In general we try to keep this blog focused on facial plastic surgery but with all the news about this historic election we thought we would take some time to examine the important points of each candidate’s proposals for health care reform.

If you’re like us, even though only a week is left before the election, you are probably still confused about both candidates’ plans. We watched all 4 debates and what we were left with was the notion that McCain wants to give a $2,500 or $5,000 tax rebate—that may or may not end up costing us more—while Obama spoke about massive reform of the system, which would cover more people under government health care but still be supported by employers paying into the system…and maybe being fined if they didn’t.

 In the last week’s Journal of the American Medical Association, each candidate tried to distill their ideas succinctly into a few pages and we are going to highlight those (and occasionally lay criticism) as equitably as possible.  

The McCain system’s highlights and low points: 

1. “The foundation of my health care plan is a belief that American families—not government bureaucrats or insurance companies—should choose the coverage that best meets their unique needs.”
2. “Simply offering increased access to a system that costs too much will not provide real reform.”- Yes, but nobody can deny that both increased access and lower costs are necessary.
3. “Only by restoring doctors and patients to the center of health care decisions can we improve quality and reduce costs…”- Nice rhetoric.  Let’s get specific…how is McCain going to do it?
4. “Government bureaucrats and the distortions they have created  in the market for health care are a prime driver of the practice patterns that lead to rising  health care costs”- This is true: if Medicare increases payment for more high tech procedures, more high tech gets done, even if it’s not needed.
5. “Expanding the government’s role in Americans’ health care will make things worse, not better- just ask our neighbor to the north.” We have firsthand experience and have to agree.  Government-sponsored healthcare sounds excellent in theory, but simply does not work in practice and leads to increased access to less specialized medicine: see our blog on Canada for more detail (http://www.rhinoplastyinbeverlyhills.com/is-health-care-in-canada-really-better).
6. To make insurance affordable for all Americans- provide a refundable tax credit of $2500 for individuals and $5000 for families to use for health insurance – We like this idea.  Many healthy, younger people who now don’t have insurance will join in and thereby help stabilize costs for everyone
7. Presently, if you leave your job you lose that insurance, thereby essentially locking some people into their job for fear of losing their coverage- McCain states his plan provides options for coverage that will follow the family from job to job so you don’t have to start over with a new doctor. Under the current system, you can be covered by a COBRA plan if you lose your job, but you may have trouble qualifying to roll that into an individual plan later if you haven’t found another job.
8. “Opening the health insurance market to nationwide competition would give people many more choices of policies” thereby “putting pressure on companies to provide better care at lower costs”- This is slightly shady to us.  Different states have different rules for insurance companies, so the federal government would have to create a minimum standard of rules for all states to abide by.
9. “My plan will create a new Guaranteed Access Plan, or GAP, to help those” with preexisting conditions or others who otherwise have denial of coverage.- It sounds good in principle, but how would he make it work? McCain states that this will not be another “unfunded mandate” but we need details. How is he going to get them to lower costs so that patients can have access?
10. “Our current tort system drives numerous inefficiencies in the health care system. Doctors are forced to perform repetitive and often unnecessary tests in order to protect themselves from the risk of lawsuits.” Not only does the tort system drive up cost, but it also limits availability of specialists- This is the heart of the issue with regard to healthcare reform.  Unless there is significant nationwide tort reform, real health care reform is impossible. As long as doctors are forced to practice “C.Y.A.” (“cover your ass”) medicine, they will continue to order more unnecessary and expensive tests that drive up cost and don’t really improve outcome.
11. Like Obama, he stresses need for government to fund early intervention programs that focus on preventive health care.  However, unlike Obama, he does not sound nearly as compelling or as convincing in how he will do this.

 The Obama system highlights and low points:

1. “The Obama-Biden health care plan will guarantee that all Americans have quality health coverage and will save a typical family up to $2500 every year on medical expenditures”- Sounds great but how will he increase coverage and save money without increasing taxes?  As we have heard time and again, Obama is planning to reduce taxes on everyone earning less than $250,000 per year (or $150,000, if you believe what Biden said yesterday), so how are we as a nation going to come up with this money?
2. “For Americans satisfied with their current health insurance, nothing will change except their costs will go down”- The devil is in the details!  How, exactly, will the costs go down?
3. “Americans will also be able to choose from a range of private health insurance options through a New Health Exchange (NHE), which will establish rules and standards for participating plans. The Exchange will also include a new public plan that will provide coverage similar to the kind members of Congress give themselves”- Sounds good…but where is the money coming from to provide for this coverage? In other words, who is paying for this? This would have the same problem as McCain’s plan in that states now place their own standards, so is the plan to do away with state’s rules and regulations and supercede them with Federal regulation? If this is the case, this is essentially the same as McCain, except it includes a National Health Exchange.
4. “Americans who cannot afford it (the public plan) and do not qualify for Medicaid or SCHIP (State Children’s Health Insurance Program) will receive a tax subsidy to pay for coverage”- How much tax subsidy? Will these people be forced to apply that tax subsidy to enroll in the public plan?
5. “Plan will require coverage for all children and require that employers either make a meaningful contribution to coverage for their employees or contribute a percentage of payroll toward the cost of the national plan. Small businesses will be exempt …but our plan will create an incentive for them via a refundable tax credit worth up to 50% on premiums”- And if parents don’t/can’t purchase insurance for their kids, or employers don’t make a “meaningful contribution”…what are the penalties? McCain raised this issue but no answer was given in the debate. How do you define what a small business is, and what is the percentage of payroll that will have to go to the national plan?
6. Make an up front investment of $50 billion in electronic health information technology to reduce errors, saving lives and money”- This truly sounds like a great idea but what is this money buying? Is the government buying one electronic medical system that they will then provide to every hospital, doctor’s office and pharmacist?
7. “Requiring health plans to disclose what percentage of premiums actually goes to patient care as opposed to administrative costs”- This is a great idea.
8. Reforming medical malpractice while preserving patient rights, and strengthening antitrust laws to prevent insurers from overcharging doctors for malpractice- Sounds good but the verbiage does not seem to be as direct with respect to tort reform needed. 
9. “Plan will allow Americans to import inexpensive and safe prescription drugs from other countries, increase the use of generic drugs in all public health plans, stop large drug companies from paying to keep generics out of markets just to preserve their profits, and create a pathway to bring generic vaccines and other biologic medicines to the market”- Good in theory…but what happens if one of the drugs you import from another country is somehow not made appropriately due to lower standards in other countries (for example, think of China and the recent milk epidemic). The overarching principle is fantastic but the details are very thorny…however, McCain in his brief outline in JAMA did not address the point of medication cost at all.
10. Like McCain, he stresses need for government to fund early intervention programs that focus on preventive health care.  He sounds more committed to funding community based clinics but again does not state where the money comes from.

Based on all of the above, you can guess we do not love either plan though both have some merits. Overall, the major point of difference between McCain and Obama is government role. While McCain may be offering too little in terms of government, it is hard to believe that even as we have exploding deficits, Medicare and Social Security bankrupting, that we as a nation can afford the Obama plan. Some can argue that we cannot any longer afford not to overhaul the system and that is very true. It may seem that we give McCain an easier time; partly, that is because it largely maintains the system as we have it and tries to remove state constraints to open options, and thereby lower prices. It is largely a band-aid.

The Obama plan is far more audacious and, as he is the front runner, far more worthy of detailed critique. We simply do not see how this plan can work with centralizing and socializing the system or by setting up a two-tier system like in England. That may sound nice—Hey! Everyone will be covered!—but the reality, based on our experience, is that you are stealing from Peter to give to Paul. In an effort to cover the millions currently uninsured, you decrease the level and quality of care received by all. It is our belief that McCain is right in his observation that privatized healthcare allows for more advanced health care, but whether this translates to improved quality depends on the parameters you use to decide.  Frankly, based on how our government has managed Medicare and Social Security, we do not believe Americans would be happy with a centralized health care plan, nor do we believe that the government can manage so audacious a plan without bankrupting the system or…if you’re ready for it…for us to ration health care- based on our experience we don’t think so. When it comes to your health or the health of a loved one, we find Americans want everything done that can be done.

We ask everyone who reads this to think for themselves and make a choice. Don’t let the polls decide or persuade you one way or the other.

After seeing the title to this blog you may be wondering:

“what is a spreader graft and who cares?”

                                                                        - that is of course if you continued to read.

Well the truth is unless you have broken your nose or had previous rhinoplasty, you probably can ignore this blog. However, if you are either of these people then this blog might interest you.

Patients who have broken their nose or present requesting revision rhinoplasty often are noted to have a depressed area in the middle portion of their nose- an “inverted V deformity.” Frequently this is associated with nasal obstruction, but not always. And unfortunately, many doctors and plastic surgeons continue to overlook or miss it.

We’re not going into the details of the internal valve or spreader grafts here (for those interested you can go to our internal valve chapter  or our twisted nose chapter ).

Bilateral Spreader grafts can be seen in position between the upper lateral cartilages and the septum.

 Suffice it to say that when the nose is broken or after previous rhinoplasty, the cartilage that makes up the middle side wall of your nose may have collapsed inward, resulting in the depression you see. For us to correct this problem, one of the things we occasionally have to do is place a spreader graft.  The spreader graft is a small rectangular piece of your own cartilage that is generally 3-4 mm long, 1 mm wide which is inserted into the space between your septum and the upper lateral cartilage. While there is no agreement of how spreader grafts work, studies have shown that they are effective in both improving breathing and in improving aesthetics. One potential problem with spreader grafts has always been the belief that spreader grafts widen the nose when placed. Well a very recent study looked to find out if there was anything to this belief. And well, the answer was that spreader grafts do widen the nose a little, but it took a computer to see the difference. And perhaps more importantly, none of the patients in the study complained about the small increase in width when they noticed the positive effects the grafts produced.

We have gotten a number of emails recently asking about what can be done for bad nostril scars. These usually result from a poorly planned nostril reduction procedure, often called alar base reduction. For many ethnic rhinoplasties, narrowing of the nostrils is a desirable goal to bring the tip into balance. There are a number of ways of doing this but all involve some sort of incision along the opening or rim of the nostril (at least that’s the only way to get a permanent change). If done well, these scars should be invisible once they are healed (watch out for our upcoming post with pics on how to do it right!).

When it’s not done wrong, it’s a whole different story. The scars can be quite visible or widened and the nostrils themselves can appear distorted or unnatural. Because deeper skin tones tend to react more strongly to injury, they are at higher risk for problems with healing in this area.

When you find yourself in that situation, help is still available. The color and contour of the scars themselves can often be improved by resurfacing them. Tools for doing this include dermabrasion, various lasers, and deep peels. These can be very effective but may require more than one treatment to see the results you want. If caught early enough, silicone gel and steroid injections may be helpful in getting the scars to settle down. If all else fails or if the nostrils are unnaturally distorted or flattened, it can get more complicated. It may be necessary to revise the procedure, remove the scars, and do other things to get some improvement.

Tune in for our upcoming blog in the near future that will show you how an alar base reduction is done right.

Since we last wrote, there has been a firestorm of political activity in Sacramento regarding cosmetic surgery. The Bill AB2968, otherwise known as the ‘Donda West Bill’, was vetoed recently by the Governor reportedly because it did not represent high enough priority legislation given the backlog he was dealing with.

The Bill was proposed after the untimely death last year of Dr. Donda West, mother of Kanye West, one day following a cosmetic surgical procedure. She was found to have preexisting high blood pressure and heart disease, though the contribution of these to her death is unknown. These unfortunate events prompted California legislators to try to find an answer to prevent this kind of tragedy in the future. The resulting bill that was overwhelmingly supported by lawmakers would have required all patients seeking cosmetic surgery to have a physical exam and medical clearance for surgery.

We are fully in support of doing whatever is possible to ensure the safety of patients. That is our oath, to first do no harm. That burden is especially high for elective cosmetic surgery where most of the patients we take care of do not ‘need’ our services. This takes nothing away from the fact that cosmetic surgery can have huge far-ranging benefits. Still, we need to take a zero tolerance policy for surgical complications if we are to do our very best for the patients in our care.

The problem is that legislators generally make bad decision makers when it comes to medicine. More and more medical practice guidelines today are based on evidence from clinical trials. The American Society of Anesthesiologists (ASA) has appointed a task force just for this purpose.

Their last report found surprisingly little evidence that routine preoperative testing does anyone any good. A good history and physical is a good idea for every surgical patient and this should be done by the surgeon and anesthesiologist anyway. For more invasive procedures and higher risk patients, the exam should be done before the day of surgery so that their general health can be optimized ahead of time. Tests, if done, should be targeted to the patient individually.

A routine across-the-board medical clearance is not supported by the findings of the ASA. It sounds pretty harmless, right? Forget about the added time and costs to the system. When we do tests without thinking and without looking for something specific, we often act on findings without thinking too, and this can lead us down the road to more unjustified tests and procedures that may do more harm than good.

If you are one of the 35 million American who suffers from nasal allergies, you might soon start hearing that a botox injection is one of the better treatment options for allergies.

Turns out a recent study was completed in Korea that compared patients with allergies who were either injected with botox, steroids, or normal saline into their nasal turbinates.

The study found that those injected with botox had both better overall improvement as well as longer lasting improvement than those who received steroid injections when they compared runny nose symptoms, nasal obstruction symptoms, and itching symptoms.

Stay tuned and we’ll let you know more as information becomes available, but this was an interesting preliminary study.

Apparently, for some there is. At least that’s what 20/20 says. According to a recent spot on the show a couple of nights ago, a plastic surgeon in New York is offering unlimited plastic surgery to the ultra-rich for the summer while they recover in the lap of luxury in a fully-stocked Hamptons mansion, and all for the low, low price of half a million dollars. Yes…you read that right…we said unlimited plastic surgery.

Well, what do you get for someone who has everything? It seems you get one of every type of cosmetic procedure available. Does anyone else see any problem with this? For one, with that price tag, we think you should be entitled to cosmetic surgery for life! But, seriously, should cosmetic surgery really be reduced to a buffet? It is perhaps not the best idea to cram as many surgical procedures as possible into a two-month period. When we brush off the fact that these are real medical procedures, we slip into dangerous waters.

Not to mention the fact that most people don’t actually need every cosmetic procedure under the sun. This is not a pick-what-you-want-off-the-shelf type of service. Our whole philosophy of plastic surgery is that the relationship relies completely on an involved discussion so that the surgeon can recommend the procedure most appropriate to achieve your goals in a reliable and safe manner. That way, you should come out feeling like a more pleasing version of yourself…not a completely different person.

Cosmetic surgery may be elective, but it is not like a salad bar or a box of chocolates. The all-you-can-eat offer can leave you with so much more than just an upset stomach.

Sorry we haven’t blogged in a while. We have just finished a tour of Las Vegas and New Mexico including a conference and consultations with patients. What was interesting to us was the similarities we see among patients’ desires and fears related to surgery. We have both practiced in big cities on both coasts but we have never had the pleasure of consulting with patients in the smaller cities of this beautiful desert country.

We talked to people who were generally well-informed and who had a great deal of interest in the latest and greatest in plastic surgery. Like our patients here in LA, they have justifiable doubts about some of the less invasive procedures that make over-the-top claims in the media. Some have had a Lifestyle Lift elsewhere and have been sorely disappointed. Most all spoke of wanting to look natural and of fearing an overdone appearance. All of them were very willing to consider surgical procedures to achieve their goals. Mostly, they were in need of doctors who would tell the truth about what they could expect from today’s surgical anti-aging procedures.

What we did not expect was the level of sun damage that a majority of patients exhibited. We probably shouldn’t have been surprised since many people in these areas spend much of their work and leisure time in the great outdoors. But, most also confessed that they did not use sunscreen at all, let alone effectively. As a result, we saw a lot of premature skin aging and most patients had had early precancerous lesions scraped or burned off. Many of these sun-related changes such as fine wrinkling, brown spots, and thickening can be treated really well with a series of peels, such as the ViPeel or Blue Peel, along with lifting and volume enhancing procedures such as our new Hybrid Lift to treat sagging skin.

But, the most important thing you can do is to protect your skin from the sun in the first place. We’re good about sun protection, yet UV-filtered photos of ourselves still show a fair bit of accumulated sun damage. So, we spent a lot of our time lecturing about sun protection. Avoidance of sun in the mid-day hours, wearing protective layers, and using a SPF 30 or greater sunscreen liberally and often (especially after water exposure) are all sensible things everyone should do, regardless of skin type. If you want to take skin anti-aging to the next level, then use of a good skin care regimen that incorporates antioxidants and bleaching agents can give your skin a healthy glow that you haven’t seen since grade school. Check out our website for more details.

Welcome to the no spin zone: no, you have not found your way to the O’Reilly blog, however when we read a recent article in the Daily Mail-UK we couldn’t help but wonder why these things would be reported in a newspaper. Do they actually research or do they decide a story they want and then find a number of people who will agree with them?

The story begins by telling us that the popularity of facelifts and anti-aging/ facial rejuvenation surgery is growing year after year, but then takes an abrupt turn by quoting a number of “cosmetic doctors,” who happen to have non surgical cosmetic practices (comprised of fillers- juvederm, restylane, perlane- and botox) who believe that surgery is bad.  What a surprise.

If you have been reading our blogs, especially those regarding the Hybrid Lift, you know by now that our Beverly Hills facial plastic surgery practice is dedicated to bringing natural looking results, and this means that we are strong advocates of a balanced approach utilizing volume enhancement, i.e. fillers, and lifting procedures in concert.

We recognize that potential patients are constantly bombarded by spin and hype from competing physicians and corporations [Allergan- Botox, Juvederm; McKesson- Restylane, Perlane, Myobloc; Artes- Artefill; Bioform- Radiesse, to name a few] and it is important for doctors to be advocates for their patients (not the corporation), so they can honestly explain all the risks and benefits of every available procedure. This is perhaps most important in plastic surgery and cosmetic surgery where we are talking about elective procedures.

The truth is that surgery works brilliantly when done correctly and for the right reasons. Let’s face it, if you have sagging skin and jowling, fillers are not the answer, though they may play a part. On the other hand, if you have hollowing in the cheeks or under the eyes, volume enhancement with a skin pinch may very well be better than traditional blepharoplasty (eyelid surgery). The key is understanding the difference between what a mini lift (lunch time lift) can do and how long it lasts as opposed to a lift that involves the deeper tissues.

Does anyone really believe you can correct these wrinkles by just filling under the skin without making this face look completely different?

We believe that for facial rejuvenation to work that lifting and volume must be coupled. Volume enhancement, for us, has come to mean fat, because some of it will last permanently and, perhaps more importantly, it is natural and safe. We remind you that none of the fillers to date have FDA approval outside the scope of the nasolabial folds (and perhaps lips but we have to check on that). As far as surgery, mini lifts occasionally are indicated, but we have found that patient satisfaction and long term results really depend on addressing the underlying, descending tissue (the SMAS).

The point of all this is that the story begins by telling us how the number of women and men having anti-aging surgery is growing rapidly. There is a reason for that: when it’s done correctly, it works.

Reading the New York Magazine we came across an interesting article that goes over a “new” phenomenon among New York’s higher echelons that involves volume enhancement using fillers and occasionally fat to restore the lost volume that many patients experience as they grow older. The article goes on to highlight a number of dermatologists and facial plastic surgeons in New York that are on the forefront of the phenomenon there.

Composite picture of Demi Moore, Angelina Jolie, Madonna, and Michelle Pfeiffer courtesy of the New York Magazine showing the natural aesthetics which are ideal when volume enhancement and facelifts are combined such as in the HYBRID LIFT

As we read the very well-written article trace the history of facial aesthetics and volume enhancement, we could not help but notice that many of the doctors and quotes noted that as patients age there is a descent of tissue, sagging of skin, wrinkles and jowling, but then they glossed over the fact that volume enhancement alone fails to correct all of these issues. The idea that adding fillers or fat can correct jowling and redundant skin is simply not true.

We don’t normally like to brag here on the post, but in this one instance we hope you permit us a minute to gloat over our HYBRID LIFT.  What we do for our own patients is a minimal incision deep facelift—this is tailored individually depending on how much skin descent and jowling there is—and then add the patient’s own fat back (as in the “new new face”) to recreate the volume so many patients lose as they age. The aesthetic results have been fantastic and our patients love that they can be up and around after only a few days.

While we respect the claims in the article and are proponents of volume enhancement, we find it disingenuous to claim that by replacing volume you can somehow correct the tissue and skin which descends with time. The  problem is that too many people with hammers begin to see everything as nails.

The key points of our HYBRID LIFT are:

1. By doing a deep lift we are able to first replace the patients’ own fallen deep tissue (the SMAS) back into its proper position

2. By using a minimal incision, we never get into the hairlines, move hair tufts, or get a windswept appearance

3. Unlike mini lifts, because we do the work in the deep layers; the results last

4. By then adding fat and restoring volume, we fill out the concavities that lead to an aged appearance and we restore the youthful heart-shaped face that people are drawn to

5. By using your own fat, we are confident that the results last and are natural. Temporary fillers unfortunately are just that: temporary. Permanent fillers are all too often not tested for safety in these other areas, are not approved for these uses by the FDA, and are used in “off- label” procedures whose safety is unclear.

For us, the HYBRID LIFT represents the culminant evolution of facial rejuvenation.  Stay tuned for the HYBRID LOWER EYELID LIFT…

Here’s a typical scenario. You’re considering facial plastic surgery to take care of a bump on your nose, a droopy tip, or a sagging jaw line. The feature may be subtle, but it’s definitely there. And you’ve been thinking of doing something about it for so long.

You’ve finally worked up the courage to tell your husband/mother/sister/brother/best friend (insert loved one here) about it and, instead of unwavering support, you hear something like “Your nose is fine. Why would you mess with it?”. Other reactions are “Whatever makes you happy, honey” or, “I was wondering when you were gonna take care of that honker”. But, the overwhelming #1 reaction is the first one.

You’re crestfallen. You start to second guess yourself. You think “I’m not imagining this. There is a noticeable bump on my nose. Why doesn’t anyone else see it?” Well, the answer is, they do and they don’t. They can see the feature you’re pointing to just as well as you can. The human eye is capable of incredible feats. Our eyes can discriminate between two objects down to 1/25th of an inch or about 1 mm. So, if we show you a photo of your nose and another photo with your bump shaved down just one millimeter, you’ll be able to see the difference every time. And, we all also have a built-in, hard-wired aesthetic sense of proportion, symmetry and ‘belonging’ness when we compare one feature to the rest of the whole. So, they know deep down that the bump is there.

But, your family or friends may not “see” what you’re talking about because they don’t wish to and they don’t attach the same level of importance to it as you do. They care for you as you are, as they should. And, they’re afraid for you. Afraid of the risk, even if it’s very small. And, afraid that you’ll change too much. After all, you may want a subtle change or a dramatic change, but they don’t necessarily see what you see.

Some of our patients who are REALLY close to family and friends and look to them for advice are really freaked out by this. We’ve even had a few patients recently who’ve nearly psyched themselves out of their decision. The important thing here is not to try to force your loved one to feel about your proposed surgery the way you do. Family are never quite as enthusiastic as you may be. Instead, you should let them know how important this decision is to you, and how much better you’ll feel if you have a positive outcome. That will often turn them around because what’s important to you is often what’s important to them. The decision to have surgery is a very personal one and is ultimately yours. You can reassure them that, if you’ve chosen the right surgeon, your results will look natural and won’t remove your identity.

What’s interesting is that the most resistant family member or friend is usually your most astonished and glowing supporter after the surgery once they see how happy you are with the change. This is just something to consider when you sit down to have “the talk”.