Secrets of a Beverly Hills Cosmetic Surgeon

By Robert Kotler, MD, FACS

The May 14, 2012 issue of STAR magazine was quite something. The cover, featuring nine photos of Hollywood celebs with ample evidence of poorly performed cosmetic procedures, boasted “335 Amazing Celebrity Photos.”

STAR was not kidding. I was quite impressed with the size of their photo archive of poor-quality, inappropriate, unnatural cosmetic surgery, and non-surgical cosmetic procedures.

It is a shame that many people in the public eye have such poor judgment.

I would recommend that people considering cosmetic surgery take a good look at this catalog of bad results. There is a lot to be learned from seeing others’ missteps. The common thread throughout the directory of inappropriate cosmetic procedure is: “Too much, too radical, unnatural, and strange.”

No patient ever wants to sign up for this.

Now, you may wonder: “If these Hollywood people with big purses, and presumably good connections, cannot get it right, how do the rest of us get good cosmetic surgery?”

Well, that is one reason why you need to do the homework. Obviously, the Hollywood folks did not. Be sure to look at as many “before” and “after” photographs in the photo albums and websites of the doctors you are considering. If they do not look good because they are overdone and unnatural, then it is time to move on to the next practice.

Remember, just because Hollywood people have money and connections does not give them common sense. Their acting, singing, and dancing talent is obvious to all, but common sense and good judgment are represented in another region of the brain.

By Robert Kotler MD, FACS

I recently finished a terrific book entitled Younger Next Year:  Live Strong, Fit, and Sexy – Until You Are 80 and Beyond by Chris Crowley and Henry S. Lodge, MD. The premise of this book is that we all have the potential to live longer and live better, provided we impose certain disciplines on ourselves.

One, of course, is weight loss. Over one-third of Americans are overweight, and this is a national health calamity. But weight can be controlled both with diet and exercise, and the emphasis in most of the book is upon a very regular exercise program.

Here is a key sample paragraph:

It may seem exhausting to fit exercise into your crazy work schedule, but that is looking at it backwards. We are not tired at the end of the day because we get too much exercise. We are tired because we do not get enough exercise. We are mentally, emotionally, and physically drained from being sedentary. Walking through the door exhausted each night is not living; it is merely surviving large stretches of the only life we are likely to have. Besides, study after study shows that the productivity gains at work outweigh the time spent exercising, and that we function better at home — with more satisfaction and on less sleep when we are fit. If you put any value at all on your quality of life, the time you spend exercising becomes a bargain.

I have seen this work for many people, including myself.  A sound diet and regular exercise are the cornerstones of fitness and longevity.

I highly recommend this book to you, and if you read it you will probably spend less time in your doctor’s office.

By Robert Kotler MD, FACS

The Medical Board of California publishes a newsletter several times a year. Included in the newsletter is a list of disciplinary actions against California-licensed physicians. The disciplinary actions may range from revocation of a license to the lesser punishment of  publishing a “Letter of Reprimand” for the public record. In the latter category was a recent action against a surgeon who had been

“Disciplined by (another state) for…failing to have after hours phone support available to patients in the event of complications following cosmetic procedures.”

It amazes me that, often, it is more difficult to get in touch with your doctor than to place a call to the White House, which has a publically listed telephone number. I have always taught my medical students and residents that a surgeon must be available to the patient around the clock, 24/7. There are sound medical reasons for being able to reach your surgeon. One never knows when questions and, even more importantly, complications will arise. For example, if a patient had a rhinoplasty and is suddenly having a major nose bleed, it is important that the surgeon know about it. First, certain actions can be taken via telephone direction. Most importantly, the mere anxiety of having a problem and not being able to reach your surgeon only heightens blood pressure, which makes the bleeding worse.

Before surgery, my patients receive a list of telephone numbers where I can be reached should any problems arise. Even a minor complication can lead to a major issue if not addressed quickly.  Major complications could include loss of tissue, which is disastrous.

So, remember to ask about doctor availability after surgery. Your doctor may provide their own contact information, or that of another doctor who is similarly qualified and knowledgeable. Someone must be available, even if it is just a matter of answering questions or adjusting medications — a patient whose pain medicine is not working is an emergency and must be aided immediately.

By Robert Kotler MD, FACS

When I was writing the early drafts for my book, Secrets of a Beverly Hills Cosmetic Surgeon, we had just been made aware of radio frequency (RF) skin treatments. The first such “machine” for these treatments was called Thermage. I wanted to have some information to present to my readers, but frankly, I was not impressed with the company’s response to my request for more information, including before and after photographs.

Now, nine years later, we know more about RF skin treatments, which have been touted as non-invasive techniques to treat skin laxity, particularly on the face, neck, and upper arms. Recently, there has been some research on this technology and whether it could help reverse the signs of aging on the upper chest.

Originally, Thermage had FDA clearance for treatment of wrinkles around the mouth. Surgeons then adapted it to the full face treatments. I witnessed some of the treatment sessions and found some immediate contraction of the skin, but I questioned whether there would be meaningful changes in the long run. I doubted that such skin contraction could possibly take the place of a well-performed surgical procedure if the main issue was sagging skin. Furthermore, the technology had no effect on wrinkles, which, of course, is a major point of dissatisfaction among patients. The patients were also in pain during the procedure, despite the claims that it could be done without general anesthesia.

As time passed, technological changes were made to the delivery of RF. In addition, other devices were brought to market using variations on the physics of the technology. One of the more recent advances was adding temperature sensors, which could control the amount of heat delivered to the tissues, thus lessening patient pain. But, of course, if less energy is delivered to the tissues, there is less effect and, perhaps, a compromised result.

I think it is difficult for prospective patients to make a reasonable evaluation about what technology would be helpful with so much marketing going on. My advice, if you’re considering this treatment, is to very carefully study the before and after photos of patients who have had RF skin treatments. When considering the procedures, be sure to ask for patient references. Ask to see patients who have had RF procedures and compare the result you see with their before photos. That’s the best single bit of information you can receive when considering such procedures, which, generally are not as impressive as either the full face CO2 laser or the phenol deep chemical peel. You need to also understand costs, recovery time, risks, and complications.

By Robert Kotler, MD, FACS

Some time ago, I discussed and compared Botox® Cosmetic and Dysport®.  Recently, a new and chemically distinct product, known as Xeomin, joined the wrinkle-filler lineup.

Xeomin has been FDA approved specifically for the vertical frown lines between the eyebrows.  Apparently, this product was previously approved for use in adults with cervical dystonia, a condition in which spasm and contractions of the neck muscles produce a very uncomfortable and unsightly appearance.  Likewise, it had been approved for blepharospasm, which is involuntary flickering of the orbicularis muscle which surrounds the eye.

To give you the most authoritative information, I am now going to quote from a review article written by Yael Halaas, MD:

“Xeomin is manufactured by Merz Pharmaceuticals and has been used by more than 84,000 people worldwide.  It is now approved for use in 20 countries.

Like other drugs in this category, Xeomin works by paralyzing wrinkles.  It blocks the signals from the nerves to the muscles.  As a result, the targeted muscle cannot contract.

Xeomin versus Botox and Dysport

Botox, Dysport, and Xeomin have a lot in common, but they also have some important differences.  Unlike its predecessors, Xeomin does not need to be refrigerated.  This may be an advantage when it comes to distribution.  What’s more, Xeomin is “naked.”  There are no additives – just botulinum toxin type A.  This may lessen a patient’s likelihood of developing antibodies to Xeomin.  When your body senses a foreign invader, it responds by creating antibodies and launching an attack.  If this were to occur with a neurotoxin such as botulinum toxin type A, it may not have its desired effects.

Xeomin is said to be more like Botox than Dysport.  It takes about one week for the full effects of Xeomin injections to be realized, and once this occurs, the results last from 3-6 months.  Dysport, Xeomin, and Botox should not be used interchangeably.  They should also only be administered by skilled injectors, such as board-certified facial plastic surgeons in sterile environments, such as medi-spas or doctors’ offices.  Xeomin should not be injected in beauty salons, malls, or at Xeomin parties in the home.”

I am pleased to know there are additional products that can be added to the palette of dermatologists and cosmetic surgeons to help neutralize facial wrinkles.

Always discuss with your doctor the pros and cons of each particular product.  I can tell you, however, that so far, the Botox Cosmetic and Dysport class of drugs have been very safe and very successful.

The popularity of these temporary muscle-paralyzing injections is deserved.

Patients coming in for surgery to make them look younger often will ask about fat injections.

There has been a lot of attention in the press about fat injections as a way to fill the grooves and troughs around the face. The areas most commonly affected by aging are around the mouth and lips. There are the nasolabial creases, the pair of which looks like parentheses, extending from the side of the nose down to the corners of the mouth. Then, there are the marionette lines, also somewhat parenthetic and parallel, running from the corners of the lower lip to the chin.

Another area that frequently tends to shrink and flatten out is the cheek bone area, particularly toward the nose under the eye. Finally, the area that shows hollowness with increasing age is below the cheek bone in the mid-cheek area.

What are the options? Today, we have more than ever. First, there is fat grafting. It begins with liposuction from the abdomen or the buttocks. It is filtered, prepared, and then injected into the areas that show shrinkage.  In excellent and in experienced and highly specialized hands, fat injections can be successful. The alternative is to fill with man-made fillers. This would include Restylane, Juvederm, Radiesse, Artefill and Sculptra.

Now, Radiesse and Juvederm are very similar – each is composed of hyaluronic acid – a natural occurring substance in human bone cartilage and skin. The product is bio-engineered in the laboratory and is considered pure and free of any possible rejection phenomenon. Complications from these injections are very, very rare. One unique property of Juvederm and Restylane, being hyaluronic acid, is that in case of overinjection, they can be dissolved using an enzyme called hyaluronidase. 

While Restylane and Juvederm have a relatively short life within the tissues, typically 4-6 months or a bit longer, some of the other products are engineered to last longer. I have seen nice results from Sculptra injections done five years prior. 

So, what about this competition between fat injections and what I will group together as the “non-fat injections”? The non-fat injections, which are laboratory made, allow a major advantage in that when the injections take place, one can see the result. Now, Sculptra is somewhat of an exception because it takes several months for the body to make new collagen and capitalize on the presence of Sculptra. The other products render an immediate, visible improvement. That is a huge advantage because the patient gets to make a decision when he/she is happy with the amount of filling. Further, one can fill a moderate amount and see how it looks in a few weeks, and go back and “top off.”  There is no need to puncture the body to obtain this as there is with fat injections.

I happen to like the concept of “testing the waters” with the non-permanent hyaluronic products, Restylane and Juvederm, almost as a “demo”. Their immediate effect and shortened longevity also allows the patient to quickly decide if they are happy with the results. If they do not see the demonstrable improvement, and do not feel that it is a reasonable investment of their time and money, they can refrain from any further injections. There is economy of dollars there. 

Now, let’s look at fat injections. I want to cite the recent discussion that took place on the pages of an excellent cosmetic surgery magazine for surgeons, Cosmetic Surgery Times. The publication interviewed two veteran cosmetic surgeons who faced off on fat injections. In the fat injection corner was J. William Little, MD, and in the “non-fat” injection corner was Val Lambros, MD.

I do not know Dr. Little personally, but he enjoys an excellent reputation nationally and internationally. I do know Dr. Lambros, and I have always admired the work that he has done, including his very unique tracking of individual facial aging using medically-consistent photographs. He has been a very good student of the subject of where the face ages, how it ages, and how, to the eye, the signs of aging can be reversed.

 Dr. Lambros made a very strong case for the unpredictability of fat injections. Frankly, I sit in that camp, also. I have always seen the unpredictability as the major disadvantage of fat injections. It does not mean that you cannot have a spectacular result, but it would take a very experienced practitioner, and somewhat of a “good day.”  Remember, not all practitioners are experienced enough to have a long track of patient observations, and Dr. Lambros referred to that.  I have selected certain quotes from his commentary because I think they are very on point. 

“Injected fat can grow. This will be the longest long-term problem with fat.”  Dr. Lambros goes on to mention that, indeed, “the injected fat cannot be removed.  Then, you have the issue of symmetry. The surgeon may inject equal amounts into both cheeks, but maybe some of the fat will take on one side, and more will take on the other.  Another point made was that, in fact, due to a variety of anatomic factors, the fat takes better in younger people.  But, it is the older people that need the fat more because the hollowing of the face is a function of aging.” 

Further, Dr. Lambros agreed with my observation that it takes quite a bit of experience and, what he calls, “finesse” and “esthetic sensibilities.”  While these are laudable and important characteristics in the cosmetic surgeon, we have to admit that not all will have this. If so, that is a negative.

Young surgeons are always taken with technology. In fact, it is a little more exciting to harvest the fat, treat it, and inject it.  It is more mechanical, more surgical than the mere injection of a syringe filled with a non-fat filler, such as Restylane, Juvederm, Radiesse, Sculptra or Artefill. 

I sense that there will always be a difference in opinion because cosmetic surgery is an art. Each practitioner should develop facility with those techniques and procedures that he finds to be most successful, and with which he is most comfortable.

For the patient, the only thing that counts?  Results.

Perhaps there was some confusion about my conclusions regarding the treatment of pores in the post Pores: A Tough Problem to Beat. The title itself implies the challenge that we doctors have. Note that in the first paragraph I wrote, “(pores are) ….there for the duration I might add.”

In the next paragraph, I stated, “…even with the most aggressive and ambitious wrinkle removal process, such as a deep chemical skin peel, or laser, pores are immune to these soldiers.”

My point was to help the reader understand that, because pores cannot be erased, as can wrinkles, age spots, even some superficial scars, one must be skeptical of any claims that purport to erase pores. (more…)

I read quite a few medical journals. I also read medical magazines, which are not peer- reviewed (pass strict evaluation by board of doctors). The magazines are advertiser supported; free to qualifying specialists. Since advertisers pay, you quickly get the implication. They are paying to get their message across to the readers.

Such publications may take liberties that the tightly-scrutinized medical journals dare not take. (more…)

One of my patients, for whom I had done a neck sculpture procedure several years ago, as well as her upper eyelid and brow lifting, came in to ask my opinion about a facial procedure she had learned about at another plastic surgeon with whom she was consulting about a possible tummy tuck.

I should tell you that this patient is a very savvy lady.  She does her homework — she does the research before proceeding with anything.  She went to see the surgeon for a tummy tuck, and he then migrated into the subject of the face lift.  The surgeon recommended that she have a procedure where stitches are placed under the skin to lift the muscle layer up and back, as a way of lifting the cheeks, and at the same time, softening the nasolabial crease.  The nasolabial creases are those “shaped grooves” that run from the lower side of the nose and go down to the corner of the mouth.  As we all get older, there is some shrinkage of fat around the mouth first, and therefore, the grooves appear.  (more…)

I am not talking about the kind of options that are traded on the Chicago Board of Options Exchange. I am not referring to any financial instruments. What I am referring to are treatment choices that exist and that should be looked at very carefully. When you have choices, I believe you should always accept the least risky and most predictable.

A real-life example of this is the patient who comes in who is unhappy with some of the aging features of their face. (more…)