If you had a closed rhinoplasty with dorsal hump reduction and possibly infractures, it is really no more difficult to perform a delayed septoplasty than if you never had any previous surgery.  (Although I'm surprised your surgeon didn't address this issue at the time of the rhinoplasty.)  If you had an open approach with a columellar strut, the septoplasty is just slightly more difficult to perform due to some existing scaring.  On the other hand, if you had previously had an aggressive septoplasty and later want to perform a reduction rhinoplasty, this scenario might be significantly complicated and could require utilization of a remote cartilage donor site.  

Nose Reshaping

Anesthetic depth is on a spectrum, and practitioners will mean different things while using the same terms. In general, twilight anesthesia means that the patient is just on the verge of being asleep and can still respond and protect their own airway - they are just at the precipice of slipping into general anesthesia. Once you enter the realm of general anesthesia, the patient cannot protect their own airway, so some type of breathing tube is used to keep it open (such as a Laryngeal Mask Airway or an Endotrachial Tube). General anesthesia is quite safe, as your airway is fully protected. Twilight is a bit of a balancing act, but can be done quite well by vigilant anesthesiologists. My concern with twilight anesthesia is that it does not necessarily require an MD anesthesiologist to be present - it could be managed by the operating surgeon and monitored by an RN. Some surgeons will go this route as a cost savings measure (MDs are more expensive than RNs), but I do not think this is a good place to cut corners. If your surgeon uses an anesthesiologist and they prefer twilight, then it should be fine. I would not recommend twilight if it is going to be managed by the operating surgeon. (Think about it - are you better at concentrating on one task, or trying to do two things at the same time?)

M. A. Bogdan, MD

Facelift

I think that computer imaging is extremely useful in discussing potential goals during rhinoplasty consultation.  When imaging is used, both the surgeon and the patient can feel more comfortable that there is no misunderstanding regarding the cosmetic goals of the procedure.  (A picture is worth 1,000 words.)  If I display a morphed image that I think is both possible and what the patient desires, and then the patient absolutely hates the image, we both really have to reconsider moving forward!  If they love the picture, I’m happy to be their surgeon.

Best regards, 

Nose Reshaping

Botox relaxes facial musculature and helps reduces "expendable" facial wrinkles.  If you are having surgery that directly affects the muscle groups, then you should wait for the Botox to wear off before the procedure.  A brow lift operation addresses forehead wrinkles, glabellar lines, and eyebrow position.  As BTX injections in the forehead, glabella, and crow's feet affect all of these regions, I'd advise you to let the Botox wear off before you have your assessment, photos, and surgery if you are undergoing a brow lift.  Although there are obicularis weakening procedures (that help with the crow's feet) which can be performed as part of a facelift, these are not common, and it should be OK to undergo a facelift and blepharoplasty while BTX is still active.  Since all patients are different and there are many intricacies of these procedures, it is best to discuss these specific issues with the surgeon performing your surgery to decide what is most appropriate in your individual circumstance.

Botox Injection

The Marionette begins to show at the corner of the mouth, and extends down towards the jaw line.  The lower aspect begins to show as the jowl develops behind it.  Fillers work well for the upper Marionette line, but using any type of filler to address the lower Marionette line is an attempt to camouflage the jowl by blunting the transition from the chin to the jowl.  The down side of this is that it will give the jaw a wider appearance.  For a patient who really wants to avoid surgery, this might be an acceptable tradeoff.  The best way to address the jowl and lower Marionette line is a face lift procedure.  I'd recommend you consult with a Board Certified Plastic Surgeon who both uses fillers and performs face lift procedures.  Discuss your goals, and they should be able to tell you if your goals are achievable with fillers, or if you are really requesting the results of a face lift.

Soft Tissue Fillers