Friday, May 21, 2010

Relocating Those Lady Lumps ? We're Not Ready To Transfer Fat To The Breast.

Imagine it, fuller more rounded breasts without the hassle of breast implants. Being rid of unwanted fat around your tummy, waist and hips ! Why not !? The idea of transferring fat to other body areas is nothing new in plastic surgery, and it has been done for years.

But there has been hesitancy amongst plastic surgeons to adapt this technique to the breast, where fat grafts may interfere with mammography or even falsify the diagnosis of cancer. Enter the non-plastic surgeons.

I know of at least two physicians (neither of them board-certified plastic surgeons) who are transferring patients' own fat from the abdomen, hips, and thighs to create a fuller breast.

On the surface, this sounds great. And it may even look great. But it's beneath the surface where the real trouble may lie. A natural and expected part of fat transfer is loss of the fat cells. These cells are very fragile, and up to 60% of them do not survive. What happens to them next after they die is a not-so-benign process called fat necrosis. The oil from the released fat cells undergoes a process called saponification (those of you who remember science class remember that soap was made this way on Sapo Hill back in ancient times, hence the name !) This involves deposition of tiny flecks of calcium, which show up on mammograms.

This process results in changes that may be felt by the patient, but are definitely seen on a mammogram. The key here is the word "spectrum" because the calcifications sometimes have a very benign appearance, but other times may closely resemble breast cancer.

Let me quote a few lines from some recent scientific articles on that particular point (the links are below for those of you who want to read more):

"Although fat necrosis may mimic various manifestations of breast malignancy, needle localized biopsy and core biopsy have demonstrated this finding in only 1.9% and 2.5% of cases"

"The mammographic spectrum of fat necrosis ranges from clearly benign to indeterminate to malignant appearing masses or calcifications."

"Five cases are presented which illustrate the spectrum of mammographic features of traumatic fat necrosis. The appearances vary from one indistinguishable from carcinoma to
single or multiple lipid-filled cysts with or without calcified

So what this means is that fat necrosis, an expected outcome of fat grafting, can produce a whole host of changes in the breast. These are unpredictable and capricious, and mimic the nature of the fat grafting procedure itself. In the buttock, where fat transfer is frequently done, this is no problem. We have no buttock cancer epidemic in the U.S. and 1 in 9 women will not be affected by it like breast cancer.

Often, a biopsy will be recommended to sort the problem out. During that time, there will obviously be confusion, concern, and anxiety for all involved.

Finding out if fat transfer is safe in the breast will require that doctors enroll large numbers of patients in a research study, and follow their mammograms carefully for a number of years. Only then can we learn how prevalent fat necrosis actually is, what it looks like, and how best to treat it. To my knowledge, the practitioners advocating fat grafting at this time sadly have no intention of doing so.

Ultimately, stem cell techniques will allow a "cleaner" way to grow and manipulate tissues of the human body, including the breast. When that time comes, replacement tissues will be available to trauma and cancer patients, as well as those seeking cosmetic enhancement. Look for plastic surgeons to lead the way.


Sunday, March 21, 2010

A Knife's View on Health Care Reform

I expect the Health Care and Education Affordability Reconciliation Act of 2010 to pass the House very soon, with barely a vote to spare. Maybe even tonight. I have been involved in the debate, writing letters and the like for the good part of a year, even though my friends and family are probably sick of it.

This is because the legislation affects so many aspects of my personal and professional life.

As A Texan, I live in the MOST uninsured state of the Union. We also have 1.5 million children without insurance. During my days as an orderly at Parkland Hospital's emergency room, I was astounded at the entire "Third World" that existed in the heart of Dallas at the time. For a white kid from the 'burbs working down there, it was a real eye-opener. So I am for anything to change and improve the dismal state of health care for the poor. Congressman Henry Cuellar, who represents the most uninsured districts in Texas, has come out in support of the bill because his constituents need it. I applaud his efforts and wish all of our representatives would vote according to what their constituents want !

Those of us who complain about overcrowding in the emergency rooms and rising insurance premiums need to consider that uninsured visits for non-emergency problems cause huge problems. We all pay for that with longer ER wait times, insanely inflated hospital bills, and higher insurance premiums. Just like how auto insurance works for all drivers, so should health insurance for all citizens, provided everyone is required to have it.

As a Physician, my patients and I are frustrated with the paperwork, delay, and denials of the insurance companies. On many occasions, I have held a letter of approval for surgery in one hand, and a payment denial after surgery in the other. My only recourse was to go through a long appeal process or bill the patient, which I have rarely, if ever, have done.

I want a system that clearly states what is covered for my patients and then promptly reimburses physicians fairly, given our long educational commitments and high overhead.

I am saddened that the Congress cannot do anything except delay for a month at a time the planned 22% cut in physician payments under Medicare. If they want to increases access for patients, this must be fixed. New doctors will not accept Medicare patients, and existing ones may well opt-out of Medicare if this pay cut stands.

I also want a system that does not leave me open to a lawsuit even if the standards of care were clearly met, and one that makes me immune from lawsuits when doing charity work or rendering emergency care. How about arbitration panels that avoid the expense and pain of a long, drawn-out lawsuit ? The current bill sadly falls short on those goals, which would save money according to the Congressional Budget Office.

When similar reforms were enacted here in Texas several years ago, we had an immediate influx of new doctors who wanted to practice here. Thousands of them, in fact. Hospitals saved millions in liability costs, and several opened new community clinics. Lawsuit reform helps patients, lowers costs, and lets doctors do their job without practicing "defensive medicine." Remember my blog about the millions of CT scans that are done yearly, and how many people (23,000 per year) will develop cancers a result ?

As a surgeon, I use the latest drugs and have access to the best technology. During my plastic surgery training, I played a small part in developing AlloDerm, a skin substitute for burn victims. It now helps patients with at least a dozen other health conditions, including breast cancer and burns. That company lost money for years, and I knew how expensive it was for them to keep operating. Yes, those companies may make out sized profits in many cases, but as long as the U.S. continues to lead the way in researching and developing new medicines and devices, I say leave them alone. I am outraged at the mega-billions the banks wasted in their investment scams that put us in this financial crises, but am unaware of a similar crisis in the drug or medical device manufacturing realm.

As a small-business owner, the bill is a no-brainer for me. I have 6 employees, some with pre-existing conditions, and I want fair and complete coverage for all of them. Period. I want to be able to "shop" plans as part of an insurance co-op so they can have a true choice between plans. For years, we have been limited in our choices to 2 or 3 plans only.

As a head of household and taxpayer, I like the idea of my kids being covered until age 26. I would like being able to compare plans with more freedom, across state lines, and end the essential monopoly of the insurers. Yes, I may be in a tax bracket that will cause my taxes to go up, including the taxes on any investments and losing some benefits from my charitable donations, but I am willing to accept that.

The nation is truly divided on health care reform, and a look at our own Congress men's votes here in Texas reflect that. The House phones lines were getting 100,000 calls an hour ! Americans have a dismal job-approval rating for Congress (like 20%.)

I personally have developed a distaste for the way our President has obsessively made this a "too big to fail" issue for his administration, instead of focusing on jobs like he promised in his State of the Union Address. The current system is broken, and it's getting worse. I would have preferred a more step-by step approach to reform instead of this giant pill we are supposed to swallow. But it's time to fix this broken car before it breaks down on the side of the road, leaving us all in an even bigger mess.

After that, those in Congress who voted against the will of their constituents can go back home and face the music.

Wednesday, February 3, 2010

Doctor's Vs. Schwarzenegger In California Court? Yep.

Some call it a "turf war", others say Gov. Arnold Schwarzenegger ignored the law when he decided to allow nurse anesthetists in California to work without a supervising physician last year. Whatever is being said, it's a mess. Several doctor's groups are now challenging the procedures used by the Governor in a lawsuit recently filed in the San Francisco Superior Court.

Those of you who are familiar with my practice know that I insist on one of two nurse anesthetists to do ALL of my cases. If you've watched us on Big Medicineon Discovery Health lately, you'll see why. Candy, the petite Asian lady behind the ether screen, is always there. And if you watch, you'll see that her eyes are always either on the monitor or on the patient. She defines the word vigilance.

You see, nurse anesthetists must have 2 years of critical care nursing before moving ahead with their nurse anesthetist training. Critical care nursing is hour after hour of bedside care. And I mean total care. I was once an orderly, and know what that means. We doctors waltz in and out of the room, but it's the nurses who truly care for the patient.

In the O.R., I appreciate and demand that the same approach be followed. Now, I'm not knocking my M.D. colleagues, and plenty of them are great. But for me, a nurse anesthetist is the way to go for cases.

But there are instances where the input of a crusty old physician is really welcomed. And it can even be lifesaving. Anesthesia can result in the need for one of several an emergency surgical procedures. A nurse would not be the best qualified to do that. And review of patients with complex medical problems is also something I feel is best left to an experienced physician.

It's painfully easy to see why they are going this route in California, and that is because there will be a cost savings. Sadly, it will come at the expense of patient safety.

To suggest that this is some kind of "turf war" where greedy nurses want their cut, and doctor's are defending their fiscal territory is naive and unfair.

After all, doctor's have been working alongside nurses for a long time without any problems. I say we keep it that way.

Sunday, January 31, 2010

Medical Tourism is On The Rise

Angioplasty in Argentina ? A mastectomy in Malaysia ? Plastic surgery in Paraguay? Or a cosmetic cut-n-paste in Costa Rica ? You've probably already heard about it, but what you may not know is that in recent years, medical tourism has grown into a multi-billion dollar business. And more growth is expected.

According to an article published in 2005 from the University of Delaware publication, UDaily:

"A heart-valve replacement that would cost $200,000 or more in the US, for example, goes for $10,000 in India--and that includes round-trip airfare and a brief vacation package.

Similarly, a metal-free dental bridge worth $5,500 in the US costs $500 in India, a knee replacement in Thailand with six days of physical therapy costs about one-fifth of what it would in the States

Lasik eye surgery worth $3,700 in the US is available in many other countries for only $730."

An estimated 750,000 Americans went abroad for health care in 2007 and consulting firm Deloitte published a report in 2008 that projected a tenfold increase in medical tourism over the next decade. The growth in medical tourism results in billions of dollars in savings to patients, and in even more in lost revenue to U.S. health providers.

Overseas surgery costs less, but why ? For one, there is a more favorable malpractice system in many countries, plus a lower cost of building, staffing, and maintaining facilities. Overseas hospitals and surgeons are also not burdened by insurance paperwork and billing because their patients typically pay cash up-front. Follow-up care, which consumes a large amount of a doctor's time, is also virtually non-existent.

Medical tourism is not without it's risks and pitfalls, however.

Patients travelling are often recruited or channelled trough a "booking agency" that receives payment for the referrals. This bypasses the usual doctor's referral and recommendation process, and patient's are largely left to word-of-mouth recommendations or the internet. Both of these processes can be influenced at various levels, and are generally a poor substitute for physician-to-physician referral.

Checking credentials on doctors and facilities in various countries is often difficult, as there is no standard that is uniformly accepted. Board-certification, for example, requires continuing medical education in the U.S. and in fact is a law to maintain licensure in all states. This varies widely in other countries.

Patients also do not enjoy the same degree of consumer protection due to the lack of an aggressive malpractice system in most other countries.

In the U.S., the Joint Commission is an independent, not-for-profit organization that develops nationally recognized standards to improve patient care and safety. They work with hospitals to help them meet standards for patient care, and then accredit those hospitals who achieve those standards.

Joint Commission Internationalis a relative of the Joint Commission in the United States that has been accrediting hospitals since 1999. Overseas institutions, mindful that American consumers value accreditation, are increasingly looking towards this international accreditation. Competition between overseas hospitals for American medical tourists will likely result in a move towards accreditation.

Unfortunately, in the plastic surgery arena, where most surgery is done in clinics, there are no international regulatory agencies in place. The highly publicized deaths of celebrities such as Donda West and Argentinian beauty queen Solange Magnano have heightened public awareness about the safety of plastic surgery procedures being done in clinics without adequate personnel and equipment for aftercare.

Likewise, the media is replete with patients who have returned from plastic surgery overseas with complications or unfavorable results. Finding care domestically is difficult or impossible for these individuals. Plastic surgery complications, usually minor, are a simple fact of life. But their treatment and outcome vary significantly, depending on whether they occur at home or abroad. Dr Jospeh Capella, a pioneer in post-weight loss plastic surgery, reported a complication rate of 50% after large procedures such as body lift, whereas Dr. Dennis Hurwitz, founder of the total body lift procedure, reposted a complication rate of 76%.

Medical devices used overseas also vary in terms of their quality warranty support. Breast implants placed outside of the U.S. by either of the 2
major manufacturers are not warrantied in the U.S. Replacement surgery, if needed due to rupture or leak, must be done in the country of origin.

Capella JF. Body Lift Clin Plast Surg. 2008 Jan;35(1):27-51.

Hurwitz DJ, Agha-Mohammadi S, Ota K, Unadkat J. A clinical review of total body lift surgery. Aesthet Surg J.2008 May-Jun;28(3):294-303; discussion 304-5.

Saturday, January 30, 2010

Obesity is Unhealthy : For Reasons You Might Not Think

A recent report on revealed an unpleasant truth in medicine, but one I've known about for years. It's shocking, but it's true: Being a woman who's more than 20pounds overweight may actually hike your risk of getting poor medical treatment. In fact, weighing too much can have surprising -- and devastating -- health repercussions beyond the usual diabetes and heart-health concerns you've heard about for years.

According ther the article, studies have found that if you are an overweight woman you:

• May have a harder time getting health insurance or have to pay higher premiums

• Are at higher risk of being misdiagnosed
• Are less likely to find a fertility doctor who will help you get pregnant

• Are less likely to have cancer detected early

Fat discrimination or obesity bias is part of the problem. A recent Yale study suggested that this bias can start when a woman is as little as 13 pounds over her highest healthy weight.

Our culture has enormous negativity toward overweight people, and doctors aren't immune. Dr. Jerome Groopman, a Harvard Medical School professor and author states "Our culture has enormous negativity toward overweight people, and doctors aren't immune," He is author of a book called "How Doctors Think." "If doctors have negative feelings toward patients, they're more dismissive, they're less patient, and it can cloud their judgment, making them prone to diagnostic errors."

With nearly 70 million American women who are considered overweight, the implications of this new information is disturbing.

When Jen Seelaus, from Danbury, Connecticut, went to her doc's office because she was wheezing, she expected to get her asthma medication tweaked. Instead, she was told she'd feel better if she'd just lose some weight. "I didn't go to be lectured about my weight. I was there because I couldn't breathe," says the 5-foot-3, 195-pound woman. "Asthma can be dangerous if it gets out of control, and the nurse practitioner totally ignored that because of my weight."

Seelaus's nurse made a classic diagnostic error, according to Groopman. "It's called attribution, because your thinking is colored by a stereotype and you attribute the entire clinical picture to that stereo­type. Because obesity can cause so many health problems, it's very easy to blame a variety of complaints, from knee pain to breathing troubles, on a patient's weight. That's why doctors -- and patients -- need to constantly ask, 'What else could this be?' "

There aren't statistics on how many diagnostic errors are due to weight, but the data for the general population is disturbing enough. Researchers at Rice University and the University of Texas School of Public Health in Houston found that as patient BMI increased, doctors reported liking their jobs less and having less patience and desire to help the patient.

Whether they know it or not, doctors' attitudes may actually encourage unhealthy behavior.

Feeling dissed about their weight can make some women turn to food for comfort. "Stigma is a form of stress, and many obese women cope by eating or refusing to diet," Puhl says. "So weight bias could actually fuel obesity."

Studies have also found that overweight women are more likely to delay doctors' appointments and preventive care, including screenings for cancer, because they don't want to face criticism. "It can be frustrating to treat obese patients," admits Dr. Lee Green, M.D., M.P.H., a professor of family medicine at the University of Michigan in Ann Arbor. "I spend most of my time treating the consequences of unhealthy lifestyles instead of actual illnesses.

Tuesday, January 26, 2010

Stem Cells Will Benefit All Aspects of Plastic Surgery

Grow your own breast implants ? Replace a broken bone or a clouded cornea ?Having your very own custom-grown tissues available "off the shelf" in case of damage or disease will happen to some degree in our liftetimes.

Researchers have already shown how cosmetic surgery might be improved with natural implants that keep their original size and shape better than synthetics.

Natural tissues, instead of synthetic implants, would also allow easier breast reconstruction after breast cancer, or soft tissue replacement following cancer or trauma surgeries.

Cells needed for the implant can be obtained by a simple needle stick, compard to the dramatic transfers of tissues from other parts of the body, which are currently the norm. The other option is tissue from cadavers, such as the recent and much-publicized face and hand transplants.

These procedures, however, require that patients take a lifetime of powerful drugs to suppress the immune system.

Interestingly, the best source of stem cells is plain old fat. As in the stuff I remove during liposuction. Maybe we shouldn't be so quick to throw it all away !

New York Wants To Take My Drug Rep Sandwich

According to a recent issue WSJ blog, Governor David Paterson of New York wants to join Massachusetts and Vermont in limiting the ties between drug companies and doctors.

Paterson’s proposal is less restrictive than some. It would still allow drug reps to bring lunch to doctors’ offices, for example, though it would ban taking docs or their staff out to a restaurant. Gifts “such as floral arrangements, artwork, compact discs or tickets to a sporting event” would also be prohibited.

The proposal also regulates consulting relationships between doctors and drug companies, and more importantly, industry funding of continuing medical education.

Health-care professionals could be fined $5,000 to $10,000 for violations !

I am certainly against the influence wielded by big pharma and the medical device companies, but I don't think a drug rep bringing pens and lunch to a doctor's office is the root of the problem. Patterson's misdirected priorities, by the way, are also leading New York to consider tax sodas. Because they cause obesity. Right.

Has anybody considered the $38 million spent by the insurance lobby to influence lawmakers as part of the problem ? Or an equal amount of time and money spent by big pharma to buy face time with lawmakers on Capitol Hill ? These are the real problem when it comes to industry influence. Always has been.

To be sure, I think that doctors who are on the payroll of the companies (usually to the tune of $100,000/year) for their cheerleading tours to promote drugs need to decide whose team they are on. Those arrangements need to be targeted for reform.

So before they vote to ban my staff from getting a few notepads and Subway sandwiches, maybe lawmakers should look at where the real problem lies.'s not in my turkey and's that lobbyist waiting outside your door.