Everybody is now concerned about their Dollars (and Pounds, Yen, Rubles, Krone and Euros!) with so much talk of a looming, double-dip, global recession. So penny-pinching is often the order of the day.
It’s no different in cosmetic surgery financing — provided you find a fully trained, qualified and experienced cosmetic plastic surgeon. (Read the Top 6 Tips for finding a good, board-certified plastic surgeon.)

Reacting to ads for low, low fee surgery is not always a bargain and can result in costs that are three to four times the amount of the first surgery to repair the damage done in bargain basement cosmetic surgery.
The top 5 ways you can save and still have a good outcome:

• Cosmetic surgery layaway

Many offices will consider taking your procedure on a layaway basis. You pay a little at a
time until the cost of rejuvenation surgery is covered. Plus, the cash discount applies!

• Plastic surgery standby

That works just like standby airline flights. If your time is your own, tell your cosmetic plastic surgeon you can fill in on short noticed – seven to ten days – when his surgery schedule has a sudden cancellation. Standby can be worth a 15 to 20 percent discount.

• Lump several procedures together into one surgical session

Say you want an eyelid lift and liposuction. Ask if you can combine the two procedures into one surgical session. That means one fee for an operating room and for the anesthesiologist with a single recovery period. The fee for your eyelid lift, or blepharoplasty, will be the standard but your liposuction may be discounted by five to 10 percent. A third surgical procedure? More discounts.

• Save up and pay cash or with a check

When you pay with plastic, the credit card company nicks the surgeon for three to five percent of his fee for the privilege. So  ask for a three to five percent discount for ponying up in cash.

• Book your procedure during the surgeon’s least busy season

Almost all cosmetic plastic surgery is tied to school schedules, with many more consumers arranging surgery when school is in session.

Thus, many surgeons offer reduced fees during the slow times of the year which includes the first two months of a new year. A twenty percent discount is reasonable for surgery during the slowest times.

Cosmetic Surgery in Yellow Pages?

With a slowly recovering economy, more people are getting around to the cosmetic plastic surgery procedures which they have been putting off.

But there are some easily avoidable mistakes that many patients make.

Essentially:

• Surgery is not right for every person
• Not every surgeon is qualified to perform the procedure

Here are the ways to navigate through the top 5 most common patients missteps:

• Jack-of-all-trades, master of none

Too often, people spring for glossy ads promising a thinner, more smoothed face you, along with a speedy recovery. But a surgeon who does all cosmetic procedures is not a good thing in rejuvenation surgery. Find a surgeon who specializes in five to eight procedures, has done it for decades and has hundreds, if not thousands, of before and after pictures to prove it.

• Plastic surgery consultations: not the first step of surgery

Go to your first meeting to a plastic surgeon as if you are interviewing a surgeon to hire. The savviest patients may go on five or more consultations, take many notes and carefully check for the most important signs of a highly competent surgeon: many before and after pictures, hospital privileges and the right board-certifications.

• Cosmetic surgery: not for everyone

The surgeon’s first job is to let you know if your surgical expectations are O.K. Or, you could have a medical condition that makes it unsafe for surgery. The surgeon will also probe why you want surgery in the first place. Many responses, like “I’ll be happier after plastic surgery” can disqualify you.

• Bargains are better. Right?

If you’ve spotted a very low price on a billboard or TV commercial for say, breast augmentations for face lifts, you can be sure corners are being cut and that more add-ons will appear on your final bill. Cosmetic surgery’s total price usually includes the surgeon, operating facility and anesthesiologist fee, along with medications and dressings. Ask for a written total figure before going ahead.

• Cosmetic surgery: not a one-man show

At your first plastic surgery consultation, ask who does the anesthesia. Many plastic surgeons use a Certified Registered Nurse Anesthetist (CRNA) but you’ll be in better hands with a qualified anesthesiologist who is, like your surgeon, an M.D. Surgeon and anesthesiologist have seen every possible wrinkle and know what to do for even the most remote complications. Also, ask about the certification level of the surgical facility.

Liposuction at home? Never!

More than a few areas require lots of training before you can get by reading up on do-it-yourself (D.I.Y). Notable examples include home owners who jump right into repairing plumbing fixtures. Cartoon artists have made a living from D.I.Y. plumbing fumbles for decades.

A few more special areas of knowledge you may not want to take up at home include:

• Nuclear power

Want a nuclear powered home? Better get a Ph.D. in physics first.

• Bomb disposal

No physics knowledge needed for things which go boom! and can blow you up. But, extensive training is required, anyhow. Also high on your never-do-at-home list should be liposuction (or any other surgical procedure.) The largest red warning flag? Anybody who knows what they are doing understands that your den, bedroom or apartment is no place to perform surgery.

The most excellent About.com blogger, Millicent Odunze, M.D.  reports that a three-member ring in Florida were busted for doing plastic surgery on people at home. None had training, a medical license or any concept of the word, “sterilize.”

The trio was busted after a patient looking to stretch her surgery bucks was hospitalized for complications. (Read more about the liposuction case.)

Unfortunately, a mini-craze exists on do-it-yourself  cosmetic surgery procedures.

Fueled by the ability to buy anything  short of nuclear reactors  on the Internet, plastic surgeons are already seeing patients who have freely engaged in D.I.Y. cosmetic surgery, including:

• D.I.Y. Botox shots

The kits contain everything needed for jabbing your wrinkles with Botox.  Keep in mind Botox is a dilute  toxin that paralyzes muscles. When your kit arrives from India or  China, you may find that too much Botox or an injection in the wrong place can have unexpected side effects. Like,  for instance, removing your ability to breathe.

• At-home chemical peel and microdermabrasion kits

These home kits are weakened versions of the real thing you would find in a cosmetic surgeon’s office. Skin peel kits, for instance, range in price from $25 to $250 but are nowhere nearly as effective as what a rejuvenation surgeon offers.

Chemical peel, with 1.1 million procedures done in 2010, is the third leading noninvasive procedure performed, right behind Botox and soft tissue fillers.

(Read more about chemical peel.)

In one of the most bizarre cases known, a Korean woman used cooking oil as a D.I.Y facial filler and suffered disastrous results.

Solution?  Why not leave all doctoring to, well, doctors?

Sinus Woe Begone!

Ever spot a slick sinus cure on TV and think you could use some over-the-counter relief? Hey, join the crowd!

According to Google.com, over 3.3 million computer users monthly type the word “sinus” into a search box, looking for help with nagging sinus blues, supposedly centered somewhere up in your schnozzle.

Another 3/4 million search for clues about “sinusitis” while an additional half million look for hints on what to do about “sinus infection.”

Count the incredible number of “cures” on the shelves at your pharmacy; all are devoted to improving blocked noses and sinus function. At one, we counted 66.

TV advertisers are hip to the many complaints, offering as “sinus relief” dozens of  remedies, including:

• Pills
• Nose drops
• Nose sprays
• Stick-on tape to open nostrils wider

But real sinusitis won’t be touched by any of the above. If your sinus passages are infected, you’ll have very serious symptoms, including:

• High fever
• Nausea and possibly vomiting
• Facial swelling
• Pain

The list of complaints really goes downhill from there, with various types of goo pouring from the nose into the throat. In true sinus cases, strong pain meds are a must.

Here’s what’s usually happening: inside your nose are various nasal parts that help breathing; some just pass air on to the lungs while others help warm it and even filter out germs and dust.

When those passages become blocked, twisted, bent or otherwise seriously tweaked, you develop bothersome symptoms that only look like true sinusitis. Even allergies can kick up problems.

Many patients first discover that some inside-the-nose help is needed when they go to plastic surgeons asking about rhinoplasty. In many cases, a deviated septum, the internal thin wall that separates the nostrils, is the bugbear.

Other symptoms that your nose needs inside help include:

• Snoring
• Healed broken noses
• Postnasal drip
• Nasal congestion
• Twisted noses

After a cosmetic nasal surgeon takes a peek inside a nose, he or she can do a type of procedure – a nasal septoplasty — that changes your internal nasal passages from the equivalent of a twisted, one-lane country road to a six-lane freeway with no speed limit on air rushing through your nose to the lungs.

Also commonly done: reduction of the inferior turbinate, a shelf of bone covered with a lining of thick skin further up in nose.  That reduction further contributes to opening the airway and reducing the chance of additional sinus problems.

Smokers have the breathing thing even worse, given the constant bath of hot, dry and irritating (to both internal nasal structures and your companions) cigarette smoke.

A purely cosmetic rhinoplasty won’t help — you need an “inside job”. Facial plastic surgeons, who typically are super-specialists with core training in head and neck surgery (including ear, nose and throat) are the experts.

Cosmetic Surgery: Decisions, Decisions

A dilemma that comes up every so often in our cosmetic surgery practice is when patient comes in for:

• Cosmetic nasal surgery
• Rhinoplasty
• And has a rather wide base of the nose

(The nasal base is the part of the nose where the nostrils meet the face.)

That could be due to either thick nostril walls (the ala), or the nostrils themselves are large, and are large because the floors of the nostrils at the sills are very wide.

(The sill is the lower part of the nostril opening where it meets the strip of skin above the upper lip.)

Typically, that occurs in certain ethnic groups, including:

• Asian Patients
• Hispanic   “

That’s an issue that must be addressed, in addition to the standard elements of the cosmetic nasal surgery, or rhinoplasty, which consists of hump removal, narrowing, refining the tip, and often, lifting the tip of the nose from the lip if it hangs down.

Often, the patient is not aware of the role of the wide nostril sill in contributing to the unsatisfactory look of the nose.

However, one of the bugaboos about narrowing the nostrils: an external incision is required.

It is not necessary to have an external incision on a routine rhinoplasty.

While the external incision approach, (or open rhinoplasty) is popular, many of we superspecialist nasal surgeons believe that the skilled surgeon certainly can accomplish everything that needs to be done in a routine rhinoplasty using the “closed” or endonasal approach: the entire operation is done from within the nose, and all incisions are closed with absorbable stitches.

But when it comes to narrowing the nostrils, an external incision must be made and is placed, logically and by necessity, in the groove between the nostril wall and the upper lip and the lower cheek.

But, what if it does not heal perfectly?  What if the scar is visible?  What if it thickens?

Ask: are you, the patient, willing to take the risk of some visibility of the incisions?

Remember that cosmetic plastic surgery never has warranties or guarantees.  Skilled surgeons exert their best efforts using the best technology and best instrumentation, products, and technology. But due to factors beyond their control, particularly, the characteristics of the skin – the scars may not be as invisible as we like.

The patient needs to ask the question whether or not the nostril narrowing is so important that they would not be happy without it.

The answer? Have the standard procedure and put the nostril narrowing on the back burner.  If a patient is happy with the overall result of the standard rhinoplasty, then consideration for the nostril narrowing is tossed out the window.

But, after six month to a year, when healing gets complete, and plastic surgery patients still feel they would like to see the very bottom of their nose, where the attachment to the lip and cheeks is kind of made a bit narrower.  This makes sense considering all concepts of proportion, then that procedure can be done separately in less than a half hour under just local anesthesia.

My advice to patients has always been: “When in doubt, do without.”  You haven’t closed the door – you just have decided to not open it for a while.  A procedure that may not be absolutely necessary –but desired — can be done at any time, accompanied by rapid healing with minimal evidence of having been performed.

Beverly Hills Botox

You could probably rank it among the great questions people have argued about for decades.

The questions? Which is better, Coke or Pepsi? Ford or Chevy? Basketball or football? Hot dogs or hamburgers?

Now, at least for those who are interested in injectable wrinkle removers, the question has become: Is Botox or Dysport better?

A recent test – albeit one funded by the makers of Dysport – found that Dysport, (in the opinion of people who tried both) leads by 33 percent.

Both Botox and Dysport are used for:

• Removing “crow’s feet” near the eyes
• Eliminating forehead wrinkles
• Reducing so-called, “Smoker’s lines” around a normally aging mouth
• Smoothing the area on the forehead between the eyes

Researchers from the University of California, San Francisco, and the Mass Clinic, also in the city by the bay, injected Botox into the crows’ feet of 90 volunteers…but, in one side only. Then, they injected Dysport into the crows’ feet area on the other side of the same face.

They then waited for a month to let the wrinkle removers settle. Both researchers and test subjects noticed not much apparent difference when the patients’ faces were at rest.

But when the subjects scrunched up their expressions by contracting their facial muscles, there was apparently a large difference.

Why?

Sixty-six percent of the subjects pointed to the Dysport side as being smoother under facial contraction. But only 33 percent pointed to the Botox side.

The cosmetic plastic surgeons involved in the tests exercised a few facial muscles of their own while scratching their heads over why Dysport seems to have produced better results. They aren’t sure and think yet another test would be required to nail it down, but one difference may be in the types of proteins found in both wrinkle removers.

Despite the study, Botox in Beverly Hills and elsewhere has literally become a household name, with the latest statistics about plastic surgery procedures recording a 12 percent increase during 2010, the most recent year for which cosmetic surgery statistics exist.  A total of 5,379,360 patients had a wrinkle remover in ’10.

(However, the bean counters also included Dysport patients in that number.)

The study appeared in the current issue of Archives of Facial Plastic Surgery, a professional article for cosmetic plastic surgeons who specialize in treating the head and neck.

(Read more about the Botox and Dysport study.

Or, look at some Beverly Hills before and after cosmetic surgery pictures.)

Several months ago, the United States Food and Drug administration gave approval to sell Allegra, an anti-allergy pill, without a prescription.  The entire Allegra family of products will be available on drug store shelves.

The product has been on the market for quite a few years and there are other products that purport to provide the same benefit.  The rationale for taking these medications is that through certain biological pathways, the medication will blunt the effect of those substances to which the body is allergic.  It is the allergic reaction which causes the symptoms of blocked breathing, runny nose, itching, sneezing, watery eyes, etc.  It’s no fun.  I can tell you from my own experience that as a child and adolescent, I had quite bad allergies particularly to ragweed which is endemic during the late summer in the upper midwest. 

According to the Asthma and Allergy Foundation of America, there are approximately 40 million Americans who have both indoor and outdoor allergies.  According to the article, the most common triggers are tree, grass and weed pollen; mold spores; dust mite and cockroach allergen and cat, dog and rodent dander. 

One issue that always comes up is how effective are these medications in terms of relieving the blocked breathing.  It has been my observation while they can be helpful when alleviating the other symptoms which besides those mentioned above can include even a scratchy throat and a red and unique sensation of itchiness in the throat.   But, I find such pills, tablets, syrups or whatever woefully inadequate in providing a normal airway for patients.

I realize I’m taking issue with a huge economic force, a large commercial market selling billions of dollars worth of medications – prescription and nonprescription  – to the public with the promise of helping breathing.   In my opinion, there is no substitute for the one-time, one-hour surgical procedure that for nearly every patient will bring lifetime relief.  The classic and typical procedure is correction of a deviated septum, if that is a factor and it often is, and thereby restricting the airflow regardless of the status of the lining of the nose which is the target for the allergic reaction, and most importantly, trimming by various means including surgical excision, laser, and other technologies, enlarged turbinates.  The most commonly enlarged turbinates are the right and left inferior turbinates.  While there are a total of six, three on each side (upper, middle and lower turbinates), it is the lowers that have the greatest potential for severe swelling as the lining is attacked by the allergen.  Incidentally, the same process takes place when you get a cold.  In that case, the virus invades the tissue inciting a reaction by the body causing the lining to swell.  When the lining swells, the diameter of the air passage in the nose diminishes.

I am an advocate of the surgery because patients appreciate that it is a one-time cure.  As one doctor-patient unfairly credited me with a big victory:  “Dr. Kotler, you cured my allergies.”  I really didn’t cure the allergies.  But what my surgery did was create such a large internal nasal airway that even when he had an allergic attack, and the lining swelled and thus diminish the airflow, there was so much extra room that he could still have satisfactory breathing. 

I liken it to converting a two-lane highway to a four-lane highway.   Even if there is a minor accident – the analogy here is that the accident is either an allergy attack or cold – there is still room for the airflow or traffic to pass.

Recently, I made my contribution to improving that operation by developing what is now known as the Kotler Nasal Airway.  This is a right and left medical grade silicone soft tube that the surgeon seats on the floor of the nose after the corrective nasal surgery that allows the patient to breathe despite the rest of the nose being swollen and/or being packed with various cotton-like substances that surgeons use to help keep the tissues in proper position and reduce bleeding. 

The patient satisfaction rate for the operation itself has been high but the postoperative period, heretofore, before use of the Kotler Nasal Airway, has been less than popular because of the misery of what one patient described as “feeling like I had a clothespin on the tip of my nose for five days.”

Science never sleeps.  We move forward and any contribution that makes an operation more palatable, comfortable and successful is always welcomed.

~ Robert Kotler, MD, FACS

CONSIDERING RHINOPLASTY?  BE SURE TO CHECK OUT YOUR CHIN ALSO.

Many people have rhinoplasty because they are not satisfied with their profile.  There might be a hump or the nose may project too far from the face.  The nose may be too long ; even  “so long” that it nearly touches your lip when you smile.  Most people do not see their profile and, rarely, can make the same objective judgment about their nose that they can about the width, which is visible from the front.  Often, photographs are what drive people to see us for consultation concerning their nose because, “Whoa, I saw what I look like from a side view, and I sure don’t like what I see.”

A complete consultation will include evaluation of the appearance of your nose in all views.  The wise cosmetic surgeon, or plastic surgeon, or facial plastic surgeon will also take into account the dimensions and position of the chin.  It is very important because often the nose appears unduly large because the rest of the face is not large enough.  In other words, there is a disproportion between the nose and the face based on how the other facial structures are formed and what their dimensions are.

The chin often needs to be augmented.  In other words, the profile is improved if the nose is made smaller, and the chin is made larger on the profile.  I am not talking about looking like Jay Leno.   But, I am suggesting, and in some people, just a very small increase in the forward projection of their chin will compliment the improvement in the nose and make the profile as good as possible.  At consultation, it is very important that all aspects of your appearance be considered.  Do not go in with a narrow-minded view of “I need a rhinoplasty.”  The point of consultation is for you to learn and understand what the anatomic issues are.  If the surgeon suggests that you consider a chin implant, do not take it as an insult, but, rather, that the surgeon is thinking about your entire face, and that is exactly what his mission should be.

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.”

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.