Skin Deep; Do My Knees Look Fat to You?

by Natasha Singer (NYTimes)

The following article which appeared in the NY Times June 16, 2006, is poignant and timely. Ms.Singer's recent articles bring much needed awareness to the public regarding the considerations one should take before undergoing plastic surgery and the necessary qualifications, or lack thereof, that one should look for in the individuals providing plastic surgery.

As a board certified plastic surgeon, my reaction to this amusing article is that there is real danger in non-surgeons performing liposuction. You would never go to a plastic surgeon to have your baby delivered so why would you think it is okay to visit an Ob-Gyn to have liposuction? Moreover, mere weekend courses that an Ob-Gyn may take to learn the procedure simple cannot compare or replace a 5-10 year surgical residency. Surgeons are taught not only surgical technique, but more importantly, what to do in case of an emergency or complication.

Anecdotal story time again... I would like to share a well known story from my time at NYU Medical Center and Bellevue Hospital that drives home that Liposuction can meet with disaster. These two facilities maeke up the foremost plastic surgery teaching center in the world--which drives the point home even more... because if it could happen there it could happen anywhere!

During a resident case at Bellevue a Chief Resident was taking a Junior Resident through a liposuction case. During the surgery the tumescent cannula (This cannula is used to put fluid in to reduce bruising and bleeding) was placed through the abdominal wall and perforated the stomach!!

Luckily enough an Anesthesiologist Resident was also training his subordinate and teaching the proper placement of a nasogastric tube(used to suction the contents of the stomach). Upon insertion they got back a large amount of clear fluid... very unusual for a patient that had been fasting for surgery. This fluid was sent to the lab and came back with lidocaine the key component of the tumescent solution!!

Needless to say, it was realized here what error had occurred and surgery was performed immediately to close the hole in the stomach.

What is the moral?

Very simple... how would a Gynecologist who took a weekend class on liposuction even know how to recognize or handle this life threatening situatioin? ... and let's be honest--how would a Dermatologist be able to deal with this?

It is my opinion that only people that come from general surgery backgrounds be allowed to perform liposuction in areas where the complications of such operations require immediate surgical diagnosis and intervention. This is a patient safety issue and not a quality of results issue. I am sure that there are plenty of non-surgeons that perform adequate liposuction and their patients are satisfied. But it is just not safe.

My Golden Standard for patients:

Make sure your doctor has operative privileges at a hospital to perform the procedure they are offering you in their office operating room. If they do not then DO NOT HAVE SURGERY WITH HIM OR HER. FIND SOMEONE ELSE!


Do My Knees Look Fat to You?

LOVE handles, saddlebags, turkey wattle. Self-conscious women have been trying to reduce those body areas for years. But now, with more efficient diets and fitness routines, women are turning to more obscure anatomical zones. The newest worries? "Bra fat" and "back fat."

Buff Enough? Not yet? Micro liposuction can take a few ounces off the knees.
"I had a little roll of fat hanging over the back of my jeans, like a spare bicycle tire in the back," said Dana Conte, a bartender in Manhattan. It was so obvious that her mother constantly came up behind her and pulled her shirt down over it, Ms. Conte said. "When your mother is doing that, it means there's a problem."
Ms. Conte, 34, says she has an hourglass figure that attracts whistles as she walks along the street. To get rid of the back fat, she tried working out — "like a lunatic," she said — five days a week. Then, she enrolled in Weight Watchers. When neither worked, she turned to plastic surgery.
Last August, she had liposuction on her lower back around her waistline, and in January, she had liposuction again, this time on her mid- and upper-back to eliminate "bra fat," bulges that can occur when "your bra pushes lumps of fat down your back and up over the bra fastening and to the sides right near your arms," Ms. Conte said.
The total fee for both procedures, $10,000, was well worth it, she said.
Last year, Americans had about 455,000 liposuction operations, making fat removal the most popular cosmetic surgery procedure, according to the American Society for Aesthetic Plastic Surgery. But in the last two to three years, liposuction, once used predominantly to reduce the flabby abdomens, hips and thighs of average Americans, has become a tool to enhance the near-perfect body parts of the already fit.
For this designer-body approach, an increasing number of doctors are using a technique known variously as precision, selective or micro liposuction. The goal is to remove an ounce or three of fat from ankles, knees, chins, necks, backs and upper arms, according to some prominent plastic surgeons and dermatologists.
"This is mostly for people who do not need much work done," said Dr. Luiz S. Toledo, a plastic surgeon in São Paulo, Brazil, who has taught the technique to American surgeons at their annual medical meetings. "It's liposuction for skinny people."
But some sociologists and medical ethicists say that using liposuction — which can cause complications ranging from infection to death — for such tweaks raises profound questions about the increasing risks cosmetic doctors and patients are willing to take in the name of perfection. They say these microprocedures may signal a shift in beauty standards in which people come to regard the body the way they do their cars or kitchens: as an object able to withstand never-ending renewal and modification.
And they worry that the idea of precision liposuction carries an inherent suggestion that everyone should have surgery, even those who are already beautiful.
"The goal posts are changing so rapidly that what was once considered cosmetically unnecessary is now considered helpful," said Victoria Pitts, an associate professor of sociology at the City University of New York, who teaches a course called Sociology of the Body. "As calves, ankles, knees and even genitalia become zones of perfectibility, we will feel more and more pressure to get involved in projects that improve them."
Dozens of experienced American doctors have been performing precision liposuction for more than a decade. But in the last two to three years, hundreds of other doctors have been adding it to their surgical repertory because it seems easier to perform than it used to be and because more patients are asking for it, said Dr. Peter B. Fodor, a plastic surgeon in Los Angeles.
"Because our equipment has gotten better, surgeons who a few years ago would not have touched areas like kneecaps, inner thighs, back rolls, calves and ankles have extended their practices," Dr. Fodor said.
New types of ultrasound machines, which can be used to break up fat before it is extracted, and daintier cannulae, the blunt-tipped hollow tubes used to dislodge and suck out fat, have made it easier for doctors to fine-tune liposuction, Dr. Fodor said.
During liposuction operations, doctors anesthetize patients, inject a numbing solution and suction fat cells out of the body with a tube inserted into incisions in the skin. Patients may be sore and bruised for several days to weeks afterward, but doctors say results are permanent on the treated areas as long as patients maintain stable weight.
Because removing too much fat can be risky, medical societies do not recommend liposuction for the morbidly obese. But it has been widely used to reduce bulges on the merely chubby.
And now, as it has grown more precise, liposuction is attracting a new clientele of body-conscious people who want to improve physiques already honed by diet and regular exercise.

"Some of them are perfect 10's who want to be 10½'s," said Dr. Howard D. Sobel, a dermatologist in Manhattan whose liposuction patients have included models and personal trainers. "These patients' 'before' pictures are what patients in the past wished their 'after' pictures looked like."
One of Dr. Sobel's patients is Judy Goss, a former Ford model who works as a model agent. "By normal standards, I'm pretty skinny," said Ms. Goss, 38. She is 5-foot-10 and weighs 126 pounds, she said. "But my arms were getting a little flappy. I could feel it wiggle every time I shook hands."
Two years ago Dr. Sobel performed liposuction on her upper arms.
Dr. Lawrence S. Reed, the plastic surgeon who operated on Ms. Conte, the bartender, said some patients who choose micro liposuction want to reduce such negligible deposits that doctors can have trouble seeing the problem when the patients are undressed.
To pinpoint the little lumps of fat, Dr. Reed, who is based in Manhattan, asks patients to wear their favorite jeans or bra right before surgery so he can mark the areas with a pen.
Patients have developed their own nicknames for these obscure fat deposits. To help doctors understand the exact locations their patients are describing, the journal Dermatologic Surgery recently published an article titled "Lexicon of Areas Amenable to Liposuction." According to the article, patients are now asking for liposuction of the "buffalo hump" (upper back), the "wings" (bulges around the bra area), the "doughnut" (around the belly button), the "banana fold" (below the buttocks), the "piano legs" (calves) and the "chubb."
"Chubb is a Southern term for the kneecap area," said one of the article's authors, Dr. William P. Coleman III, a clinical professor of dermatology at Tulane University School of Medicine in New Orleans. He has not yet heard a colloquialism for ankle fat.
Even though these miniprocedures sound superficial, sometimes marketed as "lunchtime liposuction" or "liposculpture," they can cause medical and aesthetic problems. Possible complications include infection, scarring and perforated intestines.
Liposuction can also result in death from an overdose of anesthesia or from a pulmonary embolism in which clots block blood vessels in the lungs, Dr. Toledo said. He put the death rate from liposuction at one in 5,000 procedures in an article this year that appeared in the journal Clinics in Plastic Surgery. (Not all doctors agree on the risks: a survey by the American Society for Aesthetic Plastic Surgery estimated the death rate to be one in about 47,000 procedures.)
Dr. Fodor said operations for "lesser corrections" are technically and aesthetically more challenging because the areas that are not so fatty require more experience and wider anatomical knowledge. Ankles have superficial nerves and arteries that can be damaged, he said. Fat on the back or kneecap is very fibrous and can be difficult to remove evenly. And kneecaps have sac-like cavities that can be easily traumatized, Dr. Fodor said.
Doctors are grappling over where to draw the line. Last week Dr. Toledo saw a patient who wanted to have liposuction of her pubic area.
"In Brazil, bikinis are very small, and she complained that a little bit of fat stuck out over her bikini," he said. Dr. Toledo refused to do the surgery. He said removing the fat might make sex painful for her. "Sometimes a change is so small that it is not worth the time, money and risk."
Some medical ethicists are concerned that medical societies have not established standards or guidelines for doctors on what kinds of micro liposuction are too minor to be worth the risk. "Today the cutoff point is the pubic area, and what about tomorrow?" said Sheila M. Rothman, a professor of sociomedical sciences at the Mailman School of Public Health of Columbia University.
But Rosamond Rhodes, the director of bioethics at Mount Sinai School of Medicine, does not see an ethical concern. "Humans have always been willing to invest time, energy and risk in looking attractive, so I don't see smaller liposuction procedures as a sign of doom, gloom and the downfall of our culture," she said. "It's just medicine being used to address problems that it could not address before."
Still, Dr. Rothman worries that these tiny procedures may create a demand for serial liposuction in which patients come to view surgery as a maintenance technique, like fitness.
"We already have a model for this with Botox and Restylane, where people go to their doctors every few months to get another shot whenever they feel like it," Dr. Rothman said. "Maybe liposuction will become like a gym membership where you pay a doctor $10,000 for the year and you can have as much surgery as you want."

Medical Tourism - Leaving the American Medical System is Like Gambling In Vegas With Your Life on The Pass Line

It is interesting that International Societies have started to crack down on unscupulous surgeons performing surgery for discount prices. Below you will find such an article. Let me first tell you a great anecdotal story of a flight attendant that met a plastic surgeon in Costa Rica who convinced her to have surgery. This woman had a pulmonary embolism ( a complication that can happen here as well ) but she was in a country that was not a world leader in healthcare and needed to be medivac'd by ambulance jet back to United States where she nearly died in an Intensive Care Unit at one of the finest hospitals in the country.

Now...

What is the moral of this story?

It is pretty obvious...

Back in the days when I was the chief at the famous Bellevue Hospital we had poor souls arrive half dead at JFK airport with a note that read "take me to Bellevue" and their charts in a neat folder...

The moral...

Their is no such thing as a bargain when it comes to your health... People die in surgery and plastic surgery is not exclusive. When you choose a plastic surgeon this is where you have control over this variable... people be careful...

You wouldn't gamble your life in Vegas... why would you do it in South America?

Guidelines for Plastic Surgery Tourists, Techniques and risks
New York:

The International Society of Aesthetic Plastic Surgery (ISAPS), representing nearly1,500 of the world's leading board certified aesthetic plastic surgeons in 73 countries has launched its new website with the publication of the first ever comprehensive international guidelines for consumers traveling for plastic surgery procedures - commonly referred to as Plastic Surgery Tourism. http://www.isaps.org/www.isaps.org
The ISAPS guidelines, in development for nearly one year, reflect a growing consumer trend and were created to address the thousands of inquiries ISAPS has received from consumers, medical professionals, media and governmental organizations.
Dr. Joao Carlos Sampaio Goes of Sao Paulo, Brazil, the current President of ISAPS, championed these breakthrough guidelines as well as the new ISAPS website. "Consumers around the world have looked to ISAPS for over 30 years for the most accurate and reliable information about qualified plastic surgeons and advice about up-to-the-minute procedures. Now, for the first time, there is a worldwide standard for consumers to reference when traveling for aesthetic plastic surgery."
The Guidelines were developed under the direction of American plastic surgeon, Dr. Malcolm Paul, Clinical Professor of Surgery, Aesthetic and Plastic Surgery Institute, University of California, Irvine. "These easy-to-understand recommendations are the absolute first stop before anyone should consider traveling from home for plastic surgery," noted Dr. Paul

The key guidelines for plastic surgery travelers, Techniques and risks
What is the surgeon's training?
A gynecologist performing a breast augmentation or a dermatologist doing a face lift are not an appropriate choices.
Is the plastic surgeon certified?
The ISAPS website lists the names and addresses of nearly 1,500 certified plastic surgeons in 73 countries.
Is the surgery center or clinic certified?
Ask for certification information and who the certifying body is.
Does your personal health insurance cover you outside your country?
Most health insurance providers do not cover individuals for surgery performed outside their own country. Consider obtaining extra coverage.
What about aftercare?
Patients should stay in the area where the surgery was performed for at least one week, depending on the procedure. Find out in advance where you will stay and if this facility is prepared to care for your post operative needs.
What about complications?
What doctor will care for you at home if you have complications and who will pay for secondary or revision procedures?
Do the key personnel at the surgeon's office speak your language fluently?
If you cannot be understood fully, be prepared for complications.
With whom are you communicating?
You should be talking directly with the doctor's staff and the doctor. A travel agent should only make travel and accommodations arrangements.
Is the surgeon a member of recognized national and international societies?
ISAPS membership is by invitation only and is granted only after extensive screening.
Have you checked for references?
Ask for names and contact information of patients who have recently had a similar procedure and contact them about their experience with the surgeon, their staff, aftercare facilities and post-operative follow up.
Commenting on the new ISAPS website, ISAPS president-elect Dr. Bryan C. Mendelson of Melbourne Australia, remarked, "Information that was once only available to a few is now readily accessible to consumers in virtually every country. The ISAPS guidelines for plastic surgery travelers provide consumers with vital and perhaps even life-saving yardsticks to gage if the doctor they choose for their plastic surgery is appropriately trained and certified for the procedure they are considering."