Here I sit, in the lotus position, contemplating balance, harmony and inner peace. It is with this same sense of calm that one should approach any cosmetic or reconstructive procedure on the nose.

Symmetry or balance of the facial features is ultimately the most important component of beauty. In short, all of the parts should look like they fit together, that they are all proportionate with one another. Small delicate features should be balanced with other small delicate features, while large features need to be matched with large features. A small petite nose would look very odd on a large boned football player, thus it is essential that as one begins to evaluate a nose, one must see the whole individual.

When a patient consults with me on changing the shape of their nose, I always start by first evaluating the relationship between the nose and their other facial features and then by analyzing the proportions of the individual components of the nose. Understanding whether an imbalance exists between any of these parts usually gives the best clues into what the patient is really complaining about. It also makes it easier to understand where corrections need to be made and can help lay the foundation for the planned procedure. Every patient is an individual that presents with a unique set of circumstances and require a plan that is tailored to their specific needs and goals. This is one of the reasons that I enjoy performing Rhinoplasties so much.

Never underestimate a Rhinoplasty. It should never be considered some simple and quick 45-minute procedure. Most plastic surgeons agree that it is one of the more complex and difficult procedures that we perform.

The open vs. closed approach to Rhinoplasty is a profound debate in the Plastic Surgery world that has often spilled out into the general population that leads to much confusion for patients. Both approaches work well and should be applied to the patient based on their individual need. The only practical difference to the patient is the tiny scar under the nose. This scar usually heals well and is well camouflaged under the nose where it is difficult to see. The joke in the plastic surgery world is that "it can only be seen by dogs and lovers." This one little scar however, can open up a world of possibility to the operating surgeon. Making a nose look good is done by some combination of altering the underlying cartilages and bones that give the nose its shape. Through this little incision, the surgeon can now see and make these alterations with great precision, which ultimately leads to a better final result.

In this case, peace comes from having clear and free passages on the inside of the nose. Distortions and overgrowths of the structures inside can lead to narrowing and blockage of the path of airflow as it travels through the nose. These distortions are often found in combination with the outer deformities. Those same forces, such as trauma or congenital influences, that led to the outer appearance will also lead to changes on the inside. Rhinoplasty presents an opportune time to correct these inner obstructions and with proper planning can lead to easy, free and peaceful breathing. Zen implies attaining understanding through calming meditation. I believe, after years of seeing patients in my Beverly Hills and Los Angeles practices, the best way to approach nasal surgery is with this same sense of calm confidence. Understanding the harmonious relationships between the parts of a person's face, combined with the correct approach and techniques, while placing equal emphasis on improving and maintaining clear nasal breathing are the best ways to achieve the ultimate results for this complex part of the body.

It's no secret that Botox has been the hottest item in the cosmetic surgery world since the FDA approved it for the treatment of wrinkles in 2002. In 2008, over 2.5 million people had some type of Botox injected to rid lines between the eyes, in the forehead and in the crow's feet area and Beverly Hills and Los Angeles have certainly been the epicenter of this phenomenon. Botox has also stood the test of time, by proving both its value and relative safety. Botox has also gone unchallenged by any serious competitor. That is until now. In April of 2009, the FDA approved Dysport as a treatment for facial wrinkles.

Before we get deep into specifics, it is important to understand where these two medicines fit into the overall scheme of treating the aged face. When treating facial aging, we look to "the 4 R's". The first "R" stands for Relax the muscle under a wrinkle. This is where Botox and Dysport come in. They are derivatives of the Botulinum neurotoxin, which paralyzes the small underlying muscles that cause the wrinkle. The second "R" is for Refill, which means to smooth out the lines by plumping them up with fillers such as Restylane, Perlane or Collagen. Third is Resurface, whereby the quality of the aged and damages skin is actually improved. The best of this group is Laser resurfacing where the damaged skin is actually vaporized away and new collagen comes in to tighten and revitalize the area. The last "R" is for Re-draping. This is when the excess quantity of skin is removed and the remainder is placed back into its original, more youthful location. This category includes facelifts, blepharoplasty (eyelid surgery) and necklifts.

Let's start by saying that both of these products have about the same overall effect. Both are injected into the muscle under a wrinkle to temporarily stop it from contracting, thus allowing the overlying skin to relax and smooth out. The outcome from both of these medications is greatly enhanced when used in combination with cosmetic fillers, such as Restylane. Dysport may offer some small but incremental advantages over Botox.

The effect of Dysport may occur earlier. Most people see its benefits within 2 to 4 days, sometimes as early as 24 hours after injection, while Botox typically takes 3 to 5 days before its effects are seen.

Both medicines have their peak performance between 30 and 60 days. In some studies, Dysport has been shown to last slightly longer than Botox, occasionally even lasting over 6 months, but both typically last between 3 and 6 months.

Safety is another key area to compare the two products. Again, both are considered to be generally safe, however, as within any medical treatment there is always some risk. Occasionally patients experience headaches, pain and bruising following the treatment, but the risk most physicians are concerned with is sagging of the eyelid (known medically as ptosis). Here is one area that Dysport clearly holds an advantage. The reported incidence of this occurring with Dysport is 0.7%, whereas with Botox this occurred in 5.4% of patients.

When comparing the price, the two items are comparable and currently are about equal in cost. The advent of Dysport does introduce competition into a market that was, until now, monopolized by Botox. Competition is good for patients as it has the potential to drive down the cost, making it more affordable.

To summarize, both products are effective and safe. Both can play an important role in the "4 R's" of treatment. As with most advances in medicine, improvements come in small, but incremental steps and Dysport probably represents the next step forward in the use of muscle paralyzers to treat facial aging.

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