Posts Tagged pain
Tummy Tuck surgery is almost invariably greatly appreciated by the proper patient. These top ten facts might help you figure if you are such a person.
(1) Tummy Tuck surgery is one of the largest scale operations a plastic surgeon can offer a patient.
(2) Patients who have lost a good deal of weight or completed child bearing involving large weight gain and loss are the most common candidates. Patients do not lose much weight from the operation itself in most cases….maybe a few pounds on average.
(3) Post-operative pain used to make it necessary to admit the patient to a hospital for narcotics.
(4) Pain pumps when properly utilized can decrease pain significantly. Overnight stays often reduce risk when properly supervised.
(5) Revisions are not uncommon but can often be done in a lower key environment….such as local in the office. The revision rate varies enormously between surgeons.
(6) All tummy tucks are not alike. The work of the novice really shows in this operation.
(7) Many physicians in the OC offer these operations including plastic surgeons, cosmetic surgeons, gynecologists and general surgeons. You guess which ones look the best?
(8) When you go to the bargain basement doctor, some of what may happen may not be correctable later.
(9) Drains and pump catheters will need to be used for a week or longer. They reduce risk of fluid collections that can ruin otherwise nice results (My opinion of course.)
(10) Smoking can really impair healing and lead to skin necrosis which commonly detracts from the quality of the result and delays wound healing sometimes for months. Don’t have the surgery if you can’t stop the cigarettes and tell your surgeon a true indication of how many cigarettes you are smoking daily.
John Di Saia, M.D.
Originally posted 2011-04-20 07:30:15.
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
Megan Fox is having her famous Marilyn Monroe tattoo removed from her forearm via laser. But apparently it’s not as easy as it sounds: Star magazine has a source claiming that Megan can barely stand the pain of the laser.
“After the first session Megan was freaking out over how badly it hurt,” the actress’ pal tells Star. “Her friend suggested a mouth guard to bite down on to help deal with the pain and protect her teeth.”
A mouth guard is a bit medieval. Has anybody ever heard of local anesthesia? I don’ know who is doing the work, but a good doctor could simply temporarily deaden the sensation by performing a nerve block in the two forearm cutaneous nerves. They are the medial and lateral antebrachial cutaneous nerves.
Just a thought.
John Di Saia MD
Six years or so before “A” came for consultation, I had done her friend’s breast reduction. “A” is petite and had some of the common pre-operative complaints that good breast reduction candidates report…upper central back and shoulder pain. She did not enjoy having to “scoop her breasts into a bra every morning” either. Two months after her surgery her pain was gone and her incisions healing well. She is pleased with her good results having had only 220 grams removed per side.
John Di Saia MD
Reader Laura Comment:
Athenix is a clinic that performs a water jet lipo that doesn’t use traditional anesthesia, just local. During one such procedure the patient was able to sell everything that was done to her. She said that she was screaming in pain and the Doctor wouldn’t stop. This Dr has also been in trouble before for allowing unlicensed people to inject pain meds into patients. The Dr associated with this story is under review again after violating the orders from the last incident.
“The pain was so severe that there’s no way I could forget it,” said the woman whom KOMO News has chosen to call “Terri.” She claims a simple surgery to remove fat from her stomach and thighs went terribly wrong. “It felt like a crushing, ripping and burning all at the same time,” she said. And a doctor ignored her cries for help. It was one of two surgeries Terri booked at Athenix in Bellevue. The company uses body-jet liposuction, a less invasive surgery using water jets to shape problem areas. The Athenix results pleased Terri the first time around. The second surgery in October 2010 did not. It took place in the Tacoma office of Dr. Jose Antonio Garcia, who was hired by Athenix to work part-time. During the surgery, the patient is awake but sedated with a combination of amnesia drugs, pain killers and local anesthetic.
People don’t seem to understand that liposuction is not something a machine provides. It is surgery. Surgeons differ in their skills and compassion. Patients are more successful when they concentrate upon the doctor who would do their surgery rather than the technology used for it.
When evaluating such a case one of the first things I do is check the American Board of Medical Specialties website for board certification information. I plugged in this doctor’s name in Washington and found “Jose Antonio Garcia Jr.” He appears to be a board-certified Gynecologist. What people expect when they submit to plastic surgery by a gynecologist is beyond me. Well gynecologists are used to screaming patients I guess. As we have discussed here to the point of nagging, you need to check your surgeon out before you have that surgery.
I would have preferred a little anesthesia and I employ the services of board-certified anesthesiologists to get quality anesthesia so I can concentrate upon operating. When you go for plastic surgery under less anesthesia you need to understand what you are selecting. Small scale surgery can be performed under lesser anesthesia. When the surgery gets larger in scale it can get uncomfortable at the very least.
John Di Saia MD
Originally posted 2011-03-07 07:30:02.
Labiaplasty pops up in the media intermittently. The angles vary but they frequently feature caricatures of the usual labiaplasty patients I see in Orange County:
Now, one woman has openly shared her experiences of labiaplasty – plastic surgery for female genitalia – on U.S. daytime television. The Doctors, aired yesterday on CBS, featured a 23-year-old who wanted nothing more than to correct her ‘painfully long labia.’ The segment was part of the worryingly-named ‘Gross Anatomy’ episode of the series.
The Dailymail, a uk publication featured an article discussing the case featured on the Doctors:
The trainee nurse, known only as Shannon, said that that her ‘deformed’ genitals are not only a daily discomfort but that they discouraged her from having sex – and were a factor in her relationship breakup. She said: ‘I’m self conscious. I don’t really want to have sex – I try to avoid it, so it’s kind of a big strain on a relationship.’
As a surgeon who performs labiaplasty I am frequently at least a bit peeved after these pieces air. They usually portray the labiaplasty patient as histrionic on the crazy side. Funny as I have cared for dozens of these women over the years. They have more often than not seemed pretty rational seeking normalcy not lunacy. Most have had desires that seemed pretty reasonable.
The comments of many of the “experts” quoted in these pieces usually also take issues to unrealistic extremes:
Massachusetts General Hospital obstetrician and gynaecologist, Dr Erin Tracy, seconds Dr Stevens’ findings – and Dr Stork’s beliefs. According to the news site, she said: ‘Most of the patients I have coming in asking about this are teenagers that look entirely normal. ‘The majority of them, after some probing, seem to have some underlying body dysmorphic disorder or problems in their relationship that make them think they’re abnormal.’
The fact of the matter is that there is a wide variation of that which is considered normal in the size of the Labia minora, the most common structure reduced in labiaplasty. So while the women I operate do have “normal sized” Labiae in many cases, normal size does not mean they do not have problems only indirectly related to that size. Not all labiaplasty surgery is strictly speaking vanity surgery. Some of these women have pain…pain in tight jeans, pain in many undergarments. They have pain. How much pain must they tolerate before others believe it is OK that they have it relieved?
Another common misconception seen in labiaplasty depictions in the media is that men have much to do with it:
Dr Hilda Hutcherson, an obstetrician and gynaecologist at New York’s Presbyterian Hospital/Columbia University Medical Center. She sees men as being partly to blame for the rise in labiaplasty. ‘For every single thing that’s normal about a woman’s body there’s a man trying to change it.
Women are the ones who come to my office seeking labiaplasty. They are usually alone. I specifically ask each one why she is considering surgery and have done this for a decade. The vast majority have reported that their reasons were internal and had nothing to do with men.
My usual reduction labiaplasty patient considers surgery due to a combination of aesthetic and functional reasons. Potential clients are screened to ascertain whether their complaints can predictably be alleviated by surgery. With this as a baseline, the results have been good.
John Di Saia MD
A day short of 4 weeks after Kim’s tummy tuck, she is pretty much at her baseline activity. She is taking only the occasional prescription pain medication leaning on Aleve for what she describes as minor soreness. She has seen little “Swell Hell” although admits that toward the end of the day she has mild swelling, but nothing incapacitating. Significant swelling after tummy tuck surgery is not unavoidable. Part of it has to do with technique.
On the other hand, expecting to be pain free after a large scale tummy tuck at a month is not reasonable. Patients generally have low intensity “aches and pains” as they ramp up their activity and for the most part over-the-counter medication suffices.
John Di Saia MD
Twelve days after Kim’s tummy tuck, she is getting around much better. She notes that she gets tired at the end of the day, but it is manageable. She is only taking a few pain pills a day. Her last drain was removed just after this video was recorded. Things are pretty good.
John Di Saia MD
One week after Kim’s tummy tuck, she is gaining a little independence. She can go out for short trips to get her coffee and care for herself a bit more. She left the house on post-op day 5. Pain without the pain pump is not so bad. Moving along. She really wants a good shower, but is a bit apprehensive still having one drain in place.
John Di Saia MD