There is something magical about computer imaging.  The uniqueness is that the prospective patient can see their predicted result on a computer screen and immediately understand “what it is all about.”

The discussion of cosmetic procedures is often very abstract without some visuals.  The most powerful graphic they can have would be a computerized prediction of the outcome of whatever procedure they are considering, whether it is rhinoplasty, blepharoplasty, face and neck lift, chemical skin peel or neck sculpturing with or without chin augmentation. 

Previously all we had available to demonstrate to patients would be a magic marker to “erase” the bump on the nose.  We have used computer imaging in our practice since 1989.  Today’s technology, of course, is far advanced over those rudimentary computer systems we had and patients very much appreciate the chance to have that as an important part of their consultation.

In Hollywood, the home of the stars, we sometimes kid our patients who come from out of state to see us that “Welcome to Hollywood, now we will show your transformation to a Hollywood star!”

The one great truism about cosmetic procedures is that surgery is incapable of removing wrinkles.  Surgery’s role is to correct sags and bags and reconstruct tissue.

Wrinkled skin is a matter of the skin’s deterioration.  A loss of elasticity.  The causes include too much ultraviolet light from years of suntanning, cigarette smoking, poor lifestyle including inadequate exercise and poor nutrition.  Think of wrinkled skin as having its tiny little rubber bands within it that has given its elasticity as having deteriorated and stretched out.  The skin no longer has the qualities of a new rubber band.

Understanding also that a wrinkle is the equivalent of a fault on the surface of the earth.  To some level, there is a crack in the tissues of the skin just under the surface.  Incidentally, wrinkles tend to occur more at sites of movement.  That’s why people have crow’s feet around the eyes from squinting.  They have deep vertical lines on the upper lip particularly from pursing their lips while smoking a cigarette.  So you have to look at areas of functionality and understand that usually those are the areas that begin to demonstrate wrinkling earlier in life. 

The neck skin is unique in that it is not as blessed as facial skin with respect to healing potential.  This is very important to understand.  We have very good success on the face.  We can remove wrinkles by using several techniques including deep chemical skin peeling and laser treatment.  These procedures are invasive although not surgical.  The chemical or the laser beam invades the outer portion of the skin causing the surface tissues to be erased and inducing fresh new tissue below the surface.  The new skin is indistinguishable from that of a younger person.  When the skin is injured, it knows only  how to regenerate brand new, fresh, younger tissue.

The neck has much less potential for healing because due to its unique anatomy and thinness, it cannot tolerate much injury.  If the skin cannot be subject to a controlled injury such as from the laser or chemical, it cannot be rejuvenated.

There are things that do make the neck skin look younger. Although not as successfully as the laser and chemical facial treatments.  Today, technology has delivered Intense Pulse Light and recently what seems to be a very promising technology, the second generation fractionated CO2 laser.  These procedures excel in removing brown spots, eradicating the red spots and erasing that long-term sun damaged look.  However, they are not as successful, at this point, as we would like them to be with respect to tightening the skin enough to make the wrinkles disappear.

But science never sleeps and technology continues to expand exponentially, we look for even better technologies and products coming down the line. 

Recently, the news about some cosmetic treatment has not been good.  Nonphysicians injecting the equivalent of WD40 into women’s buttocks.  Skin peels being done in doctor’s homes.  What is going on here?

The common denominator in some of these stories of outlandish and nonprofessional conduct is that procedures which may not be surgical and yet still involve treatments are being done in inappropriate locations.  Why is that?

One reason is that the practitioners do not have the qualifications to do the procedures in a facility which is accredited or licensed.  What that means is that a facility that has certain standards that all its physician staff members must meet are being bypassed.  It is easy to make a case for accreditation and, therefore, qualification of surgical facilities.

Understand that physicians are not obligated to perform procedures in properly credentialled facilities but for those physicians who wish to operate at the highest professional level, they should be.

It is not appropriate to have nonphysicians perform procedures, of course, and it is equally improper for physicians to perform procedures for which they are not qualified and yet evade the stringent requirements of a surgical facility.  There should be no “underground” procedures.

So prospective patients need to ask, where will my plastic surgery procedure be performed?  Is the facility licensed by the state, certified by the United States government or accredited by an independent accrediting organization?  In my book, THE ESSENTIAL COSMETIC SURGERY COMPANION, Don’t Consult A Cosmetic Surgeon Without This Book!,  we list the organizations which act to credential surgical facilities.

Yes, this seems like a lot of work and, yes, it takes a little bit of time but is anything more important than getting the proper care in the right and safe location?

I am glad that the internet has become such an important educational tool for all of us.  In the world of cosmetic plastic surgery, it has allowed prospective patients to do a “quick study” of the subject.  Today, patients come to the office with much more knowledge than they did previously, and I see that as very healthy. 

It is also important to demystify what we do.  There is no magic or hocus pocus in cosmetic facial surgery.  We operate and we use chemical skin peeling or lasers to erase wrinkles and age spots. We inject paralyzants such as Botox and Dysport for forehead and brow wrinkles and deep smile lines.  We treat with fillers such as Sculptra, Restylane, Perlane, Juvederm. Each of our processes, procedures and techniques have value.

Patients come in understanding what some of these procedures do.

There are other ways that we help educate and demystify. The most important is computer imaging.  Computer imaging allows us to morph your digital photo head shot and show you he predicted result of any and all of the cosmetic enhancements that are available.  Then, the patient has a very clear image of the result.  You can see for yourself whether or not the improvement demonstrated would be reasonable and satisfactory to you.  They can also decide if it is worth the outlay of dollars and time.  There is nothing like a graphic, a photo, an image, when you are talking about cosmetic surgery, a visual subject.

I have been a devotee of computer imaging since 1989.  The technology at that time was rudimentary compared to today, but we still had very satisfactory ability to communicate with the patient.  That’s what computer imaging is; a communication tool so that the patient no longer has to read the mind of the surgeon with respect to envisioning the “after”.

Besides viewing the computer imaging at the office, we send the patient a hard copy in the mail so they can keep it at home, share with their family, and receive some input.

As far as I am concerned, a consultation with a cosmetic plastic surgeon is not worth very much if it doesn’t include computer imaging.  After all, why guess what you will look like after cosmetic plastic surgery?

“Care Package” is a term very familiar to many Americans regardless of interest in cosmetic surgery.  The original Care Packages were donations of food and supplies to the poor of war-ravaged Europe, beginning in 1945.  Americans, the most generous people in the world, not only helped prop up devastated Europe through the economy-boosting Marshall Plan, but individual Americans sent care packages to share with the less fortunate in England, France, and even to our former enemies, Germany and Italy.

Today, 60 years later, in the world of cosmetic surgery, the term Care Package has now become common parlance for a kit that contains all the supplies and medications necessary for home care after cosmetic plastic surgery.  Since cosmetic facial surgery including rhinoplasty, with or without septoplasty and turbinate resection to improve nasal obstruction, face and neck lifting, eyelid surgery, chin augmentation, neck sculpting, liposuction and chemical skin peel, are outpatient procedures – not hospital procedures.  It is important that patients have all the needed supplies and medications, at hand, at home.

I have always felt that it is incumbent upon the cosmetic plastic surgeon’s office to provide as much guidance and support for the post-operative care as possible, regardless of where the surgery took place: hospital, outpatient surgery center or office operating facility. I stressed that in both my books, SECRETS OF A BEVERLY HILLS COSMETIC SURGEON and THE ESSENTIAL COSMETIC SURGERY COMPANION.  For that reason, our home care package includes pain medication, antibiotics as appropriate, and all routine wound care supplies.  Such home care supplies would consist of nose sprays, both decongestant and refreshing saline or salt water. These are important after cosmetic plastic nasal surgery or functional nasal surgery including septoplasty and turbinate resection.  The kit has vitamin A&D ointment to be placed inside the nose to prevent crusting as well as small dressing pads placed under the nostrils to collect any drainage from the nose.

Dr. Kotler's post-op care kit given to his patients to take home after surgery

The Care Package for facelifting, eyelid surgery, chin augmentation and neck sculpture would include Q-Tips and ointment for application of the ointment to the incisions.   For chemical skin peel patients, there are additional supplies including special eye drops and large amounts of antibiotic ointment to be placed on the healing facial skin.

Procedure-specific written instructions are provided for each operation performed and are also placed in the bag.  Further, the patient has a listing of my home telephone and cell phone numbers so they can reach me immediately.

As I have always stressed to the young doctors I teach at UCLA and USC, the care of a surgical patient does not end with placement of the last stitch.

Beverly Hills indeed is a Mecca for people seeking improvement in their appearance.  This applies for all the procedures done including facelifts, eyelid surgery, chin augmentation, chemical skin peels, breast augmentation and reduction, tummy tuck and liposuction.  There is a skill level in Beverly Hills that is not found in most American cities.  With the high concentration of cosmetic surgery superspecialists, there are at least five reasons that patients come to Beverly Hills for a second rhinoplasty surgery:
1. The patient had an unsatisfactory experience with a less specialized and less-experienced surgeon elsewhere.

2. Patients recognize that a revision rhinoplasty is a more difficult case and this calls for
 the talents of those who make rhinoplasty the featured procedure in their practice.

3. Patients know that Beverly Hills is well equipped to handle the out-of-town visitor and
 patient.   Nearby hotels cater to patients.  There is a professional recovery
 hideaway where one may have round-the-clock nursing services, within a hotel, which
provides 24-hour room service.  This “recovery hideaway” provides transportation to and from the office. 

4. Beverly Hills is only 20 minutes from Los Angeles International Airport.  Patients often are accompanied by friends or family. Some families with children take the opportunity to make it a mini vacation.   After revision rhinoplasty, patients are not prisoners in their hotel room.  After one or two days, it is possible to be outdoors and out and about and participate in some tourist activities.

5. There are some surgeons in Beverly Hills who do specialize in non-surgical rhinoplasty revision surgery.  Using temporary or permanent injections, often a revision rhinoplasty surgery can be avoided.  The service is generally not available in most other American cities.

Before/After of Dr. Kotler's chemical peel patient.

Chemical skin peel which is also known as a chemical facelift, is in fact the chemical wrinkle line removal process. The acid-like prescription which is prepared individually for each patient is painted onto the skin and over a period of five days, the outer layers of skin literally sloughs off revealing fresh new pink skin underneath.

The procedure is done under an anesthetic in a licensed outpatient surgery center. I always have a doctor anesthesiologist administer the anesthetic. The postoperative recovery period is also very important. All our patients stay in a professional post cosmetic surgery recovery facility for two nights. Following that period, dressings are removed and the remainder of the skin care is done at home for the next three days.

One week after the procedure, the fresh new pink, wrinkle-free, smooth and youthful skin is present. Now it is appropriate to use camouflage and cosmetics such that one can return to normal work and activities typically at two weeks after the procedure has been performed.

Dr. Kotler's patient who had a chemical peel (phenol) in 1986 and still looks amazing!