Secrets of a Beverly Hills Cosmetic Surgeon

Smoking and Surgical Risks

2011-06-30T19:24:54Z

In the recent Bulletin of the American College of Surgeons, there was a reference to a paper that was published in the medical journal Archives of Internal Medicine. The study, done in England, was an analysis of the effect of smoking cessation prior to surgery. It was noted that, “Worldwide, more than 70 million adult smokers undergo major surgical procedures every year.” That is a big number. And of course there are the issues of other medical conditions that some of these patients may have, which play into the risk factors.

In elective cosmetic surgery, typically patients are healthy and carry less risk. However, smoking up till the time of surgery is definitely a “no-no.” The study was comfortable in its conclusions that eight weeks without smoking prior to surgery significantly reduced the risk factor. Our experience has confirmed that.

However, it should be noted that cigarette smokers generally have poorer circulation as a result of many years of smoking. Therefore the surgeon still has to take into account the extent of the procedure and the risks therein when the patient has a history of smoking, since their skin circulation, even without smoking two months prior to surgery, may still be impaired.

- Robert Kotler, MD, FACS

More from WebMD

Video: Good Looks Go Up in Smoke
Slideshow: Surprising Ways Smoking Affects Your Looks and Life

Photo: iStockphoto

Fighting Acne and Aging?

2011-06-28T18:54:53Z

Can a single product fight pimples and attempt to beat wrinkles?

There was an interesting article in a recent issue of The Wall Street Journal about products targeted at adults with acne. You have probably seen products now being marketed as having an anti-aging benefit as well as bringing the fight to acne.

What I see is that the cosmetics industry realizes that they can broaden the appeal of a single product by directing interest to both young and old. Younger people suffer from acne. Older people despise wrinkles.

The article points out that the combo skin care products can contain antibacterial, anti-acne ingredients, such as benzoyl peroxide. They may also contain salicylic acid, which helps clear the pores. These medicines are the old reliable — they work. It is clogging of the pores that sets the stage for acne whether it is adolescent or adult skin. Remember, each acne spot is a mini-infection.

The other components of the dual-mission products can be moisturizers and clarifying cleansers to further improve the skin’s appearance, and, hopefully, slow the aging process. A frequently recruited fighter against aging would be retinol, a form of retinoic acid (Retin-A), as an ingredient.

Read the labels, study the components, and make a good decision. Most importantly, you do not have to spend a fortune on these products. Remember, often, the difference in product cost reflects the expensive product’s need to recapture its marketing and advertising expenses.

- Robert Kotler, MD, FACS

Sunshine and Sunscreen Surprises

2011-06-23T19:43:43Z

Recently, an excellent article appeared in the Westways magazine, a publication of the Automobile Club of Southern California. The title was, “Here Comes the Sun — 10 Things You Should Know about UV Protection.”

I learned quite a bit from this article. Here are some highlights that I want to share with you.

1. Most people do not use enough sunscreen to be effective. According to one of the doctors quoted, you need a “shot glass, a minimum of two ounces, for full-body protection.” That is a lot. That is the equivalent of four tablespoons. You will know when you have enough on when you still see the sunscreen after slathering it on.

2. You need to apply sunscreen every two hours, and even more often if you are swimming. In other words, concerning the volume mentioned above, and the frequency, be prepared to bring a large bottle of sunscreen.

3. The SPF number applies only to UVB (ultraviolet B) rays. We need to be aware of the UVA (ultraviolet A) rays, also. These also contribute to skin cancer and cause premature aging. The best bet is to buy a sunscreen that covers both UVA and UVB light.

4. Every suntan implies a bit of skin damage. Do not forget that. We all look great with a tan, but every tan is a sign of the body’s reaction to the sun. For the body to react to the sun, there must have been too much sun!

5. Just because you did not spend this year in the sun does not mean there is not a long-term cumulative effect. There is a negative cumulative effect of sun exposure. The sun we got 20 years ago, 10 years ago, and 5 years ago, like a time bomb, will manifest now and in the future. Therefore, young people need to think sun protection. Middle-aged people have already figured out that youthful skin spent in the sun won’t look so glamorous later in life.

6. Sunglasses will help protect your eyes from damage. Cataracts, thickening of the eyes’ otherwise clear lens causing cloudy vision, develop as a result of aging and sun exposure. For this reason, do not forget your sunglasses on those sunny days!

~Robert Kotler, MD, FACS

Photo: Hemera

Computer Imaging as a Reality Check

2011-06-16T19:59:50Z

Readers of my blogs know that I am a big fan of computer imaging. Computer imaging, at consultation, demonstrates the predicted results of the procedure(s) on a computer screen.

What I have always liked about computer imaging is that it puts “on the table” what can and cannot be achieved. It is no longer a mystery as to what one will probably look like after surgery when you can see it on a computer screen. I have no problems showing the anticipated result, as long as I feel I am capable of delivering it.

Like most super-specialized and experienced cosmetic plastic surgeons, I would never portray a result that is beyond my capabilities, nor achievable by the surgical techniques of the day.

Recently, we had a very interesting re-consultation with a young woman concerning her nose. This encounter reminded me of the importance of computer imaging as a common ground for the best communication between doctor and patient. I immediately realized that this story would be valuable to you, my reader.

The young woman, 29-years old, had had two prior cosmetic nasal surgeries, rhinoplasties, in her native country as a teenager. Then she immigrated to the United States and, last year, had a third operation on her nose. She was unhappy with the first two operations and was still unhappy after the third. She consulted with me to ask if any further surgery could be done to improve her nose and match her concept of the “right nose”.

As is our office’s usual practice, I asked the young lady to provide me with photographs and medical records from the last treating surgeon’s office. She did that, and I was able to see the “before” pictures. That gave me an idea of what the last surgeon was able to accomplish. This is very important for the surgeon contemplating yet another operation because it may be that the changes that were achieved were all that one could reasonably expect to be accomplished.

I was impressed with the improvement that she received from that third operation. Frankly, it confirmed my impression that she had pretty much reached the limits of what surgery could accomplish for her.

Predictably, she was disappointed with my decision that further surgery was unwise.

While she was disappointed with my stance, what helped our patient understand the wisdom of my recommendation was a very detailed analysis of her current facial features on that computer screen. These very detailed photographic images showed her that, in fact, nature had created a rather wide distance between her eyes. Therefore, the nose, which must “fill” the distance, could not be significantly narrowed. It was anatomically impossible. I felt that her request, that the nose be further refined, was not achievable. Were another attempt be made without success, the patient would be very disappointed. Certainly, the surgeon would not be very gratified.

Without this detailed analysis of how her face was structured, which was only possible looking at the images on the computer screen, it may have been impossible for our lady to appreciate why I declined to operate.

Every surgeon needs to make the important decision: “Is it likely my surgery will be successful?” Even more importantly, “will it satisfy the patient?” In this case, I felt that I could not achieve the result the patient had fashioned in her mind. Only when I explained the anatomy that we saw on the screen, could the patient acknowledge that her construction ruled out another failed attempt to achieve the impossible.

The word “doctor” is derived from the Latin, docere, “to teach”; like “docent”, one who teaches at a museum.

We doctors should always be teachers. Not only of the generation of doctors who will follow us, but teachers to patients. Patients need to understand the complexity and challenges of what we do and that not always can we meet their conceptions and desires. Often, we need to remind them of our humility; that despite our desire to serve, the decision to serve is never knee-jerk. That “Go” or “No go” must be carefully thought out.

- Robert Kotler, MD, FACS

More from WebMD

WebMD Video: Computer Imaging for Cosmetic Procedures

Photo:Dr. Robert Kotler

A “Fabulous” Book Worth a Read

2011-06-14T19:48:26Z

Recently, I was very pleased and honored to receive a signed copy of a new book, Fabulous Faces: From Motivation to Transformation Through Facial Plastic Surgery, by Peter A. Adamson, MD.

Dr. Adamson is a very distinguished facial plastic surgeon who practices in Toronto, Canada. His book, Fabulous Faces, is a collection of short essays from several patients. The patients basically “tell their story.” Each of the patients has given an excellent and comprehensive summary of all the issues of their cosmetic facial procedures.

In addition, there are good chapters that emphasize the importance of doctor selection and how skin care can enhance any surgical makeover.

I particularly enjoyed Chapter Four, “Body Image,” which explains how perception of one’s appearance is the critical issue in the decision whether or not to have cosmetic enhancements. Of course, perception often is not the same as the true body shape and form.

I highly recommend the book because it is an easy and meaningful read. It also includes an excellent bibliography and a very nice glossary.

~Robert Kotler, MD, FACS

A Subject Rarely Discussed: Hidden or Buried Penis

2011-06-07T20:23:14Z

In the world of educating the public about skin care, beauty and surgical and non-surgical cosmetic procedures, often, some conditions — usually less glamorous — can be overlooked. Yet, these conditions can cause as much distress and concern to those afflicted as teenage acne, congenitally asymmetrical or deformed breasts or super-enlarged noses.

One of those “orphan subjects”, if you will, is the hidden or buried penis deformity. In the operating room, I have seen the malformed anatomy and can understand the great anguish, not generally shared with friends or family, that accompanies the condition.

I have invited Gary Alter, MD, of Beverly Hills, to discuss the hidden or buried penis and explain how he deals with it. Dr. Alter, a world’s authority on plastic surgery of the external genitalia, is a UCLA Assistant Professor, board certified in both urology and plastic surgery, and thus uniquely qualified.

Dr. Alter, as was I, was a featured on E! Channel’s DR 90210. One of his most-enlightening segments was devoted to the surgical correction of the condition.

- Robert Kotler, MD, FACS

A “hidden” or “buried” penis refers to a penile shaft that is buried below the surface of the penile skin and also to a partially or totally obscured penis. There are numerous causes of a hidden or a buried penis including congenital, obesity, aging with an overlying fold of abdominal fat and skin, a shortage of penile skin from chronic inflammation, or an overly aggressive circumcision.

A congenital buried penis is rare. It includes an abnormally large pubic fat pad and firm tissue that pulls the penis inward. In addition, there is a congenital lack of attachments of shaft skin to the penile shaft. In a normal infant or child with congenital buried penis, inadvertent removal of excess normal shaft skin during circumcision can leave a variable amount of foreskin and a shortage of shaft skin. If the circumcision line is placed too far from the head of the penis, normal shaft skin is removed and foreskin is left to cover the shaft. Since foreskin does not have normal attachments to the deeper shaft, the buried penis is created or made worse. In addition, the incision line can narrow upon healing, further burying the penis by pushing it downward into the pubic fat.

Adults also have either inadequate skin or a lack of attachments of the penile skin to the deeper penile erection chambers. In the latter case, the penis thus goes inside the body while the skin stays on the outside, sometimes giving the appearance of an uncircumcised or absent penis. The skin of the lower abdomen and pubis sags with age, causing the penis of some men to hide under the excess skin and fat. Obesity makes the concealment of the penis worse. There is a wide variation from the very mild to the very severe deformity. The penis may look normal when standing but bury with sitting or bending over.

As with the child, circumcision on an unrecognized buried penis can remove normal shaft skin instead of foreskin, thereby worsening the situation. If a second circumcision is performed on a boy or man with concealment, it may complicate reconstruction by removing the remaining skin, thus, necessitating a skin graft.

If the patient has a severe buried or hidden penis, the penile skin and head of the penis can become chronically irritated by chronic dampness, causing discomfort. This irritation can cause progressive destruction of the penile skin with further burying and constriction of the penile skin, thus preventing the head from being visible..

A hidden penis can cause severe self-esteem issues. These boys or men may not have a visible penis while standing and may have to sit to urinate. A boy or young adult can be ridiculed and made to feel inadequate by siblings or friends. It is not uncommon for concerned parents of a young boy to go to the pediatrician or pediatric urologist. Unfortunately, there is tremendous misinformation and lack of education even amongst these physicians. The parents are usually told that their son will outgrow the deformity if he loses weight or when he reaches puberty. Unfortunately, this is untrue in most instances especially if the boy has a moderate or severe buried penis. The boy is then lives with this psychologically traumatic deformity that could be corrected with a relatively non-invasive procedure.

Adult males are also told that nothing can be done or that weight loss will correct the situation. Unfortunately, these men and boys often avoid social interactions that may require undressing, thus, severely affecting their lives. They may not participate in team sports or even date in order to avoid embarrassment and rejection. Social isolation can occur.

The surgical correction of a buried penis depends on the abnormality. However, marked improvement can be achieved in almost all patients. The correction is based on re-establishing the connection of the erectile chambers of the penis to the penile skin along with the removal of excess pubic fat and/or skin.

In severe cases of buried penis in which the patient has inadequate penis skin resulting from an overly aggressive circumcision or chronic inflammation, then the penis must be freed and covered with a skin graft.

The surgery is usually performed as an outpatient unless a skin graft is needed. The improvement in penile and pubic appearance can be dramatic. Equally impressive is the patient’s positive personality and self-esteem improvement leading to more self-confidence and social interaction.

For more information and photos see www.garyalterplasticsurgeon.com.

- Gary Alter, MD

The Psychological Risks in Cosmetic Surgery

2011-05-20T15:41:48Z

Recently, on the Huffington Post Living website, there was an excellent article by Dr. Vivian Diller, a clinical psychologist. The title was, “A New Face: What are the Psychological Risks?”

Dr. Diller has long been a good student of beauty and self image, so she is well-qualified to comment on what is a very important consideration before a patient should request, and a doctor should agree to, an elective cosmetic procedure.

As in all diagnostic sessions, Dr. Diller recommends gathering as much information as possible, beginning with the patient’s motivation. She conducts what she calls, “exploring.” It is important to know more about the patient’s desire. Particularly, as Dr. Diller mentions, “Cosmetic changes may seem superficial, but they are permanent, can have far-reaching emotional consequences, and deserve careful examination.“ Amen.

I will not belabor some of the particular points that she makes. Please read the article. I think it is well worth reviewing.

Anyone considering cosmetic surgery has to look at all issues, beginning with what the patient expects the surgery to achieve. And is it affordable? After all, it is a luxury.

I should mention Dr. Diller’s book, Face It: What Women Really Feel as Their Looks Change. I was not aware of the book, but it looks very worthwhile. I will make it my business to read it and pass on to you what I glean from the book.

- Robert Kotler, MD, FACS

Sleep Apnea and Nasal Obstruction

2011-04-26T17:06:27Z

Photo: BananaStock

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 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: a blocked nose — nasal obstruction.

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. More on this to follow.

- Robert Kotler, MD, FACS

Who Is the Best Person to See for Cosmetic Surgery Where I Live?

2011-04-21T20:28:57Z

Advice to a Friend in Another City

Often, I receive requests from friends and family who live at a distance regarding “the best person to see for cosmetic surgery where I live.”

While I know many of the most sophisticated and specialized cosmetic surgeons in the U.S., I certainly don’t know all of them. After all, there are plastic surgeons, cosmetic surgeons, cosmetic facial surgeons, facial plastic surgeons, and dermatologic surgeons in every state. I can’t know them all.However, there are some basic principles that I can impart to these friends and family members, which hopefully will help them and expedite the process.

First, I always suggest that they read good, consumer-oriented books about cosmetic surgery, which often include valuable tips on the right way to do the “homework.” And homework is very important.

Obviously, two of my favorites are Secrets of a Cosmetic Surgeon, The Expert’s Guide to Safe Successful Surgery and The Essential Cosmetic Surgery Companion – Don’t Consult A Cosmetic Surgeon Without This Book!, both authored by yours truly.

For patients considering body work, I like The Beverly Hills Shape, The Truth About Plastic Surgery by Stuart A. Linder, MD, who practices just across the street. Dr. Linder is to the body what some of us are to the face: a superspecialist. His procedures are limited to the trunk and extremities. Obviously, he has great experience in the most common cosmetic-surgery procedure performed on the body — breast augmentation. In addition, of course, he is a pro at breast reduction, revision, liposuction, and the tummy tuck. Recently he has appeared with Dr. Oz on national television in a series of three segments, which included liposuction procedures for the “muffin top” of the abdomen, the “bra bulge” just under the armpit, and the saddlebags above the backsides of the thighs.

After you’ve boned up book-wise, I suggest visits to websites. Check out the doctors who have the thickest, most rich websites, and they should be loaded with before-and-after photographs. One, two, five, or ten is never enough. There should be hundreds of technically consistent photographic examples of the doctor’s work. You also need to study the doctor’s biography and see how much training he’s had and how specialized the training was. Look for doctors who have served cosmetic-surgery fellowships after they have already become board-certified specialists. Look for comments from patients that appear on the website, so you get a handle on how they perceive their care.

After you’ve narrowed your choice down to a few doctors, go for the consultation. A consultation without computer imaging, to show you the depicted result of your procedure, is not worth very much, in my opinion. You need to get a sense of what the doctor can do for you, and he needs to be comfortable that you would be satisfied with the result that he depicts. You also need to meet with the staff and see how attentive they are to your needs. Will they provide you all the support that you need before and after surgery? Does the practice provide supplies and medications that you require after surgery; having to stand in line at a drugstore the night after surgery is nobody’s idea of fun, particularly if the patient is in pain. The top practices handle everything for you. Does the practice provide arrangements for a stay in a professional facility after surgery if you’re coming from a far distance?

Finally, the practices that are the most specialized and the most sophisticated generally have a huge roster of former patients who will not only discuss their experience with you but would meet with you in person so you can see the results. That’s even better than the before-and-after photos.

It takes a lot of work, but like everything in life, you get out of it what you put into it. You want to do cosmetic surgery right the first time.

- Robert Kotler, MD, FACS

Who is a “Doctor?”

2011-04-19T18:57:53Z

Photo: Ryan McVay

Recently, there has been some proposed federal legislation that would require health professionals to avoid patient confusion by means of a mandatory name badge indicating the doctor’s particular credential.

For example, today, the word “doctor” is to be applied to: a physician, MD; a dentist, DDS; chiropractor, DC; osteopath, DO; doctor of philosophy, PhD; doctor of pharmacy, PharmD; podiatrist or doctor of podiatric medicine, DPM. There are even “naturopathic physicians” that refer to themselves as “doctor,” carrying the degree ND for naturopathic doctor.

Yes, it is confusing. The interest in this legislation is that an American Medical Association survey earlier in the year found that “44% of 850 adults queried nationwide think it is difficult to understand health care ads.” Further, “although 90% of those surveyed said that a medical doctor’s additional years of education and training are important, the survey found much confusion about the qualifications of health care professionals.”

Being able to distinguish “who’s who” is most important in a hospital or large medical center setting. For example, in such environments, it is hard to determine the nature and role of the professional serving you. Everybody seems to be wearing a white coat. Some are wearing scrub outfits; some aren’t. You are seen by a host of people. Further, it is also hard to differentiate between physicians, residents, interns and medical students.

At my medical school, there was a rather simple way of differentiating the various rankings in the teaching hospitals. Beginning in the second year, medical students wore ties and white jackets. Interns wore the same white jacket but also wore white pants and a white high-collared shirt. Residents wore ties and long white coats. The teaching staff, the so-called attending physicians, wore ties and long gray coats with their name on it. The system worked. I’m not sure why it is not more common elsewhere 40-some years later.

Because of the looming changes in health care delivery, it is going to become even more complex to figure out who is treating you. It is important. The best way to determine the profession and rank of anyone caring for you is to merely ask. I further remind you that when in a hospital, keep a written log of the people taking care of you and don’t be shy about asking them their name and “what is your particular degree or specialty?”

After all, you don’t want any mistakes and you want to be talking to the right person.

- Robert Kotler, MD, FACS