Neck Sculpture Versus Neck Liposuction

Posted on November 19, 2010 by admin

Liposuction first arrived in 1985 and very quickly we learned to adapt the techniques to help remove excess fat from the neck. It was done with a tiny incision where the chin meets the upper neck. That’s a perfect place because it is hidden. And we would use a cannula or narrow suction tip to evacuate the fat that sat between the platysma muscle and the skin.

However, we observed that the results were not as good as we wanted them to be. We asked ourselves why this was the case.

The answer came with cadaver dissections and further anatomic studies which convinced us that the key to success was doing more, that liposuction alone was inadequate. We needed to address the sagging of that platysma neck muscle and that even direct ourselves to the next layer of fat below that muscle which would not be accessed by routine liposuction.

When these two additional components were added, the removal of fat beneath the platysma and then actually trimming the redundant or extra edges of the platysma, and then tying them together with sutures to form an internal sling or corset, the results became quite impressive. That is what a neck sculpture procedure is. It is liposuction with two other steps in the operation that allow the best possible definition between the jaw line and the neck.

Understand that this operation – since it removes quite a bit of tissue – relies on the skin’s elasticity to contract to envelope a smaller neck. If the skin is sun damaged, stretched out, very wrinkled, thin and parchment-like, it is predictable that the skin does not have the ability to snap back like a tight rubber band or like a brand new balloon and that the skin, therefore, cannot drape evenly. If the skin cannot drape evenly, the result will not look good. Patients with such skin are not candidates.

In order to assess one’s candidacy for the procedure, it is necessary to evaluate the skin’s quality, particularly its elasticity and redundancy. Typically, men can have the procedure up to the late 60s because men’s skin is thicker and tends to remain more elastic. But few women older than 45 or 50 qualify because typically the women’s skin by that age perhaps due to decline in hormones, is thin, less elastic, no longer that nice tight rubber band and would not be up to the task of contracting evenly and giving a nice smooth skin contour.

How Patients Teach Cosmetic Surgeons

Posted on November 11, 2010 by admin

“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

Posted on November 11, 2010 by admin

“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.

Revision Rhinoplasty

Posted on September 24, 2010 by admin

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.

Non-Cosmetic Surgeons Doing Cosmetic Surgery?

Posted on August 27, 2010 by admin

Non-Cosmetic Doctors Profiting by Doing Cosmetic Procedures?

A recent article in USA Today described a situation not unknown to those of us who are long-time cosmetic surgery-only practitioners.

Writers Jayne O’Donnell and Jillian Berman did a nice job of pointing out what many people in the public don’t quite know or understand: there is a migration across specialty lines by some practitioners anxious to augment their income by performing elective cosmetic plastic surgery procedures that are beyond the usual boundaries of their specialty.

Writers O’Donnell and Berman reported the history of a patient who stated that “…her OB/GYN offered to do a tummy tuck after she delivered the lady’s third child.”

Next, the same patient reported that her eye doctor suggested injectables to the wrinkles between her brows when she went in for an eye exam.

The patient couldn’t quite figure out what was going on.

Traditionally cosmetic plastic surgery procedures on the body have only been performed by plastic surgeons. Surgeons who pass the test of the American Board of Plastic Surgery are expected to be the only specialists who are duly qualified to perform tummy tucks. While OB/GYN specialists have knowledge of the anatomy of the lower abdomen, tummy tucks and liposuction are not taught in obstetrics and gynecology residencies. They are not considered part of the specialty.

What about an eye doctor suggesting injectables for the wrinkles between her brows, such as Botox or Dysport? If the doctor is a subspecialist in ophthalmic plastic and reconstructive surgery, those injections are properly part of his toolbox. But, the average ophthalmologist may not have the training and experience to be a superstar at it. Patients need to know that.

In my book, Secrets of a Beverly Hills Cosmetic Surgeon, I discuss this migration across specialty lines and why prospective patients must be on the ball when evaluating an offer from their doctor that seems unusual and at odds with respect to the typical scope of that specialty. Understand that because of the inequities and burdens of dealing with health insurance companies, many doctors are so frustrated and fed up that they look for an alternative form of practice. It is not always practical or possible to go back and take a full six or seven year residency, so many of them decide to try to master some of the techniques that have been perfected by other specialities.

This is not to say that an ophthalmologist would necessarily be incompetent at doing Botox or Dysport. Know that there is not much downside to these procedures; difficult to get into major trouble.

However, an obstetrician/gynecologist doing a tummy tuck enters a whole different realm and I would be very skeptical, as a patient, before signing up to have the procedure done by that doctor. The more appropriate doctor is one who is board certified by the American Board of Plastic Surgery and has long-time experience performing a procedure after the prescribed period of education and training.

Today, unfortunately, it is a matter of Caveat Emptor. Buyer beware.

Dr. 90210 Nose Job

Posted on July 23, 2010 by admin

Dr. 90210 Nose Job

As I write this, I am in the Upper Midwest. While I spent some of my time in a small town, Green Lake, WI, population 1,100, I didn’t have too many discussions with people about rhinoplasty or cosmetic nasal surgery. In that part of the woods, nose jobs are not very commonly done because the sub-culture of a rural area in South Central Wisconsin doesn’t emphasize cosmetic surgery.

However, what is fascinating is that the young people recognize Dr. 90210. Ah, the power of television!

We had a fun encounter on the golf course at Lawsonia, on the shore of Green Lake. On the course, high school and college students drive the refreshment carts. Refreshments include snacks, soft drinks, ice-cold water, and they are much appreciated on these hot and humid Upper Midwest summer days.

One of my golfing buddies, chatting with one of the young lady golf cart drivers, pointed to me and apparently said something to the effect of, “See that guy, he is one of the doctors on Dr. 90210.” He reported that her eyes opened widely and her jaw dropped. The thought of a “Hollywood Celebrity” being in Green Lake, WI, population 1100, may have been just too much for her. Luckily, she didn’t pass out. He said to her “Would you like Dr. Kotler’s autograph?” Apparently she did and met us at the next hole with all due speed. I was pleased to give her a copy of my Secrets of a Beverly Hills Cosmetic Surgery book card with my signature.

As I walked away to tee off, one of the guys in my group reported that she immediately got on her cell phone to call one of the other young people who work on the course to report that she “just met Dr. 90210” and that she has his autograph!

So, the Dr. 90210 fame continues and deservedly so, in my opinion. The program was educational as well as entertaining and demystified the subject of cosmetic surgery and simplified patient understanding of the course of the cosmetic surgery patient.

Rhinoplasty Surgery in Hollywood

Posted on July 2, 2010 by admin

Rhinoplasty Surgery in Hollywood

Rhinoplasty, which is cosmetic plastic surgery of the nose, has long been staple in Hollywood.
The reason is that Hollywood thrives on showing the world beautiful faces and it is impossible to have a truly beautiful face without a satisfactorily-shaped nose.

Some people are lucky and are born with a nose that is proportional and is pleasing to the eye. Elizabeth Taylor comes to mind. Likewise Grace Kelly and Catherine Deneuve.

Those who have not had luck on their side with respect to receiving a “good nose”, have always had the option of having the rhinoplasty surgery. Of all the procedures that a younger person can do to improve their appearance, rhinoplasty ranks number one. It is more important and more commonly requested than chin augmentation or blepharoplasty.

Remember, also, that many people have the rhinoplasty surgery at the same time as they have nasal septoplasty and turbinate resection to improve the airway or correct a sinus problem. This “double need” is more common in men than women, of course.

Marilyn Monroe had rhinoplasty. Comedian Milton Berle and actor Dean Martin also had rhinoplasty.

Years ago when I was researching for my book, Secrets of a Beverly Hills Cosmetic Surgeon, I visisted a photo archives facility in Venice, California. It was fascinating to leaf through the drawers and recognize that many familiar faces had indeed had rhinoplasty surgery at some point in their life.

Incidentally, some people go to great lengths to conceal the fact that they are having such surgery. If you ever saw Barbara Streisand in the movie Funny Girl, you would know that it was the story of comedienne Fanny Brice. In the 1930s, Fanny had a rhinoplasty performed in a hotel suite. She felt that was the best way of keeping it a secret.

Today, rhinoplasties are not performed in hotel suites and, frankly, they are rarely performed in hospitals. It is appropriate to perform such a procedure in a credentialed outpatient surgery center or a duly qualified physician’s office surgical suite.

Cosmetic Plastic Surgery

Posted on June 3, 2010 by admin

Four Ways to Take the Guess Work out of Cosmetic Plastic Surgery

Sometimes it is difficult for patients to envision or visualize the results of Restylane, Perlane, Juvederm, Sculptra or Radiesse fillers about the face. Other patients may also not appreciate how a poorly performed rhinoplasty or “nose job” can be improved by filling injections. Even those with a receding chin have trouble visualizing what the result might be.

One way to “try before you buy” is to have a “demo” test. This “no-risk” demonstration is achieved by injecting sterile saline (salt water, the same liquid that is used as intravenous fluid) to display the results of the proposed long-lasting filling injection or even some surgeries.

The sterile saline can be injected into the fold of the deep nasolabial creases around the mouth to show the effect of the common fillers. It can be injected into the tissues of the chin to show how the profile would look if the chin were augmented, the so-called “chin augmentation.” It can be injected into the nose to show how one who has a very low, scooped out or over-pinched result from cosmetic nasal surgery would look.

The sterile saline “test drive,” if you will, can be rendered almost painless by the application of a topical anesthetic about one half hour prior. The results will last for one to two hours. Photographs can be taken before and after for documentation so that the patient can study the improvement before making a commitment to having natural fillers.

It makes sense doesn’t it?

Beverly Hills Cosmetic Surgery Consultation

Posted on February 11, 2010 by admin

Why I Like an Interactive Consultation

I enjoy a consultation where there is a lot of give and take between myself and the patient. I like the patient to have prepared for the consultation, ideally by having visited our website and other high-quality, educational websites. If the patient has really done their homework well, they will have read or at least perused several of the excellent books that are available such as our Secrets of A Beverly Hills Cosmetic Surgeon, the Expert’s Guide to Safe Successful Surgery, or The Essential Cosmetic Surgery Companion, Don’t Consult A Cosmetic Surgeon Without This Book!

Like everything in life, preparation is essential to achieve the best results. When patients have viewed websites, including looking at the before and after photos, which is very important, and they have had a chance to read and study, they are more apt to ask some questions. I like questions.

The reason why I like questions is that patients should not have anxieties and fears based on lack of information. If I am able to answer questions either through the technology of our website or the pages that fill my books or the one-on-one with the patient, then the patient is going to have a smooth sailing through the cosmetic facial surgery process. It is when patients don’t know enough that they are anxious, uncertain, and often this leads to really not doing as well as others might.

We always tell our patients, “If you have any questions, please ask them.” And, you can ask them right up to the evening before surgery because I give my patients my home phone and cell phone numbers. Our anesthesiologist calls the patient the night before surgery so that if there are any issues concerning anesthetic, they are put on the table.

My colleagues are often amazed that I give patients my home phone and cell phone numbers. They get it when I say to them: “You know, I get very few calls at home after surgery.” Here’s why: the patients are prepared, they know what to expect, and any questions that they may have had were answered before surgery. I’m not worried about getting a deluge of calls—before or after surgery.

Beverly Hills Cosmetic Surgery Follow-Up

Posted on February 10, 2010 by admin

The Pleasures of Follow Up With a Happy Patient!

I refer you to page 108 in my book, SECRETS OF A BEVERLY HILLS COSMETIC SURGEON, The Expert’s Guide to Safe, Successful Surgery. On that page in the section on correction of protruding ears, known medically as Otoplasty, is a photo Matthew Crosby before surgery and then after surgery in the office with yours truly. The book reproduced a nice handwritten note from Matt saying, “Thank you for making me look better. You did a great job. From Matt.” Plus a smiley face.

Dr. Kotler's Otoplasty Patient

So we received a Christmas card in December from Matt and his mom, Debbie Crosby. The Crosbys live in the northwest but Matt has been going to school out east. This tripych (collection of three photos) shows Debbie with school kids in India where she did some good missionary work. Matt and Debbie are in the middle photo and on the right is Matt doing some photography. Obviously Matt is a bit more mature than what is portrayed in the book because the current photos are about ten years after his surgery. From the photos, his ears look good and natural and we are very gratified. But most importantly, the Crosbys report that it was such a very positive experience for Matt to have his otoplasty procedure because he just felt a bit self-conscious as they stood out more than that of other young people.

One of the great joys of being a physician and particularly a cosmetic plastic surgeon are the inner rewards that come from having done good work for a young person that will last all that person’s life.