One Time Permanent Wrinkle Removal

How many thousands of dollars a year does the average American woman spend on cosmetics? It varies of course, but the number is significant. Skin care is a multibillion dollar industry. Much of the marketing, including advertising of skin care products is based on a false hope. The false hope is that company A's product will make the skin look younger, smoother and wrinkle free.

The fact is that no nonprescription product applied to the skin has a chance of changing it. There is a lot of psychology and hype built into the advertising. It also appeals to people's desires for a quick, cheap fix.

There is one procedure, done by superspecialist cosmetic surgeons that will in fact remove wrinkles, age spots, brown spots and other signs of aging. Chemical wrinkle removal has been practiced in the United States for over 50 years yet remains one of the least-recognized but most successful of all cosmetic procedures. [Editor's Note: Dr. Kotler is considered the leading practitioner of this procedure and is the author of the medical textbook Chemical Rejuvenation of the Face.]

Chemical only – no surgery.

This process is a non-surgical chemical rejuvenation of the skin performed under anesthesia as an outpatient. The procedure takes approximately 2 hours in the operating room, followed by 1 to 2 hours in the recovery room. After 1 to 2 nights at a post-operative recovery facility, dressings are removed. Typically the patient can return to normal activities after 8 to 10 days. After the procedure, a reddish pink color is expected but fades naturally and the lightening process is accelerated by medications. The pink color is usually gone by 8 to 10 weeks after the procedure.

In the long run, this process is cost effective. Since it is a once-in-a-lifetime procedure with a thirty year long benefit, the middle aged woman who has it will be able to carry the wrinkle-free skin well into seniority. Think of all the money that would have been wasted on products that cannot perform for thirty years.

It's Not Just About the Surgeon. How's the Team?

John Wooden, the Iconic UCLA basketball coach, wrote about what made his teams the great champions they were. He felt he team is more important than any individual. That you can win a championship without a superstar, but you can't win a championship without the five players acting like a team.

There is an analogy to that within the operating room world. It takes a team of highly skilled professionals to best serve the patient. While the surgeon is the captain of the team, the roles of the others within the operating room are no less important.

At every operation there must be a surgical assistant. Surgical assistants, who may or may not be registered nurses, are trained to pass instruments and assist the surgeon with various aspects of the operation. He or she is always at the operating table with the surgeon.

There must be a registered nurse in the operating room at all times. The role of the registered nurse is to provide and record medications used during surgery, to assist the anesthesia specialist as needed, and to act as chief quality control officer.

Most operations are done with an anesthesia specialist in attendance for the patient's comfort and safety. That may be a Certified Registered Nurse Anesthetist or a physician-anesthesiologist. Which of these two classes of professionals serve the patient is decided by the surgeon.

Just as a basketball team with the same members playing the same position every day will develop a rhythm, consistency and efficiency, so is it in the operating room. When that same veteran team is assembled daily, great benefit is in play for the patient. There is accuracy, less chance for error. There is efficiency and effectiveness which translate to shorter operating times without any sacrifice of quality.

In surgery, repetition of the same limited number of operations by the same surgeon and his team is one of the keys to a safe and successful operating room experience. Prospective patients should always ask the surgeons about his or her team. And, whether or not there will be a nurse anesthetist or a physician–anesthesiologist "at the controls", and how often the doctor works with that particular professional.

The patient has the right to know all about who is caring for him/her.

—Robert Kotler, MD, FACS

Negotiating Fees For Cosmetic Surgery in a Tough Economy

Yes, there is a recession; some people even call it a depression. This is not the first time in the history of the United States that this has happened. Economic cycles may be shorter or longer, but they are a fact of life. Nonetheless, people still desire to improve their appearance and are looking for ways to achieve satisfaction, but on a tighter budget.

Here are my proven suggestions for lowering your costs without compromising quality:

1. Ask the cosmetic plastic surgeon's office manager if they have an arrangement for a "standby" fee. For patients who have a flexible work schedule and can be available with seven to ten days notice, some practices offer a significant cost savings because if someone has had to drop off the schedule because of business plans or illness, both the cosmetic surgeon practice and the outpatient surgery center and anesthesiologist have a space to fill on the schedule. This is not unlike an airliner offering discounted seats so that their flights take off full.


2. Another popular mechanism for saving money is known as a "friends and family group discount." This concept is great for sisters or cousins or friends who consult together and wish to have their procedures on the same or successive days. In that case, each member of the group saves a significant amount of money. The more the merrier. If more than two consult at the same time there will be even greater savings for the third or fourth member of the group.


3. Layaway plans. The layaway plans are a great way for an individual, with financial discipline, to save for a procedure. This is based on the old department store "Christmas layaway plan", whereby over the course of the year, beginning in January, one would put money into an account with the store so that by October/November the item was paid up in time for Christmas purchase. The strategy is exactly the same with the cosmetic surgeon's office. If you have the foresight and can plan ahead, by paying a certain amount of money towards the procedure each month, the practice will significantly discount the fee because it fulfills an accountant's dream to have "money in the house."

Be sure to ask about these options. They can save you a significant amount of money in tough times.

New Competition for Botox

Botox Cosmetic has long had a monopoly on the market for temporary wrinkle abatement around the eyes and forehead. Now, a new product known universally as Dysport has joined the market. This new product has a long history of success in Europe and was found there to be safe and effective. In fact, it has been used in twenty seven countries outside the United States. Until the recent approval by the U.S. Food and Drug Administration, it could not be marketed in the United States.

In the United States, Dysport will be sold by Medicis Pharmaceutical, whose Restylane was the first non-collagen filler to plump up lips and the creases between the lips and the mouth.

Some doctors who have had experience with both Botox Cosmetic and Dysport report that
Dysport may in fact last longer than Botox. The company currently makes no such claim, however. Also reported is that it appears to be "faster acting" and to have a greater internal "spread" such that one can affect minimally the areas surrounding the immediate injection site.

Of course, it remains to be seen whether or not this is the experience of all MDs. My long experience has taught me that only when a product or procedure is used or put into place by the entire corps of physicians that the benefits – and downsides – of the new medication are fully appreciated.

—Robert Kotler, MD, FACS

Rhinoplasty Tip: All Noses are Unique

Patients don't want to have a new nose that looks obviously ethnically inappropriate. It is important that your cosmetic nasal surgeon to listen carefully to your desires. A patient must be comfortable and confident that there will be not radical changes in the nose. No one wants a nose that it looks almost "stuck on" and fake because of the surgeon's proclivity to deliver the same "boilerplate" nose for all comers.

Asian noses typically exhibit the following features:

• Low flat bridge.
• Wide nasal bones manifesting as wide bridge and middle third of nose.
• Round, sometimes flat tip.
• Thick skin.
• Wide nostrils with thick outer walls.
• Softer, weaker cartilage.

Hispanic noses vary with ancestry. Those whose genetic makeup have a predominance of Spanish (from Spain) genes tend to have lighter, thinner skin, stronger cartilage and other characteristics more suggestive of Caucasian noses.

Those Hispanics whose ancestry is skewed toward Central or South American Indians exhibit the following:

• High bridge with a prominent bump.
• Thick skin.
• Wide, oblong nostrils with thick outer walls.
• A wide plunging flat tip.
• Short upper lip.
• Softer, weaker cartilage.

African-American noses, anatomically, often have some features in common with Asian or Hispanic noses. There is a greater variety and combination of these elements. Here are the features that contrast most with Caucasian noses:

• Low flat bridge.
• Wide nostrils with thick walls.
• Disproportional width compared to length.

For Asian, Hispanic and African-American noses, more often there will be a need for the surgeon to raise the bridge and shore up the tip. Narrowing the nostrils, when needed, requires external incisions which must be artfully performed so that the incisions - tucked within the crease between the wing (outer wall and the wall of the nostril) and the cheek and upper lip is rendered nearly invisible.

Related Topics:

• WebMD Video: Keys to a Successful Nose Job
• Skin & Beauty: Ethnic Skin

Quit Blaming the Sinuses. The Nose is the Real Problem.

After performing over 4,000 nasal procedures, we see many patients in our practice with nose "issues." Patients often complain of headaches, discomfort, stuffiness - they assume it's "sinusitis." But, they are mistaken. Most often, the nasal passages are the culprits.

The nasal passages are the pathways for airflow to the sinuses. Think of the nasal passages as the hallways; the attached rooms are the sinuses. If the hallway is blocked, no access into the rooms.

Sinus symptoms imply that something is wrong with the nose. The nose has problems before the sinuses do. Rarely are the sinuses independently diseased.

Why the Wrong Self Diagnosis of "Sinusitis"?

The patient cannot make an accurate diagnosis. Sinus xrays are necessary. The ubiquitous lay diagnosis of "sinusitis" has led to massive sales of all of myriad overthecounter medications. These much malignedsinuses are always the villains in advertisements from the cold, decongestant and nose spray industries.

If the Nose is the Problem, What's Wrong with It?

• Bad architecture. Most commonly, a deviated (crooked) nasal septum from an accident or from a quirk of nature. The septum, the internal vertical partition that separates the two nasal passages, when bent or crooked, can significantly block air flow, deprive the sinuses of their aeration and produce the above symptoms. It's commonly damaged by sports injuries; often an injury in the young goes unrecognized. So, the youngster grows up with no point of reference for normal breathing.


• Allergy. Turbinates are shelves of bone covered with standard issue lining that protrude into the nasal passages from the sides and top of the nasal cavities. They provide a corrugated nasal passage configuration to increase the passage lining's surface area to enhance the three core nasal functions: to warm, humidify and filter the incoming air, en route to the lungs. There are three on each side, but the inferior turbinates tend to be the usual bad boys. A target for allergy, the turbinates can swell significantly. That plus swelling of all the nasal lining defines nasal stuffiness and blockage.


• Environmental factors. A category of nasal inhalant allergy. Mold, lurking in older homes can trigger the same changes as seasonal hay fever: the lining and turbinates swell and pressure changes in the sinuses are triggered by poor inflow of air. This is the so-called "vacuum headache". Dusty environments, combined with dryness can be the nose's worst enemy, particularly in a superhot climate. So, while Midwesterners may want to ship their sinuses to Arizona for the winter when colds and flu reign supreme, those same sinuses would opt for leaving during the ovenlike Arizona summers.


• Smoking. Cigarette smoke is no friend of the nose. By heating and drying the passages, the normally thin and freeflowing mucus becomes sticky, stagnant and even malodorous. Another contribution to nasal blockage.

An Ancient, Successful but Overlooked Remedy

For over 100 years, there has been a 45-minute surgical procedure that permanently opens the air passages. Whether the passages are compromised by the chronic irritation of cigarette smoke, or by swelling caused by inhaled allergens, or because of the twisted, blockading, misshapen nasal septum, the surgery will open the air passages.

"Converting a two-lane road into a fourlane super-highway", as one patient heralded the procedure.

Related Topics:

• Surgical Repair of a Deviated Septum
• Rhinoplasty for Teens

Madonna Turns 50 - Looks Like 40; How Anyone Can Look 10 Years Younger

Push the clock back 10 years? Look 40 - not 50? Yes, it is possible.

What does it take?

By 50, most women - and some men - show some frown lines between the eyes, some deepening of the nasal labial fold (those groove- like parentheses that separate the cheeks from the upper lips).

The skin has some deterioration. The smile lines/crow's feet around the eyes, the vertical lip lines; Smokers, yours will be deeper. Plus, sun damage: brown spots (now called age spots). Some tiny, barely visible red spider veins. The skin's fresh luster is gone. To the touch, that baby skin smoothness is a memory.

Then, there is the unending force of gravity. The upper lids' pleat sits a bit lower; the eyebrow has started to descend. For those blessed with a big happy smile, one of the smile muscles tugs at the tip of the nose and drags it down. So, the tip droops, the nose appears longer.

The chin - neck angle may no longer be as sharp as it was. The profile in the mirror tells the story; there's some hanging going on.

So there you are. Blame the sun, blame the cigarettes, blame gravity and if you are particularly vindictive, blame your parents and your genes. Much of the above may not happen to other 50 year olds who somehow won a better roll of the genetic dice.

What are the answers? Solutions? Remedies?

1. To spruce up your not-so-smooth-skin, with early age spots and those tiny blood vessels, consider practical, non-invasive office procedures and home treatments. Retin-A, Intense Pulse Light, microdermabrasion, light chemical skin peels.
   
   If you live in Southern California, South Texas or South Florida and you forgot to put on your sunscreen and kept smoking, your skin may need a bit stronger rejuvenation - think medium strength peel or laser.


2. Frown lines between the brows? Horizontal forehead lines? Botox is your buddy.


3. Deepening nasal labial creases? Fillers, Restylane, Juvederm. Yes, they are temporary, but they are predictable, safe and you can pay for as much youth as your budget allows. You are in control.


4. Nose droop? A one-half hour abbreviated nose job. No bruising, minimal swelling of nose and lip. In one week, no one will know. The tip no longer hangs, the lip is longer, you look younger. Bingo.


5. Need to crank up upper lids and lateral eyebrows? Botox may just do it. You try it. If Botox doesn't pull it off, you can have a straight-forward one-hour operation through a single hidden incision in the natural upper eyelid crease and be home by noon. This can remove the saggy upper eyelid pleat and raise the lateral brow (called a brow pexy). Stitches out in 5-6 days.


6. Sagging neck? Jaw line becoming a bit obscure? Neck sculpture is the play. Through a horizontal, fine-line incision hidden under the chin, your surgeon can liposuction the nascient double chin, shape up the jaw line if needed, cinch up the loose (platysma) neck muscles. Think internal corset.

Surprising Ways to Reduce Wrinkles

Related Topics:

• WebMD Video: Peel Away Wrinkles
• Sun-Damaged Skin Slideshow