Category Archives: Beverly Hills

Cosmetic Surgery, Why Wait?

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 “Why Did I Wait So Long?”

We always hear that from patients who delayed having surgery to improve their breathing.

Those patients with blocked noses or a nose that is not attractive typically started out early in life with that problem.  It is not a matter of aging.

Patients with deviated septums, uncorrected nasal fractures and enlarged turbinates due to allergies, typically are plagued with these conditions for many, many years before they start to do something. For some, the nasal blockage pre-disposes them to sinus infections.

Frankly, some of our brethren in other medical specialties do not recognize the architectural problem soon enough.  A good family practitioner or internist should be able to evaluate the inside of the nose to see if, in fact, there is a deviated septum and/or enlarged turbinates or crookedness of the entire nose which could be contributing to the blockage causing the misery that follows a cold or allergy attack.

It is not normal to not be able to breathe. Period.

Our happiest patients are patients where we correct the deviated septum, trim the turbinates and also do rhinoplasty to improve their appearance because in one two-hour session, they have not bettered their quality of life for the rest of their life.  It is so great to do teenagers with these problems because they will not be plagued being self-conscious about their appearance or suffer from blocked noses for another 60, 70 or 80 years. 

Recently one of our patients came and uttered that often-heard remark, “Why did I wait so long?”   Well one reason was he really was afraid to have it done because he was concerned about what he heard from other people who have had the operation.  There is a little bit of “bad press” going on out there, not because of the operation itself nor the results.  It is because the pos-toperative period has been uniformly unpopular since the surgeons have had to put packing of some form inside the nose.  Unless some provision is made for providing an airway through the nose, packing equals total nasal blockage. Not fun for the patient.

Packing is placed by surgeons performing rhinoplasty, correction of deviated septum, turbinate surgery and sinus surgery because it is important to help control bleeding following the operation.  Also, today’s packings which may be cotton-like, gauze-like or even a thick liquid gel, have antibiotics and even other ingredients such as bioengineered healing factors which hasten the healing and reduce the chance of infection.

So the packing, of whatever substance or material, is important.  But the patient’s misery of having a blocked nose for up to five days has long been underestimated by head and neck surgeons, ear, nose and throat surgeons, facial plastic surgeons and plastic surgeons.

One patient likened it to having “to walk around with a clothespin on my nose for five days.”  Another claimed, “I felt I was drowning.”  Patients get anxious, somewhat depressed and complain about the dry mouth and soreness of the throat. 

I have been involved personally in trying to better that situation for over three years.  Working at my “work bench,” I developed a soft plastic airway tube that the surgeon seats onto the floor of the nose and allows the patient to breathe very well after surgery despite the remaining nasal cavity being packed with the usual packing devices or materials.

We have had over 93 patients in our clinical research study undergo the routine surgeries and yet have the benefit of the nasal airway in place.  It wins high grades with 95% of the patients endorsing it.

We always try to do better.  Science never sleeps.  Progress goes on and our aim is to have patients more satisfied, more comfortable under the safest of surgical circumstances.

Revision Nasal Surgery

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Discussion of Revision Nasal Surgery

Nasal surgery is an art based on a science, but it is not magic.  As a surgeon, I can only work with what I have been given with respect to tissue characteristics following previous surgery.  The aim is often to improve both appearance and function, and; therefore, there is a challenge introduced when the operation is not the first visit to the tissue.

I want to urge a sense of realism on the part of what the expectations could be.  We always attempt to yield the very best result possible with respect to both breathing and appearance.  So, while maximum improvement is always the surgical goal, and is, indeed, very often attainable, improvement is not the same as perfection.  The reasonable aim is to deliver a nose that is natural in appearance and functions well.

Please understand that in contrast with both primary nasal surgery, or original nasal surgery, the final result takes a bit longer to present itself.  Not that you will look terrible.  It is just that the swelling, although not necessarily highly visible to anyone, just takes a bit longer to subside.  Some noses look very good in 3-4 weeks, and others need more time for maturation.  As one patient said, “I guess it’s sort of like fine wine.  It takes a little time to get to its best.” That is true. 

After Surgery

After the surgical session, it may be important to undergo minor improvements at the postoperative office visits.  We have long experience in the use of medications that can be used to “smooth out” any irregularities or imperfections.  Another class of medication is used to help reduce internal scar tissue and unwelcomed thickening of the skin.  These are the medications that are called “shrinkers.” 

You and I make the decisions, jointly, before committing to any of these treatments.

For more information, please consult our website dedicated to revision nasal surgery at http://www.revisionrhinoplastydoctor.com/.

Fractional Laser

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Fractional Laser – How Good Is It?  

I’ve written before about laser treatments to improve skin quality.  The aim is to make the skin smoother, less wrinkled, and free of age spots, brown spots, and even some tiny spider veins, all of which contribute to an aged look.

We’ve had our ups and downs with the laser treatments since they were first introduced in the mid-90s.   The full-strength CO2 laser was difficult to manage and too many people had complications from over-treatment.  Other variations of laser technology followed. 

We’ve been carefully watching the fractionated laser.  It had some good common sense and science behind it.  Instead of the entire skin surface being treated by the invisible beam of energy, which essentially destroys the outer skin layers and promotes regrowth of new skin, the fractionated laser’s computerized handpiece lays down a series of dots in a grid-like manner.  Each dot represents an area of skin treatment.  Between the dots, the skin is untreated.  What that allows is a certain level of safety and rapid healing.  Now it is not likely one treatment can do the job.  It may take several, separated by many months, but I think we’re on the right track because the most important thing is avoiding complications. 

The question that many of us have is whether or not such fractionated lasers can make a difference in skin tightness, because it’s in the neck where our greatest challenges have been.  The neck takes the punishment from aging and the sun even more than the face because the neck skin is thinner, and it provides a riskier environment for rejuvenation because of that differential thickness. 

We’re watching very carefully to see how much rejuvenation these techniques can accomplish.  So far I’m happy with the results of the fractionated CO2 laser with respect to lightening the skin and flushing out all the pigmentary changes.  The skin is smoother also.  But how much actual tightening we can get, we’re not yet certain of.  However, we must plod along slowly so that we don’t regret our over-zealous desires to achieve perfection. 

Appropriate Age For Cosmetic Surgery

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Cosmetic Surgery For An 11-Year-Old?

Recently on the Fox News channel was one of their occasional investigative reporting series entitled “From the Fox Files.”  This project was called “Operation Teen.”

The reporter and producer called the office of a non-board certified plastic surgeon in a large metropolitan city in the south and made an appointment ostensibly for their 11-year-old child.  All this was somewhat of a ruse:  the point of the consultation was to determine what the doctor’s attitude and disposition would be with respect to the requested cosmetic surgery for an 11-year old.

The 11-year-old patient said that she wanted a chin augmentation, nasal cosmetic surgery and lip enhancement. 

With hidden cameras, the child and ostensibly the mother (in reality, the segment producer), came to the office and first visited with the doctor’s wife who is the “consultant”.  The consultant spent much more time with the patient than the doctor would subsequently.  The consultant recommended that indeed the patient have a chin implant and nose surgery and lip augmentation and said that she would “take care of everything”. 

Then, the “patient” and “mother” were escorted in to see the doctor.  His examination took 52 seconds, according to the voiceover.  He said, “Yes,” and noted that she would be scheduled for surgery the next day.  Interestingly, the program did not raise this issue but I was shocked that there were no provisions made for this patient to have a pre-operative history and physical and appropriate laboratory testing. 

The doctor’s wife had given patient and mother the quotation and all was seemingly well. 

The next day, the “patient” and “mother” plus the segment’s reporter presented themselves at the appointed time for surgery and then revealed to the doctor who they were and asked how and why he could possibly make these recommendations for an 11-year-old. Frankly, it was one of the saddest and poorest commentaries on professional conduct I have ever seen as the doctor tried to weasel out of having blessed the surgical undertaking the day before.  On this visit under tough questioning, he attempted to back pedal in saying something to the effect of “. . . well, we really make the final decision right before surgery.”

What a poor quality professional this doctor was. 

I thought it important to share this with you because, unfortunately, particularly because of the changes in the health care delivery system, many doctors are migrating into cosmetic surgery who neither have the training and background nor the proper ethics.  I am not happy about this; the medical profession at large is not happy with this but we have no control over how an individual doctor conducts his practice and how he may or may not breach the high standards we would like to see in force.

Mid Facelift

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The Mid-Face Lift Revisited

For the last 10 years or so, there was a lot of attention to the “mid-face lift”.  This was an operation that was expected to pull up the cheeks and help flatten the deep nasolabial creases which run between the base of the nose and the corner of the lower lip.  Frankly, I never saw the value of the operation. 

It is very difficult to improve that nasolabial crease by trying to reposition or pull the skin or other tissue through incisions in the hairline or in front of the ear. Typically, the face just looks “pulled”, and that is difficult to correct.  In my opinion, there have been better ways to deal with the nasolabial crease, including filling injections.  For some people, it is even improved with a deep chemical skin peel when the skin is extremely wrinkled and has lost its elasticity.  Sometimes laser treatments can be successful also.

The recognition is that the mid-face lift has not been successful enough to be considered a first-line treatment, and this parallels the rise in popularity of fillers, because fillers are doing a good job in the nasolabial creases. Some of the newer filling agents will continue to extend our talents in this direction.

The most thoughtful surgeons know when surgery is best but also when a non-surgical treatment will do the job. 

Cosmetic Surgery Anesthesiologist

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The Last Thing To Bargain About Should Be The Services of a Doctor Anesthesiologist

Today, anesthesia is safer than ever.  The reason is giant strides towards patient safety and comfort achieved by the specialty of anesthesiology. 

Several patients have asked me whether it is necessary to have a cosmetic surgery anesthesia specialist.  They ask, “Is it not possible to do the procedure under local anesthesia, without an anesthesiologist?”  I think this question is being posed because there are some marketing companies that promote “lunchtime” or “one-hour” or “quick” facelifts, whose patients do not have the benefit of an anesthesiologist. 

Not having that “second doctor” in the operating room is one of the most foolish decisions a patient can  make. For cosmetic surgery - or any surgery.  Why wouldn’t you have a specialist whose entire work is devoted to patient comfort and safety?  Is anything more important than either for you?  Today’s anesthesia is so safe that, in fact, you’re safer in a certified outpatient surgery center or hospital, with a doctor anesthesiologist at your side, than you are on the freeway or road you took to get to the surgery center! 

Finally, if people are attracted to a program that does not include an anesthesiologist within the package of services, consider that the anesthesiologist’s fee typically is no more than 10% of the total outlay for all services, including the surgeon’s fee, outpatient surgery center or hospital, postoperative medications, and postoperative recovery facility. 

It’s a false bargain to try to save money when your very life is on the line. 

How Patients Teach Cosmetic Surgeons

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“Patients Are Our Teaches, Guides, And The Inspiration For All We Do”

That reminder came from one of the speakers at a weekend seminar I attended at Cedars-Sinai Medical Center.  The presentation was about the face transplant done at the Cleveland Clinic last year.  It was quite an impressive presentation, and frankly all in the audience were wowed by the success of that operation.  And that was a tribute to the doctors who spent years planning and thinking about how significant portions of the face, when injured or destroyed, could be replaced by a transplant from a corpse. 

When doctors take on a highly experimental and perhaps unpredictable procedure, fraught with all kinds of risks and hazards, including rejection of the facial tissue by the recipient, they must do so with the strong support and will of the patient.

In reality, patients are, in such circumstances, our teachers. They are inspiring us to do what they themselves cannot do.  Remember, only a physician can do the surgery and preside over the healing.  The patient gives up certain autonomy when asking a physician to help them.

We physicians must never forget the great and unique trust that is placed in our hearts and our hands by our patients. 

Cosmetic Plastic Surgery Patients

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“Sometimes We Need To Protect Patients From Themselves” 

I heard that comment made recently at a seminar at the Cedars-Sinai Hospital here in the Beverly Hills area. 

There is a lot of wisdom there.   Patients today, while empowered and enlightened by the Internet, often cannot have appreciation of all the issues that have to be considered when decisions for cosmetic surgery are made.   Often patients cannot understand that some things  cannot be done or if done will have a low success rate.  And low success rates are not what patients – nor their cosmetic plastic surgeons – want.   It is wiser to not operate if there is significant doubt about the prospects for a happy patient and a gratified surgeon. 

When we tell patients we do not think it is a good idea to operate, it is not to insult them or to brush them off, it’s just that we have their best interests at heart.  Is it fair to do an operation that the surgeon does not believe in?  No, it isn’t. 

Medical ethics and common courtesy dictate that if the surgeon feels there is an unfavorable risk/reward ratio, he should not agree to operate.  A wise patient will accept the doctor’s reservations and respect his professionalism and regard for the welfare of the patient. 

Asian Rhinoplasty

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Noses are different within the varied ethnic groups that populate the planet.   An Asian nose has certain features which distinguishes it from the Northern or Central European nose which is different than the Middle Eastern nose which is different than the Central American nose.  One’s color which is a reflection of racial ancestry has an influence also irrespective of the geographic location.  For example, Asian patients regardless of where they dwell in the world, typically have a broad nose with a low bridge and wide nostrils with thick nostril walls.  These are racial characteristics.  Due to intermarriage, often certain features are improved or worsened depending on the genetic match.

For Asian rhinoplasties, typically, nostril narrowing may be necessary.  Now, the decision to do nostril narrowing has to be done after considerable thought and deliberation.  First, not all Asian nostrils are amenable to nostril narrowing.  The ideal candidate for nostril narrowing is a patient that has wide, oblong nostrils primarily due to a very wide sill or floor of the nostril.  That is the part that is easiest to narrow. The surgical procedure that does that is aptly called “nostril narrowing” or is also known by its eponym, the Weir’s procedure, named after the surgeon who devised it.

Nostril narrowing is done as an independent procedure or as part of a rhinoplasty or cosmetic nasal surgery.   It can be done also at the same time that functional nasal surgery is done, e.g., nasal septoplasty and turbinate reduction.  The surgeon seeks to excise a wedge-shaped portion of that sill or floor of the nostril.  Two connecting incisions are fashioned.  One is placed in the crease between the ala or nostril wall in the floor of the nose and extends into that groove between the ala and the cheek.  The second incision is made at a location which will determine how much of the skin is removed.  That is made typically in about the midportion of the widened nostril sill and, thus, the tissue between the two markings is removed.  After the blood vessels are sealed, two layers of stitches are used to close the incision such that the end resulting scar would be very fine and hidden within that crease between the nostril wall and the upper lip and cheek.

There is a very small chance that the incisions will show.  Unfortunately, people of Asian ancestry do have more of a tendency to develop thickened scars or keloid-like hypertrophic or heavy scars but these can be managed by injections of cortisone.  Rarely is it necessary to do any revisional surgery.

Here, as in all aspects of rhinoplasty, the art form and skill of the surgeon will be the determiner of the outcome.

 

Rhinoplasty Mishaps

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Arched Nostrils

Arched nostrils refers to a rather strange appearance to the nostrils that typically follows somewhat overzealous cosmetic nasal surgery or rhinoplasty.  There are some people who are born with this but that is quite rare.

Understand that typically nostrils are essentially oval.  Depending on the ethnic group, the plane or disposition of the oval may be horizontal or somewhat oblique.   For example, Asian people typically have rather wide nostrils that are oval but sit very much in a horizontal plane.  Most Caucasians’ nostrils are also oval but sit somewhat obliquely.  Occasionally people have round nostrils.  However, the arched nostrils have an inverted V configuration at the top.   That is a tip-off of nasal cosmetic surgery and there may be other visible tip-offs.

Why does this happen?  It happens when too much of the lowermost nose tip cartilage is removed.  When too much of it is removed, in the healing process, the existing cartilage “rides up,” elevates away from the previous position and pulls the nostril skin edge with it.  So what you are really seeing is a tenting up, if you will, of the upper edge of the nostril as nature’s contraction forces exerted themselves during the healing process.

Now you will ask:  “What can be done?”  There are two approaches.  One is surgical.  The surgeon can take a small piece of cartilage from inside the nose or even from the ear and implant it at the edge of the cartilage and at the edge of the nostril, through internal incisions, and, therefore, in a sense replace the cartilage that was lost and allow a more normal anatomy as this cartilage graft or implant fills out the tissue that was dragged upward.

The second approach is using a filler.  Temporary or permanent fillers can be injected at the very peak of the arch and by filling the soft tissue just underneath the skin, it will also “drive down” that edge.  It will force it down and change the configuration from an inverted V to be consistent with the general oval shape of the nostril.

Understand that problems that occur after rhinoplasty as nature exerts its healing are most commonly due to overzealous removal of either bone or cartilage.  The natural nose, where cartilage removal has been judicious and never radical, rarely shows any telltale signs such as arched nostrils.