“I had fat on my belly.  I saw Dr. X and he promised me he could remove the fat and that my skin would tighten up. Look at my belly now!”  They come to me to fix their belly skin.

Urg.

I am the one stuck with telling these lovely women I cannot help them.   These women are both fair skinned women, late 40s early 50s.  One had a child, one had not.  The issue with liposuction is it relies on the skin to shrink wrap to the smaller size.  If you have poor skin tone, cellulite dimply stuff, loose or hanging skin BEFORE your fat removal, your skin will not tighten up like you want it to.

Both of the doctors doing the smart lipo are not surgeons.  I don’t intend to single out smart lipo.  All the laser liposuction companies target non surgeons to do liposuction.  Insurance reimbursements are poor and tough to collect, so many internal medicine, Ob Gyne, and family practice doctors look for other ways to make a living.  This causes doctors to go outside of their specialty, what they were trained to do in residency.

The problem with doctors going outside of their specialty, is they don’t know when a salesman is selling them a rainbow.  When a laser liposuction company shows photos of great results and says “laser liposuction tightens the skin!  This is a liposuction tummy tuck!”  These doctors don’t know not to believe them.

AND these doctors can’t do tummy tucks.  Only board certified plastic surgeons do tummy tucks.  So when you get their opinion, they will likely recommend liposuction to you.  It’s the old “when you are a hammer, the whole world is a nail.”

So. My advice?

Get at least two opinions before doing abdominal liposuction. MAKE SURE ONE OF THOSE OPINIONS IS FROM A BOARD CERTIFIED PLASTIC SURGEON. Go to the plasticsurgery.org site to get a list in your area, or ask your doctor “are you board certified? BY WHAT BOARD?” I have had people ask to see my board certification diploma on my wall.  I am thrilled they know to ask the right questions, and I am happy to bring it out for them to see.

Tummy tuck versus abdominal liposuction is a battle.  For women past age 40, with fair skin, stretch marks, post baby, etc, the choice is difficult.  There are pros and cons to either.  Don’t be fooled by the “laser” ” new technology” “no downtime!” “no pain!” “lipotummy tuck” and flashy ads and offices.  There is no magic answer.  Trust me, as a female mother of 3, if I find the magic answer I will shout and blog from all the mountaintops.

The issue for these women is they were “promised” their skin would be tight after the liposuction.  I don’t know the doctors.  I hope these doctors were honest in their evaluation and didn’t purposefully mislead these women just to make a buck.  But this issue of laser liposuction leaving bellies a mess is one I am seeing over and over again, even here in Palo Alto, the land of hyper educated women.

Don’t come to me after someone does smart lipo and leaves your belly a mess.  Come to me before, at least for a second opinion, so you know what you are getting into.

Free vivite defining lip plumper with juvederm xc treatment.

• who doesn’t want their lips plumped a little? This is a topical you put on like lip gloss to improve the appearance of lip volume, fullness, and fine lines and wrinkles.
• Who wouldn’t use the juvederm xc? (In English, that is the Juvederm with LIDOCAINE= numbing medication= less ouch.)

Botox has a deal for $50 off your treatment.

And yes, I still have a few more of the insane deal for Latisse,

Buy one get one free. $100 for TWO BOXES OF LATISSE. And you still get to send in for your free Vivite Vibrance, a $119 value.

Three things for $100.  CRAZY! Someone please come get the last ones so I can stop.

$100 for two boxes.

(this is not expired, from a foreign country, in the back of a pick up truck. etc. it is real latisse from allergan… it is just due to a great promo i was given which i am passing on…)
AND, no kidding, YOU CAN STILL USE THE MAIL IN REBATE FOR A FREE $119 VIVITE VIBRANCE. 

*WHILE SUPPLIES LAST. call asap 650 617 9907.

Buy latisse (one box special – $100) and get vivite vibrance (value $119) for free!

It is a mail in for the vibrance. I have the slips in my office….

Go summertime long lashes and pigment free skin!!!

A board certified plastic surgeon.

Yes, I am a real plastic surgeon certified by the American Board of Plastic Surgery.  I am also a cosmetic surgeon.  I do not call myself a family practice doctor, dermatologist, or ENT- though many of those specialties call themselves  plastic surgeons.  If you want to see how someone trained, find out what their residency and board certification is.  It cuts through all the trickery and deception.

What are the boards?

Each specialty has its board.  Dermatology, Internal Medicine, Family Practice, Orthopedic Surgery, etc.  Trickery abounds- there is no “cosmetic surgery” board, yet I found a website saying there is.  The Mission Statement of The American Board of Plastic Surgery, Inc. is to promote safe, ethical, efficacious plastic surgery to the public by maintaining high standards for the education, examination, certification and maintenance of certification of plastic surgeons as specialists and subspecialists.

I sat for my first round of board exams after residency.  First for the written test, and then two years later for the oral test.  The oral boards are tough.  You have to be in practice for a while, collect cases, and submit those cases.  Then you submit some in incredible detail (with op notes, clinic notes, photos, even how you billed).  If you pass these hurdles, you sit for the oral boards.  At the oral exam, you meet with leaders in the field and are quizzed on your cases and a group of unknown cases, which you had the pleasure of seeing for the first time only minutes before.  During this exam in the imaginary cases, every skin graft and flap you do will fail.  You are guaranteed complication after complication until the examiners see how you handle adversity.  They want to see what you have done in practice.  They want to see how you think.  Will you be a good surgeon? A safe surgeon?  The true test of a good surgeon is not how you do on the cases which go well.  It is how you do on the ones which don’t.  My year, 20% of the doctors failed the oral boards.  20%.  These doctors went to medical school, accredited plastic surgery fellowship programs, and passed the written test. It is tough.

I can’t believe how times flies.  It has already been a decade.  My original certification was to expire, so I recertified.  I submitted all of my cases over a 6 month period.   They check your hospital status, references, and other paramenters. When you pass this, you take a written test.  We all take a general test- basic fundamentals of plastic surgery we should all know.  And then we take a specialized test, where they tailor this part to what you actually do in practice.  Over a decade in practice, your practice evolves.  So hand doctors aren’t tested in depth on breast augmentations, and pediatric plastic surgeons aren’t tested on breast cancer reconstruction.  My focus is cosmetic- breast, body, face.  That is what I was tested on.

I am now board certified by the American Board of Plastic Surgery until 2021.

The next time you’re at the doctor’s office, take a peek at those certificates hanging on the wall. Like gallons of milk, some of them are expiring.

For the first time since leaving medical school, many doctors are having to take tests to renew board certification in their fields — 147 specialties from dermatology to obstetrics.

Any doctor can deliver a baby, treat cancer, or declare himself a cardiologist. Certification means the doctor had special training in that field and passed an exam to prove knowledge of it.

They used to do this once and be certified for life. That changed in the 1990s — doctors certified since then must retest every six to 10 years to prove their skills haven’t gone stale.

For some specialists, like the doctors who push tubes into heart arteries to unclog blockages, this is the first year many are going through retesting.

Older doctors also are feeling the heat. More than a quarter of a million of them were “grandfathered” with lifetime certificates, but are being urged to retest voluntarily to show they still know their stuff.

http://news.yahoo.com/s/ap/20100405/ap_on_he_me/us_med_retraining_doctors;_ylt=AjmNNJyskv31bKyNLpFGxOPVJRIF;_ylu=X3oDMTJxNGJpb2thBGFzc2V0A2FwLzIwMTAwNDA1L3VzX21lZF9yZXRyYWluaW5nX2RvY3RvcnMEY3BvcwMxBHBvcwMyBHNlYwN5bl90b3Bfc3RvcnkEc2xrA2RvY3RvcnNmYWNlYg–

Number 4?

Surgeon.

Stress Rank: 197
Stress Score: 99.463
Unemployment: 0%-4%
Hours Per Day: 11
Time Pressure: Moderate
Competition: High

“Surgeons can be required to work at odd hours, and many operations take hours to complete. Operating calls for extreme precision and attention to detail, and can require quick decision making with life or death consequences.  (According to Yahoo posting of Careercast.com)

It wasn’t totally surprising to me.  Surgery is a unique field.  My typical “day at the office” is not typical at all.  Surgery residency, when I did it, was grueling.  We measured how many hours we worked in a week by subtracting out the ones we didn’t- it was easier that way.  I am curious how the new surgeons in training with restricted hours will be when they get out in practice.  But that is another blog.

Surgery can be stressful, but for the majority of the cases it’s not.  I am well trained.  I lost a decade of my life to living in a hospital, but it gave me good tools and techniques.  I saw everything during training.  Stress is when the chest or belly fills with blood.  But just like when you scuba dive, you learn panic is never the answer.  If something happens, you collect yourself, breathe, and fix it.

So I understand this poll.  But for me, my job is not so stressful.  The operating room is my zen place.  Hours fly by in minutes.  I love what I do.  Maybe I was born to do it.  My father was a plastic surgeon, and  I saw my first surgery when I was 10, “Dad move your shoulder, I can’t see!”  And my patients are the best.  I don’t know how it happens, but my practice attracts some of the most amazing, interesting women I’ve met.

So chances are in my residency, I saw something like it.  This is why I rant about non surgeons doing surgery.  It took me years of training to get to a comfortable place.  Whatever happens in the OR, I will deal with it.  I do all my steps purposefully, safely, to avoid issues. 

Surgeon one of the most stressful jobs? I have rare days which are stressful.  As I love to say, it is good to be interesting at a cocktail party, not at a doctor’s office, and definitely not in the OR.

Top 5 surgeries in 2009:

1. Breast augmentation (311,957 procedures)
2. Liposuction (283,735)
3. Eyelid surgery (149,943)
4. Rhinoplasty (nose surgery 138,258)
5. Abdominoplasty (127,923)

Top five nonsurgical cosmetic procedures in 2009:

1. Botox (2.5 million+)
2. HA fillers (Juvederm, Restylane- 1.3 million)
3. Laser hair removal
4. Microdermabrasion
5. Chemical peel

What has changed in the last decade?

Since 1997, there has been a 147 percent increase in the total number of cosmetic procedures, from 2,099,173 to a high of 11,701,031.  The numbers did slide in the past year a little (down 2%- that darn recession - though the numbers were down 17% for surgeries, and UP 1% for nonsurgical procedures).

In 2009 though Americans spent $10.5 billion dollars on cosmetic procedures.  No wonder everyone and their brother is now calling themselves a “plastic surgeon.”

What is dysport?

Why have I not offered it before?

So what do I think?

So if you want to try it, come in.

To get the monetary benefits of the challenge, you need to have your first injection done before April 30.  If you are ever going to try it, do so now- I don’t know when they will offer rebates like this again.

Call 650 617 9907 for an appointment.  As always, I will do botox on a special day, as I feel strongly fresh botox is more effective and lasts longer.

They studied the San Diego and LA area.  They looked at minimally invasive procedures like HA fillers (Juvederm and Restylane) and invasive procedures like liposuction.

What I considered the juicy findings:

• nearly 40% of doctors offering liposuction in Southern California had no specific surgical training (!!!)
• Of the 1,876 “cosmetic practitioners” from San Diego to Los Angeles only 495 of them were trained in plastic surgery
• Primary care physicians made up the fourth-largest group of liposuction providers following plastic surgeons, dermatologists, and otolaryngologists.

No law prevents doctors from doing other parts of medicine.  (Yup.  I could call myself a pediatrician or gynecologist if I wanted.)  The place where this kind of thing gets caught is by the hospitals.  I can call myself  anything, but in order to get admitting privileges in a hospital, they require I prove things like… oh… I did a residency in that specialty, I am board certified in that specialty… pesky things like that.  But the little doctor office “surgery” suite doesn’t have that review.

In the study, the authors state, “We feel that the provision of such a potentially hazardous treatment by physicians with no training in surgery poses a genuine threat to the safety of patients.” Another issue the authors bring up is the franchising of medicine.  Medispas and mall spas which offer medical services may not have an association with a particular provider.  The doctors are considered to be interchangeable and replaceable.  Patients need to know: just who is responsible for their care?  “The divorce of the practice from the  name of the responsible physician...”  When did we change from going to Dr. So and So to going to the Cosmetic Institute of America?

What to do?  Government is a poor regulator.  There are always loopholes and back office doors to go through.  The real issue is EDUCATION.  You, the consumer, need to know who is doing your procedure.  Are they trained? Did they do years in residency to learn or did they take a weekend course?

The study has great information in it.  One of my favorite points is this, “The American Society of Plastic Surgeons committee on patient safety recognized that liposuction is in fact major surgery…  According to a recently published survey of fatalities caused by liposuction, the “lack of surgical experience was a notorious contributing factor, particularly regarding the timely identification of developing complications.”

I know you are tired of hearing about “he or she is not a real plastic surgeon.”   You want a real surgeon.  You want a trained, true surgeon who did years of residency in surgery.  I wouldn’t want an untrained doctor doing surgery on you.  Don’t be lured by the flashy office, great advertising, or cheap pricing.  Look for quality.

I frequently blog about the people who use gimmicks and marketing, make false claims, and do dangerous things… When did medicine become something done in a mall?  Where anyone can claim anything without proving it does what it says?

So I was happy to see this today in the news.  The associated press reported the FDA is cracking down on the medispas who are doing lipodissolve injections.

The Food and Drug Administration is cracking down on what are billed as fat-melting injections used in spas across the U.S., saying the drugs have not been proven safe or effective.

Lipodissolve injections, a popular nonsurgical alternative to liposuction, are used to dissolve small fat deposits around the legs, arms and belly. The FDA said Wednesday the drugs have not been cleared by federal scientists, as required by law.

FDA is not aware of any credible scientific evidence to support these claims,” said Kathleen Anderson, an FDA deputy director, on a call with reporters.

Spas that offer the injections say they are safe and effective. But public safety advocates have called for proof and urge patients to think twice before paying thousands of dollars for an unproven procedure.

FDA said it has received reports of permanent scarring and hard lumps on patients’ skin, as well as skin deformations after receiving the therapy.

These fat melting injectable procedures use naturally occuring substances, mixed with other materials (a process called compounding), and then they are injected under the skin.  As I have criticized mesotherapy for, there is not good science behind these injections.  There is no “standard” mixture or protocol.  (I had a patient once who came to me after trying mesotherapy and ending up in the ICU in liver failure because of the injections.  She came to me for liposuction- the injections had not worked.) Also, with fat removal by any method, the goal isn’t just the fat being gone.  You want the result to be smooth.

I never thought I’d say this, but hooray for the FDA.  Let’s get safety, science, training, and honesty back into medicine.

to see the article, go to http://news.yahoo.com/s/ap/20100407/ap_on_bi_ge/us_fat_melting_drugs_fda