Talent, Experience and Dedication

Good in Airline Pilots and Cosmetic Plastic Surgeons

Recently, a new book came out written by Captain Chesley Sullenberger, the veteran U.S. Airways pilot who successfully landed his incapacitated jet airplane onto the Hudson River. That happened about eight months ago. Since then.Captain Sullenberger has made many personal appearances and speeches and has now written a book.

There are key parallels that I see between the conduct and proven ability of Captain Sullenberger and super-specialist cosmetic plastic surgeons.

"Sully", a product of the best education and training available, was a graduate of U.S. Air Force Academy and then served, of course, as a military pilot thereafter. Since that time he has logged thousands and thousands of hours and was considered a "top of the totem pole" pilot with many accolades from his peers. Certainly a novice pilot might be able to get through a minor flight complication, but it is unlikely that a circumstance such as having to "ditch" the airplane on water could have been as handily accomplished by someone with less history behind the controls than Captain Sullenberger. A real test of "a pro" is when the going gets tough. That's when you want the most senior person at the controls.

The operating room is analogous to the airplane cockpit. You want the most- sophisticated, most-specialized, most-experienced doctor specialists "at the controls." I like to have two superspecialist doctors in the operating room: the narrow-focused cosmetic plastic surgeon and an anesthesiologist who has "seen it all."

- Robert Kotler, MD, FACS


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You Broke Your Nose - Now, What Do You Do?

Frank Merenda /
CC BY-SA 2.0

A broken nose, or nasal fracture, is the most common facial injury. This is because the nose is the most prominent facial feature. In addition, the nasal bones are the thinnest in the body and, therefore, they are more subject to being broken.

Naturally, the key to proper treatment is to make the correct diagnosis. The following are signs and symptoms of a nasal fracture. All or some may be present.

• Swelling of the nose.
• Tenderness; soreness to touch.
• Bruising, particularly around the eyes.
• Nosebleed.
• Change in shape.
• Change in breathing.

You need to be examined if any of these features are present after an injury.

Only one feature of a broken nose represents an emergency. If there has been an injury to the internal nasal septum (the internal vertical partition that separates the left and right nasal passages, and there has developed a septal hematoma. A septal hematoma is blood accumulating under the covering of the cartilage and exerting pressure on the internal tissues. If not relieved, this collection of blood can cause destruction of the cartilage and even a partial collapse of the nose. The hallmark of a septal hematoma is that after the injury, the patient has nearly complete blockage of the nose and hardly any nasal breathing. It does require an examination by either an emergency room doctor or a specialist in facial surgery or plastic surgery. The septal hematoma which is not necessarily painful, can be dealt with quickly and the serious problems averted.

With respect to the typical management of the broken nose, an examination by a specialist is important and it should not be delayed. The risk of delay is that if a proper diagnosis is not made, then the mal-aligned broken fragments may begin to heal in their abnormal position. Typically, the window for examination and initial treatment is up to ten days. After ten days, the parts begin to weld together, where they are, and it is difficult to manipulate them back into the normal anatomic position.

The doctor will examine the inside of the nose to see if there is any fracture or injury to the nasal septum which could be causing airway obstruction. Obviously, he will look to see if that septal hematoma has developed.

The external examination of the nose is conducted to see if there has been a shift or fragmentation of the nasal bones and the cartilages attached to it. The doctor will be feeling for asymmetries and irregularities. Often, within the first hour or so, not much swelling has taken place. But typically, within 24 hours, swelling and bruising have presented themselves and maximize by 48 to 72 hours. If none of the serious issues such as septal hematoma are present, he will recommend being re-evaluated when the swelling has gone down such that the more accurate diagnosis can be made by look and feel. Typically, that time line is five to seven days after injury. Plans should be made, at that point, so that if there is to be a near-term correction, it can be done within the ten-day, first window of opportunity.

Let's assume that for whatever reason, the patient either doesn't have the nasal fracture recognized or procrastinates with respect to receiving treatment within the first ten days. If that is the case, the nose is going to have to go untreated and, therefore, maintain possibly both abnormal shape and inadequate breathing for at least two months. At that point the tissues have healed - welded together - and they can be operated upon. Prior to that, the fragments may be "egg-shell"-like and difficult to work with.

Therefore, in summary, the first window for treatment is within ten days. There is a period of no treatment for the next seven weeks or so and then at the two-month mark or thereafter, definitive treatment can take place.

-Robert Kotler, MD, FACS

Considering Cosmetic Surgery? Don't Bother If You Smoke!

Many patients are disappointed when they have a consultation and are told that, despite their wishes and the probability that the surgeon is capable of delivering a satisfactory result, surgery is not advisable. The number one reason for patients being "turned down" for cosmetic surgery is that their cigarette smoking is of such a magnitude that chances of complications - both from the surgery and anesthesia - are unacceptably high.

Smoking carries significant risk for both the surgery and anesthesia. One should not willingly increase the risk by smoking.



Typically in cosmetic surgery, one does not require a deep anesthetic because the surgeons are able to anesthetize the tissues using local anesthetics producing a pain-free zone. The tissues are numb, just like during dental procedures. Usually, with a minimal amount of drugs, the anesthesiologist or nurse anesthetist creates a state of unawareness for the patient to reduce the chance of the patient moving or acting otherwise inappropriately during the operation. Naturally, the less medication the better, plus a quicker wake-up and less chance of nausea and vomiting after surgery.

Anesthesiologists and nurse anesthetists are unhappy with smokers because the smoke creates a state of chronic irritation and inflammation of the bronchial passages in the lungs. During the surgery, the lungs will be unduly sensitive to the gas anesthetics which are frequently used. Because of that, to avoid coughing, wheezing and the production of abnormal thick mucus, the anesthesiologist will have to "deepen" the anesthesia.

If a patient is capable of stopping their smoking for weeks before surgery, that is ideal. Luckily, the body's phenomenal regenerative powers will allow the irritated tissues of the lining of the lungs to settle down and repair themselves. The longer one has smoked and the greater the number of cigarettes smoked per day, the longer it takes for such healing to take place.

Regarding the operation itself, the risks are dependent upon the procedure. In rhinoplasty or cosmetic nasal surgery, the nose has been subject to the same type of irritation as the lining of the lungs. As a matter of fact, the lining of the nose structurally and microscopically is identical to that of the lungs, hence the similar response. The nose does not take to smoking very well because the smoking dries out the normal nasal mucus which is necessary to cleanse the incoming air. The smoke paralyzes the tiny hair-like fibers which help filter the incoming air. The smoke's heat dries and thickens the existing mucus causing immobility of the mucus and what we call the "post-nasal drip": the thick, rubbery mucus eventually gets to the back of the throat, causing the reflex to cough it out. Not what you want when recovering from surgery. In addition, there is a greater chance of bleeding excessively during surgery and after surgery because the smoking has generated a proliferation of blood vessels inside the nose.

For the nose, the cigarette is an enemy. Whether they are filtered or unfiltered, light or whatever. Smoke is smoke.

Other cosmetic operations carry different risks for the cigarette smoker. Facelifts which rely on the elevation and movement of large territories of skin on the face and neck are subject to a very negative effect of cigarette smoke which can be disastrous for the tissue. The noxious elements in smoke, such as carbon monoxide, carbon dioxide and nicotine, inhibit the flow of oxygen-carrying blood to those tissues and may threaten the very survival of the tissues. This could lead to wound breakdown, infection and then scarring. Obviously, this is an unacceptable risk for an elective operation. Therefore, surgeons respectfully decline to perform face and neck lifting on patients who smoke. Period. No appeals accepted.

The same risks exist for other operations performed on the body such as tummy tuck and breast surgery, particularly breast reduction where akin to the facial operation, large amounts of skin are elevated from their bed and moved to a new location.

Frankly, for everyone, there is not a single good thing that could be said for cigarette smoking. Medically, smoking takes its toll on the heart, lungs and all internal organs.

Smoking is a friend of aging, however. It prematurely ages the skin. The skin is the last stop along the circulation railway and is chronically deprived of oxygen because of the blood-vessel narrowing by the carbon dioxide, carbon monoxide and nicotine mentioned above.

The biggest mistake a patient can make is to lie to the doctor or anesthesiologist about smoking, past or present. After all, the surgeon and anesthesiologist are responsible for your surgical outcome, your comfort, your safety - and even your life. Unlike cigarettes, they are on your side.

Don't stub your toe. A better solution than denying you are a cigarette smoker is to seek professional help which is available everywhere to stop smoking. There are even medications that help the cause. Then, when your body has recovered from smoking's damage, you can schedule the proecedure(s) you want and feel comfortable that your body is in better shape for surgery.

- Robert Kotler, MD, FACS

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Report on the National Rhinoplasty Survey

In the recent Aesthetic Surgery Journal there was a very interesting survey report. Because cosmetic nasal plastic surgery or rhinoplasty is such a complex and multifaceted operation, the researchers were trying to ascertain whether there are different methodologies between practitioners. They looked at pre-operative, operative and post-operative techniques to try to make an evaluation whether there was a correlation with such factors as specialty training and timing, type of practice (academic versus private, etc.) and length in practice. It also surveyed the issue of closed rhinoplasty and open rhinoplasty.

Here are some of the more interesting conclusions from the study that had responses from 1,923 practitioners. Some were plastic surgeons and some were facial plastic surgeons.

The most common age group for which rhinoplasty on males would be performed was 18 years of age; for females, 16 years.

Seventy-one percent of the respondents used general anesthesia more than 90% of the time.

Man-made nasal implants (instead of the patient's own tissue) are used a small majority of the time. Seventy-seven percent of respondents use them up to 12% of the time and 12% used them from between 6 to 10% of the time. The most popular were silicone, Gortex and Medpor.

Revision rates were reviewed and there was no significant difference between the revision rate between the two specialties (plastic surgery and facial plastic surgery). Nor was there any correlation in the revision rate with whether or not the operation was performed as an open rhinoplasty or closed rhinoplasty. Surgeons in practice for longer periods of time are more likely to be trained using the closed approach while the open approach has only recently become a more popular training technique.

The study also showed that facial plastic surgeons who are generally trained as head and neck (ear, nose and throat) surgeons are more likely to have a functional (breathing and sinus issues) component to their surgery; the plastic surgeons are more likely to perform purely cosmetic nasal plastic surgery. With respect to charges for revision surgery, 60% charged only a facility fee for revisions but 13% charged an additional surgeon's fee when making another trip to the operating room.

- Robert Kotler, MD, FACS

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Different Fillers, Different Missions

The use of injectable fillers into the face has become accepted practice by cosmetic dermatologists, cosmetic plastic surgeons, and facial cosmetic surgeons.

The names of the products are well-emblazoned in the vocabulary of most Americans. Recently, there has been an addition of some newer products to the list of FDA-approved fillers. Radiesse dermal filler is a unique product; it contains tiny calcium microspheres that are suspended in a gel. When the combination is injected just underneath the skin surface, it stimulates the body to produce its own natural collagen and it is the building of that additional collagen which helps plump and fill the depressions particularly around the mouth and chin.

Another product that has received attention recently is Sculptra. This is a synthetic material that originally was used to treat the aggressive facial fat loss in HIV patients. It showed its stuff and has been approved for use to fill the face for cosmetic purposes. It is particularly helpful for those patients who are seeing a shrinkage of the tissue of the cheeks and particularly those who have lost large amounts of weight. It can also be used to plump up the tissue over the cheekbones simulating larger cheekbones. It has worked nicely in the nasolabial crease, the parenthesis-like depressions that demarcate the upper lip from the cheek. It has had a ten-year run in Europe and the doctors there are still very happy with the results.

Juvederm and Restylane are well known and have proven their value. These are both made from hyaluronic acid, a naturally occurring sugar-like substance. It typically lasts four to six months. A thicker version of Restylane is known as Perlane - often a favorite for plumping the lips.

Evolence is a collagen product which has shown some promise and is just now reaching the market place. Speaking of collagen, the forerunner of all today's fillers was bovine collagen made from cow skin. It has been supplanted by the other products because it required testing to make sure that one was not allergic to this other-species product. But collagen had a long and successful track record and opened the door to the newer products.

I would suspect, since science never sleeps, there will be newer, more long-lasting products coming through the pipeline. Pardon the pun, but this stuff is here to stay.

- Robert Kotler, MD, FACS

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How Rhinoplasty Improves Your Smile

Photo Credit: Robert Kotler, MD, FACS

It is very important that the cosmetic nasal surgeon understand what makes the nose unsatisfactory. The patient in the photo has a very active depressor septi muscle which, as part of the muscles of facial expression, when employed, exerts a downward force on the nose. The profound drop of the tip of the nose with smiling, detracts from the smile itself.

The smile that tugs the nose downward makes the profile even less satisfactory. This is why it is very important that this be managed during the cosmetic nasal plastic surgery. It is not a complicated maneuver for the surgeon to perform. Through a hidden incision inside the nose, the surgeon works behind the lip to detach the muscle from its internal attachment to the nose. Then, the muscle no longer can tug on the nose during smile.

The constant smile-driven, downward pull upon the nose also has implications for aging. As we get older, the tip of the nose tends to droop naturally because of the effect of gravity, and the stretching and loosening of the connective tissue within the nose. So there is a case to be made for releasing that depressor muscle at rhinoplasty. Not only because it helps the smile but because it will slow the "aging" of the nose.

- Robert Kotler, MD, FACS

Related Topics:

• Skin & Beauty Newsletter - Tips to look good, feel great