Fractional Laser

Posted on December 10, 2010 by admin

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

Posted on December 3, 2010 by admin

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.

Cosmetic Surgery Anesthesiologist

Posted on November 24, 2010 by admin

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.

Rhinoplasty Mishaps

Posted on October 22, 2010 by admin

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

Posted on October 15, 2010 by admin

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.

Researching Cosmetic Surgery Online

Posted on September 10, 2010 by admin

Doing Research on the Internet. Better Distinguish the Cosmetic Surgery Pros from the Amateurs!

The Internet is a wonderful educational innovation. All of us use it every day to learn more. However, there are negatives. First, there is no scrutiny of many of the postings. Some of the websites are either accidentally or deliberately misleading, often for commercial purposes. Some websites have no filter or review that would prevent misinformation from being made public.

The second negative, for those researching cosmetic surgery, it is possible for a particularly cosmetic plastic surgery site to gain some attention during Internet searches, strictly by virtue of having invested large amounts of money in a website. Loading it with lots of bells and whistles, but less substance. Some websites are built to be attractive, enticing and yet the content is poor. Worse, sometimes misleading.

Site visitors may loose focus and may not understand that the most important value of a particular site is the quality and volume of the content. Plus, the history of the doctor. The training, experience, degree of specialization, continuing education and prominence in the community of like specialists. Those are the sites of the real pros.

I like to visit sites of the pros. The heavyweights of the specialty of cosmetic plastic surgery who are its superspecialists. These are doctors who have “earned their spurs” through long and intensive training including residency and fellowship. They have served their time, and therefore, have the wisdom that is delivered by that long run in the operating room and in caring for patients before and after surgery. There is no substitute for experience!

To help you understand how you get the most out of visiting websites for cosmetic surgeons, heed the following advice: First, look at the professional bio. How long the doctor has been in practice. Has he written research papers on the operations you are considering? Does he teach in a medical school? Has he served in the military – a huge advantage? Does the doctor focus his practice on a limited number of procedures or is the doctor a “Jack of All Trades”, content to perform a large breadth of procedures. Remember, in the world today, the trophies go to the superspecialists and not the generalists.

For you prospective patients, the most important part of a cosmetic surgeon’s website is the gallery of before and after photos. If you only see six or eight patient case histories, that tells you the doctor doesn’t have the long experience and a large volume of patients from which he can cull typical examples to share with you. You should be seeing hundreds of before and after photos on the doctor’s website. The top educational photos galleries show technically clear and consistent befores and afters – beware differences in lighting, make-up! Each photos case history should have a caption describing what was done. Look for solid consumer-oriented information including commentaries from patients as to what their experience has been with the practice.

Today, most sophisticated, most specialized and advanced practices offer prospective patients telephone consultation, doctor-patient conversation via Skype and computer imaging where an interested patient, anywhere in the world, from the privacy of home, can see the predicted result of their cosmetic procedure(s).

Pardon me for being a bit proud, but frankly, having authored two books for the public, my very capable and veteran staff have delivered loads of information that would otherwise not be available in a single source! Books are still great learning tools. I am proud to be among that small group of doctors who have taken the time and energy to also be writers. To help educate. After all, the root word for “doctor” is the Latin, docere, “to teach”.

Remember, websites should not about sales and marketing, hype and fluff. The best websites are about education.

Cosmetic Plastic Surgery Questions

Posted on August 27, 2010 by admin

Got a Question? Ask it! Why Worry?

I like for patients to have every question answered. Before surgery, it is very appropriate to have questions about anesthesia, recovery, pain. Even worries of nausea and vomiting, which are now rare, should be addressed.

After surgery there are questions such as “When can I resume my exercise?”, “When can I start nursing my baby?”, “When will the bruising and swelling be gone so I can return to work?” “When can I start to have sex again?”

These are important questions and deserve answers. Sometimes patients are reluctant to ask these questions because they “don’t want to bother the doctor”, or they are a little shy about asking questions, particularly the “sex question.”

I encourage patients to ask questions at any time during their care with us; before surgery, after surgery, day time and evening time. There is no reason to worry. There is no reason to fret. Often concerns and worries are exaggerated and may even keep people from sleeping.

This post was inspired by a conversation I had this morning with one of our patients who lives in another city. She came to us to have upper and lower eyelid cosmetic surgery or blepharoplasty plus brow lift and had cosmetic nasal plastic surgery or rhinoplasty. And, incidentally, at the same sitting, with a plastic surgery colleague who is a superspecialist in body procedures, she had tummy tuck and breast reduction.

She was concerned that her smile had not returned in full force. Her fear was that somehow this would be permanent. I quickly reassured her that after her particular type of rhinoplasty, or cosmetic nasal surgery, it wasn’t unusual that the smile would be limited because of some temporary swelling and malfunction of the upper lip muscles. That function always returns. I reminded her that I witnessed it in my own daughter whose rhinoplasty I did when she was 16 years old.

Being a doctor is a 24/7 job. Your doctor should be available. If you have a question make the phone call, get the answer and sleep tight.

Why Breast Implants are Big

Posted on August 20, 2010 by admin

Why Breast Implants are Big

Figuratively, not necessarily literally.

My point is that breast augmentation surgery is popular because women desire to have as fine a figure as possible. I think it is a great idea. Some women are born with breasts that are too small. Others have breast asymmetry. Some have problems with nipple inversion. Some people need to have breast surgery to reduce over large, pendulous, supersized and therefore not particularly pretty breasts.

The most common operation is the breast augmentation. It is a good operation because it is successful and has a low complication rate.

Women like to look good, that’s why clothing styles and hair and makeup are important. For those who are self-conscious, or carry a lack of self confidence because of small breasts, this one- hour operation can literally change their life. In that regard, I liken it to rhinoplasty, one of my specialty procedures, for teenagers. Both of these operations give lifelong satisfaction and an increase in self-satifaction and self-confidence. I have witnessed it for my entire career.

If breast augmentation sometimes gets a bad name it is only because of bad judgement on the part of either the patient and/or the doctor. The classic example is Heidi Montag, the aspiring actress-personality. Common sense was thrown out the window when her reasonable looking breasts were replaced by gigantic and unnatural breast implants. She became a poster girl for bad cosmetic surgery. Frankly, I blame the patient for that unrealistic desire which, by the way, in Heidi’s case was followed by some period of pain and unhappiness as reported in the media.

Cosmetic plastic surgeons have a responsibility too. They need to do the right thing and to be proud of their work. When such oversized implants are stuffed into the chest, there is a greater chance of problems and complications. Problems that discredit the specialty and the medical profession. There is nothing wrong with breast augmentation that delivers natural-looking, properly sized and proportioned breasts. With today’s terrific implants that come in various sizes and shapes, there is ample opportunity for body cosmetic plastic surgeons to do great work. And, by and large, they are doing great work. That is why the operation is so popular.

As I said, breast implants are big. I didn’t mean to imply they were oversized. What I am really saying is that the subspecialty of breast implant augmentation is popular and well accepted and that is what young people call “big.”

Unhappy with Your Cosmetic Surgery?

Posted on August 13, 2010 by admin

What Do You Do If you Are Unhappy with Your Cosmetic Surgery?

Some patients will not be satisfied with their cosmetic surgery. In many cases, their dissatisfaction is warranted; in other cases it is not – the patient may not have been realistic about what results could be achieved.

In any event, the dissatisfied patient has the right to have a detailed conversation with her or her surgeon and ask why things did not go well and what can be done to improve the situation. I also believe a second opinion, from an objective outside source – ideally a superspecialist in the procedure – is extremely valuable. I always make this recommendation: “When in doubt, seek a second opinion.”

I have had occasion in my practice where neither the patient nor I were completely satisfied with the result. He is what I say to the patient, “Frankly, I’d like to have some input from a colleague and get an opinion as to what the best step would be going forward.” Patients very much appreciate the offer. I see to it that there is no charge made to the patient for that. And often the patient and I both learn something. All this is done in the spirit of preserving a good, solid professional relationship, with the object being to have a satisfied patient and a gratified surgeon.

One thing that is very important is that the consulting doctor have access to all the medical records including pre-and post-operative photos. Remember, regardless of the state of friendliness between the patient and the original surgeon, the surgeon is obliged to provide these records to the patient. Medical ethics, and state laws governing medical practice, demand that all must be done in the interest of the patient and, therefore, any and all medical records including the photographs, x-rays or whatever, must be available to ether the patient or to a physician of his/her choosing.

The reason to have the medical records at hand during the second opinion consultation is to understand the history and to see what the pre-operative state was and make a realistic judgment as to what could be reasonably achieved and what could not be achieved. It is also important to read the operative report to see if there are extending circumstances to compromise the result. Were there complications after surgery that had a bearing on the outcome? All these things are best understood by a thorough review of complete records.

You are entitled to have the best service possible. Don’t be shy. You are entitled to the records and you are entitled to the input from another doctor who may well say that the best was done that could be done. But in any event, you will feel better about hearing it from a second source.

Dr. Kotler Speaks on Virtual Consultations on Skype

Posted on July 26, 2010 by admin

Dr. Kotler Speaks on Virtual Consultations on Skype

Today’s technology is allowing us to consult with people all over the world. That doesn’t mean that patients necessarily come here to Beverly Hills; now from the comfort and privacy of their home, patient’s can consult with me at the office.

The key is computer technology by which we can morph a patient’s digital “before” photo into a “after.” We can show the patient the predicted result of the cosmetic procedures or skin treatments. That is all done through our website. It is really quite something.

Now we are enhanced by Skype. Not only can we share with the patient our predictions for the result, but we can see the patient, speak with the patient, make some evaluations and have even more information at hand to make proper recommendations.

Virtual consultations are wise, economical and practical. Often, we can tell patient’s that they might not be a candidate and save them the trip either across the state or country, or across the ocean.

We have been a devotee of virtual consultations and continue to be so because there is nothing like chatting with the patient “face to face” and having the chance to discuss and have a meeting of the minds regarding the outcome that the patient hopes for and we predict will be achieved.