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.
John Di Saia MD
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.
John Di Saia MD
Originally posted 2011-11-24 07:30:15.
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.
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.
John Di Saia, MD
Originally posted 2005-07-01 19:47:00.
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.
John Di Saia MD
Originally posted 2012-04-25 07:30:39.
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?
John Di Saia MD
Originally posted 2012-09-10 07:30:41.
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.
John Di Saia MD
Small procedures are on the rise with the economy being depressed. Sclerotherapy (injections to improve spider veins) are pretty common.
The concept is pretty simple: inject a fluid into the vein causing it to clot and scar (and eventually go away.)
This works pretty well for small veins but frequently can leave a bruised vein for several weeks. You really should keep the treated area out of the sun while this bruise resolves or it can be permanent.
The veins can come back. They usually do to some extent so this is a maintenance therapy.
John Di Saia MD
Originally posted 2009-12-25 07:30:27.
Hello, Dr Di Saia,
I’ve had acne for a few years (it is now almost completely gone) and I am now left with a few but noticeable facial scars. What is the best way to deal with them? What fillers would you recommend? Would a chemical peel or microdermobrasion be enough?? (I personally don’t think it would be). I am 19, by the way. Thank you for your professional advice!
Acne scarring is an extremely variable problem. The treatment depends upon severity and skin type. A single facial peel will likely not be enough to improve any, but the lightest of cases. You really need an individual professional evaluation regarding peels, fillers, and other surgical options as they pertain to your specific case.
John Di Saia MD
Originally posted 2005-07-24 15:35:00.
There are good and bad aspects to running a small practice like mine. Information containment for example is easier when fewer people handle that information. But there are limits to what any practice can or will provide.
A potential client e-mailed inquiring about a procedure upon which I have good online reviews. This person e-mailed four times in a few minutes. The same message was sent so I figured it was an honest mistake and thought nothing of it. Then I started getting a number of phone calls from the same number that left no messages. The first day I received about eight of these phone calls. These calls were made to our “urgent phone line.” The latest was at 9:00 PM. I do not make it a habit of calling back unknown numbers from my urgent phone line particularly when no message is left. Time has taught me this is a safe plan of action.
The next day the multiple calls from that same number continued sans messages. I called my office gal to find that a patient called that first day for an appointment and complained that his call was not returned for a few hours. My office gal herself had had surgery that day. As I said before, we are a small outfit.
A light went on in my head. I asked her: “From what number did that person call?” Of course it was the frequent urgent phone line caller’s number. Even after getting that appointment, the caller continued to call multiple times on the urgent line without leaving messages the second day.
See the problem?
A doctor’s office is geared to answer urgent calls urgently, but calling to the point of harassment to schedule an appointment and/or getting testy about a reasonable delay in calling you back is a good way to become a fired patient.
In this kind of case, your doctor looks at an unreasonably high potential for an unhappy client and avoids it before it happens. We only have so much time in the day to handle quite a few patients. When they are reasonable we do it gladly. When they are not, some of them have to go.
John Di Saia MD
Originally posted 2013-08-05 07:30:34.