Dr. Body (

But the requests and concerns for various procedures differ according to the time of life in which patients find themselves. If you are considering cosmetic plastic surgery, take a look below at what others in your age group are doing to refresh and rejuvenate their appearances.

Both surgeons frequently appear on educational television programs and are also book authors. Doctors Face and Body belong to:

• The American Academy of Facial Plastic Surgery and Reconstructive Surgery.
• American Board of Plastic Surgery
• The American Medical Association

Dr. Face: Teenagers are an interesting group, don’t you think, doctor?

I recently rejuvenated the broken noses of two 14-year-olds and they had the maturity level of 25-year-olds.

Dr. Body: Absolutely! One of the driving forces with teens is to mesh well with their peer groups. So if a teen girl under 18 comes to me with very small breasts, or conversely, with very huge breasts (medically known as gigantomastia), I will be more likely to go ahead with breast augmentation or breast reduction if her present state is causing her misery or embarrassment. Same for a too-small breast condition known as tubular breasts and breast asymmetry. I’m a bit more strict about liposuction because a person that young — given workouts and a reasonable diet — can easily lose weight. It’s usually just a matter of giving up the couch, some TV and video games and getting moving.

Dr. Face:  It’s the same thing with facial procedures for teens and for young children. Many parents are surprised to learn that when children have very large, “stand out” ears, medical science advises ear pinning, or otoplasty, at age five, before the child starts school. Otherwise, the teasing and name-calling can completely turn the child off to school and to learning.

Dr. Body: The important thing to people in their twenties is making a great impression as they enter the adult social and working world. As women go from teens to young adulthood, you see many requesting larger breast sizes with greater projection, or how far in front the breasts go. Mating and dating are uppermost in that group’s mind.

Dr. Face: I read an interesting joint survey from the ASPS (American Society of Plastic Surgeons) and ASAPS (American Society for Aesthetic Plastic Surgery) about the changes in what’s considered beautiful and desirable according to various age groups.

Dr. Body: What did they find?

Dr. Face: In the 30s, people are hitting their full stride but may notice some age-related changes. In the 20s, 30s and 40s virtually all people find a fit, well proportioned body attractive.  In the 50s, more people are concerned with youthful, unmarred skin.

Dr. Body: I recall seeing that article and have noticed the same thing among patients who come in, asking about various body procedures. People in their 30s who answered the quiz selected their hips and waists as the main concern. That would mean a lot of tummy tucks and hip liposuctions.

Dr. Face: Yet, men and women in their twenties, forties, fifties and sixties, list the face as their main concern. That would translate into skin care in the 20s, treating acne and acne scars. Dermabrasion, microdermabrasion or chemical peels are usually just the tickets for that. Facial fillers start becoming common in the 30s along with some face lifts, starting in the 40s with even more facial and neck rejuvenation in the 50s and 60s.

Dr. Body: As women get into their 40s, I see more requests for breast explant procedures or exchanging a large breast implant size for a smaller one. Those women are usually married with their dating days behind them so a large breast size has become a pain. Also starting with 40-year-old women, I see a lot of requests for breast lifts because they are experiencing some normal, age-related sagging. In the 60s, about 25 percent of patients are concerned about their abdomen and hips and only seven percent are concerned about the breasts.

Dr. Face:  Do any other parts of the body bother women in their 40s?

Dr. Body: Their families are usually complete by then so tummy tuck requests become common.

Dr. Face: Middle age, the mid-30s through the 50s are a time when many more people start asking for correction of double chins, sagging upper and lower eyelids and wrinkling.

Dr. Body: The motivation I hear across all age groups for having cosmetic plastic surgery is boosting self-confidence. In the 20s, the main reason is to attract a mate. But in the 30s and 40s, especially among men, the reason for rejuvenation surgery is increasing professional opportunities and looking energetic in the workplace. But by the 60s, the job was the second most common reason while making new friends had become first.

Dr. Face: Check out the beauty for life website at http://www.BeautyforLife.com and learn more about what your age group is doing to look better!

Dr. Linder often repairs other surgeons’ bungled breast  surgery. Look at some of Dr. Linder’s reconstructed breast augmentation before and after pictures.

Dr. Kotler also repairs facial plastic surgery that has not been done well elsewhere. Here are some of Dr. Kotler’s reconstructed nose job before and after pictures.

Breast implants

Dr. Body (Beverly Hills board-certified breast plastic surgeon Stuart Linder, M.D.) and Dr. Face (Beverly Hills board-certified cosmetic plastic surgeon Robert Kotler, M.D.) both use implants in the body and in the face during cosmetic plastic surgery.

Because breast augmentation has become the nation’s leading cosmetic plastic surgery, almost everybody knows that a saline or silicone breast implant is involved in virtually all breast enlargements.

But the female bosom is not the only place on the human body to benefit from implant technology.

Here, Doctors Face and Body discuss the various types of implants used in rejuvenation procedures.

Both physicians are authors and belong to:

• The American Academy of Facial Plastic Surgery and Reconstructive Surgery.
• American Board of Plastic Surgery
• The American Medical Association

Dr. Body (Dr. Linder): The range of breast implants is huge. There are many different sizes, depending on how large a woman wants to be. Available are tear-drop shaped and round breast implants; choices of smooth or textured shells and choices of implants that will determine how far in front a breast will extend. We surgeons know that measurement as projection.

Dr. Face (Dr. Kotler): That really shows the need for seeing a board-certified plastic surgeon with many years of experience. He or she will also know how various implants have fared with the patient years after the procedure. Is any one breast implant the most common?

Dr. Body: The most popular singular choice right now is an implant filled with silicone. That requires a slightly larger incision – about two inches long — because silicone implants must be inserted into the breast pocket fully filled. However, a saline filled implant can be inserted flat, with no filling and the saline added after the implant is in place. So the incision for a saline implant can be shorter.

Dr. Face: Common implants for the face include nose, jaw, chin and cheek implants. Fortunately, no filling is required.  Facial implants are made from solid medical grade silicone. Incidentally, the solid silicone is perfectly safe and is routinely used to make artificial joints and heart valves.

In about 20 percent of rhinoplasties, a chin implant is used because the patient also has a receding chin. An unattractive nose can be surgically enhanced but if the patient also has a receding chin, the overall outcome is not as attractive because the patient’s profile is out of balance. Bringing the chin forward to a more normal position enhances the profile and provides balance to the rest of the face, especially in side views.

Chin, cheek and jaw implants may be inserted through the mouth or cheek implants behind your lower eyelid so there is no visible scar. Nasal implants are inserted through hidden internal nasal incisions.

Dr. Body: Body specialists often get requests for other implants used to enhance various aspects of the body. Like the facial implants you mention, those silicone implants are solid with no filling and are sometimes are very thin.

So patients who feel deficient in some area can get implants for:

• Chest
• Bicep
• Calves
• Buttocks

Dr. Face: What has been your experience with those enhancing implants which sound like something that would be attractive to body builders?

Dr. Body: I think there can be too many complications, especially for buttock implants which are basically inserted into the area of the body that supports the most weight. In my opinion, nothing good can happen from placing the entire weight of the body for most of the day on solid implants. The pressure can cause the fat and tissue around the implant to die and fluids to build up in the area.

Dr. Face: Fortunately, we don’t have the pressure problem with facial implants.  But a properly sized pocket must first be made for insertion of the implant; one that is not too small nor too large. Great talent and experience on the part of the surgeon are needed because improperly placed implants can slip out of place. I like to stitch the implants – for extra stability — to the fascia, the tough lining that covers the bone of the face. In some cases, surgical screws are used to attach implants to facial bones.

Dr. Body: That touches on one of my objections to the implants that enhance the biceps, chest and calves – the implants can move, slide around and cause the muscles to atrophy, or shrink, which defeats the whole purpose of having the implants put into those locations.  For bulging biceps, it’s better to spend extra time pumping iron!

Dr. Face: I see what you mean.

Dr. Body: Are there any other implants used in the face?

Dr. Face: Goretex, a clothlike manmade material – one version is used in skiwear – is an alternative to raising the bridge of the nose. When used in surgery, Gortex is known by its chemical initials, PTFE. Sometimes, the patient’s cartilage from an ear or from a rib is used to raise the bridge. PTFE has also been used in lip augmentation but tends not to do well over time.

Dr. Body: Well, that about covers the list of implants used in the human body for the sake of appearance.

Dr. Face: I can think of one other — implants that are rarely mentioned which can help restore appearance, if not function.

Dr. Body: And that would be..?

Dr. Face: For use after testicular cancer or trauma, the FDA has approved silicone testicular implants.

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Dr. Linder often repairs  other surgeons’  bungled breast  surgery. Look at some of Dr. Linder’s reconstructed breast augmentation before and after pictures.

Dr. Kotler also repairs facial plastic surgery that has been botched elsewhere. Here are some of Dr. Kotler’s reconstructed nose job before and after pictures.

Media Await "The Money Shot."

The eminent Beverly Hills board-certified plastic surgeon Stuart Linder, M.D – our “Dr. Body” blogger—talks about some of the behind-the-scenes stories that happen when Hollywood celebrities try to have plastic surgery in secret. Also commenting is the well known Robert Kotler, M.D., a top Beverly Hills board-certified cosmetic plastic surgeon who has appeared on television’s Dr. 90210 r. Dr. Kotler – a member of the American Medical Writers’ Association – blogs as “Dr. Face”.

The  American Plastic Surgeon bloggers additionally belong to many professional organizations, including:

• · The American Academy of Facial Plastic Surgery and Reconstructive Surgery.
• · American Board of Plastic Surgery
• · The American Medical Association

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Dr. Face (Dr. Kotler): Not too long ago, a leading talk show hostess  with a household name – and face — recognizable to everybody, scheduled some plastic surgery for 4:00 in the morning and drove herself to a nearby parking garage. But she was apparently still sleepy and crashed her car into a support beam inside the garage and attracted all types of attention, including the police, to herself.

Dr. Body (Dr. Linder): And you don’t mention her name because…….

Dr. Face: Medical privacy. There are strict federal laws these days about identifying any patient with a medical procedure. Celebrities have always required anonymity because they want to project and protect an image of natural, untouched good looks and complete natural beauty. Even though,  by the way, we doctors do not require laws to protect patient identities. Patient confidentiality, without exception, is accepted by society. Not even a court of law can require us to testify about any medical issue, including cosmetic plastic surgery, related to any patient. Famous or otherwise.

Dr. Body: I also heard a story from an older plastic surgeon about Fanny Brice, a famous actress of the 1930s and 40s. She insisted on having plastic surgery in a hotel room instead of a hospital just to keep the story out of the papers.

Dr. Body: I heard an anecdote about a celebrity who is no longer with us – Gary Cooper. I heard the story from the surgeon to whom it happened when he was working, back in the 1950s. Anyhow, Cooper thought his looks were fading a bit so he had a face lift here in Beverly Hills and then accepted an offer from the surgeon to stay in his home while recuperating. It was all supposed to be hush-hush, of course, but the surgeon’s eight-year-old son went to school and told everybody he knew. When the surgeon left for work the next morning, he found his front yard full of reporters and photographers.

Dr. Face: That situation no longer exists for celebrities who not only have cosmetic surgery in complete secrecy but have secret hide-a-ways with nursing staff in and near Beverly Hills.

Dr. Body: We also accommodate models, actresses and other celebrities with a back entrance and invented names on paperwork. It’s very important because people’s ability to make a living is at stake. When a patient leaves my office with a breast augmentation and then makes it into a Playboy magazine centerfold, well, I’ve done more than my job.

Dr. Face: Speaking of recovery centers: I can think of one well known establishment that is known in medical circles as the “Face Lift Hotel”. My patients have used it many, many times. In one case, a man who owned an entire island brought his girlfriend to the recovery center with him. Part of my post-op instructions to rhinoplasty or face lift patients are to refrain from intimacy for ten days because sexual activity will raise the blood pressure to dangerous levels.

Dr. Body: I think I see where this is headed….let me guess, he did not follow doctor’s orders, things got steamy with his girlfriend and…

Dr. Face: Yes! He started bleeding from an incision. So I was summoned from my own bed in the middle of the night to do a quick remediation which did the trick. But I do think he followed my instructions for the rest of his stay in Beverly Hills because there were no more bleeding episodes and his surgery healed just fine. I’m familiar with most aftercare facilities because it is often much easier for me to go there for the morning after surgery medical check than to have the person risk another trip to my office through the throngs of photographers.

Dr. Body: Celebrity photo hounds are so driven, they know the car license plate numbers of top actors and actresses. Thus, famous people who are more camera shy and familiar with photo stalkers wily ways just rent a car to go the plastic surgeon’s office.

Dr. Face:  I once had a very famous actress leave my office after a follow-up appointment for a nose job. But before she walked out the door, she put on a pith helmet with shoulder length dark mosquito netting attached the rim. The U.S. President could have been wearing that get-up, but nobody would ever know it!

Dr. Face:  Bottom line: about the most educated guess among Beverly Hills plastic surgeons is that most celebrities over age 40 have had some cosmetic plastic surgery and will be in the market for more, later on. So the chase will not end soon; newshounds find ever more clever ways to find out what star is having what procedure while plastic surgeons and the stars’ continue thinking up ways to avoid them.

Dr. Body: That’s right, doctor; news people pay huge tips and finder’s fees for good information; they have a whole network of eager “spies” including people on the stars’ own payrolls, bus boys, waiters, parking garage attendants, gatemen and guards at the studios and many, many others. Some news organization members have gone through surgery just to check themselves into a recovery center to get to know a star as just another patient while some news outlets have even purchased homes next door to celebrities to get the “untold” story.

Dr. Face: The only practical answer is operating in the middle of the night! The paparazzi don’t figure on us operating while they snooze.

A doctor's comforting hand

Both the eminent Beverly Hills board-certified plastic surgeon Stuart Linder, M.D. (Dr. Body) and and the equally eminent Beverly Hills board-certified facial plastic surgeon Robert Kotler, M.D. (who blogs as Dr. Face) rely heavily on the sense of touch to produce rejuvenations that delight patients.

Often mentioned are the many extra years of training – four to seven years after medical school — required to become a board-certified cosmetic plastic surgeon.

Part of that education comes through hands-on experience that teaches a surgeon’s fingers and hands to walk their way around the human body, guided by the sense of touch.

Jointly, Doctors Face and Body belong to the following medical organizations, including:The American Academy of Facial Plastic Surgery and Reconstructive Surgery; the American Board of Plastic Surgery and The American Medical Association.

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Dr. Body (Dr. Linder:) I was thinking about the sense of touch yesterday while doing some liposuction. In liposuction, a plastic surgeon uses a long suction tool, known as a cannula, inserted through a very small incision in fatty areas. And the only way I know exactly how deep I am in the body is by the way the cannula feels in my hand. I can’t actually see inside the body. And there are three levels, or planes, within two inches under the skin where I remove fat.

Dr. Face (Dr. Kotler:) Can you tell if you are no longer thrusting the tool through fat?

Dr. Body:  Absolutely! It’s the sense of touch that lets me know I have left a fatty area and am approaching muscles with the tool. In fact, one of the dangers of liposuction in untrained hands is puncturing an internal organ with that long tool.

Dr. Face: So if you read that a physician trained in, say, radiology, is offering liposuction to the public after learning the technique in a weekend course, how do you react?

Dr. Body: My hair stands on end! The basic thought in my mind is “Yikes!”

Dr. Face:  With expert plastic surgery professors as your guide, how long did it take to learn it and then feel confident offering to your patients?

Dr. Body: A good six months to learn the technique and a couple more years to offer the procedure with confidence – and also to know when NOT to do it.

Dr. Face: In my area of plastic surgery – facial surgery – surgeons must often lift the skin from the underlying facial and neck muscles. That’s done over the cheekbone, jaw and neck regions. It must be done very diligently and carefully because vital nerves and blood vessels are just underneath.

Dr. Body: Is there an instrument that tells you when enough is enough?

Dr. Face:  Not exactly. After years of watching masters and doing basic general surgery, a facial plastic surgeon uses his or her thumb and forefinger to feel the skin’s thickness to gauge the level of dissection.

Dr. Body: What about the nose? You can’t lift all of that skin, can you?

Dr. Face: Again, the sense of touch tells you. The skin must be lifted from bone and cartilage, the skeleton, to modify the basic shape of the nose. In some nasal procedures, the bones of the bridge of the nose must be realigned while cartilage may need to be trimmed.

Dr. Body: Do you mean broken?

Dr. Face: Yes. And that is also done with thumb and forefinger which first feel the precise location. The other critical part is being able to visualize all the tiny and intricate structures of the nose in your mind. Again, that comes after years of training and experience.

Dr. Body: Breast augmentations and breast revisions are somewhat like that, too. No patient wants a large scar on her breast so we make the incision only as long as necessary and then rely on the sense of touch to know how much we can stretch the incision without tearing it. Then, we use our fingers to work the breast implant into the pocket and feel when it is positioned properly.

Of course, that incision must be a little larger for a silicone breast implant. We use a surgical tool to help with that but just the right amount of force must be applied. Just a tad too much and you may have an unhappy patient.

Dr. Face: Right! The last person we want to have a “Yikes!” moment is a patient!

Surgeons at work

Are cosmetic plastic surgery patients at risk? The short answer — say American plastic surgeons Stuart Linder,  M.D. and Robert Kotler, M.D. — seems to be: depends on what nation you’re in.

The British medical journal, Clinical Risk, recently printed an article, “Cosmetic Surgery Patients at More Risk than Ever” which highlighted high and low points in plastic surgery in various nations.

The eminent Beverly Hills board-certified cosmetic plastic surgeon Robert Kotler, M.D.  (who blogs as Dr. Face) along with Stuart Linder, M.D. (the Dr. Body blogger) read – and carefully noted — the article for salient points for plastic surgery patients who want to visit a private American clinic.

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Dr. Face (Dr. Kotler): The state of plastic surgery sounds like the wild West in England, with increased marketing, lack of regulations and “overwhelming” media hype.

Dr. Body (Dr. Linder): All this came about when the editor of Clinical Risk asked leading experts in the United Kingdom to write about the state of plastic surgery in England and a few other nations.

Dr. Face:  The writers sure got off on the right foot because they look at everything from an aspect of patient safety.

Dr. Body:  One French plastic surgeon joined in the discussion and noted that any surgical procedure in his nation can only be done by a surgeon who is “a registered specialist” and deemed competent. And I wish this fact was more widely known by American cosmetic plastic surgery patients, and I quote: “Possession of a general medical degree, and the fact the practitioner is ‘experienced’ are not deemed sufficient qualifications” for performing plastic surgery.

Dr. Face: Well, that’s a good idea. In America, we have plenty of cosmetic plastic surgeons who are deemed competent by our demanding medical boards. Of course, a long formal training period is required first. At the end, surgeon must take a written and oral exam that “certifies” us as being recognized by the medical profession as a fully-qualified specialists. Rather than use the word “recognized” the phrase patents should look for in the U.S.  is “ board-certified”. That means the doctor has passed the tests and a board of examiners has declared him or her fit to treat patients. There are 23 recognized medical specialties that test and certify applicant-M.D.s.

Dr. Face: That’s right, we are members of our certifying boards and then licensed by the state or states in which we practice. The boards can also police our business practices. Of those 26 boards, two are for face and body cosmetic plastic surgeons.

Dr. Body: Also worthy of note are the remarks of the president of the International Society of Aesthetic Plastic Surgeons (ISAPS). He writes how important the “safety diamond” is.

Dr. Face: True enough, doctor! And we American plastic surgeons also concentrate on those four things: patient, facility, procedure and surgeon.

Dr. Body: We have to make sure the patient is having surgery for the right reasons, that he or she is healthy enough for surgery and that the surgical facility is also certified, having met the highest standards for patient safety.

Dr. Face: The procedure has to be appropriate, too. And that’s about doctor judgment, which can never be regulated or certified. If a prospective patient requests cosmetic plastic surgery that is either medically unsafe or unwise  – or because the risks of disappointment or even complications are too high — the patient should be respectfully declined. There are no forces that can make a surgeon operate if he does not believe it is in the patient’s best interests.

Dr. Body: As for checking on the surgeon’s particular training, background and experience, we’ve already discussed how to find the appropriate training and certification of American cosmetic plastic surgeons in their websites. It’s wise to choose somebody who does the procedure you want at least once weekly. It is no longer possible for any one plastic surgeon to be a master of all the complex and newer procedures.

Dr. Face:  European surgeons writing in the Clinical Risk article also discuss some “improvements” that would not go over in America at all.

Dr. Body: Both the British and the French authors recommend banning all forms of  direct and indirect plastic surgery advertising and publicity in whatever form, including the Internet.

Dr. Face: Whoa, there! I don’t think that’s wise. In America, honest advertising is really a source of information that allows patients to get up to speed and learn about medicine…. even if it is considered marketing or advertising. Both Dr. Linder and I have authored books that focus on the consumer issues a prospective plastic surgery patient should know about. The books contain insider information from two highly-focused, superspecialist MDs who know their stuff.  The books? The Beverly Hills Shape by Dr. Linder and Secrets of A Beverly Hills Cosmetic Surgeon by yours truly, Robert Kotler, M.D.

Dr. Body: Plus, using a surgeon’s website can be a great help. Just the vast collections of before and after plastic surgery pictures can help narrow down the search. The more research and homework you do, the more chances you will have finding the precise doctor who matches your needs.

Dr. Face: So the $64,000 question is: Are plastic surgery patients also at risk in America?

Dr. Body: The short answer is, informed patients who know what’s involved in plastic surgery and know how to check for themselves the patient “safety diamond” (patient, facility, procedure and surgeon) are very, very likely to be pleased.

Dr. Face: On the other hand, if you select a surgeon used by a friend, or a friend of a friend, make sure you at least see the before and after photos and speak with the surgeon after checking on his or her credentials. Then, you will really learn what the doctor’s practice is like.

Remember, just having an M.D. degree and some experience is not enough for performing plastic surgery.

(Read the plastic surgery report about cosmetic surgery patients at risk.