Body Contouring

November 21, 2011

Plastic Surgery After Weight Loss Works

Before:  48-year-old woman who lost 160 lbs. after bariatric surgery and after becoming an avid cyclist


After a tummy tuck.

092 (2)

Let's be honest.  We have all seen somebody who has had plastic surgery, and whom we can hardly tell whether there is a difference.  We squirm with that facelift patient, "Um. Er.  You"  We try our best to wriggle out of the discussion.

I never feel that way with my weight-loss patients.  Abdominoplasties, body lifts, brachioplasties, breast lifts, etc., on bariatric patients typically create dramatic improvements.  The results are not subtle.


February 12, 2011

New Weight Loss Drugs NOT Safe, FDA Rules

As obesity rates continue to rise, the need for a safe and effective weight loss drug is urgent.  Yet, 3 promising therapies have been halted in the pipeline this past year.

The FDA has declined to approve the diet drug Contrave.  Instead, the FDA has asked its manufacturer, Orexigen Therapeutics, to conduct a study "of sufficient size and duration" to examine the potential heart risks of the drug, which is a combination of naltrexone and bupropion HCL.

Last December, a majority of members of the US Food and Drug Administration (FDA)'s Endocrinologic and Metabolic Drugs Advisory Committee gave a thumbs-up to Contrave, something they had not done for two other diet drugs they had reviewed earlier in the year.

Lorcaserin (Arena Pharmaceuticals) and phentermine/controlled-release topiramate (proposed name: Qnexa, Vivus) were the other two proposed diet drugs not recommended by the FDA advisory committees reviewing the evidence for both drugs last year.  The FDA has subsequently rejected their marketing applications, asking for more data.

Yet another diet drug, sibutramine (Meridia, Abbott Laboratories), was yanked from the market earlier in the year due to concerns about its cardiovascular safety.

Had Contrave been given the green light, as many predicted following the advisory committee's deliberations, it would have been the first new diet drug on the US market in the past decade.

Dr Sanjay Kaul (Cedars Sinai, Los Angeles, CA), one of the seven FDA panelists who voted against Contrave's approval back in December 2010, said the FDA, which more often than not follows its advisors' recommendations, made "the right decision" and not a very surprising one.

"I went on record saying that the 13 to 7 vote is going to create a buzz that is not going to accurately reflect the tepid enthusiasm for this drug. Even the individuals who voted for the drug were not very enthusiastic for it."

In fact, Kaul points out, ambivalence and mixed feelings were a hallmark of the Contrave panel discussions:  three panel members who voted to recommend approval also voted for preapproval studies, while two who voted for postapproval studies also voted against approval.

The bottom line for Kaul was the fact that the modest weight loss achieved with Contrave was unlikely to translate into tangible morbidity/mortality benefits to offset any risks.  "You can never establish safety in preapproval assessment, so there is always some degree of risk that you are willing to trade off, providing the benefit is large enough. And in my opinion, the benefit [with Contrave] was very modest," Kaul said.

So, what are obese patients to do?  Since it doesn't look like there will be any pharmacological solutions in the near future, I would recommend seeing a bariatric surgeon for gastric bypass or laparoscopic gastric band.  While I don't offer those procedures in my own practice, I have been impressed with their efficacy and relative safety.


February 02, 2011

Warning: "Awake" Anesthesia is Dangerous

Reprinted from SELF magazine, the following is an excellent article by Sabrina Rubin Erdely.

Paulette Hacker couldn’t stop screaming.  Lying on her side on a gurney, wearing only a bra and panties, she felt as if she were being stabbed again and again.  In a way, she was.  Through incisions in her upper back, a stainless steel tube called a cannula was suctioning out her excess fat.

“Please stop! You’re hurting me!” she cried to her doctor.  Because although Hacker’s body was limp and her mind bleary from an unknown combination of drugs she’d been given through pills and a gas mask, the 38-year-old was awake part-way through the second day of liposuction on her back, underarms, abdomen, hips and neck.  That was the whole point:  She was undergoing the new and aggressively marketed Awake cosmetic surgery, which is performed under local anesthesia.

“You can’t scream, Paulette,” a gruff voice answered her.  Hacker hazily realized that the voice did not belong to her doctor; the man performing her operation was a stranger whom Hacker would later discover was a physician’s assistant.  According to Hacker, whose experience is also detailed in a Los Angeles Superior Court complaint, she could see people coming and going into the “operating room”—more like an oversize exam room—at the Rodeo Drive office of Craig Alan Bittner, M.D., a “liposculpture” practitioner in Los Angeles.  (Through his attorney, Dr. Bittner strongly denies all of Hacker’s allegations.)

“Move her into the TV room—she’s making too much noise,” a confused and terrified Hacker heard another voice say.  Her gurney was rolled down the hall and into a second room, where she could see the assistant jab her while he watched a basketball game playing in the background on a wall-mounted television. The volume was cranked up loud enough to drown out her cries.

After the five-hour operation, Hacker says the assistant and an office clerk yanked her to her feet and squeezed her into compression garments. Dazed and sobbing, she struggled into her clothes and found herself face-to-face with a beaming Dr. Bittner. The doctor gently asked why she was crying, she says.  Then he maneuvered her beside him and told her to smile for a photo.

"Awake" marketed as cheaper, more medically advanced

Hacker had been excited to fly down two days earlier from Sacramento, California. The stay-at-home mom weighed 233 pounds and was trying to slim down; she’d lost 22 pounds on her own through diet and exercise—mostly jogging—and now felt she could use some help.  But she’d never had elective surgery before and feared having general anesthesia.

Surfing the Web, Hacker had discovered the "Awake" procedure, which was advertised as a cheaper and more medically advanced alternative to lipo—and, for those inclined, to abdominoplasty and breast enhancement, too.  The price was right: Awake lipo with Dr. Bittner would cost only about $700 for each body part, versus about $3,000 if she had regular plastic surgery.  She found it comforting that the lipo would be performed in a doctor’s cozy office, not in an intimidating outpatient surgical center or hospital.  Best of all to Hacker, Awake ads promised that patients would remain lucid throughout the operation and even be able to interact with their doctor.  “I liked the idea that I’d be awake and in control,” Hacker remembers.  “The surgery really looked like it was for me.”

Unfortunately, the procedure may not have been designed to meet her needs, but rather the doctors’.  “The reason for the ‘awake’ portion of it has nothing to do with improving patient comfort,” says Joseph M. Gryskiewicz, M.D., of Minneapolis, chair of the emerging-trends committee of the American Society for Aesthetic Plastic Surgery (ASAPS).  “It has to do with doctors not needing to involve an anesthesiologist.” General anesthesia is expensive, and the specialists who provide it prefer to work in hospitals or clinics that have met high safety standards.  Awake surgery has become a way for doctors who lack hospital privileges—but who want to cash in on the plastic surgery market—to exploit a loophole by performing the operations in the privacy of their offices.  “This is just a gimmick by people who can’t operate their way out of a wet paper bag,” Dr. Gryskiewicz argues.

Hacker had chosen Dr. Bittner’s medi-spa after studying his website, which showcased his Johns Hopkins education, testimonials, and pictures of smiling patients beside the tall, tan doctor. Hacker checked to make sure Dr. Bittner was qualified, and there it was: “board-certified.” She didn’t realize that he was a board-certified radiologist. A non-plastic-surgery background is the norm for Awake practitioners, who tend to be family physicians, OBs, ophthalmologists, pathologists—any doctor willing to shell out up to $7,000 for two-day training courses held around 30 times a year by a group of recently formed professional associations.

It’s all emblematic of a growing problem of amateurism in the plastic surgery field, warns Michael F. McGuire, M.D., a director of the American Board of Plastic Surgery, the group that certifies plastic surgeons. In Southern California, 40 percent of liposuction practitioners had no training in the procedure before entering practice, according to a 2010 study in Plastic and Reconstructive Surgery by surgeons at Loma Linda University Medical Center in California. The study found that the most numerous providers of lipo after plastic surgeons were otolaryngologists—ear, nose and throat doctors. And a 2008 review of liposuction-related fatalities in Germany concluded that in cases in which patients died, “lack of surgical experience was a notorious contributing factor,” especially when it came to doctors’ failing to identify complications.

Breast augmentation takes that risk to an even higher level, Dr. McGuire says, because of the host of emergencies that could arise, including blocked airways, blood pressure changes, or collapsed lungs.  And full tummy tucks are the most invasive of all, risking pulmonary embolism and abdominal perforation; Dr. McGuire calls it “inconceivable that anyone would do such a major procedure under anything less than a light general anesthesia.”  He cites Awake surgery as part of a disturbing trend of non–plastic surgeons attempting procedures that have not been thoroughly tested—such as the not-yet-FDA-approved “stem cell face-lift,” and Macrolane injectable breast enhancement—and unabashedly touting them to the public as the Next Big Thing.  “Awake surgery is a carnival sideshow event,” Dr. McGuire says. “Your life could be at stake with some of these kooks.”

Patients alert and have input, but also agony 

An Awake breast-implant surgery in the Plano, Texas, office of Jeffrey C. Caruth, M.D., often starts with a small dose of 5 or 10 milligrams of Valium, to relax the patient. “If they take too much sedative, they’re going to have trouble picking out a size,” says Dr. Caruth, a board-certified ob/gyn who has performed more than 200 Awake breast jobs since his training course in May 2008 (as well as 1,000 Awake liposuctions, charging up to $5,000 per surgery). Using a thin needle, Dr. Caruth injects each breast with a small amount of the anesthetic fluid lidocaine. When the area numbs, he makes his first incision. There’s no anesthesiologist and, unlike with IV-administered “twilight sedation,” no drip that can be adjusted to render a patient unconscious if she’s in pain.

“They’re totally alert,” Dr. Caruth says. “It’s actually a lot of fun; we play music and talk.” He says his patients feel nothing as he uses a cannula to infiltrate both breasts with tumescent fluid—a solution of saline, lidocaine and epinephrine—and makes more incisions. Next, they feel pressure and pulling as he stretches the skin and muscle to create a pocket under the muscle large enough for the implants. Then comes the climactic moment: The patient’s gurney is ratcheted upright so she can face a mirror and see her chest inflated with temporary sizers. The doctor ushers in her partner, family or friends to help her decide if she’s happy with her new silhouette before proceeding with the implants.

This is the driving reason women choose Awake breast surgery, according to Dr. Caruth.  “They want to have input. When you go shopping, you don’t take something off the rack, throw it in the sack and go home. You try it on first,” he points out.  “Women are picky.  It’s like shopping for a new dress or a pair of shoes.”  He consults with patients before surgery about what’s feasible, but the ultimate decision comes while they’re under the knife.

A patient’s autonomy—her ability to exert control over her own body—is a huge selling point, emphasized again and again on the websites of Awake practitioners.  But the idea of asserting your rights on the operating room table is misguided at best, says Diana Zuckerman, Ph.D., president of the National Research Center for Women & Families. “A woman lying there is not in any position to be giving advice to the surgeon,” she exclaims.  “To make it sound like empowerment? The mind reels.”

For one thing, when a patient is sedated with Valium or Percocet, her judgment is clouded, making her more prone to irrational decisions or to being overly influenced by the onlookers, says Herluf Lund, M.D., a plastic surgeon in St. Louis who has researched the safety and design of breast implants.  Dr. Lund watched a video of an Awake breast surgery at an ASAPS conference—and says the roomful of doctors was aghast.  “The patient looked as if she’d had about 10 stiff margaritas” as she contemplated her reflection and—at her doctor’s urging—agreed to go up a size, he recounts.

Dr. Caruth says his patients are completely lucid because of his insistence upon minimal sedation—about half of his patients take no Valium at all—and that he’s had only two patients who wanted do-overs, both to go bigger.  “I know people who say they do Awake breast augmentation and then slam the patient with narcotics,” he says.  “That’s not the case here.”  But even among patients who aren’t sedated, the time to make reasoned decisions is before surgery, Dr. Lund argues.  The operating room is not a shopping mall, after all; if you regret your impulse purchase, you can’t easily go back and return it. “In the consultation room, the C-cup might have made more sense for your body and your life, but in the operating room, you might say, ‘Give me the D!’” Dr. Lund says, adding, “Later, if you’re not happy, the doctor can say, ‘Well, I gave you what you wanted.’”

Another Awake premise is that patients are smart to avoid general anesthesia, which causes one death per 200,000 to 300,000 anesthetics given, the Institute of Medicine estimated in 2000. But the large volume of lidocaine used during an Awake surgery poses its own risks. “The amount of local anesthesia needed to anesthetize both breasts comes close to the toxic level,” says Dr. McGuire, who is also immediate past president of the American Society of Plastic Surgeons (ASPS).  Lidocaine has not been extensively studied for breast augmentation, but plastic surgeons say a limit of 35 mg to 50 mg per kilo is wise.  Dr. Caruth says he uses about half this amount.  But in reviewing more than a dozen cases of Awake surgery gone wrong, Dr. McGuire says patients got more than the limit—and warns that a lidocaine overdose can kill.  The idea is that a high dose is safe in Awake surgery because it’s injected into fat, which, having fewer blood vessels than muscle does, is slower to absorb anesthetic.  On the other hand, “that slow absorption could mean you’re just delaying peak toxicity,” says Keith J. Ruskin, M.D., professor of anesthesiology at the Yale University School of Medicine.  “So theoretically, you could have someone on her way home from surgery, and complications like seizures and heart arrhythmias could arise.”

Without an anesthesiologist present, patients can also end up in agony. Dr. Caruth says he’s able to resolve discomfort with an extra squirt of tumescent fluid.  But “you don’t want people with a low threshold for pain,” he adds.  If a patient remains uncomfortable after a doctor has already maxed her out on lidocaine, an Awake practitioner is left with only two options: Halt the surgery, or grimace and carry on.  Responsible doctors would do the former; Dr. Caruth says he’s only once had to cut a surgery short.  But not all surgeons act responsibly, Dr. McGuire says, and if patients were to writhe in pain at the wrong time, it could spell disaster.  “The stories are just hair-raising,” he says.  “As a surgeon, I don’t want to be operating on screaming people.”

Awake doctors aren't trained in plastic surgery 

After her painful procedures, Hacker returned home bandaged, swollen and sore. “I hurt so much, I couldn’t function,” she says. Her entire body swelled out of control despite her wearing a pressurized garment for eight weeks, and she had neck and back pain so wrenching that she couldn’t lift her young daughter for the next year and a half.

The more facts Hacker learned about her physician, the more disturbed she became. Three other patients had come forward, alleging their Awake liposuction was performed not by Dr. Bittner but by his office manager—a woman with no medical license who was also his girlfriend—and that they emerged injured and disfigured. Those suits were settled or withdrawn. But Dr. Bittner still faces a felony charge for aiding and abetting the practice of medicine without certification, as well as a civil suit brought by Hacker. His lawyer, Benjamin Gluck of Los Angeles, notes that his client has “hundreds and hundreds of satisfied patients” versus “a few unhappy patients who have retracted their more colorful accusations under oath.” Given this, Gluck says he strongly believes the criminal case will resolve in the doctor’s favor.

Hacker also discovered that no doctor should have given her lipo in the first place.  It is inappropriate for obese patients because of their higher risk for complications and because surgeons can safely remove only about 5 pounds of fat, Dr. McGuire says.  Worse, experts say, doing multiple sessions of lipo on many body parts over sequential days—common among Awake surgeons—is far outside the norm and vastly increases the dangers.  When she shared post-op reports from Dr. Bittner’s office with another physician, Hacker learned her blood pressure went so high during the procedure she could have had a stroke.  “This was all about greed, not about taking care of patients,” she says.

The main organization pushing the Awake-training gold rush is the American Academy of Cosmetic Gynecologists in Tucson, Arizona—a group with an official-sounding title, but one that is actually open to any ob-gyn willing to pay $300 in dues.  Founded seven years ago, the “academy” quickly attracted so many other specialists clamoring to join that other organizations sprouted up to accommodate them—the National Society of Cosmetic Physicians, which now boasts 1,200 members, as well as the American Academy of Cosmetic Family Medicine and the American Academy of Cosmetic Dermatologists.  A fifth group, the National Society of Cosmetic Plastic Surgeons, contradicts its name by asking only that applicants be practicing “physicians,” not plastic surgeons.  (In contrast, doctors hoping to join more prestigious, long-standing societies like the ASPS and the ASAPS must be board-certified in plastic surgery, engage in continuing education, and be sponsored by current members.)

In a surprise twist, reporting revealed that despite their various names, all five Awake groups seem to be the same organization, listed at the same Tucson address, sharing phone numbers and faculty. An employee who answered the phone refused to reveal the groups’ leadership, saying only that the director’s name was “Brad” and that the groups declined to comment.

The linked organizations offer two-day courses in Awake liposuction ($5,000), tummy tucks ($7,000) and breast augmentation ($7,000).  Among the instructors is Anil Gandhi, M.D., a general surgeon in Cerritos, California, who is not board-certified in any field.  Dr. Gandhi’s workshop—which includes lectures on start-up costs, promotional materials and handling the dissatisfied patient—is complete after 22 hours.  It takes more than five years in a residency program to train surgeons to do breast augmentation.

The threat to patients is not theoretical:  After a 37-year-old Florida woman went into shock and died after undergoing lipo with a doctor trained only by short courses designed for gynecologists, the state board of medicine found that “these courses do not provide adequate training to develop the proper surgical judgment” on who is a good candidate, what form of anesthesia is safest for her and how to avoid and react to complications.

Many surgeries done in unsafe facilities

 Not only do Awake practitioners work outside their area of expertise, but many operate in facilities with few safety standards.  Most facilities outfitted for moderate anesthesia and up are accredited by one of the major nonprofit organizations that oversees safety and doctor training.  But because Awake practitioners use only local anesthesia, they often skip accreditation, too.  “Do they know anything about sterility, about occupational health and safety standards, about infection control?” asks Lawrence S. Reed, M.D., immediate past president of the American Association for Accreditation of Ambulatory Surgery Facilities in Gurnee, Illinois.  “Because they’re not accredited, there’s no way of knowing what goes on in their offices.”

Unless, of course, something goes wrong—as happened in the office of Sean Su, M.D.  Trained as a family physician, Dr. Su opened a clinic in Las Vegas called the Skin + Body Institute and advertised a “Makeover Wish” contest, the winner of which would get free Awake implants and then shill for his website.  The prize went to a 29-year-old who explained in an entry essay that she suffered from low self-esteem, partly due to marital problems.

State authorities would soon come to call her Patient A.  During her surgery in April 2009, Patient A experienced “significant pain and anxiety” for eight grueling hours, according to the Nevada State Board of Medical Examiners, which investigated her complaint.  She was slow to heal—and seven weeks after surgery, her right implant started to pop out of its incision, says Douglas Cooper, executive director of the board.  Dr. Su then performed yet another painful eight-hour Awake surgery, during which he washed the infected breast pocket, then returned the implant to her chest—right along with any bacteria that might have been left clinging to the implant.

Little surprise, then, that Patient A was admitted two weeks later to Sunrise Hospital for emergency surgery for a breast infection.  As the surgeons removed her implants, they were shocked by what they saw.  According to the investigators’ preliminary findings, Dr. Su had created a pocket too small for the implant.  His incisions were “jagged and uneven” and three times longer than appropriate.  And he’d left behind an “inexplicable mass of sutures” along the tissue of her right chest wall, increasing the odds for infection.

The board also discovered a second patient of Dr. Su’s with a similar complaint: a 25-year-old who’d also undergone an eight-hour Awake breast surgery, followed by serious infection.  Investigators found an unsterile clinic with a canister of days-old liposuction waste left in a procedure room and expired tools and medications, including the lidocaine used for Awake procedures.

In March 2010, the board of medical examiners found Dr. Su guilty of malpractice, keeping inaccurate records and trying to deceive board staff. Yet his penalty didn’t seem that bad. He had to reimburse the cost of his $25,000 investigation, pay a $4,500 fine and serve out 18 months’ probation, during which he is barred from practicing or supervising cosmetic procedures.  He is free to once again do family medicine and told self in an email that he has fixed the conditions in his office and, when his probation ends, he plans to restart his aesthetic practice, too:  “I had no other alternative but to accept their agreement due to lack of finances for a prolonged defense with a biased medical board” driven by “antiquated physicians not up-to-date with knowledge in the advancement of safer treatments.”  There is a tendency for plastic surgeons to “protect their turf from outsiders,” Dr. Su added.  “As always will be the case, such pioneering physicians as myself will be criticized when known complications occur and will thus be judged harshly and unfairly.”

A few state medical boards have become concerned enough to try to stem the tide of doctors’ “scope drift” into cosmetic surgery.  After three liposuction patients died in the care of an internist in Anthem, Arizona, that state’s board was the first to draft guidelines reminding doctors that, upon expanding their practices into new areas, they need to be competent in those areas, says the board’s executive director, Lisa Wynn.

In North Carolina, the medical board suspended indefinitely the license of an ear, nose and throat doctor who did a series of substandard plastic procedures and is finalizing a policy that could result in discipline for doctors who venture too far from their expertise.  Previously, a rash of liposuction deaths in Florida led to more stringent rules for office surgery.  These rules make a small step in the right direction but still rely heavily on doctors’ willingness to adhere to the honor code.  With little oversight, “it’s a buyer-beware situation,” Dr. McGuire says.

Just ask Paulette Hacker, who hasn’t been the same since her Awake lipo.  Her “bargain” surgery ended up costing $6,000 worth of chiropractors and hyperbaric oxygen treatments to ease her pain.  And she estimates she’ll spend thousands more to correct the aesthetic damage—because whenever she looks in the mirror, she’s reminded of her Awake mistake.

She’s been left with a lumpy back, a misshapen belly, uneven hips, a neck striated with scar tissue, an asymmetrical jawline and a conga line of polka-dot scars down her sides.  “I thought I was an educated consumer, an intelligent person,” Hacker says.  “I wish I had known: If they’re not properly trained and certified as a plastic surgeon, they have no business cutting through your skin.  If something seems too good to be true, then it is.”


December 15, 2010

Urban Myth of Plastic Surgery: Rib Removal

True or False:

Janet Jackson underwent a rib removal to thin her waist.


Women are born with different lengths to their waists.  A long distance between the lower ribs and the pelvic bones is "long waisted"; a short distance between the lower ribs and the pelvic bones is "short waisted."

Long waists (along with a minimum of body fat and lots of working out) create hour-glass figures.  Short waists tend to produce "boxy" torsos.

If you are short-waisted, what can you do to lengthen your waist?  Not much.  Theoretically, removing one (or a few) of the lower ribs would increase the distance between the ribs and the pelvis.  But I don't know of any reputable plastic surgeon who performs costectomies for cosmetic purposes.

Why don't we plastic surgeons remove ribs more frequently?  Because ribs are important!  While God may have used one of Adam's ribs to create Eve, He left the rest in place to ventilate the lungs and to protect the heart, lungs, spleen, liver, kidneys, etc.  Without ribs, you can't breathe, and your critical innards won't be protected against routine falls and bumps.

In various magazines, I have read that Janet Jackson, Cher, Elizabeth Taylor, and others have undergone rib removals.  But this is almost certainly not the case.  This is just an urban myth concocted by jealous journalists.  While many in the Hollywood set have had tummy tucks and liposuction, their beautiful figures are mostly the result of strict diets, consistent exercise, and fortunate genetics.



August 06, 2010

Crazy Sisters Kill While Pretending to be Plastic Surgeons

Two women are on the lam after allegedly killing a woman with illegal silicone injections into her buttocks.

In late June 2010, the Los Angeles police arrested sisters Guadalupe Viveros and Alejandra Viveros on suspicion of medical malpractice for allegedly running an illegal cosmetic fillers business.  The sisters were accused of practicing medicine without a license.  Moreover, they apparently used industrial-grade silicone to inject victims' faces and buttocks.

Multiple patients became ill after being injected with the silicone.  In a few cases, the fillers encapsulated and hardened, and a sizable minority developed infections.

One patient did die after silicone injections into her buttocks.  It is likely that the non-sterile, not-medically-appropriate injections directly resulted in her death.

The story, however, only gets more twisted.  Each posted $20,000 bail, and they apparently fled, presumably to their family home in Mexico.

These types of illegal injections are unfortunately more common than most people realize.  It seems that many of these phony plastic surgeons come from other countries to prey on immigrants here in the USA.

I know of no reputable plastic surgeon who uses liquid silicone injections for facial, breast, buttock, or body enhancement.  For at least 40-50 years, well-educated, Board Certified plastic surgeons have known better.

Do yourself a favor if you are considering plastic surgery.  Find a real plastic surgeon.


May 28, 2010

Another American Dies During Plastic Surgery in Mexico

Another awful tale of a Southern Californian who died as a result of a botch job from a disreputable Mexican plastic surgeon.  From

Lourdes Trinidad Died After Liposuction Procedure Performed By Dr. Louis May Villanueva

A local doctor who may have overstated his credentials is being held responsible for the death of a Chula Vista woman he operated on recently.
According to family members, 48-year-old Lourdes Trinidad underwent a liposuction procedure performed by Dr. Louis May Villanueva of Bonita.
Family members said Trinidad was a healthy and active pharmacy technician who opted for liposuction and went to May's Millennium Cosmetic and Laser Institute in Tijuana for the procedure.
"The doctor assured her it was real simple, it was a real simple procedure," said Trinidad's brother, Sergio Salazar.
It ended up becoming a deadly procedure, although Trinidad's family has yet to receive a good explanation as to why it turned out that way.
"We're just shocked and we're amazed that a doctor like that could just leave, could leave her there by herself," said Trinidad's brother, Bernard.
Trinidad's mother is warning others, not just because of her daughter's death, but what happened after. The family said May disappeared.
"He was nowhere to be found ... The doctor was gone," said Salazar.
The family said after Trinidad's accounts were frozen when she died Saturday, May still wanted his $2,000.
"On Monday, we get a call from the bank that said he tried to cash it. He had the nerve to try to cash the check that killed her," said Bernard Trinidad.
10News visited May's Bonita home for his version of events, but he was not there.
May said he is a member of the American Academy of Cosmetic Surgery, but 10News learned from academy officials that he is not a member.
Additionally, May also claims membership in the American College of Phlebology, but any member of the public who wants to learn about leg veins is allowed to join.
"We don't want any money from him. We want to stop him from doing this again to someone else," said Bernard Trinidad.
Trinidad's family will bury her Thursday, and they continue to question whether it was a complication or incompetence that led to her death.
10News contacted May's clinic and they said they did not have any information right now.
10news also contacted the Ministry of Health in Tijuana to determine if May is fully licensed, but there has been no response.

Please beware of plastic surgery in Mexico.  While there are many excellent physicians south of the border, it can be very difficult for an American to vet the qualifications of her Mexican doctor.  Even when tragedy doesn't strike, standard "botch jobs" end up costing the patient much more than she would have saved had she seen a Board Certified Plastic Surgeon in the USA.  Make wise choices.


February 20, 2010

A Full Tummy Tuck (With or Without Circumferential Extension) Will Best Correct the Upper Belly and Bellybutton

I've lost 100 lbs. after having a Lap Band put in nearly 4 years ago.  My stomach issues are very unique looking, which is why I'm having the difficulty in determining what procedure I need.  My unwanted fat and loose skin are mainly only above the bellybutton, like they're sitting on a shelf.  I am unsure of which procedure would benefit me the most among simple liposuction, a modified Tummy Tuck, a full Tummy Tuck, or extended.  I'm open to any other suggestions as well.  I believe my skin has shrunk back as much as it can already.  Thoughts?


First and foremost, congratulations on your weight loss!  What a wonderful transformation. In addition to your improved health, your figure already looks terrific.

Second, even though you might think that your tummy has "unique" issues, nothing could be further from reality. I see at least one patient per week whose tummy looks like yours.

Third, go for a full tummy tuck.

  • After 4 years, your skin is not going to shrink on its own any farther--no matter how much exercise you do.
  • Liposuction will not be helpful to treat the upper tummy (called the epigastrium) and bellybutton. Since liposuction is a fat removal technique (without any significant skin tightening), liposuction is the wrong answer.  You are already skinny!  The problem is too much skin without good tone, not excess fat.
  • Mini tummy tucks are nonsense operations. I have never found the right patient for a mini tummy tuck--even after 8 years of practice!  A mini tummy tuck is for that very rare patient whose problem area is limited to her lower middle abdomen, just above her pubis.  Obviously, this is not where you are concerned.
  • A standard tummy tuck will work.  To minimize "dog ear" formation on the bilateral hips, weight-loss patients generally get their best results when the tummy tuck is extended all the way around circumferentially.  Whether you choose to keep the surgery just in the front or all the way around will be your decision.  Both are good choices, but the circumferential technique generally produces better contours.
  • Do not do a fleur-di-lis abdominoplasty.  The vertical portion of the scar is ugly, and the operation is now recognized as obsolete.  If any doctor offers you this surgery, run away!  He is out of date!!

Fourth, make sure that your lap band port is exchanged from a high-profile to a low-profile.  Now that you are thin, the low-profile port will be less visible.  You don't need that extra prominence to find the port anyway; you've got no subcutaneous fat.  (Congratulations again!)

Fifth, make sure that your surgeon is certified by the American Board of Plastic Surgery.  And, better yet, research whether he specializes in weight-loss patients.  I do a lot of post-bariatric contouring, and let me tell you that weight-loss patients are very different from "regular" plastic surgery patients.  Your surgeon needs the expertise only garnered from years of experience with your peer group.

Good luck!


January 15, 2010

Tissue Glue Rather Than Drains (?!)

There is an old surgical adage:

If a surgeon thinks that the patient might benefit from a drain, he should put it in.  A surgeon never regrets placing a drain.

Patients, however, hate drains.  They are a post-operative nuisance.  Most patients grudgingly accept drains because they minimize fluid collections (called seromata) and infections.

Since drains are so uncomfortable, there have been a number of products and techniques developed to obviate the need for drains....

  • Quilting sutures beneath tissue flaps to minimize "dead space"
  • Tissue glues

Biological tissues glues are particularly exciting because they are quick, effective, and precise.  Unfortunately, there have been no specific research studies which have rigorously documented the safety and efficacy of biological glues for plastic surgery.  A study published in Plastic and Reconstructive Surgery in 2008 proved the success of tissue glues in a canine abdominoplasty ("tummy tuck") model; however, dog and human tissues do respond differently, and the results of an animal model can not necessarily be generalized to human beings.

To investigate human plastic surgery patients' response to biological glues, Cohera Medical, Inc., has just enrolled its first few patients in a study of its TissuGlu.  The clinical investigation is a prospective, open-label, randomized study to investigate the safety of TissuGlu, its effect on wound drainage, and its relationship to complications.  The study will compare 40 abdominoplasty patients in Bonn, Frankfurt, and Freiburg, Germany, who will undergo...

standard wound closure techniques versus

standard wound closure techniques plus the application of TissuGlu

Currently, patients who undergo abdominoplasties require the insertion of one or more drains to remove fluids that accumulate under the skin at the surgical site.  (The old surgical adage remains true in tummy tucks!)  However, TissuGlu will hopefully adhere the flaps created during the procedure to reduce fluid accumulation, and, ultimately, the duration of use of surgical drains.  With the use of TissuGlu, patients may experience a reduction in fluid accumulation, a more comfortable recovery, and a quicker return to normal activity.

If the European trial goes favorably, Cohera will apply for a larger U.S.-based trial later this year.  Let's say our prayers that TissuGlu works!...


December 30, 2009

ATX-101: FDA Approval for Dissolving Fat (?!)

Maybe, I shouldn't have been so quick to disparage injection lipolysis.  Kythera Pharmaceutical's ATX-101 just might prove me wrong.

Back in November 2009, I called attention to the farce of injection lipolysis and mesotherapy, also known as...

  • LipoZap
  • Lipostabil
  • Flabjab
  • Lipomelt
  • Lipodissolve
  • Fat-Away

Mesotherapy, injection lipolysis, LipoZap, etc., involved injecting bile acids beneath the skin to melt fat--or at least that was the hope.  Compelling advertising enabled LipoZap centers to spring up throughout the United States and Europe.  As is so often the case, clever marketing preceded any clever science.  Without appropriate testing for safety and efficacy, many patients were swindled, and some were seriously harmed.

Enter Kythera Pharmaceuticals.  Led by executives and researchers from the established biotechnology industry (such as Amgen and Allergan), Kythera seems grounded in science and safety.  ATX-101 is Kythera's fat buster.  Preliminary trials have been completed for dissolving lipomas--benign fatty tumors, affecting 2% of the population, which can be painful and cosmetically displeasing.

The traditional treatment for lipomas has always been surgical excision.  However, surgery always entails risks, such as scarring, infection, damage to critical structures like nerves, etc.  The hope is that ATX-101 will significantly reduce the size or eliminate lipomas without the need for surgery.

If ATX-101 were to work on lipomas, then I don't see why it shouldn't work on those stubborn fat deposits that we have inherited from our parents.  Analogous to current lipoma treatments, stubborn fat is now removed with surgery--liposuction.  Wouldn't it be nice to sign up for a few injections rather than a surgical procedure (albeit a minor one)?


December 26, 2009

No Insurance Company Will Pay for a Tummy Tuck

I have a PPO.  How can I get my insurance company to pay for a tummy tuck?  Or will I have to pay for it out of pocket?

-Andy in Ventura, California

Dear Andy,

I think that you are confusing 2 separate procedures:

  • panniculectomy
  • abdominoplasty

A panniculectomy is a functional procedure for removing excess skin and fat.  An insurance company MAY authorize a panniculectomy if...

  • The apron of excess abdominal skin impedes walking.
  • The apron of excess abdominal skin impedes normal groin hygiene.
  • There are recalcitrant fungal infections beneath the skin folds.
  • The fungal infections have progressed to bacterial infections, necessitating hospitalization and IV antibiotics.

A panniculectomy is NOT an attractive operation.  The goal is function, not cosmesis.

  • There is no tailoring of the skin excess.
  • There is no liposuction to contour the flanks.
  • The bellybutton is not preserved.
  • The muscles are not tightened.
  • The abdomen is not optimally flattened.

If your goals are functional, then you should consider a panniculectomy.  Find a Board Certified Plastic Surgeon who accepts your insurance, and then speak with him/her frankly.

If, however, your goals are to have a more attractive torso, then you are looking for an abdominoplasty, better known as a tummy tuck.  An abdominoplasty will take care of everything that a panniculectomy will, but it will also do more....

  • The extra skin and fat (that creates the "apron" and/or the "roll") will be removed.
  • The skin will be pulled taut, and will be tailored to your frame.
  • The bellybutton is reconstructed and rejuvenated.
  • The "six-pack" muscles are tightened.
  • The abdomen is flattened.
  • Often, some liposuction is done on the flanks to optimize the waist.

Obviously, no insurance company is going to pay for you to look cuter.  Medical insurance is supposed to help defray medical expenses.  An unattractive belly is not a medical problem; it is an aesthetic issue.  So, an abdominoplasty would be your financial responsibility.

There is one more caveat:  Sometimes, a patient suffers medical problems from an abdominal "apron."  Moreover, he/she wants not only functional relief but also aesthetic improvement.  In this circumstance, the surgeon can help the patient obtain authorization for a panniculectomy.  The patient might then pay the difference for a full tummy tuck.  In effect, the patient is getting the best of both worlds:  functional improvement (covered by the insurance company) and cosmetic enhancement.  Check out this example below...





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