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.

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. 

That is what a patient said to me after we performed rhinoplasty, or cosmetic nasal plastic surgery, upon her teenage daughter.

Perhaps what she saw as setting us apart was that in our practice, it is 24/7 coverage for the patient.  Our patients receive my home phone and my cell phone numbers.  They are free to call me at any time.  If I am not out of town, I am on call 24/7 every day.  Of course, when I am out of town I have coverage from not only our office staff but two doctors as backup.

Yes, we do practice the old fashioned way.  We stay in close touch with our patients.  We see them often after surgery to check and make sure all is going well; we don’t like surprises.  And, Saturdays and Sundays are just another work day for us when patients need to be seen for either routine or special post-operative care.

The mother appreciated that we brought to the table many years of experience and a high degree of specialization in cosmetic facial surgery of the face and neck. Particularly in rhinoplasty, with over 4,000 nasal procedures having been performed. Such a track record comes with having been in the trenches of practice for many years and becoming a master surgeon, the highest accolade the world of surgeons can bestow.

Since I trained in the golden era of medical education, the 1960’s and 70’s, that should help one understand the value old school holds. In those grand days before teaching hospitals became weakened by all the changes in medical care delivery, we had terrific training and experience. The hours were long –but fascinating. We had demanding and strict teachers. That explains why it was expected of us to conduct ourselves in a manner that today is known as old school.

I am not sure what the new school is like, but I do know one thing, that the old school was the right school to attend. And, that, friends, is always appreciated by patients and their families.

I have been thinking a lot about men’s rhinoplasty or cosmetic plastic surgery of the nose, the last several days.  In the last two days we performed nasal cosmetic and reconstructive surgery on two gentlemen.

The first was a middle-aged businessman who had difficulty breathing, but who also was motivated by the fact that he felt his “nose was growing”.   The nose, in fact, doesn’t grow, but the tissues within the nose, the loosen, the tip drops and the nose appears more bulbous and longer.  The gentleman’s motivation for that cosmetic enhancement was proper.  Likewise, the desire to breathe was very reasonable and the patient’s deviated septum and enlarged turbinates were causing blockage such that snoring and poor sleep quality was the result.  So it all made sense. 

In the case of that middle-aged gentleman it was very important to fully understand the man’s wishes.  He expressed on several consultation visits the need to have a natural looking nose that would not look artificial, “done” or drastically different from that which his face had carried for many years.  A surgeon needs to listen carefully to these words and understand the mission.  Any miscommunication could result in an unsatisfactory result and an unhappy patient.  That is not what a conscientious and competent cosmetic facial surgeon wants.

The second nasal case involved a young man who had had two prior nasal surgeries, one for breathing and one for appearance.  The former, the nasal septoplasty, was accompanied by reduction of the turbinates.  The turbinate reduction was quite satisfactory but the septum was still deviated to one side, meaning he had internal nasal blockage because of the shift of the septum which is the vertical partition that separates the two nasal passages.  Those “ revision septoplasty operations are not easy because typically some of the cartilage has been taken out of the septum and there is quite a bit of scar tissue underneath the internal lining of the nose.  It does call for considerable experience, expertise and judgment.

The young man’s other wish was to have his nose appear less long.  Indeed the nose was too long for his face and, as he ages, the length would have only increased.  Apparently the original operating surgeon did not heed the patient’s advice and the result did not match the patient’s wishes.

At this young man’s surgery, very conservative elevation of the nose was done such that it no longer looked too long as if it would touch his lip when he smiled.  And indeed, regarding smile, part of the problem was that he had a very strong muscle which, upon smiling, would depress the tip of the nose further.  The breathing problem was corrected by straightening the septum and some other relatively routine internal procedures, and we were able to lift the nose off the lip, release the muscle which had been exerting its downward force on the lip and give him a natural looking nose which was not radically different from what he had before. But certainly better and in keeping with his desires.

It is very important for surgeons to listen to patients, to get a good sense of what they want.  Also, in my opinion, it’s important have computer imaging available so that the perspective patients can see the predicted results of the procedure that the surgeon deems achievable and reasonable.  A meeting of the minds should take place at the computer imaging session such that the patient and the doctor are on the same page based on that computer visualization of the end result of the cosmetic rhinoplasty.

We have used computer imaging in our practice since 1989. It is helpful and important to patients who need the comfort of seeing the projected outcome.

Blocked air passages are extremely common.  Common causes include deviated septum, nasal allergy, enlarged turbinates (turbinates are normal, shelf-like structures within the nasal passages).  Some blocked noses are permanent due to abnormal architecture.  For example, after a broken nose, the bones and cartilages may be shifted out of position and, therefore, compromise the airway.

Sometimes nasal blockage is temporary such as during a common cold or an allergy attack.

Regardless of whether the problem is intermittent or constant or whether or not it is caused by allergy or architectural issues, blocked noses can be helped.  For nearly 100 years, a very successful operation has been performed totally within the nasal interior to straighten the deviated septum which is the most prominent player in causing the blockage and reducing the size of enlarged turbinates. 

There are some people who almost have no need for their nose.  They are not using it to breathe.  But if so, something is wrong.  Nature gave us a nose for a reason.  We are not supposed to bring air into our bodies through the mouth; the nose is the preferred route.  Long ago, it was established in laboratory experiments, that lung function improves when the air is delivered to the lungs through the nose rather than through the mouth. 

So what are the reasons for this complete nose blockage?  There are a limited number of reasons why the nose does not allow enough air through it.  The first is that the passages are blocked from a previous injury.  When the nose is injured, the support structures cave in, become crooked and become an impediment to airflow. The nasal septum is broken, crooked, deviated. Often the injuries occur when we are young and so the adult patient has no knowledge of “normal breathing.”  They have only known complete nasal obstruction.

Another common reason is nasal allergy, particularly when it is superimposed upon an architectural deformity such as uncorrected broken nose.  The lining of the nose is very sensitive to certain allergens in the air.  For some people in springtime it is grass and trees.  For others it is indoor mold.   Others have very specific sensitivity to ragweed pollen which only grows in certain parts of the country.  But whatever the offending allergens, the nose blocks up because the lining swells.  Two normal structures within the nasal passages called the inferior turbinates are particularly subject to this.   The two inferior turbinates are larger than the four other turbinates can expand to nearly twice normal size.  Such a blockage within the nasal passages has dire consequences for breathing.

If you combine a deviated nasal septum as part of an uncorrected nasal fracture or just because one was born with it, with nasal allergies causing swelling of the lining and particularly thickening of the inferior turbinates, you have the setting for very poor breathing.

There is good new about this sad story, however.  Modern techniques of surgical correction sometimes in concert with certain simple medications can make a huge difference.  One of the most rewarding things for a surgeon is to give a patient his breathing back.  And, incidentally, when you give the breathing back, you also give the sense of smell back.  Because if air does not enter the nose, the smell receptors high in the nasal passages are not activated and the sense of smell is non-functional.  People think that taste comes from the tongue in the mouth but the reality is that the tongue has very primitive sensors that detect only salt, sweet and bitter.  But the actual aroma of food, for example, comes when air passes through the nose and stimulates the olfactory nerve which carries the sensation of smell to the brain.  Now you know why “food does not taste very good” when you have a cold.  Colds are temporary.  Think about those people who have permanent blockage and never have the pleasure of smelling a blooming rose or even a great dinner dish.

We all read the in-flight airline magazines while traveling.  Personally, I find them always interesting and I particularly enjoy American Airlines’ American Way mainly because of the Mensa quiz.   Those are real brain-teasing questions and I always try to pit myself against the smartest people in the world.

I also enjoy the feature articles. In the February 15 issue, for an article entitled Vacationing for a New You, Dr. Stuart Linder and I were honored to be resources. The well-written piece describes the influx of patients, from throughout the world, to Beverly Hills for their cosmetic surgery.  I won’t steal the thunder of the article’s content but rather suggest that you follow the link to it.  I think you will find it interesting and enlightening.

Incidentally, Dr. Linder and I represent somewhat of a new wave or new trend in cosmetic surgery.  I see it as a very positive trend for the specialty.  Each of us is a superspecialist.  I operate only on the face and neck; Dr. Linder only operates on the body. While I perform facelifts, eyelid surgery, nose surgery — both for appearance and function — and procedures chin augmentation, neck sculpting and ear pinning, that’s the limit of my procedures.  No reconstructive surgery.  No cancer surgery, no accident surgery, no major reconstruction.

Likewise, Dr. Linder performs only breast augmentation and reduction, breast lifting, tummy tucks and body liposuction.

None of us can be experts in everything and typically the best results always come from those specialists who further refine their practice within a given specialty. Only via such narrowing of practice scope can they become what we in the medical profession refer to as master surgeons. That should be the goal of every surgeon in practice.

A very savvy business friend of mine said to me several months ago: “I don’t know of anybody who has not been adversely affected by the very difficult economic times now facing the United States.”

Certainly, when the economy is tight, people have less money available for nonessential services such as cosmetic surgery.  Therefore, plastic surgery practices will see decreasing patronage.  For that reason, practices have to be realistic and ask themselves if there is not a way that they can contribute to helping ease the discomfort of a slow economy and at the same time benefit their practice.

I hereby submit that there are three good reasons why a cosmetic plastic surgery practice is wise to lower its fees: 

1. Physicians have a responsibility to help patients.  If economic difficulties present themselves, there is no reason why we cannot soften the blow by reducing our fees.   After all, physicians who treat illness such as internists, pediatricians, surgeons have treated the needy in exchange for diminished fees.  It is a tradition in medical practice that all be served.  Even though our work is not medically necessary, it is still a valuable and important service to patients.  Therefore, it is perfectly consistent with medical ethics that we lower the economic barrier for the sake of our patients.

2. To be most proficient, surgeons need to be busy.  “Beware of the surgeon who operates infrequently” is an ancient and well-respected axiom in the world of surgery.   My experience and that of other superspecialist surgeons is that in fact, the most gifted and proficient surgeons are busy.  They are busy because they attract patients through their talents.  They are also busy because they will accommodate themselves to the needs of the patients including the economic realities.

3. From a purely business standpoint, it is still better for the practice to do a case at a significant courtesy discount than not to do the case at all.  Medical practices have large fixed expenses including rent and staff salaries.  Accountants have long held that for elective surgery, a practice would be foolish not to discount its fees and continue to keep the operating schedule busy rather than take an aloof and distant stance and pass on surgical cases that would otherwise help the practice and the business’s bottom line.