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

Comments

Reader Laura On Dental Course on Botox and Fillers

Reader Comment:

This is a company that is offering training for “Botox® and Dermal Fillers for Every Dental Practice”. They are offering a 1 day course to train Dentist on how to use Botox and fillers. How much training do plastic surgeons receive to do these procedures? How likely will it be for a regular dentist to be able to perform these procedures without mishaps?
Source: commonsensedentistry.com/BotoxDermalFillersCourse.aspx

I could teach a monkey to inject Botulinum toxin. Plastic surgery residents pick it up very quickly. Fillers are just about as easy as long as reasonable limits are observed. Some users do not know where to stop and/or inject the less safer “semi-permanent” fillers in large quantities. This can lead to scary results.

I was actually approached by a CME company not long ago about teaching such a course. It would be pretty easy. The question of how good the attendees will actually be at the procedures and what their judgment might be is another question entirely. In the right hands with the right judgment, internists inject these items safely every day.

Best Regards,

John Di Saia MD

Originally posted 2010-11-05 07:30:31.

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Dr D’s Baby Got Back – Plastic Surgery Edition

The sound quality is very low tech, but surgeons need to a little fun too now and again…..

Best Regards,

John Di Saia MD

Originally posted 2011-04-15 07:30:37.

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Epic Ear Plug Hole Repair

Ear Plug Hole Repair is sought more frequently when people with large holes and stretched lobes look into the job market.

People with Ear Plugs may decide to remove them and have the holes repaired. The reasons usually revolve around work. Here is a gent who wanted to enter the service and was told by his contact that the ear plug holes needed to be closed before he appeared for duty. He had removed his plugs several months before which we usually recommend as the holes will close down somewhat by doing this. His repair was performed in our South Orange County office under local anesthesia. At 2 weeks the repair looks pretty good although they improve over the months that follow.

Best Regards,

John Di Saia MD

Originally posted 2011-07-12 07:30:55.

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Dr D in a Prius Poll?

Initial Post 11/3/11 7:30 AM

Hello all,

I am thinking of changing my ride. The idea of driving a Prius appeals to me. I get to use less gas which makes me feel a bit better about not contributing so much to our pollution and gas industry problems. There are a few environmentalist quirks I picked up as a Berkeley undergrad. :) The nerd in me likes efficiency and with the miles I drive I might need to stop less frequently. Some of the docs around me have commented that they are not so sure my clients will take well to their plastic surgeon driving a more green machine however.

So you can vote on it:

<a href="http://www.sodahead.com/fun/should-a-plastic-surgeon-like-dr-d-drive-a-prius/question-2259327/" title="Should a Plastic Surgeon Like Dr D drive a Prius?">Should a Plastic Surgeon Like Dr D drive a Prius?</a>

Update 9/26/12 – I have had my Prius for nearly a year and really love it. It is not a really sexy ride but I have been over that for years. It has been reliable and not stopping for gasoline so much has been pretty cool. The AC could be a bit stronger, but otherwise I am happy.

Best Regards,

John Di Saia MD

Originally posted 2011-11-03 07:30:41.

Comments

Reader – “Help Dr D, My Plastic Surgeon is an ahole!”

Reader Question:

I know you can’t fix this but can you help me cope? My plastic surgeon is an ahole. He has no time for me now that he has operated. He just ignores my concerns. I look OK but I want to do what I can to get the best result possible. He doesn’t care about me.

I am in Orange County. I so wish I knew you before I let this toad touch me! He is a short arrogant little twit though in Laguna Hills. I don’t regret my plastic surgery just my choice of a plastic surgeon.

I frequently remind people to choose carefully when they are in the market for a plastic surgeon. Once surgery has been performed it is hard to switch. Many docs will not accept patients who present liability challenges from the onset. This includes fresh post-ops and people who look like they might sue someone.

The first thing is to try to deal with the surgeon you have. Try to get through to him. How was he when you first met? Docs who never have time for their patients before surgery frequently don’t afterward.

Maybe you can develop a relationship with a contact person in the office and get what you need from that person? Otherwise you can try to call around and find another local surgeon who can help you. Try to choose better this time.

Best Regards,

John Di Saia MD

P.S. I think I know who you might be writing about, but I can’t put his name here for obvious reasons.

Originally posted 2011-03-17 07:30:34.

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Tickle Lipo – Breakthrough or Gimmick?

Liposuction is plastic surgery’s “gimmick procedure” having had more angles applied to it than a child’s toy. There is however money to be made in fat reduction so the gimmicks will just keep coming.

Enter Tickle Lipo, a new technology superimposed on the liposuction game. In this newer version of the basic liposuction technique, the cannula, the instrument used to remove the fat, vibrates like a whip inside your fatty layers. This supposedly helps remove the fat more evenly and with less pain.

Tickle Lipo looks like a hybrid between two other forms of lipo already on the market – power-assisted lipo (Pals) in which a motorized cannula breaks up the fat and ultrasonic lipo in which sound waves do it. Will Tickle be better or worse than its fat sucking competitors? That will likely depend upon the technology and the skill of those who handle it.

A funky high tech instrument will not make a non-surgeon into a master plastic surgeon just like a hot race car will not make me into Jeff Gordon. Check the credentials of anyone who wants to use this thing on you and go from there. At this point I would consider Tickle an experiment.

Best Regards,

John Di Saia MD

Related:

Dr D’s Orange County Liposuction

Originally posted 2011-02-07 07:30:59.

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Good Plastic Surgery in the OC – Pretty Eyelid Surgery

Good Eyelid Surgery Orange County California

This nice lady came to the office with tired looking eyes. She had an upper and lower lid blepharoplasty with canthopexy and 4 weeks later she was looking good.

Best Regards,

John Di Saia MD

Originally posted 2012-08-16 07:30:09.

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Blue Cross Breast Reduction Denial After Pre-approval

Healthcare insurance companies are on my short list for contempt.

They underpay, take forever to pay, deny after approval and rescind for fun. Why should I not pitch them the BS they deserve in return?

Today I received a particularly funny (and O-So-Typical) letter concerning a woman for whom I performed breast reduction a few weeks ago. This case was the largest I have done this year with over 4 pounds of breast tissue in the removed specimen. Her back pain is gone. She can stand up straight. And her husband looks like an worked-up fiancé (amongst the best compliments in my book).

Bottom Line: This case was medically-indicated and I did a great job. Sorry Blue Cross.

Nevertheless, Blue Cross via letter issued a denial/delay of payment after the surgery had been performed (and after their own pre-operative approval). They are trying to make payment the responsibility of the HMO arm of her insurance plan. I am not an HMO provider. They know it won’t work, but it will delay payment.

This is Health care Insurance Company B.S. Maneuver #1 from the “We’re Cornered But We Can Still Delay The Payment” chapter.

They know this abuse is amongst the reasons doctors drop insurers. I can certainly see why many of my friends have done so.

More of that wonderful treatment from your insurance industry.

Best Regards,

John Di Saia MD

Originally posted 2005-06-30 20:09:00.

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Nursing Home Patient With Skin Cancer – An Ethical Dilemma

An interesting philosophical conundrum arose at a sub acute hospital at which I see patients. These are not the plastic surgery patients you see on reality television. They are ill complicated patients too sick to go home. Sometimes they are people with brain injuries after having had surgery or a stroke.

What do you do when one of them gets a skin cancer?

I was asked to see such a patient recently and seeing what I believed to be an obvious skin cancer I obtained a biopsy. Another doctor seeing the patient asked me why I bothered. To him operating to remove the cancer for this patient was a “waste of resources.” I respectfully disagreed. Most skin cancers do not kill, but this one had obviously been left alone for quite a while. It had grown large and will likely leave deformity when (or if) it is removed. But not doing anything dooms the patient to a slow erosion of his facial features. It was pretty ugly. In my opinion it would have been better to remove this cancer when it was much smaller, but I didn’t see him then.

Unfortunately entertaining removal of the cancer opens more questions. The man does not have a conservator for medical affairs. Until one is appointed, consent for surgery cannot be obtained unless two doctors document an emergency. This is not an emergency.

My philosophy is to obtain evidence of cancer and present this to the patient or medical guardian with a series of options. This seems to be a matter of opinion.

The philosophy of your doctor makes a difference in your care. This is an interesting crossroads of such philosophies.

Best Regards,

John Di Saia MD

Originally posted 2010-12-15 07:30:54.

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