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 – “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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Safe Breast Augmentation – How To Get Yours.

Safe Breast Augmentation?

The level of confusion regarding breast implant surgery is enormous. Can you get implant surgery without the drama?

safe breast augmentation

There are sites with scary stories of women (including this one) who went to horrifying B movie type doctors and had horrendous results. There are also stories of women who went bigger and bigger and bigger until their breast tissue just gave out and failed.

Safe Breast Augmentation is possible as long as you exercise proper judgement. Suffice it to say there are plenty of women who have had safe breast augmentation:

“Dr. D!!! They are still so awesome! They aren’t hard or sagging, almost 16 years later. Unbelievable! They look great and feel like a part of my body. You are the best and you can tell everyone I think so!!”
-G: Los Angeles, Ca. – Breast augmentation patient 2013

This woman had her breast implants placed in 1997 by yours truly. They were placed in an operating facility under her pectoral muscles and were saline-filled models of a moderate size. Now fifteen years later, she has needed no additional surgery and feels and looks great.

Beware advertising gimmicks and promises of the extreme. Choose a qualifed board certified plastic surgeon and moderate enhancement guided by his or her advice. That “happy medium” might just last you ten or more years. :)

Best Regards,

John Di Saia MD

Originally posted 2013-04-01 07:30:53.

Comments

Patient Comment – A Plastic Surgeon in Orange County For Skin Cancer – Who Knew?

Patient Comment:

I am so thankful that you were able to remove and repair my skin cancer. I didn’t know that a plastic surgeon would do this for me and Medicare would pay. Thank you. It really looks better and better every week. You are great! I really think you should blog on this as I am not sure people know that plastic surgeons are willing to help with skin cancer. Why would I ever go to a dermatologist for this again?

Thanks for the kind words.

I have been taking care of skin cancer for years and am a regular Medicare (not Medicare HMO) provider. I guess not many people know that they can often have skin cancer removed and repaired by plastic surgeons to minimize the appearance of the event. Repair of disfigurement might also be covered but it varies by insurer.

Best Regards,

John Di Saia MD

Originally posted 2010-12-07 07:30:20.

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What’s Your Gimmick Doctor? Dealing With The Media

Anyone running a private practice in plastic surgery now should be quick to realize that the media can be a powerful resource.

The sad fact is that the public does not know of your talents unless you let them know about them. My father’s long held statement that “the cream floats to the top” is naive to say the least. People do not know the best. They only know the doctors of whom they have heard. They just assume that they are the best. Sometimes they are. Sometimes they aren’t.

Early in my interactions with the media, it was apparent that they prefer to feature “breaking news items.” Their definition of breaking news is something new and different. Most of us in medicine know that these “breaking news items” we see actually featured tend to more often be not-so-new news. Some are factually incorrect. You may also add some unadulterated bull pucky. Breaking this news to your friends in the media will get you rarely featured unfortunately. They want what they want.

When dealing with the media, they in essence want to know “what’s your gimmick?’ They want a pitch. They want a story. Those who are more successful with them give them what they want. I give them the truth branded somewhat with my opinion. So I have made the truth my gimmick. It may not be so frequently successful, but I sleep well at night.

[Originally written for and published on MedicalSpaMD.com:

http://medicalspamd.com/the-blog/2012/7/2/whats-your-gimmick-doctor.html]

Best Regards,

John Di Saia MD

Originally posted 2012-07-13 07:30:21.

Comments

Reader Question: Hard Breast Implants – Will Capsulotomy Help?

I had breast implants and they have become hard over the last few years. Will capsulotomy surgery help?

Breast implants can harden (actually the tissue around the implants can harden) resulting in distortion of the breasts and at times pain. We have discussed the problem (Capsular Contracture) here before.

Significant breast implant hardening does not complicate all breast implant patients, but when it does additional surgery is the only good solution. The process involves the formation of a “capsule” of scar surrounding the breast implant. At times this capsule has an elastic consistency and at other times it can be “studded” by deposits of calcium that make it really rock hard.

Surgery to soften the hardened breast can involve scoring the scarred capsule to release the tension (Capsulotomy.) When the capsule is quite firm or studded with calcium, more involved surgery is in order. Capsulectomy involves the removal of all or parts of that scarred capsule.

Whether either of these treatments will work depends upon the cause of the contracture. Usually the implants can be replaced, but in really severe cases they need to be removed.

What you really need is a good evaluation by an experienced plastic surgeon to figure your best course of action.

Best Regards,

John Di Saia MD

Related:

“What Do I Do With These Old Breast Implants?”

Originally posted 2011-07-06 07:30:03.

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