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  • Dr. Robert Kotler, Plastic SurgeonDr. 90210 TV Series regular Dr. Robert Kotler practices exclusively in face and neck plastic surgery and believes that the best surgeon for a patient is one who specializes in the procedure that you seek out. Dr. Kotler says “who wants to be in the hands of a jack-of-all-trades, a master of none? The surgeon who excels at breast augmentation or breast reduction is not necessarily the best surgeon for a nose job.” This exclusive interview in which Dr. Kotler shares his wisdom backed by 30 years of experience is part of a series that Make Me Heal is conducting with well-known plastic surgeons who specialize in facelifts.

    Make Me Heal: What are the new innovations in facelift techniques that you employ in your procedures?

    Dr. Kotler: I believe the great “victory” in face lifting always revolves around improving the neck and jawline. With time, the neck and jawline become saggy and ill-defined. Yet, this is where the most youthful appearance reward can be obtained. This is done by spending time and effort on the neck and jawline through the hidden, horizontal incision fashioned just underneath the chin. The first step in a successful face and neck lift consists of liposuctioning the superficial fat just under the skin. Next, the deeper layer fat pad is removed with standard surgical technique. Then, a third and deeper deposition of fat — beneath the often lax and sagging platysma muscles– is also removed. Then the platysmal muscles are re-united in the midline with using permanent but hidden sutures.

    All of the above render a sharp jawline and a good neck-chin angle. That, in addition to re-draping the excess lower face and neck skin is what gives one a youthful appearance.

    Make Me Heal: What do you think of the so-called “lunch time” and scarless facelift techniques? Do any of them work and which ones do you recommend?

    Dr. Kotler: From observation and listening to dissatisfied patients, I think these are ill-conceived and universally unsuccessful. We knew that 30 years ago, but every generation of young surgeons seems to have to sadly learn that lesson. In a short period of time such fad operations will again be relegated to history.

    Thoughtful patients do understand that when one is trying to reverse the effects of 20 to 40 years of aging, there cannot be a successful half-hour or “lunch time” quick fix. What is required is a sound, proven operation based on traditional surgical approaches, and that means removing excess tissue, tightening up the underpinnings, and re-draping and then removing excess skin. As in many things in life, there are no shortcuts.

    Make Me Heal: Do you think that in the distant future there could be a scarless facelift, face transplant, stem-cell or nano-technology aided facelift technique that could replace the traditional facelift?

    Dr. Kotler: I doubt that anything will replace the traditional facelift for the reasons mentioned above. However, I do believe that many ancillary techniques, such as using fillers (collagen, Restylane, Juvaderm, Hylaform, Sculptra, et al) to replace the shrinking fat, particularly around the mouth, and using other injectables, will be helpful. Likewise, Botox Cosmetic is doing a great job for forehead and crows feet lines.

    Make Me Heal: What do you think is the youngest age for a person to consider a facelift or mini-lift?

    Dr. Kotler: Chronologic age is the least important factor in selection of a procedure. One makes the decision based on appearance and one’s health and vitality. Here in Southern California, with the ravages of the sun, we see skin that may look 20 years older than the patient otherwise looks and feels. It is rare to perform a full face and neck lift on a woman under 40 and likewise a man under 50.

    Make Me Heal: If you’re in your late 60s or 70s, can you still have a facelift? Is there any age cut-off?

    Dr. Kotler: Yes, one can have a facelift in their 60s or 70s, but of course, at any age, a history and physical must determine that the procedure would pose no risk to one’s general health. There is no specific age cutoff, except that, frankly, few people after the age of 80 have the interest nor the pristine medical condition to proceed with having a facelift.

    Make Me Heal: What is your favored technique in doing a facelift?

    Dr. Kotler: I believe the facelift must combine the following elements:

    1. Sculpting of the jowls, which represents excess fat deposition and sagging.
    2. Removing the “double chin,” which is a combination of gravity – driven sagging of excess fatty tissue and loosening of the previously tighter neck muscles. After the excess tissue is removed, creating an internal corset to provide support to the remaining tissues by sewing the edges of the right and left platysma muscles together to form a gentle sling.
    3. Re-draping of the lower face and neck skin and excising the excess.

    Make Me Heal: What can a patient expect after 4-5 years of performing the procedure? How lasting are the effects?

    Dr. Kotler: In four to five years after the procedure, the patient should have very little change. When the procedure is meticulously performed, it is rare for a patient to need a “touchup” in fewer than 10 to 15 years. Some patients, including my wife, still look terrific 20 years after their original face and neck lift.

    Realize that what cosmetic surgeons do is turning back the clock. We cannot stop it from ticking. However, if one practices good health habits, including weight stabilization, no smoking, vigorous exercise, and proper nutrition, expect greater procedure longevity. The skin is the mirror of the patient’s general health.

    Also, what some people do not realize is that they have the ability to influence their aging. Unquestionably, we are going to see a greater role for vitamins and other nutritional supplements in helping forestall the aging process.

    Make Me Heal: What are the risks of a facelift?

    Dr. Kotler: The most common significant complication of a facelift is that there is bleeding underneath the skin, which usually takes place within the first 24 hours and up to ten days. This is why patients are advised to refrain from strenuous exercise and to avoid medications such as aspirin, which interfere with blood clotting. A more serious risk is poor healing, wound breakdown, and possible loss of some of the tissue. This is more apt to occur if in fact the patient did have bleeding after surgery and particularly if it was not recognized promptly.

    The surgeon must set the conditions for the skin to thrive after surgery, and this requires judgment with respect to not overtightening. Over-tightening is one of the conditions that predisposes to poor healing. Further, should a cigarette smoker re-engage in smoking immediately after surgery, the circulation to this re-draped tissue will be compromised, and the chance of tissue breakdown or loss becomes significant.

    Infection is very rare today.

    Make Me Heal: Following a facelift, what daily beauty regimen do you recommend to prolong the aesthetic results?

    Dr. Kotler: I believe the most valuable contribution the patient may make is to maintain a healthy lifestyle with weight stabilization, no smoking, exercise, and good nutrition. Also, depending on where one lives, protection from the sun, using sunscreens, is extremely important since the ultraviolet rays of the sun are among the principle causes of premature aging of the skin. Moisturizers and Retin-A help keep the skin looking younger.

    Make Me Heal: How much scarring is caused by a facelift?

    Dr. Kotler: The longevity of the facelift actually does depend on the good, invisible scarring beneath the surface. A thin layer of scar tissue is laid down, and this is what provides the “internal tightening.”

    What people don’t want is any visible external scarring. If the incision sites are thick, wide, raised, and in any way visible, it is generally a factor of the surgeon’s technique. The wounds need to be meticulously closed without excess tension, and excess tension usually arises when the surgeon has inadvertently removed too much skin and is struggling to bring the edges together. The experienced surgeon has a sense of the appropriate amount of skin removal and will be less likely to have a wound closure under less than the best circumstances. Ideally, the wounds are closed in several layers so that the body is allowed to heal from within, avoiding undue tension at the surface. To avoid such tension at the very surface of the skin, absorbable stitches are placed below the surface. The visible, superficial sutures can be removed five to seven days after surgery, and not leave any signs of their presence.

    Make Me Heal: Is skin type and color a relevant factor when considering a face lift? Are there ethnic-related considerations?

    Dr. Kotler: Skin type and color are a factor in patient selection and result. The ideal candidates are fair-complexion people with thin skin. Thicker skin and darker skin patients will often require additional maneuvers or techniques to enhance the prospects for invisible incisions.

    Those patients with thick, heavy, oily skin may present with, at least temporarily, more evident incisions. Further, patients of color may demonstrate temporarily darker skin, but these are all reversible with spontaneously or by bleach cream treatment.

    Make Me Heal: What celebrity (or celebrities) do you think had a great facelift and what celebrity (or celebrities) do you think had a bad facelift?

    Dr. Kotler: In the celebrity or non-celebrity population, it is easy to spot poor results. Poor results announce themselves: the over-raised eyebrows and the pulled, windblown look. Some people look like they were strapped to a 747! The over-scooped, pinched, over-upturned nose is a cardinal sign of a poorly performed nose job. A stare-like, hollow –eye appearance is diagnostic of an over zealous eyelid lift. So there are many ways that poor cosmetic surgery announces itself.

    Unfortunately, some celebrities and high-profile people have not done their research and have either chosen their surgeon poorly or have submitted to an inappropriate procedure. They are no more immune to bad decision making than the rest of us. Homework trumps fame and wealth.

    Make Me Heal: What new information does your bookSecrets of a Beverly Hills Cosmetic Surgeon” convey to the public?

    Dr. Ko0tler: This book is a primer and a guide to making good decisions. It shares with patients my 30 years of experience by explaining what I consider to be the wise, expeditious process of surgeon selection and choosing what procedure is most appropriate. I find that the public today is often unsophisticated as to the degree of specialization within the specialty of cosmetic surgery.

    Our most talented and accomplished surgeons — the ones you and I want — have a very narrow focus; they excel at a limited number of procedures. Such is the superspecialist that patients need to seek out. Understand that the field of cosmetic surgery is way too broad for any surgeon to be an expert in all areas. Who wants to be in the hands of a jack-of-all-trades, a master of none? The surgeon who excels at breast augmentation or breast reduction is not necessarily the best surgeon for a nose job.

    Make Me Heal: Describe the recovery from a facelift.

    Dr. Kotler: 10 to 14 days is a reasonable and common recovery time. At 14 days one can return to work, attend social functions, and a reasonable but not overly strenuous exercise program. For the first day or two, there will be some light bandages in place. Often there is a small suction/vacuum tube placed under the skin for a day or two to remove tissue fluid and thus reduce bruising and swelling.

    Typically, stitches are out by 5 to 7 days, the discoloration is gone by 7 to 10 days, and people feel pretty much like themselves by that 10 to 14 day period. Individual recovery time depends on one’s motivation, their general health, and of course, the care with which the surgeon performs his craft. The most skilled surgeons are capable of producing results with less swelling, less bruising, and thus setting the stage for more rapid healing and a return to normal activities.

    Make Me Heal: What can a patient do to maximize recovery and reduce recovery time?

    Dr. Kotler: The patient needs to follow the surgeon’s instruction. Paramount issues are no smoking, a gradual return to light exercise promptly, reduction in the use of pain medicines, sedatives and sleeping pills, good nutrition, and a positive spirit.

    Make Me Heal: What should a patient expect when the bandages are taken off?

    Dr. Kotler: One should not expect to look like something out of a horror movie. While there may be some slight swelling and bruising, some people may have so little that they actually look quite good. I know patients that were able to return to work and normal activities within 7 days. However, expect some swelling, mild bruising, and perhaps a little bit of tingling and unnatural sensation. In the best hands, no one looks like they just collided with an 18 wheel trailer.

    Make Me Heal: Do patients experience problems with chewing and opening the mouth?

    Dr. Kotler: No, patients can eat whatever they like the day following the procedure.

    Make Me Heal: What recovery products do you suggest for the facelift? Below is a link to some post-surgery products for the facelift (you can simply name the products):

    Dr. Kotler: I believe that SinEcch, which is Arnica montana, a homeopathic medication, may be helpful in reducing bruising. We use this routinely for all of our procedures, as do many surgeons. We provide the Design Veronique chin and neck support strap for the first four to five days after a major face and neck lift. This handily gives support to the tissues and counteracts the swelling effect of gravity.

    Often, temporarily, the skin around the incisions may be particularly dry and for that we suggest Eucerin Dry Skin Therapy or Aquaphor Healing Ointment.

    Vitamin A & D ointment is applied to the incisions for the first 14 days. Thereafter, we prescribe silicone gel such as Mederma, Scar Fade, Xeragel, Cimeosil, or Kelo-cote.

    Such clear, toothpaste-like gels can be applied for invisible round-the-clock use to promote rapid incision healing and scar reduction.

    Robert Kotler, MD, FACS is the founder of the Cosmetic Surgery Specialists Medical Group of Beverly Hills, California. A Clinical Instructor at University of California, Los Angeles (UCLA), and currently appearing in the hit show Dr. 90210, Dr. Kotler is the author of two best selling plastic surgery books: Secrets Of A Beverly Hills Cosmetic Surgeon, The Expert’s Guide To Safe, Successful Surgery and The Essential Cosmetic Surgery Companion, Don’t Consult A Cosmetic Surgeon Without This Book! As a well known Beverly Hills plastic surgeon, Dr. Kotler has appeared on Oprah, 48 Hours, CNN and Fox News. As a Beverly Hills plastic surgeon, he has been featured in Newsweek, W, Town & Country, In Touch, US Weekly, The Los Angeles Times, Allure and Los Angeles Magazine.

    For more information, visit Dr. Robert Kotler’s website.

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