Cosmetic Surgery

Is Your Plastic Surgeon on Speed Dial?

2010-02-09T08:39:00.000-08:00

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

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

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

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

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

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

- Robert Kotler, MD, FACS

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Foods That Can Help You Heal

2010-02-04T06:39:00.000-08:00

How You Can Help Your Healing After Cosmetic Plastic Surgery

angelcandy.baby / CC BY 2.0

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

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

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

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

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

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

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

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

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

- Robert Kotler, MD, FACS

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

2010-02-02T04:30:00.000-08:00

Magazine Cover Photo "Touch-ups"

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

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

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

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

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

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

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

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

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

- Robert Kotler, MD, FACS

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

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The Case for Surgery by Two Complementary Cosmetic Surgery Superspecialists

2010-01-27T16:32:00.000-08:00

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

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

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

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

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

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

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

The bottom line - think superspecialist!

- Robert Kotler, MD, FACS

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Rhinoplasty During Winter - A Good Idea?

2010-01-21T12:39:00.000-08:00

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

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

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

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

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

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

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

- Robert Kotler, MD, FACS

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Heidi Montag, Businesswoman

2010-01-19T13:43:00.000-08:00

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

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

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

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

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

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

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

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

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

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

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

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

Probably tax deductible, too.

- Robert Kotler, MD, FACS

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Top Ten Hints To Look Younger and Better in 2010

2010-01-15T13:43:00.000-08:00

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

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

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

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

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

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

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

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

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

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

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

- Robert Kotler, MD, FACS

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New Filler: SCULPTRA®

2010-01-12T10:42:00.000-08:00

Previously, I discussed briefly some of the newer filling injections that we are pleased to have available for our patients. I think it's important that I go into a bit more detail concerning one of the newest but chemically and functionally unique fillers, Sculptra® Aesthetic.

The unique role of this injectable is that rather than merely acting as a filler and taking up space for a finite period of time and then disappearing without any leftover benefit, Sculptra actually encourages the body to refashion its tissue. Sculptra is made of injectable poly-L-lactic acid (PLLA). This is the same material that we have used for years in the form of absorbable surgical stitches or sutures in the operation room.

The FDA has approved Sculptra Aesthetic and it has been well researched and used in clinical studies for many years. I have known about it for many years because I followed its progress in the medical research world and happened to have a close colleague, Gail Humble, MD, of Redondo Beach, California, who is one of the original investigators and had long-term follow-up reports for us.

Most patients understand the need for facial fillers, to plump those areas where nature's aging process reduces the amount of fat under the skin and begins to give a hollow and less youthful look. Uniquely, Sculptra Aesthetic, when injected over several weeks, stimulates the body to form new collagen. Now more than one session is necessary; it may be that as many as three to four sessions are necessary, depending on the patient particulars and the volume needed.

Sculptra Aesthetic injected underneath the skin and in certain areas like in the temples and jaw line and cheek areas will be effective in plumping those areas for two years and perhaps longer. I have actually heard from Dr. Humble that some patients who were among the original group treated are now five years post injection and still "holding their own."

Understand that the results need to be studied over a long period of time but right now, this product looks promising. Certainly, there is little chance of allergic reaction because it is a synthetic material not derived from another animal species.

Patients need to understand that unlike other fillers such as Restylane® and Juvederm® - whose mission should not be dismissed since they are very appropriate and effective in certain areas - Sculptra Aesthetic requires a bit of faith on the part of the patient. Because after the injections have been made, the volume of liquid injected dissipates since much of it was water and local anesthesia. But it has left the key ingredient to begin the process of stimulating the body to develop its own new collagen.

- Robert Kotler, MD, FACS

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Cocaine Use and Its Effects on Rhinoplasty

2010-01-05T11:30:00.000-08:00

Sadly, people still abuse cocaine. What happens to the body after is never good. The worst effect is what happens to the heart and blood vessels - high blood pressure that can possibly lead to a stroke or even death.

How does this relate to nose surgery? Surgical problems are always an issue for patients abusing cocaine. Two problems come to mind. The inside of the nose is irritated and inflamed, which makes it impossible to safely do nasal surgery. Secondly, cocaine abusers can have a hole within the internal partition of the nose. We call this a nasal septal perforation. The size of the hole can range from a pen tip to the size of a nickel.

Crusting, whistling and bleeding can result from septal perforations. It creates many challenges. The greatest one being the difficulty for the surgeon to surgically close that hole. It is possible to insert some appliances that can act as a "stopper," but a long-time cocaine abuser will most likely have problems.

It is also important for me to mention that a patient should NEVER have cocaine in their system during surgery. The mixture of cocaine, anesthetic drugs and the local anesthetic could be catastrophic!

It is better to be honest with your doctor, rather than feel embarrassed. Your doctor will not judge you. In fact, whatever is told to the doctor is completely confidential and can never be revealed without the permission of the patient. Being honest with your doctor will result in a safer and more positive surgical experience.

- Robert Kotler, MD, FACS

Related Topics:

Can a Pretty Face and a Shapely Body Improve One's Disposition?

2009-12-28T09:00:00.000-08:00

I read recently of a research study that reported that "roughly one third of patients who take antidepressants and undergo cosmetic plastic surgery discontinue these medications after the operation."

That’s impressive. It seems to tip its hat to the power of cosmetic surgery to improve one's self image and hence attitude. Now certainly there are a variety of medications that are used for patients that have varying degrees of anxiety or depression, but for that high a percentage of patients to no longer need medications seems to be a significant finding.

It has been long known that patients who are self-satisfied with their appearance seem to fair well in life. This was first brought home by Maxwell Maltz, MD, a plastic surgeon who became a well known author and described in his book, Psycho-Cybernetics, many examples of life improvement attributed to cosmetic plastic surgery.

I will echo those sentiments because, for nearly forty years, I have been a witness to the power of cosmetic surgery. There is just something very positive about people looking in the mirror, being happy with their appearance, and then going out to face the world with a smile on their face, a big reserve of energy and happiness to be with other people.

- Robert Kotler, MD, FACS

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The Five Cardinal Signs of a Poor or Overdone Rhinoplasty

2009-12-21T11:19:00.000-08:00

How Did It Happen?

We have all seen an otherwise pretty face supporting a nose that just looks wrong. It's not natural, looks fake, overdone and often as if it were turned out on a production line.

Photo courtesy of Dr. Robert Kotler

Here are the five flags of an unsatisfactory rhinoplasty or cosmetic nasal surgery:

The profile is too scooped.
The nose is too upturned.
The tip is pinched.
The nostrils look too large.
The front of the nose looks pencil-like because the tip has been narrowed as much as the bridge.

An unsatisfactory nose calls attention to itself. A well-done nose is silent. Those of us who trained with cosmetic nasal plastic surgery superspecialists were taught that the best results "never carry a sign."

(In the image above, the patient had 2 rhinoplasty surgeries elsewhere and was not happy. He wanted Dr. Kotler to correct his nose. Dr. Kotler didn’t think surgery would be a safe approach so he used permanent filling injections to correct the appearance.)

Let's review the signs of poor rhinoplasty craftsmanship:

On profile the nose looks scooped when the bridge is too low. Typically, the surgeon filed down the bone too much and shaved down the cartilage too much. Or in the course of the operation, particularly if there was a deviated septum causing nasal obstruction, too much tissue was removed internally, structural support weakened and the nose collapsed somewhat.

If the nose is too upturned, that means that the nose was shortened too much. The surgeon took too much tissue off the front part of the nasal septum in an attempt to raise the nose from the lip. That is difficult to correct, incidentally.

A pinched nose means that too much cartilage and internal nostril skin was removed from the alar or tip cartilage. Often, radical narrowing of the tip of the nose may cause a breathing problem.

If the tip of the nose is the same width as the bridge, the surgeon failed to recognize that in an "ideal nose" the tip is always a little wider than the bridge and that relationship should have been maintained even if both were wider originally.

Nostrils look too large or too wide when the nose has been shortened or the surgeon has failed to recognize that the floor of the nostril was too wide and should have been narrowed.

The master nasal cosmetic surgeon has a keen sense of what looks right. We call it the aesthetic sense. It is hard to teach; either you have it or you don't.

- Robert Kotler, MD, FACS

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How Do Some Surgeons Make Recovery Less of an Ordeal Than Others?

2009-12-18T12:10:00.000-08:00

We still hear stories about patients having rhinoplasty, cosmetic plastic nasal surgery – with resulting massive facial swelling and bruising. Those days should be gone. The most skilled surgeons, the superspecialists, those doctors at the top of the totem pole, will have mastered the surgical techniques which allow for efficiency and hence less operating time. The rule is, the more operating time, the greater the swelling and bruising.

Today's modern science has delivered excellent anti-swelling and anti-bruising medications which should be used. In something as simple as ice pack application around the eyes following rhinoplasty will be very helpful in reducing the swelling and bruising.

It is also important for doctors to remember that patients need to have adequate pain control. Of course, the humanitarian reason is primary, but the secondary reason is that patients in pain have elevated blood pressure and elevated blood pressure translates to more swelling and bruising. There is a variety of safe prescription medications to control pain – and without nausea or vomiting.

Further, patients need to rest after surgery. The more active they are, the higher the blood pressure, and again, the greater the risk of swelling and bruising. I like to see patients report that they are sleeping well at night but if they are not, I have no reluctance to prescribe sleeping medicine for several days.

Remember, the doctor's care does not end with the last stitch in the operating room. Meticulous post-operative care is just as important to achieve a satisfactory surgical result as attention to detail in the operating room.

— Robert Kotler, MD, FACS

Once Again, the Tax Collector Comes Knocking on Cosmetic Surgeons' Doors

2009-12-11T06:01:00.000-08:00

Cosmetic plastic surgery is again a target for governmental agencies groping for more money. Early this year, here in Beverly Hills, the taxpayers defeated, by a vote of 81 to 19 percent, an initiative that would have placed a 10% tax on the services of physicians and dentists. Just to make it look more egalitarian, these misdirected politicians also included corporations headquartered in Beverly Hills.

The inclusion of the corporations was a tactical mistake on the part of the Beverly Hills City Council because corporations are very good at mobilizing large amounts of funds to defend their self-interest and turf. The campaign against the initiative was spearheaded by a major medical office building corporation that saw this as merely a grab for dollars. During the campaign, it was revealed that additional revenues were not even necessary. The city of Beverly Hills was fiscally sound, was not tottering. Bureaucrats were merely looking to pad the city checkbook and saw medical professionals as easy pickings.

Now comes Senate Majority Leader Harry Reid with another poorly conceived initiative – a 5% tax on elective cosmetic surgery, attached conveniently to the new healthcare legislation – that deputizes cosmetic plastic surgeons as tax collectors for the federal government.

At first glance, perhaps some Americans will say "What do I care? I'm not having cosmetic surgery." Yes, not all Americans have cosmetic surgery.

There is a bigger, more universal and sinister issue lurking, however – a freedom issue. It's about the powers of government to further intrude and peer into our private lives. I don’t know how the collection process will be conducted – and I’m not sure anyone does – but we’ve heard that cosmetic surgery practices will collect the 5% levy and submit it to Washington. This is presumably not unlike the practice of collecting the Federal Income Tax and FICA when we pay our employees. The concern is that if we are to submit the money, there will have to be a record kept of the individual from whom it came. I know of no other tax withholding that is processed in any other way. Otherwise, it is impossible for the government to audit.

As an MD, it upsets me because cosmetic surgery is private, confidential, and nobody's business. For any bureaucrat to maintain information in a database of elective cosmetic plastic surgery patients is contrary to eternal medical ethics that protect patient privacy. No tax collector in Washington or anywhere else, or Senator Harry Reid or even Speaker of the House, Nancy Pelosi (who, it is my impression, appears to have availed herself of cosmetic surgery services) should be privy to a private and discretionary surgical procedure.

I don't want to digress extensively on the sorry state of governments in Washington and here in Sacramento, CA. However, this must be said: Our politicians foolishly will decimate a home-grown American industry that creates jobs right here in America; we don't operate via call center in Mumbai. And, we generate income tax revenue every day. Given its misguided way, Congress will drive more cosmetic plastic surgery patients across the border into Canada, Mexico or even Costa Rica to have elective cosmetic plastic surgery. There, American patients will be received with open arms.

In the end, another industry – like steel, cars and shipbuilding – will begin to slide away from the U.S.

Let's keep our eyes on Washington, and our hands on our wallets.

— Robert Kotler, MD, FACS

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Screening Mammography: What's the Controversy?

2009-12-04T15:00:00.000-08:00

The press has given much attention to recently revised recommendations regarding routine screening mammography. Of course, as a specialist in cosmetic plastic surgery of the face and neck only, I am not an expert in areas beyond my territory. However, the issue of breast cancer, including how it is diagnosed and how it is treated is important to the world of cosmetic and plastic reconstructive surgery. Our brethren who specialize in breast and body cosmetic and reconstructive plastic surgery are often called to participate in the care of breast cancer patients.

I have always believed that early detection and treatment is the key to defeating any and all cancers. Breast cancer, now nearly epidemic in Western societies, needs to have our attention.

Therefore, I have asked Stuart Linder, MD, FACS, of Beverly Hills to discuss his view of the controversy over the timing of mammography for middle-aged women. Dr. Linder is the classic cosmetic plastic surgery superspecialist because of his focused and narrowly-based practice which deals only with breast and torso cosmetic and reconstructive plastic surgery.

Dr. Linder's commentary:

Recently, the U.S. Preventive Services Task Force has changed the screening mammography schedule for women in the United States. The recommendation was to do yearly mammograms only for women over 50.

This has become a very controversial subject. However, as a board certified plastic and reconstructive surgeon, a Diplomate of the American Board of Plastic Surgery, a Fellow of the American College of Surgeons and as a specialist in breast surgery, including breast augmentation, breast revision, breast lifts and breast reduction surgery, I strongly oppose this new change for several reasons.

First, breast cancer is one of the most common malignancies in women. Screening mammograms general are quite inexpensive, ranging between $80 and $150. This is a small price to pay to detect early pre-malignant or malignant cancers even in younger females in their 30s and 40s when malignancies tend to be more aggressive. Since one of eight and a half women will develop breast cancer, screening mammograms will save lives .

Secondly, I believe that all women at 40 years of age, regardless of family history, should have screening mammograms. Multiple studies have shown that mammograms at 40 years of age save lives. In fact, in my practice we have performed breast reconstruction operations for bilateral mastectomy patients in their late 20's and early 30's. If these patients had not had mammographies they would certainly be dead.

Victor G. Vogel, MD, MHS, FACP, national vice president for research at the American Cancer Society (ACS) in Atlanta, Georgia, has cited several lines of evidence which support the American Cancer Society's recommendation for screening mammographies for women between the age of 40 and 49.

Patients who undergo breast surgery, including implants, breast reductions and breast lifts should undergo preoperative diagnostic and screening mammography at age 35.

Therefore, for the above reasons, I will continue to recommend mammograms for all women at the age of 40, for any woman with a family history of breast cancer and women who undergo any type of breast surgery at age 35.

- Robert Kotler, MD, FACS

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Is A Medical Spa The Right Place For Invasive Surgery?

2009-11-20T07:35:00.000-08:00

A recent article in The New York Times Style section relayed the unfortunate death of a young nurse as a result of a misguided liposuction procedure in a "medical spa".

Invariably, every year or so, a similar tragedy comes to awareness. Typically, a patient undergoes a surgical procedure in an environment which does not meet the minimum safety standards.

Often patients underestimate the complexity and potential hazards of any surgical procedure regardless of how anatomically superficial it may be. Yes, liposuction involves only suctioning that layer of fat directly under the skin. And, yes, no major body cavity, such as the chest or abdomen is entered.

In the Florida case discussed in the New York Times, the liposuction was performed and local anesthesia was used. Even just local anesthesia has hazards. Unlike a dentist's office where local anesthesia is used in very small volumes, perhaps just several cc's, liposuction usually calls for large volumes of the anesthetic solution with added epinephrine to increase the duration of the anesthetic and to reduce tissue bleeding. But both types of medications, local anesthetics and the epinephrine class of drugs, can have an effect on the heart. Should the medication be absorbed too quickly or should too-strong a concentration be formulated, then the risk of untoward reaction increases.

There are two issues which every patient needs to understand with respect to surgery. First, there is always the potential for problems and the best insurance against having a catastrophic outcome is to have the procedure performed in a fully equipped surgical facility. A medical spa is not a bona fide surgical facility.

The facility should be either licensed by the state, accredited by the United States Department of Health and Human Services (accredits facilities to qualify for Medicare payments) , or by one of three well-known private accrediting organizations: Accreditation Association for Ambulatory Health Care (AAAHC) , the American Association for Accreditation of Ambulatory Surgical Facilities(AAAASF) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO), which accredits hospitals. Fully accredited, licensed facilities must have the same resuscitative equipment, emergency drugs and supplies and infection control standards as a hospital. They have passed the test.

Finally, I would never have any type of significant surgical procedure, whether done under local anesthesia or with local anesthesia with sedation or general anesthesia, without the services of a board certified physician anesthesiologist. Certified Registered Nurse Anesthetists (CRNAs) may be appropriate in some situations. In any event, you want an anesthesia specialist at the controls. Such specialists are another "insurance policy" for you because they will not work in a substandard facility.

Yes, there is some added cost to have an anesthesia specialist on your side and at your side. But, the incremental cost in having such specialist is very reasonable. After all, what is your comfort, safety - and even your life - worth?

- Robert Kotler, MD, FACS

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Dr. Oz Discusses Massive Weight Loss and the Necessary Plastic Surgery "Finishing Touches"

2009-11-10T16:11:00.000-08:00

On Tuesday, November 3, 2009, Mehmet Oz, MD, Columbia Medical School professor, OPRAH alumnus and now the host of his own highly-rated daytime talk show, The Dr. Oz Show, had a fascinating and educational segment.

Becky Keenan, a traveling carnival owner, had long been plagued by obesity. It seemed that regardless of what she tried, success eluded her. Finally, she had a stomach bypass operation which was very successful. Her weight dropped 140 pounds!

That was the good news. The bad news was that the skin that had previously draped a rotund trunk was now excessive and hanging. Plus, her breasts had elongated downward and were no longer appropriately sized or shaped for her slimmer body. She still had not reached the finish line.

Becky sought the services of our colleague Stuart Linder, MD, of Beverly Hills. Dr. Linder meets my definition of a superspecialist because he limits his plastic surgery to the trunk and breasts. He does no facial work. Only breast surgery - augmentation, lifting or reduction. Plus tummy tucks and liposuction. He is at the forefront of a positive trend by which practitioners narrowly focus their practice.

For Becky, Dr. Linder performed breast lift and reduction, plus lifting and removing the apron of hanging abdominal skin. We viewers saw photo results at one week which were very impressive. Natural. Perfectly proportional.

Using very clever graphics and demonstration tools, Doctors Oz and Linder explained why the tissues of a once-plump body lose their elasticity.

As Dr. Linder pointed out, this is reconstructive plastic surgery at its best. It brought a happy ending to a long story of personal dissatisfaction. The segment was a tribute to one woman's determination and persistence to improve her life.

The segment can be viewed on the Dr. Oz Show's website.

- Robert Kotler, MD, FACS

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Overview of the Recent American Society of Plastic Surgeons' Annual Meeting

2009-11-04T09:13:00.000-08:00

I did not attend, but I spoke with colleagues who gave me a capsule summary of the meeting including substance of the presentation and even the mood and spirit of the attendees. Also, I reviewed the Society's website for its synopses of the presented papers and discussions.

My friends reported good attendance although there is concern by plastic surgeons regarding the difficulties of a slow economy. Practices that are primarily elective cosmetic plastic surgery, particularly in some areas of the country, are suffering greatly. And for those practices that are still heavily engaged in reconstructive plastic surgery, which relies on health insurance payments, there is the uncertainty of how the new health care legislation, being bandied about in Congress, will effect practitioners.

Apropos of the concerns of reconstructive plastic surgeons, it is important that the public be reminded that plastic surgery has both reconstructive and cosmetic surgery arms.

There were awards given to patients who underwent reconstructive plastic surgery and "triumphed over adversity". An Iraqi citizen injured in the war there, a breast reconstructive patient, a patient with port-wine stain, as well as a patient with a difficult skin cancer on the nose were identified and their stories told.

The Society's underlying message is that plastic surgery is not exclusively about beautification, celebrities, and high-profile public figures. Every day, plastic surgeons are in the trenches performing necessary repairs wrought by injury, accidents, cancer, and birth deformities.

It is very important that plastic surgeons continue to have training in these areas to help relieve misery and suffering.

There were a variety of subjects discussed that will be of interest to the public.

During the Hot Topics session, there was discussion about Lipodissolve, a fat-melting formula that has been controversial heretofore. Traditionally, this has been suspect with respect to its ability to essentially melt away the fat deposits which have been heretofore handily dealt with by liposuction. The science has been reviewed and there may be, in fact, some strong potential for utilization of this technology. Stay tuned, we need more information. Another important Hot Topics discussion that took place which I will discuss shortly, was the role of fat injections to enhance the breast size as a possible alternative to breast implant placement.

GENES ARE STILL KING – OR QUEEN

How often I have heard patients sit in my consultation room and say, "I'm starting to look like my mother. And I don't like it."

At the meeting, there was a discussion regarding the prediction of the signs of aging in specific facial areas. It was interesting to recognize that the essence of the study was what we have all known intuitively: as your mother (or your father) ages, so will you. If your mother's sags, bags and wrinkles first manifested in the eye area, the advice is "keep an eye open" on your eye area. You have a peek into the future.

However, I am pleased to say that today cosmetic plastic surgeons have more tools in our toolbox than ever. While we can't stop it from ticking, we turn back the clock daily. There is Dysport and Botox Cosmetic to ease the wrinkles caused by muscle contraction, particularly between the eyebrows, forehead and around the eyes. There are the great and reliable fillers: Restylane and Juvederm. And, now Sculptra, longer lasting. To bring back the skin's more youthful appearance, the venerable work-horses: chemical skin peels, lasers, micro-dermabrasion and Retin-A and bleach creams. Yes, your body is programmed to age as your ancestors have but today there is help out there.

LIFTING BREASTS AND FILLING CLEAVAGES WITHOUT SURGERY?

My practice is limited to cosmetic surgery of the face and neck and so when it comes to breasts and body issues, I am an observer and reporter rather than an expert.

But I do understand the chemistry of products that are being used and I, of course, understand the anatomy.

There was a report and discussion about using Botox Cosmetic as a possible breast lifter. The anatomic basis of that would be that if the pectoralis minor chest muscle, one of the "pecs", had its function neutralized by the muscle paralysant, then there would be unopposed lifting of the breast by other muscles in the area. Now, of course, this is not permanent. Muscle paralysants tend to last between four to six months. And this would be an off-label use.

The doctors reporting on this possible new role for Botox Cosmetic - and perhaps the newer Dysport - suggest that the procedure would be ideal for younger women between 30 and 50 with relatively small cup sizes.

There were some naysayers who pointed out that it is unlikely that patients would have satisfaction from a technique that may not be any better than better posture. And, that in fact, the volume of the medication, since the aim is to paralyze a large muscle, could be significant and that would translate into perhaps too high a dollar cost to be practical. There were other medical issues raised including some increased risk since perhaps the drug could spread to muscles participating in breathing.

I consider papers like this to be stimulating and most valuable by furthering thought and research. This technique will not replace surgical breast lifts in the near future until more information has been gained.

FAT INJECTIONS INTO THE BREAST RETURNS AGAIN FOR CONSIDERATION

Fat injections into the breasts as a means of enlarging the breasts is not a new concept. It has been performed in other countries and has its champions. One paper reported a study of 46 women who received fat injections into the breasts after a breast lift. Apparently they demonstrated "improvements in the size and shape of the breasts after one year." It is important to follow patients for many months and ideally many years to see what the effect is since transferred fat has an uncertain fate. It could shrink, it can form some firm nodules and all this would have long-term implications.

Understand that there has always been a concern about whether or not fat transfer might compromise diagnosis of breast cancer. Certainly women would not want to decrease the likelihood that an early breast cancer could be discovered because there was concealment by transplanted fat. Apparently, the authors argued that "It's easier to see breast tissue in breasts that were augmented with fat than implants." Again, I am not an expert and I believe that we need much more time to study the issue. There needs to be more research studies. Achieving a major increase in size would require large volumes of fat. And, typically, the greater the volume of tissue transplanted, the more uncertain the fate of the transplants.

One of the doctors at the meeting commented that the amount of augmentation was an increase of only 212 cc which is 14 tablespoons of liquid. It may not be enough to satisfy most patients.

— Robert Kotler, MD, FACS

Cosmetic Plastic Surgery Ads: Good or Bad?

2009-11-02T07:35:00.000-08:00

We live in a world inundated by advertising. Since 1985, when advertising by professionals was given a green light by the judicial system, there has been advertising by lawyers, physicians and dentists in magazines, newspapers, on the radio and on television.

Actually, I have nothing against advertising because through advertising we can become wiser consumers. Good quality advertising gives us information that is helpful. But there is always the issue of misleading advertising which exists in all arenas of commerce. There will always be advertisements promising "Six-pack abs in two weeks," or "Lose 7 pounds in 7 days" on a crash weight loss program. Human beings, unfortunately, are often tempted by such unrealistic promises.

Likewise, in the world of cosmetic plastic surgery, I marvel at the unrealistic and often absurd claims and promises being made in both text and photographs.

In the last few years, there has been a heavy pitch made towards convincing people that "One-hour Facelifts" or a "Lunchtime Lift" is somehow going to magically deliver the same result as a well-crafted, meticulous five-hour surgical procedure. It can't be.

When deceptive photographs are employed, such as those where the wrinkles on the neck have disappeared as the result of a one-hour noon-time procedure, then you know that the prospective patient is being led down a dark pathway. No procedure - surgical or otherwise - is capable of completely erasing the wrinkles on the neck. Such ads play on patient wishful thinking.

For a while we had a run of quick fixes promised by "thread lifts," another less-than-an-hour procedure whereby fishing line-type stitches were placed under the skin, hitched to taut tissue in the temple with the goal of pulling up the neck and jaw line. It was absurd that such an operation would have longevity. Typically, in the world of surgery, the shorter the operation, the less the duration of the procedure. Indeed that was the case with this quickie face lift. In fact, there were even some complications because the skin does not do well when it is pulled without being freed up from its underlying attachments and repositioned.

As you look at advertising, ask yourself, "Is it possible that this is too good to be true?" Are the photos results - always depicted as a monumental improvement - inconsistent with a very low- cost and brief operation? Might it be that the photos are "touched-up" a bit?

Can one really have such a procedure, awake, with just local anesthesia and not have the services of an anesthesia specialist? As a visit to the dentist? Will this low-priced operation really give value? Value is defined as great benefit for a reasonable cost. A low-cost operation with either an inadequate or short-term result can never be a value.

In cosmetic plastic surgery as in life, there are very rarely big bargains. Do your homework. Don't make a mistake. Sometimes, a bargain can be very expensive.

- Robert Kotler, MD, FACS

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Talent, Experience and Dedication

2009-10-30T06:35:00.000-07:00

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?

2009-10-26T07:33:00.000-07:00

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!

2009-10-20T16:31:00.000-07:00

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

2009-10-09T06:11:00.000-07:00

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

Related Topics:

Different Fillers, Different Missions

2009-10-05T06:11:00.000-07:00

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

Related Topics:

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How Rhinoplasty Improves Your Smile

2009-10-02T06:10:00.000-07:00

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:

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Open Rhinoplasty vs. Closed Rhinoplasty

2009-09-30T06:10:00.000-07:00

Open rhinoplasty vs. closed rhinoplasty - there is a lot of bandying about of these terms by perspective patients. The "open rhinoplasty" describes an operative technique by which an external incision is made to gain access to the interior of the nose. This is in distinction to the "closed rhinoplasty" in which all incisions are made entirely within the nasal interior.

There are disciples, defendants and proponents of each within the nasal cosmetic plastic surgery community. It is a matter of the surgeon's preference as to which technique he is most comfortable with for a given case. The nasal cosmetic surgery super-specialist will be adept at both techniques. He or she will choose a technique that seems appropriate for the case at hand.

Generally, younger surgeons appear to prefer the open technique because that is the way they have been trained. In the last twenty years that technique gained popularity, initially as a teaching device since it is easier for a student or trainee to see the nasal contour through the open approach. The more veteran nasal cosmetic surgeons were trained using the closed technique and generally were comfortable with it. But, it is not difficult for the highly experienced and specialized nasal surgeon to master the open rhinoplasty technique.

If you have never seen a photograph or a sketch of the open rhinoplasty, understand that using a horizontal incision connecting the two nostrils just below the tip, the skin is lifted as one would lift the hood of a car. Then one gets access to see the tip cartilages and when a certain instrument is placed through that opening, one can even see up to the bridge of the nose. No question that, for the novice and inexperienced surgeon or occasional rhinoplasty surgeon, this exposure is advantageous.

The open rhinoplasty tradeoff is the external scar which, while generally heals well, in some patients doesn't. Also, there is the uncertainty of how much tightening or contracture could take place during the healing.

The closed rhinoplasty, done entirely within the nose, does take greater manual dexterity and the technical facility to perform an operation "through a keyhole". Experienced surgeons will tell you that their visualization is not impaired, and in fact, this approach of course has been used for nearly 100 years with great success.

Of ultimate importance is that the surgeon be comfortable with his or her favorite technique. If you have confidence in the surgeon, have confidence in his or her judgment. Most likely, you will also be comfortable with the results that the chosen technique delivers.

If you are concerned about the visibility of the open rhinoplasty's incision, ask to see many before and after open rhinoplasty photographs, particularly close-ups. Then, you can evaluate for yourself the visibility or lack of visibility of the external incision.

- Robert Kotler, MD, FACS

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