After Cosmetic Surgery

Some things go to together like oil and water. Or fire and ice.

So discovered the star of British reality show “Only Way is Essex” actress Lauren Pope who complained that a nose job ruined her love life because plastic surgeons banned any romantic bedroom activity while undergoing healing. (Read more about Pope’s nose job.)

Immediately after any cosmetic plastic surgery, surgeons’ post-op orders are: do not do anything in the weeks after surgery that will raise your blood pressure. Included would be weight lifting, aerobics or other strenuous activities, usually for two to three weeks.

For those who do not already know, bouts of amour raise blood pressure and can cause recently closed incisions to bleed and possibly bruise and swell.  So it’s a good idea – even if you believe that instant gratification takes too long – to put off romantic intimacy after surgery.

Actually, more than one couple has encountered episodes of fresh bleeding after a plastic surgery procedure because they rushed things too soon in the boudoir.

In fact, we and several other cosmetic plastic surgeons were once interviewed for an article, Hook-Up Hiatus: The Truth About Sex After Plastic Surgery in W Magazine; the article was about post-surgery patients who were old enough to know better but apparently could not resist intimate moments.

In our case, the call came in the middle of the night from a 50-ish gentleman who had undergone a face and neck lift only five hours before. Our patient went to a Beverly Hills recovery center – which will go nameless for now – where he was overwhelmed by the charms of yet another, younger recovering plastic surgery patient who fell into his arms soon after meeting.

Results?

Predictably enough, his and her blood pressures were raised beyond normal limits, with our patient suffering bleeding from his freshly closed incisions. The other result, alas, was that we were summoned from a warm bed and restful sleep to again close his incision in the wee hours.

Our patent later lamely admitted he may have forgotten his post-op instructions because he was coming out of anesthesia when the post-op, no-sex rule was first mentioned.

In any event, we can only pass along the advice of a New York state plastic surgeon who tells his surgical rejuvenation patients to carefully manage “The 3 E’s” after surgery: emotions, exercise and eroticism.

Cosmetic Surgery Start to an Emmy

Promoting cosmetic surgery books for consumers lead to one of the most
prestigious awards in television, an Emmy. Well, we should say “lead
indirectly” to an Emmy.

And on Father’s Day, no less. What a gift! Our daughter, Lindsey Kotler, won
the coveted award for her work as a producer at the Dr. Oz show.

Here’s how it all started: Back in 2003, your humble blogger penned a
typically modest – well, for us, anyhow — book, SECRETS OF A BEVERLY HILLS
COSMETIC SURGEON.

After that, in 2005, we wrote an equally modest tome, THE ESSENTIAL COSMETIC
SURGERY COMPANION. (Read our last post about the various uses – door stops
and paperweights, notwithstanding – for that cosmetic surgery book.)

It was something of a family-related business, because Lindsey Kotler was
cutting her professional teeth as the director of sales and marketing for
both books. It got her out of the house and all, allowing me to turn her
room into a wonderful gym… although I must say we do miss her rent. But I
digress.

After she did a wonderful job moving dad’s books, Lindsey cranked things up
a notch and landed a job as a  executive assistant to the vice president of development at Oprah Winfrey’s
Harpo Productions in Chicago.

There, she really developed some professional chops!

So many, in fact, she next landed at the Dr. Oz show where she toiled away
producing until bagging that Emmy.

What’s next? Well, we don’t use the home gym any more so we were thinking of
offering Lindsey her old room back if she would return to Los Angeles and
move a few more books for dear old dad again.

Plus, we just might write another book about cosmetic plastic surgery with so
much high-powered marketing savvy on hand.

How about it, dads? What would you do in my shoes?

But if she turns our generous offer down, we will probably just shuffle
around the house, muttering King Lear’s famous line: “Oh, how sharp it is
like a serpent’s tooth to have a thankless child!”

And, hey, while you’re mulling over your sagest bit of advice on
parent-child relations, why not grab a chance to check out the two cosmetic
surgery books that started such an auspicious journey?

Recently, the Health & Wellness section of the Los Angeles Times had two excellent articles that dealt with the problem of sleep apnea and snoring

According to the Los Angeles Times, “2% of women, or at least 4% of men, suffer from obstructive sleep apnea.”  If you are not familiar with sleep apnea, it is a condition “in which the airway collapses and blocks breathing for 30 seconds, or even up to a minute or two.  The brain senses that it isn’t receiving enough oxygen and sends a signal to the patient to wake.”

People with sleep apnea (apnea is translated as “without breath”), find themselves in an unsatisfactory and untenable situation because their sleep quality is poor.  Poor sleep quality can generate  a myriad of problems including sleepiness at work and leisure, and even possible elevations of blood pressure, and other imperfections in your normal bodily function.

Maybe there is a connection between the rise in obesity in the United States and sleep apnea.  The paper says, “the incident rises with age: experts estimate that it affects about 40% of people age 65 and older.”  What we are seeing in the United States is that older people tend to be heavier.  That is not good news on many fronts. 

The articles also points out that it’s not just about age.  The overweight issue is very significant.  Overweight patients have double the risk of sleep apnea according to Dr. Lawrence Epstein, of a sleep center chain in Massachusetts.  Incidentally, if you have ever seen kids with large tonsils and adenoids struggling to get breath when they are sleeping at night, which is not that uncommon, you have a clue as to what sleep apnea is like. 

The article pointed out that there are mechanical remedies available including the infamous CPAP (“Continuous Positive Airway Pressure”) device, which is a spaceman-like mask which affixes tightly and to the face, akin to a scuba mask.  An external electrical power source drives the air into the lungs under pressure at night.  It is not too pretty; but, it does provide relief for people. 

Other technical aids are dental mouth pieces, and even some of these external nasal breathing strips. 

I was a bit disappointed that the article did not discuss management of one of the key causes of sleep apnea – that is a blocked nose. Nasal obstruction.

More on that to follow because there is a huge pool of patients in the United States, and worldwide, whose problems can be helped with a veteran, venerable, and reliable one-hour surgical procedure – nasal septoplasty and turbinate resection, with or without rhinoplasty. 

~Robert Kotler, MD, FACS

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

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 an 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. 

Now, Heidi Montag is complaining that she had too much cosmetic surgery.  This lady really knows how to work the media and get some press. 

Apparently, Heidi made the comment that of all the ten procedures she had on that one marathon day, the ear surgery, known as otoplasty, was the most painful.  I guess she has to say something to fill the pages of the newspapers.

I don’t know why she found the ear surgery so uncomfortable.  Our experience has been that it is not painful unless there is a complication whereby blood leaks under the skin, is trapped, the skin expands and causes pain.

We take every precaution to prevent that, of course, with very meticulous sealing of blood vessels and placing what is known as a “drain” which is a rubber band-like strip of fabric or rubber to encourage migration from inside to outside of any fluid that accumulates underneath the skin.

Know that the incisions are hidden behind the ear and are typically closed with absorbable stitches. 

No patient should ever suffer from pain.    With the large variety of pain medicines, why should anybody be plagued with pain?  If one does not work, we merely prescribed another.  We go up the line until pain relief is achieved.  Sometimes we have to use very strong pain medications like Percocet or morphine or Demerol but that is rare.  Most patients having routine cosmetic facial and body surgery get along very well with mid-strength Tylenol with codeine or Vicodin. 

As a matter of fact, excess pain is a warning sign, as I mentioned above, possibly heralding bleeding or fluid collection underneath the skin.   So when we hear that the patient is having pain, particularly if their pain medication requirement is going up, we need to see them and make sure that nothing bad is happening.

As in all areas of surgery and medical practice, early recognition of complications and problems is essential.

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/.

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.

Rhinoplasty or cosmetic nasal surgery for Middle Eastern patients must take into account the following typical features of the nose:  There is usually a bump or hump.  The nose tends to be long and somewhat curled down.  When smiling, the tip of the nose drops down even further.  The nose may be wide with very broad lower cartilages causing large nostrils.

The management of such noses has to be very judicious.  It is important to remove the bump without causing a scooped-out appearance.  The nose should be narrowed but never pinched.  The tip needs to be raised up such that the nose no longer seems like it is going to touch the lip when smiling.  And, speaking of smiling, the little muscle that causes the tip to depress with smile generally has to be severed.

The ideal result would be a nose that has not been made too small, is not turned up too much and, as noted earlier, does not have a scooped bridge or a pinched tip. Improvement with preservation of ethnic identity is the key to success. 

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. 

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.