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.

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. 

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.

Consulting Affirmed

We have been big fans of consulting with patients long distance by using Skype.  We have used it to consult with patients both in the United States and overseas.  It gives us a chance to get a good sense of the patient’s request and problem if a new patient and also the ability to follow the progress of our postoperative patients. 

There was an article in The New York Times on Sunday, May 30, entitled, The Doctor Will See You Now, Please Log On.

The article discussed the advances in technology and the increasing popularity of what has now been labeled “telemedicine.”  The paper noted “spurred by health care trends and technological advances, telemedicine is growing into a mainstream industry.”

The article further stated “the technology has improved to the point where the experience of both the doctor and the patient are close to the same as in-person visits and in some cases better.”

I don’t agree with that statement because nothing beats a face-to-face meeting.  However, we have to accept some imperfections in indirect communication. If we do not have the chance to see the patient in the office to look, to feel and evaluate, certainly consultation via Skype is a second best.

The article brought to my mind the fact that three days prior to this article, on Thursday, May 27, we operated on a 15-year-old girl who came to us from Texas to have both rhinoplasty and functional nasal surgery including septoplasty and turbinate resection.  She also had placement of our post-operative nasal airway system to ensure breathing post-operatively. 

We had originally been contacted by the patient after she had visited our web site to learn more about the nasal surgery.  Following exchange of e-mails and phone conversations with our patient consultant, a Skype consultation was arranged. We had a good session the teen and her mother.  We also had the opportunity to provide, for the patient’s benefit, computer imaging to show the predicted result of the surgery since the patient was able to supply us with digital front and profile photos.

That Skype consultation went into very deep detail as much as we would in the office with regard to the patient history including the difficulty breathing, clogged ears and some of the medical issues.  We always ask about allergies, medications being taken, past history, so there is no short-cutting in the history and there is no reason not to address all issues past and present.  The only faculty we don’t have available is touch. 

Based on our long-distance consultation, computer imaging and Skype session, the patient came here prepared for surgery.  Her history and physical and all laboratories were done at home in Texas and she arrived the day before.

At the “pre-surgery” visit, I had a chance to examine the patient’s nasal airway and affirm that which I had learned from the history and also from reviewing the x-rays that were taken of the nasal passages and sinuses in her home town.   I also took further digital photographs that I could use to study before surgery and all questions were answered that had been posed by the patient and her mother.

As is routine for all our patients, whether local or national or international, all arrangements had been made for the patient to have her post-operative medications filled by our local pharmacy.  The patient’s post-operative kit was at hand so that she could start some of the medications that night prior to surgery.  The office had also assisted the patient’s mom in making hotel arrangements.

Certainly, technology is giving us a leg up on better pre and post-operative care and allows patients from afar to make contact with us and have meaningful conversations and consultations from nearly anywhere in the world. 

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.