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.


April 21, 2011

6 International Consensus Statements on Plastic Surgery Controversies

The International Confederation for Plastic, Reconstructive, & Aesthetic Surgery (IQUAM) recently published consensus statement regarding controversies in plastic surgery.  I thought that my readers might find this list interesting...

  • Multiple "medical studies have not demonstrated any association between silicone-gel filled breast implants and carcinoma or any metabolic, immune, or allergic disorder."

Translation:  Silicone breast implants are safe.  They do not cause breast cancer.  They do not cause lupus, rheumatoid arthritis, psoriasis, etc.

  • "Silicone-gel filled breast implants do not adversely affect pregnancy, fetal development, breast-feeding or the health of breast-fed children."

Translation:  If you have had silicone implants, feel free to breast feed your babies.

  • "Phosphatidylcholine has been used for prevention and treatment of fat embolism for many years, but it is currently being used 'off label' for dissolving fat in aesthetic applications.  Data concerning the efficacy, outcome, and the safety of its use for aesthetic indications in subcutaneous tissue have not yet been established. Further basic science and clinical trials are needed."

Translation:  "Lipodissolve" and "LipoZap" injections have not been shown to be either effective or safe.  While I know that everybody wouldn't mind getting rid of a "love handle" or two, don't submit to any unproven injection technique.  Liposuction remains the gold standard.

  • "Botulinum toxins (BTxA's) have been used extensively for aesthetic purposes. BTxA's in high dosages have been used in various therapeutic clinical applications with minimal reported significant adverse effects. Current clinical data confirm the safety of BTxA’s for aesthetic indications when used by experienced doctors under sterile office environment. Patients should be provided with detailed information, and a signed informed consent should be obtained prior to performing the procedure."

Translation:  Botox and Dysport kick ass!

  • Regarding injectable fillers...  "Today, more than 35% of the procedures performed by plastic surgeons are no longer purely surgical.  The use of resorbable substances is preferable to the use of nonresorbable fillers, as recommended by many national health authorities or academic societies....Permanent fillers (excluding autogenous tissue) can give a definitive correction, but have been reported to be associated with long-term, irreversible complications and should be used with extreme caution."

Translation:  Fillers are increasingly popular.  Choose one of the common resorbable fillers (such as Restylane, Juvederm, and Radiesse) rather than a permanent filler (such as Artefill or liquid silicone) because the temporary fillers are safer.

  • "IQUAM urges governments to pass legislation to prohibit the use of non-certified products and to protect patients from untrained physicians and nonmedical personnel injecting or implanting materials for various indications."

Translation:  Board Certified Plastic Surgeons wish that patients were protected from poorly trained injectors.  However, there are few laws that limit the practices of doctors and nurses, many of whom suck.  Make sure that your injector is certified by an appropriate specialty board.

(By the way, the only board recognized by the American Board of Medical Specialties to certify phyisicians in the practice of plastic surgery is the American Board of Plastic Surgery.)


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 27, 2010

The Vampire Facelift - More Nonsense

Dubbed the "Vampire Facelift" by the news media, the Selphyl System is a technique marketed as increasing the volume of the face.

  • A sample of blood is drawn from the patient.
  • It is placed into a centrifuge to separate the liquid from the cells and proteins.
  • Then, the platelets, fibrin, and growth factors are reinjected into the face in areas that are particularly hollow.

The treatment is performed in the office, similar to fat grafting and Sculptra.

  • Like fat transfer, the Selphyl System employs your own tissue.  Unlike fat grafting, however, drawing blood itself involves little morbidity (while harvesting fat from your tummy or hips via liposuction can really hurt!)
  • Like Sculptra, the Selphyl System entails minimal downtime.  Frankly, both are pretty easy for the patient; expect to return to work that afternoon or the next day.  The big difference between the Vampire Facelift and Sculptra is that Sculptra is an off-the-shelf product rather than an autogenous technique.  Sculptra is not your own tissue.

Are you thinking, "Sign me up!  I wouldn't mind looking as young as Robert Pattinson"?

The problem with the Vampire Facelift is that there is little to no proof that it actually works.  While fat grafting and Sculptra have been extensively studied, the Selphyl System has been heavily advertised but poorly researched!  The photos on the web site might look great, but I have yet to read a single, high-quality, scientific analysis proving the efficacy of the Selphyl System.

Until I seem some proof, I am going to continue to recommend...

  • Sculptra for in-office facial filling
  • fat grafting for filling in the operating room

And, oh yeah, to look young, stay out of the sun.  The vampires have got that right.


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!


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)?


October 27, 2009

Why Am I Gaining Weight After Liposuction?

I had liposuction of my tummy about a year ago.  My doctor removed 2000 cc.  I didn't lose weight, but I looked good.  But, now, my love handles are growing.  I have a muffin top, and I am up 5 pounds.  What gives?  I thought that I wasn't supposed to gain weight after lipo.  Isn't there some kind of guarantee?

- Heather C., from Oxnard, California

Heather, let's reeducate you about liposuction...

Myth #1:  Liposuction is great for weight loss.

Liposuction is not a good weight loss technique.  Most patients usually lose just 1-2 pounds after liposuction.

Liposuction removes stubborn fat deposits and thereby improves a patient's contours.  Ideal liposuction patients are already at their ideal weights; they just can't lose those darn saddle bags, or tummy pooch, or chin fat, or whatever.

Heather, I am therefore not surprised that you didn't lose much (if any) weight after liposuction.  This is typical.  However, you did get what a good liposuction procedure should provide:  a better appearance and more confidence.

Myth #2:  After liposuction, I won't ever gain weight again.

Liposuction cannot change the future!  If a liposuction patient ingests more calories than she burns, then she will gain weight.  If she wants to lose weight, she should either eat less or exercise more (or better yet, both).

Liposuction removes fat cells.  They are gone and will never come back.  However, if a patient ingests more calories than she burns, then her body will deposit fat somewhere.  It's just less likely to be stored in the liposuctioned area than somewhere else.

Heather, your 5 pounds are being stored preferentially in areas that were not liposuctioned.  Since your tummy was treated, the weight is going elsewhere--to your flanks and hips.  Hence, you have developed love handles and a "muffin top."

If you lose those 5 pounds, I bet that you'll get back your old post-op "look."

Myth #3:  Plastic surgeons can and should guarantee their work.

Plastic surgeons can't, in good faith, ever guarantee their work.  There are too many variables.  Biological systems (i.e., human bodies) are far too complex for any person to perfectly control in all instances.  Abnormal healing, infections, and other acts of God can mar the results of the best surgeons.  Patients themselves overindulge in sweets, forget to exercise, forget to follow post-operative instructions, etc.  And, yes, even superstar surgeons have bad days; Michael Jordan didn't dominate every basketball game.

Rather than a guarantee, Heather, your surgeon should have offered you a frank discussion about liposuction, including all the risks.  In my pre-operative conversations, I always inform patients that weight gain after liposuction can detract from the final result.

I hope that this helps, Heather.  Try to lose those 5 pounds; skip desserts and increase your exercise regimen.  Then, recheck your figure.  You'll probably look great again...without the muffin top!


October 19, 2009

Patient Dies in Florida After Liposuction...Performed by an Occupational Medicine Specialist

Awful stories of bad plastic surgery outcomes abound on the internet.  Unfortunately, there is a common theme:  The plastic surgery is often NOT performed by plastic surgeons.

Rohie Kah-Orukotan, who was herself a nurse, died after liposuction surgery on September 25, 2009, in Broward County, Florida.  The operation had been performed in a medical spa by Dr. Omar J. Brito Marin, an occupational medicine specialist, who had taken a three-day course on cosmetic surgery procedures.


This case nearly brings me to tears.  Not only is she an attractive young lady with a bright future, but the circumstances surrounding her death are unsafe and bizarre.

  • Her physician is an occupational medicine specialist.
    • What the heck is that?!  I have been a physician for 13 years, and I don't even know what an occupational medicine specialist is.
    • Everyone should know what a real plastic surgeon is--a physician who has been certified by the American Board of Plastic Surgery
    • How could a nurse not know the difference? 
  • He took a three-day course on cosmetic surgery.
    • I spent close to seven years in surgical training after four years of medical school
    • How could a nurse not know that a three-day course over a long weekend is not adequate?
    • Couldn't she have found a Board Certified Plastic Surgeon with years of training?
  • The surgery was performed in a medical spa.
    • Liposuction is real surgery.  It should be performed in a real operating room!
    • Safety equipment and appropriate monitoring is essential to ensure good outcomes.
    • Board Certified Plastic Surgeon are required to use accredited facilities.  No occupational medicine specialist would even be let in the door to a certified facility.
    • How could a nurse not know that it is unsafe to have surgery in a spa where people usually just get massages?
  • Apparently, the liposuction was performed with carboxytherapy, which supposedly reduces stretch marks and cellulite.
    • How could a nurse fail to know that she was being duped with a gimmicky procedure?

This case teaches me that even professionals can be tricked.  If a nurse can be convinced to undergo gimmicky liposuction in the back room of a spa by a non-surgeon after he trained over a long-weekend, then the lay public is in deep trouble.


October 06, 2009

Water-Jet Assisted Liposuction: Breakthrough or Gimmick?

More than in any other surgical technique, liposuction technology is marketed directly to consumers with little (to no) scientific evidence.  Some background...

  • Standard suction assisted lipectomy employs a strong vacuum to remove stubborn fat deposits.
  • Most surgeons add tumescent fluid to numb the surgical area and to constrict blood vessels (and thereby minimize bleeding).
  • Power assisted liposuction involves a vibrating handle to minimize surgeon effort when removing the fat.
  • Ultrasonic assisted liposuction uses ultrasonic energy to melt the fat before it is sucked out.
  • Laser assisted liposuction uses a laser for melting fat before it is vacuumed out.
  • Water-jet assisted liposuction supposedly limits intra-operative tissue distortion caused by the tumescent anesthetic fluid.

If all you knew about plastic surgery was learned from daytime television, then you would think that plastic surgeons perform liposuction...

  • in their offices
  • under local anesthesia--with tumescent fluid alone
  • employing lasers to melt the fat
  • water jets to minimize distortion

The truth is much less sexy.  The vast majority of Board Certified Plastic Surgeons prefer...

  • an accredited surgical facility rather than the back room of their office
  • heavy sedation--either "twilight sleep" or general anesthesia provided by an appropriately trained anesthetist
  • some quantity of tumescent fluid for additional comfort and to decrease bleeding
  • performing the actual liposuction with... standard techniques, power assisted devices, or ultrasonic machines

While I do like ultrasonic assisted liposuction (and I use the VASER system), as a Board Certified Plastic Surgeon, I have to admit that there are no good scientific studies documenting the superiority of ultrasound or laser-assisted liposuction relative to standard or power-assisted tumescent liposuction.

The water-jet is so new on the scene that there are exactly ZERO articles about it in the most prestigious plastic surgery publication Plastic & Reconstructive Surgery.  So, is water jet liposuction a breakthrough or gimmick?  I have absolutely no idea.

The best study on laser-assisted liposuction (from Chile, and published in Plastic & Reconstructive Surgery in 2006) demonstrated no major clinical differences between standard liposuction and laser assisted liposuction.  However, there were higher concentrations of free fat molecules floating in the blood of the laser patients, which alerts me to the possibility of potential damage to the liver, kidneys, or lungs.

So, truthfully, when patients ask me about laser and water-jet liposuction, I don't even know what to tell them.  In the past, I have mentioned the potential dangers of minimally tested technologies, and patients have actually become angry at me for my skepticism!  It's amazing to me that my caution turns people off.  Typically, patients express disbelief that lasers or water could be anything but positive.

The effects of marketing can obviously be pernicious.  It's incredible that the makers of these product have been able to convince the public of their products' efficacies before they have even convinced the surgical community!  Crazy!!


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