Articles by Dr. Kotler

by Robert Kotler, MD, FACS

Medicine is one of those fields where serendipity – or, happy accidents – often happens. If a physician recognizes that a serendipitous moment is happening before his or her eyes, patients can benefit from new, unexpected discoveries.

The great French doctor, Louis Pasteur – himself blessed by serendipity for the discovery of rabies and anthrax vaccines – once said: “Chance favors the prepared mind.”

The famous anti-wrinkle substance, Botox, started with a chance discovery in 1987.  By 2011,  5,670,788 people enjoyed a shot of Botox, Dysport or newcomer Xeomin, according to the most recent statistics of the American Society of Plastic Surgeons, (ASPS)

                                             Botox’s  Start

Back in ‘87, Jean Carruthers, M.D., a doctor in Canada, was treating a patient for an eye disorder, blepharospasm, which causes constant eye blinking. In some patients, the disorder causes the eyelids to suddenly slam shut and stay closed.

Dr. Carruthers treated the woman with Botox, which back then was a mostly unknown drug used to reduce a few overactive muscles by blocking the nerve impulses that triggers the muscles.

It was a seemingly unlikely use of deadened botulinum toxin, which in its purest form, is the deadliest poison known. Some scientists reckon a glassful of pure, active botulinum could wipe out the entire human race.

The treatment worked to end the maddening eye blinking. But even with no eye symptoms, that patient kept returning to Dr. Carruthers’ office, reporting each time she received an injection of Botox for her eyes that the wrinkles between her brows seemed to go away, leaving her expression with a relaxed look. The patient said she actually looked younger after each injection, as hard as that was to believe.

From there, pillow talk took over.

Jean’s dermatologist husband, Alastair, immediately picked up his eyebrows when he heard the story. So he started looking more into how Botox could enhance people’s appearance.
It was there, over pillow talk, that one of the world’s most popular drugs came into being. And the rest, as they say, is history.
“When we first experimented with Botox to produce a more youthful look, we never thought it would be the most sought after cosmetic procedure worldwide today,” says Dr. Alastair Carruthers.

In cosmetic surgery, Botox and its siblings, Dysport and Xeomin are currently used to relax:

• Frown lines between the brows
• Make crows’ feet go away
• Facial wrinkles caused by age, sun and smoking.

                              Nasal Surgery’s Own Serendipitous Moment

The Botox story has a lot of meaning for us because we also had a serendipitous moment that has worked to benefit nasal surgery patents.

Years ago, a man who wanted to repair a botched nose job done somewhere else, came to see us for a consultation about revision rhinoplasty. After an exam, we told the patient we could help him and set up a date for surgery. He rose from his chair, opened the door and stopped in his tracks, saying: “Hey, this does not involve nasal packing, does it?”

Nasal packing takes place after many nasal surgeries to stop bleeding, if any, and to deliver important medications that help prevent infections and promote healing. But while the packing is in the nose, the patient must breathe through the mouth. Many complain it feels like a clothes pin is pinching off the nose while the packing is in place. So many patients dislike nasal packing so much, many surgeons no longer use it, even when medically advisable.

But we told the patient, yes, that nasal packing would be used. He then exclaimed, “Forget it, I won’t go through that again!”

He cancelled the procedure and walked out.

We had often puzzled how to do both during rhinoplasty, nasal surgery, septoplasty and turbinate reduction surgery — get the benefits of packing while allowing the patients to breathe comfortably. Then, one day while walking through a museum, we noticed that a life mask of a famous 18^th century artist had two tiny holes in the nostrils. We asked the docent about the holes and she explained that thick straws had been inserted into each nostril for breathing while the clay on the artist’s face dried.

Eureka! We could only wonder why nobody thought of doing it before.

Here’s how it works:

• Lay two, soft silicone plastic tubes into each nostril after a nasal procedure
• Tie the tubes together where they exit the nostrils
• Place the packing around the tubes
• Remove packing and tubes at the same time

Of course, many, many steps had to be taken before the tubes – now known as the Kotler Nasal Airway – came into use. A study had to be organized and conducted over some years on actual patients to show it was safe and did what the inventor claimed. The FDA studied the records and then granted clearance for general use. Then, a lengthy patent had to be written, applied for and granted. Tons of paperwork and tens of thousands of hours were involved, but the following types of patients now have even happier recoveries:

• Rhinoplasty
• Revision rhinoplasty
• Deviated Septum
• Turbinate reduction
• Sinus surgery

(Read more about the Kotler Nasal Airway)

Most of us give little thought to our noses unless we become concerned with:

• Its appearance
• Breathing difficulties

Cosmetic nasal surgery was actually born while developing functional nasal surgery to help people breathe better.

In the early 20th century, improvements in anesthesia and operating room sterility caused pioneering European physicians to venture into cosmetic nasal surgery and better looking noses.

Forward thinking Chicago surgeons like Drs. Sam Fomon and Maurice Cottle traveled to the Continent, learned techniques from the European masters and brought them back to America.

Following the WWII advent of antibiotics, a new affluence in America and a social renaissance accepted self-enhancing surgery and nasal reshaping gained momentum.

Chicago then became a focal point for educating future surgeons. Physicians such as Drs. Tresley, Becker and Tardy contributed new thoughts and techniques into the art and science of nasal surgery.

Today, Chicago still remains a prime destination for young surgeons who want to learn the latest methods of nasal reshaping. Yearly, Chicago plays host to scores of local and international visitors interested in learning about the “Chicago method” of rhinoplasty.

Below are some FAQs (frequently asked questions) from people seeking rhinoplasty.

                                            Rhinoplasty for Myself?

Currently, teens, men and women of all ages want improvement in the appearance of their noses and go under the knife for rhinoplasty.

According to a 2010 American Academy of Facial Plastic and Reconstructive Surgery survey, rhinoplasty (nasal reshaping) surgery leads the list of cosmetic plastic surgeries at 252,691, a 35 percent increase over the year 2000.

Of course, nose surgery is an individual question and usually one that has been well thought out. For some, the desire to improve their nasal appearance stems from deeply stinging teases and taunts experienced in childhood.

Others may want to regain a nose they once had before an injury. While there is no age that is too old for nasal surgery, adolescents who have yet to go through their growth spurt or who are emotionally immature are put off from surgery until they reach a more appropriate age.

                             Deviated Septums and Broken Noses?

Because of the nose’s leading position on our face, it has the most frequently injured facial bones. That often leads to progressive nasal deviations and breathing difficulties, commonly found in people who snore or use a CPAP – continuous positive air pressure -- machines. (Read more about nasal surgery and CPAP machines.)

Overlooked nasal injuries sustained in childhood later on lead to:

• Nasal obstructions
• Deviated septums
• Crooked noses

The nasal septum is the partition down the middle of the nose separating the two nostrils. The septum also provides structural support to the bridge and the tip of the nose. When injured, the septum may cause the nose to deviate or collapse.

Deviated septums and broken noses are diagnosed:

• At the time of a first surgical consultation
• Usually repaired during cosmetic nasal surgery

Following surgery, many are thrilled to be able to breathe normally through their noses again, not realizing the magnitude of difficulty they had with nasal breathing before their procedure.

                                  Rhinoplasty and Breathing?

Cosmetic nasal surgery can adversely affect breathing, especially if the support of the nose is not taken into consideration before surgery.

It’s important to discuss with your plastic surgeon any concern about maintaining good breathing function following the rhinoplasty surgery.

If cosmetic nasal surgery is done at the same time as a surgical procedure to improve breathing, the functional part of the surgery may be covered by your health insurance.

If you have nasal breathing difficulties and have tried — but failed — to gain improvement with medicines, you may be a candidate for insurance coverage. Your own insurance carrier will give you details.

                                         Nose Job Surgery Hurt?

Most patients are surprised to learn that there is very little, to zero, pain after rhinoplasty. An anesthesiologist makes sure you are comfortable during surgery; following surgery you may be uncomfortable for, say, a day or two at most. Swelling inside the nose will make you feel like you have a cold but that can be expected to resolve within a week.

                              Rhinoplasty: How long for healing?

Significant bruising and swelling have become uncommon with modern surgical techniques. Also, uncomfortable nasal packing frequently used years ago is often bypassed because patients dislike it. One week after surgery, most patients return to their usual routines, however high impact sports should be avoided for four to six weeks.

If nasal packing is required, be sure and ask for the Kotler Nasal Airway which allows normal breathing while the nose is packed with absorbent materials to promote healing, soak up blood, forestall infection and hold everything in place.

One important point:  be patient. A nose job’s final result will take up to one year. The definition and shape of the nasal tip continues to improve throughout the healing time.

 

                                       Choose the Type of Nose I Want?

Within reason, you can choose your outcome. However, it’s not like going to the grocer and picking a nose you like off the shelf.

It’s important to clearly discuss with your cosmetic plastic surgeon the aspects of your nose you want improved.

Computer enhanced video imaging has been a helpful tool to communicate your desires and to see what your final results would look like.

Keep in mind that many factors determine your outcome including:

• Skin thickness
• Previous surgeries, if any
• Underlying cartilage positions
• Dimensions of your face

Be realistic in your expectations. You may want the nose of your favorite supermodel, but it may be impossible. Her nose on your face just won’t be a good fit. Also, goals of cosmetic nasal surgery, like styles, have changed over the years. For instance, the turned up, cute button noses of the 1950’s are no longer in style.

The goal of rhinoplasty surgeons now is to maintain a natural look that draws attention to, and enhances, the best features of your face. The top result is that you will still look like yourself but with a nose that is:

• In better balance
• Blends harmoniously with the rest of your face
• Provides a pleasing profile

                    Rhinoplasty: Who Performs It?

Rhinoplasty is a complex surgical procedure performed by well- trained surgeons.

Unlike many other cosmetic procedures, nasal reshaping first started as a functional procedure. Therefore, it is important to seek out and find an expert who frequently does the surgery and who respects the breathing mechanisms of the nose.

Certainly, board certification in a respected field is a strong prerequisite. Other relevant inquiries for a patient researching rhinoplasty surgeons include:

• Hospital privileges for rhinoplasty
• Academic affiliations
• Peer-reviewed articles in professional journals
• Dozens, if not hundreds, of before and after nose job pictures

It is essential that your surgeon be able to balance aesthetic improvements of the nose while maintaining or improving the nose’s ability to breathe,  its chief function

If you are considering cosmetic nasal surgery, do complete and thorough research, (like some patients who research surgeons for a year) consider consulting with two to five highly rated nasal surgeons and then go forward taking comfort in knowing a well done rhinoplasty is a commonly performed procedure you will enjoy the rest of your life.

Many people with blocked nasal passages and troubled breathing don’t realize their breathing is blocked until they have a nose job. After all, blocked breathing is nothing new to them; they have always breathed that way.  These same patients also usually snore at night like our pal, above.

Then, during a rhinoplasty or some other cosmetic nasal surgery, the cosmetic plastic surgeon finds that the inside of the nose needs some corrective surgery that is causing the blocked breathing.

Of course, during the cosmetic surgery is not the time to make an assessment of the patient’s breathing, right?  The time to completely evaluate the nose is at the first doctor-patient consultation. It’s like before leaving for a long car trip: besides filling up with gas, you check under the hood.

Before any rhinoplasty surgery, the plastic surgeon should check two critical inside-the-nose structures:

• The septum, the thin wall that divides the nostrils
• The turbinates, structures farther up in the nose that can swell

A septum can become bent or twisted at birth, injured in an accident or during the heat of sports.

(Read more about surgical repair of a deviated septum  or surgical turbinate reduction)

If the septum is bent or twisted or if the turbinates are swollen, that changes the architecture of the nose, making the interior nasal passages narrower and thus harder for the patient to breathe.

To get a better idea, the surgeon must figure out how much air normally passes through the patient’s nose.

One way to do that is asking the patient – with the mouth firmly sealed — to breathe through only one nostril and then the other. If the breathing is noisy in either nostril, there may be a blockage up inside the nose.

Nasal blockages may also be caused by:

• Polyps
• Non-cancerous growths
• Nasal allergies like hay fever

So one or all of the above can cause the turbinates and entire nasal lining to swell and thus reduce air flow to the lungs.

For the Beverly Hills cosmetic plastic surgeon who does many nose jobs, the dead-bang giveaway sign of blocked nasal passages is when a patient reports:

• “I have four or five sinus infections yearly.”
• “Every time I have a cold, it goes into my sinuses. I am miserable when that happens.”

Actually, true sinusitis, while rare, requires an X-ray to confirm the diagnosis and antibiotics for treatment.

Moreover, real sinusitis causes serious symptoms, including:

• Pain in the cheeks
• A high fever
• Pain around the eyes and forehead
• Often, a foul discharge dripping down into the throat

There is often confusion for patients about what is actual sinusitis or sinus infections.

In the normal state, clear nasal passages allow for airflow to and into the sinuses, which are small hollow chambers, inside the skull.

But with the blockages in the nose, come pressure and a boring sensation deep inside the head. That may be due only to failure of air to enter the sinuses.

The headache-like sensation is known as a vacuum headache because the nasal blockage, preventing air from entering the sinuses, causes a negative pressure and the vacuum within the sinuses.

However, a condition in which the internal nasal blockage causes headaches, stuffiness and other discomfort is far more common than a case of true sinusitis which is a far more serious condition.

Other likely candidates for blocked nasal passages and breathing troubles are:

• Uncorrected broken noses, usually with a deviated septum
• Nasal drainage problems
• Allergies. Turbinates and nasal linings can swell in response to certain substances like dust, plant pollens, mold or hay fever.
• Those who use CPAP (continuous positive air pressure) machines to stop snoring
• Cigarette smokers

A CPAP machine forces air under higher pressure into the nose and down into the lungs.  The machine is often prescribed after testing the sleeping patient in a sleep lab to stop problem snoring.

Basically, a snoring patient is one who does not breathe well at night. That results in a sleepy, poorly performing person during the next day. The lack of oxygen from poor sleep affects every organ in the body.

Surgery to correct a deviated septum or swollen turbinates can be combined with a cosmetic rhinoplasty that creates a nose with a more pleasing appearance, and one that flatters the face.

 

Everybody has concerns about having any surgery and we are not reluctant to share our own experience, having had several.

Rhinoplasty was our first.  We traveled to New York to have a nose job done by the plastic surgeon who we thought was the best in the world, Howard Diamond, M.D. He was also our most important teacher, among many.

Our personal concerns about surgery?  Many, including:

• Anesthesia
• Recovery
• Results
• Pain

Despite having done nearly 1,000 nasal surgery procedures at the time our own was done, we still had not been on the operating table or “on the other side of the consultation desk.”

For those reasons, it was very enlightening and helpful to us as a practitioner to understand how patients may feel.

We have many years’ experience listening and working with patients to help allay their fears; we think we understand the main issues they carry with them in a consultation with a cosmetic plastic surgeon.

There are about seven main concerns, hesitations, and sometimes mental blocks that patients erect.  This is not to say that they are unrealistic or improper but negatives do exist. So it is important that every doctor who consults with these patients address fears and concerns head-on.

Here are the seven most common and important concerns that patients have while considering:

• Rhinoplasty
• Cosmetic nasal plastic surgery

Incidentally, some will have additional concerns because they are also going to have functional nasal surgery like septoplasty and turbinate surgery to improve the airway and their breathing.

Rhinoplasty patients are not only unhappy with the appearance of their noses, they are unhappy with its function: breathing. So it makes sense for them to address all these issues because they are considering both the cosmetic nasal plastic surgery and the functional nasal surgery during one procedure.

(By the way, that is a very wise consideration!  There are many advantages to having both surgeries done at the same time, including the economies of time and even dollars.)

                                                Cosmetic Surgery

Here is my short list of the concerns, worries, and questions that people have posed to me in my 34 years of practicing cosmetic surgery.

1 .General worries about having an elective (nonessential to life) operation and anxiety about anesthesia.

This is very understandable.  Remember, if you have been injured in an auto accident you do not have much choice but to enter the operating room and have your broken limb fixed by an orthopedic surgeon.  Or, if you have been walking around with a painful hernia in your abdomen for many years, it is wise to go ahead and have it repaired.

Injuries or bodily functions are medically indicated procedures; but rhinoplasty is strictly elective.  You decide to have the surgery because you want it, not because it is needed, so patients feel they are taking on some risks in having such an operation and are often worried and anxious about it.

We usually remind the patient that, statistically, they are safer in a certified outpatient surgery center or hospital under the care of a board certified doctor/anesthesiologist than they are on the streets or freeways getting to the operating room.  The statistics concerning safety of surgery for healthy patients should be very comforting.

                                                  Cosmetic Nasal Surgery

Today, because of the advancements in anesthesia, cosmetic nasal surgery and functional surgery are conducted under very light anesthetic primarily provided by propofol, which is one of the greatest advances in anesthesia we have seen in our entire career.  As a matter of fact, we would vote improved anesthesia second only to the cardiac and respiratory computerized monitoring systems that came into use in the mid-1980s.

Of course, before anyone goes under surgery he or she must have a clear physical examination including appropriate labs and x-ray studies under the direction and approval of their personal physician.  You have to pass through several gates to make sure you are fit and healthy enough to have the surgery. If you are not, we do not do the surgery.

So, for a healthy patient undergoing a procedure in a certified operating room and qualified professional staff are in attendance, there is very little risk of complications occurring in a  surgical session.

2. I am concerned about my appearance, doctor.  I am so freaked about looking unnatural.  I see too many unnatural noses and noses that signal they were “done”.

We understand that concern because everybody sees these people marching down the streets.  We dislike it because such patients reflect poorly on the medical profession and on the specialty of cosmetic plastic surgery.

However, patients who have overdone, highly obvious noses made a mistakes in judgments.  Frankly, they did not do enough homework.  They did not select the right surgeon because not all surgeons automatically deliver noses that are too pinched, overly scooped, too short or just don’t fit the person’s face.

It has everything to do with doctor selection and that’s why patients must do:

• The legwork and visit several surgeons
• Homework and read a book or two
• Investigation by checking surgeons’ records
• Research medical board for discipline cases

All that will help make sure you are in the hands of a properly trained, experienced doctor who can do a superior job.

The best way to convince yourself that you will be in the right hands is to see the doctor’s before and after plastic surgery pictures.

You should see dozens if not hundreds or more examples of the doctor’s art form.

Would you commission a painting from someone whose work you have never seen? Likewise, why sign up for a surgical procedure if you don’t have a sense of the doctor’s talent?  It is very important.  We visit l various surgeons’ web sites and are amazed at how few photographic examples some of the doctors have.  Why would that be?  Maybe they don’t have any.

3. People are always concerned about how long it takes before they are “back in action.”

Patients need a reasonable estimate of how long it will be before they can return to work or, if the patient is a student, how long before they can resume classes.  These concerns are about how they look.

Nobody wants to show up at work or school with swelling and bruising. So we doctors must give them a reasonable estimate based on how much work has to be done in their case.

Typically, seven to ten days is a very reasonable and reliable estimation how long it will take to be resuming normal activities including exercise.  Today, many people are very concerned about their vitality and exercise is a very important part to them.

At ten days, unless we run into extenuating circumstances, most people can resume their entire physical workout plan.  If people tend to be “slow healers” or “easy bruisers”, as they often describe it to us, then figure on two weeks but hardly ever is anyone not fit to be back in full action in more than 14 days.

By the way, during that healing period you are not confined to a bed.  You are not disabled; you are not an invalid.  People whose work or schooling doesn’t require that they be with the public can be very productive at home.

4. Will it be painful?

Everybody is concerned about pain.  My answer to our patients: “If a doctor in 2011 cannot relieve you of post-op pain, then he or she should be doing something else in life.”  Today we have a fine array of anti-pain medications that provide quick relief with little chance of nausea and vomiting.

A thorough patient history should also include questions about the patient’s experience with:

• Surgery
• Anesthesia
• Pain control

Often patients will tell us “Tylenol with codeine worked very well for me” or “I don’t like Vicodin because it made me nauseous.”

So, the patient’s past history guides us, and as we tell our patients, we will prescribe for you a medication we believe will provide adequate pain relief; however, if it doesn’t, we will quickly know, will call the pharmacy and get you another medication.  Whatever it takes, we will keep you comfortable

5. Patients are concerned about what their family, friends, or even people at work might think about their change in appearance. 

 

                                      Cosmetic Nasal Plastic Surgery

This is an important issue for some; they are a little concerned they will somehow be viewed as different. So the most important issue is that they look natural.  If they look unnatural, they will be wearing a sign that they are not happy and tell everyone that they had cosmetic nasal plastic surgery.

With the above consideration, it is important that the patient receive a natural looking nose; they must also realize that they are doing the procedure for themselves and not for somebody else.  Surgery is not to satisfy anyone else.  That is an important issue among teenagers who come in often accompanied by a gaggle of relatives and friends. We are glad to have their input and are pleased to see the support but it is the patient’s sole decision.

One of the things we learned is when everybody but the teen patient is asking questions, we conclude we must put a little more thought into the decision if this young patient really wants the operation. Or, is he or she doing it at the direction of strong willed relatives?

It is very important that the teen be the only decision maker.  Often, if we sense the teen is a bit indecisive, we suggest putting off the procedure for at least a year.  We say to them, “You know, I think you should think about it.  Come back and see me in a year and we will review the situation.”

6. Cost of Plastic Surgery

Of course, the cost of cosmetic plastic surgery is important.  Not everyone is a mega-millionaire. Today, the cost for cosmetic procedures is held at reasonable levels because it is important that the services be available to a large segment of the population.

Doctors need to be busy to keep their skills up; one way to be busy is to make sure that the fees are affordable.  Often, patients do not have a clear idea what the costs are and therefore, it is very important to have the consultation because each case is different.  Often, some cases can take more time in the operating room and that becomes a factor in the fees.

                                        Financing Cosmetic Surgery

The American way to “buy” services and products often includes credit.  For that reason, many people use credit cards as a way of financing.  They can also use their company’s credit union.  In addition, today there are large national financing companies usually owned by banks who do financing of cosmetic surgery.

It helps if you have good credit but even people without good credit can have cosmetic surgery.  So, there are many ways to manage the cost issue.  We don’t think people should have an elective cosmetic procedure unless they are comfortable with the expense, but remember – most particularly with rhinoplasty — the operation will last a lifetime.

Often, it’s helpful to consider the cost spread over a lifetime.  In fact, a teenager having a nose job today who lives well into the 80s will engender a cost of less than 30 cents per day in terms of “amortizing” or spreading out the cost over their lifetime.  You can’t even get a soft drink for that.

7.         What doctor would be the best doctor for my procedure?

That is the question that takes the most investigation, homework, research, and thoughtfulness.  We now share with you some “inside information” known to physicians and few lay people.

Typically, the best results in surgical procedures are achieved from surgeons who are the most specialized.  Today, because of the complexity of all cosmetic and plastic surgery, your chances of satisfaction are directly proportional to how specialized your doctor is.

The plastic surgeon that does reconstructive surgery as well as all the other dozens of cosmetic procedures is not likely to excel at any one. In cosmetic plastic surgery, a Jack of All Trades is a master of none.

Conversely, the doctor who limits his practice to a single region of the body and then further sub-specializes by performing only a handful of procedures, perhaps six or fewer, is more likely to be the surgeon that delivers superior results.

That’s how it is in other medical specialties like general surgeons who further specialize in hernia surgery or orthopedic surgeons who limit their practice to hand surgery.  These are the superstars of the profession.

Ask yourself this: “Is the doctor I am seeing as specialized as possible?”

When you do your homework, ask the office staff if the doctor practices the full range of reconstructive and cosmetic plastic surgery.

Or does he limit himself to only several purely cosmetic procedures?

That will give you the answers you most need.

In our book, “Secrets of a Beverly Hills Cosmetic Surgeon”, we devoted a chapter to helping readers understand the overlap between specialties that perform cosmetic surgery and also gave an insight into the training of cosmetic surgeons.

One section of chapter two,” “The Terrible Truth about Some Cosmetic Surgeons,” is entitled, The Training Program Problem.

In that section, we discuss the reality of today’s training; that most plastic surgery residents do not receive adequate training in cosmetic surgery.

 

                                        Plastic Surgery v. Cosmetic Surgery

Remember that “plastic surgery” and “cosmetic surgery” are neither identical nor synonymous.

Cosmetic surgery is a branch of plastic surgery.  Just as reconstructive surgery is a branch of plastic surgery.

Reconstructive surgery includes correction of defects and deformities caused by cancer, burns, and accidents.  It includes correction of congenital birth defects.

Cosmetic surgery, of course, is surgery to only enhance one’s given appearance.

In our book, we quoted William P. Graham, III, MD, former chairman of the American Board of Plastic Surgeons, who, in 1994, wrote:

“Although aesthetic (cosmetic) surgery is absolutely integral to a basic plastic surgery education, it is the fact that the quality of esthetic training varies greatly among residencies.  Training opportunities in esthetic surgery are not as accessible to the large super-specialized university center as they are to the free-standing facility, or small private hospital.  How do we ensure the availability of appropriate esthetic surgical training to all plastic surgery residents?  What minimum standard should be set for residents’ experience in esthetic surgery?”

That quote appeared in the medical journal, Aesthetic Surgery Journal.  It was part of an editorial entitled, Aesthetic Surgery Education: A Personal Perspective, by Stanley A. Klatsky, M.D., the editor-in-chief of the journal.

 

                                                                 Plastic Surgeon

We believe that Dr. Graham’s comments were very spot on.  In fact, we are still dealing with the burden of the residency graduate, including one who is board-certified, having inadequate experience in the narrow subspecialty of cosmetic surgery, whether it is facial cosmetic surgery or body cosmetic surgery.

In the October 2011 issue of Plastic Surgery Practice, there appeared an excellent article highlighting the practice of  W.Grant Stevens, MD, FACS, a highly-regarded plastic surgeon here in Southern California.  Dr. Stevens raises this exact issue.  Here is a quote from his article:

“Stevens holds, as a priority, the open discussion of what is in store for the future plastic surgeon. He actively promotes the liability and continuation of cosmetic plastic by plastic surgeons.

“It turns out that 72% of board-certified plastic surgeons make the majority of their income from doing cosmetic plastic surgery,” Stevens notes. “Now there is a disconnect there.  If 70% of the surgeons are making more than half of their income from cosmetic surgery, why aren’t we teaching cosmetic surgery?”

                                        Cosmetic Plastic Surgeon

 

The article goes on to confirm what Dr. Graham said: perhaps the best source of education for today’s graduate plastic surgeons is additional training apart from the university setting.

Fellowships, which are the “finishing school” for surgeons, (one of which we were able to join) are extremely valuable.  The fellowship is highly specialized training after a young surgeon has successfully finished an approved residency program. In a fellowship, the younger surgeon works side-by-side with a more experienced cosmetic plastic surgeon for anywhere up to a year.

In our case, we served a fellowship after receiving board certification and after a tour of duty as a major in the Medical Corps, U.S. Army.

What we found interesting was Dr. Stevens noting that none of the major residency programs in the country:

“Gave emphasis to, and had fellowships in, microsurgery, hand surgery, burn surgery, craniofacial surgery, pediatric surgery – all subdivisions of plastic surgery, but did not really have a significant commitment toward esthetic or cosmetic plastic surgery.  The fact is, it seemed to be a stepchild, and still is a stepchild, in most plastic surgery divisions.  Most people come out, they have very little experience, are self-taught, or they go to a lot of meetings.  They go to ASAPS (American Society of Aesthetic Plastic Surgeons) meetings, and it takes them 5, 10, or 15 years to learn how to really do quality Aesthetic surgery.”

 

                                                    Facial Cosmetic Surgery

 

The term “stepchild” certainly rang a bell with us because in that chapter, The Terrible Truth about Some Cosmetic Surgeons, the last section was entitled, “Unfortunately, in Most Residency Programs, Cosmetic Surgery is Still a Stepchild.”  This is what we noted:

“I am aware of several young local surgeons who, although well trained in reconstructive surgery, enter private practice with precious little facial cosmetic surgery experience, particularly in face lifts, neck lift surgery, and nasal surgery. Alas, the aspiring, but neophyte, surgeons, had to learn cosmetic surgery ‘on the job.’ Uninformed, unwary patients inadvertently became teaching cases that should have been provided during the formal training period.”

Graduate medical education in the US needs to get onto this matter and quickly. There are too many surgeons performing cosmetic procedures at less than the highest level because of inadequate formal training and education.

Sinus cases are rare but blocked or untreated broken noses are far more frequent. Actually, most people discover nose blockages only when they see a cosmetic plastic surgeon for rhinoplasty surgery.

Having performed somewhere over 4,000 rhinoplasties, we have looked inside many noses and found blocks that cause breathing problems.

But most people don’t realize the problem because they have always breathed with difficulty and assumes everybody breathes like that. However, as part of a proper pre-surgical exam before rhinoplasty, any cosmetic plastic surgeon should take a close look at the internal structures of the nose.

                          Nose Jobs

Why? In many nose job procedures, the patient has asked the cosmetic surgeon to make the nose smaller, in which case the architecture of the nose is changed. And that changes the function of the nose whose chief job is to pass air to the lungs. So a borderline block, if present inside the nose, becomes more significant. Thus, a thorough and complete exam during the first consultation includes an evaluation of the nose’s function: healthy breathing

To do that, the doctor does the following, among other checks:

• Judges the strength of the bones and cartilage
• Decides if the proposed rhinoplasty will make those structures less strong
• Checks to see if that patient has softer cartilage

If the cartilage happens to be soft, the rhinoplasty surgeon knows that not too much inside the nose can be changed, least the nasal framework be made less sturdy.

Moreover, the rhinoplasty surgeon must judge the nose framework in the lower part of the nose on the inside and outside.

A surgeon also has to consider and define the amount of air that normally can pass through the inside of a nose. That is done by:

• Asking the patient to breathe only through the nose, with lips tightly closed
• Comparing the amount of air going through each nostril, one at a time

If air passage is reduced in one of the nostrils, it is very quickly apparent. Another way to judge blocked air flow is by sound. If one nostril is blocked, you can almost always hear it. Doctors learn in medical school that healthy breathing is quiet but troubled breathing is noisy.

                                                                  Rhinoplasty

Some patients first learn about their blocked breathing just before a rhinoplasty consultation because no previous doctors ever looked up into their noses.

However, surgeons who are trained in conditions of the nose can evaluate the internal passages of the nose for other problems, like troublesome sinus conditions or allergies.

Other conditions can rear their ugly heads, too. Nasal polyps – cancer-free growths and thickenings on the nasal passages — can be found with a close, expert examination. That close-eyed check is important, too, because any hard-to-spot signs of infection must be cleared before rhinoplasty surgery can start.

                                                                 Turbinate Surgery

Infection is every surgeon’s ever present arch foe so we must look carefully for it long before rhinoplasty surgery. Infection is such an ever-present bugbear, we have seen procedures cancelled on the day of surgery because the patient arrived with a pimple on the nose!

Yet another red warning flag is watching for the rhinoplasty patient who reports nosebleeds. The problem could lie in prominent blood vessels inside the nose that could cause problems during the actual nose job surgery. In some cases, septoplasty or turbinate surgery must be completed before the cosmetic rhinoplasty.

If you are thinking about having rhinoplasty and your surgeon does not also examine the inside of your nose, be sure and ask for the status of your breathing to be evaluated. That one step can prevent problems later on.