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. 

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.

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. 

1. Computer imaging.   On a computer screen, you can see the predicted result of the procedure. If your nose has a bump or is too long or the tip is too wide, all of the changes that the surgeon proposed can be seen after the “before” is morphed to the “after”.  Our practice, among others, conducts remote computer imaging.  If patients e-mail us photographs taken in proper views, we will perform the imaging in the office and e-mail back the results. Very cool.

2. Saline demo.  Using saline to inject into the deep nasolabial creases or into a previously operated over-scooped , narrowly-pinched nose to show the result is a wonderful way for the patient to see three dimensionally “live” what can be achieved using filling injections.  The filler will dissipate in two hours and photographs were taken before and after, of course, so that the patient can review them before making a decision about having either a temporary or permanent fillers.

3.  Photo archives. The most comprehensive and detailed web sites will have such a large collection of before and after photos, typically numbering in the hundreds, that you will be able to identify a patient who had a situation to yours.   You need to judge the “after” photos to see if you would be satisfied with the type of result shown

4. Meeting actual patients who have had similar procedures.  There is nothing that beats being able to stand in someone else’s shoes to understand the process and results. Many patients act as volunteer consultants for practices and make themselves available to speak with patients who are considering the surgical procedures or injections or nonsurgical processes that they had.  A wonderful way to learn and even to be able to assess the incision location and quality, etc.