Facelift – What You Need to Know

Posted on June 25, 2010 by admin

A Facelift at an HMO?

Recently we had a lady present with evidence of rather poor cosmetic plastic surgery done at a local HMO. She had had a facelift which was not satisfactory. Then followed, by the same medical group, a second procedure. Then, some injections of fat into the neck – an unorthodox procedure – to correct some still persistent deformities.

I reviewed the medical records and was very dismayed at what I saw. It was obvious to me that the surgeons were not focused and dedicated cosmetic surgeons. Of course it makes sense. An HMO is a “Health Maintenance Organization”. It is in business to provide health services; medical care for illness. It is not a cosmetic surgery institute.

Why an HMO takes on cosmetic surgery or allows its surgeons to do that is a bit beyond me. It may not be the norm in the world of HMO’s; I really don’t know.

This is not to belittle the importance of HMO’s as members of our medical care delivery system. I interned at an HMO and found the medical care to be extremely good.

What I do know is that a prospective patient must ask themselves before committing to have procedures done by an organization whose focus and experience is not in the realm of cosmetic surgery, how well trained and experienced their surgeons are. If they are in fact dedicated to doing cosmetic surgery, why are they working at an HMO, whose mission is treating illness not beautification.

It took seven hours of work to repair the inadequacies and complications of the surgery done by the HMO surgeons. Luckily, the end result is quite excellent and the patient is ecstatic.

As the patient said to me, “I really don’t know why I had these procedures done at an HMO. I certainly should have known better!”

Amen.

Rhinoplasty Training and Specialization

Posted on June 24, 2010 by admin

“Dr. Kotler, You Really Are Old School!”

That is what a patient said to me after we performed rhinoplasty, or cosmetic nasal plastic surgery, upon her teenage daughter.

Perhaps what she saw as setting us apart was that in our practice, it is 24/7 coverage for the patient. Our patients receive my home phone and my cell phone numbers. They are free to call me at any time. If I am not out of town, I am on call 24/7 every day. Of course, when I am out of town I have coverage from not only our office staff but two doctors as backup.

Yes, we do practice the old fashioned way. We stay in close touch with our patients. We see them often after surgery to check and make sure all is going well; we don’t like surprises. And, Saturdays and Sundays are just another work day for us when patients need to be seen for either routine or special post-operative care.

The mother appreciated that we brought to the table many years of experience and a high degree of specialization in cosmetic facial surgery of the face and neck. Particularly in rhinoplasty, with over 4,000 nasal procedures having been performed. Such a track record comes with having been in the trenches of practice for many years and becoming a master surgeon, the highest accolade the world of surgeons can bestow.

Since I trained in the golden era of medical education, the 1960’s and 70’s, that should help one understand the value old school holds. In those grand days before teaching hospitals became weakened by all the changes in medical care delivery, we had terrific training and experience. The hours were long –but fascinating. We had demanding and strict teachers. That explains why it was expected of us to conduct ourselves in a manner that today is known as old school.

I am not sure what the new school is like, but I do know one thing, that the old school was the right school to attend. And, that, friends, is always appreciated by patients and their families.

Rhinoplasty For Men

Posted on June 18, 2010 by admin

Men’s Nose Jobs

I have been thinking a lot about men’s rhinoplasty or cosmetic plastic surgery of the nose, the last several days. In the last two days we performed nasal cosmetic and reconstructive surgery on two gentlemen.

The first was a middle-aged businessman who had difficulty breathing, but who also was motivated by the fact that he felt his “nose was growing”. The nose, in fact, doesn’t grow, but the tissues within the nose, the loosen, the tip drops and the nose appears more bulbous and longer. The gentleman’s motivation for that cosmetic enhancement was proper. Likewise, the desire to breathe was very reasonable and the patient’s deviated septum and enlarged turbinates were causing blockage such that snoring and poor sleep quality was the result. So it all made sense.

In the case of that middle-aged gentleman it was very important to fully understand the man’s wishes. He expressed on several consultation visits the need to have a natural looking nose that would not look artificial, “done” or drastically different from that which his face had carried for many years. A surgeon needs to listen carefully to these words and understand the mission. Any miscommunication could result in an unsatisfactory result and an unhappy patient. That is not what a conscientious and competent cosmetic facial surgeon wants.

The second nasal case involved a young man who had had two prior nasal surgeries, one for breathing and one for appearance. The former, the nasal septoplasty, was accompanied by reduction of the turbinates. The turbinate reduction was quite satisfactory but the septum was still deviated to one side, meaning he had internal nasal blockage because of the shift of the septum which is the vertical partition that separates the two nasal passages. Those “ revision septoplasty operations are not easy because typically some of the cartilage has been taken out of the septum and there is quite a bit of scar tissue underneath the internal lining of the nose. It does call for considerable experience, expertise and judgment.

The young man’s other wish was to have his nose appear less long. Indeed the nose was too long for his face and, as he ages, the length would have only increased. Apparently the original operating surgeon did not heed the patient’s advice and the result did not match the patient’s wishes.

At this young man’s surgery, very conservative elevation of the nose was done such that it no longer looked too long as if it would touch his lip when he smiled. And indeed, regarding smile, part of the problem was that he had a very strong muscle which, upon smiling, would depress the tip of the nose further. The breathing problem was corrected by straightening the septum and some other relatively routine internal procedures, and we were able to lift the nose off the lip, release the muscle which had been exerting its downward force on the lip and give him a natural looking nose which was not radically different from what he had before. But certainly better and in keeping with his desires.

It is very important for surgeons to listen to patients, to get a good sense of what they want. Also, in my opinion, it’s important have computer imaging available so that the perspective patients can see the predicted results of the procedure that the surgeon deems achievable and reasonable. A meeting of the minds should take place at the computer imaging session such that the patient and the doctor are on the same page based on that computer visualization of the end result of the cosmetic rhinoplasty.

We have used computer imaging in our practice since 1989. It is helpful and important to patients who need the comfort of seeing the projected outcome.

Using Skype for Cosmetic Surgery Consultations

Posted on June 11, 2010 by admin

Our Faith In Skype –

Consulting Affirmed

We have been big fans of consulting with patients long distance by using Skype. We have used it to consult with patients both in the United States and overseas. It gives us a chance to get a good sense of the patient’s request and problem if a new patient and also the ability to follow the progress of our postoperative patients.

There was an article in The New York Times on Sunday, May 30, entitled, The Doctor Will See You Now, Please Log On.

The article discussed the advances in technology and the increasing popularity of what has now been labeled “telemedicine.” The paper noted “spurred by health care trends and technological advances, telemedicine is growing into a mainstream industry.”

The article further stated “the technology has improved to the point where the experience of both the doctor and the patient are close to the same as in-person visits and in some cases better.”

I don’t agree with that statement because nothing beats a face-to-face meeting. However, we have to accept some imperfections in indirect communication. If we do not have the chance to see the patient in the office to look, to feel and evaluate, certainly consultation via Skype is a second best.

The article brought to my mind the fact that three days prior to this article, on Thursday, May 27, we operated on a 15-year-old girl who came to us from Texas to have both rhinoplasty and functional nasal surgery including septoplasty and turbinate resection. She also had placement of our post-operative nasal airway system to ensure breathing post-operatively.

We had originally been contacted by the patient after she had visited our web site to learn more about the nasal surgery. Following exchange of e-mails and phone conversations with our patient consultant, a Skype consultation was arranged. We had a good session the teen and her mother. We also had the opportunity to provide, for the patient’s benefit, computer imaging to show the predicted result of the surgery since the patient was able to supply us with digital front and profile photos.

That Skype consultation went into very deep detail as much as we would in the office with regard to the patient history including the difficulty breathing, clogged ears and some of the medical issues. We always ask about allergies, medications being taken, past history, so there is no short-cutting in the history and there is no reason not to address all issues past and present. The only faculty we don’t have available is touch.

Based on our long-distance consultation, computer imaging and Skype session, the patient came here prepared for surgery. Her history and physical and all laboratories were done at home in Texas and she arrived the day before.

At the “pre-surgery” visit, I had a chance to examine the patient’s nasal airway and affirm that which I had learned from the history and also from reviewing the x-rays that were taken of the nasal passages and sinuses in her home town. I also took further digital photographs that I could use to study before surgery and all questions were answered that had been posed by the patient and her mother.

As is routine for all our patients, whether local or national or international, all arrangements had been made for the patient to have her post-operative medications filled by our local pharmacy. The patient’s post-operative kit was at hand so that she could start some of the medications that night prior to surgery. The office had also assisted the patient’s mom in making hotel arrangements.

Certainly, technology is giving us a leg up on better pre and post-operative care and allows patients from afar to make contact with us and have meaningful conversations and consultations from nearly anywhere in the world.

A Cosmetic Surgeon's Thoughts on Memorial Day

Posted on June 11, 2010 by admin

Thoughts on Memorial Day From a Former Military Surgeon

As is my personal tradition for many years, I don my Army uniform and join the public and past and present members of the military at the traditional memorial services at the Los Angeles National Cemetery here in West Los Angeles adjacent to the Westwood UCLA campus. The cemetery, as nearly all military cemeteries are, has a certain beauty and holiness about it. 85,000 military are buried here cemetery.

As we listen to speeches and commemorations from soldiers past and present and our civilian leaders including Governor Schwarzenegger, and Los Angeles Mayor Antonio Villaraigosa, there is plenty of time for thought. I think particularly about some of the advances in medical care that have followed war-time experience.

Today, in 2010, surgery upon blood vessels, so-called “vascular surgery,” is very common. Blood vessels are rerouted, bypassed, all of which allows injured patients whether in the civilian or military sector often to still have functioning arms and legs. During the civil war, the most common operation was amputation. Nearly every injury to the extremities was addressed by amputation. There was no attempt at repair and the surgical world at that time being unsophisticated did not have the ability to save limbs which typically are lost because of damage to the major veins and arteries.

Even in World War I and World War II, not much progress had been made in salvaging severely damaged arms and legs. But during the Vietnam War, particularly due to the activities of one surgeon, Colonel Norman Rich, battlefield and military hospital advances were rapid such that techniques were used to repair and bypass and replace injured blood vessels such that the amputation rate was much lower.

Yes, wars are horrible. Nonetheless, a positive by-product of recent wars has been enormous advances in battlefield medical care, including rapid evacuation of the wounded. Today, 99% of all injured soldiers who reach a battlefield medical facility will survive their wounds. An amazing accomplishment!

Robert Kotler, MD, FACS
Former Major, Medical Corps, U.S. Army

Plastic Surgery Residencies

Posted on June 3, 2010 by admin

What’s Wrong With Today’s Plastic Surgery Residencies?

Cosmetic plastic surgery has a dilemma in that most of the training programs in plastic surgery are not spending enough time in the training and maturation of competent cosmetic surgeons.

Unfortunately, almost all the residencies of plastic surgery are conducted at universities where the emphasis is on reconstructive – not cosmetic – surgery. University budgets are not adequate to support residency training for procedures where there is no insurance reimbursement. And patients are reluctant to go to universities because they understand that surgeries are done by surgeons -in -training and not by experienced practitioners.

The answer is that doctors who wish to practice cosmetic surgery must take additional training after the residencies and even after achieving board certification. Because most of the residencies emphasize the reconstructive arm of cosmetic surgery and not the cosmetic arm of cosmetic surgery, it behooves those who wish to practice solely cosmetic surgery to take additional training in the form of a fellowship which is an apprenticeship beside an experienced practitioner.

A wonderful way to learn and well worth the extra time and effort.

Cosmetic Plastic Surgery

Posted on June 3, 2010 by admin

Four Ways to Take the Guess Work out of Cosmetic Plastic Surgery

Sometimes it is difficult for patients to envision or visualize the results of Restylane, Perlane, Juvederm, Sculptra or Radiesse fillers about the face. Other patients may also not appreciate how a poorly performed rhinoplasty or “nose job” can be improved by filling injections. Even those with a receding chin have trouble visualizing what the result might be.

One way to “try before you buy” is to have a “demo” test. This “no-risk” demonstration is achieved by injecting sterile saline (salt water, the same liquid that is used as intravenous fluid) to display the results of the proposed long-lasting filling injection or even some surgeries.

The sterile saline can be injected into the fold of the deep nasolabial creases around the mouth to show the effect of the common fillers. It can be injected into the tissues of the chin to show how the profile would look if the chin were augmented, the so-called “chin augmentation.” It can be injected into the nose to show how one who has a very low, scooped out or over-pinched result from cosmetic nasal surgery would look.

The sterile saline “test drive,” if you will, can be rendered almost painless by the application of a topical anesthetic about one half hour prior. The results will last for one to two hours. Photographs can be taken before and after for documentation so that the patient can study the improvement before making a commitment to having natural fillers.

It makes sense doesn’t it?