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. 

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.

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.

We are pleased to hear that Alexa Joel recovered from the overdose of over-the-counter mediations that she took.  These episodes should act as a wakeup call to patients who are considering cosmetic surgery.  The point is that one must understand that even over-the-counter medications have the potential to cause major problems.  That is why, before having any cosmetic procedure or any other surgical procedure, it is very important that the surgeon and the anesthesiologist both know all the medications one is taking.  That includes homeopathic and non-prescription medications, as well as prescription medicines, of course.  We even need to know about vitamins and supplements because, believe it or not, all these things can have an effect on the safety of anesthesia and even on blood clotting. I discuss all of this in great detail in my book, Secrets of a Beverly Hills Cosmetic Surgeon.

We always ask about “the 5Gs.”   The 5Gs are medications that can possibly interfere with normal blood clotting:  Ginkgo (biloba) , garlic, ginseng, ginger and goldenseal. Remember, we’re on your side.  We want you to have a safe, successful operation.  We’ll do everything on our end to have a successful outcome for you.  We only ask that you give us all the medical information that we ask for so that nothing is overlooked. So that going into the operation, all the “ducks” are lined up for a satisfactory and safe operation with a great outcome.

“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.

Before and After Photo from Robert Kotler, MD

First, the patient should have been told that until she lost weight she wasn’t an acceptable candidate.  Secondly, the procedure that she needed was a standard face and neck lift which would have addressed not only the excess fat in the neck, but the sagging skin, the sagging muscle and would have allowed for the maximum benefit.

The procedure was approximately 15% of the cost of a standard face and neck lift.

There are no bargains in life.  There are no shortcuts.  Indeed, in cosmetic plastic surgery as in other things, you do get what you pay for.

So why are we seeing so many redos?  My sense and that of other experienced nasal surgeons is that the rate of revision rhinoplasty is too high.   There is a small percentage of patients, who in the best of rhinoplasty surgeons’ hands will require touchups. However, my sense is that currently the percentage of poor results and dissatisfied patients is too high and would be unacceptable in other surgical specialties such as chest surgery, heart surgery or neurosurgery.

So what is it about cosmetic nasal surgery that lends itself to a high percentage of unsuccessful results?  I believe the reasons are related to the surgeons performing the procedure.  Today, because there are so many cosmetic and plastic surgery procedures that can be performed, often the training in each individual procedure during residency training is diluted. Too many residency graduates have had too little experience in cosmetic procedures and hardly any nasal cosmetic surgery training.  Nasal surgery is unquestionably the most technically demanding and artistic of all the cosmetic procedures.  It takes many cases performed under supervision of superior surgeon-teachers to deliver great results. If one cannot get that experience as a resident, the likelihood of practice success with those procedures, unless additional training is pursued, is dismal.

Dr. Kotler's patient - Revision Rhinoplasty before/after photo

Further, patients bear some responsibility.  They practice poor decision-making. The best-informed patients, who did their homework, realize that this is the age of superspecialists.  Surgeons who offer a multi-page menu of services are not likely to be superior at any of them.  Conversely, those cosmetic and plastic surgeons who offer a very limited menu, who operated as a boutique, rather than a department store, are more likely to deliver better results and, therefore, have a lower dissatisfaction rate. 

In my career, having performed over 4,000 nasal surgeries, including rhinoplasty septoplasty and turbinate surgeries to improve the airway, I have tackled some very difficult cases.  I do not think I would feel comfortable managing them were it not for my long experience, my superior training at several universities and my preceptorships plus my experience as a military surgeon during the Vietnam War.

In my book, Secrets of a Beverly Hills Cosmetic Surgeon, I mention that great training and long experience plus superspecialization is the formula for success in nasal plastic and nasal cosmetic surgery.

As I indicated in my best-selling book, SECRETS OF A BEVERLY HILLS COSMETIC SURGEON, we cosmetic surgeons need to understand the patients’ desires and need to study what they feel is important for their care and satisfaction.

We even asked about negative experiences that patiients have had with cosmetic surgery and also what are the informational sources that people rely on to get meaningful information as they begin their research to study cosmetic surgery.

Here is a synopsis of our findings:

• Most people who had previous cosmetic surgery had a good experience.  Those who did not have a good experience frequently cited the poor attitude and nonchalance of the office staff rather than dissatisfaction with the sugical procedure.  I find that very interesting that one’s impressions and, therefore, referral potential can be based more on issues of personal service by practice personnel rather than the technical quality of the result.

• We were interested in specific sources that people avail themselves of to learn about cosmetic procedures.  One of the strongest sources for many of the respondents was that they would value a personal referral.  They also place great importance on seeing the doctor’s before and after photo collection.  For those who are internet savvy, they relied on web sites for information but recognized that many of the sites regurgitate the same stale messages. 

• We asked the importance of communication in understanding what the patient could expect.  For that reason,  computer imaging got very high scores.  Most of the ladies were familiar with computer imaging although a relatively small proportion had it offered to them by surgeons they had consulted with. 

• Anesthesia issues came up.  Patients seem to have an inappropriate and uninformed fear of general anesthesia.  When we explained that many of the procedures are, in fact, done under heavy sedation with local anesthesia and yet are misinterpreted as general anesthesia by the patients, they were quite surprised.  This is a tribute to the quality of business, a tribute to the talents of our anesthesiologist such that in fact they were able to avoid some of the down sides of general anesthesia and yet give the patient complete freedom from knowledge and discomfort during the procedure. 

• One service that few offices offer and yet that I have always felt was a very important component of a good consultation is for prospective patients to speak with or meet, in person, the patients in our practice who have had a procedure identical to that which we propose for the prospective patient.   Those patients who have had previous procedures and had the opportunity to have such conversations and meetings were very rare but were highly valued. 

In summary, we understand that the most beneficial consultation to a patient will be when the most services are offered to the patient as part of the consultation.  This includes a consumer-oriented book that the doctor may have written, pamphlets and other handouts.  Also highly ranked was computer imaging, the before and after photo collection and an opportunity to speak with previous patients.

There were reports that an American neurosurgeon was summoned and flew immediately to evaluate Ms. Raymond who had been placed in a state of “induced coma” to hopefully minimize brain and/or heart damage suffered when her heart stopped.

This story is illustrative of several issues that I feel are worth examining.

First, the wisdom of leaving the United States for an elective procedure.  Traveling for cosmetic surgery may have some benefits but also carries some risks that do not exist “at home.”  Now, we are not privy to Ms. Raymond’s reasons for traveling to Brazil to have the procedure.  Did she go there because she felt that a surgical procedure or technique was available in Brazil but not available in the United States?  It is true that Brazilian cosmetic surgeons are a bit edgier than their American counterparts. Generally, it seems to us that they are comfortable taking on more aggressive – and hence riskier – surgical procedures.  That may be attractive to some Americans who cannot find a surgeon here willing to perform a more ambitious procedure that the patient seeks. 

Presumably, Ms. Raymond was not looking for a bargain. But, some Americans leave the U.S. is to save money.  Brazil may not be the least expensive venue for cosmetic surgery, but many countries offer services at considerably less cost.   But some of these countries verge on membership in the third world and, therefore, there are health and safety issues which should be addressed.   There are tradeoffs for saving money in all things in life.

There has been speculation that Ms. Raymond left the country to avoid the paparazzi.  That may well be.  However, most high profile or celebrity people having cosmetic surgery can – with proper planning with the office staff – avoid the paparazzi.   It is beyond the scope of this essay to describe the execution of such tactics, but “paparazzi evasion “is executed on a daily basis in Beverly Hills. 

So what might have happened and what lessons may be gleaned from Ms. Raymond’s experience?  First, we do not know how well she was “worked up” before the procedure.  It is very important that a reasonable yet thorough medical examination be done for any elective surgery.   There may be a consensus that eight weeks after delivery is not enough time for the body to reconstitute itself.  Typically, body repair can take up to one hundred days after any operation or trauma.  We do not know how the evaluation went but when in doubt, it is always better to postpone an elective procedure until well beyond a prior medical experience.
Recall that in 2004, when author of The First Wives Club, Olivia Goldsmith, died of an anesthetic mishap, prior to the start of a cosmetic procedure, The New York Times reported:  The Health Department cited the hospital with failure to do thorough pre-operative work-up on Mrs. Goldsmith…… How well Ms. Raymond was evaluated by her doctor and another prior to scheduling the procedure is as yet unknown.
That leads us to the issue of anesthesia. Since what happened to Ms. Raymond was a direct consequence of anesthesia rather than surgery, the question is:  “Who was at the controls?”  Was it a doctor anesthesiologist whose credentials might match those of board certified American anesthesiologists?  Was a nurse anesthetist in charge of anesthesia?  Did the surgeon conduct the anesthetic?  We do not know answers to that but we do know that the risk in elective surgery is from the anesthetic and not from the cutting and sewing.  
As I discuss in my book, Secrets of a Beverly Hills Cosmetic Surgeon, when complications occur  far from our shores, the mechanics and logistics of getting American-level care can be challenging.  It, of course, depends on where one is.  Brazil is not an unsophisticated country.  But obviously the family felt more comfortable having consultation by an American brain specialist. Thus, prospective foreign-surgery patients need to consider the “what if” of a possible complication and how it might be managed.  Also how long the patient might have to stay in that foreign country, and at what cost of dollars, inconvenience, stress for the family. 

Traveling for cosmetic surgery is most typically done to save money.  Whether for that reason or others, the decision to leave the US for such care carries additional risks.