The Most Popular Questions Asked During a Cosmetic Surgery Consultation

I have been consulting with patients for cosmetic surgery for nearly forty years. Interestingly, regardless of their background, level of education or previous experience, there is a consistency in the questions that are asked. Today's consumers, particularly because of the excellent books available and of course, the internet, are asking good and important questions. Here is a list of those questions which are most often posed to me at consultation:

1. Will this operation hurt?


2. What kind of anesthesia will be administered?


3. How long will the operation take and how long a time is spent in recovery?


4. How long will I be away from work or normal activities?


5. When can I return to work? To my normal exercise program?


6. When will I look normal enough to appear in public?


7. Who would I need to take care of me after the operation?


8. Where is the operation performed? In a hospital? Your office? Outpatient surgery center?


9. What type of preparation do I have to undergo for the procedure?

These are all good questions and should be answered in detail by the doctor or one of his trusted staff. None of the questions address the qualifications of the doctor, which should be reviewed, of course, prior to the consultation. There is no sense consulting with someone who doesn't have the training, experience and degree of specialization that you want.

Incidentally, every doctor should welcome questions. In our practice, patients are told that if they have any questions after the consultation they can e-mail them to us or call. If the patient wants to talk to me for whatever reason, they are certainly welcome to. Our staff is well-trained, has long experience, and can answer most of the questions. But, if the patient requests to speak with me, I am glad to speak with them. I also believe in the value of a "reconsultation" if the patient thinks of other questions that were not asked at the consultation. Also, we always welcome friends and family to join the patient either at consultation or re-consultation because often family or friends pose important questions too.

I like patients to feel that by the evening before surgery any and all questions have been answered. If not, they need to call me. For that reason, the patient gets my home phone or my cell phone. That same "night before", the anesthesiologist will call to discus the anesthetic.

I like when patients come to the surgery center in the morning and I greet them and I say "How are you doing?" and "Any other questions I can answer?" Most commonly, they say "No, you and your staff answered every question. I'm ready."

- Robert Kotler, MD, FACS

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• WebMD Video: Is Cosmetic Surgery for You?
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• Skin & Beauty Newsletter - Tips to look good, feel great

Some Thoughts About Cosmetic Surgery and Medical Education

I recently returned from our annual summer visit to friends and family in the Midwest. First, we visited Green Lake, WI for a reunion of our college friends. Then, my family and I visited Chicago, where my family has lived for six generations. This year, I even played in my high school's annual golf tournament where, interestingly, some of the best performances were by some of the graduates in their 70's or 80's! I guess that says a lot for practice makes perfect.

I also had an opportunity to visit my alma mater, Northwestern University Medical School. This year, I had the great pleasure of spending time with one of my most important and beloved teachers, who is still practicing and teaching half-time at Northwestern. He took me on a tour of the new Northwestern Memorial Hospital. We sadly looked at an excavation site which was formerly the home of the Lakeside Veterans Administration Hospital where my teacher taught and did research and where I had my junior year rotation in Internal Medicine under him. I also did extra work in the Pathology Department there and held a moonlighting job. I get a lot of good warm feeling when I return to the campus, although I could hardly recognize it. But, it was the seat of my medical education and I am very appreciative of the excellent education I had.

Earlier in the day, I visited the University of Illinois Chicago Medical Center. That medical center, when I was a student and resident, was the largest in the country with more hospitals and beds concentrated within one square mile than any location. The Cook County Hospital alone had over 3,000 beds. Today it has 500.

I thought a lot about the difference in education then and today. Recently, there have been a lot of constraints placed on medical education. Much of it is financial because hospitals are strapped for cash because of diminishing and poor payments from insurance companies, and the large load of either uninsured or welfare patients for whom the state and federal governments pay very little.

A tight economy and near-bankrupt governments makes it tougher to educate the students, interns, residents and fellows. During my residency, we had unlimited opportunity to perfect our cosmetic surgery skills. We were allowed to perform cosmetic procedures on patients for as little as $100. Granted, $100 then, would translate to $500 today, but still, that is a pretty reasonable price to have a nose job or eyelid surgery and for another few hundred dollars you could have a full face and neck lift. By offering patients such reasonable fees, our surgery schedule was full. And, a full schedule meant maximum learning.

Cosmetic surgery training requires experience and excellent teaching. Without patients who are willing to have their surgery at the university, where does the young trainee hone his skills? Today, there are few situations that match the wonderful opportunity we had as residents. For that reason, I see graduates of residency programs coming out with a lot less experience and skill than those of my generation. I have talked to some of the graduates who tell me they have only done five nose jobs for example. That is nowhere near a reasonable number. In a residency program, if one would do 25-50 cosmetic nasal surgeries under supervision, that would be a minimal, but adequate number. To come out with fewer cases under one's belt is inadequate to begin practicing.

In universal terms, as the United States medical care delivery system is sure to change, I am concerned that medical education will slip far down the line in priorities.

The consequences for all of us are not good.

- Robert Kotler, MD, FACS

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• WebMD Video: Choosing Your Surgeon
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"Dr. Kotler, You Won't Remember Me But ..."

Yesterday I was at a party and happened to be talking to a friend when a bubbly and attractive lady walked over to us dressed with a big smile. She looked at me and nodded her head and then mentioned to my friend something she needed to say to him and said to me, "Hold on, I want to tell you something."

After her exchange with my friend, she turned to me and said, "Dr. Kotler, you won't remember me but 28 years ago, you did my nose."

This was a very nifty encounter because, in fact, I did remember this patient. While her last name had changed through marriage, when she told me her married name, I did remember her very well.

What was really touching was when she said, "I have to tell you that you really changed my life." And I must say I was very proud of the appearance of her nose. It was natural, it fit her face and obviously she has happily worn it for the last 28 years.

It was a particularly cute and unique happening because also attending the party was an internist whom I have known for many years. Just five minutes earlier we had been discussing some of the early days of our practices at one of the local hospitals. Our nose patient, Phyllis, had reminded me that we originally met, her husband had broken his nose playing basketball and was brought to the emergency room. The emergency room was at the very hospital my colleague and I had been discussing a few minutes earlier.

I recalled that ER episode and the fact that shortly after I took care of her husband, we had a discussion with Phyllis about what could be done for her nose.

I share this with you because in the 33 years that I have been in private practice and nearly 40 years of doing this work, I am continually reminded of the great power that changing one's nose has. Cosmetic nasal surgery for many patients is a major positive in their life and I am proud to be part of that.

Apropos of that let me share a letter than I received from a patient whose "before and after" photos are in my book, SECRETS OF A BEVERLY HILLS COSMETIC SURGEON. Prior to publication, I had written to her to ask for her permission to reproduce those before and after photographs in the book. I received an extremely gracious and positive response. She wrote that she was more than glad to print the visuals of her cosmetic nasal surgery and chin augmentation because, "If this encourages people to go forward and have it done and give them as much pleasure as these procedures have given me, then by all means, feel free to share them with your readers." This lady, now the mother of an 18-year-old was herself 18 years old when she had her nasal surgery.

As you can see from Marian's photos, there is even a difference in her hair style and makeup which she changed without prompting by us. I find that people tend to care more about their appearance after cosmetic nasal surgery and do everything they can to enhance their appearance.

- Robert Kotler, MD, FACS

Related Topics:

• WebMD Video: Keys to a Successful Nose Job
• Cosmetic Surgery Slideshow: Before and After Pictures
• Skin & Beauty Newsletter - Tips to look good, feel great

Returning to Work After Cosmetic Procedures

Facial procedures generally fall into two categories with respect to recovery: The "short recovery" procedures and the "longer recovery" procedures. In the first group are chin augmentation, upper and/or lower eyelid surgery with or without brow lifting, otoplasty (correction of protruding ears), cheek implants and nasal surgery, both for function and appearance.

Procedures with a longer recovery are face and neck lifting, chemical wrinkle removal and some neck sculpturing procedures.

While I do not perform body procedures, I do understand that there is a similar categorization for body procedures. Breast reduction, tummy tuck and major liposuction generally require longer recovery. Breast augmentation and breast lift require a shorter recovery.

Here are the definitions: the short recovery procedures are those where the patient can return to work and normal activities including light athletics in ten days. Long recovery procedures are two weeks or slightly longer. And for some, the period of suggested refraining from athletic activities can run up to three weeks. For that, think in terms of breast reduction where running, jogging and other exercises would produce bounding or movement of the breast tissue. Abdominoplasty or tummy tuck likewise takes several weeks and while one may typically return to work at the two-week mark, major exercises are best deferred for at least one other week.

None of these common cosmetic procedures require prolonged bed-rest. It is quite proper to be up and about within a day or two and, in fact, all surgeons recommend walking , beginning the next day, as an exercise which is not likely to put any stress on the healing tissue regardless of the procedure. Walking is a wonderful exercise because it promotes relaxation, stimulates circulation and even offsets the tendency towards constipation in the post-operative period since patients often through lessened activity and the use of pain killers are apt to have a slow down in colon function. And, never forget that doctors worry about blood clots in the legs. The best prevention: Get up and about quickly.

- Robert Kotler, MD, FACS

Five Ways To Hasten Your Rhinoplasty Recovery

Cosmetic nasal surgery or rhinoplasty, is an outpatient procedure with a rather prompt recovery is rarely a burden for people. When I had my rhinoplasty, I was back in the office and operating exactly one week to the day that I had it done; Monday to Monday. But there are ways for people to speed up the process, particularly if they may have additional functional nasal surgery such as deviated nasal septum correction or enlarged turbinate correction at the same time as the cosmetic plastic surgery.

Here are five suggestions to shorten your rhinoplasty recovery:

1. Don't smoke. Smoking delays wound healing. It also makes the patient more uncomfortable since it dries out the mucus inside the nose.


2. Sleep with your head slightly elevated as compared to the rest of the body. The reason is that if the head is elevated, the swelling fluid that accumulates mainly around the eyes and alongside the nose will drain faster in a downward direction. Lying flat is not ideal.


3. We recommend patients use decongestant nasal sprays such as Afrin™ or Otrivin™. Because these shrink the lining of the nose, there is better airflow into the nose. Patients feel more comfortable and they are able to be more active. Listlessness is the enemy of good healing.


4. Get up and move around! This follows on the heels of number three. Lying in bed for four to five days is silly because it is not going to help matters and, in fact, makes things only worse because the more one moves around, the greater the circulation to the tissues and the easier it is for the body to reduce the swelling.


5. Take certain medications that the doctor prescribes. Some medications are very safe and practical. We give our patients small doses of dexamethasone which is a cortisone medication. Such steroids do reduce the swelling and hence hasten the recovery. We also believe in using a particular homeopathic medication, Arnica. There is some evidence that Arnica may be helpful in reducing bruising which, of course is an aim in the postoperative period.

— Robert Kotler, MD, FACS

Which Magazines Covering Cosmetic Surgery Do the Best Job?

Many of the women's magazines predictably devote some pages to the issue of aesthetic improvement. They will cover everything from injectables and skin care treatments to the mainline surgical procedures. Some magazines tend to be a little bit more investigative than others. And, some tend to glamorize cosmetic surgery rather than explain the advantages – and risks. Other magazines have very experienced writers who cover the subject exclusively and while other mags assign general interest writers to this rather narrow and sophisticated subject.

In my experience, the weekly tabloid-type magazines such as People, The Star, OK!, and In Touch tend to cover cosmetic surgery only as it is an indulgence of the Hollywood and celebrity crowd. These magazines are not educational. They entertain and sensationalize. Their mission is to peek into the private lives of celebrities. So don't look there for any meaningful information.

Other magazines take the job of explaining cosmetic surgery and illuminating its readers more seriously. Allure, for example, has very experienced writers on its staff who focus only on cosmetic surgery issues. Joan Kron, Allure's Editor at Large, is the top long-term student of and writer on cosmetic surgery in the country. I know that she maintains her own reference library that includes medical journals. Joan's writing always "gets it right."

Other magazines are equally specialized and faithful to the job of educating and not necessarily glamorizing. Marie Claire does a nice job. Cosmo occasionally devotes some pages to it. W is an excellent publication with first class research and writing. WebMD's magazine, Vogue, Elle and Town and Country also offer the latest and most informative data in the field of cosmetic surgery.

The weeklies, Time, Newsweek and U.S. News, occasionally cover cosmetic treatments and procedures and do it well.

USA Today does sketchy but good reviews. The New York Times and The Wall Street Journal, the top daily newspapers in the U.S. have the first-class writers, many of whom are very up on the latest in our profession. They, too, always get it right.

—Robert Kotler, MD, FACS

Revision Rhinoplasty With or Without Surgery

When you consult for revision rhinoplasty, understand there are quite a few options available to you. First, not the entire rhinoplasty operation needs to be repeated. Often, just a portion of the nose needs attention. In some patients, improvements can be obtained without another trip to the operating room. Some "bumps" or "rises" can be permanently flattened by shrinking the soft tissue underneath the skin. This is done through a series of injections that are typically scheduled four weeks apart – which effectively shrink the fat-like tissue underneath the skin and can permanently erase the mogul or irregularity.

In the opposite situation, where there is a dip, depression, groove or hollow, that can be filled, permanently, with a series of injections but using a different material. The only material that has lifetime benefit is medical grade liquid silicone. Medical grade liquid silicone which is an FDA approved product (approved for use inside the eyeballs, so you can understand how safe it is) is injected underneath the skin to fill the defect.

Both injections are done in the office using magnification. The skin is made numb to make the injection virtually painless, using an anesthetic cream.

For those patients requiring revisional rhinoplasty because of nasal obstruction, due to either deviated septum or enlarged turbinates, there isn’t an alternative to surgery. No injections can cure the architectural problem.


— Robert Kotler, MD, FACS

Forehead Lift, A Cure For a Migraine?

Recently, a rather abbreviated research study into the efficacy of surgical forehead lifts to block migraine headaches was shared with the public.

At this point, I am skeptical as to whether this remains a practical cosmetic solution for a functional and neurological problem.

Yes, there has been some evidence that Botox may be helpful for some migraine headaches, because it relaxes the forehead muscles. We also know that any surgical procedure in which the forehead muscles are detached from the underlying skull will temporarily cause insensitivity and weakness for those muscle groups. That might explain the observation that "the Botox helped the migraine."

The answer will come with time and observation. Over a period of many years, will the patients who claim to have relief from migraines find relief from the one-time surgical procedure?

Migraine headaches have had a long and often poorly understood history. For many years, it was thought that migraine headaches were related to dilatation of blood vessels in the head and for that reason, certain medications that tend to constrict the blood flow by lessening the diameter of the blood vessels were used. There are other types of medications also. But interestingly, as noted above, Botox seemed to have a salutary effect for many patients raising the issue as to whether or not the real culprit all along was muscle contraction and not dilatation of blood vessels.

— Robert Kotler, MD, FACS

Secondary Rhinoplasty

Secondary rhinoplasty is always a challenging procedure in view of the fact that there has been previous surgery done. The dissection is more difficult and bleeding may be more challenging. Scar tissue requires that the surgeon plod along a bit more slowly since it is more likely that the dissection will be more intricate.

But before one has a secondary rhinoplasty, they need to ask themselves: "Could my appearance be improved without another surgery?" In some cases, it can be by the use of permanent fillers. Because typically overdone noses tend to be too scooped out or too pinched, the patient is burdened by a loss of tissue. Can the lost tissue in fact be replaced by a filling injection? Yes, it can in most cases. This must be explored before surgery because another trip to the operating room has time, cost and some discomfort consequences.

To use a filler to correct the divots, dips, moguls and asymmetries is an office procedure. The nose is anesthetized with a topical cream prior to the injections which themselves take only seconds. And while a series of three to five may be required, each successive injection yields improvement to the point where the patient is satisfied.

— Robert Kotler, MD, FACS