Regrettable Rhinoplasties

Does seem as if young Hollywood starlets all share a common gene pool? The ubiquity of the narrow bridge, defined tip, straight dorsum– something distinctly American and that you won't find on screen in foreign films– isn't due to the great melting pot, it's the surgeon's knife.

Like diamonds, rhinoplasties are forever. Once you've purchased it, you'll be wearing it for the rest of your life.

The nose doesn't grow back or stretch with time. The very best of the rhinoplastic surgeons (and there are fewer of them than you think) can improve on a bad result, but revision surgery will never restore your original nose to your face.

As they say in the business: "you want to hit a home run the first time you're up to bat."

So what makes for a poor result?

First, an anatomical primer. Surgeons identify the supporting structure under the nasal skin by its anatomical parts:

From the apex or nasal tip, the columella projects inferoposteriorly toward the center of the superior lip, adjacent on either side to the nares. Encompassing the border of the nares are the alae of the nose superiorly and laterally, and the floor of the nose inferiorly. At the posterior aspect of the base of the nose is the piriform aperture, bordered superiorly and laterally by the frontal processes of the maxilla and the nasal bones. The inferior portion of the cartilaginous nose, otherwise considered the base of the nose, includes the lobule, which consists of the lower lateral cartilages, the tip, the alae, and the columella. In the midline, the posterior aspect of the medial crura of the lower lateral cartilages articulates with the caudal membranous septum. Anteriorly, the medial crura are enclosed within the columella. The lateral crura of the lower lateral cartilages project superiorly to overlap the inferior aspect of the upper lateral cartilages in the midline. Laterally, these crura loosely attach to the piriform aperture....

And now to illustrate. Double-click on any of these images to get a close-up. Take a good look.

The nose falls apart over time, ie, the underlying architecture of the nose is so compromised that the look (and function) can't be maintained. Repeated surgeries become necessary. Michael Jackson (50) is the poster child for what is termed a 'crucified nose.'

Alternately, the surgical result may stay put but it's a look that doesn't appear in nature ala LaToya Jackson (51). Closely related to this phenonmenon is the 'operated look,' a nose that is plausible but clearly the result of surgery, distracting even to the untrained eye. Calista Flockhart (43) has just such a rhinoplasty. Her skin is thin and her resected greater alar cartilage on one side almost pokes through the tip, like a knuckle.

Scarring and overly aggressive resection of the cartilage causes a 'pinched tip' (thinning of lateral cura) and/or 'notched nostrils' (lateral crus). That girl, Marlo Thomas (70) has both.


Her first cosmetic surgery was way back in 1965. Joan Rivers (73) was actually much prettier than she ever thought she was and her initial surgeries made her only slightly less so. But her nose has been, for some time now, the classic example of too much, too often. The net result is a 'putty nose,' one which looks as if it was fashioned out of silly putty and stuck on her face.

Now you see it, now you don't. Onlay grafts to build up the dorsum are always tricky. Alloplastic grafts (eg, silicone, gortex) tend to become infected and extrude; allografts (eg, cadaver donor tissue) reabsorb over time. Only autogenous ones (eg, the patient's own septal/ear cartilage, rib, iliac bone) tend to last. Just ask Lil' Kimberly Jones (33).

Polly want a cracker? No. The pollybeak deformity is a disproportionate fullness in the supratip which evolves postsurgically. It can be cartilagenous or soft tissue in nature and is often the result of a misjudgment on the surgeon's part. Furthermost left is a 1983 preoperative photo of Meg Ryan (46); the next two date from '01 and '08.

Excessive 'columella show' can cause the operated nose to have the appearance of a long, drooping tip. And seeing inside someone's nostril can provide fodder for embarrassing rumors about what's up inside there. Here are three postoperative views of Paris Hilton (27).

Correction of the twisted nose poses one of the greatest challenges in septorhinoplasty. "My face is full of imperfections and it is what it is." Easy to say when you're Dr. McDreamy and have landed gigs as the face of both Versace and Avon campaigns this year. Patrick Dempsey's (41) rhinoplasty took place sometime around 1991-1994. Symmetry is defined by an imaginary line drawn equidistance between the medial canthus (inner corners of the eye) through the middle space of the two front teeth/cupid's bow.

Perhaps the most incongruous mistake is when a perfectly natural-looking result simply doesn't suit the wearer. Jennifer Grey's (48) new nose so disoriented her fans that her career faltered. Twenty years postoperatively, it still hasn't recovered.

To hear more, tune in to hear Anne discuss it all with Kevyn Burger on FM107.1 at 10am Thursday.

Freaks & the Fair (Sideshow Anomalies)

As long as there have been circuses, carnivals, and fairs, there have probably been human oddities exhibited for public voyeurism: the freak show. It's not at all PC any more, but there it is.

As science advanced in the 20th century, the once mysterious anomalies were explained as genetic mutations or diseases, and pity rather than fear or disdain became the norm. But deep under the socialized response still lurks a morbid curiosity, a disturbing fascination with nature gone awry.

The real shift has been in venue: off the Midway and onto the internet.

A distinction is made between "born freaks" and self-made freaks. The latter is the most common today (if you don't believe me, check out the tattooed Puff the Magic Dragon). In the late 19th century the fascination with abnormalities surged, partly due to the publication of Darwin's theories of evolution in 1859. During it's heyday, the outright fakes were "gaffed freaks" but medical conditions accounted for most of the authentic "oddities."

The majority of these human marvels displayed themselves for their own reasons and quite often reaped large financial and personal rewards for doing so. Some performers, those not of legal age or mentally handicapped, were exploited against their will.

For most, it was a way to make a living.

Joseph Merrick is familiar to many because of the the 1980 movie The Elephant Man starring John Hurt. Merrick had a disease only identified 100 years after his death. It was not elephantiasis or neurofibromatosis, but an extremely rare hereditary disorder: Proteus syndrome, named after the Greek god who could change his shape.

Some of the conditions were skin-deep: albinos and "piebalds," the latter having the same disease Michael Jackson suffers from, vitiligo.

Excessive hair in the wrong places could earn a gig as the "Bearded Lady" or "Dog Boy." Female beard growth is the result of a hormonal imbalance (usually androgen excess); wolfman hair arises from a rare genetic disorder known as hypertrichosis.

The pituitary gone amuck resulted in exploitable height differentials (before basketball or Mike Myers's movies were employment options). Today there's even a blog devoted to it. But back in the mid-19th century, a woman like Anna Swan had limited career opportunities at 7' 5.5" tall.

At one time "the human skeleton" and "the fat lady" were sideshow draws; today emaciation and morbid obesity are on display for free.

"The Rubber Man," or if female "The Elastic Lady" were contortionists who had Ehlers-Danlos syndrome, an inherited disorder affecting the production of collagen, a connective tissue found throughout the body. In some it allows the skin to be pulled away from the body as if elastic (skin extensibility), in others joint hypermobility.

Congenital anomalies were highly prized.

The archetype is perhaps conjoined twins, the most well known being the 19th century "Siamese twin" brothers Chang and Eng. Today their joined sternum and livers would be surgically separated with ease within the first months of life.

Grady "lobster boy" Stiles was a big draw in this century. His hereditary deformity was ectrodactyly, where the fingers and toes are fused together to form claw-like extremities. The word literally translates as "monstrous fingers."

(Our own Minnesotan Bree Walker was born with ectrodactyly and worked as a TV news anchor as well as roles such as the "Sabina, the Scorpion Lady" in the HBO series Carnivale).

Intersex performers, individuals with both male and female secondary sex characteristics, have had their fans since before the time of Christ. At left is a famous 1st-century BC sculpture: "Reclining Hermaphrodite."

In 1932, Tod Browning used his experience as a former member of a traveling circus to direct and produce Freaks. This horror film about sideshow performers was based on Tod Robbins' short story Spurs. Browning cast real people with deformities rather than using costumes and makeup– unheard of at the time.

Today's performers are for the most part "made freaks." Witness the rise in the puppet look first popularized by that hand sock drag queen Madame. Chin and cheek-submalar implants on skinny women with tight facelifts look like this. Madame should sue!

Doing Due Diligence (Certification)

Just how does one perform due diligence when selecting a cosmetic surgeon? Being an informed consumer seems more difficult than ever, given the bewildering display of high-profile disasters.

Michael Jackson, at the peak of his earning power and fame, repeatedly received very poor value for his surgical dollar. (And no, boys and girls, that's not a prosthesis; it's surgical tape on the tip of his nose.) If having more than enough money and unlimited access doesn't ensure a good outcome, what does?

The common online sentiment casts the ethical cosmetic surgeon as paternalistic gatekeeper. Most of the public expects these and all physicians to at a minimum abide by primum non nocere (not actually part of the Hippocratic Oath). It's safest to stick with caveat emptor: "let the buyer beware."

The most often hyped consumer advice is to choose a board certified surgeon. This is what Kanye West's dead mother did not do, having apparently evaluated her surgeon's credentials based an Oprah appearance.

For the prospective patient, board certification is the most readily accessible confirmation of a surgeon's training and experience. This is different than state licensure, ie, is the doctor behaving, which is confirmed here.

The vast majority of safe elective cosmetic surgery is performed by board certified plastic surgeons and otolaryngologist–head and neck surgeons. There is plenty of bad territorial ju-ju between the two specialties arising from intense competition for cash. It colors and distorts most of what is published about how-to-pick-a-surgeon. What makes these two kinds of cosmetic surgeons different from one another? There are two divergent training and certification pathways.

Here, along with the alphabet soup, is a set of cliff notes and links so you can be an informed consumer.

All physicians with M.D. after their name complete the basic 8 years post-high school education of undergraduate and medical school.

Cosmetic plastic surgeons go on to an additional 7+ years of training and certification in:

• General Surgery Residency - 5 years
• Plastic Surgery Residency - 2 years (some combined programs are 3 years of each)
• ABPS board written and oral examination in Plastic Surgery

If passed, the surgeon (and about 6,600 others) now has a ABPS-recognized specialty certificate in plastic surgery and joins the member society ASPS.

• optional Fellowship - 1 year
  
• ABPS board subspecialty examination (Plastic Surgery Within the Head and Neck)

This surgeon will continue to identify him/herself as a plastic surgeon or cosmetic plastic surgeon. More societies will be joined: ASAPS. These specialty societies are the sources of the yearly continuing education of the surgeon.

Cosmetic otolaryngologist–head and neck surgeons go this direction for 5+ years:

• General Surgery residency - 1 year
• Otolaryngology - Head & Neck residency - 4 years
• ABOto board written and oral examination in Otolaryngology - Head & Neck Surgery
  

If passed, the surgeon (and about 12,000 others) now has a ABOto-recognized specialty certificate in Otolaryngology and joins the member society AAO-HNS for continuing education in the field.

• optional Fellowship - 1 year
  
• ABOto board subspecialty examination (Plastic Surgery Within the Head and Neck) or the ABFPRS subspecialty exam

This fellowship-trained surgeon will now refer to him/herself as a facial plastic surgeon. More societies will be joined: AAFPRS. More continuing education.

The American Board of Medical Specialties (ABMS) is the major examining organization whose Member Boards (of which the ABPS and ABOto are two) certify physicians in more than 130 specialties and subspecialties. For a chart listing the current certificates offered by ABMS Member Boards, go here. (There are other, overlapping certification organizations as well.)

These board certification exams are probably the most difficult, stressful part of the not-so-young physicians training experience. The written boards are all-day specialty-specific computer-based examinations (completing the more general knowledge exams taken at the end of the first residency year). If passed, an excruciating oral examination takes place where senior physician examiners interrogate the candidate and pass judgment on the ethical and technical aspects of his/her practice.

Subspecialty certification is not required in order to practice cosmetic surgery. It's important to physicians preparing to practice because it is a recognition of exceptional expertise and experience specifically in that field.

What's important for the consumer is that board certification under the ABMS umbrella brings with it an requirement for continuing education and re-testing every 10 years. That makes these surgeons a safer bet for you and me.



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Darker Side of Tanning

Here's the myth: it is overexposure, or sunburn, that might be the cause for any of the negative things you read about sunlight and health. Overexposure and sunburn are not synonymous! In reality, tanning is an art that converts animal skins into leather. Exposure to UV light turns on the melanocyte color producing cells as a response to injury to the epidermis. This is the opposite of vitiligo, the skin disease Michael Jackson suffers from, in which those same cells lose the ability to produce pigment of any kind.

Historically, a tanned body belonged to the working classes who labored out-of-doors, while fashionable pale skin belonged exclusively to the upper classes and aristocracy. For many centuries and well into the nineteenth, a whitening agent for the face was used, composed of carbonate, hydroxide, and lead oxide. Arsenic was commonly employed starting in the mid-tenth century. It brings a whole new meaning to the idiom "suffering for beauty."

Who single-handedly changed this? Designer Coco Chanel inadvertently gave the Paris fashion world the tan after cruising from Paris to Cannes on the second Duke of Westminster's yacht early in the 20s. (She liked his clothes.) The suntan had arrived as the symbol of wealth and leisure. A tan in the winter meant the bearer had enough money and status to vacation in an exotic, warm climate.

The search for the perfect tan has led to basking in the sun, wipe-ons pioneered by Coppertone, tanning beds, and now spray-on airbrushed tans. The first greased Little Miss Coppertone was not Jodie Foster, but rather a 3-year-old girl in pigtails named Cheri Brand, daughter of the Bronxville illustrator who sketched the original 1959 ad campaign: Don't be a Paleface!

And Hollywood jumped in, too, glamorizing a tan with technicolor film in the late 30s. The perennial tanning idol of the screen was immortalized by Doonesbury's Zonker and his entry into the George Hamilton Cocoa Butter Open. The current rage for Paris Hilton-types is the sunless tan, again pioneered by our orange friends at Coppertone. DHA (dihydroxyacetone) is a chemical refined from sugar cane which temporarily colors the skin by reacting with the keratin protein found in the top layer. DHA is considered completely safe, but it gives no protection from sun damage: it doesn't stop UV light.

Speaking of ultraviolet light– both UVA and UVB rays are harmful to the skin. Tanning beds employ UVA radiation, which actually penetrates deeper into the skin than UVB. The research unequivocally points to UV exposure as the source of common skin cancers. The rate is rising by leaps and bounds. At highest risk are those with light eyes/skin/hair or a family history of skin cancer, but anyone can move into the high risk category just by tanning. Basal cell (affecting deepest layer of the epidermis) and squamous cell (middle layer of epidermis) carcinomas are the most common of all cancers. Malignant melanoma, though less common, is the most dangerous, the leading cause of skin disease death. If you get one, you will get more.

In the end, tanning early on makes for a hagged-out look later in life: sagging skin, deep wrinkles, uneven tone, broken blood vessels, and age spots (macules and solar lentigines). Take a good look at the hands, decollete, and neck of any tanned woman over 40. It isn't pretty up close. Plastic surgeons delicately refer to it as "photoaging."

Lest you think baking in the sun is done and over, just think of how many Hollywood stars are photographed on the beach in bikinis. Do you think they've got on their SPF 40?

Tanning the old-fashioned way invites paparazzi. It's easy to find popular stars on the internet wearing not much more than their sunglasses: Jennifer Aniston, Sharon Stone, Elizabeth Hurley, Natalie Portman, Janet Jackson, etc. (But you never did really think of them as role models, now did you?)

Children and adolescents are thought to be the most vulnerable because their skin cells are dividing and changing more rapidly than those of an adult. One blistering sunburn in childhood more than doubles a person's lifetime chances of developing a melanoma. And, as the ozone layer thins, exposure to natural UV radiation exponentially increases. So learn to love your sunscreen.

And all you prom kids? Go ahead, slap on a tan and have fun– just don't do it via a tanning booth.



Hear Anne live on the Kevyn Burger show 11:00 to noon every Thursday featuring Knifestyles of the Rich & Famous.