Cosmetic Surgery: Thinking it Over

Virtually every plastic surgery procedure starts with a first meeting in the office between a new patient and the plastic surgeon. It’s known as the consultation and is a chance for the surgeon to learn about the changes you want in your appearance.

Here, Dr. Body (Stuart Linder, M.D.) and Dr. Face (Robert Kotler, M.D.) explain what patients can expect in a consultation appointment and what things they should look for as the signs of an excellent plastic surgeon.

Most board-certified Beverly Hills plastic surgeons charge a nominal fee for consultations. Many usually apply the fee to the costs of plastic surgery. But if you’re on your toes, you can have a second consultation for no additional fee. Drs. Body and Face tell how.

(Read more about what to expect in a fitst Los Angeles or Beverly Hills consultation.)

Dr. Linder is an eminent board-certified Beverly Hills plastic surgeon who specializes in breast augmentation, breast revision surgery, and tummy tucks along with male and female breast reductions.

(A revision is when a botched plastic surgery done elsewhere by another surgeon is repaired by a highly skilled cosmetic plastic surgeon.

Dr. Kotler performs surgery of the head and neck exclusively along with many rhinoplasty, revision rhinoplasty, face lifts and ear pinnings, a procedure technically known as Otoplasty.

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Dr. Face (Dr. Kotler): Whew! What a day. I had eight rhinoplasty consults this afternoon. Was it the same for you with a lot of consultations?

Dr. Body: (Dr. Linder): Actually, I had a string of second consultations. Some patients wanting breast augmentation or breast revisions in Beverly Hills had already spent an hour in my office asking about surgery and, before leaving, said they wanted to think more about it and do a little more research.

Dr. Face:  And you said?

Dr. Body: I responded that it was a perfect idea, that the more the patient knows, the better for all and please come back with any additional questions or thoughts. And, there would be no additional fee.

Dr. Face: Good plan! For a plastic surgeon, that is a perfect tack to take. After all, many patients are nervous at first. After they leave, all types of questions pop into their heads.

Dr. Body: Most returning patients say, at the end of the first consultation, say: “Doctor, I would like to mentally digest everything you said and do a little more research before making a decision on the surgery.”

Dr. Face: I often do the same thing and add that no additional charge is involved. If the surgeon does not mention it, it’s perfectly acceptable for the patient to ask before leaving: “Will I have to pay another fee if I come back for a second consultation?”

Dr. Body: Another way patients can get even more information on a first or second consultation is ask, “Doctor are there any patients in your office right now who have had a similar procedure? And if so, may I speak with them?”

Dr. Face: Perfectly acceptable! In fact, I often excuse myself from the room in such meetings, saying: “You two go ahead and chat. Let me know if you need me for anything.”

Dr. Body: I remember one lighting expert who was asked in a consultation how many people were required to change a light bulb.

Dr. Face:  And…?

Dr. Body: The consultant said “Three – one to change the bulb, one to document the process and one to coach him on how to conform to the process.”

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Look at some before and after breast revision photos

View some before and after nose job revision pictures

Surgeons preparing for an operation

Two plastic surgeries at once? By two surgeons? Yes.

It’s extremely efficient for one patient to have two plastic surgery procedures by two rejuvenation surgeons — Drs. Linder and Kotler–during a single session.

It’s a common service offered by the eminent Beverly Hills board-certified cosmetic plastic surgeon Robert Kotler, M.D.  (who blogs as Dr. Face) and Beverly Hills board certified plastic surgeon Stuart Linder, M.D (the Dr. Body blogger) tell why it’s to a patient’s advantage to have several cosmetic plastic surgeries in one session when he or she wants procedures of the face and body.

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Dr. Face (Dr. Kotler):  We’ve already talked a great deal about how a patient is well served by seeing a superspecialist cosmetic plastic surgeon, one who specializes in just a handful of procedures and performs them at least weekly, if not daily.

Dr. Body (Dr. Linder): Because that surgeon performs the procedure so often, he or she is swift and efficient. That leads to less bruising, bleeding and soreness so healing is usually quicker.

Another benefit is that surgeon has seen all the wrinkles in a particular surgery. For instance, one rare complication of breast surgery is when a patient’s breast implants roll together under the skin. Known as symastia, many refer to it as a “uniboob” deformity.  It is extremely difficult to repair but many cases are referred to me because I specialize in surgery of the breast.

(See a picture of a breast augmentation that resulted in symastia.)

Dr. Face:  The two surgeon approach translates to a savings of time, money and convenience.  Two cosmetic plastic surgeons teaming up to do their respective cosmetic surgery work during one operation equals one session under anesthesia, one charge for the M.D.-anesthesiologist and one recovery and healing period. Not to mention one stay in Beverly Hills if you have traveled here from abroad as many of our patients do.

Dr. Body: Recently, a patient wanted to have liposuction of the body and cosmetic nasal surgery as well as some surgery inside the nose to correct and improve her breathing. Of course, we can’t work simultaneously. So I go first because liposuction requires vigorous movement, using long, thin tools through fatty areas of the body and that creates a little jostling. Dr. Face’s nasal surgery, however, is extremely delicate and the patient cannot be jostled.

Dr. Face: As you may know, I specialize in cosmetic procedures of the head and – on a daily basis — perform rhinoplasty and other nose surgery, face lift, eyelid lift, ear pinning, or otoplasty plus nonsurgical wrinkle removal. I was trained in all aspects of  face and neck plastic surgery but limit my practice to just the cosmetic procedures, including revision rhinoplasty.

Dr. Body: I, on the other hand, only perform procedures of the body and specialize in breast surgery, including breast surgery revision and reduction – for both men and women – plus liposuction and tummy tuck. Revision breast surgery is also one of my specialties.

Dr. Face: When the patient goes under anesthesia, one or the other of us will do our procedure and then step aside for the other surgeon. The anesthesia time considered safe in cosmetic plastic surgery is up to ten hours.

Dr. Body: But because we are both highly focused specialists, the total time for our joint procedures is usually somewhere around two and one-half hours.

Dr. Face: There are over 125 different plastic surgery procedures. It’s impossible for any one surgeon to master them all. Plastic surgeons are becoming ever more specialized. For  instance, some do only plastic surgery of the hand while still others only do reconstructive surgery.

Dr. Body:  In fact, all of American medicine is becoming extremely superspecialized.  While some surgeons specialize in chest surgery, others specialize in heart surgery only. Some eye surgery specialists only perform surgery on the retina while others limit their practice to cataract surgery.

Dr. Face: Today,  some heart surgeons super specialize in one area like the coronary arteries while another will specialize in operating on heart values.

Dr. Face: I know superspecialization is great for the patient because I was a surgical patient not long ago.

Dr. Body: What did you have?

Dr. Face:  I needed a hernia repair and choose a surgeon who does nothing but hernia repair. A neighbor of mine had the same procedure but went to a general surgeon who does many other operations.

Result? I was hiking  the next day! But my neighbor took weeks to recover.

Look at Dr. Body’s before and after breast augmentation pictures.

See Dr. Face’s before and after rhinoplasty (nose job) pictures.

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Dr. Body (Dr. Linder): Driving to the office this morning, I could not help but notice a billboard showing a broadly smiling doctor in a white coat offering a breast augmentation for a low, low price.

Dr. Face: (Dr. Kotler): That type of advertising is common but the catch is almost always the same: the low price is only for one aspect of the surgery. By the time, you add on a fee for the operating room and the anesthesiologist – as well as other typical fees – the final price is not so low, after all.

Dr. Body: I personally don’t like it because shopping for price is not the wisest way to find a fully-trained surgeon, one who is board-certified to work on the area in which he has been certified. Today, some doctors are migrating to cosmetic plastic surgery specialties without completing a plastic surgery residency and becoming board certified. There are better ways to find qualified plastic surgeons besides reading billboards.

Dr. Face: I agree. There is nothing wrong with starting by searching for the superspecialist surgeons on the Internet.  Don’t look for advertising that emphasizes low cost. After all, it’s your face or body. Unlike a car or refrigerator, you can’t return your face or body if you are not happy. It’s okay and quite proper to talk about discounts once you have met the surgeon, but the first consideration must be: “Is this the doctor to whom I am going to entrust my body or face – and my life?”

Dr. Body: The professional societies to which we belong don’t look kindly upon gimmicky advertisements, particularly with “small print” at the bottom which would tell ( if you could read it) that you get no anesthesiologist or nurse anesthetist. Rather, maybe a couple of pain pills. Is that the way to have surgery in 2009? What if there is a problem with your heart? Who will be there to care for that?

Dr. Face: But wait — it can get worse! Some plastic surgeons have been so bold as to offer cosmetic plastic surgery as a prize or a reward for winning a contest. That’s another no-no because the winner may not really need or even want plastic surgery. Besides, the professional societies think a plastic surgery contest cheapens the specialty. Despite all that, you will see frequently see such contests, especially on radio stations. Forget it. You want a dignified, serious doctor, not a circus side-show barker.

Dr. Body: Truth is, a bargain surgery can easily turn into the most expensive thing you can imagine. Why? Because the repair on a botched job can cost anywhere from two to five times the price of a well done procedure. Remember, plastic surgery is still real surgery and there are a number of slight risks that go along with any surgery. You want it carefully done correctly the first time.

Dr. Face: So what is O.K. in cosmetic plastic surgery advertising and marketing? Start with patient testimonials on doctors’ websites. The patent experience directly relates to the skill and training of the surgeon who owns the website. Another good starting place are the before and after cosmetic plastic surgery photos. There should be many – dozens – of the procedure in which you are interested. Also, check out the doctors’ professional bios. Make sure the doctor “majors” in cosmetic plastic surgery. Not hand surgery, burns, cancer or emergency room work. You want the most highly trained, narrowly focused specialist available, the “superspecialist”.

Dr. Body: Rough rule of thumb: if you want breast augmentation, lift, reduction or revision, find a board certified plastic surgeon who does breast surgery at least twice a week.

Dr. Face: While choosing the surgeon via the lowest price is medically risky, finding a plastic surgeon who has the highest price is financially risky. A surgeon who focuses and concentrates on offering only several procedures will be able to do the procedure faster, with less fuss and at a more reasonable fee because he or she works extremely efficiency. He and his staff are tuned up like a top NBA team.

Dr. Body: Here’s another insider tip that is rarely revealed but tells a lot about a surgeon: Look on his or her website for the surgeon’s hospital privileges. Hospitals are expert at credentialing.  They know which doctors have the right qualifications for staff membership. Crossovers from other specialties are not welcomed.

Besides, you never know when you might need to be hospitalized. The most caring doctors always have a back-up plan in place when needed.

Infectious agents are always lurking in some corner and watching over a surgeon’s shoulder  for a happy place to land and multiply.

Even in the most experienced of hands that follow all the sterilization guidelines in the cleanest and most sterile of operating rooms, the standard rate for infection everywhere is about one patient per hundred.

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Dr. Face: (Dr. Kotler) Have you been stern lately, doctor?

Dr. Body:  (Dr. Linder) Yes, I had a patient recently to whom I gave an absolutely beautiful breast augmentation that healed nicely. But when she went home, she thought that she – and perhaps others – could see that one breast was a tad larger than the other. And she wanted a redo – she wanted the equivalent of a shot glass worth of silicone (50cc’s) added to the breast implant she perceived as smaller.

Dr. Face:  What did you do?

Dr. Body: I explained the risks that attend any plastic surgery and that such a tiny adjustment was not worth risking a possible infection or other complication and thanks for asking but I could not do the procedure. She went elsewhere, had the surgery, got a terrible infection and had to have one implant removed while that breast healed for six months.

Dr. Face: Plastic surgeons are, by nature, perfectionists but that is a perfect case of what we mean by “reasonable expectations.” Most people, including her significant others, only saw a huge, healthy improvement. But any time the surgeon opens a chest or takes a breast implant out of its sterilized package and exposes it to air, the slight risk of an undesirable complication like infections is present.

Dr. Body: Unfortunately, most rejuvenation surgeons are wont to talk about a negative issue like infection. But the truth is:  infective agents are floating around in the cleanest, most sterile of operating rooms. Also, human skin is alive with all sorts of flora, including bacteria that can get into an open wound. Of course, the surgical area is painted with germ killers but there are super resistant bugs that can survive and start their own colonies.

Dr. Face:  Make that, their own colonies even though every precaution is taken. Implants for the face and body are packed in sterile materials, the implants are soaked in sterile agents after opening and the surgical site of the body or face is irrigated with an antibacterial solution before closing.

Dr. Body: That’s one of the reasons we want to see plastic surgery patients in the morning after the procedure. It’s apparent to us — even before the patients — when an infection is developing so we leap on it as early as possible. Some infections are so powerful, they can digest cartilage. But if the surgical area can go three to six days with no infection, we can be relatively sure we are home free.

Dr. Face: American plastic surgeons and the U.S. medical care system is very concerned about infections and also happens to be very good at tracking down the source.

Dr. Body: I bet you are talking about the case several years ago when the U.S. Centers for Disease Control (CDC) got involved in solving an infection outbreak in New Jersey.

Dr. Face: That’s right. An unusually large number of women were reporting to their doctors with infections in what appeared to be liposuction cases. The CDC interviewed the women and found they all had liposuction in the Dominican Republic at a particular clinic. The source of the infections turned out to be  unsterilized liposuction wands.

Dr. Body: So it’s more important than ever to check your surgeon’s website for information about his or her surgery center. Those facilities marked:

• AAAASF (American Association for Accreditation of Ambulatory Surgical Facilities)
• JACHO, (Joint Commission on Accreditation of Healthcare Organizations)
• AAAHC (Accreditation Association for Ambulatory Health Care)  
• Medicare certified

and will be following all the the standard sterilization procedures known.