Please take a look at the article I recently finished for the QMP Plastic Surgery Pulse.  Here is the link to the main page of the Plastic Surgery Pulse.  http://www.plasticsurgerypulsenews.com/2/  This is a newer Online Journal.  I was asked to give an article so I chose to give a technical analysis of a DIEP Flap.  Here is the direct link to my article. http://www.plasticsurgerypulsenews.com/2/article_dtl.php?QnCategoryID=18&QnArticleID=43  Please read the article and allow me to answer any of your questions!

My friends, please dont have Plastic Surgery on your Face, Breast or Body by an Emergency Medicine Physician, OB/GYN, Radiologist, or Primary Care Physician!

We have had two patients come to our office after getting consults from non-surgeons for Liposuction this week. One patient was afraid because she would have to be awake for the entire procedure. Another was concerned about having surgery in the office.

These stories make me incredibly upset as I sit beneath My Board Certification in Surgery and Plastic Surgery! These were not obtained at a 20 or 30 hour couse over a few days at a resort. My surgical training has spanned 9 years after I finished Medical School!

This is constantly happening these days.  As more and more state budgets are looking for revenues these physician taxes are going to be continually brought up.  What people fail to understand is the Federal Government pays less than 26 cents on the dollar.  This is in the face of a Sustainable Growth Rate formula that is flawed.  The formula pays doctors.  Each year a fix has to be put into place because of threatened cuts in payments to physicians who care for Medicare patients.  I am heading to Capitol Hill tomorrow to try and get some information regarding future plans to eliminate this formula or replace it with another.  Each year I have traveled to Capitol Hill over the past several years no one has been very interested in discussing this issue or others related to Medicare.  I am interested to see their level of interest now!

Texas has been a leader in Tort reform and now the state is working hard to introduce Medicare Reform with a grassroots effort.  I just received this in my email this morning. It is a link to http://www.meandmydoctor.com/ a site that allows you to participate in a petition to change the SGR.  This is the hurdle that has not been able to be passed.  I have went to Capitol Hill each year with this item on our agenda and virtually had no response from the staff of any representative on this issue.  Most people don't know but this formula has not been changed and cost millions of dollars to the system.  Physicians are excluded from changes despite in inflation and changes in the environment that we have to work.  If sustainable change is not made to the SGR more physicians will stop taking Medicare Patients, crating an access to care issue which has not existed in this country.

Patients are incredibly concerned as they shold be with natural appearing results.  I have been asked recently about whether not patients would be able to have liposuction.  There are several factors I take into consideration when evaluating whether not a patint is an appropriate candidate or liposuction.  First I address if the patient has had changes in their  weight over the past several months that could unfortunately compromise the result.  I want patient to be at their current weight over the past 6 months and sometimes over the past year in a patient who has had surgical weight loss.  i would like the patient to have a BMI of less than 30 normally.  If these factors are within reason then we will delve into what area or areas they are interested in improving.  Liposuction doesn't remove all the fat in any given area.  I prefer patients to have a greater than 2 to 3cm pinch in any given area they desire liposuction.  Typical areas to have liposuction are the abdomen, flaks, hip roll, inner and outer thighs.  These can be done in conjunction with other procedures but I am not an advocate of large amounts of liposuction on the legs and thighs as well as excision procedures like tummy tucks.  There is an increased risk of DVT with combination procedures of the legs and abdomen.  I typically with confine the liposuction to the lower back, abdomen, flanks with the addition of a tummy tuck.  I feel the extremities can be dealt with in another session.  Also I would prefer that all patients after abdominal rejuvenation whether tummy tuck with or without liposuction feel very comfortable with walking in order to help prevent blood clot development in the veins of their legs.  It would make sense that patients would be less inclined to get up and move around if they have had liposuction of their abdomen, flanks and a tummy tuck as well as liposuction of the thighs and lower legs.  Liposuction is always associated with a certain amount of swelling.  The more swelling that develops the more difficulty the patient will have with pain control after surgery.  As soon as the procedure is finished and the wounds are closed my patient's are placed into the appropriate garments to help decrease swelling.  Swelling typically peaks at 48 to 72 hours after a procedure.  With the compression provided by the garment the patient will help limit their swelling.  This in essence will allow them to move around with less discomfort.  In addition pain medications are more effective when there is less swelling at the operative site.  These are some of the considerations for patients before and after their procedure.  Liposuction is a great technique to both improve those difficult areas of the abdomen, back, flanks, inner and outer thighs as well as a great sculpting tool in thinner patients.

Diep flap surgery in the past was limited by a patient tissues.  I am speaking directly to those patients seeking reconstruction with their own tissues who do not want implants under any circumstances.  In many instances patients who were deemed to thin or those on the other hand who were felt to be to obese were denied the opportunity for this type of breast reconstruction.  Several thoughts have changed regarding DIEP flap surgery and breast reconstruction.  Since the introduction of the bipedicled DIEP flap, double stack DIEP, stacked DIEP flap more women who are relatively thin have been given the opportunity to have breast reconstruction surgery using their own tissue in the form of the DIEP flap.   This is particularly advantageous in situations where patients are having skin sparing mastectomy surgery.  This allows for the most complete breast reconstruction result where the mastectomy or breast skin has been saved by the breast surgeon and the plastic surgeon has the opportunity then to perform breast reconstruction surgery either with the abdominal tissue like a DIEP flap for optimal reconstructive outcomes.

Read an interesting Article in Scientific American, "The Naked Truth", on a flight home recently.  It distills down the pressure the environment posed for the early humans to adapt to the sweltering tropical climates in Africa.  We continue to evolve but the skin seems to be a constant battle.  Bare skin keeps cool but I am constantly asked by patients about laser hair removal.  In breast reconstruction where one breast is in the natural position, slightly drooping, I have to lift it, augment it or both.  If someone is concerned with the appearance of the facial tissues.  Many times unnatural appearances can be created if just the skin envelope is adjusted without any change in the position of the underlying tissues of the cheek and jowls.  It is part of the process of evaluation in  an office consultation to come up with a plan that will fit a given patient in terms of their expectations and the ability to reach expectations with their own tissues.

Several interesting topics were discussed at the Breast Surgery Symposium in Atlanta, GA at the Southeastern Society of Plastic and Reconstructive Surgeons Meeting.  A panel discussing Oncoplastic Breast Conservation Surgery & Nipple Preserving Mastectomy was extremely interesting.   For decades Plastic Surgeons have provided reconstructive options for women undergoing partial and complete mastectomy which are included but not limited to the permanent silicone gel implant, tissue expanders that are later exchanged for implants, expanders and or implant in addition to a latissimus flap, and the now various forms of flap from the lower abdomen and thighs such as the TUG flap, Free TRAM, Pedicled TRAM, and the increasingly popular DIEP flap. Despite all of the options less than 30 percent of women get a reconstruction.  This leads to finger pointing on both sides.  The plastic surgeons think the general or breast surgeons are not referring or discussing breast reconstruction in their initial consultation with the patients and the general surgeon or breast surgeons feel like they cannot get a plastic surgeon to see the patient.  Sometimes because of location there may not be a plastic surgeon nearby.  This is becoming less the case with the aid of the internet.  Finding physicians and surgeons is becoming easier.  There can be hurdles with insurance after that with respect to the providers.  Fortunately it is a Federal Law that women have the ability to under reconstruction after mastectomy and any symmetry procedures on the opposite breast.

One of the take home points from the panel to me was that great reconstruction outcomes can only  happen with great mastectomies.  That means the general or breast surgeon has to do a great job performing the mastectomy in order for the plastic surgeon to then perform the best reconstruction.  In cases of nipple sparing mastectomy the general or breast surgeon performs the mastecomy and sentinel lymph node biopsy and then performs a biopsy of the tissue behind the nipple to confirm there is not cancer.  At this point the plastic surgeon can perform the reconstruction with a comination of expanders and acellular dermal matrix.  The techniques can very among the plastic surgeons who perform the procedure but the outcomes should be great if the mastectomy was done well.  The final product shold look like a breast augmentatin rather than a breast reconstruction.

Fat grafting lips, fat grafting cheeks, fat grafting buttocks, fat grafting breasts have all been described over long periods of time.  Recently I attended the Southeastern Society of Reconstructive Surgeons Meeting in Altanta.  One of the Hot Topics was fat grafting.  In particular autologous fat grafting for breast augmentation.  There are numerous cosiderations with breast augmentation including breast augmentation cost, breast augmentation recovery time, breast augmentation risks, breast augmentation size as well as concerns of the patient on how they will look after breast augmentation.  Concerns over the natural appearance have led many, but most notably, Board Certified Plastic Surgeons, to seek out new avenues to provide durable, natural results with fat.  Liposuction surgery or liposuction plastic surgery allows a Board Certified Plastic Surgeon to harvest fat from the abdomen, flanks, hips and thighs in order to provide fat to augment a breast.  This process can be seen in liposuction surgery video or liposuction surgery pictures on websites and on television.  The majority of patients can be seen and examined to determine whether or not they are good candidate for liposuction surgery and autologous fat grafting breast surgery.  Liposuction procedures and liposuction prices will vary according to the region of the country where you are located.  Many times liposuction can be performed with the use of local anesthesia and sedation.  Liposuction plastic surgery for fat grafting lips, fat grafting cheeks, fat grafting buttocks, and fat grafting breasts can performed safely by Board Certified Plastic Surgeons.

It’s reported that in the United States an estimated 11.7% percent of the population (5.6% male and 17.1% female) is directly affected by chronic migraine headaches.  Chronic migraines are more common than asthma and diabetes combined.  Up until now there have been very few treatment options for patients who suffer from chronic migraines.

Recently it has been shown that the use of Botulinum toxin injected into muscles in the back of the neck, the temple area and the forehead can provide relief from chronic migraines.  In many instances there will be an elimination of the migraine.  If the patient responds to Botulinum Toxin they can be evaluated for the surgical treatment of Chronic Migraines.

Surgical treatment involves the release of the nerves in the back of the neck, the greater occipital, the nerves in the temple area, zygomaticotemporal, and the nerves in the forehead, supraorbital and supratrochlear nerves.  In addition several patients report headaches or symptoms related to the sinuses.  Each patient is evaluated for sinus issues as well as airway issues.  Patients can have problems within their nose that can actually cause a migraine such as a septal spur.  If appropriate patients with septal problems can undergo a procedure to correct this at the same time of at a later date.

I feel fortunate to be able to offer this as another alternative to patients with Chronic Migraines.   It is my hope that I will be able to help as many patients as possible by giving them back the quality of life they’ve lost due to chronic migraines.