Cosmetic Surgery

Does Cosmetic Surgery Need More Government Oversight?

2008-06-10T11:57:00.000-04:00

"California lawmakers want increased oversight of doctors performing cosmetic procedures in outpatient facilities." -Los Angeles Times

California Assembly Bill 2968 was generated by the death of Donda West, 58 year old mother of Kanye West.

Donda - according to the L.A. County Coroner - did not die from any operating room slip-up, nor from a specific error under anesthesia. But there still lingers a question as to how well Mrs. West's state of health was evaluated, well before surgery.

Common sense and sound medical practice suggests that patients, of any age, should have "medical clearance". Medical clearance is a history and physical plus appropriate laboratory, x-ray and electrocardiogram testing as a basic means of evaluating suitability for - and the risk of - both the operation itself and the anesthesia. Sometimes, additional consultation with other specialists, such as cardiologists, is called for. In Mrs. West's case, we know that she had significant risk factors such as family history of heart disease, borderline diabetes, obesity, high blood pressure and other factors that made her higher risk than might be acceptable.

What seemed to be lacking in the West case is what we doctors call clinical judgment; just plain old medical common sense. Whether the patient is a celebrity or not, a cosmetic surgeon's first obligation is to ponder whether or not the operation is "too risky". As we teach our trainees, "Think before cutting."

Despite these good intentions of legislators, there are only so many laws that can be put into place to regulate medical practice, already the most overseen and highly -regulated of all professions.

It is naive and unrealistic to propose yet another law intended to control thought processes and decision-making.

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Technorati Tags: cosmetic surgery, Donda West, risk factors

Spring Allergies: How a Nose Specialist Deals with His - and His Patients'

2008-05-06T15:53:00.005-04:00

Photo Credit: SpooSpa

Ah, springtime. Trees, grasses and other plants return. The world looks green and better. Except for those of us with inhalant allergies. The lining tissues of the nasal passages swell, the nose becomes stuffy. This gives rise to the pressure sensation, headache, difficulty breathing, itching, sneezing, post-nasal drip, coughing and sometimes even loss of taste, due to temporary loss of smell.

While allergies are rarely "cured" (they represent a mismatch with the environment), relief of symptoms is the goal. And, while some people have long-standing breathing problems because of a deviated nasal septum or nasal fracture, even they can obtain relief when further burdened by an allergic attack.

The following treatment plan has been effective, for me and my patients, to relieve the burdensome nasal symptoms.

I use two nasal spray medications. First, Afrin, or Otrivin, well-known, non-prescription spray-mists, which shrink the lining of the nose and provide almost instantaneous relief from the blockage and pressure sensations. This drug, a cousin of adrenaline, shrinks the internal nose's blood vessels, which are dilated maximally as part of the body's reaction to the inhaled allergens. Typically, I will spray four sprays into each nasal passage, wait four minutes, and then again install four sprays into each nasal passage. It is important to allow that four-minute waiting period, since the initial sprays will shrink only the swollen front portion of the nasal interior. Following the pause, the second round of sprays will then gain access to the back portion of the nasal passages.

While it is easy to fall in love with the effectiveness of these sprays, the user is reminded that after five to seven days, there comes the "rebound effect", whereby the internal nose becomes intolerant to the spray that now does less and less. Some unfortunates become habituated to its use. I once had a physician-patient who had become so hooked, he sported an Afrin-containing holster on his belt!

The second medication is a prescription cortisone nasal spray. Brand-names include Flonase, Nasalide, Nasacort, Vancenase, Beconase, Nasonex. The mission of these sprays is to blunt the biochemical reaction that the offending invisible allergic particle has incited, causing the swelling of the tissues. These sprays are designed for long-term use; there is no tolerance developed. However, there is a several day "ramp-up" before the medicine reaches peak effect, hence the wisdom of utilizing, temporarily, the immediate-action oxymetrazolamine to provide relief until the steroid spray kicks in.

Non-prescription decongestant nasal sprays last eight to twelve hours; the prescription cortisone nasal sprays typically last twelve hours. For the first week of treatment while waiting for the cortisone to take effect, as both sprays are being used, I use the decongestant first. One half-hour later, the steroid spray, now entering an unblocked nose has room to work its magic.

Incidentally, the same program works for the common cold. In that case, the nasal tissues become swollen because of the reaction to the cold-causing virus.

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Technorati Tags: spring allergies, nasal allergies, nose sprays

Mommy Makeover Book Misses the Mark

2008-04-17T13:54:00.002-04:00

People have been asking about some new book that apparently advises high-anxiety mothers planning a Mommy Makeover cosmetic surgery. The book purports how Mom should explain and justify the surgical experience -- including the immediate and not glamorous post-operative appearance -- to her ostensibly worried 4-7 year old youngsters.

Frankly, I see this as an inane book in search of a need. Of the six billion people on earth, the book's potential readership might fit into the local school auditorium. Do parents really require scripting to explain their decision and then the temporary bruising and swelling? Cannot the average parent, in their own words, better allay any anxiety or answer questions posed by the little ones?

Is a how-to book necessary for every occurrence in life?

Has there ever been a book-for-kiddies delivering scripts on how to explain the also-temporary bloating and swollen ankles of pregnancy? Or, spoon-feeding advice on handling an irritable Mommy during menopause? Or, why Mom can't trampoline with the kiddies one day after her bunionectomy?

Have we no confidence in the innate common sense and sensibility of today's parents? Are we all thought to be that stupid and lacking adequate communication skills?

In all fairness, I have not had a chance to read the entire book because, right now, it lives only in its pre-publication promotion and PR phase. So, currently, we must rely on the news media to deliver the book's message and purported wisdom. Perhaps there will be a better book than the press releases suggest; I hope so.

However, given limited budgets and bookshelf space, perhaps parents should think first of books that teach universal life lessons, broaden awareness, stimulate imagination, expand vocabulary and teach tolerance and respect. Think the Dr. Seuss series. Or, for old-fashioned, real-life practicality, Everyone Poops (My Body Science). After all, the pool of 4-7 year olds -- nervously grappling with how to understand their Mommy's makeover sojourn -- is rather miniscule. But, every kid needs a running start in mastering the essential basic life skills.

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Technorati Tags: cosmetic surgery, parenting, mommy makeover, books

Priscilla Presley and Silicone

2008-04-11T13:03:00.003-04:00

"Priscilla Presley is the victim of botched cosmetic procedures."

From (TMZ):

Priscilla, whose face looks ... strange on "Dancing with the Stars," went to Dr. Daniel Serrano around 2003. Serrano was a good-looking doc from Argentina who hooked into Hollywood's social A-list and started giving them what he claimed were miracle injections that worked better than Botox.

In fact, Serrano was injecting industrial, low-grade silicone similar to what's used to lubricate auto parts in Argentina into the faces of these women.

Another celebrity falls into the hands of the wrong doctor for cosmetic surgery. So much for fame and fortune immunizing against bad selection of professionals.

If these people - presumably with savvy connections - and living in the world's epicenter of cosmetic surgery, Beverly Hills, can't pick the right doctor, or at least one with a CA medical license, what about the less sophisticated of America?

My latest book, The Essential Cosmetic Surgery Companion, a unique workbook, really makes it easy to avoid doing dumb things. It even has links to the Federation of State Medical Boards to facilitate checking that the doctor working out of his patients' homes (a huge RED FLAG) has a valid medical license.

It's sad that the great accomplishments of modern cosmetic surgery are tainted by crooks, charlatans and grifters. But, in this world, medical or otherwise, it is "Buyer Beware!"

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Florida Teen's Cosmetic Surgery Death Explained

2008-03-26T19:08:00.001-04:00

Since yesterday, there have been many reports and comments about the Florida teenager who died during breast augmentation surgery. Some report highlights:

Malignant hyperthermia, the cause of death, is hereditary and thus any patient undergoing GENERAL anesthesia should be asked: "Family history of problems with anesthesia?" If so, there is a diagnostic test available

MH, very rare, but reversible if detected early and treated aggressively. Every anesthesia specialist and surgeon should know the management.

An accredited, licensed or certified surgical facility, whether hospital, outpatient surgery center or office facility is required to have the specific antidote, a drug called Dantrolene, on the premises for emergency use.

What we know, so far, is that the 18-year old Florida patient developed the very rare complication of general anesthesia, malignant hyperthermia, literally "dangerous elevated temperature". But the temperature, per se, is not the only, nor typically the first, sign of this acute erroneous error of muscle metabolism. It is merely the most striking sign because few other elements of surgery or anesthesia will generate a high temperature in the middle of an operation.

While the patient's pre-disposition is hereditary, because of the condition's rarity, few patients can report a family history. Therefore, unless suspected, the condition arises without warning during surgery.

Here are the classical signs of malignant hyperthermia:

Sudden and otherwise unexplainable RAPID and STEEP rise in the pulse rate, e.g from 80 to 150 within minutes.

Rapid rise in breathing rate.

Major temperature elevation, which usually follows the above. Can rise to 106 F or more.

Think in terms of a marathon runner. The muscles are working overtime and the body attempts to self- regulate by automatically increasing heart and breathing rate and the temperature rises to "cool down" the body.

In malignant hyperthermia, the muscles are working overtime but not carrying the patient anywhere.

The immediate treatment is well-established. The general anesthestic agent, is "turned off"; 100% oxygen is driven into the lungs. To stop the muscles' hyper-metabolism, a drug, Dantrolene -- specifically used for malignant hyperthermia -- is given intravenously. The body is cooled by packing in ice and the patient is transported to a hospital intensive care unit.

The key to successful treatment and saving the patient's life is early recognition by the surgeon and anesthesia specialist. Because most anesthesiologists have not seen a case in their careers, they must carry a high index of suspicion when the computerized monitors' warning lights and bells suddenly go off for no apparent reason.

Appreciation to Kevin Tehrani, MD, Chief of Anesthesia at the Summit Surgery Center, Beverly Hills, CA., for his input. In preparing this, I consulted with Dr. Tehrani whom I recalled had successfully treated a case of malignant hyperthermia at the USC-LA County Hospital.

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Technorati Tags: florida, teenager, breast enlargement, augmentation, death, malignant hyperthermia

Peels, Lasers and Microdermabrasion? Which is Best?

2008-03-25T15:00:00.004-04:00

What is the difference between the non-surgical skin treatments: peels, lasers and microdermabrasion? How do you select the best one for aging skin?

With over 100 treatments now available, it is daunting to know what is best for your skin.

"Light" Chemical Peeling Agents

Alpha-hydroxy Acids: These mild peeling agents act as a deep exfoliant removing the dead cells from the skin surface and accelerating the maturation of the remaining cells. The aim is to make the skin smoother to the touch and more lustrous in appearance. The most commonly used alpha-hydroxy acids are lactic acid, glycolic acid and citric acid. Alpha-hydroxy acids (in concentrations of less than 10 percent) are used in cosmetic preparations; in concentrations of 10-70 percent, as skin peeling agents. In antiquity, women bathed themselves in sour milk in the hope of softening and smoothing the skin. Perhaps they understood intuitively that sour milk contains lactic acid, now used for, the same purpose.

Medium Strength Chemical Peels

The most common medium strength agent is trichloroacetic acid ("TCA"). Typically used in concentrations between 20 percent and 50 percent, TCA, a strong acid, destroys the epidermis (the outer layer of skin) and penetrates into the dermis (deeper skin). As a result, it stimulates the formation of new, fresh skin that is richer in collagen and elastic fibers, and is more taut with fewer wrinkles. Trichloroacetic acid has been used by experienced practitioners for many years. Because of the strength of this chemical and the possibility of complications, TCA skin peels should be performed only by experienced dermatologists and cosmetic surgeons. Anesthesia may be required for patient comfort and safety. This process of skin rejuvenation may take five to seven days of "down time" after which the skin is red. Cosmetics are required until the red color fades. When red, the skin is extremely sensitive to the effects of the sun and, therefore, a comprehensive skin program emphasizing sun protection is mandatory.

The "Heavy Hitters"

Deep Phenol Peels

"Phenol peels," the so-called "heavy weights" of skin rejuvenation, have a long and successful history. They have been performed in the U.S. as a mainstream procedure since the early 1960's.

Phenol is an acid-like chemical that, when mixed with other agents, becomes a potent prescription, resurfacing the skin by removing wrinkles, crow's feet, age spots and other superficial skin imperfections. Experienced practitioners regard phenol formulations as the standard against which all other skin resurfacing procedures must be measured.

Because of its ability to penetrate to the deeper layers, there may be some permanent lightening of the skin.

Laser Peels

Nd:YAG (Neodynium) laser: penetrates below the outer layer of skin, stimulating fresh collagen without causing a destruction of the outer-most layers. This translates into a shorter healing time. But this procedure, because it is less intense, requires maintenance treatments and has not lasted as long as the other laser treatments, and may not last as long as other laser treatments.
Carbon Dioxide (CO2) laser: The first widely utilized skin laser, introduced in 1995. Strongest, most invasive laser. Less popular today because of high percentage of over treatments (think complications) and undertreats (think disappointed patients).
Fraxel Laser: Less invasive, faster healing. Good for improving sun damaged skin, spider veins, age spots and some acne scars.

Skin Rejuvenation Technology

Titan®: Light flashes purportedly restructures the dermis to tighten the skin without surface changes.
Thermage®: Radio frequency technology. Superheats the skin and claims to thereby tighten the skin by strengthening the collagen. Little down time, but reports of a very high percentage of disappointed patients.
Plasma Energy New: Claims resurfacing of the skin to "reduce wrinkles and improve skin tone and texture". Further evaluation is needed.
Intense Pulse Light (IPL): Flashes of light to reduce spider veins, pigmentation, also employed against acne. Has been well accepted with very low complication rate.
Microdermabrasion: Gentle sandblasting to smooth the lines and lighten age spots and other signs of skin damage. A minimal treatment.

Note: This list is not intended to be all-inclusive. I have chosen a variety of the more popular and/or promising treatments so that one may understand the variety in procedures and technology available today.

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Technorati Tags: cosmetic surgery, peels, lasers, microdermabrasion, aging skin

Getting a Nose Job? What Can Be Fixed -- And What Can't

2008-02-25T13:52:00.004-05:00

PART I - ANALYSIS

The best cosmetic nasal surgeons are adept at very detailed analysis of all aspects of the nose. The outside and the inside. For some patients, the evaluation of the inside is critical if there is a breathing, allergy sinus problem or all of the above. All this is about diagnosis. The right diagnosis leads automatically to the right procedure.

THE OUTSIDE

The external nose is comprised of areas and zones. Each may have imperfections that contribute to an overall unsatisfactory look. To help patients understand what we can - and cannot - do, at consultation, I analyze each portion of the nose that is unsatisfactory to the patient and relate what changes can be performed on that portion

Here is a list of the anatomical features of the nose that we most commonly are asked to correct:

The bump.

The entire nose is too wide.

The nose juts out too far from the face.

The bulbous tip.

Unsightly nostrils.

The nose-lip angle.

THE INSIDE

Remember, I mentioned that when the specialist examines the nose, he must understand the internal structure of the nose - inside and outside. The hidden interior architecture always has a bearing on the outside appearance. That internal partition, the septum, composed of both bone and cartilage, has a major influence. A crooked nose will almost always be accompanied by a crooked or deviated internal nasal septum. As a matter of fact, it is axiomatic in the world of nasal surgeons that, "As the septum goes, so goes the nose". Even the lower (towards the lip) segment of the profile is a reflection of the height and strength of that septum.

That nasal septum runs a long course, from the front of the nose, where it sits behind the vertical partition that separates the nostrils, the columella ("little column"), to the back of the nasal cavity, where the upper throat begins.

A proper and thorough examination of the nose - breathing and sinus problems, allergies or not - should always include an evaluation of the internal septum and other key internal nasal passage structures called the turbinates. The turbinates, three in each nasal passage, are finger-like shelves attached to the lateral wall of the right and left nasal passages. Their function is to help moisturize, filter, and warm incoming air. The lower, or inferior, turbinate plays a major part in airflow volume. Enlargement of the turbinates takes up valuable nasal passage space and will diminish breathing. Typically, when turbinates are enlarged, allergy is the culprit. The doctor should also check for blockage of the openings to the sinuses, those air-filled chambers within the face bones. "Sinus sufferers" may learn that their problems begin within a blocked nose.

Had prior nasal surgery? "Inside", "outside", or both? The doctor will need to be particularly thorough with both the external and internal examination when the tissue has already been visited. Often some tissues are absent or still enlarged and misshapen, and all this has a bearing on what needs to be done.

PART II - WHAT DOES THE SURGEON DO AND HOW IS IT DONE?

Remember, no two patients require the same services. You should know - prior to surgery - what is on the surgeon's "To-Do" list.

The hump: The surgeon tunnels under the skin. Using delicate filing and shaving instruments, he shaves down the bump to a more satisfactory level. The "excess" skin is never removed; it naturally shrinks down to conform to the new architecture.

The entire nose is too wide: If the entire nose is wider than you want it, you will have to face that unfairly castigated, but really not too bad, "breaking the nose". But don't worry, you'll be asleep. You won't know it is happening and you won't feel it is happening. And it causes minimal discomfort after surgery. There is no other way to improve a wide nose. It takes the nasal surgery super-specialist only 90 seconds and "Bingo!" your nasal bones are closer friends. Less time than temporary, intricate makeup applications devised to make the nose look narrower. Plus, surgery is permanent.

The nose juts out too far from the face: In Part I, I described what anatomical imperfections cause the nose to over-project, to be "too far forward". It could be a combination of several factors; one or all may need correction. A prominent nasal spine is handily amputated; the owner of the nose won't miss it. A too-high nasal septum is shaved down. If the tip of the nose rides in a too-tall position, the columella, mentioned previously, that separates the nostrils can also be shortened.

The bulbous tip: That unattractive tip will be refined by using classic sculpture techniques to reshape and redefine the cartilage that comprises the tip, all with attention to symmetry and a natural look. Somewhat amazingly, all done "under the skin". Just as with the bridge, the excess skin that once covered large, bulky tip cartilages will contract to envelope the smaller tip.

The unsightly nostrils: Changing nostril size and shape is tricky. The surgical maneuvers that create a nicer tip will automatically effect the size and shape of the nostrils. For some patients, that is adequate to improve the nostril appearance; for others, it will be necessary to additionally remove a portion of the wings and/or the floor of the nostrils to achieve a satisfactory result, but that requires external incisions that could be somewhat visible.

The nose-lip angle: The nose that sits close to the lip and that hangs down will be improved by removing a portion of excess internal support structures, such as the front portion of the nasal septum. This allows the nose to ride up and away from and to shorten the nose. This is done essentially at the expense of the lip. The same technique is used to sharpen the angle between the nose and the tip when there is a somewhat round and unfeminine transition between the nose and the lip.

The nose that droops with smiling: A small but strong muscle that runs vertically from the internal upper lip to the hidden portion of the front of the nasal septum, appropriately called the "nose depressor", can be released from the nasal attachments through an invisible incision. This is done by dissecting where the nose meets the lip as a continuation of the standard internal incisions.

Click here to view a patient who needed all parts of her nose corrected. (Front view here)

All these procedures are done through hidden, inside-the-nose incisions, which are closed with dissolving stitches. External incisions, used for the "open rhinoplasty" are sometimes necessary but need not be used routinely.

A FEW WORDS ABOUT CROOKED NOSES. YOU NEED HELP BOTH INSIDE AND OUTSIDE

Whether from injury or just because Nature made you that way, your nose might be crooked. And, if it is, I'll bet that you also have a breathing problem. Because a crooked nose on the outside is almost certain to be crooked on the inside.

If you have been told that the external nose can be straightened without tackling the crooked or deviated internal nasal septum, you need a second opinion. It is nearly impossible to cure a nose that is not straight unless you tackle the internal support structures that are driving the external appearance. Please also understand that it may be impossible, at least in one operation, to get that nose perfectly straight on the outside and/or inside. Often, the tissues were so severely damaged from one or more broken noses that perfection is unlikely. However, with today's excellent filling injections --- temporary or permanent--- following surgery, as an office procedure, these fillers in minute amounts can be used to correct asymmetries that cause the crooked appearance.

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Technorati Tags: nose job, rhinoplasty, cosmetic surgery, deviated septum

Donda West Lessons: The Pre-Op Exam

2008-01-23T16:02:00.001-05:00

The Importance of the Pre-operative Medical Exam

Last week, when Donda West's autopsy story broke, I reviewed the post-surgery recovery location. Now there is further focus on that, plus review of recently revealed post-op findings.

Was Donda West a High-Risk Patient?

The January 11th Los Angeles Times brought forth additional information that may have significance in understanding what went wrong after Mrs. West's five and one-half hour body plastic surgery.

Because the LA County Coroner found no specific cause of death, such as a heart attack or blood clots in the lungs, attention turned to a combination of negative factors that taken alone might not cause death but, when taken together as a constellation of predisposing conditions and post-op events, might push a 58-year-old patient over the safety edge to death.

The Deputy Medical Examiner wrote that West had "...coronary artery disease" and that the heart's main arteries were "50-75% blocked". In retrospect, this is not surprising since it has been already revealed that there was a strong family history of major heart and blood vessel disease. The Los Angeles Times article stated that "a sister died of a heart attack two years ago, and her brother had hypertension (high blood pressure). It has been reported that Donda had a history of hypertension."

The newspaper further stated: "The Coroner's office learned that she (Donda West) had been diagnosed with hypertension, which she believed had gone away. She was a borderline diabetic and obese."

Add up an unquestionably significant family history in a patient with three well-known risk factors for heart trouble--high blood pressure, obesity, and borderline diabetes--and you are seeing a patient who may not have been an acceptable candidate for an elective but long plastic surgery.
How was Donda West evaluated for surgery's risk? and, by whom?

An unbending rule of the surgery world is that every patient having any surgery under general anesthesia, from emergency to elective, should have "medical clearance". Medical clearance is a history and physical plus appropriate laboratory, x-ray, and electrocardiogram testing as a basic means of evaluating suitability for -- and the risk of -- both the operation itself and the anesthesia. In fact, sometimes, the findings of that medical exam drive the decision regarding the appropriate and safest anesthesia technique. In other words, the patient's medical status generates many decisions.

What doctor conducts this "pre-op exam" is always important and may be significant in Mrs. West's surgical sojourn. While hospital, outpatient surgery center, and office surgery suites' accreditation, or licensure, requires such an exam, there is no specification as to what specialty doctor should perform it.

There are four possibilities:

The surgeon

The anesthesiologist

The patient's personal physician

An outside, independent family practitioner/internal medicine specialist, who is recruited specifically to perform the examination.

Here is my personal read on the value and the appropriateness of each, as I discuss in my book, Secrets of a Beverly Hills Cosmetic Surgeon, The Expert's Guide to Safe, Successful Surgery.

The surgeon The surgeon may be the least qualified. Why? Because, and pardon my syntax, a surgeon is a surgeon and not a diagnostician as are family practitioners and internists. This is about division of labor; surgeons operate, the others don't. Conversely, all day, every day, the internists and family practitioners do physical exams but don't operate. So, who is more qualified to evaluate the heart and lungs, to order and interpret the lab tests, and to interpret the all-important electrocardiogram, particularly in a 58-year-old with significant medical problems?

You know the answer.

The last time I felt qualified to do a top quality history and physical was the last day of my internship. After that, I began training as a surgeon. I left the world of diagnostic medicine and entered the world of surgery. You can't go back.

The anesthesiologist: The specialty of anesthesia is defined as the practice of internal medicine exclusively in the operating room and allied environments. So anesthesiologists are internists who don't have offices open to the public but practice internal medicine in a specific location--the operating room and recovery room. Therefore, as both internists and as the administrators of anesthesia, anesthesiologists are--in my opinion--the optimal assessor of risk. But a logistic issue generally blocks their role as the director of the requisite physical examination; they don't have standard office hours and they generally don't meet the patient until the surgery day. And while they can -- and should -- speak with the patient several days prior to the surgery, the "Go or No go" decision needs to be made weeks before the surgery in deference to the patient's, doctor's, and surgery staff's schedule.

The patient's personal physician. This doctor is most often the logical and appropriate MD to conduct the medical clearance. He or she already knows the patient's history -- including family history. And, most importantly, has invaluable records. The prior lab, x-ray and cardiogram tests allow comparison with the current recent physical exam to best evaluate the patient's current medical condition. The personal MD can be objective and impartial in his evaluation and recommendation regarding medical suitability for the procedure. He has no stake in it. And, perhaps significantly in the Donda West case, would have probably sought consultation with a cardiologist and he most likely would have known of or discovered all of these lingering questions concerning the cardiac status.

Unfortunately, some patients do not have a personal physician and so the wisdom and consult of a personal physician is unavailable.

The outside, independent internist or family practitioner. Another very good choice. In our practice, for patients without a personal "primary" physician, we offer a roster of family physicians and internists whom we know to be receptive to accepting new patients and who clearly understand the "pre-op" medical clearance issue. This doctor, to whom the patient is new and thus medically unknown, will conduct a thorough comprehensive evaluation, taking it from the top with no pre-judgment and no predispositions. He acts 100% independently and is given the authority to give us a green light ("OK" for the proposed surgery), yellow light (Can't say yet, needs to have more tests and possibly consultation with one or more specialists), red light (Surgery not advised, major risk factor, recommend cancelling).

So, who did Donda West's pre-op history and physical? Did that doctor not ask enough questions? Not order the right tests? In view of her personal and family history, should a cardiologist have been consulted?

What about the anesthesiologist? The media has reported that an anesthesiologist administered the anesthetic. What was his view? What was his appraisal of medical suitability and risk assessment?

What I have discussed regarding the requisite and so important pre-op medical evaluation is a series of gates the patient should have to pass through. Any one of the gatekeepers can close the gate to surgery if they perceive the risks are unacceptably high.

Right now, we don't yet know enough about the gatekeepers, their action, and particularly why Mrs. West's ominous family and personal history may not have been probed.

Was this a matter of the convergence of several risk factors combining to create an unsurmountable burden for the heart and lungs?

That January 11th LA Times article also revealed that "West had vomited during intubation (insertion of anesthetic air tube into the lungs)" and that "pneumonia was found in West's lung." This is very significant because while apparently the Coroner did not see a major pneumonia which would have on its own caused death, it may be that the pneumonia present was yet another burden upon Mrs. West's borderline heart function. Also significant was the speculation by a surgeon, not participating in Mrs. West's care, that "she has a tight dressing (on her chest) and then you're adding a pneumonia that decreases oxygen. That puts a further strain on the heart."

I think that's a plausible theory based on what we know to date.

Assuming that, indeed, there was a tight, or possibly overtight, compression dressing on the chest, the site of the breast surgery, then, that is another factor that might have conspired with the aforementioned unsatisfactory heart and blood vessel pathology that paved the road to a tragedy.

Let me expound on this theoretical scenario. The patient enters the operating room with underlying medical conditions that, of themselves, under non-strenuous, non-stressful daily activity are not necessarily incapacitating. While, technically, the surgery goes well, the anesthesia experience is less ideal because some vomitus is inhaled into one or both lungs. During surgery, apparently there is adequate lung function, but perhaps that was because respiration was aided by a mechanical ventilator. Without such technical supplement, the lungs may have demonstrated themselves to be functioning sub-par.

The heart and lung performance is different during recovery, however. First, the possibly pneumonia-impaired lungs may not be ventilating adequately. Additionally, lung excursions may be limited due to the tight chest binder-dressing. Then, add to the mix the possibility that the breathing is further suppressed by pain medications and sedatives. Should that be the scenario, lung function is now considerably sub-optimal and this has a bearing on how well the heart functions. Because the heart relies on a generous supply of oxygen-rich blood coming to it from the lungs, should that percentage of oxygen saturation of the blood supplying the heart itself be inadequate, the heart may fail.

Apparently and unfortunately, in the home where Mrs. West was recovering, there was no oxygen monitoring equipment. And while pulse and blood pressure are helpful parameters to gauge how patients are doing, they are relatively crude. The far more sensitive function of how well the patient's heart and lungs are functioning is an automated oxygen saturation monitor.

In summary, therefore, for the patient whose heart function is borderline, when the lung system is compromised by pneumonia plus possibly inadequate ventilation due to dressing constriction plus reduction of the rate of breathing by medications, the stage is set for a constellation of events that can lead to death.

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Technorati Tags: Donda West, heart disease, hypertension, surgery risk factors, obesity, autopsy

Lessons From Donda West

2008-01-11T18:21:00.001-05:00

The Right Post-operative Care is No Less Important Than the Right Surgeon

Donda West did not die in the operating room; she did not die from an error or immediate complication of surgery, nor from anesthesia, according to the L.A. County Coroner. The exact cause of death could not be determined, however the AP reported that: "...two unidentified women told a dispatcher that West suffered a heart attack and unsuccessfully tried to revive her".

I have often been asked: "Is home the best location in which to recover after you have a long and complex operation under anesthesia?" Since surgical care does not end with the last stitch, here are questions that I believe should be asked, at consultation, of the doctor, regarding the immediate postoperative period and safety issues related to it:

Given my age and my health status, am I at greater risk for postoperative complications or problems?

Answer: Teens and young adults having cosmetic nasal surgery, breast augmentation or reduction, or correction of protruding ears, rarely take prescription drugs regularly. They have no underlying disease processes and they are on no medications that might have a bearing on their recovery. Thus, they present nearly zero risk for anesthesia and for the postoperative recovery period.

However, older patients, particularly having longer, more involved procedures, such as face and neck lifting, tummy tucks or full-body liposuction, are often being treated by their internists for several chronic medical conditions. The most common are high blood pressure, arthritis and elevated cholesterol. Those, among others, require long-term medication and all medications have some side effects and possible interactions with drugs used during surgery or in recovery. Such patients place greater demands on the anesthesia specialist during surgery and are at higher risk for postoperative problems and complications. Also, there is some stress placed upon the body during the first several days of recovery. For those with low tolerance to pain or who do not fare well under stress, there is presented an extra burden to the body. Sometimes, and under certain circumstances, such stressors may cause significant medical complications.

Given the type of procedure (and the length of the operation), how does that impact on my decision as to where to recover and who will be attending to me?

Answer: The patient needs to make a decision, with their doctor, as to which of the following locations is most wise with respect to safety and care issues:

Hospital, home with family or friend caregiver, home with a nurse, home with a nurse experienced with and specializing in post-op care of cosmetic surgery patients, or, a professionally-staffed, exclusively post-cosmetic surgery recovery facility.

For healthy, young patients, little postoperative care is required and may properly be provided by any adult family member. Having a "nurse" who might be a nurse's aide or even a registered nurse is helpful and provides an extra level of professional knowledge and attentiveness.

Having a nurse experienced with and specializing in postoperative care of cosmetic surgery patients is an excellent one-on-one, high level service.

Recovering in a professional recovery hideaway has the advantages of full service medical and care functions; room, board, nursing and transportation to the doctor's office for post-op visits. This includes having its own medical formulary and immediate access to a pharmacy 24 hours a day. These facilities also have round-the-clock staffing of nursing assistance and registered nurses who have a high level of experience and specialization. These facilities are outfitted to measure oxygen saturation and lung function after surgery, in addition to the usual pulse, blood pressure and temperature monitoring.

So as you see, much thought should be given beyond "what procedure should I have". One's particular medical and personal requirements need thoughtful evaluation. That is why the top practices know that personalized, super-attentive care before, during and after the operating room are all necessary to have a safe and satisfactory experience for the patient.

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Technorati Tags: donda west, cosmetic, surgery, complications, news

5 Questions to Ask Before Getting an Eye Lift

2007-12-31T17:12:00.001-05:00

With newer techniques, better technology and an enhanced understanding of what "looks good" and what doesn't (see some celebs who don't look good, e.g. Kenny Rogers), prospective patients need to do more homework than ever. Here are some questions that you need to ask in order to be fully informed before signing up for eyelid surgery.

Will the eyebrows also be lifted with the upper eyelids?

Eyebrow elevation is not automatically done. However, evaluation of the brow position and its influence on upper eyelid excess is essential. For females, the ideal brow position is at the bone level or slightly above. The brow should be arc-shaped. For men, the brow should sit at bone level or slightly below. The ideal time to deal with droopy brows is when the upper lids are being lifted. The doctor needs to check this out thoroughly at consultation.

My upper lids feel very heavy and it seems my vision may be affected. Will insurance help pay?
In the extreme, heavy upper lids can obscure vision. This needs to be confirmed by an eye specialist. When confirmed on testing, it is considered a medical condition and usually insurance benefits apply.

I wear contact lenses. How soon can I resume wearing them after surgery?

Contact lenses can be worn as soon as upper lid swelling has receded such that the lash-line sits at the normal position just above the iris colored portion of the eye); usually 5-7 days. Then, the contacts will not be pushed down by the heavy lids. After only lower lid surgery, the contacts can be inserted in one or two days.

Besides heavy upper lids, I have baggy lower lids. What is done for those?

Bagginess of the lower lids is usually caused by fat pads pushing forward. Correction via hidden incisions, behind the lid; the excess fat is removed or repositioned or both. If there is excess wrinkled skin, additional measures may be required.

I'm afraid of that surprised, startled look, the tell-tale sign of poor eyelid cosmetic surgery. Is that automatic? And, if not, what is done to avoid that unsatisfactory look?

No one likes to look like "a deer in the headlights". That startled look is the consequence of amateurish, overzealous surgery. Too much was done. Either the brows were lifted too high or too much overhanging eyelid skin and fat removed. Not easily corrected. Your best protection: Be sure to see lots of the doctor's before-and-after photos. Ask to see some former patients. Those surgeons who specialize in eyelid surgery, such as ophthalmic plastic surgeons and cosmetic surgeons who do more facial than body work are less likely to error. Always select the most specialized doctor who works from a short menu. Think superspecialist.

Doctors' Board Certification

2007-12-26T04:50:00.001-05:00

What is it? What is the Importance?

The terms "board certification" or "board certified" have been much bandied about recently. The death of Kanye West's 58-year-old mother has naturally focused on the qualifications of her surgeon. As the media dissected the doctor's resume, it was reported that although he practiced the specialty of plastic surgery, he was "not board-certified by the American Board of Plastic Surgery".

Not all lay people understand "board certification". Does a doctor being "board certified" – or not - impact on their medical care? How important is it?

Succinctly, a doctor who is "board certified", whether he be a plastic surgeon, pediatrician, internist or radiologist, has met the standard of the medical profession to be able to hold himself to the profession and the public as a specialist. The credential is awarded after successfully completing an approved residency of anywhere from two to six years, and subsequently passing a series of oral and written exams. Some specialties, including plastic surgery, require specific practice experience before one can take the exams. Think of this as the medical educational system's version of the Good Housekeeping Seal of Approval, awarded by fellow specialists.

The concept of long, supervised training, demonstrated actual in-practice experience and passing tests is laudable. No other occupation or profession demands such an exhaustive and rigid requirement for formal recognition. This is the medical profession's and specialties' way of saying: "Our student, the product of our highly-structured educational (book learning) and training (hands-on, practical) program is deemed fit to practice this specialty. He has met our standards which have been designed to protect the patient."

Some doctors may choose to not take the exam; some flunk it. They still have a license to practice and obviously their knowledge, skill and talents are there to be employed. However, many hospitals will not grant staff privileges to those not certified and one has little chance of being accepted as a teacher by any of the medical schools without such a diploma.

Should all this matter to you, the patient? Frankly, it should. Because when one voluntarily expends time and energy to pass the exam and then can proudly say to you, his patient, that he has met the standards of his profession and his specialty, doesn't that does say something about his desire for excellence and dedication? That, of his own volition, he studied hard and did "pass" every test presented along that interminable, laborious route of medical education and training.

Voluntarily taking the ultimate, final test for certification as a bonafide specialist does say a lot about a person and his character. About individual tenacity, diligence and focus; about going the extra mile. All to benefit the patient.

That is why I appreciate and respect the concept of board certification. Hence I prefer to have board certified doctors as consultants for my patients, my family and myself.

Robert Kotler, MD, FACS

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Technorati Tags: cosmetic surgery, board certification, medicine, wellness

5 Most Common Questions Asked of Cosmetic Surgeons

2007-12-05T13:13:00.000-05:00

We find that some of the same questions repeatedly come up when prospective patients are consulting with me. We have listed the most popular ones. I don't want to sound like a broken record, but it's extremely important to be informed and feel that all your questions are answered when deciding to have cosmetic surgery. If you are left with unanswered questions, you should be concerned.

Q: If I see a picture in a magazine of a particular feature that I like, should I bring the photo to the consultation?
A: Yes, this can help the doctor understand your desires. It is also helpful when the doctor offers computer imaging so you can see the predicted result of your procedure. Imaging is the best way to determine what you like and what will look the most natural.

Q: Will I meet the doctor during the consultation?
A: The answer better be "yes". It is imperative to meet with the doctor who will be performing your procedure.

Q: In addition to reviewing the hundreds of before/after photos on the website and in the photo albums in the office, would it be O.K. to speak with a patient who already had the procedure?
A: This is a great way to get first hand knowledge of someone's experience the doctor and the office. You will also learn about recovery from a patient's viewpoint. An even better opportunity would be to meet the patient.

Q: I did not realize I needed several different procedures to accomplish what I hoped for. I may be exceeding my budget. Are there ways for me to reduce cost, but without compromising the result?
A: Yes there are. In Chapter 11 of my book, Secrets of a Beverly Hills Cosmetic Surgeon, I share some very practical strategies. For example, if you have flexibility in your schedule and can fill a surgery center opening when one arises, you can save a healthy percentage of the surgeon's fee. There are other ways too. No shame in asking.

Q: I am concerned about pain.
A: Today, there is no reason for any patient to suffer pain. We have a big assortment of pain medications and tranquilizers to keep you comfortable and relaxed. If you have had experience - good or bad - with certain medications, we need to know and we can alter our prescription plans accordingly.

~Robert Kotler, MD, FACS

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Technorati Tags: cosmetic surgery, consultation

The 10 Don'ts of Cosmetic Surgery

2007-11-20T12:04:00.000-05:00

With doctors pouring into cosmetic medicine, some skipping the traditional and arduous residency and fellowship route, some practitioners don't have the talent and judgment that comes with that long experience pathway. And, patients get short-changed.

With interest in cosmetic procedures at an all-time high, prospective patients often fail to do the necessary homework to make the proper surgeon and location decision.

Donda West, the mother of hip-hop mogul Kanye West, died last week one day following a cosmetic procedure. While the exact cause of death has yet to be determined by the Coroner, questions have arisen regarding whether or not she underwent adequate doctor and lab exams to evaluate her medical suitability for surgery and the level of post-operative care she received. Understanding that cosmetic surgery is still surgery...

...Here are my personal 10 Don'ts of Cosmetic Surgery.

Don't use a cosmetic surgeon only because you saw him on television. Entertainment industry criteria for doctors' appearances are not the same as the classical medical profession's standards. For Hollywood, often - but not always - board certification, fellowship training, medical school affiliation, a high degree of specialization and reputation among other specialists are of little importance. Telegenicity, a big personality and entertainment industry connections may count more. So, carefully check out the TV doctor's Professional Bio and not his screen credits.

Don't ask the doctor to reproduce Brad Pitt's nose or Salma Hayek's eyelids. Your surgeon is not David Copperfield; he is not a magician. He does the best with what he has.

Don't make the doctor selection strictly on costs. Some surgeons can charge less because they do not provide a doctor-anesthesiologist or do not operate in a fully licensed or accredited facility. Or, the practice is a low-cost, high-volume production line offering little contact with the doctor. Beware false economy; top quality is rarely cheap.

Don't select a "Jack of All Trades, Master of None". The doctor who has a department store practice claiming to do "everything" from hair transplants, to calf implants - and everything in between - is rarely the most talented. Rather, look for a boutique practice: a superspecialist doctor who limits his practice to a few procedures. He'll be the master you want.

Don't forget to ask about anesthesia and the surgery facility. Safety first, always. You want a doctor-anesthesiologist or a nurse-anesthetist at your side for anything but a minor procedure. And, make sure the facility, whether office or outpatient surgery center has the medical equivalent of The Good Housekeeping Seal of Approval: licensure by the federal or state government and/or accreditation/certification by the organizations that accredit hospitals, surgery centers and office surgical facilities.

Don't be hustled into the operating room by an overly-aggressive staff. Some practices hired commissioned salespeople to fill their surgery schedule. Others won't even let you meet the doctor until you have signed up and paid some money. These are very risky places. Their interest is your wallet, not you.

Don't believe that every procedure is a "piece of cake" and that you will be "back to work in no-time". That's a salesman's one-liner and it's just not true for many cosmetic procedures. Certainly not for a five-hour face and neck lift or a four hour body liposuction and tummy-tuck. While these are not dangerous operations, adequate time must be given the body to heal. Generally no procedure or combination requires more than ten days to two weeks. But the "lunch-time facelift" is often an ad man's sales pitch surgery. Be realistic. There are no wise shortcuts.

Don't ever go into an operating room to please anyone else or if you are not positive about the undertaking. Cosmetic procedures are always elective. It's not as if your appendix is about to burst where time is critical. Take the time to examine your own motives. Is this what you want? Or, does a friend or loved one think it's a "good idea". Cosmetic surgery is no guarantee of job or social success. And, it won't shore up a shaky marriage or relationship. You must be comfortable with and confident in your decision. You don't want "buyer's remorse".

Don't have a cosmetic procedure by yourself. It is important to have a family member or friend with you for 24 hours after the procedure. With the more invasive procedures, it might be a good idea to stay at a professional recovery hideaway. In my practice, there are certain procedures which mandate sending my patients to a recovery hideaway.

Don't have cosmetic surgery without being examined by your internist or family physician. Make sure you are declared healthy and "low risk" before you schedule surgery. Remember this is surgery, not a salon visit.

The Neck is the Most Important Part of a Facelift

2007-10-22T15:27:00.000-04:00

One of the most misunderstood issues in facial cosmetic surgery is "the neck". The word "facelift" is bandied about when discussing reversing the outward signs of aging. But what is a facelift? Is it lifting the jawline? Elevating the cheeks? Tightening the temples? Opening the eyelids? Raising the eyebrow? Smoothing the forehead?

In fact, depending on the patient's desires and the surgeon's philosophy and talents, the blanket term "facelift" might include some or all of the above elements. Remember that there should not be "one size fits all". Your operation should be customized, not a cookbook copy of the last patient's procedure. A great cosmetic surgeon is an artist, not the operator of a production line. So, ask for a list of the component elements of that particular doctor's "facelift".

Decision making, a joint effort between doctor and patient, follows attentive analysis by the doctor and, ideally, computer imaging to show the prospective patient the predicted result in that doctor's hands.

So, what about the aging neck? The double chin, jowls, sagging vertical platysma (muscle) bands, and the wrinkled, crepy, discolored, sun-damaged skin? There can be a lot of extra baggage there.

My 38 years of consulting with thousands of patients has taught me that the public is fixated on the face, yet the neck is where the biggest victory is always won.

Of all tell-tale signs of aging above the collarbone, most often the neck demonstrates the first. The main reason is that the neck skin - thinner and less elastic than that of the face - succumbs earliest to the forces of gravity. Among the earliest signs of aging are, in fact, some jowls and the "double chin".

One of the reasons so many patients are dissatisfied with their "facelift" is that it did not include an aggressive neck lift. Often, what was done on the neck, perhaps only liposuction, was inadequate. For most women over 45 and men over 55, the facial rejuvenation effort must include a "neck lift". The neck lift is performed simultaneously with the facelift. The skin of the cheeks, jaw, and neck may be lifted from its attachments as one large sheet. Ultimately, after liposuctioning of excess fatty tissue and removal and/or tightening of the lax neck muscles and tightening of the below-the-skin layers of tissue, some of that broad sheet of skin will be discarded after being "lifted" or re-draped.

Those heavily-advertised, promoted, and marketed shortcut facelift operations give no attention to the neck. Hence, a higher patient dissatisfaction rate after these shortcut face-pulling procedures. The cheeks may look better, but there is no way that doing surgery via only incisions in front of the ears can improve the folds, sags, and loose skin of the neck, particularly the lower half of the neck above the collarbone. It is disingenuous for anyone to propose that such a minimal, quick, and shortcut procedure can do it all - and have longevity.

Yes, it sounds good to have a cheap, one-hour facelift. But, like most things in life, you not only get what you pay for, but the result is proportional to the time and effort put in. Shortcuts in surgery are notorious for short-term benefit. My advice: When consulting, your menu of questions should start with the neck. Your questioning should "work up" to the face. You may find that the neck - not the face - is the area that needs the most help.

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Technorati Tags: neck lift, facelift, cosmetic surgery

As You Grow Older, the Nose Grows?

2007-10-09T06:12:00.000-04:00

Not really, but it does appear that way. It does not grow; but, it drops, droops and elongates.

Here's why. The nose is subjected to two "downward forces" over one's lifetime.

First, gravity. Not unlike other body structures, particularly those that may be deemed "attached", e.g. earlobes, breasts and men's genitals, the nose is another victim of gravity. By the fifth or sixth decade of life, the skin and soft tissue underneath the skin will have naturally stretched and thinned. Under the unrelenting force of gravity, the nose hangs down, looks longer and is misinterpreted as having grown.

The second influence is one particular smile muscle that, when contracting, visibly pulls the tip of the nose downward. That depressor septi muscle runs vertically from the upper lip to the front part of the nose. In a good percentage of men and women, such involuntary depression of the tip of the nose will occur with every smile. One cannot deliberately prevent that specific muscle from contracting. Thus, the years of smiling take their toll as the nose, subjected to innumerable smiles over decades, suffers from the same stretching and lengthening that gravity fosters.

Because some seniors are perturbed by the eldernose's longer, larger appearance, it is appropriate to perform very conservative elevation of the droopy nose to its original and more youthful location in conjunction with facelift and eyelid surgery.

Only those who have had rhinoplasty or cosmetic nasal surgery escape their nose's downward journey. As Nature heals the nose after such surgery, a thin layer of internal scar tissue is created. This tissue, stronger than the natural internal tissue resists the forces of smiling and gravity and prevents the nose from being seen as "growing".

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Technorati Tags: cosmetic surgery, rhinoplasty, nose job, health and wellness

Red Carpet Prep

2007-09-26T10:47:00.000-04:00

For all of the award shows - MTV Video Music Awards, Golden Globes, Emmys, Oscars, People's Choice, and others - the Red Carpet is a show of its own. And that means celebrities get serious about looking their best for the Red Carpet. Here is a list of the most popular celebrity secrets.

Diuretics/laxatives/limited caloric intake/ assorted rapid weight loss diets: Short-term, the old standbys.

Helpful clothing appliances: Push-up bras, etc. The legendary Howard Hughes a pioneer; developed a special bra for actress Jane Russell for the movie "The Outlaw" (1943). Controversy as to whether or not she actually wore such in the movie.

Body wraps: They are designed to improve the texture and appearance of the skin by helping to rid the body of excess fluids. They supposedly benefit the body by contouring, losing inches and tightening the skin. This procedure is risky for the celebrity who wants to stay out all night. Body wraps have a Cinderella effect; the results are temporary and the body begins to expand after several hours.

Rubber-band face "Lifts": Venerable Hollywood contraption. Best when hair is long and covers ears and cheeks. Hidden barrette-like anchor fixes to hair close to scalp. Rubber bands affixed to the barrette and then to scotch tape adhesed to skin at strategic positions, e.g. just behind and under jaw, at temples to "lift" the face and neck mimicking the effect of a surgical face and neck lift.

Fillers Restylane, Juvederm , Sculptra to plump lips, fill marionette lines, soften cheek hollows. Best done several weeks prior to allow for spontaneous reduction in injection-induced swelling and/or bruising.

Botox injections to forehead wrinkles and between the eyebrow frown lines. Trade off is a less-emotional face. Like "fillers", best done several weeks prior to appearances to allow for full effect to emerge.

Botox injected into arm-pits to prevent sweating.

Certain prescription meds, e.g propanolol (medication used to reduce blood pressure and slow heart rate) to prevent facial sweating and reduce "jitters".

Original formula Preparation H (still available in Canada) to temporarily "erase" crow's feet.

Foot Injections of collagen, Restylane, Juvederm into soles of feet, "padding" to help prevent pain from prolonged walking on 4" high or stiletto heels.

Oxygen facials. Of questionable value, but favored by celebs. Harmless. Purported to nourish and "plump-up skin" to give an airbrush effect. Rumored that Madonna owns her machine and has an oxygen facial everyday.

Dermatology office treatments: Micro-dermabrasion (mild medical sandblasting) to soften skin and develop luster. Minor laser-like treatments to remove visible red spots and other superficial skin discolorations. Best done weeks prior to allow proper healing.

Finally, why do Beverly Hills cosmetic surgeons and dermatologists load up on WD-40? To keep the hinges of their office back doors from squeaking as the high-profile folks slither in and out for their treatments and preps!

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Technorati Tags: cosmetic surgery, Hollywood, red carpet, award shows

New Hope for Unhappy Nose Job Patients

2007-09-13T12:44:00.000-04:00

Office Injections Save Patients a Second (Or Third) Trip to The Operating Room and Thousands Of Dollars

I've unfortunately noticed that there is an increased number of patients coming to my practice needing "touch-up" cosmetic nasal surgery. Their original surgery, performed by other surgeons, was unsatisfactory. Nearly 20 percent of patients consulting with me have had poor work done elsewhere. In a future post, I will discuss the "why" of this problem and how you can avoid being a dissatisfied patient.

These patients are unhappy because, typically, the nose was "overdone" with grooves, moguls, depressions. Too much bone and cartilage was taken out. That's why these patients complain that "my previous rhinoplasty makes my nose appear too-pinched and too-scooped." Fortunately, for some patients unhappy with their result, and even unhappier with the prospect of more surgery, now there is a better option.

Surprisingly, few patients know about a highly predictable and reliable non-surgical alternative: filler injections. I was recently consulting with a patient who was unhappy with her original rhinoplasty, followed by multiple other surgeries to correct the damage done at the first session. She came to the consultation resigned to having another complex operation. When I informed her about the benefits filler injections, she became overwhelmed with emotion and began to cry. She was so thrilled I could fix the appearance of her nose, without yet, another surgery.

I favor such filler injections when appropriate. Droplets of liquid silicone, deposited just under the nasal skin with a short, ultra-fine needle, work magic to correct nasal irregularities. Typically, patients are only offered expensive, complex operations, usually with somewhat unpredictable bone and/or cartilage tissue grafts.

Cosmetic surgery re-do's require additional time off from work, another trip to the operating room, some discomfort and more money. Yes, there are some situations whereby surgery cannot be avoided, such as when breathing is still blocked. But, doesn't it make more sense, whenever possible, to permanently correct an imperfection - more handily - by a series of office injections, with no down time, very little pain, back-to-work immediately with no swelling or bruising?

Silicone-gel breast implants, with FDA approval are back and popular. The liquid form of silicone is FDA-approved for use inside the eye, a pretty delicate and critical area. So, we nasal surgeons feel comfortable and safe using it, off-label, for droplet placement under the nose skin. The total amount needed to do the job is less than 1/5 of a teaspoon. Silicone, a great man-made material - in its solid form - is used for FDA-approved artificial joints and heart valves. And, nearly everyone has had exposure to the liquid form; hypodermic needles to draw blood or give injections are coated with it for ease of puncturing the skin.

Incidentally, lest there be any confusion, liquid silicone as a filling injection is permanent. Other fillers that are sometimes used for the same purposes, such as collagen, Restylane and Juvederm are not permanent. They may last up to six months but ultimately will dissolve away and need to be repeated.

To Demonstrate the Final Result, There's Even a "Demo"

For patients who are reluctant, unsure, or just curious, I have devised a clever and practical "Salt-water Demo." I demonstrate to the patient, mirror-in-hand, the predicted result by injecting sterile saline (salt-water). This "test-drive" allows immediate visualization of how the permanent injections will correct the dents and defects. The saline filler dissipates within an hour. We take before and after digital photos, which we can e-mail to the patient, to show the family for their input.

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Technorati Tags: cosmetic surgery, rhinoplasty

Tummy Tucks and Liposuction

2007-08-31T14:21:00.000-04:00

(Because I limit my practice to cosmetic surgery of the face and neck, I asked Dr. Leif Rogers of the Cosmetic Surgery Specialists Medical Group of Beverly Hills to respond. Dr. Rogers specializes in body sculpture procedures. He is certified by the American Board of Plastic Surgery and had additional fellowship training in cosmetic surgery. Here are his thoughts on tummy tucks and liposuction. -- Dr.Kotler)

Tummy tucks CAN be done immediately following childbirth but the results will never be as good as if one waits 6 months to a year after childbirth.

Immediately after childbirth the uterus is still enlarged and most people have some extra weight on them from pregnancy, both of which will prevent the optimal abdominoplasty result. If a woman were to get an immediate tummy tuck following childbirth, they will almost certainly have some recurrence of loose tissues (skin and abdominal muscles) due to shrinking of the uterus over 6 weeks and the usually weight loss most women experience over the next 6 months to a year after childbirth. The extra volume of the uterus and subcutaneous fat will prevent maximal tissue tightening. Should this happen, a revision may not even provide an equally optimal result as compared to abdominoplasty after the patient's body reaches a steady state or new baseline.

Liposuction (or suction lipectomy) by definition is the removal of subcutaneous fat by the mechanism of negative pressure (or suction). Therefore any variation on the theme is purely an additional mechanism to assist the basic technique. Any technique that does not remove the fat via liposuction is not a variation of liposuction, but a different technique entirely. I will touch on those techniques as well.

Liposuction and Liposculpture refer to the same technique that requires the infusion on fluid that contains epinephrine to help control bleeding and lidocaine to control discomfort. The fluid also assist the fat to flow through the cannula more easily. Liposculpture is actually the same as liposuction, though some have come to use the term to refer to liposuction meant to fine tune the physique.

Liposuction techniques do vary in terms of the amount of fluid pre-injected prior to the suctioning out of the fat, the most common of which is named the "Super-wet" technique. Liposuction can also be done under local anesthesia (awake) or general anesthesia(asleep) depending on how many areas and patient/surgeon preference.

The most common mechanical enhancements for liposuction currently include "Power Assisted Liposuction" (PAL) and the "Vaser". PAL refers to a mechanical cannula that allows the surgeon to pass the cannula through the subcutaneous tissue with less effort and possibly more precision. The Vaser is a pre-liposuction step which treats the subcutaneous fat layer with ultrasound, which partially liquefies the fat allowing the suctioning step to be more effective, and possibly induces more skin shrinkage.

Other techniques of fat removal include Laser, injections, radio-frequency, infrared light therapy and combinations of the previous.

SmartLipo is a laser device that is applied under the skin in a similar fashion to a liposuction cannula and melts fat. However, the fat is not removed, the body resorbes the melted fat. The results are less predictable than liposuction and less dramatic.

Mesotherapy is a injection (Lipodissolve is one trademarked formula) that emulsifies the fat. The key ingredient in all mesotherapy recipes is lecithin, with essentially acts as a detergent.

Radio Frequency (RF) is an electromagnetic energy wavelength that can be delivered through the skin, targeting and super-heating the fat layer causing destruction of fat cells. This technology is still under development and available in limited efficacy at the time of this writing.

Infrared, another electromagnetic wavelength is currently available with limited efficacy for fat reduction, applied similarly to RF.

Ultrasound (very high frequency sound waves) are being applied across the skin that heat the fat layer. Ultrashape has been used in Europe for several years and Liposonix is new company with a similar device. Neither is yet FDA approved in the US at this time.

LipoZap is a Trademarked process that uses a combination of mesotherapy, RF and Infrared.

True liposuction is still the gold standard.

Liposuction can be very effective for reducing specific pockets of fat, and can give patients a way to lose those areas that are resistant to diet and exercise.

However, liposuction can have some less desirable effects. Liposuction is not a good treatment for cellulite. In some instances the appearance of cellulite can be improved, but in some instances it can become more pronounced. It is difficult to predict which patient will have which result.

Liposuction is also not a license to eat an unhealthy diet. Weight can be gained again, however, the distribution of fat WILL be different. Some areas may appear to gain weight faster than before liposuction. This occurs because the fat cells removed from a given area never grow back. It can be assumed that all fat cells in one's body are approximately the same size, therefore, as one gains weight all cells grow at approximately the same rate. Since the ratio of fat cells from on body part to another have been altered permanently by liposuction, so will the ratio in which fat is deposited.

Another potential pitfall is uneven contour. This can be caused by uneven suctioning, but just as likely, can be caused by scar formation that is specific to each patients physiology. Just as some people form thick scars in the skin regardless of surgeon skill, so do some form thick scars in the deeper layers. Exuberant scar formation in the skin does not seem to predict similar scarring in the deeper layers and vice-versa.

Loose skin can also be a problem after liposuction. This is more common for older patients who have lost much of the elasticity in their skin. Occasionally skin resection is necessary to remove the excess skin. Women in their 40s to 60s are more likely to have irregular contour as well due to thinning of the skin, which will show imperfections.

In instances when irregularities do not improve with time, fat transfers and touch-up liposuction can correct irregularities.

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Technorati Tags: tummy tuck, liposuction, fat removal, SmartLip, Mesotherapy, laser, infrared, ultrasound, body sculpting