Is A Medical Spa The Right Place For Invasive Surgery?

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"

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

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?

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

Good in Airline Pilots and Cosmetic Plastic Surgeons

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

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

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

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

- Robert Kotler, MD, FACS


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

Frank Merenda /
CC BY-SA 2.0

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

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

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

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

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

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

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

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

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

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

-Robert Kotler, MD, FACS

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

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

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



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

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

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

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

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

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

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

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

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

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

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

- Robert Kotler, MD, FACS

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Report on the National Rhinoplasty Survey

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

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

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

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

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

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

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

- Robert Kotler, MD, FACS

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How Rhinoplasty Improves Your Smile

Photo Credit: Robert Kotler, MD, FACS

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

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

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

- Robert Kotler, MD, FACS

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Open Rhinoplasty vs. Closed Rhinoplasty

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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Fake Doctors and Real Doctors - Who is Injecting You?

Marie Claire Magazine Reports On Fake Doctors Taking Advantage of Patients

A recent special report in Marie Claire, a magazine that covers beauty and fashion quite nicely, reported several incidents of patients having injections and even surgical procedures by lay people - not licensed MD's. There have been reports of this in the past. The most common offenses tend to be patients having injections by these "pseudo-doctors" of non-medical grade silicone to pump up butts, breasts and other areas. It is hard to believe that people would submit to these treatments without understanding the background and qualifications of the person holding the syringe and needle, but it happens. The complications that were described were really quite bothersome and somehow it is hard for law enforcement to keep up with many of these self-styled practitioners who enter the United States, make a quick bundle of money and then leave a trail of unhappy, maimed and disfigured patients behind.

The "take away lesson" from this article is that one needs to do their homework. Here are some points that are worth remembering.

First, if a "doctor" doesn't have an office and sees you in your home or a friend's home, be suspicious that the "doctor" isn't. These bogus doctors are clever scam artists. Often they will even set up shop in a neighborhood or store front clinic but typically they are not allowed to practice in a bonafide medical facility such as a hospital or surgery center.

The best way to protect yourself is to ask for the doctor's resume, see what hospital and surgi-center staff he is on, and where he was educated and trained. It never hurts to check with the state medical board to see if indeed the person's name appears on the roster of licensed physicians.

In my book, The Essential Cosmetic Surgery Companion - Don't Consult a Cosmetic Surgeon without This Book!, I list the Federation of State Medical Boards of the United States website and phone number whereby you can make contact with the Medical Board in your state to verify credentials.

Finally, if the price seems too cheap, it probably is. Typically, these fakes attract patients not by qualification, experience or talent, but strictly because there are cheap. Caveat emptor! Buyer beware.

- Robert Kotler, MD, FACS

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Second Chances for Your Nose

The recent Elle Magazine had a feature article written by an experienced medical writer in which she discussed the issue of a second nose job - the so called "secondary rhinoplasty." The operation is always challenging and there are as many ways to do these operations as there are surgeons to perform them.

A few weeks ago, I participated in a seminar where several lecturers and panel discussions dealt with the issue of the "nose job re-do's." Everyone agrees that it is difficult, less predictable and this often translates to a lower level of patient satisfaction. There are procedures employed, including transplanting portions of rib, cartilage and even skull bone in order to reconstruct a nose that has not fared well with the first operation. This is why the procedure becomes unpredictable; the fate of these tissues when implanted into the nose is often unpredictable.

I was a bit disappointed that hardly any attention was given to the alternatives to grafting and transplanting tissues, that is the use of injectable "fillers." The mission is the same, to replace tissue that has been over sculpted, over-removed leaving dips, depressions, pinches and scooped out bridges. There is a place for these filling injections, some of which are permanent. I think patients owe it to themselves to check out all of the alternatives, surgical and nonsurgical before committing to a second major nasal reconstructive surgery.

-Robert Kotler, MD, FACS

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Today's Cosmetic Surgery Anesthesia Techniques

Photo: Robert Kotler, MD, FACS

Today's cosmetic anesthesia techniques and medications are extraordinary! The above photographs tell it all. The photo on the left taken at 2:26 pm shows a patient who has just completed a five-hour face and neck lift. The dressings are in place and the patient is about to be taken to the recovery room.

The second photo taken 3 minutes later at 2:29 pm shows the patient at her station in the recovery room fully responsive and when asked, "How are you feeling?" gives the thumbs up sign. That is a strong indication that the patient's faculties and brain function are intact.

The third photo is taken at 3:48 pm, approximately one and a half hours after the patient emerged from the anesthetic. She is alert, pleased, and particularly joyful because she had a history of having nausea and vomiting with a previous surgery. The patient will now be transported to a professional recovery facility where she will be observed overnight before she sees her surgeon the next day.

What is significant is that the patient had a particular cutting edge anesthesia technique. This technique is known as "PK" anesthesia. The "P" stands for propofol and the "K" stands for ketamine. Now propofol, which is the chemical name for the medication marked as Diprivan, has gotten a lot of attention recently because it has been implicated in the improper prescribing of medications for Michael Jackson. However, that should not at all dissuade anyone from availing themselves of this marvelous anesthetic which has a very quick onset and a very quick "wakeup." The "K" medication, ketamine, is a perfect partner for the propofol. The medication places the patient in a detached state whereby they are conscious but are totally isolated from any stimulation and, therefore, pain is not registered in the brain. While the patient is maintained on the propofol medication throughout the case, the ketamine is used only in anticipation of when local anesthesia is injected. Understand that the operation relies on local anesthesia - administered after the propofol-ketamine has been given intravenously - to render the tissues pain free.

It is remarkable that the patient required no oxygen, did not have a mask or tubes on her face or in her nose. She received no narcotics or any other medication that might be apt to make her nauseous and delay the emergence from anesthesia.

This technique has been popularized, worldwide, by anesthesiologist Barry Friedberg, MD. Dr. Friedberg, who is on the faculty of University of California, Irvine, is author of a very specialized medical textbook for cosmetic surgeons and anesthesiologists entitled, Anesthesia in Cosmetic Surgery.

- Robert Kotler, MD, FACS

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What Are Talent, Experience and Superspecialization Worth?

Recently, I reminded myself that one of the consistent business truths of life is that there are three variables in every purchase we make. The first is cost, the second is quality and the third is service.

What reminded me of this was when I visited my shoe repair shop with an urgent repair need. The shop has done very good work, and their turn-around time - the measure of service - is always short. However, their charges are higher than average. But, I don't mind paying the extra amount because I am getting quality and service.

The converse would be any low-priced service. If the price is low, then either the quality and/or service must also be low. What comes to mind is the typical fast food operation. The service is quick, the prices are low but the quality is not fantastic. So, you only get two out of three.

So how does this parallel the subject of talent, experience and superspecialization?

The most gifted cosmetic plastic surgeons with long experience and narrow focus - the superspecialists - generally deliver high-quality results. That is why they are at the top of the totem pole among other doctors. Typically, their offices render top service because they have developed efficiencies in both their surgery and practice operation. Rarely the lowest price.

You do get what you pay for.

- Robert Kotler, MD, FACS

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The Most Popular Questions Asked During a Cosmetic Surgery Consultation

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

1. Will this operation hurt?


2. What kind of anesthesia will be administered?


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


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


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


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


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


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


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

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

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

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

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

- Robert Kotler, MD, FACS

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