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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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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LaViv: A Better Filler?

A friend of mine at a local media outlet was pitched a story about Laviv and asked for my thoughts. So I looked into it for her. We talked about it here once before, but I updated my search to be fair:

Laviv is a fibroblast cell product which is formulated as a tissue filler. The idea is new though. The company takes a sample of skin from behind the ear and use a little cell culture magic and make many new patient “cloned” fibroblasts. Then these are injected into the skin of that same patient in three parts separated by 5 weeks or so. The cool thing is that these are cells that should be identical to some of the cells the patient would have there already. Then again fibroblasts are basic cells to healing, but who is to say what a big pile of them injected below someone’s skin will do?

A key question is what is the long term effect here and that of course is not known. The FDA approval was based on a relatively small study showing better than placebo effects on nasolabial folds six months after a three treatment series. The study group was only 421 patients. There are post study approval requirements from the FDA; another 2700 patients to be followed.

The idea is very high tech and expensive. Another central question is how dangerous might it be (cancer, etc) and how long will the results (if we get any) last? How will Laviv compare to other products on the market which are ten to twenty times cheaper? The FDA pre-approval study did not compare it to anything but a lack of treatment. Not very encouraging.

I wouldn’t be getting too excited, but then new high tech stuff rarely gets me excited without some real proof behind it. We have little of that here.

Best Regards,

John Di Saia MD

Originally posted 2012-04-10 07:30:44.

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Emergency Plastic Surgery – Why Plastic Surgeons are Not So Interested

I have been less available for emergencies as of late, but got caught up in one recently. A young lady had been bitten by a pit bull and a portion of her nose had been removed. What followed was a three day run around partially due to the nature of the law and the health care system. Let me explain…..

Specialists like Plastic Surgeons are at times hesitant to see emergency patients as they represent poorly compensated or uncompensated liability. When we are even called to see emergencies our names are added to the medical record which immediately puts us in line for a lawsuit. If the care of that patient goes poorly, the law permits a lawyer to sue essentially any doctor’s name who appears on that patient’s chart. In addition, there are laws regarding the care of emergency patients that forbid a doctor from inquiring as to a prospective patient’s health insurance status when being called for an emergency. Essentially we cannot even try to insure we get paid for whatever care we render. And many emergency room patients are uninsured and do not pay their bills.

Even when patients do have health insurance, the nature of that health insurance and additional laws again slant the deck against the doctor. In California former Governor Arnold Schwarzenegger signed an executive order that a doctor could not balance bill a patient for anything an insurer did not pay on an emergency bill. So even if the patient is insured the doctor has no assurance of being able to get paid anything reasonable. The insurance plan pays what they want pretty much knowing that the doctor has little recourse. Thanks Arnold.

Back to my dog bite consultation: a 20 year old woman had a portion of her nose gnawed off by a dog. She needed surgery after the wound was allowed to heal for a few days and was discharged with wound care and follow-up instructions. My office interfaced with her insurer. It turns out that she had “Health Net administered Medi Cal.” Nearly a dozen phone calls from my office to her provider doctor were made. I had to write a letter to fax to them to indicate what she needed. We did this the day after her injury. The following day we received a phone call and a fax indicating that the patient had been re-routed to a provider doctor meaning one who takes her insurance. So at that point we had spent hours on the care of a patient who was sent to another surgeon by her insurer for her surgery. This work was all done without compensation of any sort.

This amounts up to a colossal waste of time and more potential liability: Would the patient get her surgery in time to minimize her deformity? Would I be liable for any deformity she might have even though her plan essentially took her away from me? I was not really interested about the amount that Health Net was going to pay anyway, but to receive any liability on a case like this is kinda ridiculous.

These are amongst the reasons that I like many other Plastic Surgeons have greatly curtailed my willingness to become involved in emergency cases. As my Grandfather used to say, everybody has to make a living.

Best Regards,

John Di Saia MD

Originally posted 2011-11-24 07:30:15.

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Belly Button as a Mark of a Good or Bad Tummy Tuck Result

Belly Button Repair Tummy Tuck Immediate

We have discussed before the issue of tummy tuck surgery and quality. There are many docs who perform tummy tuck surgery and they have not all had residency training as plastic surgeons. Even some well-trained docs are in too much of a rush to do the “fine touches” that make a good tummy tuck great as well. One of the areas that may serve to separate the good tummy tuck from the mediocre (regardless of the surgeon) is the quality of the belly button repair or umbilicoplasty.

At the top of the post here is a fresh belly button repair by someone untrained or in a rush (my opinion of course.) The blue sutures show the belly button to be held in place primarily by external stitches that will require removal. Better tummy tuck surgeons use more “under the skin” sutures and fewer “over the top” types. Things scar less this way. This belly button isn’t one of mine.

Best Regards,

John Di Saia MD

Related:

Dr D’s Website Umbilicoplasty page

Dr D’s Tummy Tuck FAQs

Originally posted 2011-10-24 07:30:51.

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When a Necklift Doesn’t

An article I wrote for the Sun Post News……


When a Necklift Doesn’t

Extreme Makeover and other “fantasy” plastic surgery television has definitely had an effect on consultation traffic in my office. The notion that more than a few large operations can and should occur in one operative session has become almost commonplace. My own disagreement with the general premise has been the subject of this column more than once.

There are specific situations however in which one procedure can and does contribute to the success of another. Necklift surgery is a prime example. As of late I have seen a few consultations for necklift as well as a patient in whom another surgeon’s necklift left her nonplused.

In the vast majority of cases, a necklift and at least a minimal facelift go together. The reasons for this are practical. A basic facelift includes dissection and repositioning of the “middle” of the face and neck. These structures are in continuity with one another so movement of one affects the other. Patients with more than minimal banding (the famous “turkey gobbler” neck) require repositioning using a facelift approach. It is possible to not do a facelift at the same time, but this affects the ability to reposition the neck without a deformity at the jawline. When the tissue planes are exposed, correcting them both seems logical. My opinion is that the result is potentially more long lasting.

There are those surgeons who have chosen to work from the neck alone. The benefit here is that of less trauma from less surgery. The second opinion consultation patient I mentioned above had had a “neck only” neck lift by her former surgeon. The result by her estimation was less than wonderful. While I cannot comment on her pre-operative appearance (which is very important in judging the result of an operation), lesser surgery in the neck often leads to dissatisfaction.

“But my surgeon was on one of those ‘Extreme Makeover’ television programs. He came well-recommended.”

I’d wager that her case won’t be featured on an upcoming show. Television can be edited. Real life cannot.

The Advice:

Plastic surgery is surgery and there are different methods to obtaining a good result. Any surgical plan is an estimate based upon the experience of the surgeon concerned. Both patient and surgeon need to be on the same page before entering an operating room. If your surgeon offers lesser surgery, ask what you might expect in the way of an outcome. A few consultations are never a bad idea when coming to a decision in this regard.

Best Regards,

John Di Saia, MD

Originally posted 2005-07-01 19:47:00.

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Jason Segel – Ordered to Lose Weight?

A slimmed-down Jason Segel stopped by the “Late Show With David Letterman” last night and revealed that he was told to lose weight for his role in Universal’s romantic comedy “The Five-Year Engagement.”

“I was forced to lose weight for this movie,” Segel said. When Letterman pressed further about who did the forcing, Segel responded with a laugh, “The studio president.”

“I was told that it had to be conceivable that Emily Blunt would ever choose me to be her husband,” said the star, who added that his weight situation became even more complicated because he portrays a chef and had to eat on camera in many scenes.

Hollywood is unusual in that it gets away with items like this that wouldn’t fly in the “real world.” Try to say something like you are too fat to someone working for you and see that person in court.

Then again the camera makes you look heavier. I have seen this myself as I have looked a bit chubby in some of the opportunities that I have had to get in front of one. :)

For those who have surmised that lipo might have something to do with this, lipo rarely results in much weight loss. It can slim you down in some hard to slim areas though.

Best Regards,

John Di Saia MD

Originally posted 2012-04-25 07:30:39.

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How to Get Dr D To Not Operate On You

People sometimes surprise me. A lady e-mailed me recently after I had seen her a year or so ago. There are good things and bad things about seeking care at a small practice. We remember you.

This lady originally came for a reconstructive operation that her insurance would not cover. Plastic surgeons cannot guarantee that an insurance company will approve surgery or pay for what you want. When we were unable to get her operation pre-approved, we lost contact with her.

Later on, she became angry when her insurance assigned her consultation bill to her. She had an unmet deductible. She proceeded to drag her feet and not pay this bill. Eventually she mailed partial payment with a nasty letter basically saying “this is all he is worth.” We left it alone even though we did not collect the amount we billed.

Now more than a year later, she is e-mailing asking if we can do her operation. Now why would I want to do that?

Understand that surgeons are people too. If you treat yours with disrespect, why would he want to take care of you?

Best Regards,

John Di Saia MD

Originally posted 2012-09-10 07:30:41.

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Expressions Dermal Filler Recalled – Dr D’s Experience

These days I do very little dermal filler business but go to a friend’s office in the Inland Empire (Upland) a few times a year to offer some. It was there a year or so that a product representative offered a few samples of a new dermal filler called Expressions. We gave away a few sample injections and heard nothing more of it until recently. I did not order the product as I have been happy with the Prevelle I have been using.

A year or so later my office gets a call from a representative of the company that was selling Expressions saying it had been recalled and asking if we had any. Rumor has it that the material was never approved for injection by the FDA.

Live and Learn:

Soft tissue fillers are good in limited amounts to lessen but not eliminate the signs of aging. They can be used effectively in this regard but the safer products are very temporary. Newer products should be looked at with suspicion even by the doctors who are being encouraged to use them.

Best Regards,

John Di Saia MD

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