposed. You noted our fee in 2002, 19 years ago: $7000 total. You also noted that other surgeons’ current fees were from $18,000 to $27,000. Now, frankly, if you were to consult with any surgeon, first, it should have been with me. No surgeon knows the patients nose as well as the original operating surgeon. I would have carefully examined the internal and external structure and given a recommendation. Apparently, you chose not to consult with me because there was a discussion of fees. You were given a quote, over the phone, of $14,000. As per above, that is far less than any other MD and not likely any of the others have my degree of specialization and long military and civilian experience. So, even financially, you would have been at an advantage to consult with me. Our fees are very reasonable for many reasons and your homework proves that.
I just do not think it is fair to give us a bum rap for a mysterious process that occurred 5-6 years after our work was complete and very satisfactory. Sometimes, strange things happen in this world, but the important issue is if they can they be helped or corrected. They can.
I appreciate your commentary that I am a “nice guy” and “a trustworthy human being in general” and frankly, if that is your sense, then – for sure – I wish you would have given me a chance to see how I could help you.
No surgeon can be responsible for things unusual things that happen beyond his or her control. Actually, our patient forms, instructions and consents do refer to these unanticipated misbehaviors of Nature.
All this said, if you wish, our doors are open to you. My experience and highest level of specialization is a plus for, for you, particularly, for many reasons. If you still feel that I am “a trustworthy human being in general”, that is extremely important. That recognizes that you know me, have appraised my character and would be comfortable again as a patient. We are a proven entity. As the community knows when reading our reviews, we get high marks for our conduct and results. Your appraisal of me echoes that.
Call us, make an appointment. No charge, of course. Let’s see if I can help you, possibly without another surgery.
Robert Kotler, MD, FACS
Beverly Hills, CA
I try to make that as clear as possible in the review that I think you are a respectable, knowledgeable, and trustworthy surgeon, and that my gripe was not knowing this risk and setting my expectations better. Hell I even say in the review I still would have gone through with the surgery knowing what I know now, but maybe I would've favored an open approach to preserve more structure, would've set aside $1-2k per year for the revision. It's on me for not doing enough research in advance of the surgery to have an opinion on the technique. I get that I signed consent forms. But those consent forms also say I might die in surgery, they're not a book of informed consent.
Again, my negativity is a response to the claim it's rare - it's not rare for the nose to keep changing for years after the primary with tissue excision reducing structural support or septum wanting to go back to its original position. In fact it looks like this happens in most (all?) cases, but it's only problematic in 10-20% of patients who end up seeking a revision. But please correct me if I'm wrong, you're the surgeon and I'm merely a student of the internet. Maybe your revision stats are very low and I'm really the 1% case for your practice.
Re your skepticism that 5 years later it mysteriously moved suddenly, that's not what I meant. I didn't wake up one day with a new nose I hated suddenly, it was a slow progression - it just became noticeable in pictures after about 5 years and could see that the progression I didn't like continued from year 5 to year 10.
Re giving you a chance to help me first, the $14k quote, I did go to you first, this quote was in person. You said you didn't think it was worth correcting because a revision would be open and leave a scar and it doesn't look that bad, You then took a picture and then agreed with me that pictures and flipped perspective it becomes much more noticeable, but said in person it doesn't look as severe. You suggested silicone fillers your office provides. In fact, I went to see you in year 5 or 6 when I started to see issues way before I started actively looking for revision, and went to you first when I did decide I wanted a revision.
Again, I never said it was botched, I intentionally highlighted this and your great conduct in my negative review, which most people would not do. My big gripe is calling this "rare," and getting quoted $14k for a revision. Again I understand this is a great price for Beverly Hills revision work (Side note for patients: I've since started moving my search outside of BH and starting to see $8-12k for qualified revision specialists in the US. I search academic articles for 5-15 years ago related to the revision procedure I'm looking for to focus on skill rather than good marketing, SEO, and bedside manner.) for surgeons , but I don't think it's a great price when it's a follow up to your primary, especially if it's a rare occurrence. I get it's out of your control because it happens, but I feel if it's so rare and it was your primary, the more fair thing is to have me pay anesthesiologist and OR and other ops overhead, and to not charge for your 4, 6, 10 hours on the 1% of patients who do have this rare occurrence. Or if it's not so rare of an occurrence and the economics on that don't make sense, then to make it clear it's not rare.
I'll admit that I was disappointed that the "great price" for a revision was $1k off, that I was upset it was called rare, but I'm in no way hostile towards you or your practice, I just support people knowing what they're signing up for.