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Cosmetic Surgeon, Plastic Surgeon, and Credentials

March 21, 2015

A woman was found dead, lying on a massage table with bloody gauze on her buttocks inside a business that performs eyelash extensions in Dallas on February 19th. It appears that this woman had paid about $520 to have something injected into her buttocks as a buttock enlargement procedure. Exactly who injected exactly what is not clear at this point, but arrest warrants have been issued for Denise Ross, who goes by the name of Wee Wee, and her transgender companion Jimmy Joe Clarke, who goes by the name Alicia, for practicing medicine without a license (both are pictured above). This is such a tragic story, and unfortunately it's not all too uncommon. News reports keep popping up about people who have silicone injected directly into their buttocks or breasts, the procedure being performed by someone who may be in the area only for the weekend. Complications occur, and the injector has long-since vanished.

It is precisely because of tragedies like this that credentialing is so important. One type of credentialing is word of mouth. A friend or colleague went to this place or that place, had something done, was happy with the result, and she tells you about it or posts a positive review online. That type of credentialing can be very helpful and may (or may not) come from a trustworthy source. In medicine, another type of credentialing comes through certification by a Board recognized by the American Board of Medical Specialties (ABMS). This is an entity composed of 24 medical specialty Boards. The American Board of Plastic Surgery is one of the twenty-four. Doctors who are Board Certified by one of the 24 ABMS member Boards and who participate in the Maintenance of Certification program are part of a demanding process that repeatedly assesses and enhances their professionalism, judgement, medical knowledge, and clinical techniques.   ABMS and its member Boards establish lifelong learning standards that ensure physicians keep abreast of the latest practices and treatments.  Before becoming Board Certified by the American Board of Plastic Surgery, a candidate must have completed a plastic surgery training program at an accredited institution.  A list of those institutions reads like a Who's Who, including essentially every major university medical center you have ever heard of.  A surgeon cannot become Board Certified by the American Board of Plastic Surgery without completing training at one of these 100+ member institutions.

From time to time I'll Google some key words, like 'breast augmentation Fort Worth', just to see what pops up.  Occasionally I run across something unexpected, like a website of a surgeon that is new to the area, or at least new to me.  So, I'll look at the website and try to find out a bit about the doctor.  Who is he/she?  What type of practice is it?  Where did the doctor do his/her training?  What types of certification does he/she (I'll just use 'he' or 'his' from this point forward) have?  Sometimes the information is easy to find on the site.  Sometimes it's almost impossible.  As consumers we all want to know as much as possible about the products and services we buy.  With something as important, even 'intimate', as surgery, we have a right to know what qualifications a person who may be operating on us has.  One thing I've found as I've looked at these various websites is that a doctor who trained in plastic surgery will display that training proudly on the first page of the website and on his biography page.  It's not hidden in the website somewhere; you don't have to dig through pages of the site to find it.  A surgeon who is certified by the American Board of Plastic Surgery displays that information on page one.   On the other hand, another thing I see a lot on websites relates to doctors who say they are 'Cosmetic Surgeons'.  Frequently those sites look great.  Lots of animation on the site, lots of color, lots of pictures, even some nice testimonials.  All of this sounds and looks just great, and often these are very good doctors and surgeons.  Something that bothers me about many sites like this, however, is that it's often hard to find out the details.  What is the doctor's background, and where did he do his training? It may be surprising to learn that often these doctors originally did their training in something like family practice or radiology, then decided to start doing cosmetic surgery. In situations like that, it might be worth knowing how exactly the doctor got into doing particular procedures, for instance, liposuction or breast augmentation. Did he attend a weekend course and start doing it? On many of these types of websites that information just is not displayed. The websites look great, but the depth of content regarding training is lacking. And that, at least to me, raises questions.

I am not comparing these doctors to the unknown, non-physicians who inject unknown substances into people, similar to the situation mentioned at the beginning of this blog. To be a licensed physician in Texas, a doctor has to have undergone verified training and passed specific examinations. On the other hand a random person injecting unknown substances into buttocks in a nail salon...well let's just say his or her training is more suspect. What it really comes down to is this: credentialing matters. Word of mouth and positive online reviews are helpful. Board certification in Plastic Surgery or Cosmetic Surgery is, at least in my opinion, essential.

Medical Tourism and Plastic Surgery

February 11, 2015

One of the great things about Fort Worth is the ease of access to the world afforded by DFW airport. American Airlines has its headquarters here in town and DFW is its largest hub. With U.S. based airlines like United, Delta, and Spirit, it's easy to either fly here from anywhere in the country, or to fly from here to anywhere else. DFW now even has nonstop flights to and from Australia on Qantas, the UAE on Etihad and Emirates, Seoul on Korean Air, and a number of carriers to many places in Europe.

So, why am I talking about this on my plastic surgery blog? Because of medical tourism. It has become all the rage. Forbes magazine estimated that 1.25 million Americans would travel abroad for some type of medical care in 2014. That number seems a bit high to me, but it's Forbes and they seem to know a lot about numbers. The point of the Forbes article is that Americans are traveling to other countries for care. Costs for many treatments and many surgical procedures are higher in the US than many other places in the world. If quality of care is high, outcomes are good, and cost is low, why not go?

Seoul, South Korea, is one of the "hot spots" listed in almost any article about medical tourism. Apparently Chinese citizens are traveling there in throngs to undergo cosmetic surgery. The Ritz Carlton in Seoul even partnered with hospitals there, offering an "anti-aging beauty package" for a mere $88,000 (US dollars). Sounds like a bargain! Other popular places people are going for surgical procedures include Costa Rica, India, and Mexico. To see what all the fuss is about I thought I'd check into what it would cost for a woman to undergo breast augmentation in each of these four hot medical tourism destinations: Seoul (Korea), San Jose (Costa Rica), Mumbai (India), and Monterrey (Mexico). As a comparison, breast augmentation in Fort Worth typically costs somewhere between $4,000 and $5,000, depending on the specific breast implants used. This cost includes the breast implants, surgeon's fee, facility fee, anesthesia, and preoperative and postoperative visits. Different surgeons charge different amounts, but I believe the total cost of $4,000 to $5,000 is about right for Fort Worth. If you travel to Seoul, be prepared to pay about $6,000 for your augmentation. Monterrey Mexico? About $4,000. Mumbai: about $3,800. Costa Rica will also cost about $3,800. Interestingly when looking at websites that promote international medical tourism, I found that those websites typically list the "average" cost of breast augmentation in the US to be $9,000. Gulp. $9,000!! So of course it seems like $3,800 in Costa Rica is a huge bargain when you compare it to $9,000. There probably are places in this country that charge $9,000; I just don't know where. Maybe Manhattan? But really, when you compare the cost of breast augmentation in Fort Worth, Texas to those four "hot spot" medical tourism destinations, it almost makes me wonder why anyone from North Texas would travel to one of those places to undergo this type of cosmetic surgery.

Having been a plastic surgeon in Fort Worth for 20 years, I have had the privilege of performing cosmetic surgery for women not only from all areas of Texas but also from places like California, Canada, New York, and Florida. DFW airport makes the travel easy, but it's our outcomes that make it even possible. I do surgery in hospitals and ambulatory surgery centers that undergo strict accreditation processes. If you want to see a hospital administrator sweat, tell her that The Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO) is coming to do an inspection of the facility. The Joint Commission has created and continuously improves strict sets of standards and clinical practice guidelines that hospitals and other facilities must meet or exceed if they want to continue providing care for patients. Failing a Joint Commission Survey means a facility may have to close. Facilities are inspected every three years. It is through inspections like these that surgical facilities in the United States maintain some of the very highest standards in the world. The Joint Commission doesn't just look at the physical layout of a surgical facility. It also inspects things like the credentialing process the facility uses to make sure that the doctors who work there are qualified to do the things they are doing. For instance, if I want to do breast augmentation surgery at a facility, the facility needs to make sure that I have completed appropriate training and have met certain national and community standards. Board certification by the American Board of Plastic Surgery is one measure that facilities use to help them make sure a surgeon is qualified to perform cosmetic surgery. The facilities also request information about where a surgeon did his or her training, about malpractice suits, and about having a medical license to practice in that state (in my case, Texas). The American Board of Plastic Surgery has its own rigorous process regarding certification of plastic surgeons. This all sounds great, but if you are still reading you're probably getting a little bored by now. The point of all of this is that if you undergo breast augmentation in Fort Worth, Texas by a plastic surgeon who is certified by the American Board of Plastic Surgery, you have a pretty good idea about the qualifications of the facility and the qualifications of the surgeon who is doing your surgery (preferably me!). Can you really say that about undergoing breast augmentation in Costa Rica or Mexico or some other country? Maybe, maybe not. Certainly different countries have requirements regarding who can do what as far as surgical procedures are concerned. One of the biggest problems is that we, as consumers, don't really necessarily understand what those qualifications are. Are standards regarding sterilization processes of instruments the same in India as in Dallas? Maybe. What about standards regarding immunization status of the personnel who will be taking care of you? The same in all places, or different, and does that really matter? In the U.S., you know that there are amazingly high standards of care. There may be similar high standards in all of these hot spot medical tourism destinations as well, but it's just not as clear.

Now, suppose you take the next step and actually go to another country to undergo breast augmentation. Maybe you're thinking, hey, it costs a little less (excluding the travel, of course), you've researched what you can, and what the heck, there's a little vacation thrown into the mix. After all, travel to Costa Rica can be pretty exciting. Monkeys, exotic butterflies, rain forests...just an amazing place. But when you are being wheeled into the operating room, do you know what implants are going to be used? Different countries have different implants available. Just ask women in France how they liked their PIP implants. That company used industrial grade silicone rather than medical grade silicone for their implants, the implants had twice the rupture rate of other implants, and the head of the company was sentenced to four years of prison for fraud. While those implants are no longer even available, they were available and being used at one time. Knowing specifics about the breast implants that will be used is really important. Also, will there be a warranty with the implants being used? Probably, but you better make sure. And making sure might be kind of difficult. While your surgeon probably speaks and understands English well, most of the staff responsible for getting you safely through surgery and the recovery area probably don't.

Medical tourism is a growing industry. Travelling abroad is exciting, and people usually have good results. There are some uncertainties, though, that are worth considering as discussed above. Here in Fort Worth we see patients from all areas of Texas as well as from all over the country. The distances some of these people travel make this, too, a form of medical tourism. However, undergoing surgery in the U.S. does provide some certainties regarding standards. Language is not usually an issue. Cost definitely varies around the country. In my experience costs for cosmetic surgery are lower in Fort Worth than almost any other city of similar or larger size in the U.S., and similar (at least for breast augmentation) to costs in the international hot spots for medical tourism. So, skip the passport and the immunizations! Jump on American Airlines or Delta or United or Spirit or load up the car and come on down/over to Fort Worth. It's a great city with a vibrant art scene and cool downtown, nice places to stay, and all kinds of interesting places to eat. My office is in the downtown medical district and we would love to have the opportunity to help you fine tune your image!

Shaped Silicone Breast Implants ("Gummy Bear" Implants)

February 5, 2015

More and more women are asking about shaped silicone gel breast implants. There are other names that people use for these types of implants, including "form stable", "cohesive gel", "gummy bear", and "5th generation" implants. As the name suggests, these implants have a shape to them; they are not round. Shaped silicone breast implants provide a different look than round breast implants. They have a tapered shape, being a little thin at the top and thicker at the bottom. Because of this shape some people think of a "tear drop". These are called 'form stable' implants because, unlike round implants, when you place shaped silicone breast implants on a firm surface, they maintain their shape. Round breast implants, on the other hand, do not maintain the same shape in the upper part of the implants when they are placed on a firm surface. Women who choose shaped silicone gel breast implants typically are hoping to achieve a somewhat tapered appearance of their breasts, with a gradual transition from the chest to the breast. Shaped silicone implants may not provide the same projection (front-to-back dimension) as a similar volume round implant. The look that 375 cc shaped silicone implants provide may be moderately different than the look obtained from 375 cc round implants, with less projection but perhaps more height with the shaped breast implants.

The reason that shaped silicone gel breast implants maintain their shape is that the silicone gel is formulated differently than the silicone gel in round silicone breast implants. The gel is more firmly bonded in these implants than round breast implants. While not an exactly accurate analogy, it is kind of like the difference between having jello in a ziploc bag versus having water in a ziploc bag. If these two bags are placed on a table, the bag with jello will have more height to it than the bag with water. The jello is bonded differently than the water. People sometimes refer to shaped implants as "gummy bear" implants because if a shaped silicone implant were to be cut in half, the silicone does not leak out. It is a similar consistency to a gummy bear candy. If a round silicone gel breast implant were to be cut in half, the silicone would eventually leak out and the implant would lose its shape.

Women who choose shaped silicone breast implants choose them because they are looking more for a shape rather than a size. Women who want to wear a certain size bra, perhaps a full C or D cup, may be happier with round implants. While shaped silicone breast implants may also provide a full C or D cup result, there are some nuances in using these implants that need to be thoroughly discussed.

I participated in one of the original studies that led to FDA approval of shaped silicone gel breast implants (Allergan style 410 implants) and have been using them for several years. If you come visit with us in the office regarding breast augmentation we will certainly talk with you about all of the breast implant styles available. We do not choose the implants for you, but instead help you understand the differences between the different breast implants and how they may affect your final look. Call the office and come learn about breast implants!

Fat Grafting of the Breasts

January 27, 2015

While it may sound crazy, fat grafting of the breasts is the real deal. Suctioning out unwanted fat from one area of the body and adding it to specific areas in a breast helps create a more refined, sculpted look. Initially used for breast cancer reconstruction, techniques continue to evolve and the technique is now being used more and more in cosmetic breast surgery as well.

Fat grafting of the breasts is not new. In 1895, a German physician named Vincenz Czerny described breast reconstruction of a 41 year-old singer. She was concerned about how she would appear on stage after having to have a breast removed. She had a large lipoma (fatty tumor) in her lower back, so this was taken and placed in the mastectomy defect. In 1919 another German doctor, Erich Lexer, published "Free Transplantations", a 2 volume text about grafting. In this text he described some clinical applications of fat graft breast augmentation and reconstruction. Melvyn Bircoll, a Los Angeles surgeon, published his experience with breast augmentation using liposuctioned fat in 1987. Emmanuel Delay in Lyons, France began using fat grafting for breast reconstruction in 2000. Gino Rigotti, in Verona, Italy, presented a large series at a 2007 European aesthetic plastic surgery meeting. Over the last 10 to 15 years fat grafting has been championed in the United States by Sydney Coleman in New York, Daniel Del Vecchio in Boston, Roger Khouri in Miami, and Kamran Khoobehi in New Orleans.

Methods for obtaining the fat, processing it, and placing the fat into the breasts are changing all the time, allowing for ever-improving shapes and contours with enhanced safety and predictability. One of the early concerns about fat grafting was that it may make mammograms more difficult to interpret. Clinically this has not been found to be the case. Del Vecchio and others have published their experiences, with a very low incidence of oil cysts and calcifications seen after fat grafting. Peter Rubin in Pittsburgh also reported a study showing that mammograms of women who have undergone breast reduction surgery are actually more difficult to interpret than mammograms of women who underwent fat grafting.

Many women come to the office with a desire to have more shapely breasts. An area that almost all want to have addressed is the flattened area at the top of the breasts, where the chest transitions to the breast. Breast implants help fill that area and may be all that's needed. Sometimes, however, adding a little fat to the upper breast may create an even more subtle transition and more filling in that area. Fat may also be added in other areas as well, depending on the specific findings and desires. A woman who is thinking about breast augmentation who also happens to have fullness in her thighs or abdomen may be an ideal candidate for fat grafting of her breasts. Using slightly modified liposuction techniques, the fat is removed from the areas where contour improvement is desired. The fat is collected and cleansed of oils and blood cells. The cleaned fat is then injected into the desired areas of the breasts.

The surgery may take two or three hours to accomplish. Recovery is similar to that of a typical liposuction operation. For a few days there is some soreness at the sites from which the fat was taken, and the breasts feel fairly tight. Swelling begins to subside after five or six days but the final shape of the breasts and the suctioned areas won't be seen for a few months.

Fat grafting of the breasts is an exciting, evolving technique. Women now ask about it frequently when they visit the office. If you have been thinking about changing the shape and appearance of your breasts, fat grafting is something you should at least know about. Call the office and come learn about this intriguing procedure!

24 Hour Saline Breast Enlargement

September 10, 2014

It seems to be all the rage in New York these days. Saline injected directly into the breast tissue. Wow!

So, why on earth would a woman have something like that done? There are a few reasons. Some women who are considering breast augmentation want to have a good idea of what they'll look like with breast implants. Rather than trying on implants in their bras, they can have a doctor inject saline into their breasts. Seeing what 350 cc's of saline in the breast looks like may provide some indication of the look a 350 cc implant may create. Some women have no desire to actually get breast implants, they just want to have larger breasts for about 24 hours. The injections can certainly provide an amazing look for parties, weddings, and red carpet type events. The effect, however, only lasts about 18 to 24 hours. In New York City these procedures go for $2500 to $3500. That's quite a bit to pay for a 24 hour pick-me-up.

I understand the thoughts behind saline injection into the breasts. On some level it makes sense. On the other hand, in our office we use the Vectra XT three dimensional imaging system to help women understand about how they may look with specific breast implants. Rather than do multiple needle sticks (some of which invariably will pass through milk ducts, potentially introducing contaminants into the breast tissue), the Vectra system lets the computer do the work to help show potential results. A study published just last month found that this system has about a 90% accuracy rate. Saline that is injected directly into the breast will not give a reliable representation of what a breast implant will do. Saline that is injected into the breast is placed in the breast tissue itself; an implant is placed behind all of the breast tissue and in most cases partly behind the pectoral muscle. Saline injected into the breast tissue will expand the skin and breast tissue in all directions. An implant placed behind the tissue pushes the tissue forward. The look really is different.

There may be some risks to the saline injections. As mentioned above, they may push contaminants into the otherwise sterile breast tissue. This could lead to infection, even if the procedure is done as sterilely as possible. Also, if you've ever been given a shot, you know that some bruising may occur. Injecting saline deeply into breast tissue requires fairly large needles to pass through a lot of tissue, including some blood vessels. That's likely to create some bruising and soreness. Finally, if the procedure were to be done multiple times to the same woman, it's possible that her skin would stretch and become droopy. That's not likely to happen with one or two injections, but it's conceivable that it would happen after multiple procedures.

I have not yet had a woman come into my office asking for saline breast injections. If she wanted to do it for some special event and understood the effect would only last about 18-24 hours, I would probably consider it. On the other hand, if her thought is that she'd like to see how she would look with that volume implant, I would have her try three-dimensional imaging with the Vectra system. I think it's likely that the Vectra system will provide a more accurate representation of the potential outcome, and do it with no real risk.

Come by and see the Vectra XT three dimensional imaging system. We use it with almost every patient we see in the office. It's cool, it's powerful, and it makes the consultation process so much more meaningful.

New Fort Worth Aesthetician

August 14, 2014

We are proud to announce that Katie O'Keefe has joined the practice!  We interviewed dozens of applicants, waiting patiently to find the person we think can provide outstanding results for her clients while maintaining the practice standards of customer service, client education, and desire for continued improvement.  Katie is all that and more!  From every-day skin care programs to chemical peels, dermaplaning, and microderm, Katie would love to personalize a treatment regimen to help your skin achieve optimal health and appearance.  She went to TCU, is an avid hockey fan, and loves animals.  Come visit with Katie and see why we're so excited she's here!


College applications

August 5, 2014

With one son having graduated from high school this year and another who will graduate in 2015, we've become quite familiar with the college application process.  What an ordeal!  There's the common ap, of course, but then the individual college applications all want something a little different.  And the essays!  I particularly like the one where they ask the student to complete the essay in exactly 28 words, no more, no less.  Having great letters of recommendation, well, that goes without saying.  Great grades? Of course!  AP test scores of 4 or 5?  Better have it all.  We saw the movie 'Admission' last year as our son started this process.  Funny movie, but I can say it actually kind of mirrored the entire experience.  This is a great time in my sons' lives, whether they realize it or not.  And mine too.  Watching them grow, mature, make meaningful decisions, and start down paths over which I have no control...fantastic stuff!  It's scary, but I sure am enjoying it!

Thank you for reading this small digression from the usual plastic surgery information.


July 8, 2014

We are excited to introduce microneedling (also known as collagen induction therapy, or CIT) to the practice!  This evolving technique uses an electronic device to create controlled channels or microwounds into the skin.  These micro-passages stimulate the normal wound healing cascade by releasing growth factors, leading to the production of new collagen, elastin, and microscopic blood vessels (capillaries).  The micro-channels may also be used to aid delivery of cosmeceuticals, growth factors, and bioactive peptides into the dermis.  Microneedling has many uses, including improving scars (acne scars, surgical scars), reducing stretch marks, improving fine lines, and helping create more even skin pigmentation.  Unlike laser treatments and deep chemical peels, microneedling causes minimal injury to the skin.  This makes microneedling a versatile technique, being able to treat areas that lasers cannot like the neck, chest, and hands.  Collagen induction therapy is an area of growing interest in cosmetic plastic surgery. Come visit and learn more about microneedling!

June 26, 2014

I just came back from a fantastic meeting in Las Vegas.  This was a multidisciplinary meeting with plastic surgeons, dermatologists, ophthalmologists, and ENT facial surgeons from around the world.  I was looking for an opportunity to see how physicians in other specialties address issues that I see as well.  For instance, how do ophthalmologists who do cosmetic eyelid surgery treat patients with baggy eyelids?  How do ENT facial surgeons do facelifts?  I have been to many, many meetings in the past where plastic surgeons talk about how they do things; this was an opportunity to meet with many types of doctors.  I spent time talking with a doctor from Dublin, Ireland who gives talks around the world about research showing that Botox may actually be medically helpful in patients with depression.  Another interesting doctor I spent time with was an ophthalmologist from Beirut, Lebanon.  We talked about fat grafting around the eyes, as well as life in Lebanon in general.  The meeting exceeded my expectations.  So much information!  The only 'downside' is that now my office staff will have so many new things to integrate into the practice!

April 9, 2014

Each year in April Fort Worth, Texas magazine publishes its list of Top Doctors.  The magazine sends a survey to 4,500 local physicians and asks them to submit the names of the physicians in each field that they think are the best in Tarrant County.  I am once again honored to be selected to the list for 2014 (my 14th time!).  Texas Monthly magazine similarly publishes a list of Texas Super Doctors in its November issue, and I have been named to that list 10 consecutive years as well.  More than just me, however, these awards are a reflection of my entire office staff and their dedication to outstanding outcomes and experiences for our patients.  There are certainly other excellent plastic surgeons in Fort Worth.  Call around, then call us.  Visit with them, then visit with us.  Come experience how and why this practice has been selected to so many Top Docs and Super Doctors lists!

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