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There has been a lot of discussion in the media regarding teen actress and singer Ashley Tisdale's decision to have here nose fixed for a functional breathing problem early in December. When she emerged approximately 3 weeks later, it was difficult to recognize her, similar to the way Jennifer Grey of Dirty Dancing fame emerged after her nasal surgery. It is clear that both of these actresses underwent not just breathing surgery, but an operation called a rhinoplasty (nose job) to alter their appearance. Interestingly, both of these young women were attractive in their own right, and likely wanted only to have minor changes in their nasal shape to better enhance or define their beauty. Interestingly, the extremely small and pinched look of the tip of Ashley Tisdale's nose indicates that a lot of cartilage was removed from it, and this usually causes difficulty breathing; this is the very reason why she embarked on her surgery in the first place. 

The unfortunate truth about rhinoplasty is that approximately 7 to 10% of rhinoplasties performed in the United States require revision surgery because the person undergoing the surgery is not satisfied with its look, or because of post-surgery breathing problems. So yes, there is a way to restore Ashley Tisdale's nose to a more natural appearance that does not erase her identity. In her case where the nasal cartilages and bones were overresected (too much removed) this would involve replacing the removed cartilage with cartilage borrowed from other portions of the nose or body like the nasal septum (a piece of cartilage inside the nose) the ears or in very severe cases, unlike Ashley's nose, the rib cartilage. This requires the expertise of a facial plastic and reconstructive surgeon that specializes in both revision cosmetic surgery and reconstructive surgery, and these doctors can be found both through the American Board of Facial Plastic and Reconstructive Surgery or the American Academy of Facial Plastic and Reconstructive Surgery. 

So how does the actress or everyday prospective patient prevent this problem when choosing a surgeon? The first step is ensuring your doctor is board certified and specializes only in facial plastic surgery and not a generalist also performing other cosmetic surgery procedures like breast augmentation, liposuction and tummy tucks. Avoid the "jack of all trades." One way of ensuring this is by choosing a doctor board certified by the American Board of Facial Plastic and Reconstructive Surgery as noted above. But this is only the beginning. 

When interviewing a doctor for surgery during a consultation, you should be allowed to see hundreds of examples of their work. During your review of these photos, make sure that all the noses do not look the same because that indicates that the doctor has a "cookie cutter" approach to surgery and that your nose will look just like all the others. This is important as each rhinoplasty surgery should be sculpted to balance with other facial features and stature. For example the 6 foot runway model with a long face should not have an overly small and upturned nose because it will look ridiculous. 

Additionally, their needs to be an extensive discussion with each patient to arrive at what their concept of beauty is and what their desire is for surgery. If you were Ashley Tisdale and only wanted your bridge slightly refined and wound up with a nose half it's originally size that would be horrible. The best way for a surgeon to arrive at this conclusion is by taking digital pictures of the patient and using digital morphing technology to manipulate the photos so that there is a clear understanding of what a patient wants their nose to look like. This becomes the road map for surgery. This is not a gimmick, and I and a minority of surgeons across the country use this to make sure we are going to deliver what each person wants. Many plastic surgeons will not use this technology as they cannot tailor their operation but give you the "Doctor Smith Nose." 

Their needs to be a merging of good techniques, the aesthetic understanding of the surgeon, and the desire of the patient defined by digital morphing to prevent unwanted results. But who knows, maybe Ashley wanted her nose to look that way!

According to the American Society of Plastic Surgeons, over 11 million procedures were performed on people seeking to improve their appearance, up from 8 million just three years ago. The message is clear that Americans are embracing cosmetic surgery, and that these treatments are becoming more "main stream." With this large number of procedures across the country, and the diverse group of doctors that perform them, the number of patients dying from surgery is an extremely small fraction of one percent. So how does an affluent and educated woman like Donda West, a retired professor and former chairwoman of the Chicago State University English department, die from plastic surgery? 

While we do not have all the specifics of the case, the Los Angeles Coroner states that preliminary information indicates West died from "complications of surgery", rumored to having had a tummy tuck and breast reduction. "Complications of Surgery" can mean many things, but the two primary issues are whether she had a complication from anesthesia or a complication from the surgical procedure. 

Before we consider whether there was a physician error, the anesthesiologist or the surgeon, the first step in ensuring a safely executed procedure is that the patient is healthy enough to withstand the physical stress of anesthesia and surgery on the heart and pulmonary (lung) systems. This requires a complete medical pre-operative evaluation, performed by an internal medicine doctor (not a surgeon), including complete blood work, an electrocardiogram, and chest X ray. Sometimes more extensive testing is required if a patient has a history of heart problems; a stress test or echocardiogram, etc. Simply put, some people are not good candidates for surgery and one should never have surgery before having a medical clearance. I have patients that are in their 40s that have many significant medical problems and are not candidates for surgery, and others in their 70s who get a face lift after they had a full medical clearance. It has been rumored, but not confirmed, that the surgeon took on the Donda West's case after other surgeons told her it was not safe for her to have surgery. 

The next step to a safely executed procedure is choosing the correct surgeon. The surgeon who cared for Donda West is Dr. Jan Adams. Dr. Adams is currently under investigation by the California state medical board, has been the target of malpractice lawsuits and has paid out nearly $500,000 in civil settlements. The board is also investigating whether Adams' license should be revoked or suspended after two alcohol-related driving arrests in the past four years, according to records. 

Where do we start when looking for a qualified plastic surgeon? On the internet? In a television show, or a magazine article or a phone book advertisement? A referral from a friend? Cosmetic surgery is more acceptable today than ever before, especially with the media's coverage of Botox and television shows such as Extreme Makeover. Unfortunately people are still secretive, and trying to get information about a good cosmetic surgeon or a good experience with a cosmetic procedure, even from friends, can be difficult. 

The reason for caution is that any physician with a medical degree and a license to practice medicine can legally perform plastic surgery in the United States. This is why OB/GYN doctors are performing liposuction, laser skin resurfacing, and Botox in their offices, and dentists are performing rhinoplasties.

Credentials are just the beginning when choosing a plastic surgeon. The public, in my opinion, is confused about this subject and with good reason. In today's competitive environment, in order to attract patients, it has been claimed that there exists only one board that certifies surgeons to perform plastic surgery. This is clearly not the case. There are five different legitimate boards that are either member boards of the American Board of Medical Specialties (ABMS) or equivalent boards. These boards include the American Board of Facial Plastic and Reconstructive Surgery and The American Board of Plastic Surgery. 

You should also check your doctor's hospital affiliations. If a physician has privileges to perform surgery at an accredited hospital, this demonstrates that his or her performance and credentials are subject to regular scrutiny. While most plastic surgeons perform surgery only in their office, they do have privileges to perform surgery at a local hospital. If a doctor does not have these privileges, do not use that doctor. 

Unfortunately, board certification is only the beginning to choosing your doctor. Board certification in Plastic Surgery or Facial Plastic Surgery means that your doctor has completed his or her residency training, passed rigorous comprehensive written and oral exams, and presented a series of surgical cases. But this does not mean he/she is a skilled surgeon; not all surgeons are created equal. Just as there are certain people who excel in sports due to their unique motor skills, there are a small percentage of surgeons who have the ability to use their hands to sculpt tissue in an aesthetic way. What I am trying to say is that there are good surgeons and there are great surgeons, and to use our sports analogy, your job is to figure out who the pros are versus the minor leaguers. 

How do you do this? Ask your friends and your personal physician. Ask to see examples of the surgeon's work, or talk to one or more patients about their surgical experience. Physicians who do the procedure you are interested in regularly, and do good work, will have an abundance of examples. Do not accept statements from your surgeon like . . . "my patients do not want me to show you their pictures" or "my patients are very private." This usually means that there are no examples of their work that they would want you to see. Most of my patients come from word-of-mouth referrals. 

Check out the surgeon's office and staff; be sure you will be treated the way you expect and that you feel comfortable there. Be sure the doctor is easy to talk to and is someone with whom you can relate. If you do not get along with your surgeon before surgery, do not expect things to get better after surgery. 

In the end sum, you have to be your own best advocate, ensure you overall health first, and do extensive research on your doctor.

EVOLENCE is a new, collagen-based, soft-tissue filler that quickly and effectively restores shape to facial wrinkles – with benefits lasting for at least 12 months. It is not FDA approved, but is currently available in Europe. 

The long-lasting effect of EVOLENCE means that repeat injections may only be needed once a year or less, unlike some other biodegradeable fillers which often need repeating 2–3 times a year. Hyaluronic acid fillers such as Juvederm, Retylane and Perlane usually will require 2 treatments a year to maintain correction. I would be extremely cautious with this new product as most fillers when they first come to market claim they last twice as long as they actually do. For example when the first collagen was launched in the 1980s they said it would last 2 years when it actually lasted 2 months!

The company says that EVOLENCE achieves its long-lasting effects because it is specifically engineered to enhance stability and mimic the properties of natural collagen found in the skin. The filler is produced via the revolutionary Glymatrix™ technology. EVOLENCE is produced in the laboratory by polymerization of porcine (pig)collagen followed by glycation with natural sugar. BECAUSE IT COMES FROM A PIG IT WILL REQUIRE TWO ALLERGY TESTS PRIOR TO BEING ABLE TO USE IT FOR WRINKLE CORRECTION! Many patients also have objections to eating or putting any pig products in their body, so this would also be a potential problem for consumers.

A recent study published in the July 2007 issue of Plastic and Reconstructive Surgery noted EVOLENCE safety in 12 patients, but does not study how long it lasts. The jury is out in my mind until better studies are established in the US.

Posted by Dr Jacono at 10:30 PM