Posts Tagged orange county
“My mother has been paralyzed for many years and needed many surgeries. She has had a problem after a recent pressure ulcer surgery. The wounds have opened. Can you help her out? Her recent pressure wounds had been there for over a year and weren’t healing.”
Occasionally this blog connects me with potential patients who live locally in Orange County. I rarely meet this kind of person via the blog however and am not always able to help patients after recent surgery by another surgeon. With pressure ulcer surgery on large open wounds there are periods of opportunity during which surgery has the best potential. Right after an operation complicated by wound disruption, the wounds are frequently fragile and need to heal for a while before surgery can be performed successfully.
Pressure ulcer surgery is difficult in that it requires a protracted period of care after the operation itself. Medicare restricts how long a patient can be kept in an acute care hospital, so I do these cases in a long term acute environment (LTAC.) I specifically do the cases in an LTAC that I frequent. Other surgeons deal with these cases differently. Not many plastic surgeons spend much time doing decubitus ulcer surgery. These cases take time and are not infrequently complicated even when everything is optimal.
Pressure ulcer surgery is also best accomplished with a motivated patient who is ready and able to restrict pressure to the newly operated wound. Patients who sit on their newly-operated wounds shortly after surgery have poor success rates.
John Di Saia MD
Originally posted 2011-11-09 07:30:11.
After reading a post at a forum that I occasionally visit, I figured an explanation of what thigh lifts can (and cannot) do was appropriate. Many plastic surgeons look at thigh lifts with a degree of exasperation. They not infrequently require revision. Those in large weight loss or gastric bypass patients can be a big job.
The amount of excess skin that so unattractively jiggles in the inner thigh is the question. To reduce said jiggling requires incisions. If the excess is mild to moderate, we can usually get away with just an incision in the crease between the thigh and groin. Gastric bypass and extreme weight loss patients often require an additional incision vertically down the leg. These incisions heal with variable scarring. The scars can migrate down the leg although this is less frequent than it was years ago.
We pull and often liposuction to make the tissues as tight as we can. Then to an extent they loosen over a year or so then we see how we did.
John Di Saia MD
Originally posted 2005-10-24 09:56:00.
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.
John Di Saia MD
Originally posted 2010-12-07 07:30:20.
As some of you might know I serve as an expert witness for the California Medical Board in cases of suspected negligence and malpractice. Not long ago I testified in a case of a not-so-qualified doctor (my opinion) in a liposuction death. Remember as the medical expert in this case, I reviewed the doctor’s training and experience. It was so weak that he would have failed a hospital credentials committee evaluation for sure. Unfortunately, these cases are confidential and I can’t divulge the name.
What I can divulge is that leafing through the OC Weekly recently I saw an advertisement by the aforementioned doctor offering incredibly inexpensive breast implant and liposuction work. I wonder if his dead former patient found him in these ads. Be careful when you select a surgeon this way.
John Di Saia MD
Originally posted 2011-03-16 07:30:57.
Do you know a good plastic surgeon for me in the OC?
I wonder if I am spending too much time blogging when I get asked a question like this one….but seriously do you expect me to recommend someone else in my practice’s backyard?
I practice in San Clemente and Orange.
In all seriousness, the answer to your question really depends upon what exactly you are looking to have done. I specialize on breast and body work although I also do “skin” work and some facial cosmetic surgery as well. No one “specializes” in everything. You need to do your homework to find the best for your area of choice and budget of course.
John Di Saia MD
Originally posted 2011-06-06 07:30:19.
Im looking for a practice that can offer me the best price for liposuction. There is a very small area just below my belly button I would like to have done. What would be a rough estimate for that procedure?
I get e-mail like this now and again. When you go about looking to go on the cheap for liposuction, you are going to find your way to a non-plastic surgeon for it. There are many other types of doctors who perform liposuction and the non-plastic surgeons have lower overhead. I am not saying I would recommend it or that they are very good at it, but they are cheaper.
Just be aware of what you are seeking because you just might find it…and end up in a bad place because of it.
John Di Saia MD
an Orange County Plastic Surgeon
P.S. By the way, when you receive a price on an operation without being examined first, that is a red flag too.
Originally posted 2011-03-10 07:30:08.
Frequently patients who have received liposuction care elsewhere (usually somewhere else in Orange County California) find my practice or the blog here and e-mail. The points of confusion are usually issues regarding the qualifications of their former doctor and expectations of their result.
Who Can Do Liposuction Surgery?
Anyone who can get you to sign up….yeah really. There are no laws against practitioners trained in nearly any specialty performing liposuction. Doctors of differing backgrounds will have different technical skill in the surgery and will likely charge differing amounts for the service. Their philosophies will also likely be different. If a doctor only offers liposuction, he or she will probably perform it on anyone and everyone. There are practices of non-plastic surgeons who offer lipo to people to whom I would not. That is just a fact.
Can I Use Liposuction to Lose Weight?”
Practically speaking, liposuction is not a good way to lose weight. It is a contouring procedure best used on people with good skin tone meaning elastic non-droopy skin. You are better off having lipo when your weight is in a stable range…plus or minus a few pounds.
Will the Fat I Have Removed Ever Come Back?”
The fat cells you have removed are very unlikely to return, but you can fill the remaining fat cells up more. The is a technical point not frequently stressed by the shady outfits that advertise their liposuction services. This is why doing lipo is not weight loss. You need to use diet and exercise as well. Lipo can be good for areas resistant to diet and exercise.
Can New Liposuction technologies like Smart Lipo Tighten Skin? Are They Worth The Extra Money?
Not really. I have performed laser-assisted Liposuction, Smart Lipo and Ultrasound-assisted Lipo. After trying these differing technologies, I have returned to wet liposuction (a variant of tumescent lipo,) because I see the same results with less BS. I do not push BS.
Will a Plastic Surgeon Ever Tell A Patient “No?”
One who has integrity will and he or she is the one you want.
John Di Saia MD
Originally posted 2010-07-07 07:30:04.
A recent study…shows that male physicians and plastic surgeons are more inclined to recommend surgery to alter the physical appearance of an otherwise healthy vulva. Published in the Journal of Sexual Medicine, the study was conducted in the Netherlands with a set of 210 doctors who were shown photos four healthy vulvas, two pre-labiaplasty and two post, following about six months of healing. These vulvas belonged to two women, one age 35 and the other 40, who underwent cosmetic surgery to shrink the size of their labia minora (aka inner pussy lips) which they felt extended abnormally beyond their labia majora (aka outer pussy lips). 164 of these 210 doctors completed this survey, and most (90 percent) agreed that the smaller labia minora were closer to society’s ideal.
I have written a labiaplasty article for the Journal of Sexual Medicine. I have also served as an article reviewer for articles being considered for publication at the journal. I did not review this article. Even if I had I am not sure I would have recommended it for publication.
Needless to say there are quite a few misconceptions about labiaplasty surgery. Each labiaplasty surgeon has his (or her) own particular philosophy through which he offers the surgery. Mine has not been to judge women’s privates, but rather serve to make them more to the liking of their owners within reason. I am not running some kind of Playboy bikini contest. Local Orange County women do not drop their drawers to ask me whether they “need” their Labia reduced either. When the question is presented in this manner, very few do. Women have their reasons for considering labiaplasty surgery and some of these make pretty good sense.
This study seems to have looked at the impressions of a group of doctors regarding what was more acceptable by current societal standards in the way of the Labia. My contention is that these standards really do not matter. “Normal” labial lip size can still be large enough to cause pain in today’s small string underwear. So normalcy per se has little to do with the consideration of labiaplasty in many cases. In consultation, the patient and I try to figure out what bothers her and what I might do about it. I am not there to label. I am not there to judge. We are there to figure what (if anything) might be improved.
Studies like this one just muddy the waters and they are already pretty muddy. It is all a matter of philosophy anyway.
John Di Saia MD
Breast reduction is defined as the reduction and lifting of naturally enlarged breasts. Medical insurance can cover this surgery but the insurance requirements vary from insurer to insurer. The insurers pay variably as well for surgeons who are Provider doctors and those who are not. Some pay so poorly that I can’t afford to take their rates. You will find few MediCal plastic surgeons in Orange County. There will be very few good ones.
The process for obtaining health insurance coverage generally involves your plastic surgeon writing a Letter of Medical Necessity to the insurer requesting coverage. This should be done before surgery and does not absolutely guarantee coverage, but at least makes it almost certain.
The letter generally needs to have a picture of the woman’s breasts and a description of her problems. Her height and weight and a prediction of the mass of breast tissue to be removed (in grams) are traditionally also indicated.
There are certain ICD-9 diagnostic codes that are pertinent in a letter of medical necessity. They indicate problems for which breast reduction might be helpful. A few that we indicate in our letter when appropriate are:
611.1 Hypermastia – Excessively enlarged breasts
611.7 Mastodynia – breast pain
719.41 Pain in joint; shoulder region, Scapula
724.5 Back pain unspecified
If this letter is successful, a return letter from the insurer indicates a conditional pre-approval. They are always vague on this item. Sometimes the insurer will require physical therapy for a period of time or a weight loss program prior to approval or ask that another pre-approval be sought after non-surgical therapy is tried.
There is no general rule. Each insurer has its own process and they are not forthcoming on exactly what they require. Blue Cross, Blue Shield and United Healthcare are the same only in that they will not tell you how they come to a decision. Some patients are approved and others denied. There is an appeal process in most cases.
Your surgeon should know if you are a reasonable candidate to try for insurance coverage. The worst they can do is say no.
John Di Saia MD
We have discussed health insurance games before. They commonly entrap doctors and patients in red tape and denials of care and payment. The public only occasionally becomes involved in the situation when they are affected directly. This time 20,000 Orange County Blue Shield HMO patients are involved, so there is interest:
Nearly 20,000 Orange County HMO patients are caught in the middle of contract dispute between Blue Shield of California and Monarch Healthcare, an Irvine-based medical group with more than 2,000 doctors. Starting May 1, Blue Shield will no longer have a contract for its HMO patients to see Monarch’s network of doctors across the county. Yet the insurer alleges that patients are being falsely told they are losing their doctors this month, and in a few cases, have been denied care.
Health care contracting is a complex maze. HMO patients generally buy their insurance from one of the large health care insurers such as Blue Shield. Few if any doctors can bill an HMO directly though. The usual arrangement is for the large health care insurer to sell (yeah, sell) the responsibility of the care of the patients in groups to an IPA (Independent Practice Association.) The kicker is that the large HMO insurer gets to keep up to 30% of the premium payments in this sale. That amounts to less money available for the care of the patients! Physicians must join an IPA to get paid on HMO business. The IPAs pay poorly for specialty services, so many sub-specialists (like Dr D ) do not deal with them.
The bottom line here is that for HMO patients to get regular care they need to maintain a relationship with a doctor who is a member of an IPA that is contracted to their HMO. They essentially enroll in that IPA to set up the linkage. When the chain is broken, the patient finds him or herself without a doctor. In this case that happened due to a contracting dispute between Blue Shield and Monarch IPA.
John Di Saia MD