Category Archives: Cosmetic Plastic Surgery

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. 

 

Rhinoplasty and Septoplasty Clinical Trial

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The Exciting New Postoperative Nasal Airway Clinical Trial

Our practice is very excited about a clinical trial that we are currently conducting. Nearly three years ago we developed a concept that we felt was very important for patient comfort and safety after rhinoplasty, septoplasty and turbinate resection and sinus surgery. The driving theme is that patients should be comfortable after these surgeries and be able to breathe immediately upon awakening from the anesthetic.

That does not sound too revolutionary but the fact is the operation has been done for 100 years and is typically accompanied by the nose being “packed” after surgery. What that means is that cotton or gauze-like material is placed within the nasal cavities after the operation to hold the reconstructed tissues in place and be capable of reducing the chance of nosebleed. These packings may also be used to deliver medications to the interior of the nose. So the rationale for having the packing makes sense, but from the patient’s standpoint, it is no fun because they cannot breathe. One patient described the experience as “like having a clothespin on my nose for five days. I was miserable.”

Patients complained about dry mouth, discomfort, difficulty sleeping and even anxiety. Another patient said “I felt I was drowning. I couldn’t catch my breath!” Sometimes we had to prescribe anti-anxiety medications like Valium.

It was in September, 2007, that it dawned on me that perhaps we could do better. Through a very prompt evaluation, we determined that it was possible to seat drinking straw-like soft plastic nasal tubes on the floor of the nose at the end of the formal operation, and pack the nose as indicated. The tubes would allow the patient to breathe through the nose, the preferred and normal channel, immediately after the surgery and during the first five or fewer postoperative days. Over the last three years, we developed variations in the design, all with patient comfort and safety in mind and recently were awarded clearance by the FDA to make the airway tube available to other doctors.

In our practice, 70 patients accepted our offer to have the tubes placed at the time of surgery and of those, 67 were extremely pleased and laudatory. The last phase of our research included cases where patients volunteered to be part of our clinical trial whereby only one of the two nasal passages would have the soft latex-free silicone tube placed. Therefore, in keeping with standard medical research standards, the side without the tube -completely packed – acted as the “control.” The tube side was the so-called “test” side. To date, we have had nine patients undergo that experience as part of the clinical trial and all nine agreed that they had a happier experience on the side that had the tube in place.

We have just about wrapped up the clinical trial and are about to present our work to the medical profession. To the facial plastic surgery, plastic surgery and head and neck (ear, nose and throat) specialties, who perform these procedures. Our research study will be submitted to a peer- reviewed medical journal for publication that will reach specialists world-wide.

Based on the result of our research study, we have proven that we are going to be able to afford our patients a more comfortable and anxiety-free post-operative experience. Next, will also make this airway device available to other doctors to also avail themselves of the opportunity to provide a better post-op experience after surgery.

With advances in modern technology, newer diagnostic tools, such as limited, simpler CAT as making it easier, more practical and less expensive to make the right diagnosis for those with blocked breathing, lessen their allergy symptoms, control snoring and sleep apnea and help free them of the plague of multiple sinus infections. To facilitate more successful and safe nasal and sinus operations, impressive high-devices and instruments are coming on-line.

Once again, Science Never Sleeps.

Dr. Kotler Nose

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The Dr. Kotler Nose

Patients always kid me that they want a “Dr. Kotler Nose.”  When I ask them what they think a “Dr. Kotler nose” is, they usually reply “Well, one that looks natural.  It seems that you have the knack of producing natural noses.”

I am flattered by that.  I also take pride in those observations, because that has always been my aim.  I want to deliver a nose that looks natural, as if the patient had never had nose surgery. As if the patient were born with it.

The opposite of a “Dr. Kotler nose”, or a natural, un-done nose, is one that looks unnatural, fake, and over-done.  The nose that is too scooped out, that is too narrow, that has a pinched tip that has an overturned tip such that one is looking directly into the patient’s nostrils.  No one wants the unnatural nose.  We all understand that.

Incidentally, “The Dr. Kotler Nose” is worn by Dr. Kotler.  I had my nose done.  It was done by the world- renowned, and first rhinoplasty superspecialist, Dr. Howard Diamond, in New York City, in 1980.  Dr. Diamond was the unquestioned heavyweight champion of the world when it came to doing cosmetic nasal plastic surgery. He was one of my principal teachers and mentors.

I have a set of my pre-operative photos in the office, and I am always willing to share them with patients so they can see what I looked like “before”.  I like my nose because it looks natural, fits my face, and it is a better nose than I had.  That is the definition of success.

Revision Rhinoplasty

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Rhinoplasty Revision – Is Simpler Better Than Complex?

Recently we saw a patient who was a student at a local university.  One year ago he had rhinoplasty performed and was very unhappy with the results.  He certainly had ample reason to be dissatisfied.  The nose was just terribly unsightly.  It was crooked, asymmetrical.  There was a gouge on the left side.  It had been over-shortened, overdone, and had entirely changed his ethnic appearance.  He brought in photographs to show me what he looked like prior and it was shocking how radical the change. Very poor judgment and substandard craftsmanship by the surgeon

I told the patient it was my opinion that much of what he disliked could, in fact, be improved without surgery.  By using a combination of filling injections and perhaps some shrinking injections, that he would have a much improved nose which would have a better “fit” with his ethnicity.  The common denominator was that, at his surgery, too much was done.  And when too much is done, often the most practical answer is to use filling injections under the skin to essentially plump up the skin. To replace the over-removed portions of bone or cartilage underneath the skin. The results of the injections resemble the results of having  surgical procedures which would involving grafting or transfer of tissue from one part of the body to the other. Often, in such complicated revision rhinoplasty cases, there may be more than one operation necessary to achieve a satisfactory result.

The patient was a little incredulous that I thought that I could achieve a satisfactory result –without any surgery – so I then did a “saline demo.”  We inject sterile saline, the same solution in intravenous fluids, underneath the skin that mimics the result of the final permanent filler injections. It made an amazing difference.  The nose was not perfect.  I would have liked to have seen some minor changes otherwise but they would require surgery.  But to achieve an 80% or 90% improvement without having surgery is impressive. And, practical and inexpensive compared to one or more trips to the operating room.

The patient related to me that he had seen another surgeon who told him he would require a seven-hour reconstructive surgery and that cartilage or bone would have to be taken from his chest and transplanted or grafted to the inside of the nose.  Disregarding the cost and the duration of surgery and all the other inconveniences and burdens, the question is whether or not the end result would be satisfactory.  Often, transplanted tissue can shrink or twist or partially disappear and this adds another level of complication and the need for even further surgery.

I think there is a place for simplicity that when an office procedure can do the work of surgery, it should certainly be considered. It’s not always the only treatment that is needed, but injections can do much of the work.

Before the operating time is reserved, the patient’s common sense might say: “Why not?”. Because there is great value to simplicity, economy and predictability.