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.

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.

Here, in Zip code 90210, there are some of the world’s most sophisticated cosmetic surgeons. “ The Golden Triangle of Beverly Hills, Zip 90210” has eye doctors who specialize in cosmetic surgery of the eyelids and brow and dermatologists who specialize in chemical skin peels and filler injections such as Juvéderm, Restylane, Perlane and of course, Botox  and Dysport.  We have other cosmetic plastic surgery specialists that have particular expertise in cosmetic breast surgery, both primary and revision breast augmentation.  There is one surgeon whose practice is nearly only breast surgery and he does revision breast augmentation for patients who have had work done elsewhere and are dissatisfied.

Other cosmetic plastic surgeons specialize in tummy tuck and liposuction.

I have always felt that the most specialized and highly focused talents should be the choices for patients.  Patients often don’t recognize or are unaware of the degree to which all medicine has become specialized, sub-specialized and superspecialized.  A superspecialist is a doctor who practices a very boutique practice, focusing on six or fewer procedures. Typically, he has taken additional training beyond a long residency and even after passing the rigorous board exam to become “board certified”.

As one of the doctors who appeared on Dr. 90210 and as a rhinoplasty superspecialist, I can attest to the fact that, unfortunately, there are patients who come to see us who have had substandard work done by surgeons who have had very little training in cosmetic and functional nasal surgery, and who have no focus in that area.  These surgeons may do everything from hair transplants to thigh implants and everything in between.  Rarely will they be the most experienced and proficient practitioners.

What prospective patients need to know is that if they put themselves in the hands of those surgeons who have long experience and a fine degree of specialization, they are more likely to have a satisfactory outcome.

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!”

Do rhinoplasties cost more in Hollywood than in other parts of the country?  I suspect they do.  There are several reasons for this.  One is that we do have more superspecialists here performing cosmetic procedures, including rhinoplasty.  Superspecialists tend to command slightly greater fees because of their prominence, their excellence lower rate of re-do or revision surgery.

The cost of doing business is higher in Hollywood than it is in Lincoln, Nebraska or Appleton, Wisconsin.  The labor costs are higher; nurses and surgical assistants command higher wages, all of which are a factor of the higher cost of living in California. Ditto for New York and other centers of excellence.

If one had blepharoplasty and chin augmentation he or she would expect to pay a bit more than you would elsewhere, although not greatly more than in other large cities that have very sophisticated practitioners of cosmetic plastic surgery including New York City, Miami and Houston.

When looking at costs in Hollywood or anywhere else, always be mindful to ask about “the entire cost.”  You need to know what additional costs there would be for the outpatient surgery center, and anesthesia specialists, medications and perhaps even a postoperative recovery facility in which to stay for one or two nights.

Hollywood has always been synonymous with stardom, with glamour, with beauty.

Not every Hollywood star arrived to make their career in the same state that they were delivered on earth.  What I am suggesting is that many people in Hollywood  have undergone cosmetic plastic surgery to improve their appearance because much of their success is tied to what their face and neck look like on the screen.

For some of the greats like Marilyn Monroe and Dean Martin it was a nose job or rhinoplasty.  For others it was upper eyelid surgery to reduce the sleepy look.  For those with bags under the eyes, the appropriate procedure would be lower lid blepharoplasty.  There have been chin augmentations and neck sculptures and even pinning back of ears.  Some stars should have had their ears pinned back, e.g. Clark Gable.

But the best rhinoplasty surgeon in Hollywood would be the surgeon who delivers natural looking results so that you would not know that the patient had ever had a rhinoplasty.  I have visited photo archives and I have seen many of the before and after photos and I could tell you that Dean Martin had an excellently performed cosmetic nasal surgery and you would be hard pressed to know that he was born with any other nose – but he was.

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. 

As is my personal tradition for many years, I don my Army uniform and join the public and past and present members of the military at the traditional memorial services at the Los Angeles National Cemetery here in West Los Angeles adjacent to the Westwood UCLA campus.  The cemetery, as nearly all military cemeteries are, has a certain beauty and holiness about it.  85,000 military are buried here cemetery. 

As we listen to speeches and commemorations from soldiers past and present and our civilian leaders including Governor Schwarzenegger, and Los Angeles Mayor Antonio Villaraigosa, there is plenty of time for thought.  I think particularly about some of the advances in medical care that have followed war-time experience. 

Today, in 2010, surgery upon blood vessels, so-called “vascular surgery,” is very common. Blood vessels are rerouted, bypassed, all of which allows injured patients whether in the civilian or military sector often to still have functioning arms and legs.  During the civil war, the most common operation was amputation.  Nearly every injury to the extremities was addressed by amputation.  There was no attempt at repair and the surgical world at that time being unsophisticated did not have the ability to save limbs which typically are lost because of damage to the major veins and arteries.

Even in World War I and World War II, not much progress had been made in salvaging severely damaged arms and legs.  But during the Vietnam War, particularly due to the activities of one surgeon, Colonel Norman Rich, battlefield and military hospital advances were rapid such that techniques were used to repair and bypass and replace injured blood vessels such that the amputation rate was much lower. 

Yes, wars are horrible. Nonetheless, a positive by-product of recent wars has been enormous advances in battlefield medical care, including rapid evacuation of the wounded. Today, 99% of all injured soldiers who reach a battlefield medical facility will survive their wounds. An amazing accomplishment!

Robert Kotler, MD, FACS
Former Major, Medical Corps, U.S. Army

Cosmetic plastic surgery has a dilemma in that most of the training programs in plastic surgery are not spending enough time in the training and maturation of competent cosmetic surgeons. 

Unfortunately, almost all the residencies of plastic surgery are conducted at universities where the emphasis is on reconstructive – not cosmetic – surgery.  University budgets are not adequate to support residency training for procedures where there is no insurance reimbursement.  And patients are reluctant to go to universities because they understand that surgeries are done by surgeons -in -training and not by experienced practitioners. 

The answer is that doctors who wish to practice cosmetic surgery must take additional training after the residencies and even after achieving board certification.  Because most of the residencies emphasize the reconstructive arm of cosmetic surgery and not the cosmetic arm of cosmetic surgery, it behooves those who wish to practice solely cosmetic surgery to take additional training in the form of a fellowship which is an apprenticeship beside an experienced practitioner.

 A  wonderful way to learn and well worth the extra time and effort.

Several weeks ago, I was in the Palm Beach, Florida area visiting friends and my parents who are snowbird-refugees from the Upper Midwest.

We discovered that my father was having difficulty with one of his teeth and a root canal problem was suspected. We called the endodontist or root canal specialist to whom we were referred by my father’s family dentist. Understanding the urgency because there were some corollary medical issues involved, the dentist’s staff was extremely accommodating and made room in their schedule for the consultation on a relatively short notice.

I knew I was dealing with a first class office when I called and requested driving instructions to get to the office since I wasn’t familiar with the Palm Beach area. The staff was happily helpful and understood my plight as a visitor. When we arrived, we received a warm welcome and my dad was promptly seen by the doctor. He made his assessment and agreed with the diagnosis of the family practitioner that the cause of the pain and possibly a lurking infection was a root canal problem. He recommended that a root canal procedure be done but graciously offered my dad the choice of either having it done by him or by a similar specialist in his home town. When we decided that we were comfortable and that the time was short to correct the problem and hopefully avert any further infections, the dentist staff changed their schedule for the afternoon to allow the additional time necessary to perform the procedure.

Following the procedure, the dentist called my father’s family dentist back home to report on what he had found and made some recommendations. He then dictated a report that would accompany a portion of the tooth that had to be removed for the benefit of both the general dentist and the endodontist specialist who would be seeing my father when he returned home.

Everything was done so smoothly, efficiently and with the interest of the patient at heart.

I have always felt that dentists excelled in the management of their professional practices. I suspect that is because their curriculum in dental school includes courses and instruction on practice management. In the world of medical education, we do not have parallel education experience.

I relay this information to you because you are always entitled to receive the best from professional offices and you can usually tell from the very first phone call how welcome you will be and how attentive to your needs both the doctor and his staff will be. If at any point in the relationship with the doctors office you are not comfortable because you feel that you are “being treated like a number” or there only as a dollar sign to be posted to the bank account, my suggestion is that you respectfully decline further care, ask for copies of your medical records and move on to another specialist.

Kudos to the Dentist in Palm Beach, Florida for the excellence of his professional services and being an inspiration for this blog.