A few years ago, a new anesthesia gadget called the BIS monitor, short for bi-spectral index, made the headlines. The claim was that this new monitor would ensure that the patient was truly “asleep” and unaware of the surgery…but not getting too much medication either. It works by calculating a score from EEG (brain-wave) patterns. The BIS monitor divided anesthesiologists – some felt it was the latest and greatest thing, others felt it was not particularly accurate.

This week, in the New England Journal of Medicine, a randomized study compared awareness after anesthesia in patients treated with standard monitoring versus the BIS monitor.

More than 6,000 patients were randomized to receive intra-operative monitoring by either BIS or End-Tidal Anesthesia Concentrations (the standard). Forty-nine patients reported intra-operative memories. Expert review determined that 9 of these patients (0.15%) had truly experienced definite awareness.

The group with standard (End-Tidal monitoring) had a lower incidence of awareness: compared to 7 out of 2,861 patients in the BIS group, only 2 out of 2,852 patients in the standard group experienced definite awareness (p=0.98).

There was no statistically significant difference in the rate of intra-operative awareness between the two monitoring systems.

Editor’s note: This is a good study that gives clinically helpful information. The BIS monitor isn’t magic – there’s still a lot about the state of consciousness (or lack thereof) that we don’t fully understand. So, it’s not surprising to me that the BIS monitoring system isn’t foolproof.


A Phoenix, Arizona physician who had three patients die during liposuction surgery was found guilty of murder and manslaughter last week in Maricopa County Superior Court. He was not a trained plastic surgeon, nor a surgeon of any kind.

Dr. Peter Normann had been an emergency-room physician, certified as an internist, and had never done a residency in plastic surgery. He had undergone six days of training in liposuction and had done some “hands-on training” in liposuction and breast augmentation.

Normann was pronounced guilty of second-degree murder in the deaths of Ralph Gonzalez, 33, of Scottsdale, and Leslie Ann Ray, 53, of California, and of manslaughter for the death of Alicia Santizo Blanco, 41, of Gilbert.

In her closing arguments earlier this week, Attorney Jeannette Gallagher claimed that two of the deaths constituted second-degree murder because of Normann’s “extreme indifference to human life,” and the third death was manslaughter because of Normann’s “conscious disregard of substantial and unjustified risk of death.”

Furthermore, the attorney said, his operating room lacked proper oxygen and monitoring equipment, and he worked without anesthesiologists or nurses, relying on a massage therapist and a former restaurant worker with little or no training as medical technicians.

The massage therapist, who assisted in surgery, has already pleaded guilty to eight counts of unlawful practice of medicine and was sentenced last year to five years in prison.

Source: www.azcentral.com

Editor’s note: There seems to be an ongoing problem with surgery done by untrained physicians, with a lack of trained anesthesiologists, in substandard facilities… and the complications that can happen, as in this sad tale, are not at all good.

Whether you call it aesthetic surgery or cosmetic surgery, it’s still surgery.

Fireworks are beautiful – but care and safety are needed to avoid burns and injuries. Dr. Ramona Bates, from the suture for a living blog, has written an nice review piece about how to safely deal with fireworks. The link is below. It’s especially timely with the July 4 holiday fast approaching. Please read it, and explain it to your kids & teenagers. Nobody wants burns or eye injuries, after all!

Firework Safety Review

Have a wonderful 4th!

photo credit: digital-photography-school.com. A photo of fireworks over Vancouver harbor.

Usually, at the major plastic surgery meetings, the procedings and questions are very polite and discussions are very calm…but not this morning. The gloves came off and the sparks flew. The topic: the latest technologies in liposuction, particularly laser liposuction.

An all-star panel, moderated by Dr. Steve Teitelbaum, showed great results by several talented surgeons, all of whom use different methods, including standard liposuction, PAL, SAFElipo (which I also use), and laser assisted liposuction.

Here are some highlights from the panelists…the tone of the comments will become immediately apparent.

– Dr. Simeon Wall reviewed the peer-reviewed scientific literature on laser-assisted (“smart”) liposuction: no difference versus standard liposuction. Interestingly, there is no proof showing that laser liposuction is better, or has a quicker recovery, even though the laser machines have been on the market for several years.

– Dr. Constantino Mendieta: “The bottom line is – Smart lipo just doesn’t work”. He called his laser lipo machine the best (and most expensive) “dust collector” in the office. He doesn’t use it anymore.

– Dr. Steve Teitelbaum stressed that it’s not the machine that makes a difference, but the skill of the surgeon using it. He felt that even though a few, highly talented pro-laser surgeons might get reasonable results with laser liposuction, that it just might be too dangerous, with too high a rate of complications, for general use.

– Dr. Bela Fodor, former ASAPS president, commented from the audience, that in his practice, which is about 50% revisional (fix-up) liposuction cases, that 80-90% of these cases were from laser liposuction. Dr. Wall agreed – In his practice, he also does a large amount of revisional liposuction – and says it is more difficult to fix deformities resulting from smart lipo than any other liposuction method.

Humorously, Dr. Teitelbaum suggested that when patients call, asking whether he does Smart Lipo, he has his staff say, “No, he does brilliant lipo!” I think I might get my staff to say that too, when people call for a liposuction consultation!

Overall: a huge backlash against laser-assisted liposuction….it was like a Boston Tea Party in the world of liposuction. Maybe it was “the shot heard around the world”

Yesterday, I attended the “Boston Breast Workshop – 2011”. This was a whole day of scientific presentations and panel discussions on the many controversies surrounding the uses of fat grafting for both reconstruction and cosmetic enhancement of the breast. Panelists included local experts Dr. Dan delVecchio and Dr. Jay Austen, as well as Dr. Roger Khouri, Kotaro Yoshimura, Syd Coleman and others of international repute – truly a group of heavy hitters.

It’s pretty clear that fat grafting can work, and can be done safely in selected patients. There seem to be two major methods that work: pre-expansion of the breast with the BRAVA system, or use of Cell-Assisted Lipotranfer (CAL). So far, it’s not yet clear which method is better – as there hasn’t been a head to head comparison study. (This is in the works.) Other methods have pretty much fallen by the wayside. It is important to state, though, there is still concern about breast cancer issues, particularlly in patients with a strong family cancer history or those who have had a lumpectomy for breast cancer.

Essentially, one can sub-divide the operation into three parts: harvesting, processing and reinjection.

1. Harvesting – can be done with syringe liposuction or with manual liposuction. Jay Austen presented data to suggest that regular liposuction suction did not adversely affect the quality of the fat cells. Khouri prefers a spring-loaded syringe technique. New information suggested that low-power VASER (an ultrasonic lipo machine) could be used, but wasn’t any better than standard manual lipo in terms of the cells harvested. Water-jet lipo seems to wash the important stem cells out of the fat…which theoretically would be a bad thing, since Yoshimura feels that these cells are key to the success of the procedure. Power-assisted liposuction is still being looked at, to see whether it harms the fat or not.

2. Processing: lots of debate here. Coleman favors a high speed (1280 g) centrifuge. Khouri thinks that his low-speed 15g machine is better. Cohen reported that the Puregraft 250 system, which doesn’t use a centrifuge at all, gives the least amount of free lipid in the specimen to be grafted (free lipid is bad).

3. Injection: most authors avoid the glandular parenchyma of the breast. Coleman likes to put quite a bit of fat into the pectoral muscle. Khouri favors subcutaneous injection. Yoshimura puts it both above and below the parenchyma, but not in the muscle, injecting slowly and methodically. Delvecchio stresses a rapid procedure, to reduce ischemia time for the fat.

New gadgets: Khouri showed off his “lipografter” system. Jac-cell showed off their lipo cannisters and re-injection equipment. Cytori showed their new Puregraft 800 filter system.

Lots of good stuff. I’m still evaluating and digesting the new material, and how it’s going to affect what I do. But, it looks like, for women that want to have this technique, that use of the BRAVA system to prepare the breast is mandatory. One bit of consensus: if the breast was not pre-expanded, you can’t expect to get more than 100 cc of fat to survive.

File this under “medical tourism” meets “back-room procedures”. Another sad story about discount cosmetic surgery in a foreign country, this time with a twist…****
Hector Cabral of New York has been indicted for illegally performing cosmetic procedures on several women, leaving some of them permanently disfigured. He was charged with 10 counts of unauthorized practice of a profession, in this case medicine, according to the North Country Gazette.The illegal operations took place between November of 2006 and November of 2009. Cabral allegedly charged the women a fee for consultations and examinations held at various spas and beauty salons in the state of New York. The women would then travel to the Dominican Republic, where Cabral would carry out the procedure.

Following the illegal treatment, Cabral would instruct the women to visit his accomplice, Alma Melo, for “post operative treatment” back in New York. Melo was served with two charges for a first-degree scheme to defraud and a fifth-degree conspiracy.

Cabral could face more than 20 years in prison if convicted. He is currently free on bail, and a warrant has been issued for the arrest of Melo.

Editor’s note: I believe this is the first time that someone has been prosecuted for illegal surgical services when the surgery was performed overseas, and only the pre-operative consultation and post-operative recovery phases were performed in the U.S. It sets a new legal precedent.

Source: ASAPS

Recently, I saw an TV ad for a local personal injury attorney that really disturbed me. In it, he promised his clients that he would fight to get them the largest settlement possible, and boasted of his prowess in doing so.He didn’t talk about finding the truth.
He didn’t refer to doing the best possible job for his clients.
He didn’t mention the idea of helping people who were wronged.It was all about the money, and the lottery-style payout you might get if you select him to be your attorney.

In a related story, a prominent NY law firm is running a “Guess the Verdict” contest. The contest takes the form of a description of an actual personal injury or medical malpractice case and asks the contestant to guess the amount of the settlement or verdict. The closest guess to the settlement amount wins the contest and a free iPad2.

Seems to me that this somehow turns the whole legal process into a nauseating game.

It’s not about “the people” anymore or about “doing the right thing”, is it? It’s just about the money.

I find it discouraging that our society has sunk to this level. I’m sure there are some noble attorneys out there – and I’d appreciate hearing how they feel about these advertisements.

What are your thoughts?

Want to prevent 2 million complications of surgery, just in the United States alone? Have smokers quit smoking for at least a month prior to surgery.

In the United States, approximately 8 to 10 million procedures requiring surgery and anesthesia are performed on cigarette smokers each year, out of the estimated 50 million that are performed in total, nationwide. A recent study (click here) estimated that, if all patients were offered a smoking-cessation intervention before surgery, and assuming a 25% cessation rate, this could result in 2 million complications avoided.

The meta-analysis was done by reviewing all of the randomized trials evaluating the effect of smoking cessation on postoperative complications, and performing statistical calculations to examine the impact of time, in weeks, on the magnitude of effect.

Smokers that quit smoking before surgery had 41% fewer complications. The researchers found that each week of cessation increases the effect by 19%.

Trials of at least 4 weeks’ smoking cessation had a significantly larger treatment effect than shorter trials (P = .04).

Smokers that quit had lower rates of total complications, fewer wound healing complications, and fewer pulmonary complications.

In plastic surgery, smoking also can cause higher rates of flap necrosis (where the skin turns black and dies – as shown in the black area of this mastectomy patient). As you might imagine, this is a major problem for patient and surgeon alike, and can result in bad scarring, a poor cosmetic result, and functional problems.

Both cosmetic and reconstructive surgical procedures have been found to be affected by smoking, including: facelifts, tummy tucks, breast reductions, breast reconstructions after mastectomy, microsurgical free tissue transfers, flaps and grafts of many varieties, and finger replantation after trauma.

Even for surgery performed in the head and neck area, where there is usually a very good blood supply, smokers show a 8X increase in wound healing complications, compared to their non-smoking brethren.

There is no safe minimum number of cigarettes that you can sneak before surgery. Even a couple can do you in…

My recommendation is to totally avoid smoking (all kinds) and nicotine (all sources) for two complete months before surgery. This is especially important for facelifts, tummy tucks and breast lift surgeries.

Source: WebMD.com

March 2, 2011 — The FDA today announced steps to remove more than 500 prescription cold, cough, and allergy products from the market because of potential safety concerns.

The FDA asked companies to stop manufacturing the 500 products within 90 days and stop shipping them within 180 days. Some manufacturers must stop making and shipping their products immediately, the FDA warns.

Here is the list of banned products.

The FDA does not know if these prescription drugs are safe or not largely because they were grandfathered in before changes to the FDA’s drug approval process were enacted.

“We don’t know what they are, whether they work properly, or how they are made,” said Deborah M. Autor, director of the FDA’s Office of Compliance at the Center for Drug Evaluation and Research (CDER) in Silver Spring, Md., during a teleconference. “The problem is that we don’t know what the problem is.”

For example, some of these cough, cold, and allergy drugs are labeled as “time-release.” These are complicated to manufacture, and the FDA has not reviewed whether the active ingredient is released in a consistent matter over a period of time, she says. “They may be released too slowly, too quickly, or not at all.”

Others contain an “irrational” combination of the same types of products, such as two or more antihistamines, and some are inappropriately labeled for use by infants and young children, she says. Many contain the same ingredients as the over-the-counter cough and cold products that are no longer supposed to be used in kids under 2.

Yolandra Hancock, MD, a pediatrician at Children’s National Medical Center in Washington, D.C., praises the FDA’s move.

“The new FDA decision supports modern-day pediatric practice to avoid cough syrups in children under 2 because they do more harm than good,” she says. Some may slow down breathing, and others decrease cough and allow mucus to sit in the chest, where it can cause other problems such as lung infection, she says.

“I fully support the FDA’s move in controlling access to these medications in children; it is highly appropriate and long overdue,” she says.

As to the risks these drugs pose, “for the most part, [these adverse reactions] are not serious,” says Charles E. Lee, MD, medical officer of the division of new drugs and labeling compliance at the CDER.

After the FDA crackdown on the use of over-the-counter cough and cold medicine in children younger than 2, the number of emergency room visits for adverse events decreased by 50%, he says.

To find out whether a medication you are using is FDA-approved, click this link, and enter the name of the medication in the search box. If it shows up, it is FDA approved, and is safe to use as directed.

An FDA flyer for consumers about this action can be viewed here.

Just last week, I did a consultation on a young lady who had an “awake breast augmentation” done in Maitland, Florida, less than 8 months ago. She was already in my office, getting a consultation on how to fix her poorly done surgery, so she could look normal again.

She had a lot of comments about her unhappy experience. She didn’t want anyone else to go through what she had to go through.

First of all, regarding getting to pick the implant size during surgery – she said she asked for a different size and shape during surgery, and her surgeon “pooh poohed” her suggestions. She didn’t get what she wanted. So much for that supposed advantage of awake surgery.

Secondly, the surgeon had trouble getting the implant behind the muscle, due to the lack of muscle relaxation during awake surgery. As a result, they made the pocket larger towards the armpit, so the implant would fit… and now it has migrated even further downwards and outwards toward her armpit.

Since her “cosmetic surgeon” (who actually has no surgical training at all, but is allowed to do this in his office due to a loophole in Florida Law) chose a small, high profile implant that was way too narrow for the patient’s frame, she has a large gap in between the breasts, which she doesn’t care for.

She went back to her original surgeon, who:
a) made her feel bad for bringing up these legitimate problems,
b) wouldn’t even acknowledge the suboptimal surgical result, and
c) didn’t offer to fix it.

So now she’s here at my office, hoping it can all be made better. Fortunately, her situation is repairable. Some of the problems I see are not.

I asked the young lady whether she would have “awake” surgery ever again. She said emphatically, “No way! I want to be asleep next time!”

It’s really frustrating for me to see this sort of situation; most of these problems could have been avoided with a properly trained plastic surgeon using standard, accepted techniques.

Florida patients need to be protected from inadequately trained practitioners.

Bottom line: Quality may cost a little more initially, but it’s usually worth it in the long run. Only have plastic surgery performed by real plastic surgeons. Ask your political representative to change the law: if the doctor doesn’t have privileges to perform the surgery in a hospital, why should he/she be able to do it in the office?

Plastic Surgery In Florida