Archive for category Dr D’s Truth
Plastic surgery can be so great, but the negatives are far more often featured than the positives in the media. This can tend to scare the hell out of many potential clients. The very freely used term “botched plastic surgery” tends to lend the potential patient to believe that surgeons do the wrong thing by patients frequently. Well trained and ethical ones don’t.
Here are a few simple pointers to help lead you away from the land of the botched plastic surgery patient:
(1) Do not allow doctors trained in other specialties to do your plastic surgery. You wouldn’t go to a plumber to have your car fixed would you?
(2) Get your general health in order first. Smokers and others with health issues are far more likely to not heal well after even well-performed plastic surgery.
(3) Don’t pick Dr Cheapie. You wouldn’t go to “Pick and Save” for lobster would you?
(4) Avoid surgical marathons and the doctors who proscribe them like they are handing out an Aspirin.
These points have worked well in my practice for over a decade.
John Di Saia MD
Originally posted 2010-10-14 07:30:51.
It is change your Medicare season so the advertisements are blaring for Scan, Secure Horizons and the other Medicare HMOS. Many Medicare patients do not understand how things change when they sign with a Medicare HMO. Regular Medicare patients have choices and do not need to wait for approval before receiving care.
I saw a Medicare HMO patient this month with a wound on his foot. The wound looked ready for skin grafting. As his HMO does not have a plastic surgeon under contract at the hospital where this patient was admitted, I was told he would have to wait for evaluation by their podiatry doctor. An operation I could have offered him in days waits weeks or longer. That is the HMO compromise. You wait for them to decide what you need.
Ultimately the podiatrist saw him and decided the wound would heal without surgery. It might, but it will take longer…maybe months longer. Then again passing on surgery will cost the IPA (HMOs usually contract with other health care companies called IPAs) less money and that is often the name of the game in health care.
When you change your health insurance you really don’t see the big picture unless you come to really need it.
John Di Saia MD
Originally posted 2010-12-22 07:30:57.
I had a return patient come in today to consider more Myobloc (the Botulinum toxin that I use in the office the most frequently). Her friends at her office had had alot of Botox…in their foreheads, in their eyelids, in their Crow’s feet… Another doctor had done this. She wondered if she “needed” more. Well nobody “needs” this. The real question is whether or not she might benefit from more.
I discouraged her from using it for more than the central forehead (base of the nose) and a little at the crow’s feet.
(1) I like people to have some facial expression. Blunting some wrinkles is OK. I don’t like “Stony” faces.
(2) There is some evidence that injecting too much into the entire forehead can drop the eyebrows and lead to the desire to have a forehead lift. I am not comfortable about causing the need for a cosmetic operation that a given patient may not want.
Botox and/or Myobloc is/are fine, but there is definitely a place at which too much makes you look kinda foreign.
Remember my blog = my opinion
John Di Saia MD
Silly Disclaimer…..like a real commercial (LOL):
The foregoing message has not been approved by any company making outrageous profits from the sale of Botulinum toxins. They would rather you inject every square centimeter of your body on daily basis until you are broke or dead.
Originally posted 2005-09-15 21:07:00.
I hear radio commercials with the smell good plumber. Why can’t you sneaky doctors learn to do that? I need to have a skin cancer removed from my face and went to a plastic surgeon. After arranging the surgery I called to ask what I would be paying after my insurance. They said they didn’t know. How can that be?
Health insurance is just as frustrating for your doctor’s office as it is for you. Believe it or not, when I do surgery under a patient’s insurance and bill a certain amount I really do not know what the insurer will pay on the case, when they will pay or what they will tell the patient to pay. Sometimes they assign most of the bill to the patient. Other times they try to discount the bill enormously. Still other times (really rarely) they pay the whole bill. Insurers actually pay variably for the exact same billing code between different patients and these differences can be huge. It plays out as a big game over months frequently.
When asked, my office staff can tell patients what billed surgeon’s fees for a particular insurance case will be, but prefaces that with the above facts. It is not fair, but it is not our fault either. If health insurers would pay reliably and consistently, we would not be charging patients as much and would be able to tell patients what their share of cost would be in a particular case. We might be able to use our insurance billing service less (which also costs us money) and simplify matters for everyone.
The way things are, the only way we can tell patients what their share of cost for surgical services will be is for cases in which their health insurance is not involved.
John Di Saia MD
Originally posted 2011-06-08 07:30:28.
Reader Laura Question:
Some scientists warn users that they have been using so much and so often that they are building up an immunity to Botox and it’s no longer as effective for them. That as many as 1 in 200 no longer can use Botox. Have you seen anything like this happening with patients coming to your office? Do you think this would be something that is permanent or would they be able to use it again after going without Botox for some time? Also, is there anything else they could use if they could no longer use Botox?
We have discussed the reasons why Botox results vary before. Amongst the ideas not elucidated there was the concept of antibodies. Botulinum toxins are foreign proteins to the human body, so it is only natural that at least some patients would develop these in response to the treatments. There are patients who over time experience decreasing effectiveness with Botox. Whether or not this is due to antibodies is debated. At times changing to another toxin can be helpful. There are however at times people in whom the alternatives still produce less than satisfactory results.
This is amongst the reasons I advocate the judicious use of these toxins in hopes of extending the period of usefulness to the individual. My opinion is of course only my own.
John Di Saia MD
The new study, evaluated 301 patients having liposuction, either alone or in combination with abdominoplasty, using standardized photographs and computer-assisted measurements of body dimensions obtained preoperatively and at least three months after surgery. The study revealed no evidence of fat regrowth in treated areas of the arms, abdomen, or lower body. Additionally, upper body dimensions were unchanged after surgery, indicating no fat redistribution. Average reductions in hip measurements remained significant in patients followed one year or more after both liposuction and combined liposuction/abdominoplasty procedures. The average hip reduction was significant even among a subgroup of 34 patients who gained five pounds or more after surgery.
We have discussed fat returning after liposuction before.
Despite the fact that liposuction removes fat, it is not weight loss surgery. People have a hard time realizing this in part because advertising demonstrates the opposite picture usually.
People in whom large weight swings are common have a high redo rate or are just plain unhappy with liposuction. In their cases, weight tends to come back. The best patients for liposuction are those with stable weight.
Technically, the fat removed doesn’t “return.” The cells that were removed during surgery do not come back. You can however fill the fat cells that remain after surgery with more fat depending upon diet, exercise and your metabolism. In this newer study, it should be noted that tummy tuck surgery was included which has better long term rates of fat removal than other operations.
So both the study showing fat returning after liposuction and this newer one showing fat not returning after liposuction and tummy tuck surgery can both be correct…in the right patient groups. It depends upon the general conditioning of your average liposuction patient and this varies.
As always patient selection and consent are all important in choosing your procedure and your surgeon; that is, if you want that fat to stay off.
John Di Saia MD
Originally posted 2012-08-01 07:30:57.
The opinions of doctors are desired now and again on issues of health care and reform. For those of you who know me, I have a big mouth…opinionated quite possibly to a fault. Being that I listen to Larry Elder’s talk show in Los Angeles, I happened to hear a call in which a physician Dwayne presented an opinion that emergency medical services should be covered by some kind of state or federal financial coverage. This fried my bacon. I noted a hint of representation in his tone as if he were speaking for doctors throughout the country. He doesn’t speak for me.
My opinion does not stem from my profession as a physician, but rather from a philosophical point. I do not believe that the government using other people’s money should be paying for some people’s health care. This is what we have now. Some people go to the emergency room and get 100% of their care at no cost. Others pay dearly for that same care. That is not right.
One of Dr Dwayne’s points with which I was not in disagreement is that the government should not be mandating that hospitals and doctors care for emergency patients and not insure payment for it. This is not fair either.
I believe that some middle ground should be sought. While I am not a believer in ObamaCare, I do believe reform is needed. It is too political a subject for a fair job to be done most likely.
This was not the entirety of the discussion on my “call in,” but it was a large part. I was surprised that Larry’s screener (producer?) seemed to recognize me (from my cell phone number perhaps?) I call Larry’s show because the treatment is fair and I agree with most of the things he says.
John Di Saia MD
Originally posted 2011-01-21 07:30:17.
Looking online you look like a “dark horse” candidate for a list of best oc tummy tuck surgeons. I see your results look nice and your medical board sheet is clean. You write that you don’t do liposuction with your full tummy tucks though and you keep your patients overnight with a private nurse. How do you get tight looking results without the lipo and is the overnight really necessary?
Thanks for the kind words “best oc tummy tuck surgeons” although the “dark horse” part is kinda plus and minus.
Lipo really doesn’t tighten anything. In tummy tuck surgery it is the design of the tissue removed and the closure that does that. The blood supply of the tissue after a tummy tuck makes lipo (in my opinion) risky if done too aggressively. I see my tummy tuck patients with less swelling and with a better shorter recovery since I dropped the flank lipo years ago. I do not make “Swell Hell” patients very often and my skin necrosis rate is very low.
The overnight stay with the private nurse is mainly for leg vein clot prophylaxis as well as to teach patient the “dos and don’t s” of tummy tuck post-op before they go home. I insist upon overnight stays of this sort for anything over a minor tummy tuck in a really healthy patient. The cost is nominal and my safety record has been really great.
I guess I have a defined philosophy for tummy tuck surgery and thus far it has worked pretty well.
John Di Saia MD
Originally posted 2011-07-01 07:30:51.
Prospective tummy tuck patients are often surprised by my advice that liposuction in the sides at the time of the tummy tuck surgery is more trouble than it is worth. That is probably because most of my local competition sells the liposuction as a good thing.
The bottom line is that tummy tuck surgery is a big deal and healing afterward as well as swelling (the accursed “Swell Hell”) can be limited. Technique to a large extent determines the outcome. Seroma refers to fluid collections that can be persistent at times after large scale operations. It has been my opinion that liposuction plus tummy tuck equals an unacceptable risk of seroma. Now a study has affirmed my position:
Conclusions: Patients should be counseled regarding an increased risk of seroma formation following abdominoplasty when combined with liposuction of the flanks. In addition, patients who are overweight are at increased risk for developing a postoperative seroma compared with patients with normal body mass indices.
The actual incidence of seroma in the study was very high compared to what I see, but they did see fewer seromas with tummy tuck sans flank liposuction.
John Di Saia MD
Originally posted 2012-10-02 07:30:58.