2009 March | Rhinoplasty Surgeon Beverly Hills Blog

Revision Rhinoplasties – Why Are There So Many?

Posted on March 30, 2009 by admin

Last Thursday I performed four nasal surgeries. Two of the four patients each had three previous rhinoplasty surgeries!

So why are we seeing so many redos? My sense and that of other experienced nasal surgeons is that the rate of revision rhinoplasty is too high. There is a small percentage of patients, who in the best of rhinoplasty surgeons’ hands will require touchups. However, my sense is that currently the percentage of poor results and dissatisfied patients is too high and would be unacceptable in other surgical specialties such as chest surgery, heart surgery or neurosurgery.

So what is it about cosmetic nasal surgery that lends itself to a high percentage of unsuccessful results? I believe the reasons are related to the surgeons performing the procedure. Today, because there are so many cosmetic and plastic surgery procedures that can be performed, often the training in each individual procedure during residency training is diluted. Too many residency graduates have had too little experience in cosmetic procedures and hardly any nasal cosmetic surgery training. Nasal surgery is unquestionably the most technically demanding and artistic of all the cosmetic procedures. It takes many cases performed under supervision of superior surgeon-teachers to deliver great results. If one cannot get that experience as a resident, the likelihood of practice success with those procedures, unless additional training is pursued, is dismal.

Dr. Kotler's patient - Revision Rhinoplasty before/after photo

Further, patients bear some responsibility. They practice poor decision-making. The best-informed patients, who did their homework, realize that this is the age of superspecialists. Surgeons who offer a multi-page menu of services are not likely to be superior at any of them. Conversely, those cosmetic and plastic surgeons who offer a very limited menu, who operated as a boutique, rather than a department store, are more likely to deliver better results and, therefore, have a lower dissatisfaction rate.

In my career, having performed over 4,000 nasal surgeries, including rhinoplasty septoplasty and turbinate surgeries to improve the airway, I have tackled some very difficult cases. I do not think I would feel comfortable managing them were it not for my long experience, my superior training at several universities and my preceptorships plus my experience as a military surgeon during the Vietnam War.

In my book, Secrets of a Beverly Hills Cosmetic Surgeon, I mention that great training and long experience plus superspecialization is the formula for success in nasal plastic and nasal cosmetic surgery.

Dissatisfied With Your Cosmetic Surgery

Posted on March 20, 2009 by admin

I am often asked by friends and family about “a friend who is unhappy with her cosmetic procedure done elsewhere.” My answer is that the patient should not despair. The patient has options. Most importantly, if the dissatisfaction is early in the post-operative period, most likely the situation will either improve with time or can be corrected.

I recommend that the patient re-visit with the operating surgeon and ask for an explanation as to why the difficulty arose and what the doctor recommends. Often, some simple treatments and time will cure the problem. The patient should not become irate or unhappy, nor should the doctor become discourteous and detached from the problem.

A second opinion is always wise, of course. But, before going for a second opinion, make sure that you will have at hand – when visiting the consulting doctor - a copy of your operative report, doctor’s notes and the photographic file, including the “before” photos. This will help the doctor understand “what you looked like before you started” and what the doctor did. Depending on the situation, it may also be helpful for the consulting doctor to speak with the original doctor. Professionalism dictates that your desires and aspirations are paramount.

[video]http://www.youtube.com/watch?v=5zeh2H1NqfI[/video]

If the second opinion doctor has an opinion that is different from your surgeon and you are not certain as to whose advice to follow, then a third opinion is appropriate.

Finally, remember that if time does not cure the problem, a minor touch-up may be all that is needed to render satisfaction.

Appearance and Job Prospects in a Tough Employment Market

Posted on March 13, 2009 by admin

A recent article in one of the major magazines, Marie Claire, was entitled “A Career Lift”. The author did a good job of making a case for why appearance is important and perhaps even more important in tough economic times.

They cited a survey by the American Academy of Facial Plastic and Reconstructive Surgery in which 78% of respondents indicated that “appearance is at least somewhat important in getting ahead at work”.

It has been appreciated that there is a direct relationship between one’s appearance and success in the world. It is accepted by psychologists that better looking people – fairly or unfairly – seem to fare better in life.

This is not to say that everyone needs to have a full face and neck lift, eyelid surgery or other procedures. My point is that often one’s appearance can be improved by chemical skin peeling to remove wrinkles or Restylane or Juvéderm injections to plump up some deep lines, or Botox to wash away forehead and eyebrow creases.

Combine some judicious skin care with these doctor-administered procedures with a bit of exercise, sound nutrition and weight stability and you have a good formula for looking your best.

Beverly Hills New Eyelash Enhancer Is The Real Deal

Posted on March 10, 2009 by admin

Recently, the FDA approved Latisse ® as a beauty treatment to darken, lengthen and thicken eyelashes. It is interesting to note that this effect was noticed as an unanticipated side effect of treatment with a parent drug for glaucoma.

I am rarely super enthusiastic about cosmetic products because frankly most of them do not work. But this does, otherwise it would not have received approval and I have spoke with ophthalmologists who had witnessed the accidental – yet beneficial – effect from the original glaucoma treatment medication.

According to Allergan, the company that produces the drug, patients can expect to see improvement in their lashes possibly as soon as eight weeks. Typically it takes about four months for the peak effect to take place.

The medication is applied with a little brush just as liquid eyeliner would be. It should be noted that if one stops using it, the lashes will revert to their pretreatment appearance.

The product is safe with very few possible side effects. It is important that patients who use extended wear contact lenses check with the prescribing physician.

We are keen on the medication and make it available to our patients by either prescription or dispensing directly in the office.

Why am I so excited about this? Because unlike most non-prescription cosmetics that make outlandish promises and never deliver, this prescription works!

There is no other product on the market that produces such sustaining results.

Many patients have long-asked for something that was the next best thing to permanent; this is it.

What We Learned From Focus Groups

Posted on March 6, 2009 by admin

In the past several months, we invited a cross section of Los Angeles ladies who spent some time with us in a focus group.

As I indicated in my best-selling book, SECRETS OF A BEVERLY HILLS COSMETIC SURGEON, we cosmetic surgeons need to understand the patients’ desires and need to study what they feel is important for their care and satisfaction.

We even asked about negative experiences that patiients have had with cosmetic surgery and also what are the informational sources that people rely on to get meaningful information as they begin their research to study cosmetic surgery.

Here is a synopsis of our findings:

Most people who had previous cosmetic surgery had a good experience. Those who did not have a good experience frequently cited the poor attitude and nonchalance of the office staff rather than dissatisfaction with the sugical procedure. I find that very interesting that one’s impressions and, therefore, referral potential can be based more on issues of personal service by practice personnel rather than the technical quality of the result.

We were interested in specific sources that people avail themselves of to learn about cosmetic procedures. One of the strongest sources for many of the respondents was that they would value a personal referral. They also place great importance on seeing the doctor’s before and after photo collection. For those who are internet savvy, they relied on web sites for information but recognized that many of the sites regurgitate the same stale messages.

We asked the importance of communication in understanding what the patient could expect. For that reason, computer imaging got very high scores. Most of the ladies were familiar with computer imaging although a relatively small proportion had it offered to them by surgeons they had consulted with.

Anesthesia issues came up. Patients seem to have an inappropriate and uninformed fear of general anesthesia. When we explained that many of the procedures are, in fact, done under heavy sedation with local anesthesia and yet are misinterpreted as general anesthesia by the patients, they were quite surprised. This is a tribute to the quality of business, a tribute to the talents of our anesthesiologist such that in fact they were able to avoid some of the down sides of general anesthesia and yet give the patient complete freedom from knowledge and discomfort during the procedure.

One service that few offices offer and yet that I have always felt was a very important component of a good consultation is for prospective patients to speak with or meet, in person, the patients in our practice who have had a procedure identical to that which we propose for the prospective patient. Those patients who have had previous procedures and had the opportunity to have such conversations and meetings were very rare but were highly valued.

In summary, we understand that the most beneficial consultation to a patient will be when the most services are offered to the patient as part of the consultation. This includes a consumer-oriented book that the doctor may have written, pamphlets and other handouts. Also highly ranked was computer imaging, the before and after photo collection and an opportunity to speak with previous patients.

Tameka Raymond (Usher’s Wife) Suffers Cosmetic Surgery Cardiac Arrest

Posted on March 2, 2009 by admin

Recently the newspapers were filled with whatever sketchy details were available. What we know is that Tameka Raymond went to Brazil to have liposuction two months after giving birth. Prior to the beginning of the actual surgery, Ms. Raymond suffered a cardiac arrest. She was placed in the Intensive Care Unit of the hospital in which she was to have the surgery and a day later was transferred to a major medical facility in Sao Paulo, Brazil.

There were reports that an American neurosurgeon was summoned and flew immediately to evaluate Ms. Raymond who had been placed in a state of “induced coma” to hopefully minimize brain and/or heart damage suffered when her heart stopped.

This story is illustrative of several issues that I feel are worth examining.

First, the wisdom of leaving the United States for an elective procedure. Traveling for cosmetic surgery may have some benefits but also carries some risks that do not exist “at home.” Now, we are not privy to Ms. Raymond’s reasons for traveling to Brazil to have the procedure. Did she go there because she felt that a surgical procedure or technique was available in Brazil but not available in the United States? It is true that Brazilian cosmetic surgeons are a bit edgier than their American counterparts. Generally, it seems to us that they are comfortable taking on more aggressive – and hence riskier – surgical procedures. That may be attractive to some Americans who cannot find a surgeon here willing to perform a more ambitious procedure that the patient seeks.

Presumably, Ms. Raymond was not looking for a bargain. But, some Americans leave the U.S. is to save money. Brazil may not be the least expensive venue for cosmetic surgery, but many countries offer services at considerably less cost. But some of these countries verge on membership in the third world and, therefore, there are health and safety issues which should be addressed. There are tradeoffs for saving money in all things in life.

There has been speculation that Ms. Raymond left the country to avoid the paparazzi. That may well be. However, most high profile or celebrity people having cosmetic surgery can – with proper planning with the office staff – avoid the paparazzi. It is beyond the scope of this essay to describe the execution of such tactics, but “paparazzi evasion “is executed on a daily basis in Beverly Hills.

So what might have happened and what lessons may be gleaned from Ms. Raymond’s experience? First, we do not know how well she was “worked up” before the procedure. It is very important that a reasonable yet thorough medical examination be done for any elective surgery.   There may be a consensus that eight weeks after delivery is not enough time for the body to reconstitute itself. Typically, body repair can take up to one hundred days after any operation or trauma. We do not know how the evaluation went but when in doubt, it is always better to postpone an elective procedure until well beyond a prior medical experience.
Recall that in 2004, when author of The First Wives Club, Olivia Goldsmith, died of an anesthetic mishap, prior to the start of a cosmetic procedure, The New York Times reported: The Health Department cited the hospital with failure to do thorough pre-operative work-up on Mrs. Goldsmith…… How well Ms. Raymond was evaluated by her doctor and another prior to scheduling the procedure is as yet unknown.
That leads us to the issue of anesthesia. Since what happened to Ms. Raymond was a direct consequence of anesthesia rather than surgery, the question is: “Who was at the controls?” Was it a doctor anesthesiologist whose credentials might match those of board certified American anesthesiologists? Was a nurse anesthetist in charge of anesthesia? Did the surgeon conduct the anesthetic? We do not know answers to that but we do know that the risk in elective surgery is from the anesthetic and not from the cutting and sewing.
As I discuss in my book, Secrets of a Beverly Hills Cosmetic Surgeon, when complications occur  far from our shores, the mechanics and logistics of getting American-level care can be challenging. It, of course, depends on where one is. Brazil is not an unsophisticated country. But obviously the family felt more comfortable having consultation by an American brain specialist. Thus, prospective foreign-surgery patients need to consider the “what if” of a possible complication and how it might be managed. Also how long the patient might have to stay in that foreign country, and at what cost of dollars, inconvenience, stress for the family.

Traveling for cosmetic surgery is most typically done to save money. Whether for that reason or others, the decision to leave the US for such care carries additional risks.