“Extreme Makeover,” “The Swan” and similar media have increased the number of potential cosmetic surgery clients. These people are not always good candidates for surgery however. Some need to come “Down to Earth” before they can have surgery.
“Reasonable Expectations” Still Reign Supreme
The vast majority of patients want to have a pleasant encounter with cosmetic surgery. The problem is trying to figure what patients expect. Communication is important. The problem is magnified when their potential surgeon doesn’t care to inquire or doesn’t make time to evaluate.
Face it. Surgeons Get Paid To Operate.
In my local practice environment, I have amongst the longest cosmetic surgery consultations and I meet all my potential surgical patients personally. This has been the source of grief between prior office mates and me (I am now in solo practice). Most of my prior office mates were primarily fixated on the bottom line. Many plastic surgeons simply do not make the time to talk with their potential patients for more than a few minutes. This makes it pretty hard to figure a patient’s options, motivations or expectations. I don’t claim to have a 100% success rate, but the vast majority of my patients are happy. Then again if I get the impression that a patient is set up for disappointment, I will not recommend surgery.
Why would I say “NO?”
When patients seem fixated upon operations which will lead down a path of complications or problems, I tend to say “No.” When patients have had too much surgery and appear distorted or strange, I say “No.” What one patient finds undesirable, however another will want. I operate if it seems I can deliver what the patient will want and I will be OK with it after I am done. Every surgeon draws his or her own line here. Being one of the few that will lose money in recommending against an operation makes me pretty unusual in my locale. To many of the surgeons practicing in Southern California, this is akin to heresy. I look at this as having integrity and proving myself trustworthy. Having predominantly happy patients makes my patient referral rate very high. My practice grows by referrals. I do very little advertising compared to other surgeons.
Be Very Careful Of Looking Too Hard
When an honest surgeon says he doesn’t feel that he can help you, it is not the end of the world. It does complicate things a bit however. You have to worry that if another surgeon offers you surgery, that he may be simply operating for the money. I have had patients for whom I recommended other than what they said they wanted. Some have come back after they had surgery elsewhere and looked pretty awful. Sometimes I can fix these things, but not always. In Southern California, there are so many plastic surgeons that even a poor surgical candidate will find one willing to operate if he or she keeps looking. Caveat emptor.
John Di Saia MD
I originally wrote this for my web site a few years ago. It still applies to this day however.
Originally posted 2013-01-14 07:30:12.
The games that many health insurance companies play make doctors wary of becoming a “Provider.” Provider status is nothing more than a contract in which the doctor relinquishes quite a few rights, for example the right to determine what a service should be paid. I am selective about contracting with health insurance companies for this reason. And I still do some work for insurers to which I am not contracted.
How can this work?
Some of the surgery I perform is not elective. It involves hospitalized patients who have wounds that won’t heal (or haven’t healed) without surgical help. In some of these hospitals I am the only plastic surgeon on staff.
Why does this make a difference?
If you need surgery and the only available surgeon is not a provider for your insurer, you will find your insurer may be willing to make an agreement with the surgeon for that one case. My office interfaces with the insurer and often we come to an agreement and are able to do the operation as a covered benefit. Some insurers are more receptive than others. Others simply offer an unacceptably low rate knowing no good surgeon will take it.
This is not 100%, but can work. Some patients have actually called their human resource departments at work and helped the process along too. The fact is that surgery costs your insurer money and without some pushing you might not get it. Be prepared to get involved if you want better care.
John Di Saia MD
Originally posted 2011-05-05 07:30:55.
Here we have images of a woman I first saw a few years ago. She had had two breast implant operations before and noted after her second (an enlargement with full lift) that her left breast progressively dropped (over about a year). I recommended re-operation to re-set the lift and downsize her implants. She agreed to the lift but not the implant size decrease. Smaller implants do not weigh as much so the rate of recurrent sag should have been less. As these were silicone gel implants this is particularly important. They weigh more than saline-filled implants.
The After image was taken at 1 month. She moved Out of State, but I predict that the sag probably recurred at least to some extent.
(1) Large implants are hard to keep up. Plan on smaller implants or more surgery later if you select larger implants. Large silicone implants also harden (capsular contracture) more frequently/severely than smaller implants or saline implants. This also contributes to a higher redo rate.
John Di Saia MD
Originally posted 2007-05-15 07:30:21.
Statin Muscle Pain
On researching the internet on muscle pain with Statins I found that it was being down played by many (including the drug companies) and hyped by others. Some studies indicated muscle pain only occurred in a few percent of Statin users. This seemed implausible to me as back pain is exceedingly common. It is probably difficult to talk about back pain relating to any drug as back pain is so common. But I noticed when I was on Statins (several different Statins) that certain muscular pains were more common and seemed to go away entirely with removal of the drug for a week or two. They may not be causing the pain but who is to say they may not make existing pain worse?
My muscle pains seemed to be more prominent at night. At first I noticed tingling cramping type pain in my feet. Later I had low back pain which I figured was just over exertion and in addition on occasion I had forearm pain and lower leg cramping pain especially with exertion. I cheeked my Creatinine Kinase (CK) a few times and it was either normal or a little above normal. So the feared rhabdomyolysis was not going on. It was the more mundane myositis (muscle inflammation) or so I ascertained. I do workout 3-4 days a week mostly swimming between 1000-1400 yards a day.
Statin muscle pain in my experience seemed to be more of a sensitivity to pain from this exercise. Hydration helps it a bit. I was later to find that other things could decrease it as well. Stopping the Statin for a week or two made each of these pains go away. I did this several times before concluding that the Statins were involved with the pain.
It seemed reasonable to play with the doses and the exact drugs a bit to try to find a tolerable medium ground.
My baseline cholesterol over the years on Statins (before the pains became a problem) had been pretty good:
In 2011 on Simvastatin 80 mg a day:
Total Cholesterol: 143
LDL Cholesterol: 67
HDL Cholesterol: 42
I did notice reviewing these labs that even in 2011, the Statin may have started to irritate my liver as my ALT was 62 a tad bit above the normal range of 60.
John Di Saia MD
Originally posted 2014-07-08 07:30:21.
A young bank clerk who stole £46,000 from her employer to help achieve her dream of becoming a model told police she had earned the money from working as an escort. Mother-of-one and law graduate Rachael Martin, 24, ‘spent money like water’ after getting a job with Barclays in Liskeard, Cornwall, where she was responsible for dealing with cheques.
The stolen cash paid for a breast enlargement, thought to be worth £4,000, dental work worth £1,700, and liposuction, as well as nights out, drink and drugs. She has now been jailed after stealing £46,000 in just two months from her employers.
This 24 year old law graduate stole from a bank to fund plastic surgery and nights on the town. Interestingly she by report told those who asked about the source of the money for her indulgences that she worked as a prostitute. The judge apparently had pity on her when he sentenced her. I am sure that will make the bank that is out the money quite happy.
John Di Saia MD
Originally posted 2012-10-03 07:30:49.
Dr D’s “Liability Call For Your Plastic Surgeon” was published.
I am doing a bit more Op Ed writing these days. This is a piece that was written for Medical Economics regarding liability in a surgeon’s practice. This post was originally linked to the piece on their site but they took it offline.
John Di Saia MD
Originally posted 2012-02-07 07:30:45.
A short video shows a 27 year old ruptured silicone gel implant and the calcified scar capsule the patient’s body made to try to contain it. It helps explain why some silicone breast implant patients develop rock hard breasts and what can be done to fix the situation.
It also helps explain why most often I prefer saline-filled breast implants that do not tend to encourage the formation of rock hard breasts. Seeing calcium deposition on the implant capsule (which is what makes the breasts really hard) in a woman who has never had silicone gel implants is extremely rare.
John Di Saia MD
Originally posted 2011-05-30 07:30:13.
I had a tummy tuck two months ago. Now I have a little water-filled “pouchie” above my couchie where the water waves move when I poke it. My surgeon says it is not a problem and will go away. Should I be worried?
A seroma is a lymph filled pocket in your soft tissues. We are most aware of them when they are just under the skin as they can demonstrate a “fluid wave” phenomenon when they are tapped. Larger scale surgery is more of a risk toward the formation of a seroma and tummy tuck surgery is included.
On the positive side, these things tend to resolve when small and wounds are newer. The longer they manage to persist, the greater the chance that they will not go away, but rather form a scarred in cavity that will tend to stay. In a worst case scenario they can require surgery to fix. Alternate treatments include draining them intermittently with a needle or with a drainage tube or injecting them with a chemical to encourage them to shrink or go away. Opinions as to how often or urgent treatment of a seroma is vary substantially. Left alone they can mar good tummy tuck results, so I like to deal with them quickly. My tummy tuck results have benefited by this policy by my way of thinking. I haven’t needed to re-operate to repair one in over ten years.
Seromas are best avoided. The best ways to do this involve the proper use of drains and compression garments after a large scale operation as well as tailoring that operation to be less risky.
John Di Saia MD
Originally posted 2011-06-09 07:30:09.
It is common knowledge that pop icon Michael Jackson had Propofol (trade name Diprovan) administered in his home and it turned out badly. Propofol is used commonly in outpatient plastic surgery and is quite safe. I have performed surgery on literally hundreds of patients who have been given Propofol and not a single one had a problem with it. Then again I perform surgery in safe approved operative centers…hospitals and surgery centers.
Propofol is very potent however and is absolutely not for home use. It is used as an induction and a maintenance agent meaning it puts the patients under and keeps them there. Alternatives to Propofol usually involve more narcotics and sedatives that wear off more slowly and make the patients more nauseated and groggy.
One of the first cases I reviewed for the California Medical Board years ago involved the improper use of Propofol by a nurse in a doctor’s office operating room. The staff were not properly trained and the operating room did not have the proper equipment.
The point is that this drug is safe, but only when given in the right environment by the right people. It is used daily in most outpatient surgery centers in the US. Unlike alternative drugs people awaken from anesthesia quickly and without much nausea.
John Di Saia MD
Originally posted 2013-01-15 07:30:18.
The American Society of Aesthetic Plastic Surgery publishes statistics every year indicating which cosmetic operations are on the rise. A journalist at the OC Register asked a group of plastic surgeons why this might be. Being that I am opinionated (why do you think I blog here,) I figured I’d take a shot at some of these:
I. Statistic: TEENS – Nosejobs and Otoplasty (commonly referred to as “ear pinning”) on the rise
Dr D: Part of the development of the teen psyche involves becoming aware of social norms. As they do this, they also become aware of differences and develop standards of beauty. Many of these teen nose jobs are justified as medically-needed, but appearance usually factors in. Otoplasty is a similarly social operation.
II. Statistic: YOUNG ADULTS – Breast implants. Ages 19-34. 166,000 a year. (ASAPS)
Dr D: “Beauty standards” are important motivators here as well. Young adults in the workplace (and social groups) see those around them doing these things and often being complimented. Some of these patients may also be seeking after childbirth “body repair.”
III. Statistic: EARLY MIDDLE AGE – Liposuction. Ages 35-50. 143,000 a year. (ASAPS)
Dr D: A slowing metabolism in this age group combined with more involved work schedules (with increased sedentary time) equals increased trouble “holding back the fat.” Liposuction is easy and can help with that. Add some post-pregnancy issues here as well.
IV. Statistic: YOUNG ADULTS – Botox. Ages 19-34. 371,000 a year. (ASAPS)
Dr D: The fad of Botox use in the really young is an advertising phenomenon as there is no good reason for young people to do this other than to “feel” hip.
My opinions of course.
John Di Saia MD
Originally posted 2011-07-04 07:30:33.