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.

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.

In a seeming celebration of things American, two of Beverly Hills many eminent cosmetic plastic surgeons are being featured in this month’s American Way, the inflight magazine of American Airlines.

Your humble bloggers, the 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. (our Dr. Body blogger) tell more about  why Beverly Hills is widely regarded as the world Mecca of plastic surgery and why many patients come here from lands far outside the United States. Apparently, some fly the friendly skies of American Airlines.

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Dr. Face (Dr. Kotler): I’ve read a lot of amazing things about you, Dr. Linder, but according to this month’s American Way magazine, you are – and I quote  –  “one of the highest regarded breast revision surgeons….. in the world!” And, I would agree.

Dr. Body: (Dr. Linder): I’m humbled; there are many, many highly competent plastic surgeons in Beverly Hills, so it’s a real honor to receive that type of praise.

Dr. Face:  As the magazine so aptly points out, there are 39 cosmetic plastic surgeons on our street alone – and this is a very short block! Our other neighbors include 11 cosmetic dentists and 5 dermatologists, some of whom perform minor plastic surgery services like dermabrasion. You could almost call the talent in Beverly Hills an embarrassment of riches. No wonder the magazine wants its travelers to know more about the area.

Dr. Body: I’ve noticed on the television program, Dr. 90210, some surgeons tell patients, there are more plastic surgeons in one Beverly Hills office building alone than in the entire state of Montana.

Dr. Face: While we do sit cheek-by-jowl with Hollywood and its movie and T.V. industries, Beverly Hills cosmetic plastic surgery long ago stopped servicing only  the rich and famous. Sure, wealthy people still shop and use other exclusive services but the reality is that the explosive growth of Beverly Hills cosmetic plastic surgeons in the last several decades happened because the procedures became affordable for most American and International patients. The costs of face lift, rhinoplasty, breast augmentation, tummy tuck and other popular procedures came down due to:

• Better technology
• Better medications
• Shorter operating times
• Going from expensive hospitals to private outpatient surgery clinics.

Dr. Body: And so our and our colleagues’ work sits up there on the silver screen, allowing 60-year-old actors to look perhaps 40 or 45. Southern California is a huge area, so many ordinary people who also want surgical rejuvenation come to Beverly Hills. And apparently, thanks to the Internet, the word has spread to other U.S. states and foreign nations. For instance, how many patients from abroad have you served in your practice?

Dr. Face: At last count, it was patients from 33 foreign nations, and all 50 U.S. states. It’s easy for patients because they are picked up at the airport, taken to their choice of many, many local hotels and then, for the night after surgery, stay at one of several plastic surgery recovery centers which have been aptly been named “face lift hotels” by local wags.

Dr. Body: On my website, I have an interactive map of the world, showing where international patients have traveled from, including China, the Middle East and Australia. (Look at the map of Dr. Linder’s plastic surgery patients’ home nations.) I think the statistics are like yours with patients traveling in for surgery from 23 nations and 40 U.S. states.

Dr. Face: With loads of theaters, various ethnic restaurants, night-life clubs – some of which are frequented by celebs pictures in People, OK and other celebrity observers – there is much here to take in before returning home. There’s just no place like Beverly Hills and greater Los Angeles. For instance, this month’s Saveur Magazine, a guide to fine dining worldwide, devoted an entire issue to Los Angeles.

Dr. Body: A great deal of all this is possible, thanks to the Internet and the “virtual consultation.”  People in foreign nations can take some pictures of the body or facial areas they want treated and tell the surgeon a few other details so we can “virtually” consult through email, on the phone or via Skype.

Dr. Face:  But don’t get the idea it’s email-to-the-operating room. Once the patient arrives in one of our offices, we go through everything again with the concept that we have never seen this patient before.

Dr. Body:  And don’t forget economics! Currently, the U.S. dollar is relatively weak and creates some attractive bargains for people in Asia, Europe and the Middle East. Sure, exchange rates fluctuate, but right now, America looks “cheap” to much of the world.

Dr. Face: For instance, a man in Italy told me it would be more cost-effective for him to come to Beverly Hills, have nose surgery, stay for seven to ten days and fly home than to have plastic surgery in Switzerland, which was about two hours from his home.

Dr. Body: Well, here we are, doctor, talking all about the American Way article when, thanks to the Internet, we can send people there to read about for themselves.

Dr. Face: Capital suggestion! Read the plastic-surgery-in-Beverly-Hills article in American Way. Enjoy!

Doctors Face and Body (

Among eight other minor nips and tucks, Heidi had two major procedures done over, including:

• A revision rhinoplasty

• A breast augmentation revision

Revision surgeons go back and repair cosmetic plastic surgeries that weren’t done correctly the first time.

Dr. Kotler (who blogs as Dr. Face) and his erstwhile colleague, Dr. Linder (who blogs as Dr. Body) are both board-certified Beverly Hills cosmetic plastic surgery revision specialists.

As you might guess from their blogging names, Dr. Kotler performs surgeries of the face while Dr. Linder handles many breast and body cosmetic plastic surgery.

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Dr. Face: (Dr. Kotler) Of  the breast surgery revisions you do, doctor, is there a common mistake the doctor before you has made in the first surgery? And how many breast surgery revisions are you doing these days?

Dr. Body: (Dr. Linder) Yesterday was typical; of the six initial consultations, three patients wanted breast surgery revision because the first, second or even the third were not done correctly. I saw one woman several days ago whose breasts had been operated on five times – and all five were poorly performed! Overall, I would say half of my patients ask for breast revisions.

Dr. Face: What seems to be the problem with the surgeries before you perform your corrections?

Dr. Body: I see several problems. Daily, I see patients from all over the world whose previous surgeon started the procedure with an incision in the belly button or in the arm pit. The idea is to hide the resulting scar but the surgeon is starting too far away from the breast to create a good pocket and place the breast implants correctly.

Dr. Face: Do you see other common patterns that result in unhappy patients?

Dr. Body: I see quite a few “double bubble” patients. That happens when the implants break through the skin near the breast bone and roll together. Conversely, I also see many patients whose implants are so far apart, the patient has no cleavage. After healing, their breast augmentation looks like two grapefruit halves stuck to their chests.

Dr. Face: Well, what incision do you use to get good results and repair these bungled breast augmentations?

Dr. Body: I start with an incision in the areola region, the dark area surrounding the nipple. I favor that approach because I’m working and standing right over the breast and can more easily center and balance the implants to provide natural looking results. Additionally, the important structures in the chest – directly beneath the breasts — that must be operated on for a complete, proper placement of the implants are only two inches away. I can clearly see everything relating to the internal anatomy of the breast and chest.

Dr. Face: I also see many patients for a rhinoplasty revision surgery to provide a better looking nose and to make sure their breathing is good. The most common mistake I see? Previous surgeons taking away too much nasal tissue and, often, too much of the bones and cartilage inside the nose.

Dr. Body: You have such a small area to work in doctor; it must be like watch making or building ships in bottles!

Dr. Face: The situation is close to that, but there is another factor at work — it takes many years to realize how the passing years can affect a nose job. It’s almost like there are three people involved in a rhinoplasty – the patient, the surgeon and Mother Nature whose healing process can change or complement what I’ve done in surgery.

Dr. Body:  Well, how do you account for what the healing process is going to do?

Dr. Face: One, by being conservative during the surgery. I can always go back later and perform some refinement, if necessary. Two, if there are very minor imperfections surprisingly delivered by Mother Nature, we can often correct them in the office using filler injections instead of another surgery. I have read that as many as 25 percent of rhinoplasty patients across the board are not satisfied with their nose jobs. That explains why we are seeing a record number of patents requesting we re-do the work first done first elsewhere by more inexperienced surgeons.

Dr. Body: Being that the nose is a three-dimensional structure, some of the bones and cartilage inside the nose must be the equivalent of weight-bearing walls in a house.

Dr. Face:  That’s correct — the same thing can happen to a nose as to a house. If you remove too much of the weight bearing walls, the structure can collapse or partially cave in.

Dr. Body: Then what do you do?

Dr. Face: If it’s very serious, I can take donor tissue from the rib area or an ear and recreate the wall. But sometimes, if only a divot or scooped out area shows on the outside of the nose, I can avoid surgery altogether and, again, use injections of facial fillers to make the nose aesthetically pleasing once more.

Dr. Body: If you were a patient, what would you do to make sure your nose or breast augmentation was done correctly the first time?

Dr. Face: In addition to reading everything about a surgeon’s training and experience, I would check their websites for the number and type of revision surgeries performed. Because the surgeon who repairs the work of other surgeons surely knows how and where the mistakes are made and how to get it right the first time. So patients are well served to always search for the cosmetic plastic surgeon who is the most specialized and has the longest run of experience.

Look at  Dr. Kotler’s before and after rhinoplasty revision photos.

View Dr. Linder’s before and after breast augmentation revision pictures.

Researching surgeons

In real life, our blogger Dr. Face is the eminent Beverly Hills board-certified facial plastic surgeon Robert Kotler, M.D.  Joining the discussion is an equally eminent Beverly Hills board-certified plastic surgeon, Stuart Linder, M.D. (who blogs as Dr. Body.) Both are constant consumers of professional cosmetic plastic surgery publications and help patients – along with other American plastic surgeons  – understand the importance of new scientific findings about the rejuvenation arts.

Doctors Face and Body frequently boil down the articles for News & Views, a capsulated review of the latest and greatest from the professional press.

Here is their second such offering.

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Dr. Face: (Dr. Kotler) Have you read any interesting articles about plastic surgery work on the body, doctor?

Dr. Body: (Dr. Linder) Odd you should ask. I spotted a survey, asking 500 board certified American plastic surgeons about their current breast augmentation practices.

Dr. Face:  Do you mean practices like location of the incision, type of implant, length of the operation and so on?

Dr. Body: Exactly. Because I place hundreds and hundreds of saline and silicone breast implants yearly, I was very curious how other surgeons approach and do their work.

Dr. Face: Did you find any surprises?

Dr. Body: A few. For instance, I noticed that only 32 percent of board-certified surgeons can perform an operation in under an hour. Actually, a well trained, board-certified plastic surgeon should take no more than 30 to 40 minutes to complete the procedure. And that’s with minimal blood loss and operating with a board-certified anesthesiologist.

Dr. Face: Did all the respondents use a board-certified anesthesiologist?

Dr. Body: Actually, one-third of the survey group reported using registered nurse anesthetists. That may keep costs down somewhat but to insure patient safety, a plastic surgeon should use a board-certified anesthesiologist – who is another M.D. He or she knows precisely what to do in any emergency.

Dr. Face: A good point, doctor. In point of fact, the development of the nurse anesthetist position was in the military where it was designed to be under the direct supervision of an anesthesiologist. The concept was one M.D.-anesthesiologist could supervise a handful of nurse anesthetists during operations.

Dr. Body: I also note that 81 percent of the survey group report using 300 to 400 cc breast implants. That’s about what I use in my practice. And, also like in my breast augmentation practice, I note that while silicone is available, the surgeons report more patients choosing saline breast implants.

Dr. Face: There are four possible incisions a plastic surgeon can use in breast augmentation. Did the survey show any preference for any particular one?

Dr. Body: About 66 percent of the surgeons report starting a breast enhancement with an incision in the inframammary location, the place where the bottom of the breast meets the chest wall. About 25 percent say they use a periareolar, or around the nipple, approach. I was surprised the figures were not reversed.

Dr. Face: Why the surprise?

Dr. Body: The inframammary was the standard approach to breast enhancement during the 1970s and 80s and is considered outdated for extremely busy surgeons who perform large volume of breast enlargements. Also, the majority of the responders were from the American South and East. If more California plastic surgeons had returned the survey, I think readers would have seen more up to date responses. In my opinion, the periareolar approach allows the surgeon to work right over the breast. So, looking down,  it is much easier to line everything up for natural looking results.

Dr. Face: I’ve read that starting a breast augmentation through the areola results only in temporary nipple numbness for a few patients.

Dr. Body: That’s true. But the medical literature of breast augmentation shows that the most common long-term complications are bleeding and then infections.

Dr. Face: Where could we find the study?

Dr. Body: In the March-April, 2009, Aesthetic Surgery Journal; it’s a magazine written and read by, plastic surgeons. The title is: Primary Breast Augmentation Today: A Survey of Current Breast Augmentation Practice Patterns.

Many American plastic surgeons, like

Both are also voracious readers of those publications and do their best to help patients – and even other doctors – understand the importance of new findings.

They often summarize their readings and findings in News & Views, reviews of the latest articles from the professional press.

While many more professional news reviews will follow from time to time, here is just one.

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Dr. Face:  (Dr. Linder)Everybody is interested in identical twins. But did you know that many, many twins have been studied before and after plastic surgery? One famous study compared twins who lived a healthy lifestyle with twins who smoked, drank, spent too much time in the sun and partied unto the wee hours. Guess which twin most needed facial plastic surgery?

Dr. Body: (Dr. Kotler) Probably the “bad” twin. But do I sense something new in the works about twins and plastic surgery?

Dr. Face: Indeed you do, doctor. As you may know, surgeons have always debated which particular surgical procedure yields the best and most long-lasting results. To find out, four plastic surgeons operated on four sets of twins back in 1995. Each surgeon used his own favorite surgical method which included neither unorthodox nor experimental approaches.

Dr. Body: Good idea for a study. What did they find?

Dr. Face: Plastic surgeons followed the twin patients at professional meetings in 1996, 2001 and 2005. At the last comparison, all of the twins looked good although nobody could answer the question, “Was it the surgeon or the technique?” The twins still look like each other, even after plastic surgery.

Dr. Body: What conclusions did you draw?

Dr. Face: That experienced plastic surgeons who perform a lot of procedures, say. at least two times a week of one particular procedure, get great results, even if they are using a different procedure.

Dr. Body: Very interesting! In what publication was the study printed?

Dr. Face: Plastic and Reconstructive Surgery, Volume 123, # 3, March, 2009.

Dr. Body: The article on twins I read was in the same magazine a month later. 186 sets of identical twins filled out a lifestyle questionnaire and provided photos. A panel of experienced cosmetic plastic surgeons then analyzed everything and presented their conclusions.

Dr. Face:  What was found?

Dr. Body: Of the leading most important lifestyle factors – things like marriage, body mass, sun exposure and even hobbies – cigarette smoking was fingered as one of the most significant. Because you could compare a subject to another person who is a genetic match, it was shown that every ten years of smoking equaled a two and one-half year older appearance.

Dr. Face: Another good reason not to smoke! If one twin smoked for, say, 30 years, he or she would look seven and one-half years older than the non-smoking twin. That is significant for somebody in the late 40s or 50s.

Dr. Face: Another important finding was that sunscreen did offer some protection from sun damage. Also, the study showed that women who had hormone replacement therapy after menopause looked younger than twins who skipped that therapy.

Dr. Body: For people who want to look that study up, how can they find it?

Dr. Face:  Just ask the medical librarian for Journal of Plastic and Reconstructive Surgery, volume 123, #4, April, 2009.

Note: Dr. Body is a leading breast surgery revision specialist while Dr. Face specializes in revision rhinoplasty surgery.

Because you are reading this, you are obviously interested in the websites of American plastic surgeons.

There are some key features to look for on any surgeon’s website that will tell you volumes, letting you know if you are barking up the right tree and if you are onto a fully qualified and trained surgeon.

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Dr. Body (Dr. Linder): Start your search with a Google search box. Just enter the city where you want to have plastic surgery, then what procedure and then the word “specialist.”

Dr. Face (Dr. Kotler) So if you are looking for breast augmentation in California, a search phrase may  be: “Beverly Hills, breast augmentation, board certified specialist.” Or, if you’re  going to the East Coast and want nose surgery, you would enter: “New York City, rhinoplasty, specialist.”

Dr. Body: The top ten selections should be on the first page of the search engine report page, the SERP.

Dr. Face: Next, go to a plastic surgery website and click on the surgeon’s before and after plastic surgery pictures. There should be hundreds of the procedure you want, not five or ten.  Additionally, all the pictures should have been taken under the same conditions. The camera angle, the lighting, the distance from the camera to the patient and the backgrounds should all be the same. Only the patients are different.

Dr. Body: Why so many pictures? You want a surgeon who concentrates, focuses and specializes on the same four to seven procedures, does them over and over, week after week, year after year.

Known to their colleagues as “Master Surgeons,” those surgeons perform the procedures so often they will:

• Be very efficient
• Produce less bruising and swelling
• Disturb less tissue

Dr. Face: Now, let’s make it a little more challenging and do some detective work.

Because plastic surgery has been considered so lucrative, some doctors not trained in cosmetic plastic surgery – or even general surgery – have entered the field. That is not illegal in the U.S. Each state licenses physicians without regard to a presence or lack of board certification in the doctors’ specialties.

But from the standpoint of pursuing excellence through the long and laborious residencies and fellowship training programs, there simply are no shortcuts.

The lesser trained physician will not know some important things and probably lack a few essential skills.

Dr. Body: So on the doctor’s website, look for the surgeon’s bio or vitae and take a note on:

• The medical school
• The internship
• The residency
• The fellowship
• The board certification

Here’s what you’re looking for: The residency should have been in either plastic surgery or head and neck surgery. Those are the only two recognized specialties that fully qualify surgeons to perform the major invasive cosmetic plastic procedures like:

• Facelifts
• Rhinoplasty
• Tummy tucks
• Breast augmentation or reduction
• Liposuction.

The important board certification should be in one of the following:

• The American Board of Plastic Surgery
• The American Board of Otolaryngology/Head and Neck Surgery

A fellowship after the residency focuses on even more training and is usually considered a preceptorship at the side of an older, much more experienced surgeon.

Dr. Face: Don’t stop reading until you note exactly which board certification.  Because there can be a fly in the ointment: some doctors have board certification in, for example, radiology or gynecology. Sure, their ads will say “board certified” but the certification was in a field other than the accepted cosmetic plastic surgery specialties.

Dr. Body: It’s important because the training that qualifies a cosmetic plastic surgery is longer than medical school itself! A surgeon who takes that training has at least three to five years in a plastic surgery or head and neck surgery training program, performing surgery under the supervision of a very skilled and experienced professor. Many then go into a one or two year fellowship after that. All that is a huge commitment and personal sacrifice but it is the patient who ultimately benefits and that is very healthy.

Dr. Face: Compare all of that with, say, a board certified radiologist, gynecologist or proctologist  who has only taken a week-long course in liposuction.

Whom would you rather perform your surgery?

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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.

Having served the cosmetic surgical needs of many hundreds of  top celebrities – often in total secret – both Beverly Hills board-certified plastic surgeon Stuart Linder, M.D. (who blogs as “Dr. Body”) and  Beverly Hills board-certified cosmetic facial surgeon Robert Kotler, M.D. (“Dr. Face”) tell why so many famous people have gone so terribly wrong with cosmetic plastic surgery when the very best is so close at hand.

Entire websites are devoted to Hollywood celebrities and film stars who come away with less-than-perfect plastic surgery. Yet, Hollywood and Beverly Hills—the world capital for plastic surgery — sit next to each other in Southern California. What’s more,  virtually all celebrities can afford the best of anything, rejuvenation surgery included. So what goes wrong?

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Dr. Face: (Dr. Kotler) The list of film stars and other celebrities with bad plastic surgery seems to grow each year. Recently, we’ve seen Priscilla Presley, Kenny Rogers, Meg Ryan, Bruce Jenner and others sporting features that are unnatural, artificial-looking and not at all complimentary to their cosmetic plastic surgeons.

Dr. Body. (Dr. Linder) Unfortunately, true. I know in plastic surgery of the body, the dead giveaway to either quick or untrained plastic surgery is when a breast augmentation patient turns up with breasts that look like two grape fruit halves or bowls stuck to her chest – along with a wide space between the breasts that in no way can be called “cleavage.”

Dr. Face: Cosmetic plastic surgeons of both the body and the face want a surgical rejuvenation to look natural. After healing, the person should look rested and refreshed – not someone who draws attention to him-or-herself due to huge fattened lips, surprised looking eye lifts, facial skin as tight as an overinflated balloon or the breasts you mention.

Dr. Body: Sure, the key to good cosmetic plastic surgery is that the patient looks very, very good but still, other people can’t quite put their fingers on what the change is. People usually guess at a new workout program, a vacation, losing weight or a new romance.

Dr. Face: Yet when he was alive, Michael Jackson turned up at the offices of many Beverly Hills plastic surgeons asking for yet more rhinoplasty, long after his nose was already overdone. I’ve known of many famous people who turn on all the charm to pressure a younger surgeon into yet another surgery – one which will do the celebrity no good or one the person should not have for reasons of health.

Dr. Body: So there are many times when the dedicated but thoughtful surgeon must say no. In my practice, I routinely say “no” to anybody with diabetes, celebrities included. Most cosmetic plastic surgeries of the body involve long scars which stand a good chance of separating before healing if the person has diabetes.  Or a terrible infection may set in.

Dr. Face: I’ve also noticed that many celebrities are very given to embracing the latest fad procedure or practitioner. Priscilla Presley (the first wife of singer Elvis Presley) was shown on the television program, Dancing With The Stars about a year ago; viewers could easily see her immense, out-of-proportion lip augmentation. A bogus doctor had gained his way into celebrity, A-list circles and was essentially injecting them with low grade industrial silicone – at a premium price. The “physician” in that case turned out not to be a doctor at all, was later convicted on several charges and deported.

The largest red warning flag of all?

The so-called  “doctor” was operating from his home! Legitimate cosmetic plastic surgeons work from well-staffed, well-equipped offices.

Dr. Body: Actually, many, many Hollywood celebrities have plastic surgery and have it in secret. In a later blog post, we’ll tell you how they do it. But, understandably, celebrities appearances often depend on whether they work or not. So they should be the ones to do the most homework and find the most skilled plastic surgeons possible.

We’ll also tell you how to do that in a post later  on!