Medical Clearance – Dr D’s Concept

As some of you may know I perform medically necessary as well as cosmetic surgery. Not infrequently medically-complicated patients are assessed for the possibility of surgery for wounds and patients and their families do not understand the concept. So let’s explore it a bit:

What is Medical Clearance?

Medical Clearance is a assessment requested usually by a surgeon and performed by internists. It looks into a patient’s ability to withstand anesthesia and the relative risk of the stress of surgery in such a patient. Internists will clear a patient for the surgery, but the exact meaning of that “approval” varies. Many internists provide a risk assessment usually for problems like heart attack or stroke following the surgery or even during the surgery. So a patient could be “cleared” for surgery and assessed as “high risk” at the same time.

What determines a Good Surgical Candidate?

There are surgeons who will operate upon any patient who has been cleared for surgery. I am not one of them. As far as I am concerned the “fitness” for surgery is more complicated than a “yes” or “no” answer. I look at each patient in a “Risk versus Benefit” paradigm. I look at their nutritional status as well as their medical clearance and the nature of their wound(s) to determine the probability of healing versus the possibility of catastrophe. If the possibility of a poor outcome is high relative to the possibility of a good healed wound, I may not choose to operate.

So not all medically cleared patients get surgery by Dr D.

Best Regards,

John Di Saia MD

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The Plastic Surgeon versus Cosmetic Surgeon Turf War

Most patients are comfortably oblivious to the wide open nature of cosmetic surgery and the doctors who perform it. There are no laws against doctors of any level or type of training in cosmetic surgery opening their private clinics to the masses and performing surgery. The question of what training is really needed to entitle a doctor to perform this kind of surgery is hotly argued in many cases by the same doctors who wish to garner your business.

Board certification often comes into play. The problem is that there are many boards and relatively little oversight. I have been criticized by those representing cosmetic doctors for my lack of respect for their prowess. It is often hard to respect a doctor with little if any verifiable training who purports to be my equal. Unfortunately for consumers their experiences often can be subject to trial and error as they wade through the marketplace.

My point of contention is and has been that doctors who have not completed residency training and have not been certified by verified ABMS (American Board of Medical Specialists) boards that include cosmetic work in their residencies are not good bets for their patients. Inspection of your prospective surgeon regarding qualifications before surgery is an absolute must if you want to maximize your potential for a good outcome. News stories that have run recently have reinforced this point a great deal.

Best Regards,

John Di Saia MD

Related:

Credentials in Plastic Surgery

Originally posted 2011-01-07 07:30:03.

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Boob Job Redo Video

Boob job redo surgery is certainly more difficult than first time cases. Looking over some of my older YouTube videos, there was a desire to fix some up a bit. I had this boob job redo video with a patient testimonial. This video is now new and improved with reduction of annoying music and re-arrangement of the elements. It tells the story better now.

The story in short was this very nice young woman had been operated by a local surgeon who reported himself as the “best of the best.” Sound familiar? He nevertheless ran into a complication and after three operations left her pretty deformed. He reported to her that “this was as good as it was going to get.” Then she found Dr D through a friend. This was not an easy case and her result is just as much due to my work as her persistence, faith and patience.

Best Regards,

John Di Saia MD

Originally posted 2012-09-20 07:30:14.

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Over the Counter Scar Therapy Recommendations

As I perform Scar Revision surgery and deal with scar treatment not infrequently, people ask about over the counter scar treatments. Do any of them work?

As we have discussed before scar healing occurs in phases and treatment to minimize scars should only be done after the wound is closed and without scabbing. If you have had surgery, you should ask your surgeon when the best time to begin scar therapy has arrived. I like early treatment once the wound has achieved early healing.

I have used some of these products with my own wounds particularly after I had my triceps repaired a few years ago. The silicone sheeting products tend to be my favorites here as they do not make a mess and can be re-used. They also cover the scar keeping it away from sunlight.

Don’t be fooled by cheap sheeting products or gels. They don’t work as well.

Best Regards,

John Di Saia MD

Related:

Early Wound Care To Help Minimize Scars

Originally posted 2011-02-21 07:30:43.

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Dr D Peeks at the Plastic Surgery Gift

DrD_Xmas

Due to the season, I am reminded of the topic of gifting plastic surgery. This topic always meets me with mixed feelings.

As some of you might know, I used to write for the Sun Post News a few years back. These were editorial pieces as I have no lack of opinion and like to write. This can of course be both good and bad. :) One of my topics was the gift of breast implants for high school graduation. While the businessman in me might be OK with gifting plastic surgery, as a stepfather to a young girl, the idea makes me a bit twitchy.

Supporting your daughter as she goes into the World financially is one thing. Making her even more attractive for the hordes of hormone-peaking college freshmen is something else. Not a good picture.

On the basic topic of gifting plastic surgery, I think a good deal of discussion has to come before the gift (which of course may ruin the surprise.) Encouraging another to get cosmetic surgery is a potentially explosive position. The inference might be made that you think the recipient of the gift “needs it.” Again not a good picture.

Ideally the happy plastic surgery patient considers surgery for him or herself. Having cosmetic surgery done for someone else is a bad start. I wrote a piece for Coed Magazine which was somewhat related on “What to Do When Your Girlfriend Hints Breast Implants.” In this case, our hypothetical woman presumably had hinted at the idea. Even then it can be a tricky subject if you don’t support her from the position of her not “needing them.” The “take home” point is that people are sensitive about their appearance. Surgery to change that appearance will be looked at positively by some and very negatively by others.

The potential gift of plastic surgery needs to be approached carefully so as not to tread harshly on one’s feelings. A gift that hurts someone’s feelings is a gift that should not have been given anyway, right?

Best Regards,

John Di Saia MD

Originally posted 2012-12-24 07:30:16.

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Tummy Tuck, Progressive Tension Suture and Drains

Plastic surgery goes through periods in which things are fashionable and then not long later unfashionable. Some developments are presented as “epic” as if plastic surgery as a science and art steps forward with their introduction. Suffice it to say, the “hype factor” can be huge in plastic surgery.

I do a fair number of tummy tuck operations and have for quite a few years. My results are very good and my patients have greatly reduced discomfort from those I did even ten years ago. Much of this is due to my technique of pain pump placement. I modified that which I have been taught and it works very well.

On the issue of drains I am old school. My seroma rate (fluid collection rate) after tummy tuck surgery has been very very low for years. This is one of the reasons I am not a fan of the “no drains” progressive tension suturing technique that has become popular in some circles.

Drains are an inconvenience, but with the addition of pain pumps are more needed than ever before. The pain pumps also make them much less uncomfortable than they were a decade ago.

Best Regards,

John Di Saia MD

Originally posted 2011-05-13 07:30:11.

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Dr D versus the V-Loc: A Patient Story

I had a patient come for scar revision surgery who had previously some scars revised by another surgeon using the V-Loc suture device. This resulted in wide (nearly 2 cm wide) wounds at the site of groin scar revisions. I do not use these contraptions as I do not see them making me better than I am already. :)

What is the V-Loc?

The V-Loc is a barbed suturing device made to save the surgeon time in closing wounds. Barbed sutures have been popular developments in the past five or so years. I have been reluctant as I have said in using them. Why change things that are working well? The V-Loc uses polyglyconate suture material (Maxon TM) which is actually a pretty good material when used properly.

I revised one of the patient’s scars using my own technique. We will see how the wound heals. Maybe the patient will allow me to share his images as his scar matures.

Best Regards,

John Di Saia MD

Originally posted 2012-01-27 07:30:13.

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The Truth About Plastic Surgery Trends

For the layperson reading the reports of plastic surgery in the media is a bit “hit or miss” regarding truthfulness. There is a whole lot of hyperbole in there. This is amongst the reasons I started writing this site so many years ago. :)

Trends in Plastic Surgery

Media reports often exaggerate the growth in a particular plastic surgery procedure making it sound like it is “in fashion” and everybody’s doing it. In most plastic surgery practices, there are trends in what is being done, but the variance is not as huge as the media would make it seem. It is not like people are flocking to a fringe procedure in mass. It is true that over time, less invasive procedures have become much more common. This also coincided with the shrinking economy. Less invasive is much less costly than more invasive in general.

The trends today more commonly are in the magnitude of what people are doing. When money is in shorter supply, larger scale procedures are less commonly performed. People may choose liposuction instead of a tummy tuck or a facial peel as opposed to a facelift. Lesser procedures tend to correct less so in most cases you are getting less bang for your buck. Then again you are spending fewer bucks. :)

Best Regards,

John Di Saia MD

Originally posted 2012-10-12 07:30:52.

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Misti Gold – A Story of a “Better” Breast Implant

Misti Gold breast implants were an alternative to conventional silicone gel breast implants placed in the early 90’s. They were filled with polyvinylpyrrolidone-hydrogel instead of silicone gel or saline and were advertised as the “newer better” breast implant. Shortly after their introduction however problems started occurring more frequently than with their predecessors. They were found to form more severe contracture and had an annoying tendency to swell after placement progressively. The study I quoted below cited about a 60% removal rate in about 4 years.

MISTI Gold breast implants (Bioplasty, St. Paul, Minn.) filled with polyvinylpyrrolidone-hydrogel were developed as a promising alternative to silicone-filled implants. Some studies have reported on the positive effects of the implant, such as improved radiolucency and biocompatibility of the gel; however, there are also reports that such implants increased in volume and were subject to capsular contracture in the human body, resulting in demands for their removal. The purpose of this retrospective study was to analyze the long-term results of a series of patients with MISTI Gold breast implants. Between 1991 and 1993, the authors inserted 83 MISTI Gold implants in 61 patients with an average age of 46 years (range, 16 to 69). The authors were able to follow up 48 patients with 71 MISTI Gold implants. The average follow-up was 68 months (range, 10 to 108 months). The retrospective study found that 59 percent of all MISTI Gold implants were removed after an average period of 4.14 years. The main reason for implant removal was an increase in volume of 38 percent, followed by capsular contracture in 14 percent of all 71 MISTI Gold implants.

Source: ncbi.nlm.nih.gov/pubmed/12409763

To make a long story short, the FDA forced the Bioplasty company to recall these implants in 1991 and in 1992 the company stopped making breast implants entirely.

In breast implant surgery it can be hazardous to rush into the use of any “newer better implant” until it is actually proven to be better that is.

Best Regards,

John Di Saia MD

Originally posted 2011-03-02 07:30:07.

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Tanning Salon Owners Mislead Clients

Many tanning salons are downplaying the health risks associated with indoor tanning while claiming that time in a tanning bed offers an array of health benefits, according to an investigative report from Democrats on the House Energy and Commerce Committee. Committee investigators, posing as fair-skinned teenage girls, called 300 tanning salons across the country, and found that 90% said that the use of tanning beds did not pose a health risk. When pressed about skin cancer risks, some salon employees said the link to indoor tanning was “hype” or “a big myth.”
Source: skinandallergynews.com/newsletter/the-skinny/singleview40946
/tanning-salons-mislead-teens-congressional-probe-
finds/4aaea3a6b8.html

Studies showing tanning bed use is associated with increased risk of skin cancer and even melanoma skin cancer are now plentiful. It is funny though to expect businesses outside of medicine to discuss risk much. Does it really surprise anyone that tanning salon management downplays the risk of the services they provide?

As far as I am concerned tanning salons are cancer traps. They should have warnings similar to those on cigarette packages proclaiming the absolute foolishness their patrons have in using their services. I will even donate to the hypothetical copy of such a statement:

“To our Clients,
While we appreciate your patronage please be advised that tanning beds have been associated with increased risk of skin cancer and premature aging. The money you are pouring into our pockets might be better spent on sunscreens and sun avoidance clothing. By using these facilities you have decided to go against your better interest and as such the ownership takes no responsibility for the cavernous wrinkles, cancer and even death you might receive in the bargain.
Thank you.”

Best Regards,

John Di Saia MD

Originally posted 2012-02-09 07:30:06.

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