Plastic Surgery Taxation Discussed By Terry L. Hand, MD

Help me understand this.  I choose to have a Botox injection.  You choose to have your hair cut and colored.  I save Read the rest of this entry »

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The Marin County Facelift Cunundrum

OK, you have decided that you want a facelift.  Easy enough, but now you are worried.  Should you have the Lifestyle Lift or maybe the Quicklift or possibly the Acculift?    These procedures can be viewed on slick advertisements with glowing testimonials on TV and in print ads.  Of course, all of these are names for facelift type of procedures.  Why are they named?  Well, it’s the new (pardon my pun) wrinkle in cosmetic surgery, the copyrighted procedure!  The government in its wisdom has, appropriately so, prohibited the use of patent restriction of any surgical procedure.  However, anyone can take an existing surgical procedure, alter it or not alter it and give it a name, which is then copyrighted.  What this means is, any doctor who performs facelift procedures, can do any procedure on you but cannot call it by the name that has been copyrighted.  Only a franchise doctor can use the copyrighted name.  This then is an advertising and promotional gimmick.  There is no secret magic to the surgical procedure.

So you ask, what is different when evaluating these cleverly named procedures?  All facelifts are not the same.  Most of the procedures currently performed were developed over many years, by a variety of contributors.  Traditionally cosmetic surgeons named the procedures with rather unsexy but descriptive names such as the SMAS  facelift, the deep plane facelift or the minilift.  Facelift procedure techniques  have always been reported upon at professional meetings and in medical journals.  Techniques evolved because of the willingness to share knowledge and to further the skill sets of both cosmetic surgery colleagues and new physicians.  In the current advertising market,  old techniques are renamed and branded as spanking new techniques that may only be performed by a select few doctors.  The truth is that any real plastic surgeon that is certified by the American Board of Plastic Surgery and a member of the American Society for Aesthetic Plastic Surgery and the American Society of Plastic Surgery has been well trained in all of these techniques, regardless of whether or not he utilizes the cool new name.  The choice of which technique would most benefit the individual patient is what is truly important.  In my industry, one size does not fit all.

The facelift procedure by any name is designed to rejuvenate your facial appearance.  The problem with your facial appearance may be skin, muscle and/or neck laxity possibly combined with fat excess and/or atrophy.  Some patients may need only a skin tightening procedure.  Others may need a procedure that tightens both skin and muscle or possibly the neck bands.   Of these,  some may need an extremely limited procedure and some may need an extensive procedure to achieve maximum benefit.  The skin itself may need to be resurfaced to correct aging changes.  The facial skeletal structure may need to be supplemented with fat or a dermal filler,  or perhaps a chin or cheek implant.   The bottom line… multifactorial facial aging changes means one procedure does not serve all needs.

If you go to a heavily advertised facelift mill or copyright promoted surgeon and receive only the promoted procedure, you are generally receiving a minimally invasive procedure that does little more than skin tightening (often costing more than the same procedure with your local plastic surgeon).   The allure of many of these promoted procedures is that there is minimal downtime,  minimal cost, rapid recovery and can be done under local anesthesia.  This sounds wonderful.  It’s kind of  cheap and quick with no anesthesia risks, and I can go back to work in a couple days.  Who would not want that?  Cosmetic surgeons who are well-trained and aware of all the variables that are involved in achieving an optimal outcome, would be doing these lesser procedures without the copyrighted name on every patient,  if indeed they were all you needed.  Also,  in my many years of performing cosmetic surgery in Marin County, I rarely have seen a facelift that does not require at least a week of downtime to look socially presentable.

In some of the TV and print ads that I’ve seen  for procedures with copyrighted names, the results as shown were wonderful.  However, most often the individual in these ads  has obviously also had a brow lift, a blepharoplasty (eyelid lift) , dermal fillers,  fat removal and/or repositioning and a neck band revision.  The cost of these additional procedures  would certainly exceed the baseline advertised price.  The time involved to perform the additional surgeries would monumentally add to the  complexity of the case.  The advertised 1 hour procedure would certainly be extended to  four or five hours, making it virtually impossible to perform the procedures comfortably or safely on a patient without general anesthesia.  Is this a bait and switch?  Consider this as well, if you read the fine print on the bottom of the TV screen, the advertising physician is not the one who has performed the surgery on the individual shown.  And, your chances of getting the doctor who did perform the surgery that you are admiring are slim to none.  You have seen a great before and after that was not performed by the doctor advertised.  Also, if you have the surgery at that facility, you may never see the doctor who operated on you again.  Follow-up, even if you have problems, may be done by ancillary personnel.

If you are considering responding to ads that you’ve seen, I would ask that you first see a local board-certified plastic surgeon (names readily obtainable from the ASAPS online).  During this consultation, have the doctor explain what needs to be done:  skin, muscle, fat, fillers, resurfacing.  Ask specific questions regarding scar placement and what your anticipated recovery time will be.  Remember that just because an ad makes a claim, reality may look very different.  Make sure that you view before and after photos of actual patients that have had a procedure performed by the doctor that you are considering.  If your budget is limited, tell him what you can afford and ask what his recommendations would be.  Remember, if a surgical procedure is quick, minimally invasive, and cheap;  you usually don’t get much no matter where you have the procedure.  You may indeed benefit if you need  minimal correction from less of a procedure.  However, if the procedure will do little or nothing to correct your concerns (example:  sagging neck skin),  it is unethical for the doctor to take your money.  The maximum benefit that you will receive is best called, a wallet lift.

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Breast Lift Or Breast Augmentation, Maybe Both!

What is the best choice of cosmetic surgery procedures in San Francisco and Marin County for the woman that has sagging breasts and would like to restore or add some volume to the breasts?  A breast lift (mastopexy) or a breast augmentation.  Maybe both!

I see many variations of patients in my San Francisco Bay Area/Marin County plastic surgery practice that are primarily seeking correction of sagging breasts and often looking for  more youthful and fuller upper breasts.  Often because of pregnancy, breast feeding or simply a weight loss, the breasts begin to look flattened at the upper poles, the cleavage is much less firm and the general volume of the breast itself is greatly reduced.   At the cosmetic surgery consultation, I am often asked if a breast augmentation alone will “fill up” the breast enough to correct the sag.  The answer is sometimes.  Not a very definative answer and here is why.  A minor amount of sag in a small to medium sized breast is often correctable with an implant.  The implant diameter must be appropriately sized in order to achieve a natural cleavage.  If  too small diameter implants are placed, the breasts seem as if they are spaced too far apart.  When the implants are too large, the breasts seem very close and the breasts appear too large for the woman’s chest.  Sometimes,  the best solution is to lift the breast while enlarging it to a naturally full and youthful size again.  The desired outcome of breast augmentation is a larger breast with the nipple at a natural position.  It is not aesthetically pleasing to have a nipple that continues to point downward, even though the breast is fuller. A quick consultation can confirm the appropriate solution to accomplish the desired correction.

Recent years have also brought the advent of implants with moderate to high projection.  These are valuable tools because I often see small chested women that request large breasts.  When a standard moderate implant is used, the diameter of the implant may be too large for the chest.  The patient almost always is desiring projection rather than breasts that fill the entire chest wall.  A high profile implant will have the same amount of fill volume but with a smaller diameter.  Thus, more projection is achieved with a more natural look to the chest wall.

I perform a variety of different breast procedures but always recognize in the surgical planning that the outcome should correlate to the patients lifestyle, athletic choices and desired result.  

 

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Some Thoughts About Healthcare Reform

After  a bit of a hiatus, OK four months, I am back to blogging.  Sorry about the stop and start but I realized that I did not just want to blog about current plastic surgery topics and procedures.  I wanted to share my opinions as I said I would.  Soo ….. forget about the PC safe subjects only, today I have another issue on my mind.  I’ve been following closely the national debate over health care reform.  As a practicing plastic and reconstructive surgeon, I have been amazed by some of the statements I have heard.  A couple of examples: When the insinuation that doctors perform certain medically necessary surgical procedures solely for the purpose of greater financial remuneration was made, I almost jumped out of my seat. When I heard President Obama state that if hospitals sent a patient home and he became ill 2 weeks later, they didn’t do it right and should be penalized financially, again I was livid. The suggestion that maybe the American public would have to get used to the usage of generic instead of brand named medications, only added to the absurdity of the generalized explanation of the problems with health care.  I can only speak definitively for my practice and experiences in providing health care, but I know many of my colleagues in most specialties practice the same standard of medicine as I and are hesitant at best to have this group of bureaucrats deciding the future of American health care.Â
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Doctors as a group are a hardworking and ethical group, following a standard practice of conservative care first and surgically intervening only when a non-surgical course does not or cannot solve a problem.  Sometimes, a patient is in eminent danger or the problem cannot heal itself without dire consequences.  Do I operate on folks that I don’t think need surgery, NO!  What great gain is in it for me if I do?  When I do a surgery that is insurance related, the visits within the following 90 days after surgery are considered follow-up care, as they should be.  There are no additional charges for visits (which can be frequent depending on the surgical issue) , dressing changes, suture removal, etc.  I can charge anything I want, but what insurance will pay is the real factor. Most physicians base their charges on standard billing amounts for the appropriate descriptive codes.  Medicare sets the trend for physician reimbursements and the health insurance companies follow.  How many of you have gotten the note from your insurance company that a bill is “beyond the reasonable and customary amount”?  I can’t count the number of patients that are amazed at how little I was paid given the level of time and expertise it took to put them back together.   Â
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As for the hospitals, human beings are protoplasm that is constantly changing.  Most will leave the hospital and continue to do well, some will become ill again.  There are multiple factors in recovery from any illness and some individuals will struggle because of preexisting health issues or chosen behaviors.  Think about this example, a 65 year old diabetic smoker with a wound infection.  He goes home, does not monitor his blood sugars, has a few drinks and lights up.  Oh, and he only takes his antibiotics once a day instead of 2 times.  He doesn’t come in to his doctors office for his follow-up appointment.  Guess what happens, it is the weekend and he starts running a fever and has a large red area around his wound.  He heads off to the emergency rooms to “fix it up again”.  Is the hospital at fault? Perhaps the doctor?  Maybe the patient? Regardless, if this man has insurance, he is and should be covered for this problem.  The slippery slope of 2nd guessing fault instead of accepting responsibility for the delivery of health care to an insured individual,  is one that most of us probably do not wish to start down.  What happens next?  Will it cost more for health insurance to be 10 pounds overweight, to ride a motorcycle or to have a genetic propensity for high cholesterol? 

I do believe that presidential speechwriters do alot of research and are masters of wording, but, and it is a big but, they are not physicians and neither is he.  There are many times that I believe a generic medication can be used, but often a brand named drug is the most recent addition and the most appropriate.  What is the difference?  The brand name is “on patent” for 10 years, the generic is no longer on patent.  Why does the brand name cost more?  Of course, there is profit involved, but also expensive research and development and the process of safety checking and research studies needed to gain approval by the FDA.  I and most of my colleagues understand the importance of making prescriptions financially reasonable for our patients.  Almost daily, my office deals with an insurance company that will not honor a prescription unless it is changed to a less expensive one on the drug formulary.  This is the part of health care that is broken and what does our government do?  Agree with the insurance companies!  There might be more to worry about in my opinion like the salaries of health care company CEO’s that range from a paltry 3 million to 24 million dollars a year.  Maybe if that was regulated too, we could all get the name brand medications!

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Marin County Vaser Liposuction

One of the most popular procedures for both men and women in my Marin County plastic surgery practice is Vaser liposuction.  Although I have been performing liposuction for over 20 years, I am always delighted to see the difference this procedure can make for so many of my patients.

The ideal liposuction candidate is at a comfortable, stable body weight pounds.  Liposuction is commonly performed on the neck, arms, abdomen, flanks, thighs and knees.  Vaser liposuction is not a method of weight reduction but very often my patients will continue to lose a small amount of weight after the procedure to compliment their result.  It really is a  “feel good” surgical procedure in that it resculpts annoying areas that previously were resistant to weight loss or exercise.  I also utilize  liposuction to tailor bulky adjacent areas when performing breast lift or abdominoplasty (tummy tuck).

I find that with Vaser liposuction there is very little postoperative pain.  Most of my patients experience about 2 hours of real discomfort after the procedure and are minimally sore in the following days.  I do require that they wear a special liposuction garment for about 3 weeks that greatly assists in postoperative swelling and skin retraction.

The above patient is an excellent example of a woman that is of normal weight but has experienced accumulations of fat on her abdomen, hips and upper thighs.   The contour of her hips and thighs were greatly improved and her  abdominal definition and shapely waist were redefined.  Her general appearance in and out of clothing was very pleasing to her.

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2008 Top Plastic Surgery Procedures

I always find these statistics interesting as to what the top plastic surgery procedures are nationally compared to our practice.  This survey was performed by the American Society of Aesthetic Plastic Surgery, the only professional society requiring  a plastic surgery residency and board certification by the American Board of Plastic Surgery and documented specialization (lots of cases!) in cosmetic surgery of the face and body.

For the past 11 years, liposuction has always been the top surgical procedure.  This year breast augmention has taken over with liposuction as 2nd, eyelid surgery 3rd, rhinoplasty 4th and abdominoplasty 5th.  Botox continues to lead the nonsurgical procedures as most popular with  laser hair removal and hyaluronic Acid dermal fillers in popularity.

The top 2 procedures for women were breast augmentation and liposuction.  The top 2 procedures for men were liposuction and rhinoplasty, with eyelid surgery following the top two for both sexes.    At my Marin County cosmetic surgery practice, I would probably designate vaser liposuction and eyelid surgery as my top 2 requested  procedures.  Often, different areas are addressed at the same  time surgically,  particularly with mommy makeover  (breast and tummy)  and facial surgery.  Of  interest this year is the increased usage of dermal fillers and Botox for patients interested in correcting minor facial issues with little downtime.

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Franchise Plastic Surgery – Good or Bad?

So today I want to talk about a topic that I find to be very frustrating for both board certified plastic surgeons and patients alike, franchised clinics employing questionably qualified, inexperienced doctors to perform cosmetic surgery . I recently had a consultation at my Marin County practice with a patient in her mid 60′s that was referred in by another of our patients. She had told her friend about this plastic surgery clinic she had visited after seeing their amazing results on TV. After a consultation, she was told she needed a minifacelift, her procedure would be finished in an hour and she could have it in a comfortable chair with nice music and minimal sedation, at a fraction of the cost of a real facelift. Her friend said “That doesn’t sound right, why don’t you check with Dr. Hand.”

Her friend was correct in questioning the procedure. After examining this delightful lady, it was clear that she had many of the typical aging changes associated with being in her 60′s with no prior corrective procedures. Her neck had lost definition and had sagging skin. Her jowls, midface and facial muscles were lax. What she really needed was a complete facelift that would resuspend and redefine her neck. Her facial muscles needed to be lifted and skin needed to be removed from in front of the ear and behind to lift the face and neck homogenously. To have kept this lady comfortable, general anesthesia would have been necessary for a 3 to 4 hour procedure, not 1 hour. A minifacelift would only have lifted the skin in front of the ear and would not have addressed her concerns adequately. Her neck would have remained the same and her muscles would not have been lifted. She would have seen very little improvement based on her initial facial issues.

When digging a little further, she had seen before and after photos but wasn’t sure they were the results of the doctor that had consulted with her, or even if he would be performing the surgery. She was pressured that she needed to sign up today for this great deal. Her free consultation turned into a $400 visit by the end of the appointment.

My opinion is this: here in the San Francisco Bay Area, we are lucky to have many plastic surgeons certified by the American Board of Plastic Surgery and that are members in good standing of the American Society of Plastic Surgeons . Additionally, many of those are members of the American Society of Aesthetic Plastic Surgery, a society that recognizes experience and proficiency in aesthetic cosmetic surgery. Both of these organizations represent the gold standard for plastic and cosmetic surgery training. In California, any doctor can represent themselves as a cosmetic surgeon if he or she is board certified in something, anything. Think about a OB/GYN, ER doctor or radiologist taking a weekend course and viola, a procedure is learned. Experience, training and education matter. Research your doctor, do not be pressured, go in for as many consults as you need and don’t fall in love with the salesperson at the office that promises great things. The surgeon is the one doing the surgery and should answer all of your questions until a complete understanding is achieved. Photos that are presented should be of patients your doctor has performed the surgery on, not of someone else’s work . Make sure the surgeon is doing your followup and will be accessible for hand holding after a procedure. A patient should know how often followup will be scheduled and that a drop in appointment is available for concerns, any concerns.

The patient I just discussed went on the further research the clinic that had seemed so promising and realized she would not have been happy with the procedure. She is now making a plan to have a facelift procedure that will actually correct her concerns when she is ready to schedule.

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Liquid Facelift Vs. Marin County Cosmetic Surgery

Let me give you an example,  the patient below needed a facelift and eyelid lift.  Her neck had lost definition, her jowl lines were softened and her midface was sagging.  To have merely injected dermal fillers and Botox into her face would have created relaxed muscles in the areas that were already relaxed and a puffiness to her face that did not match her distinctive look.  She was better served by performing a facelift and an eyelid lift, followed by strategically utilizing  injectable dermal fillers, Radiesse and Restylane, to correct the nasolabial lines.  Her facial muscles were tightened, her midface was lifted with her eyelid lift, her neckline redefined and the extra skin from her face and eyelids were removed.  No Botox was used on this patient.

The next patient was an excellent candidate for Botox and injectable dermal fillers, but again, they were used as an adjunct to cosmetic surgery.  Before surgery, this patient had lower lid puffiness and upper lid drooping that was correctable only by an eye lift.  She had midface laxity and her nasolabial lines were prominent,  as were the lines between her brows.  Botox was  utilized to weaken her brow lines and the the lines in her crow’s feet areas, and to slightly lift her brows.   Restylane was used to correct her nasolabial lines.  However, the greatest correction was seen following her upper and lower eyelid lift.  At that time, extra skin and muscle were removed, the malar fat pads (over the cheekbones) were repositioned and the midface was lifted.

There are certainly times when the physical anatomy of the face or financial choices make the usage of Botox and injectable dermal fillers, without cosmetic surgery, a wonderful choice.  My concern is that patients need to be informed of all methods, tried and true, that may be of benefit  for the cosmetic concerns that they are trying to solve.  Dermal fillers and Botox are great temporary solutions, but when used in great quantities to avoid a surgical solution, their costs can be equally as daunting.

My recommendation:  By all means utilize these valuable nonsurgical solutions, however, an informed plastic surgeon can assist you in providing a reality based plan for your short-term and long-term goals.  At my Marin County plastic surgery practice, I evaluate every patient’s individual needs so that you understand all of your options prior to treatment.

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Eyelash Lengthening Treatment Latisse In Marin County

Now available at our Marin County cosmetic surgery office, Latisse!   We are very excited to be offering the first FDA-approved treatment for eyelashes.  Latisse has been shown to produce a 25% increase in eyelash growth (length), a 106% increase in fullness and thickness and a 18% increase in darkness.  Results start to be apparent 4 weeks into a once nightly treatment regime with increased length.   The length, volume and darkness will continue to progress. After about 16 weeks or when your lashes reach a length that pleases you and your lash volume has dramatically increased, treatment can be stepped back to 2 to 3 times per week.

Since this is a prescription treatment, a quick appointment and discussion about  the application of Latisse will be necessary.  My office staff will be using Latisse and documenting their progress monthly.  Stop by and get your supply.  We’ll photograph you at 2 month intervals to document your progress too! 

These photos are unretouched patients prior to starting treatment with Latisse and then again at 16 weeks.  Pretty impressive!  Call our Marin County office  (415-461-6742)  in the San Francisco Bay Area soon to get started.

 

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San Francisco Bay Area Plastic Surgery

Welcome to my inaugural blog! For so many years I have had the privilege of treating wonderful patients from all over the San Francisco Bay Area and beyond. My challenge has always been keeping up with new and old faces (sorry for the pun!) and making my patients aware of the latest in interesting cosmetic surgery procedures as well as what is happening in our practice. I will share with you innovative research and techniques in the plastic surgery community and my opinions regarding their value. I can most often be found with a medical journal in the evenings and have seen in my years of practice, many variations on almost every procedure. Some are time tested and true. Some are hype. I will share my honest opinions and experiences.

My Marin County plastic surgery practice provides face, breast and body recontouring procedures as well as non-invasive procedures such as Botox, injectable fillers and Latisse.  Thanks for checking out my blog, more soon!

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