Is Your Plastic Surgeon on Speed Dial?

After Cosmetic Surgery, Shouldn't You Have Your Doctor's Home Phone and Cell Phone?

samantha celera
/ CC BY-ND 2.0

It has long been our practice to provide our patients with my home phone and cell phone numbers. We give that information to the patient when they schedule their surgery so that even before surgery, should any question arise, I can be contacted.

We think it is wise to be as accessible to the patient as possible. After all, what good is the doctor to a patient if he or she is not available? While very few true emergencies arise, there are issues that can come up.

For example, just this weekend one of our patients found that she couldn't tolerate the pain medication that we had given her because she was becoming a bit nauseous with it. She was able to reach me on my cell phone and I immediately phoned in a prescription to her pharmacy for a replacement pain medicine. Incidentally, we also have the patient's pharmacy in our office records, so that we can very quickly phone in a prescription.

Occasionally questions arise, ranging from how often patients have to change their nasal dressing after the rhinoplasty plus nasal septoplasty and turbinate resection to improve the breathing. Any question should have an answer because the last thing we want is an anxious patient. Sometimes even administrative issues arise, such as patients forgetting the time of their next appointment.

Even when I am out of town, as long as I am within the United States, I can be reached by cell phone. Patients appreciate this. How great are cell phones! Technology helps us deliver the best possible care.

- Robert Kotler, MD, FACS

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Foods That Can Help You Heal

How You Can Help Your Healing After Cosmetic Plastic Surgery

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Last week, on the Today Show, Leslie Goldman, a well- known medical writer and the author of The Locker Room Diaries, discussed how various foods may aid one's health and even healing after any surgery.

Leslie even discussed how certain foods reduce swelling and bruising post-operatively.

Leslie mentioned that she learned - from yours truly - that fresh papaya and fresh pineapple are very helpful in reducing the swelling and bruising after rhinoplasty. Many friends and patients called the office and e-mailed saying how much they enjoyed seeing that segment.

The fact is, as indeed Leslie explained, certain foods do have specific properties which aid in the resolution of bruising particularly. Remember that bruising occurs after injuries in general and after surgery, specifically, because there is a leakage of blood from veins and arteries which are inadvertently opened during the course of surgery. Often these veins and arteries are nearly invisible. What is bruising anatomically? Bruising is merely blood-staining of tissue, just under the skin. While circulating blood is bright red, the blood that has escaped blood vessels and leaked into the skin at the surgical site has turned color, dark purple or reddish-purple. That's because these red blood cells no longer have access to oxygen.

What follows in every patient, is that the body, recognizing injury and blood leakage outside of the blood vessel system, sends certain scavenger elements to the site to digest the blood. In the course of digestion, the color of the blood changes from dark purple or reddish-purple to green and then to yellow as Nature performs the biochemical miracle of tissue debris-hauling and then repair.

Papase, a natural enzyme found in fresh papaya and fresh pineapple, aids the body's the digestion of the noname papase, since that enzyme is also used commercially in meat tenderizer, such as Adolph's Meat Tenderizer, the economical homemaker's good friend. The enzyme papase digests some of the fibrous tissue which would otherwise make meat tougher.

Many patients feel it is no burden to enjoy flavorful fresh pineapple and fresh papaya that are in ample supply year round. As part of a healthy post-operative diet, it make sense.

That post-opertive diet should include plenty of protein, the building block of tissue repair. Lean meat, fish, nuts, and dairy food. Also be sure to take vitamin supplements if your diet is not complete. Lots of liquids, of course, particularly fruit juices since they are a good insurance policy against constipation, the old nemesis.

Why concern over constipation? Two reasons. First, people are not as physically active immediately after surgery. Second, pain medications after surgery predispose to constipation. So fresh fruits and fruit juices, fresh vegetables, lots of liquids of any kind are the order of the day. Once the patient is up and about, the colon becomes more active and the incidence of constipation lessens.

- Robert Kotler, MD, FACS

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Kourtney Kardashian & Demi Moore: When Does Photography End and Fiction Begin?

Magazine Cover Photo "Touch-ups"

Recently, we were treated to disturbing examples of the depths to which magazine portrait photography has descended in trying to depict celebrities as more physically-blessed than they are.

The photograph on the cover of a recent W magazine of Demi Moore had an obvious disconnect between the shape of the upper thigh and the hip. It appears that Ms. Moore's hips and upper thighs are probably portrayed as more slender and fashionable than they are in real life. Obviously there was some imperfect "Photoshop" activity. The photo editor was asleep at the proof-reading desk.

Now, we have another story of a bogus cover photo. OK magazine, a tabloid, ran a cover story on one of the famous-for-no-particular achievement Kardashians. The cover designer presented a photo of the proud and particularly slim and trim new mom, Kourtney K., holding baby Mason. The Huffington Post related that the "real photo" upon which the computer- doctored photo was based, ran in the January 11 issue of another publication, Life and Style. That photo showed Kourtney's protuberant tummy and a torso to match - not unusual right after delivery, by the way. Kourtney claims to have gained 40 pounds while pregnant so it is improbable that, so suddenly post-partum, her svelte figure could return.

So the scoop is that the OK cover shot of the erstwhile TV reality star bears no resemblance to reality.

This subject has bothered me for a long time as I see so much "digital cosmetic surgery", particularly on the covers of the women's magazines. Gone are the days when just lighting and makeup would make someone look better. Now, using the computer, photo editors not only "air brush" out every line on the face, but "digitally" liposuction hips, tone abdomens, and buff-up arms.

No body need be portrayed as it is. Why? Are we to believe that congenitally, these folks are super-normal or super-human? That they - unlike the rest of us - don't age?

Hollywood people are not free of the same skin imperfections and contour irregularities as the rest of us. Whether or not they have had cosmetic surgery, they will never be perfect.

All this is nuts. We need some standard of reality. We must have something to hang our hats on, to believe in. So that we all live on a level playing field, there should be a significant limitation on how much their skin, facial features and body structure can be altered.

Otherwise, what will the next step be? Will every magazine's cover graphic be done by one of Avatar's animators? And, at that point, will fashion photographers have become extinct?

- Robert Kotler, MD, FACS

Original photo by Albert Michael/startraksphoto.com.
Slim and trim post-partum cover photo courtesy of computer imaging.

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The Case for Surgery by Two Complementary Cosmetic Surgery Superspecialists

This past week I engaged in an operation at which both I and another cosmetic plastic surgeon cared for a particular patient.

The patient wanted to have body liposuction and, at the same time, have rhinoplasty, cosmetic nasal plastic surgery as well as nasal septoplasty and turbinate resection to correct her airway because she had difficulty breathing.

It made perfect sense for her to have both operations at the same time under the same anesthetic and to require only one recovery period. What made the operation particularly logical was that she had two surgeons. I operated on the nose and my colleague, Stuart Linder, MD, FACS, whose cosmetic surgery practice is limited to body sculpture, breast augmentation and reduction performed body sculpture.

Dr. Linder and I have worked together on many cases because we both share the same philosophy. We each believe in the concept of superspecialization, whereby a surgeon works from a very limited menu and therefore has superior focus and the highest degree of specialization.

When perspective patients are told of the wisdom of having two surgeons, each with complimentary and yet separate surgical skills, operate at the same time, they always want to avail themselves of it. Few surgeons can be excellent at all the procedures in the world of cosmetic and reconstructive plastic surgery. It is impossible. And today, patients are more discerning than ever. They are not interested in mediocre/average results; they want a superior result. They understand that a superior result will come from a surgeon who is the most focused, the most specialized and who perform the operation they want on almost a daily basis.

I believe the time will come when more and more surgeons will be one or two operation practitioners. We are already seeing that in some areas of orthopedic surgery where the specialty is so broad and complex that certainly it is very hard for any one surgeon to maintain superior skills performing everything from back surgery to hand surgery to repairing broken limbs, etc. It is the same in ophthalmology where now we have ophthalmic plastic surgeons - we have ophthalmologists who specialize in corneal replacement or retina surgery or cataract surgery.

The one truism that applies everywhere in the world of surgery, across all specialty lines, is that the more specialized the surgeon, the greater the likelihood of a satisfactory outcome for the patient.

The bottom line - think superspecialist!

- Robert Kotler, MD, FACS

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Rhinoplasty During Winter - A Good Idea?

The question came up recently regarding the wisdom of having cosmetic and nasal plastic surgery during the cold weather months. The patient was from a state located in the upper Midwest. That's where winter is really winter compared to our Southern California climate.

Somehow, the patient was concerned that cold weather would interfere with healing and had heard some stories of people who had some difficulty, particularly with their nose being dry during the cold weather siege of his home state, Wisconsin.

Frankly, there is no reason not to have a rhinoplasty during the winter months, but one must understand the nature of the indoor environment. During the cold winter months, we all have our heating systems working. The problem with indoor heating systems is that the air is very dry. The humidity is almost zero. Not much different than the Sahara Desert, believe it or not, and dryness is the ancient enemy of the interior of the nose. When it is warm and dry indoors, the nose has an extra burden to produce additional moisture beyond what it normally does. But after nasal surgery, particularly rhinoplasty, when accompanied by nasal septoplasty and turbinate resection to improve nasal obstruction, correct a deviated septum and prevent sinusitis, there can be a reduction in the formation of some of the nasal fluids.

What patients perceive under those circumstances is a very dry nose and a dry mouth and they are uncomfortable. They may even have some crusting inside the nose which further worsens their discomfort.

We always advise patients after surgery to be aware of the extreme low humidity and dryness of the indoor environment and do provide medications to help. The first medication is a saline spray or gel. Saline, or sterile salt water, is the best way to re-humidify the nose until the normal mucus production presumes. One can use the spray or place the gel every hour or so. The other helpful thing to do is to use an ointment inside the nostrils where most of the dissolvable stitches have been placed. Stitches will dissolve more quickly when they are kept soft and well-moistened and nothing beats an ointment. We generally provide Vitamin A and D ointment, but frankly Vaseline would also be fine.

The other recommendation: drink lots of fluids and do not smoke. Right behind winter's indoor dryness, smoking is another venerable enemy of healing. The nose tissue, when it becomes dry either from the indoor environment and/or from smoking, becomes slower to heal.

Bottom line, before nasal surgery, whether it is functional and cosmetic or just cosmetic, if you smoke, plan on cutting down drastically or quitting. Besides, your anesthesiologist will be happier with a patient who does not smoke. Be sure to have on hand saline nasal spray and ointment for inside the nose. Also think about either buying or renting an inexpensive humidifier for your bedroom or certainly open the windows. Even though the air that comes in is cool, it will probably have more moisture than inside the house. You can compensate for the cold by adding on another blanket!

- Robert Kotler, MD, FACS

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Heidi Montag, Businesswoman

Now that Heidi Montag's one day, ten-procedure cosmetic surgery marathon has been packaged and delivered in a well-executed P.R. campaign, this event will be the talk of the tabloids and TV talk shows until interest peters out or is replaced by fresh celebrity shenanigans.

Media and other people have called and asked me "What do you think about Heidi Montag having all this surgery?" Maybe they were looking for me to criticize the decision to have all these procedures at once because it is not safe. Well, it is safe provided the proper pre-operative medical evaluation is done and an anesthesiologist is OK with doing the case. Typically, young people - if healthy - are at very low risk for elective surgery.

Or, perhaps there is a question of whether such a young person's body is so decrepit or aged-appearing that it requires so much "fixing". "Isn't she so young to be doing all this?" they ask. Well, she did not look too aged to me in the "before" photos. But, this was not anti-aging cosmetic surgery; this was "optimization" surgery. The lady seeks to monetize her assets.

"Did Heidi really need to have yet another rhinoplasty, installation of larger breasts, chin reduced, neck liposuction, et al?"

My answer: It's not what I think; it's really what Heidi thinks about it. And cosmetic surgery, per se, is not about need, as in medical need, it is about "want". Heidi is the owner of the body and face, and they are hers to do with what she wants. If the doctors think the procedures are safe to perform, it is all systems go.

Such is the essence of the decision-making in cosmetic surgery. It should be done only as an act of self-satisfaction. Not as a reason to help rebound from a divorce, to insure landing a new job or to guarantee better social and marital prospects. Or, because a family-member or friend is "pushing" to have something done, a la parents pulling a teen by the arm into the consult room to have a "nose job".

But this maximally-publicized Heidi Montag saga, a "staged event", is a different issue. I see this as a deliberate publicity move; deliberately calculated and meticulously scripted and executed to elevate Heidi's name-recognition in Hollywood and the rest of the world. A strong attempt to be at the "top of the organic listings on the first page on Google".

In the recent People Magazine, when asked "Do you finally feel beautiful?" Heidi answered "Yes, I think I look way better and I am way happier." Well, frankly, that is what it is all about. If all ten procedures have made her happy, fine. Some people make themselves happy by acquiring tangibles, such as automobiles, jewelry, or clothing. For others, ultimate happiness is just hanging out with grandkids and family. It is about personal choices. We may or may not agree with Heidi Montag's motives because we ourselves might not undertake such a body re-building process. But what counts is that she, an adult, made the decision, accepted the risks, was willing to accept the consequences, and decided to move on with her own program of self-improvement for whatever stated or deep-seated reasons she harbored.

I suspect that this entire episode will prove to be successful, business-wise. The layout in the magazine was very well executed. A fashion photographer took the dazzling "before" picture, and a fashion photographer took another dazzling "after" picture. In both she was well-coiffed, perfectly made up and for her image purpose, scantily clad. She was properly outfitted to portray the image she seeks to distribute to the world. A photographer was even present at the surgery center to record the immediate pre-surgery appearance including the surgeon's marking pen outline of the day's work. The right moves were made to illustrate this cosmetic surgery sojourn all along the way. Most patients, including the high-profile brand, consider such a log of the experience no one else's business. In this case, in Heidi's grab for fame, she hopes it's everyone's business. A huge PR coup.

Please understand that in Hollywood, business is business since "There's No Business Like Show Business". Joan Rivers used her first cosmetic surgery to help catapult her career. The tactic was so successful that she just continued having more and more cosmetic surgery, as though each time she would get a new burst of attention and material for her self-deprecating jokes. For Joan, cosmetic surgery was a prop or the gasoline for her marketing engine. Even Phyllis Diller, an outstanding comedian in her own right, as well as an accomplished musician, joked about her cosmetic surgery to benefit her career.

Remember Greta Van Susteren, about whom there was much ado when she had her eyelid surgery? Of course, Greta's cosmetic surgery just happened to coincide with her moving from CNN to Fox News. Frankly, the surgery didn't change Greta's appearance that much. But the procedure sure gave a little extra mileage to the P.R. campaign to help ramp up her ratings. Something else to talk about and P.R. is always cumulative and additive.

In the entertainment world, the numbers are everything: TV ratings, box office ticket sales. For young females seeking to ascend to bigger time stardom, sometimes the right numbers are 36-24-36. And, if it takes the help of cosmetic plastic surgeons to get to those numbers, so be it. When the gal's accountant write that check to the cosmetic plastic surgeon, it's just another business expense.

Probably tax deductible, too.

- Robert Kotler, MD, FACS

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Top Ten Hints To Look Younger and Better in 2010

Here are my ten "secrets" to looking younger. The beginning of a new year is always a great time to make changes that will improve your health and appearance too.

1. Eat well and eat wisely. Cut your consumption of fats, watch the calories. Make sure you are getting at least five portions of brightly-colored fruits and vegetables each day. Drink lots of water.

2. Exercise. It is right up there with sleep and healthy foods to maintain health and vitality. Try to get at least 3-4 sessions in a week if a daily workout is not possible. You have to sweat and be tired to have it worthwhile.

3. Check your weight. You know what your ideal weight is. Few people are under the ideal; most are over. There is only one proven way to lose weight and that is take in fewer calories and burn up more calories. Consume fewer calories and burn more calories. That's all you need to know.

4. Have a basic physical examination with your doctor. Think of it as insurance against having medical problems to be confronted later. Particularly if you are working out, make sure your heart has no problems and that your blood pressure is normal. Medical problems can make you look older and sap your strength.

5. Protect yourself from the sun. Regardless of where you are, particularly in the summer months, the sun is not your friend after 20 minutes. To get your daily dose of Vitamin D, that's how much time you need in the sun. After that, you might burn your skin, so slather on the sunscreen. If you are exercising, make sure that you replenish hourly.

6. Expression or worry lines on the forehead and around the eyes that are becoming unpopular - think Dysport or Botox. They work, they are safe and you can decide whether you like the benefit and feel it is worth the money.

7. Getting grooves around the mouth, lips and chin? Think about fillers. Today, we have great plumpers and fillers. Juvéderm, Restylane, Perlane and now Sculptra. Some last longer than others and Sculptra takes months before the effect is noted, but the products are safe and proven.

8. Don't like your wrinkles? Well, there are ways to deal with them. The classic all-time winner to remove wrinkles is the deep chemical skin peel. Other technological helpers include certain lasers. Also, there is some value to microdermabrasion.

9. Get rid of the jowl sags and bags. No shortcuts here. You need surgery. You may not need a full face and neck lift. Perhaps just take the bags out from under the eyes, liposuction the jowls and the neck, perhaps lift the neck through an incision underneath the chin. A consultation with an experienced cosmetic facial surgeon will give you the answers.

10. Looking tired around the eyes? Maybe the upper lids need a little tuck or maybe your eyebrows need a little lifting. Both can be done at the same time and even through a single incision. Check into it.

- Robert Kotler, MD, FACS

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