From the Miami Herald comes a terrifying story about a plastic surgery group tied to multiple patient deaths. The surgical group which operated out of three different south Florida clinics are responsible for at least three deaths, including the recent death of a young woman from West Virginia, Heather Meadows, 29, who had traveled to south Florida looking for cheap plastic surgery.
In addition to this case, come reports that the group housed post-operative patients in a local horse stable. The clinics; Encore Plastic Surgery in Hialeah, and two Miami clinics; Vanity Plastic Surgery and Spectrum Aesthetics have also been linked with multiple serious medical complications including the case of Nyosha Fowler who was comatose for 28 days after surgeons at the clinic accidentally perforated her intestine and then injected the fecally contaminated fluid into her sciatic nerve during a liposuction/ fat transfer procedure. Ms. Fowler, who is lucky to be alive, is now permanently disabled and facing a two-million dollar medical bill for the life-saving care she received at an outside facility.
Now, Heather Meadow’s death has been ruled accidental, which is no comfort to her family or the numerous patients harmed by these surgeons. While the state of Florida has reprimanded two of the surgeons in the surgical group in the past, this hasn’t affected their practice, and the surgical clinics continue to accept new patients from across the United States and operate on unsuspecting clients.
Beauty, at any price?
While Florida state health officials issued an emergency restriction prohibiting one of the group’s surgeons, Dr. Osak Omulepu from operating, no charges have been made despite cell phone photographs documenting horrific conditions at the horse stables where patients were forced to stay while they recuperated from various procedures. In fact, Dr. Osak Omulepu continues to have four star ratings on several online sites. His license is listed as active on the Florida Medical Board, with no complaints listed under his profile page. However, under the disciplinary actions page, there are eight separate listings that do not appear on his general profile.
One of these Complaints, (posted here) related to the death of a 31-year-old woman due to repeated liver perforation during liposuction. The complaint also cites several other cases against the doctor and notes that Dr. Osak Omulepu is not a board certified plastic surgeon. In fact, according to the complaints filed in March, the good doctor, holds no certification in any recognized medical specialty.
Now this Florida story has botched written all over it – from start to finish.. It starts with an insecure man seeking ‘underground’ penile injections from an unlicensed person for penis enlargement.. and from there, it only goes downhill..
From bad to worse..
After being deformed and defrauded by a scam artist named Nery Gonzalez who offered illegal, and dangerous ‘penile enhancement treatments’, the bargain-seeking Florida resident stumbled into the offices of another incompetent provider,Dr. Mark Schreiber, a plastic surgeon who lost his license several years ago after several botched plastic surgeries following initial investigations in the deaths of two of his patients.
Dr. Mark Schreiber – multiple patient deaths, license revoked, but had a nice website
After the death of the second patient (also a penis enlargement case) in 2002, Florida revoked Dr. Schreiber’s license. In 2008, he went to prison for practicing medicine (and operating on patients) without a license.
In the most recent case, the victim is now deformed, and unable to perform sexually due to his disfigurement.
There’s a new editorial over at the IMJT on Ebola, medical tourists and the medical travel industry. In the article, “Ebola: a hot topic for the next medical tourism event?” by Ian Youngman, he explores the potential pitfalls from medical tourists who are seeking treatment overseas. As an insurance expert, who makes his living by preparing for “What if?” scenarios, the author offers valuable insight on a topic that has provoked wide speculation and fear-mongering among the general media.
Mr. Youngman explores current medical screening at airports, the impact on current medical tourists as well as the potential impact of a global pandemic/panic on the medical tourism industry. Mr. Youngman urges for a clear, reasoned and cohesive discussion and response from leaders in the medical tourism industry.
Death of young patient raises questions of safety
IN other news, the BBC is reporting on the recent death of a 24 year old British medical tourist. While the BBC article offers few details on the patient who died during a liposuction procedure in Thailand, a more in-depth report from the UK Mail reports that the woman stopped breathing after receiving anesthesia at the private medical clinic. The article reports that this was a repeat visit for the patient, who had previously undergone another plastic surgery procedure at the clinic.
Now questions are being raised about the doctor’s qualifications to perform the procedure, as well as the lack of availability of life-saving medical equipment at the medical clinic. The doctor at the clinic, Dr. Sombob Saensiri has been arrested while this case is being investigated.
Note: There are conflicting reports regarding the exact circumstances of this patient’s death. An Asian story reports that the patient had returned after a recent surgery with complaints of a developing infection.
As reported on Sky News and the New York Times, there has been a radical turn around regarding the use of bariatric surgery to prevent/ control and even “cure” diabetes.
Not a vanity procedure
Once relegated to the category of a” vanity” procedure, bariatric surgery has emerged as a legitimate, life-saving intervention which has been scientifically proven to have multiple major health benefits.
For years, patients have had to jump numerous hurdles to be considered for this procedure. One of the biggest hurdles was often that patients were not considered fat enough to qualify for this procedure. The traditional guidelines restricted surgery to morbidly obese people, and then required these patients to perform numerous tasks to be considered eligible candidates of surgery such as attaining a diagnosis of “carbohydrate addiction” and losing weight prior to surgery as a sign of “commitment” to weight loss. This was in addition to several months of therapy with nutritionists and counselors.
A punitive process
While including this ancillary education may have assisted patients post-operatively, it also felt punitive to people who were seeking medical help. No one forces lung cancer patients to attend smoking cessation courses or counselling before having their cancer treatment nor do we require several sessions of pre-operative classes prior to a bowel resection.
New guidelines – perform surgery earlier (2012)
But as the data started to emerge that showed long-lasting health benefits of surgery-assisted weight loss, debates raged between International and American physicians. Several years ago, several international organizations such as the International Diabetes Federation began to recommend lowering the eligibility criteria for bariatric surgery – particularly for patients with documented complications of obesity present (diabetes, coronary artery disease, severe orthopedic injuries). But these recommendations were ignored by American medical societies and many physicians including the doctors responsible for initiating referrals to bariatric surgery programs. Americans. it seemed were reserving the the more effective treatments (like gastric bypass or gastric sleeve) for the super-obese, and the prototypical 600 pound patients.
Obese patients who did not meet these rigid guidelines were often sent for less effective procedures like lap-band or balloon placement. Insurance companies often denied payment stating that surgery in these patients were ‘not medically necessary’ and thus it was considered a ‘vanity’ procedure. Additionally, in most cases, the procedures failed to produce meaningful or long-lasting results.
Adding stigma and shame to a medical condition
Patients who were overweight and seeking definitive treatment were often made to feel “lazy” for being unable to lose weight without surgical assistance. They were also told to return only if they continued to fail (or gain weight).
The Diabetes Pandemic
But as the obesity pandemic continued to escalate at breakneck speed along with obesity-related complications (and healthcare costs skyrocketed), the evidence began to become too overwhelming to ignore.
New guidelines were passed for eligibility criteria for gastric bypass procedures. These guidelines reduced the necessary BMI to qualify for surgery, especially in patients with co-morbidities such as diabetes. But it still ignored a large segment of people; non-morbidly overweight people with early diabetes – the very group that was most likely to have a high rate of success and immediate normalization of blood sugars*.
But now the government of the United Kingdom and the National Health Service (NHS) have adopted some of the most progressive recommendations world-wide; aimed at stemming the tide of diabetes and diabetes-related complications such as heart attacks, strokes, renal failure, non-alcoholic fatty liver disease (NASH) and limb ischemia leading to amputation.
The NHS should be commended for their early adoption of eligibility criteria that lowers the BMI requirement to 30 in diabetic individuals and eliminates this requirement entirely in diabetes of Asian descent**. Conservative estimates believe that this change will make an additional one million British citizens eligible for bariatric surgery.
* As a ‘cure’ for diabetes, gastric bypass is most successful in people who have had the disease for less than eight years.
Surge of patients but few surgeries
But can supply keep up with demand? Last year, according to the our source article (NYT), only 9,000 bariatric procedures were performed in the UK.
**Diabetics of Asian and East Indian heritage (India, Bangladesh, Pakistan) often develop a more severe, aggressive, rapidly progressive form of diabetes which is independent of BMI or obesity.
In the most recent case, four individuals have been arrested for impersonating surgeons and operating an unlicensed surgery clinic. According to the media reports, only one of the four people charged is a licensed physician, nurse or other trained healthcare provider – but that didn’t stop them from performing major operations such as liposuction and abdominoplasty procedures on their unknowing patients. While Dr. William Marrocco* was the doctor on record for the clinic – patients report that he wasn’t the one operating!
Unlike many of the ‘chop shops” we’ve written about that take place in garages, motels and private ‘parties’, in this scenario, unwary consumers were duped by a savvy group of criminals who had owned and operated the “Health and Beauty Cosmetic Surgery” clinic in downtown West Palm Beach.
*The good doctor Marrocco remains a legally licensed doctor in the state of Florida – though interestingly enough – he does not have prescriptive privileges. One the Florida Department of Health website, Dr. Marrocco (whose secondary address corresponds with the clinic address) reports active licenses in Virginia, Pennsylvania, Michigan, Indiana and Nebraska.
But let’s check it out… so I did my own preliminary online search –
Virginia: No records found. No active or past licensees (expired in the last five years) found. So he may have had one – but not recently.
Michigan: Three expired licenses – one for student status (resident) and one as a pharmacist.
Indiana: Dr. Marrocco was a licensed plastic surgeon in the state of Indiana from 2000 to 2011 and has a notation “reinstatement pending‘. Maybe Dr. Marracco is planning on heading back to Indiana – where his license remains unblemished – despite the scandal surrounding the 2003 death of his wife after he performed liposuction on her). License # 01052282A
Nebraska: Expired, license #2909, educational license permit (training) affiliated with Indiana University
Jorge Nayib Alarcon Zambrano – (one of the individuals charged) is listed as a member of the Colombian Society of Plastic Surgeons – from Cali, Colombia. So he may be a trained surgeon, just not a very good one (and not licensed in the United States).
Licensing isn’t everything..
Kind of goes to show some of the pitfalls of relying on licensing boards for consumer protection. Dr. William Marrocco was a licensed plastic surgeon, but that’s little consolation for many patients at that West Palm Beach clinic.
In fairness to Dr. William Marrocco, Jorge Alarcon and the other individuals in the case – they have been charged with multiple counts, but have not been convicted of any crime. Until that time, they remain innocent until proven guilty.
Apologies to my loyal readers for the long lapse in posts but my plate has been pretty full. But I will be finishing my latest assignment in a few weeks and starting a couple of new projects for the summer months.
I applied for and received a new assignment from Examiner.com to expand my focus to include more than just health topics. Now I will be able to write more articles focusing on life and culture in Latin America.
Colombia Moda 2014
To kick-start my new assignment, I have applied to attend Colombia Moda 2014.
Last year’s speakers were promoting the concept of “re-shoring” and changing from the traditional ‘seasonal’ lines and collections to an ongoing, evolving fashion line with new designs and items being designed, developed and sold to the public in shorter mini cycles.
This year – I’ll be able to cover all of this – along with interviews with individual designers, fashion lines and the Colombian fashion and textile industry. (Last year, my articles were focused on the role between fashion and plastic surgery).
Fashion is so intrinsic to Colombian life, and many parts of Latin America, so I am really excited about it. It plays such an important role in the economic, social and an even personal lives of many Colombians.
I won’t have an assistant this year – but I am getting a new lens for the event (I will be journalist/ photographer for the event).
After Colombia Moda, I will be flipping back and forth between writing about culture and my ‘usual’ medicine and health storylines.
I will be staying in Colombia for several weeks as well as covering the Latin American Association of Thoracics (ALAT) conference at the end of July. It’s one of the biggest international conferences in thoracic medicine/ surgery with many of the legends of thoracic surgery planning to be in attendance.
In August, I’ll be heading across the globe to interview the head of an innovative surgical program.
I’ll be checking in along the way – and posting photos, interviews and articles as I go.
I’ve heard that several times since I’ve been here – but it’s not exactly as it sounds. It’s slang: like saying “goofy-footed” when referring to snowboarders. It means that I am left-handed, or left-hand dominant, since the operating room requires you to be somewhat ambidextrous.
So this week – that was one of the things I set out to do – to become more proficient with suturing with my right hand. It wasn’t as hard as I expected but I certainly don’t have the speed I have with my left hand (which sadly, isn’t that fast).
Monday
Today wasn’t a great day. Everything went well – harvested vein, closed incisions, in the operating room so it should have been another fantastic day – but…. I just a felt, a little lonely today, I guess. Or maybe lonely is the wrong term – since I live with three other people here in Sincelejo. I guess what I meant to say is it’s the first time I’ve really felt alone since I’ve been here – and it was kind of surprise to feel that way.
I guess because I am used to traveling frequently and in making unfamiliar surroundings my home that it came as an unexpected pang when I suddenly missed the camaraderie I have had at other hospitals. Everyone has been fantastic here – particularly Iris, who I consider to be a good friend, but it’s not quite the same.
My name is Kristin.. Kristina is someone else
Here in Colombia, many people struggle to pronounce my name so it’s usually simplified to “Kristina”. But that’s not me. Just like my name, I feel like a bit part of my personality just doesn’t translate into Spanish well. Not as a cultural metaphor or anything ‘deep’ like that – but literally. When something that you take for granted – like having an extensive vocabulary at your disposal, is redacted, it kind of changes how you express yourself. It also changes peoples’ perceptions of you.
Just for five minutes – I desperately wanted at least one person who really “knew” me to be there.
Dr. Barbosa is a fantastic teacher and a very intelligent and kind person – but we don’t have the kind of friendship that I had with either Dr. Embrey (in Virginia) or Dr. Ochoa (in Mexicali). Part of that is probably due to the fact that I just haven’t been here all that long. I worked with Dr. Embrey for almost three years. Dr. Ochoa and I were together five to six times a week for months.
The other part is Dr. Barbosa himself. Our perspectives are fairly different, so that tends to complicate things. He is always friendly but still a bit reserved with me. That might be due to the fact that I am still lacking fluency in Spanish. (I understand a heck of a lot more that I can speak – but even so, colloquial phrases and subtle nuances in speech are usually a complete mystery to me). So I miss most of the jokes in the operating room, or figure it out about five minutes too late to be part of the conversation.
But after a little while that feeling of intense ‘alone’ dissipated – and everything went back to normal, whatever that is.
Tuesday
This morning I went by the Cancer Institute of Sucre. I had written to them last week, but received no reply, so I decided to stop in. After about an hour, I was able to talk to one of the administrators but she said that I had to submit all my questions about their cancer treatment programs in writing, in advance. I explained that is not how it usually works, and left my card. I am sure that will be the last I hear from them. It’s a shame because the facility is beautiful, sparkling and new. They advertise a wide variety of cancer treatments including brachiotherapy and thoracic surgery so I would have liked to know more. (The website looks like something circa 1996, so it’s not really possible to get information from there.)
Another case today – another saphenectomy! But this one came with a potent reminder. While I still need practice, I feel more capable of performing the procedure that I did before. Things proceeded well, if slowly (still need a headlamp!) but then it turned out that the internal mammary wasn’t useable so Dr. Barbosa needed more vein conduit. Which he proceeded to harvest himself, in about five minutes. So – I still plenty to aim for.
The holiday week started mid-week, but I am still hopefully for a few new consults tomorrow. I know we probably won’t have any surgeries over the ‘Semana Santa” period, but I can’t help but keep my fingers crossed anyway.
Wednesday
Aortic valve replacement*** today. Dr. Salgua showed up early today – and looked pretty determined, so I decided just to stay out-of-the-way. I figured since it wasn’t a vein harvesting case, I shouldn’t make a fuss. After all, I am just a visitor here – and I’ll be leaving soon.
Not my best photo by far – but my favorite part of this surgery – placing the new aortic valve into position
Instead, I stayed behind the splash guard and took pictures – since aortic replacement is the “prettiest” of all cardiac surgeries. Unfortunately, my position was a little precarious, balanced in two steps – and still barely above the splash guard. So many of the best shots – ended up partially obscured. (But I don’t want to give up any more surgeries to get better photos.)
Received a consult from the cath lab today but surgery will probably be delayed due to the Easter week holiday. (The team is willing to operate 24/ 7 – but few else are.)
Both our patients from earlier this week are doing great. Monday’s patient passed me several times doing laps on the med-surg floor. He’ll probably go home tomorrow or Friday.
Thursday
No surgery scheduled for today. Rounded on the patients from this week and spent some time explaining medications, post-discharge instructions and other health information with the patients and their families. While I love the operating room – this is the part I enjoy the most: getting to know my patients, and getting to be part of their lives for just the briefest of moments. It is this time with patients – before and after surgery that makes them people, families – not legs or valves or bypasses. Without this part, I am not sure I would have the same satisfaction and gratification in my work*. I love seeing patients when they return to the clinic for their first post-operative visit – to see how good they look, and how much better many of them already feel.
This afternoon – was exactly that as one of my first patients returned to the clinic after surgery. The patient looked fantastic! All smiles, and stated that they already felt better.
After seeing patients in the clinic, we packed up and headed for home. Since we currently have no surgery scheduled for next week (Semana Santa), and our other consults are pending insurance authorization, I don’t know when or if I will be returning to Sincelejo before I depart for the United States.
*As I say this, ironically, I am hoping for a ‘straight surgery’ position for one of my future contracts, so I can refine/ improve my surgical skills for future contracts in different settings that encompass a variety of duties.
***More Aortic Valve articles, including my famous “Heinz 57” post can be found here:
Since I have very limited wi-fi while in Sincelejo, I have been keeping a diary of my time on the cardiac surgery service of Dr. Cristian Barbosa. But then again, maybe I should explain why I am here.
I came to Colombia to learn how to perform skip harvesting saphenectomies with Dr. Barbosa. As I mentioned previously, we’ve kept in contact since we first met, and he was gracious enough to offer to teach me.
Before I ever left Virginia, it took a lot of paperwork and diplomacy, but we were able to secure administrative permissions for me to study sapheneous vein harvesting with Dr. Barbosa at the hospital in Sincelejo. While this isn’t medical tourism, I thought my readers might enjoy hearing about daily life as part of Dr. Barbosa’s cardiac surgery service.
Cardiac Surgery in Sucre, Colombia
outside the operating room
While the cardiac surgery program is located in Hospital Santa Maria, Dr. Barbosa and his team often travel to nearby hospitals and clinics to see new consultations. This program is the only program in the state of Sucre and patients come from all parts of the state.
Many of the patients come from tiny pueblos of a few hundred (or thousand people). Many others come from impoverished backgrounds. (Colombia has a tiered health care system with a national health care plan for people from lower socio-economic classes, kind of similar to the Medicaid concept.)
We arrive in Sincelejo on Monday, March 24th in the evening. We have a busy day tomorrow and the doctor wants to get started early (without facing the 3 hour drive in the morning.)
En Familia
In Sincelejo, we live en familia, in a large airy apartment with big windows that overlook much of Sincelejo. There are four of us here, the surgeon, the anesthesiologist (who is Director of the program), the perfusionist and myself. Iris and I share a large room with a private balcony. Meals are shared and we usually travel as a group to the hospital and on errands.
After our arrival Monday evening, the doctor, the perfusionist and I head to the largest grocery store and shopping center in town. We shop as a family, picking out fruit, arepa corn flour, coffee and other essentials. We then head to the food court. (They are treating me to Corral, due to my proclaimed love of Corral’s famed hamburgers).
It sounds like it could be uncomfortable – this domestic scene with my boss and the cardiac surgery team, but surprisingly it isn’t. Iris, the perfusionist (and my roommate both here and in Cartagena) always says they are a “cardiac surgery family,” and it feels that way – in a comforting, cozy way.
I joke and call Dr. Barbosa, “Papa” as he is the natural father figure of the group, and somehow it feels appropriate.
‘Papa’ of our cardiac surgery team
25 March 2014 – Tuesday
Today we travelled to Corozal to see two consultations in the intensive care unit. Then we returned to Sincelejo to see another patient at another hospital, Maria Reina. We eat lunch at the apartment, en familia . Afterwards, we go back to the office to see patients before heading off to surgery. (We had to delay surgery for several hours because the patient decided to eat breakfast. I guess s/he was hungry too).
Finally after this delay (to prevent anesthesia complications), we head to the operating room. There are the typical delays while the patient is being prepped and prepared. This gives me a chance to get to know the rest of the crew, Anita (the instrumentador or surgical tech) who runs the operating room table, Raquel, an experienced instrumentador who is training to work in the cardiac suite, and the two circulating nurses, Patricia and Estebes.
Raquel (right) and Anita, the instrumentadors
The circulating nurses are responsible for taking care of all the duties that fall outside of the sterile field, like fetching additional supplies, medications or instruments. They also control the environment by regulating the temperature, and adjust the electronic machinery (like the electrocautery unit, or the sternal saw) according to the surgeon’s immediate needs and specifications.
Patricia and Estebes, circulating nurses
Dr. Salgua is the medical doctor who works in the office, seeing patients and assessing their medical (nonsurgical needs.) For the last year, she has also worked as Dr. Barbosa’s First Assistant in Surgery. If there is any chance for friction in the operating room, most likely it will come from her. I am cautiously nice but optimistic when I realize she is fairly quiet, and not overly aggressive. (I relax, but just a bit. I am still nervous about how the team will take to me, even though the common Oops! “accidental” needle stick scenario seems unlikely here.
Dr. Salgua
Everyone is very friendly and welcoming and even before starting the actual surgery, I am breathing easier and starting to think that maybe I could belong here, with this group.
The surgery went well (valve replacement and annuloplasty). After the surgery, we transport the patient to the intensive care unit and give report to the doctors and nursing waiting to assume care of the patient.
Note: patient did well and went home on POD # 3 on 3/28/2014.
26 March 2014 – Wednesday
More surgery today, but still no coronaries (and thus no saphenectomies). It was a great day in the operating room – I closed the sternal incision.. (BTW, surgery went beautifully). I am already starting to feel more at home with the operating room staff, and I feel like they don’t mind having me around. Dr. Salgua has been very kind in assisting me during procedures, which is a relief. She still stays pretty quiet during the cases, but I think maybe sometimes she is a bit nervous too.
with the team
After transferring the patient to the ICU, our second visit to the patient from yesterday finds her over in the general surgery ward. (This morning she had been sitting up in a chair in the ICU when we arrived.) She looks good and states she is sore, but otherwise fine.
The cardiac catheterization lab calls; there are four cath films they want us to review, and patients to discuss regarding surgery. The patients themselves are resting in the recovery area after the cath procedure, so our administrative assistant, Paola makes appointments for each of them and instructs them to bring their families, medications and any questions.
The most interesting part of the cath lab is who is doing the caths. It’s a nurse, while the cardiologist sits behind the protective radiation shielded glass enclosure viewing the films and calling out for additional views. I wonder if the nurse knows that in the United States, a similar position would pay over 100,000 dollars. But this is one of the things that I see a lot of her in Colombia and in Mexico. Well trained nurses being essentially nurse practitioners (making diagnoses, treating disease, performing invasive procedures) but without the status or the compensation.
My roommate and I talk about this disparity sometimes. She’s a master’s trained nurse herself, so it makes for some very interesting discourse and insights. (She doesn’t like to have her picture taken, so I haven’t.)
We finish seeing patients and head home. The doctors head off for a siesta. Dr. Barbosa has been up since before five for his daily exercise before surgery.
As for me – after some scouting of the immediate areas around the hospital and the apartment, I went on my motorcycle tour. It was great fun but I got an important reminder of the perils of motorcycles just a few days later.
Note: After and uneventful surgery (defect repair), patient recuperated quickly, and was discharged 3/29/2014.
27 March 2014 – Thurday
The week is really flying by. I’ve been having fun with the operating room team. They are a great group. Everyone has been extremely nice and welcoming. (You can never be sure how your presence is going to be tolerated or change the existing dynamic.) Dr. Melano and I have a couple of animated discussions over current practices, literature and recent meta-analyses. It’s an enjoyable discourse even though my vocabulary often fails me. I hear myself making grammatic mistakes and repeated errors in Spanish but it seems with some much going on (reviewing my anatomy, practicing my suture ties, assisting in the operating room and trying to keep up on my writing )- I just can’t seem to remember as much as I should in Spanish. I inwardly cringe when I substitute ‘conocer’ for ‘saber’ yet again, but the word is out of my mouth in reply to a question before I can corect myself.
Dr. Salgua assists Dr. Barbosa
I sit out this surgery (still no coronaries) and spend some time taking pictures to document my experiences here. I got a couple of shots that I really like, including one of Dr. Barbosa, Dr. Salgua and Raquel.
one of my favorite pictures from that day
Note: Patient discharged home 3/29/2014.
28 March 2014 Friday (and coronaries!)
Today is my big day – and I am excited and a little scared too. I got up at five this morning and went with Dr. Barbosa to the exercise park, so I would have a place to walk while he played tennis. It helped me get ready for the day, and I got to see where Dr. Barbosa uses up all of his pent-up aggression. He turns it into a power slam. (I don’t know tennis terms, but whatever swing he was doing – it must be responsible for his tranquil overall demeanor.)
After breakfast, we head to the hospital. We check on our hospitalized patients before going to see today’s surgical patient in pre-op.
Our patient is a bit fragile-looking so (of course!) I worry about her and how she will do with surgery. I also worry that I might not sew straight, now that it’s time for me to get to work.
Some of my previous OR “lessons” have been brutal, including several at a troubled facility that sent me running away from cardiac surgery (of all kinds) for several months*. This is what fuels my anxiety. (I am not anxious by nature).
But here in Sucre, in this OR, this experience is nothing of the sort – Dr. Barbosa is an excellent teacher. I don’t know why it’s a surprise. He’s always been a bit of a Clark Kent of the operating room; pleasant, calm and methodical.** This is just the same. In his soft burring voice he goes over the procedure with Dr. Salgua and I. The he oversees our attempts, gently encouraging and coaxing. It is yet again, a comfortable experience, instead of a traumatizing, horrible one.
a pretty great teacher
I don’t have any pictures which would show my twinkling eyes which are the main indication of my happy grin beneath my mask as I finished closing the last leg incision.
We wrap the leg when we finish and move up to the ‘top’ of the operating room table. (I’ve learned that the top and the bottom of the operating room table are two very different places.)
I close the chest incision – surgery is over. We transfer the patient to the ICU. She remains a little fragile but has no immediate problems.
After making sure the patient is stable, the team heads over to Clinica Maria Reina. We have received a call that a trauma patient is being placed on ECMO (to support his lungs) after developing a fat embolism. We are standing by to help, as needed.
As I look around, and talk to the staff, I find that there are three patients in the small ICU, all young men in their twenties, all intubated with critical injuries, all due to motorcycle accidents. One patient, just barely an adult has lost a limb as well. He is awake and hitting the siderails with his remaining hand to capture the nurse’s attention. She holds his hand and speaks soft to him and he calms down. Watching this, along with the patient struggling to survive as doctors rush to connect ECMO is a sobering reminder of how devastating my joyride could have been.
The patient is connected to ECMO without incident. As a weary unit, all four of us return home.
The view from my private dance floor..
Everyone is exhausted – but I am exhilarated! I just want to dance – so I do, by myself, on the balcony with my phone blaring out some music. Later that evening, we go out for dinner to celebrate a successful week. I am still in a joyous dancing mood which probably drives my companions a little crazy but it’s been such a great day.. so when we return home, I dance some more.
March 29th, 2014 – Saturday
In the morning after my dancing spree – Dr. Barbosa and I walk down to the hospital. Our fragile patient from yesterday is doing okay, and our other two patients are ready to go home. I review discharge instructions with each patient, and hope that I am not mangling my Spanish too badly. But they seem to understand me, so maybe I am doing alright. The doctor is nearby, writing prescriptions, to clarify anything I have trouble explaining.
One patient asks about getting out of a chair without using his arms (and stressing the sternal incision) so I demonstrate my favorite technique, and together we practice.
After we finish, we head back to the apartment to eat breakfast, finish packing and head back to Cartagena. Dr. Melano is staying behind (along with Dr. Salgua, who lives in Sincelejo) to check on our remaining patient.
The ride back is pleasant, but I start to feel some of the fatigue from all of the excitement of the week. I also feel a little sad to be leaving our little cardiac ‘family’ for a few days, which is probably crazy considering how much time we’ve all spent together. I guess it’s because I know it’s just temporary.
Iris and I head back to ‘our’ Cartagena apartment where the neighborhood cat, Ximena is waiting for us.
Now we will relax, write and get ready for the return trip on Tuesday.
* A deliberate elbow to the face was just the beginning of a series of humiliations at a previous facility.
Long time readers are familiar with our plastic surgery horror story archives. These archives (mainly) consist of cases of illegal/ unlicensed surgeons and botched plastic surgery procedures but there is also information on how to find a board certified surgeon. Most of these cases take place in the United States where both clever marketing and underground clinics flourish due to the high costs of plastic surgery.
Buttloads of Pain
Now there is a new documentary that explores the dangers of unlicensed operators and ‘booty enhancement’.
Thanks to my friend, Matt Rines for sending me the link to the Vice documentary,”Buttloads of Pain” which talks about and talks to victims of unlicensed (and illegal) gluteal augmentation procedures (such as direct injection of silicone and other substances).
Gluteal Augmentation Procedures
For more information on legitimate gluteal augmentation procedures, read our interviews with licensed plastic surgeons.
For readers that have been asking about the background, history and the profound psychological and sociological impact of the ‘big booty’ and other Colombian influences on (global) plastic surgery trends & beauty ideals – this article by Mimi Yagoub at Colombia Reports may be a bit of an eye-opener.
Happy Thanksgiving to all of my American readers! I hope everyone has a wonderful and safe holiday.
I’m home for a while, sort of.
After returning from Mexico this October, I’ll be spending the rest of the Fall/ Winter here in the United States while I replenish my writer’s budget by completing some travel assignments. (Coming soon – to a hospital near you!)
Now that I am home, I have been catching up on all of the local news – and it looks like Obamacare hasn’t really kicked off to a wonderful start. Of course, it was naive to think that anything SO large/ SO involved / Affecting some many people could go off without (several) hitches, but as one of the people losing their coverage because of it – I certainly understand all of the anxiety and worry out there.
In the midst of continuing coverage of the current Obamacare fiasco, as millions of Americans lose their existing health care, several new articles on medical tourism have been making headlines across the country. Here’s a look at some of the latest news and reports from this past month.
In the Bay Area, NBC news‘ Elyce Kirchner, Jeremy Carroll and Kevin Nious published “Medical tourism: the future of healthcare?” along with a televised report. It’s the usual patient narrative along with an overview of medical tourism.
Kevin Gray, at the Men’s Journal talks about the domestic and international options available in his narrative, “Medical Tourism: Overseas and under the knife.” Gray takes a slightly different approach and discusses how consumers can comparison shop for health care services.
Among these publications, is “Medical tourism: Spanning the globe for health care,” by Kent McDill which includes information from one of my publications and a recent interview published right here at Latin American Surgery.com
The sky’s the limit?
Also, in counterpoint to the numerous press releases and newspaper articles talking about Iran, Bermuda, and various other medical tourism destinations seeking to “cash in” on the phenomena, British researchers (Lunt et al.) have published a report that contradicts the “if you build it, they will come” philosophy which has taken over the industry in many quarters.
Medical News Today published a summary of their findings early this month. Researchers also point out that much of the credible data required to provide a full and accurate picture regarding medical tourism is absent.
On a related note: While I talked about the limitations in medical tourism, accuracy of reported statistics and public perceptions in-depth during my 90 minute NPR interview, you wouldn’t really know it from my 2 sentence quote.
Pitfalls..
USA Today also published a story on some of the pitfalls for destinations with thriving medical tourism. Kate Shuttleworth takes a look at the strain that Eastern European medical tourists have placed on some Israeli facilities.
Is medical tourism on the rise? or is it all a spin of the numbers? I guess it all depends on who you ask.. But for now – Obamacare is not a viable alternative to medical travel.
Medical tourism is for boob jobs, liposuction and poor people without insurance
Many people think medical tourism is only for people without health insurance.. Or people seeking treatments or procedures that aren’t covered by the typical health insurance policy (like some types of plastic surgery.)
But that’s not true.
While medical tourism is often a ‘saving grace’ for the uninsured and underinsured patients in the United States, other medical tourists are often referred to overseas practices by their insurance companies.
Insurance companies want to save money too..
Insurance companies collect premiums from their subscribers. When subscribers need care, the companies pay out claims at pre-set rates for services. Companies negotiate for ‘volume discounts’ for many services but use several other strategies to make a profit while meeting their commitments to subscribers.
Paying for services while balancing the bottom line
They balance claim payout with profit-making several ways;
1. Deny claims. One of the ways insurance companies can save money on claims – is to not pay them… So companies may deny certain claims or by limit access to care for subscribers with expensive pre-existing conditions. (The New ‘Obamacare’ legislation is aimed at preventing this practice, but we won’t know how effective it is for a couple of years).
2. Promote health ..Many insurance companies also offer incentives to their subscribers for health promotion activities. Quit smoking? Lose weight? Exercising daily? Then the insurance company might even lower your premium a bit – since these activities may reduce their future payouts.
3. Use less costly services. Another way insurance companies can reduce their payouts is through medical tourism. Since surgery is significantly less expensive outside of the United States, it benefits the insurance company to have patients travel for services. So – even if your insurance company doesn’t advertise (loudly) its medical tourism division, it probably has one.
and even if your insurance wants to send you to India – they will probably pay for you to go to Mexico, Colombia, Costa Rica or wherever you chose.
But, if you are like me, you still have some questions.. How difficult is it to file a claim internationally? Is it more difficult for Americans to have their claims processed in other countries? How long does it take for claims to be processed and paid? Do patients need to start researching and preparing their claim ahead of time?
Meet Myriam
While I was in Mexicali – I took advantage of the opportunity to interview someone who negotiates with American insurance companies every day. Myriam is an insurance billing specialist for a bariatric surgeon in Puerto Vallarta, Mexico.
Meet Myriam.
The bilingual Myriam has been processing international health insurance claims for over 12 years now. She laughs out loud when I ask about processing claims for American patients. “Those are the easiest,” she said. “The companies are happy to pay. They never give us any problems.”
As part of her job, Myriam helps patients with information and files their insurance claims. Myriam explains that as part of the claims process for bariatric surgery, for example, claims must be filed when the patient is actually in the hospital. “The insurance company requires us to submit the claim at the time of service, not before.”
[So in this practice],” we have the patient provide us with a credit card prior to the procedure. We don’t bill it without speaking to the patient but that way we can use the credit card for the deductible or co-pay. Insurance usually pays within 60 days of the procedure, Myriam explains. If you aren’t sure if your insurance carrier will cover the claim, call them ahead of time.
In the operating room with Dr. Gustavo Gaspar Blanco
Hospital de la Familia,
Mexicali, B.C.
Mexico
After interviewing Dr. Gaspar, he graciously invited me to join him in the operating room as an observer for several cases during the week.
Hospital de la Familia
As reviewed in the Mexicali! mini-guide to medical tourism, Hospital de la Familia is widely acknowledged as “the second best hospital in Mexicali.” Much like the Hertz automobile rental campaign “We try harder,” the directors of Hospital de la Familia have embarked on an aggressive publicity campaign to attract patients and physicians to their facility. This includes medical tourism – as Hospital de la Familia has partnerships with multiple brokers including PlacidWay and Planet Hospital.
Dr. Gaspar exclusively operates at Hospital de la Familia.
In the ORs at Hospital de la Familia
OR #3 is the plastic surgery suite. It is spacious and well-lit with modern and functional equipment. Along with a designated OR, Dr. Gaspar has an operating room team consisting of an anesthesiologist, an assistant surgeon, scrub nurse and circulating nurse.
Dr. Gaspar and his OR team
Anesthesia is managed by Dr. Armando Gonzalez Alvarez. He monitors the patient with due diligence and remains in attendance at all times. He avoids distractions during surgery (like texting or excessive cell phone use) and remains patient-focused.
Dr. Gonzalez Alvarez, Anesthesiologist
Dr. Binicio Leon Cruz, is a general surgeon who serves as Dr. Gaspar’s assistant surgeon during the case. Monica Petrix Bustamante is the instrumentadora (scrub nurse), and she is excellent, as always*. She knows the surgeries, easily anticipates the doctors’ needs while maintaining surgical sterility and ensuring patient safety.
Monica prepares a prosthesis for implantation
Adherence to international protocols
The majority of procedures are under an hour in length, which means that patients do not need deep vein prophylaxis during surgery. The procedure (including site) and patient identity are confirmed prior to surgery with active patient participation before the patient receives anesthesia with both surgeons, nursing staff and the anesthesiologist in attendance. Patients are then prepped and draped in sterile fashion, with care taken to prevent patient injury.
As with many plastic surgeons, Dr. Gaspar does not administer IV antibiotics for infection prophylaxis prior to the first incision. Instead, all patients receive a course of oral antibiotics after surgery***.
Surgical sterility is maintained throughout surgery. For the first case, after receiving adequate tissue preparation, since only limited liposuction is needed (for very specific sculpting), the patient receives manual liposuction (without suction) to prevent overcorrection or excess fat removal. Despite having significant adhesions due to previous liposuction procedures, there is very minimal bleeding during the procedure.
Following the procedure, the patient is awakened, extubated and transferred to the recovery room for hemodynamic monitoring and adequate recovery prior to discharge.
Throughout the case, (and during all subsequent checks in the PACU), the patient is hemodynamically stable, and maintains excellent oxygenation.
The second case, is a breast augmentation revision – in a patient with a previous breast reconstruction after mastectomy for breast cancer. The patient developed a capsular contracture which required surgical revision**.
Abdominoplasty
On a separate occasion, Dr. Gustavo Gaspar performed an abdominoplasty with minor liposuction of the “saddle bag” area at the top of the thighs. For the abdominoplasty case, the patient received conscious sedation with spinal anesthesia.
While an abdominoplasty, “tummy tuck” is a much larger procedure, the case proceeded quickly (1 hour 15 minutes), and uneventfully. There was very minimal bleeding, and excellent cosmetic results.
skin, and adipose tissue removed during an abdominoplasty
Gluteal augmentation (Gluteoplasty)
However, it was the gluteal augmentation case that attracted the most interest. As mentioned during a previous interview, Dr. Gaspar is well-known throughout Mexico for his gluteal implantation technique.
Pre-surgical planning
Due to the proximity to the anus, and potential for wound infection and contamination, the area is prepped in a multi-step process, in addition to the standard surgical scrub. A Xoban (iodine impregnated dressing) is applied to the area to prevent bacterial migration to the area around the incision.
For this procedure, Dr. Gaspar uses gluteal prostheses for intramuscular implantation. Using one, small 3 cm incision, Dr. Gaspar dissects through the gluteal tissue to the muscle plane. He then inserts the prosthesis and adjusts it into its final position. When he has finished placing the implant, it is buried deep in the tissue and invisible.
after the implant is placed within the muscle it is invisible to the eye
He explains that by placing the prostheses in the intramuscular layer, the implants remain in a stable position, and are invisible to the eye and imperceptible to the touch. (Even with movement and manipulation – there is no edge or pocket seen or felt after the gluteal prosthesis is placed).
The procedure is repeated on the opposite side. Two small drains are placed, and the incision is closed. The entire procedure has taken just 18 minutes.
incision and drains at the conclusion of surgery
Despite the speed by which Dr. Gaspar operates, he is meticulous in his approach. He frequently re-assesses during the procedure (particularly during bilateral procedures) to ensure symmetry of results.
*I frequently encountered Ms. Petrix during previous visits to the operating rooms at Hospital de la Familia during research and writing of the Mexicali book).
** Capsular contraction is one of the most frequently occurring complications of breast augmentation using breast prosthesis (implants).
*** this practice is somewhat controversial but the most recent surgical guidelines and literature on antibiotic stewardship suggest that pre-operative antibiotics may be unnecessary for some surgical procedures.
Thank you to the kind patient who graciously gave permission for publication of pre-operative, intra-operative and post-operative photographs on this site.
Additional readings: Gluteoplasty
The majority of publications originate in Latin America and Latin American journals (and are written in Spanish and Portuguese.) Here is a small selection of open-access, English language journals.
This is a page re-post to help some of my new readers become familiarized with Latin American Surgery.com – who I am, and what the website is about..
As my long-time readers know, the site just keeps growing and growing. Now that we have merged with one of our sister sites, it’s becoming more and more complicated for first time readers to find what they are looking for..
So, start here, for a brief map of the site. Think of it as Cliff Notes for Latin American surgery. com
Who am I/ what do I do/ and who pays for it
Let’s get down to brass tacks as they say .. Who am I and why should you bother reading another word..
Of course, I also think readers should know why I have embarked on this endeavor, which has taken me to Mexico, Colombia, Chile, Bolivia and continues to fuel much of my life.
I also write a bit about my daily life, so that you can get to know me, and because I love to write about everything I see and experience whether surgery-related or the joys of Bogotá on a Sunday afternoon.
What I do and what I write about
I interview doctors to learn more about them.
Some of this is for patient safety: (Is he/she really a doctor? What training do they have?)
Much of it is professional curiosity/ interest: (Tell me more about this technique you pioneered? / Tell me more about how you get such fantastic results? or just tell me more about what you do?)
Then I follow them to the operating room to make sure EVERYTHING is the way it is supposed to be. Is the facility clean? Does the equipment work? Is there appropriate personnel? Do the follow ‘standard operating procedure’ according to international regulations and standards for operating room safety, prevention of infection and overall good patient care?
I also write about new technologies, and treatments as well as emerging research. There is some patient education on common health conditions (primarily cardiothoracic and diabetes since that’s my background). Sometimes I talk about the ethics of medicine as well. I believe strongly in honesty, integrity and transparency and I think these are important values for anyone in healthcare. I don’t interview or encourage transplant tourism because I think it is intrinsically morally and ethically wrong. You don’t have to agree, but you won’t find information about how to find a black market kidney here on my site.
I also write about the culture, cuisine and the people in the locations I visit. These posts tend to be more informal, but I think it’s important for people to get to know these parts of Latin America too. It’s not just the doctors and the hospitals – but a different city, country and culture than many of my readers are used to.
Why should you read this?well, that’s up to you.. But mainly, because I want you to know that there is someone out there who is doing their best – little by little to try to look out for you.
How the site is organized
See the sidebar! Check the drop-down box.
Information about surgeons is divided into specialty and by location. So you can look in plastic surgery, or you can jump to the country of interest. Some of the listings are very brief – when I am working on a book – I just blog about who I saw and where I was, because the in-depth material is covered in the book.
information about countries can be found under country tabs including cultural posts.
Issues and discussions about the medical tourism industry, medical safety and quality are under quality measures
Topics of particular interest like HIPEC have their own section.
I’ve tried to cross-reference as much as possible to make information easy to find.
If you have suggestions, questions or comments, you are always welcome to contact me at k.eckland@gmail.com or by leaving a comment, but please, please – no hate mail or spam. (Not sure which is worse.)
and yes – I type fast, and often when I am tired so sometimes you will find grammatical errors, typos and misspelled words (despite spell-check) but bear with me. The information is still correct..
Dr. Gustavo Gaspar Blanco is a plastic surgeon in Mexicali (Baja California) Mexico. He is well-known throughout Baja and Northern Mexico for his gluteal augmentation techniques using gluteal implants. While this is one of the procedures he is most famous for, he also performs the complete range of body, facial plastic surgery procedures, and post-bariatric reconstructive surgery.
It was an engaging series of interviews as Dr. Gaspar is extremely knowledgeable and passionate about his craft. “Plastic surgery is different from other specialties, it is an art. The surgeon needs to have an eye for beauty and symmetry in addition to surgical skill.”
There are multiple methods of gluteal augmentation (or buttock enhancement). Dr. Gaspar performs both fat grafting and gluteal implantation procedures. He prefers gluteal implantation for patients who are very thin (and have limited fat tissue available for grafting) or for patients who want longer-lasting, more noticeable enhancements. (With all fat injection procedures, a portion of the fat is re-absorbed).
He recommends fat grafting procedures to patients who want a more subtle shaping, particularly as part of a body sculpting plan in conjunction to liposuction.
Breast Implants and attention to detail
Like most plastic surgeons, breast augmentation is one of the more popular procedures among his patients. The vast majority of his patients receive silicone implants (by patient request), and Dr. Gaspar reports improved patient satisfaction with appearance and feel with silicone versus saline implants. He uses Mentor and Natrelle brand implants, and is very familiar with these products. In fact, he reports that he has visited the factories that create breast implants in Ireland and Costa Rica. He says he visited these factories due to his own curiosity and questions about breast implants**.
Once he arrived, he found that each implant is made by a time-consuming one at a time process versus a vast assembly line as he had envisioned. He was able to see the quality of the different types of implants during the manufacturing process. These implants, which range from $800.00 to $1200.00 a piece, go through several stages of preparation before being completed and processed for shipping. He also watched much of the testing process which he found very interesting in light of the history of controversy and concern over previous silicone implant leakage in the United States (during the 1960’s – 1970’s).
Another aspect of breast augmentation that Dr. Gaspar discusses during my visits is the breast implantation technique itself. While there are several techniques, in general, he uses the over-the-muscle technique for the majority of breast implantation procedures. He explains why, and demonstrates with one of his patients (who had the under-the-muscle technique with another surgeon, and now presents for revision).
“While the under-the-muscle technique remains very popular with many surgeons, the results are often less than optimal. Due to the position of the muscle itself, and normal body movements (of the shoulders/ arms), this technique can cause unattractive rippling and dimpling of the breast. In active women, it can actually displace the implant downward from pressure caused by normal muscle movements during daily activities. This may permanently damage, displace or even rupture the implant.”
Instead, he reserves the under-the-muscle implant for specific cases, like post-mastectomy reconstruction. In these patients (particularly after radiation to the chest), the skin around the original mastectomy incision is permanently weakened, so these patients need the additional support of the underlying muscle to prevent further skin damage.
Not just about outcomes
While his clients, from all over North America, are familiar with his plastic surgery results, few of them are aware of his deep commitment to maintaining the highest ethical and medical standards while pursing excellence in surgery.
Commitment to ethical care of patients crosses language barriers
While Dr. Gaspar is primarily Spanish-speaking, his commitment to ethical practice is crystal clear in any language. He explains these ethical principles while offering general guidelines for patients that I will share here (the principles are his, the writing style is my own).
Advice for patients seeking plastic surgery
Be appropriate:
– Patients need to be appropriate candidates for surgery:
Around fifty percent all of the people who walk into the office are not appropriate candidates for plastic surgery, for a variety of reasons. Dr. Gaspar feels very strongly about this saying, “Unnecessary or inappropriate surgery is abusive.”
– Plastic surgery is not a weight-loss procedure. Liposuction/ Abdominoplasty is not a weight loss procedure. Plastic surgery can refine, but not remake the physique. Obese or overweight patients should lose weight prior to considering refining techniques like abdominoplasty which can be used to remove excess or sagging skin after large-scale weight loss.
fat removed during liposuction procedure
– Have surgery for appropriate reasons. Plastic surgery will not make someone love you. It won’t fix troubled relationships, serious depression or illness. Plastic surgery, when approached with realistic expectations (#3) can improve self-esteem and self-confidence.
– Realistic expectations – just as plastic surgery won’t result in a 25 pound weight loss, or bring back a wayward spouse, it can’t turn back the clock completely, or radically remake someone’s appearance. There is a limit to what procedures can do; for the majority people, no amount of surgery is going to make them into supermodels.
– Know the limitations
Not only are there limits to what surgery itself can do, there are limits to the amounts of procedures that people should have, particularly during one session. “Marathon/ Extreme Makeovers” make for exciting television but are adangerous practice.
Stay Safe:
Just as patients should avoid marathon or multi-hour, multiple procedure surgeries, patients should stay safe.
– Avoid office procedures
As Dr. Gaspar says, “The safest place for patients is in the operating room.” With the exception of Botox, all plastic surgery procedures should be performing the operating room, not the doctor’s office. This is because the operating room is a sterile, well-prepared environment with adequate supplies and support staff. There are monitors to help surgeons detect the development of potential problems, life-saving drugs and resuscitation (rescue) equipment on hand. Should a patient stop breathing, start bleeding or develop a life-threatening allergic reaction (among other things), the operating room (and operating room staff) are well prepared to take care of the patient.
Communicate with your surgeon –
Give your surgeon all the details s/he needs to keep you safe, and have a successful surgery. Talk about more than the surgeries you are interested in –
– bring a list of all of your medications
– know a detailed history including all past medical problems/ conditions and surgeries.
If you had heart surgery ten years ago – that’s relevant, even if you feel fine now. Have a history of previous blood transfusions/ radiation therapy/ medication reactions? Be sure to tell the doctor all about it.
Even if you aren’t sure if it matters, “My sister had a blood clot after liposuction” – go ahead and mention it.. It might just be a critical piece of information such as a family predisposition to thromboembolism (like the example above).
Lastly
Surgical complications are a part of surgery. All surgeons have them – and having a surgical complication in and of itself is no indication of the quality or skill of the surgeon. Complications can occur for a variety of reasons.
However, how efficiently and effectively the surgeon treats that complication is a good indicator of skill, experience and expertise.
As part of this, Dr. Gaspar stresses that medical tourism patients need to prepare to stay until they have reached an adequate stage of recovery. This prevents the development of complications and allows the surgeon to rapidly treat a problem if it develops; before it become more serious.
“There is no set time limit for my patients after surgery, everyone is different. But none of my patients can go [return home] until I give my approval.” This philosophy applies to more than just medical tourists from far off destinations. It also applies to any patients have large procedures and their hospitalizations. While many surgeons race to discharge clients as same-day surgery patients, Dr. Gaspar has no hesitation in keeping a patient hospitalized if he has any concerns regarding their recovery. “Hospitals are the best places for my patients, if I am concerned about their recovery.”
Dr. Gaspar attended medical school at the Universidad Autonoma de Guadalajara. He completed both his general surgery residency and plastic surgery fellowship in Mexico City at the Hospital de Especialidades Centro Medico La Raza.
He is a board certified plastic surgeon by the Mexican Society of Plastic and Reconstructive Surgery, license number #601. He has been performing plastic surgery for over 20 years. Surgeons from areas all over Mexico train with Dr. Gaspar to learn his gluteal implantation techniques.
** He has also visited the facilities in Germany where the Botulism toxin is prepared for cosmetic/ and medical use.
I met Dr. Betancourt Parra at IQ interquirofanos while observing surgery with Dr. Luis Botero,. Dr. Betancourt was friendly, and immediately amendable to an interview but it took a little while to coördinate our schedules.
In person, he reminds me a bit of Dr.Carlos Ochoa Gaxiola, the kind and talented Mexican surgeon who graciously permitted me to study with him at Hospital General de Mexicali for several months while writing the Mexicali book.
Maybe it was his laid-back and open conversational style, or the braces on his teeth, giving him a bit of boyish charm that belies his years of experience. Maybe it was his enthusiasm for his work, but whatever it was, I found the discussion to be especially informative and interesting.
Aesthetic plastic and reconstructive surgery
Dr. Betancourt is a plastic surgeon in Medellin. He performs a wide range of aesthetic and reconstructive plastic surgery including corporal (body) and facial procedures such as rhinoplasty (nose), face-lifts, blepharoplasty (eyelid lift), breast augmentation, liposuction etc. but his true love is post-bariatric surgery procedures.
He also performs reconstructive surgery such as breast reconstruction after breast cancer.
Post-bariatric surgery is a subspecialty area of plastic surgery (reconstructive surgery). Many of these patients have lost very large amounts of weight (100+ pounds) and have large amounts of sagging, drooping and excess skin.
This skin is more than aesthetically displeasing – it can also contribute to the development of skin irritations such as intertriginous dermatitis and infections. It is particularly prone to causing problems for females – due to an excess build up of moisture, and friction in the genital areas. It can also make simple tasks like showering, getting dressed and cleaning after using the bathroom difficult. Patients sometimes have to “tuck” loose skin from the abdomen into support garments to prevent this skin from slipping down to their thighs. This excess of skin (and the resultant movement/ friction) can prevent people from participating in normal activities like exercise.
The psychological impact of the appearance of, and the challenges of daily living can be extremely distressing – especially for someone who have spent months or years trying to lose weight.
The group of procedures used to treat this problem is called “Body contouring”. For the majority of patients – this body contouring process will require several months and several separate surgeries.
Body Contouring
One of the primary procedures for body contouring is called a “lower body lift/ /belt lipectomy/ torsoplasty”. This is actually two separate but very similar techniques; with the belt lipectomy being a modified lower body lift procedure. However, they are often grouped together to simplify discussions about body contouring procedures. The lower body lift or belt lipectomy is usually one of the first procedures as part of the reconstructive process after massive weight loss.
This procedure is the core procedure – which removes the majority of excess skin and tissue which is usually in the abdominal/ torso area. This is a dramatic and large surgical procedure which I liken to “the open heart surgery of plastic surgery.” This procedure can take 2 to 6 hours, and often requires a 1 to 2 night hospital stay.
The remaining procedures are more of a ‘fine tuning;, as they are smaller procedures with lesser effects as they are aimed at smaller, more specific areas of the body. These procedures include brachioplexy to remove excess skin (aka “batwings”) from the upper arm/ bicep area, reduction mammoplasty to remove excess skin and drooping from the breast area, or a thighoplasty, to remove excess skin from the thighs/ upper legs.
One year minimum wait after bariatric surgery
Dr. Betancourt requires a minimum of one year after bariatric surgery before patients begin considering body contouring procedures.
This is important for two reasons:
1. Patient’s weight should be stable prior to performing surgical procedures.
2. This period gives patients a chance to adjust to their new weight. Several studies have demonstrated that it may take months to years to adjust the mind’s eye (mental image) to a person’s actual appearance.
For an excellent article by Salwar & Fabricatore (2008) on the psychological considerations for patients after massive weight loss – click here.
Mirror versus mind’s eye
This is why many people literally “do not see” recent changes in our weight / appearance (particularly subtle/ small changes) when looking in the mirror. However, as time passes, the mind’s perception of our image/ appearance usually changes to accommodate changes in our ‘real’ appearance – whether weight loss/ gain, signs of aging (fine lines, wrinkles) or even the loss of a limb or appendage.
photo from uhs.uk
When the mental / mirror image “mismatch” is dramatic, long-lasting, accompanied by depression/ anxiety or leads to dangerous practices like anorexia, hypergymnasia or self-mutilation – it is called body dismorphic disorder (BDD). Patients who have successfully adjusted to their new size and appearance are much more likely to have realistic expectations, be satisfied with surgical outcomes and be able to maintain their weight over the long-term.
Dr. Betancourt explained that he enjoys the intellectual challenges of caring for post-bariatric surgery patients for several reasons. These patients, often differ greatly from the majority of plastic surgery patients due to the presence of multiple co-morbid conditions relating to their previous obesity. Patients may also have body image issues following the initial bariatric surgery as they adjust to their new bodies. These patients may require multiple procedures for a complete reconstruction, making treatment a somewhat lengthy process.
Dr. Betancourt states that this is what makes it so gratifying; to be able to provide patients with dramatic body changes, help improve their self-image and enable patients to successfully adjust to their new lives. He also finds it very rewarding because of the high level of patient satisfaction after these procedures.
These patients account for approximately 1/3 of his practice.
Education and Training
Dr. Betancourt has been a plastic surgeon for twelve years. For eleven years, he worked in a public hospital, Manuel Uribe Angel in Enviagado, providing reconstructive surgery services to all patients at all socio-economic levels in Antioquia, Colombia . For the last several years, he has devoted a significant portion of his practice to the sub-specialty of post-bariatric surgery. He has attended several post-bariatric surgery conferences to learn new techniques and exchange ideas with many of the leaders in the field including Dr. Alaly (USA), Jean François Pascal (France) and Dr. Ricardo Baroudi (Brazil).
Dr. Betancourt attended medical school at Universidad CES (University of Health Sciences) and graduated in 1993. He is currently a professor at CES.
He competed in general surgical residency at the public hospital, Hospital Ipiranga in Sao Paulo, Brazil before completing his plastic surgery fellowship at the Universidad Santo Amaro, (in Sao Paulo, Brazil).
He is a member of the Colombian Society of Plastic Surgery (SCCP), as well as the Brazilian Society of Plastic Surgery.
Dr. Betancourt speaks Portuguese and English in addition to his native Spanish. He reports some trepidation with his English but was readily able to communicate with me without difficulties.
While the majority of Dr.Betancourt’s patients are from the local area, he does see international patients. After an initial contact by email, or via his internet page, Dr.Betancourt solicits a complete medical history including previous surgical reports (from previous bariatric or plastic surgery procedures) and current photos. Patients will also need to have blood work, and EKG as part of the pre-operative evaluation. Additional studies may be needed depending on the individual’s history and diagnostic test results. (Patients may be referred to Internal Medicine specialist, as needed).
Following the on-line/ email communications, patients will be seen, for an in-person consultation and full physical examination. Dr. Betancourt’s office will make arrangements for a translator and companion to accompany the patient, as needed. With the patient’s assistance, a full surgical treatment plan will be designed at that time – which discusses how many surgeries and what the anticipated timeline and recovery will be.
As discussed above, the torsoplasty/ belt lipectomy is usually the first procedure performed, often followed by reduction mammoplasty/ mammoplexy.
With the torsoplasty, patients are usually hospitalized for 1 to 2 nights. They are encouraged to be active and ambulatory as soon as possible after surgery to prevent post-operative complications such as thrombosis and pneumonia. Dr.Betancourt usually engages private nurses to assist patients following their discharge from the hospital.
Sufficient recovery from return travel usually requires 3 weeks, and is monitored by Dr.Betancourt.
Dr. Betancourt also provides psychological / counselling referrals as needed for patients.
Additional References / Reading and Resources on post-bariatric surgery
* Recommended reading: Langer V, Singh A, Aly AS, Cram AE. (2011). Body contouring following massive weight loss. Indian J Plast Surg [serial online] 2011 [cited 2013 Aug 11];44:14-20. Available from: http://www.ijps.org/text.asp?2011/44/1/14/81439
Excellent article with general overview of the issues and procedures with before and after photographs.
* Recommended reading: Shrivastava P, Aggarwal A, Khazanchi RK. Body contouring surgery in a massive weight loss patient: An overview. Indian J Plast Surg [serial online] 2008 [cited 2013 Aug 11];41:114-29. Available from: http://www.ijps.org/text.asp?2008/41/3/114/43607
Additional Readings
“Distressing skin problems” – a 2011 first person story about skin problems after massive weight loss from the UK paper, Daily Mail.
Giordano S, Victorzon M, Koskivuo I, Suominen E. (2013). Physical discomfort due to redundant skin in post-bariatric surgery patients. Plast Reconstr Aesthet Surg. 2013 Jul;66(7):950-5. doi: 10.1016/j.bjps.2013.03.016. Epub 2013 Apr 9. [free full text not available].
Song AY, Rubin JP, Thomas V, Dudas JR, Marra KG, Fernstrom MH. (2006). Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring). 2006 Sep;14(9):1626-36. [no free full text available].
Just posted a new article over at Examiner.com based on a series of interviews with local plastic surgeons here in Medellin, Colombia.
The article summarizes the newly emerging trend of ‘less is more‘ meaning smaller breast implants, less fat grafting, and more sculpting liposuction, and Botox..
As we discussed in a previous post – the evolution of beauty ideals is a continuous process – and can change dramatically over the course of a decade. So after the ‘I like big butts’ and porn-star ideals of the 1990’s and lush, voluptuous 2000’s, is it much of a surprise that plastic surgery is heading towards a more athletic idea (of sculpted abs) and smaller, less dramatic curves?
So, consumers, keep in mind – as you consider procedures – less is more, and what’s beautiful today – may be considered excess tomorrow.. Try to find a procedure/ ideal/ and outcome that suits you, and your body – instead of conforming to an ever-changing ideal..
Dr. Rodrigo Diaz is a plastic surgeon at the Clinicas de Las Americas in Medellin. He primarily specializes in facial plastic surgery (rhinoplasty, blepharoplasty, forehead surgery, facial endoscopy, face-lifts and fillers) and breast surgery (augmentation/ reduction). He reports that he receives most of his clients by work of mouth but does see a significant percentage of medical tourists.
The majority of his patients are private practice (self-pay) patients but he does see patients from many of the major Colombian health care insurance plans such as Colseguro, Liberty, Sur America, Colsanitas. While American insurance companies do not traditionally cover elective cosmetic procedures, it is worth investigating with your insurer as many of the larger plans such as Blue Cross/ Anthem now have ancillary plans for cosmetic procedures.
Dr. Diaz has been a practicing plastic surgeon for thirty years, and a professor of plastic surgery at the Universidad de Antioquia for the past 12 years. He attended the Universidad de Antioquia medical school and completed his plastic surgery residency there as well.
Like all Colombian surgeons profiled here at Latin American Surgery.com, he is a member of the Colombian Society of Plastic, Aesthetic and Reconstructive Surgery. He is also a member of the American Society of Plastic Surgeons (ASPS) and the International Society of Plastic, Reconstructive and Aesthetic surgery.
Pre-operative process
As we talk, he reviews the pre-operative process for his patients. “It usually starts with an email from the patient,”he states. Then he solicits a complete medical history from the patient, including medications, past surgeries, social habits (smoking, drinking etc), current and past medical problems (like hypertension) and family history. This also includes photographs so he can best determine exactly what procedure(s) they will need, plan the procedure and discuss anticipated results.
If they have a single problem (like high blood pressure), then he sends the patient for a complete medical evaluation.
All smokers are required to quit at least 2 months before the procedure, and Aspirin (and other anti-platelets) must be discontinued 8 days before the scheduled procedure.
Out-of-town patients are encouraged to bring another adult with them, and additional translators are provided as needed.
Plan for adequate recovery time
One of the things he stresses heavily during our interview is the need for medical tourists to allocate adequate time to the recovery process before returning to their home country. This is something that has been brought up in previous interviews with other surgeons, as well but bears repeating. Even smaller surgeries require adequate healing time, so the idea of a ‘weekend surgical makeover’ should be dismissed from the minds of potential clients.
Most important aspect is post-operative care
The time necessary for adequate healing is usually 15 days to three weeks depending on the procedures. This period is also important for surgeons to be able to detect small problems such as delayed healing before it becomes a bigger problem. “It is better for me to see an incision that isn’t healing right away so I can treat it immediately, then for the patient to put it off – and then seek treatment weeks later when it is a much larger problem.”
Another reason he encourages patients to not to rush home, is that surgeons in their home countries may be unwilling to care for patients who have surgery elsewhere.
Patients take priority
Dr. Diaz prides himself in providing excellent post-operative care. All patients have his cell phone, and he encourages them to use it for all and every question or concern – day or night. “If they need me, I am here.”
And – don’t worry, if you are hesitant to call him – he is going to call you anyway, just to check in and make sure you are doing well, and your pain is controlled. He calls all of his patients the day after surgery, and continues to check-in and see patients frequently during the first weeks after surgery.
“My patients always take priority, even after they return home. If I have a patient Skyping me in the office – well, that takes priority over other things because I know what a hassle it is for them.”
He speaks English fluently but reports he continues to take weekly classes in English and American culture. He feels that it is impossible to have a complete understanding and good communication of his clients without understanding the culture.
Trends in facial plastic surgery
During his lengthy plastic surgery career, Dr. Diaz has seen a lot of trends come and go in aesthetics. He reports that one of the main trends he has seen over the last few years, is a trend for lesser facial procedures such as facial endoscopy, eyelid surgery or use of fillers by his clients versus a full face-lift. He states the reasons are multiple. Patients want to avoid the dreaded “plasticized / surgerized” artifical appearance that has been highly visible in popular media such as American reality shows, and prefer more subtle results, so his patients tend to seek treatment earlier, just a lines and folds appear. While many of these treatments are temporary like fillers or laser re-surfacing, the results are more natural and aesthetically pleasing.
Secondly, patients want to avoid the longer downtown involved with a larger procedure like a face-lift which may have residual bruising, or swelling for several weeks. These patients want to be refreshed and back in the office quickly.
Lastly, as he reflects on his career and the ‘style’ of plastic surgery – he reports that for many of his clients (particularly Colombian client), the focus is so heavily on the body (breast and buttock augmentation) that the face is secondary in consideration.
Dr. Juan David Londoño, plastic surgeon (photo provided)
Dr. Juan David Londoño is a plastic surgeon here in Medellin who specializes in body procedures such as liposuction, abdominoplasties and breast augmentation.
He shares an office with Dr. Jorge Aliro Mejia Canas in the Forum building, next to the Santa Fe shopping mall in the upscale Poblado neighborhood.
He is also one of just a handful of surgeons here who specialize in hair restoration.
Dr. Londoño attended medical school at the Universidad de Antioquia, graduating in 1995. He completed his plastic surgery residency at the same institution and completed his training in 2003. While he trained in both reconstructive and aesthesthic plastic surgery, he states that he prefers aesthetic surgery because of the close relationship it entails with patients.
Today we talked primarily about Hair Restoration procedures because it’s his favorite procedure, and one I don’t know much about.
Patience is the key, he states as he explains the ins and outs of hair restoration treatments. Patience was certainly the order of the day as he carefully and graciously explained the principles of hair transplantation to me. Patience is necessary he explains, as in, there is no ‘quick fix’. Hair restoration techniques have evolved with the development of newer procedures but it remains a painstaking process.
Not just for male pattern baldness
While people traditionally think of this treatment as exclusively for male pattern baldness, women also undergo hair restoration in cases of thinning hair. People can also use this treatment to restore hair to other areas of the body such as the eyebrows (or as commonly publicized in Turkey) for beard restoration.
Treatment options
As Dr. Londoño explains, there are a range of treatments available for the treatment of hair loss, such as male pattern baldness, or thinning hair. While these treatments run along a continium of scalp massage –> medications –> surgery; these treatments can also be used to compliment each other.
Probably the best well-known treatments are the medications such as topical applications of minoxidil (Rogaine) or oral (finesteride) Propecia tablets. Many people are familiar with these medications due to long-standing and widely viewed pharmaceutical advertisements in the early and late 1990’s. Both of these medications were originally developed to treat other conditions (hypertension and BPH) and hair growth was quickly noted to be a frequently occurring side effect. These medications underwent additional clinical trials and study by the FDA before being re-formulated (as a topical spray), in the case of minoxidil, and re-marketed to treat hair loss.
However, these medications are less than ideal for treating a long-term problem like hair loss. While the medications can prevent additional hair loss, in most cases – additional hair growth is modest and requires continued medical therapy (pills) to maintain.
Scalp massage, is believed to stimulate blood circulation in the scalp and improve the health of the scalp and hair. It is also quite pleasant for most people. However, the results of scalp massage as a sole treatment are minimal at best when it comes to the treatment of alopecia.
Surgical methods of hair restoration
The original surgical methods of hair transplantation (or hair restoration) are more widely known for their limited results. “Hair plugs” refer to the artificial appearance due to the technique of implanting a group of hair in one area, with the finished results often having a row-like appearance (like a doll).
More modern techniques include the strip method, and the most recent technique called Follicular Unit Extraction (FUE).
With the strip method a small area of scalp on the back of the head (where hair is usually the densest, and has the greatest longevity) is surgically removed in a long strip. The scalp is then sutured closed, leaving a small linear scar. The area of scalp, and hair follicules are then used for implantation. By taking a portion of the scalp, the surgeons are able to ensure that the critical portion of the hair shaft – the root is preserved. This root is needed for hair to survive and grow after implantation.
With the newer Follicular Unit Extraction, each hair, including the root is extracted using a 1mm punch biopsy technique. (This is like a skin biopsy punch but much smaller.) Since each root is extracted individually, this is a painstaking and time consuming process. He reports that depending on the degree of hair loss, the length of the sessions and the results desired by the patient – determines the number of sessions a person will need. Since this procedure requires multiple sessions, some patients elect for shorter sessions but require a higher number of sessions since this is often more convenient for the schedules of working people.
The first treatment is usually done to re-establish the natural hairline. Subsequent treatments are needed to fill in areas of hair loss.
For patients who have very little remaining head hair, hair can be taken from other parts of the body. In general, surgeons use hair from areas (like the so-called “fringe area”) where hair persists despite months or years of hair loss. These areas are less likely to have hair that will succumb to the processes that caused alopecia in these individuals.
There are newer methods of FUE which use a more automated process, but as Dr. Londoño explains this often incurs a higher cost – and does not improve the outcomes (but does shorten the process somewhat.) He has the Artas Robot to assist him with the process, (if needed), but cautions readers not to be fooled by surgeons advertising the latest and greatest machinery. We digress into a conversation about general plastic surgery and the widespread advertising of specifically trademarked (and very expensive) equipment such as SlimLipo, Ultrasound and Vaser.
It’s more about the surgeon than the tools
He cautions consumers not to be fooled into thinking that having the most expensive equipment equals the best surgeon as often these devices are employed only to attract customers and command more expensive prices. As we discussed in a previous post, these devices were designed for specific uses that may not even be needed for many clients.
Why should patients pay for ultrasound-assisted liposuction when standard liposuction will be equally effective in their case? That’s kind of how he feels about the hair transplant robot. He has it – and he will use it if he needs it, but it isn’t for everyone.
Results take time
Results of this procedure are not immediate. The scalp takes time to heal from the transplant procedure, and the newly implanted follicules need to adjust to the transplantation process. Usually, the initially transplanted hair sheds – leaving living, hair producing roots behind. These hair roots will then grow new hair as part of the normal hair growth cycle. But hair takes time to grow – so many patients won’t see the full results of their procedure for up to six months afterwards as the hair grows in to the patient’s normal length.
Costs of the procedure
The near universal standard for hair restoration at many facilities is a dollar a hair. When you consider that the average (full) head of hair contains 100,000 hairs – the potential costs of this procedure* can be daunting. However, Dr. Londoño does not apply a “one price fits all” approach to his patients. Instead his assesses the client, their restoration needs (a small area versus the entire coronal area), the amount (and type) of treatments involved, and the expected results before determining a price. It is a more personalized and individualized accounting that may not suit some medical tourists who are looking for bargain basement prices however, it seems a better practice.
*Generally patients would only need a small fraction of this number for hair restoration.
References and Resources
Khanna M. (2008). Hair transplantation surgery. Indian J Plast Surg. 2008 Oct;41(Suppl):S56-63. An excellent overview of the procedures used in hair transplantation with photographs depicting these techniques and results.
Note: the feature photograph(on the front page) has been heavily edited (by me) to depict a gentleman with a receding hairline. This model actually has a lovely head of hair, but I did not want to use the photo of a real person without permission. (This photo is open source). This photo is for article art only and is not an attempt to dupe or trick readers. It is my policy to always disclose when photos have been altered from the original image.
Please note that some of the images in this article have been edited to preserve patient privacy.
Today, Dr. Luis Botero has invited me to observe surgery at IQ Interquirofanos in the Poblado section of Medellin. He is performing full-body liposuction and fat grafting of the buttocks.
Dr. Luis Botero, in the operating room
The facility: IQ Interquirofanos
Interquirofanos is located on the second floor
IQ Interquirofanos is an ambulatory surgery center located on the second floor of the Intermedica Building across the street from the Clinica de Medellin (sede Poblado). The close proximity of this clinic to a hospital is an important consideration for patients in case of a medical emergency.
The anesthesiologists estimate that 90% of the procedures performed here are cosmetic surgeries but surgeons also perform gynecology, and some orthopedic procedures at this facility.
The are seven operating rooms that are well-lit, and feature modern and functional equipment including hemodynamic monitoring, anesthesia / ventilatory equipment/ medications. There are crash carts available for the operating rooms and the patient recovery areas.
There are fourteen monitored recovery room beds, while the facility currently plans for expansion. Next door, an additional three floors are being built along with six more operating rooms.
Sterile processing is located within the facility with several large sterilization units. There is also a pharmacy on-site. The pharmacy dispenses prosthetics such as breast implants in addition to medications.
The only breast prosthetics offered at this facility are Mentor (Johnson & Johnson) and Natrelle brand silicone implants (Allergan). In light of the problems with PIP implants in the past – it is important for patients to ensure their implants are FDA approved, like Mentor implants.
In the past seven years, over 31,000 procedures have been performed at Interquirofanos. The nurses tell me that during the week, there are usually 30 to 35 surgeries a day, and around 15 procedures on Saturdays.
Prior to heading to the Operating Room:
Prior to surgery, patients undergo a full consultation with Dr. Botero and further medical evaluation (as needed). Patients are also instructed to avoid aspirin, ibuprofen and all antiplatets (clopidogrel, prasugrel, etc) and anti-coagulants (warfarin, dabigatran, etc.) for several days. Patients should not resume these medications until approved by their surgeon.
Complication Insurance
All patients are required to purchase complication insurance. This insurance costs between 75.00 and 120.00 dollars and covers the cost of any treatment needed (in the first 30 days) for post-operative complications for amounts ranging from 15,000 dollars to 30,000 dollars, depending on the policy. All of his clients who undergo surgery at IQ Interquirofanos are encouraged to buy a policy from Pan American Life de Colombia as part of the policies for patient safety at this facility. International patients may also be interested in purchasing a policy from ISPAS, which covers any visits to an ISPAS-affiliated surgeon in their home country.
Today’s Procedures: Liposuction & Fat Grafting
Liposuction –Liposuction (lipoplasty or lipectomy) accounts for 50% of all plastic surgery procedures. First the surgeon makes several very small slits in the skin. Then a saline – lidocaine solution is infiltrated in to the fat (adipose) tissue that is to removed. This solution serves several purposes – the solution helps emulsify the fat for removal while the lidocaine-epinephrine additives help provide post-operative analgesic and limit intra-operative bleeding. After the solution dwells (sits in the tissue) for ten to twenty minutes, the surgeon can begin the liposuction procedure. For this procedure, instruments are introduced to the area beneath the skin and above the muscle layer.
During this procedure, the surgeon introduces different canulas (long hollow tubes). These tubes are used to break up the adipose tissue and remove the fat using an attached suctioning canister. To break up the fat, the surgeon uses a back and forth motion. During this process – one hand is on the canula. The other hand remains on the patient to guide the canulas and prevent inadvertent injury to the patient.
fat being removed by liposuction
Due to the nature of this procedure, extensive bruising and swelling after this procedure is normal. Swelling may last up to a month. Patients will need to wear support garments (such as a girdle) after this procedure for several weeks.
Types of liposuction:
In recent years, surgeons have developed different techniques and specialized canulas to address specific purposes during surgery.
Standard liposuction canulas come in a variety of lengths and bore sizes (the bore size is the size of the hole at the end of the canister for the suction removal of fat tissue.) Some of these canulas have serrated bores for easier fat removal.
Ultrasound-assisted liposuction uses the canulas to deliver sound waves to help break up fat tissue. These canulas are designed for patients who have had repeated liposuction. This is needed to break up adhesions (scar tissue) that forms after the initial procedure during the healing process.
Laser liposuction is another type of liposuction aimed at specifically improving skin contraction. This is important in older patients or in patients who have excessive loose skin due to recent weight loss or post-pregnancy. However, for very large amounts of loose skin or poor skin tone in areas such as the abdomen, a larger procedure such as abdominoplasty may be needed.
During laser liposuction, a small wire laser is placed inside a canula to deliver a specific amount of heat energy to the area (around 40 degrees centrigrade). The application of heat is believed to stimulate collagen production (for skin tightening). Bleeding is reduced because of the cautery effect of the heat – but post-operative pain is increased due to increased inflammatory effects. There is also a risk of burn trauma during this procedure.
There have been several other liposuction techniques that have gone in and out of fashion, and many of the variations mentioned are often referred to by trademark names such as “Vaser”, “SmartLipo”, “SlimLipo” which can be confusing for people seeking information on these procedures.
Fat Grafting
Fat from liposuction procedure to be used for buttock augmentation
Fat grafting is a procedure used in combination with liposuction. With this procedure, fat that was removed during liposuction is relocated to another area of the body such as the buttocks, hands or face.
In this patient, Dr. Botero injects the fat using a large bore needle deep into the gluteal muscles to prevent a sloppy, or dimpled appearance. Injecting into the muscle tissue also helps to preserve the longevity of the procedure. However, care must be taken to prevent fat embolism*, a rare but potentially fatal complication – where globules of fat enter the bloodstream. To prevent this complication, Dr. Botero carefully confirms the placement of his needle in the muscle tissue before injecting.
Results are immediately appreciable.
fat being injected for buttock augmentation. (Photo edited for patient privacy).
The Surgery:
Patient was appropriately marked prior to the procedure. The patient was correctly prepped, drapped and positioned to prevent injury or infection. Ted hose and sequential stockings were applied to lessen the risk of developing deep vein thrombosis. Pre-operative procedures were performed according to internationally recognized standards.
Sterility was maintained during the case. Dr. Botero appeared knowledgeable and skilled regarding the techniques and procedures performed.
His instrumentadora (First assistant), Liliana Moreno was extremely knowledgeable and able to anticipate Dr. Botero’s needs.
Circulating nurse: Anais Perez maintained accurate and up-to-date intra-operative records during the case. Ms. Perez was readily available to obtain instruments and supplies as needed.
Overall – the team worked well together and communicated effectively before, during and after the case.
Anesthesia was managed by Dr. Julio Arango. He was using an anesthesia technique called “controlled hypotension”. (Since readers have heard me rail about uncontrolled hypotension in the past – I will write another post on this topic soon.)
Controlled Hypotension
However, as the name inplies – controlled hypotension is a tightly regulated process, where blood pressure is lowered to a very specific range. This range is just slightly lower than normal (Systolic BP of around 80) – and the anesthesiologist is in constant attendance. This is very different from cases with profound hypotension which is ignored due to an anesthesia provider being distracted – or completely absent.
With hypotensive anesthesia – blood pressure is maintained with a MAP (or mean) of 50 – 60mmHg with a HR of 50 – 60. This reduces the incidence of bleeding.
However, this technique is not safe for everyone. Only young healthy patients are good candidates for this anesthesia technique. Basically, if you have any stiffening of your arteries due to age (40+), smoking, cholesterol or family history – this technique is NOT for you. People with high blood pressure, any degree of kidney disease, heart disease, peripheral vascular disease or diabetes are not good candidates for this type of anesthesia. People with these kinds of medical conditions do not tolerate even mild hypotension very well, and are at increased risk of serious complications such as renal injury/ failure or cardiovascular complications such as a heart attack or stroke. Particularly since this is an elective procedure – this is something to discuss with your surgeon and anesthesiologist before surgery.
The patient today is young (low 20’s), physically fit, active with no medical conditions so this anesthesia poses little risk during this procedure. Also the surgery itself is fairly short – which is important. Long/ marathon surgeries such as ‘mega-makeovers‘ are not ideal for this type of anesthesia.
Dr. Julio Arango keeps a close eye on his patient
However, Dr. Arango does an excellent job during this procedure, which is performed under general anesthesia. After intubating the patient, he maintained a close eye on vital signs and oxygenation. The patient is hemodynamically stable with no desaturations or hypoxia during the case. Dr. Arango remains alert and attentive during the case, and remains present for the entire surgery. Following surgery, anesthesia was lightened, and the patient was extubated prior to transfer to the recovery room.
He also demonstrated excellent knowledge of international protocols regarding DVT/ Travel risk, WHO safety protocols and intra-operative management.
Surgical apgar score: 9 (however, there is a point lost due to MAP of 50 – 60 as discussed above).
Results of the surgery were cosmetically pleasing.
Post -operative care:
Prior to discharge from the ambulatory care center after recovery from anesthesia the patient (and family) receives discharge instructions from the nurses.
The patient also receives prescriptions for several medications including:
1. Oral antibiotics for a five-day course**. Dr. Botero uses this duration for fat grafting cases only.
2. Non-narcotic analgesia (pain medications).
3. Lyrica ( a gabapentin-like compound) to prevent neuralgias during the healing period.
The patient will wear a support garment for several weeks. She is to call Dr. Botero to report any problems such as unrelieved pain, drainage or fever.
Note: after some surgeries like abdominoplasty, patients also receive DVT prophylaxis with either Arixtra or enoxaparin (Lovenox).
Follow-up appointments:
Dr. Botero will see her for her first follow-up visit in two days (surgery was on a Saturday). He will see twice a week the first week, and then weekly for three weeks (and additionally as needed.)
* Fat embolism is a risk with any liposuction procedure.
**This is contrary to American recommendations as per the National Surgical Care Improvement Project (SCIP) which recommends discontinuation within the first 24 hours to prevent the development of antibiotic resistance.
Dr. Sergio Franco wrote the book on heart surgery.
It was exciting and illuminating to talk to Dr. Sergio Franco, who is one of Colombia’s most prolific writers and professors of cardiac surgery. The 50 year-old cardiac surgeon has authored multiple textbooks for surgeons and edited ten others, making him one of the nation’s definitive experts on cardiac surgery.
Dr. Franco stands near a collection of his textbooks
Currently he is the Medical Director of the Cardiopulmonary and Peripheral Vascular Center of the Fundacion San Vicente in Rio Negro, as well as Chief of Cardiothoracic Surgery at the Clinica de Medellin. For the last 12 years, he has also been the program director for post-graduate studies at the Universidad CES medical school. Between the two clinics, and the five other surgeons he works with (2 at Clinica de Medellin and 2 at Rionegro), he estimates that the cardiac programs see volumes of 700 – 750 cases per year.
For our first interview, we meet at the Clinica de Medellin to talk. He later invites me to see the hospital at Rionegro.
Education/ Training / Experience
Dr. Franco attended medical school, general surgery residency and cardiac surgery fellowship at the Universidad Pontifica Boliviarana. He finished his fellowship in 1996. As part of his fellowship, he spent nine months training in heart and lung transplantation at Loyola University Medical Center in Chicago, Il. During his heart and lung tranplantation training, he received an award as “Best Foreign Medical Fellow.” He graduated with high honors due to his exemplary grade point average.
He has additional training in thoracic and thoracoabdominal aortic surgery (Missouri Baptist, 1998), and minimally invasive valvular surgery (Cleveland Clinic).
Selected awards and special recognition
He was also the first surgeon to perform endovascular harvesting of the saphenous vein in Colombia in 1997. He received second place for a poster presentation based on this technique at the Colombian Congress of Cardiology and Cardiovascular Surgery, Cartagena, 8 to 11 February 2006.
He received the Cesar Uribe Piedrahita Medal from the Colombian Medical Federation and the Antioquia Medical College in 2003 for academic and clinical excellence, in addition to several other awards for academic achievement.
He was the chapter president of the Colombian Society of Cardiovascular Surgery and the Colombian Surgical Consensus for multiple terms. He was also the Chairman, and Medical Advisory of the first Latin American Forums on cardiovascular surgery.
He has received several awards including “The best of 2006” from Hospital General de Medellin for his assistance in the development, creation and commissioning of the cardiovascular services unit at that facility. He has also presented his work at numerous national and international conferences.
He speaks English in addition to his native Spanish.
Dr Sergio Franco
San Vicente Fundacion
Cardiovascular Surgery
Medical Director, Cardiopulmonary and Vascular Surgery
While I requested a visit to the operating room, an invitation was not forthcoming.
Selected writings of Dr. Sergio Franco
Book chapters:
1. Franco S., Restrepo G. Momento Quirúrgico óptimo en el paciente con enfermedad valvular cardiaca. Libro Tópicos selectos en enfermedades cardiovasculares 2000. Unidad cardiovascular Clínica Medellín. 1 Edición. Página. 101-112. ISBN 958-33-1541-9
2. Franco S. Endocarditis Infecciosa: Visión Quirúrgica – Indicaciones de Cirugía. Libro Tópicos selectos en enfermedades cardiovasculares 2000. Unidad cardiovascular Clínica Medellín. 1 Edición. Páginas 201-211. ISBN 958-33-1541-9
3. Franco, S. Estenosis Mitral – Tratamiento Quirúrgico. En: Franco, S. (Ed) Enfermedad valvular cardiaca. Sociedad Colombiana de Cardiología. Editorial Colina, 1 edición, Pgnas 111-116 Abril 2001. ISBN : 958-33-2244-X
4. Franco, S., Giraldo, N. , Vélez JF. Uso e Indicaciones deHomoinjertos – Cirugía de Ross. En: Franco, S (Ed) Enfermedad Valvular Cardiaca. Sociedad Colombiana de Cardiología. Editorial Colina, 1 edición, Pgnas 70 – 77, Abril 2001. ISBN : 958-33-2244-X
5. Alzate L., Franco S. Factores hemodinámicos y físicos de las válvulas cardiacas artificiales. En: Franco, S. (Ed) Enfermedad Valvular Cardiaca – Sociedad Colombiana de Cardiología. Editorial Colina, 1 edición, Pgnas 222 – 228 Abril 2001. ISBN : 958-33-2244-X
6. Franco, S., Vélez, J. Revascularización Quirúrgica del Miocardio: Estado actual. En: Tópicos selectos en terapéutica cardiaca y vascular 2001. Cardiología Clínica Medellín. P: 108 –120. Primera edición, Octubre 2001. ISBN : 958-33-2607-0
7. Vélez, JF, Franco, S., Tamayo L. Tratamiento quirúrgico de la enfermedad coronaria. En: Enfermedad Coronaria. Pineda M, Matiz H, Rozo R. (Ed), septiembre 2002. Capitulo 36, pgnas 609-630. ISBN : 958-33-3945-8
8. Franco, S.Intervencion Quirúrgica de los síndromes coronarios agudos. En: Tópicos selectos en enfermedades cardiovasculares, 2002. Pgna 177-192 (Velásquez D, Uribe W, editores) Ed. Colina, Departamento de Cardiología Clínica Medellín 2002. ISBN 958-33-3663-7
9. Franco, S.Cardiopatías Congénitas del Adulto. En: Tópicos selectos en cardiología de consultorio 2003. Pgnas 193-211. (Restrepo G., Uribe W., Velásquez D., editores). Ed. Colina, Cardiología Clínica Medellín, 2003. ISBN : 958-33-4858-9
10. Franco, S.Enfermedad Valvular Cardiaca: Indicaciones de Cirugía. En: Libro II Congreso medicina cardiovascular y torácica. . Hospital Departamental Santa Sofía de Caldas, 2003 (Jaramillo O., Editor) Editorial Tizan. Pgnas 87-104
11. Franco, S.Tratamiento Quirúrgico de la Fibrilación Atrial. En: Libro II Congreso medicina cardiovascular y torácica. Hospital Departamental Santa Sofía de Caldas, 2003. (Jaramillo O., Editor) Editorial Tizan. Pgnas 123-131
14. Franco, S., Giraldo, N. Tratamiento Quirúrgico del Paciente Valvular en Falla Cardiaca. En: Enfermedad Valvular Cardiaca. Paginas 169 – 176. (Franco, S., Editor). Editorial Colina. Primera Edición 2004. 227 paginas. ISBN 958-33-6218-2
15. Franco, S. Jiménez A. Factores Físicos y Hemodinámicos de las Prótesis Valvulares Cardiacas. En: Enfermedad Valvular Cardiaca. Pgnas 223-227. (Franco, S., Editor). Editorial Colina. Primera Edición 2004. 227 paginas. ISBN 958-33-6218-2
16. Franco, S.Guías de manejo de las valvulopatias aorticas. En: Tópicos Selectos en Guías de Manejo en Enfermedades Cardiacas y Vasculares 2004. Pgnas 143-149. (Uribe, W, Velásquez D, Restrepo G., Editores). Editorial Colina. Primera edición, 2004. 195 paginas. ISBN 958-33-6285-9
17. Franco, S.Guías de manejo de las valvulopatias mitrales. En: Tópicos Selectos en Guías de Manejo en Enfermedades Cardiacas y Vasculares 2004. Pgnas 149-155. (Uribe, W, Velásquez D, Restrepo G., Editores). Editorial Colina. Primera edición, 2004. 195 paginas. ISBN 958-33-6285-9
18. Franco, S.Tratamiento Quirúrgico de la Fibrilación Atrial. En: Falla Cardiaca, Diagnostico y manejo Actual. 2004. Pgnas 271- 287.. (Castro, H; Cubides, C. Editores) Editorial Blanecolor, Primera edición, 2004. 431 pgnas. ISBN 33-6689-7
19. Escobar, A. Franco, S. Trauma de grandes vasos torácicos. En: Tópicos Selectos en guías de manejo en enfermedades cardiacas y vasculares – 2005. (Velásquez D., Uribe W. editores) 1 Edición, editorial colina, 2005. pgnas 160- 169. 193 paginas. ISBN : 958-33-7698-1
20. Franco, S., Vélez, A. Trauma cardiaco. En: Tópicos Selectos en guías de manejo en enfermedades cardiacas y vasculares – 2005. (Velásquez D., Uribe W. editores) 1 Edición, editorial colina, 2005. pgnas 154- 159. ISBN : 958-33-7698-1
21. Franco, S., Jaramillo, J. Tumores cardiacos. En: Tópicos Selectos en guías de manejo en enfermedades cardiacas y vasculares – 2005. (Velásquez D., Uribe W. editores) 1 Edición, editorial colina, 2005. pgnas 117 – 123. 193 paginas. ISBN : 958-33-7698-1
22. Franco, S., Vélez, A. Trauma cardiaco. En: Tópicos Selectos en guías de manejo en enfermedades cardiacas y vasculares – 2005. Manual Condensado. (Velásquez D., Uribe W. editores) 1 Edición, editorial colina, 2005. pgnas 362- 366. 388 paginas. ISBN : 958-33-7698-1
23. Franco, S.Guías de manejo de las valvulopatias aorticas. En: Tópicos Selectos en Guías de Manejo en Enfermedades Cardiacas y Vasculares 2005. Manual condensado. Pgnas 177-182. (Uribe, W, Velásquez D, Restrepo G., Editores). Editorial Colina. Primera edición, 2005. 388 paginas. ISBN : 958-33-7698-1
24. Franco, S.Guías de manejo de las valvulopatias mitrales. En: Tópicos Selectos en Guías de Manejo en Enfermedades Cardiacas y Vasculares 2005. Manual condensado. Pgnas 183-188. (Uribe, W, Velásquez D, Restrepo G., Editores). Editorial Colina. Primera edición, 2005. 388 paginas. ISBN : 958-33-7698-1
25. Jaramillo, J.S., Franco, S.Implante Quirúrgico del Electrodo Epicárdico en el Ventrículo Izquierdo Mediante Cirugía. En: Duque, M., Franco, S. Editores. Tratamiento no Farmacológico de la Falla Cardiaca. Sociedad Colombiana de Cardiología y Cirugía Cardiovascular. Primera Edición, Editorial Colina, Pgnas 89-92, Abril 2006. ISBN : 958-33-8661-8
26. Franco, S.Cirugía de Remodelación Ventricular en Falla Cardiaca. En: Duque, M., Franco, S. Editores. Tratamiento no Farmacológico de la Falla Cardiaca. Sociedad Colombiana de Cardiología y Cirugía Cardiovascular. Primera Edición, Editorial Colina, Pgnas 168 – 182, Abril 2006. ISBN : 958-33-8661-8
27. Jaramillo, JS., Franco, S., Vélez, JF. Revascularización Coronaria Quirúrgica. En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores. Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte. Primera Ed, 2006, Editorial Colina. Pgnas 559-576. ISBN : 958-33-9493-9
28. Franco, S., Vélez, JF, Jaramillo, JS., Cirugía en Enfermedad Valvular Aortica. En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores. Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte. Primera Ed, 2006, Editorial Colina. Pgnas 588 – 595. ISBN : 958-33-9493-9
29. Franco, S., Vélez, JF, Jaramillo, JS., Valvulopatia Mitral. En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores. Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte. Primera Ed, 2006, Editorial Colina. Pgnas 596 – 603. ISBN : 958-33-9493-9
30. Franco, S., Vélez, JF, Jaramillo, JS., Cirugía en Enfermedad Valvular Pulmonar y Tricúspidea. En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores. Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte. Primera Ed, 2006, Editorial Colina. Pgnas 604 – 606. ISBN : 958-33-9493-9
31. Jaramillo, JS., Franco, S., Vélez, JF, Disección Aortica. En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores. Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte. Primera Ed, 2006, Editorial Colina. Pgnas 607 – 617. ISBN : 958-33-9493-9
32. Franco, S., Vélez, A., Trauma de Corazón y Grandes Vasos. En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores. Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte. Primera Ed, 2006, Editorial Colina. Pgnas 618 – 625. ISBN : 958-33-9493-9
33. Franco, S., Jaramillo, JS., Vélez, JF., Tumores Cardiacos. En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores. Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte. Primera Ed, 2006, Editorial Colina. Pgnas 626 – 635. ISBN : 958-33-9493-9
34. Vélez, JF, Franco, S., Jaramillo, JS., Cardiopatías Congénitas del Adulto. En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores. Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte. Primera Ed, 2006, Editorial Colina. Pgnas 649 – 659. ISBN : 958-33-9493-9
35. Uribe, W., Franco, S., Gil, E. Fibrilacion Auricular. En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores. Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte. Primera Ed, 2006, Editorial Colina. Pgnas 441 – 466. ISBN : 958-33-9493-9
36. Restrepo, G., Franco, S.Endocarditis Infecciosa. En : Texto de Cardiologia. Sociedad Colombiana de Cardiologia y Cirugia Cardiovascular. Legis, S.A. 1 Ed, 2007; Capitulo VI, pgnas 614-30. ISBN : 958-97065-7-6
37. Franco, S., Sandoval, N. Tratamiento Quirurgico de la Fibrilacion Atrial. En : Texto de Cardiologia. Sociedad Colombiana de Cardiologia y Cirugia Cardiovascular. Legis, S.A. 1 Ed, 2007; Capitulo IX, pgnas 835-842. ISBN : 958-97065-7-6
38. Franco, S., Jaramillo JS. Trauma Cardiaco. En : Texto de Cardiologia. Sociedad Colombiana de Cardiologia y Cirugia Cardiovascular. Legis, S.A. 1 Ed, 2007; Capitulo XVI, pgnas 1442-49. ISBN : 958-97065-7-6
39. Franco, S., Velez, A. Trauma Vascular Cervical. En : Guias de Manejo en Enfermedades Cardiacas y Vasculares 2007. Manual Condensado, 3 Edicion, Cardiologia Clinica Medellin; 2007. Capitulo 31, P 425 – 433. ISBN : 979-958-98111-9-1
40. Franco, S., Velez, A., Jaramillo JS. Trauma Cardiaco. En : Guias de Manejo en Enfermedades Cardiacas y Vasculares 2007. Manual Condensado, 3 Edicion, Cardiologia Clinica Medellin; 2007. Capitulo 30, P 419 – 423. ISBN : 979-958-98111-9-1
41. Franco, S.Guias de Manejo de las Valvulopatias Aorticas. En : Guias de Manejo en Enfermedades Cardiacas y Vasculares 2007. Manual Condensado, 3 Edicion, Cardiologia Clinica Medellin; 2007. Capitulo 25, P 379 – 385. ISBN 978-958-98111-9-1
42. Franco, S.Guias de Manejo de las Valvulopatias Mitrales. En : Guias de Manejo en Enfermedades Cardiacas y Vasculares 2007. Manual Condensado, 3 Edicion, Cardiologia Clinica Medellin; 2007. Capitulo 26, P 387 – 392. ISBN : 979-958-98111-9-1
43. Jaramillo, J.S., Franco, S.Guias de Manejo de la Revascularizacion Coronaria Quirurgica. En : Guias de Manejo en Enfermedades Cardiacas y Vasculares 2007. Manual Condensado, 3 Edicion, Cardiologia Clinica Medellin. Capitulo 24, P 369 – 377. ISBN : 979-958-98111-9-1
44. Franco, S.; Velez, JF.; Jaramillo,JS. Complicaciones mecanicas del infarto agudo del miocardio. En : Topicos Selectos en Enfermedad Coronaria – 2008. Velasquez, D. ed; Distribuna Ed, Cardiologia Clinica Medellin, 2008. P. 115-126. ISBN 978-958-8379-09-8
45. Jaramillo,JS.; Franco, S.; Velez, JF. Guias de manejo de la revascularizacion coronaria quirurgica. En : Topicos Selectos en Enfermedad Coronaria – 2008. Velasquez, D. ed; Distribuna Ed, Cardiologia Clinica Medellin, 2008. P. 197- 218. ISBN 978-958-8379-09-8
46. Franco, S.; Jaramillo, J.S. Guías de Manejo de la revascularización Coronaria Quirúrgica. En: Guias de manejo en enfermedades cardiacas y vasculares. Manual Condensado 2009. Velásquez, D. Ed. Editorial Distribuna, 1 edicion 2009, 503 paginas. P. 429-440. ISBN : 978-958-8379-19-7
47. Franco, S.; Jaramillo, J.S. Guias de Manejo de las valvulopatias aorticas. En: Guias de manejo en enfermedades cardiacas y vasculares. Manual Condensado 2009. Velásquez, D. Ed. Editorial Distribuna, 1 edicion 2009, 503 paginas. P. 441-448. ISBN : 978-958-8379-19-7
48. Franco, S.; Jaramillo, J.S. Guias de Manejo de las valvulopatias mitrales. En: Guias de manejo en enfermedades cardiacas y vasculares. Manual Condensado 2009. Velásquez, D. Ed. Editorial Distribuna, 1 edicion 2009, 503 paginas. P. 449-456. ISBN : 978-958-8379-19-7
49. Franco, S.; Jaramillo, J.S. Trauma Cardiaco. En: Guías de manejo en enfermedades cardiacas y vasculares. Manual Condensado 2009. Velásquez, D. Ed. Editorial Distribuna, 1 edición 2009, 503 paginas. P. 487-492. ISBN : 978-958-8379-19-7
50. Franco, S.; Jaramillo, J.S. Trauma Vascular Cervical. En: Guías de manejo en enfermedades cardiacas y vasculares. Manual Condensado 2009. Velásquez, D. Ed. Editorial Distribuna, 1 edición 2009, 503 paginas. P. 493 – 503. ISBN : 978-958-8379-19-7
51. Franco, S.; Jaramillo, J.S. Trauma Vascular Cervical. En: Guías de manejo en enfermedades cardiacas y vasculares. Manual Condensado 2010. Velásquez, D. Ed. Editorial Distribuna, 2 edición 2010, 511 paginas. P. 501 – 511. ISBN : 978-958-8379-29-6
52. Franco, S.; Jaramillo, J.S. Trauma Cardiaco. En: Guías de manejo en enfermedades cardiacas y vasculares. Manual Condensado 2010. Velásquez, D. Ed. Editorial Distribuna, 2 edicion 2010, 511 paginas. P. 495 – 500. ISBN : 978-958-8379-29-6
53. Franco, S.; Jaramillo, J.S. Guías de Manejo de las Valvulopatias Mitrales. En: Guías de manejo en enfermedades cardiacas y vasculares. Manual Condensado 2010. Velásquez, D. Ed. Editorial Distribuna, 2 edición 2010, 511 paginas. P. 457 – 463. ISBN : 978-958-8379-29-6
54. Franco, S.; Jaramillo, J.S. Guías de Manejo de las Valvulopatias Aorticas. En: Guías de manejo en enfermedades cardiacas y vasculares. Manual Condensado 2010. Velásquez, D. Ed. Editorial Distribuna, 2 edición 2010, 511 paginas. P. 449 – 456. ISBN : 978-958-8379-29-6
55. Franco, S.; Jaramillo, J.S. Guías de Manejo de la Revascularización Coronaria Quirúrgica. En: Guías de manejo en enfermedades cardiacas y vasculares. Manual Condensado 2010. Velásquez, D. Ed. Editorial Distribuna, 2 edición 2010, 511 paginas. P. 437 – 447. ISBN : 978-958-8379-29-6
56. Franco, S.; Bucheli, V. Anatomía Quirúrgica de la Válvula Mitral. En : Enfermedad Valvular Cardiaca. Franco, S. Ed., Editorial Colina, Primera Edición 2010, 440 paginas. P. 26 – 31. ISBN : 978-958-44-7706-4
57. Franco, S.; Bucheli, V. Anatomía Quirúrgica de la Válvula Aortica. En : Enfermedad Valvular Cardiaca. Franco, S. Ed., Editorial Colina, Primera Edición 2010, 440 paginas. P. 33 – 38. ISBN : 978-958-44-7706-4
58. Franco, S. Endocarditis Infecciosa. En : Enfermedad Valvular Cardiaca. Franco, S. Ed., Editorial Colina, Primera Edición 2010, 440 paginas. P. 85 – 113. ISBN : 978-958-44-7706-4
59. Franco, S. Criterios para la Selección de una Prótesis Cardiaca. En : Enfermedad Valvular Cardiaca. Franco, S. Ed., Editorial Colina, Primera Edición 2010, 440 paginas. P. 433 – 440. ISBN : 978-958-44-7706-4
60. Franco, S., Atehortua, M. Endocarditis Infecciosa. En : Estado Actual en Enfermedades Cardiacas y Vasculares 2011. Ed. Editorial Distribuna, 1 Edición 2011, 744 pnas. Pgna 153 – 184. ISBN : 978-958-8379-46-3
61. Franco, S., Atehortua, M. Valvulopatia Mitral. En : Estado Actual en Enfermedades Cardiacas y Vasculares 2011. Ed. Editorial Distribuna, 1 Edición 2011, 744 pnas. Pgna 717 – 727. ISBN : 978-958-8379-46-3
62. Franco, S., Atehortua, M. Cirugía Valvular Aortica. En : Estado Actual en Enfermedades Cardiacas y Vasculares 2011. Ed. Editorial Distribuna, 1 Edición 2011, 744 pnas. Pgna 707 – 717. ISBN : 978-958-8379-46-3
63. Atehortua, M., Franco, S. Revascularización Coronaria Quirúrgica. En : Estado Actual en Enfermedades Cardiacas y Vasculares 2011. Ed. Editorial Distribuna, 1 Edición 2011, 744 pnas. Pgna 675 – 690. ISBN : 978-958-8379-46-3
64. Atehortua, M., Franco, S. Evaluación y Momento Optimo de Intervención en el Paciente con Enfermedad Valvular Cardiaca. En : Estado Actual en Enfermedades Cardiacas y Vasculares 2011. Ed. Editorial Distribuna, 1 Edición 2011, 744 pnas. Pgna 691 – 707. ISBN : 978-958-8379-46-3
65. Atehortua, M., Franco, S. Cirugía en Enfermedad Valvular y Tricuspidea. En : Estado Actual en Enfermedades Cardiacas y Vasculares 2011. Ed. Editorial Distribuna, 1 Edición 2011, 744 pnas. Pgna 727 – 744. ISBN : 978-958-8379-46-3
66. Atehortua, M., Franco, S., Velez, L.A. Guias de Manejo de Revascularizacion Coronaria. En : Guias de Manejo en Enfermedades Cardiacas y Vasculares Estado Actual – 2012. Ed. Editorial Distribuna, 3 Edición 2012, 708 pnas. Pgna 619 – 630. ISBN : 978-958-8379-60-9
67. Velez, L.A., Franco, S., Atehortua, M. Guias de Manejo de las Valvulopatias Aorticas. En : Guias de Manejo en Enfermedades Cardiacas y Vasculares Estado Actual – 2012. Ed. Editorial Distribuna, 3 Edición 2012, 708 pnas. Pgna 631 – 642. ISBN : 978-958-8379-60-9
68. Atehortua, M., Franco, S., Velez, L.A. Guias de Manejo de las Valvulopatias Mitrales. En : Guias de Manejo en Enfermedades Cardiacas y Vasculares Estado Actual – 2012. Ed. Editorial Distribuna, 3 Edición 2012, 708 pnas. Pgna 643 – 653. ISBN : 978-958-8379-60-9
69. Velez, L.A., Atehortua, M., Franco, S. Cirugia en Enfermedad Valvular Pulmonar y Tricuspidea. En : Guias de Manejo en Enfermedades Cardiacas y Vasculares Estado Actual – 2012. Ed. Editorial Distribuna, 3 Edición 2012, 708 pnas. Pgna 655 – 661. ISBN : 978-958-8379-60-9
70. Franco, S., Bucheli, V., Atehortua, M., Velez, L.A. Guias de Manejo en Endocarditis Infecciosa En : Guias de Manejo en Enfermedades Cardiacas y Vasculares Estado Actual – 2012. Ed. Editorial Distribuna, 3 Edición 2012, 708 pnas. Pgna 671 – 690. ISBN : 978-958-8379-60-9
71. Franco, S., Bucheli, V., Atehortua, M., Velez, L.A. Guias de Manejo de los Sindromes Aorticos Agudos. En : Guias de Manejo en Enfermedades Cardiacas y Vasculares Estado Actual – 2012. Ed. Editorial Distribuna, 3 Edición 2012, 708 pnas. Pgna 691 – 702. ISBN : 978-958-8379-60-9
72. Franco, S., Atehortua, M., Velez, L.A. Trauma Cardiaco. En : Guias de Manejo en Enfermedades Cardiacas y Vasculares Estado Actual – 2012. Ed. Editorial Distribuna, 3 Edición 2012, 708 pnas. Pgna 703 – 708. ISBN : 978-958-8379-60-9
Journal articles
1. Franco Sergio, Hincapié Miriam, Mejía Olga. Estudio Epidemiológico de Teníasis. Cisticercosis, San Vicente Antioquia – Colombia, 1985-1986. En: Medicina Tropical y Parasitología Vol. 2 No 1, Ecuador, Diciembre 1985.
2. Franco Sergio, Hincapié Miriam, Mejía Olga. Estudio Epidemiológico de Epilepsia y Neurocisticercosis. En: “Revista Universidad Industrial de Santander – Medicina¨ Vol. 14 No 1, Mayo 1986, p 143- 74.
3. Botero D., Franco S., Hincapié M., Mejía O. Investigaciones Colombianas Sobre Cisticercosis. En: Acta Neurológica. Vol. 2 No 2 Septiembre 1986, p. 3-6.
4. Franco Sergio; Londoño Juan. Dermatopoliomiositis – Reporte de un caso – Revisión del Tema. En: Medicina – U.P.B. Vol. 7 No 2, Noviembre 1988. p. 115.
5. Franco Sergio; Vásquez Jesús; Ortiz Jorge. Infarto Segmentario Idiopático del Epiplón Mayor – Presentación de dos casos y revisión del tema. En: Medicina – U.P.B. Vol. 10 No 2. Octubre. 1991, p. 109.
6. Franco Sergio. Choque Hipovolémico. Medicina U.P.B., Vol. 13 No 2, Octubre, 1994. P. 139-160.
7. Montoya A., Franco S.,. Lung Transplantation for Bronchoalveolar Cell Carcinoma. First Case Report in the Word Literature. 1996 – Loyola University Chicago Annual Report Magazine.
8. Franco S. Autopsy Results in Patients Following Lung Transplantation. Department of Pathology at Loyola University Medical Center. 1996 – Loyola University Chicago Annual Report Magazine.
9. Franco S., Giraldo N., Flórez M. Tratamiento Quirúrgico de la Coartación Aórtica Seguimiento a Largo Plazo – 8 años. Revista Colombiana de Cardiología. Vol. 5 No 5, Diciembre 1996.
10. Franco S, Giraldo N. Trauma Cardíaco: Revisión del Tema. Revista Colombiana de Cardiología. Marzo de 1997.
11. Franco S., Giraldo N., Ramírez C., Vallejo C., Castro H. Revascularización Miocárdica en pacientes con fracción de eyección menor del 30%. Departamento de Cirugía Cardiovascular. Unidad Cardiovascular Clínica Medellín. XVIII Congreso Colombiano de Cardiología. Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 301.
12. Franco S., Giraldo N., Fernández H., Ramírez C., Vallejo C., Castro H. Transección Aórtica Traumática: Presentación de tres casos, revisión de la literatura. Departamento de Cirugía Cardiovascular. Unidad Cardiovascular Clínica Medellín. XVIII Congreso Colombiano de Cardiología. Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 330.
13. Franco S., Giraldo N., Vélez S. et al. Fístula de la arteria coronaria derecha al tracto de salida del ventrículo derecho. Reporte de un caso – revisión del tema. Departamento de Cirugía Cardiovascular. Unidad Cardiovascular Clínica Medellín. XVIII Congreso Colombiano de Cardiología. Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 319.
14. Giraldo N., Franco S., Ramírez C., Vallejo C., Castro H. CIV y Banding de la arteria pulmonar en un paciente adulto. Departamento de Cirugía Cardiovascular. Unidad Cardiovascular Clínica Medellín. XVIII Congreso Colombiano de Cardiología. Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 333.
15. Giraldo N., Franco S., Ramírez C., Vallejo C., Castro H. Ruptura Ventricular post implantación de válvula mitral. Departamento de Cirugía Cardiovascular. Unidad Cardiovascular Clínica Medellín. XVIII Congreso Colombiano de Cardiología. Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 340.
16. Castro H., Ramírez C., Franco S., Mesa J. et al. Anestesia y técnica quirúrgica en pacientes sometidos a implantación percutánea de endoprótesis en aneurismas de la aorta abdominal. Reporte de tres casos y revisión de la literatura. Departamento de Cirugía y Anestesia Cardiovascular. Departamento de Hemodinámica. Unidad Cardiovascular Clínica Medellín. XVIII Congreso Colombiano de Cardiología. Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 331.
17. Vallejo C., Castro H., Ramírez C., Franco S., Duque M. et al. Anestesia y técnica quirúrgica en pacientes sometidos a implante de cardiodesfibrilador automático. Reporte de 20 casos. Departamento de Cirugía y Anestesia Cardiovascular. Departamento de Electrofisiología y Arritmias. Unidad Cardiovascular Clínica Medellín. XVIII Congreso Colombiano de Cardiología. Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 336.
18. Ramírez C., Vallejo C., Castro H., Franco S., Giraldo N. et al. Protección Miocárdica: Solución de HTK en Cirugía Cardiaca. Departamento de Cirugía y Anestesia Cardiovascular. Unidad Cardiovascular Clínica Medellín. XVIII Congreso Colombiano de Cardiología. Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 336.
19. Ramírez C., Vallejo C., Castro H., Franco S., Giraldo N. et al. Protección Miocárdica: Comparación entre la Solución de HTK y la Solución de Buckberg en Cirugía Cardiaca. Departamento de Cirugía y Anestesia Cardiovascular. Unidad Cardiovascular Clínica Medellín. XVIII Congreso Colombiano de Cardiología. Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 336.
20. Vallejo C., Ramírez C., Castro H., Giraldo N., Franco S. Hipotiroidismo y enfermedad cardiaca: Administración de hormona tiroidea vía oral en pacientes sometidos a cirugía cardiaca. Departamento de Cirugía y Anestesia Cardiovascular. Unidad Cardiovascular Clínica Medellín. XVIII Congreso Colombiano de Cardiología. Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 334.
21. Franco, S., Giraldo, N., Fernández H., Escobar A., Ramírez, C., Vallejo, C., Castro H. Revascularización miocárdica con arteria radial: Estudio de Casos y Controles. Departamento de Cirugía Cardiotorácica, Clínica Medellín. XIX Congreso Colombiano de Cardiología. Noviembre 27 – Diciembre 1, 2001. Revista Colombiana de Cardiología, 2001, Vol. 9(2): 197.
22. Giraldo, N., Franco, S., Fernández H., Escobar A., Ramírez, C., Vallejo, C., Castro H. Revascularización miocárdica Off Pump: Requerimiento de derivados sanguíneos. Departamento de Cirugía Cardiotorácica, Clínica Medellín. XIX Congreso Colombiano de Cardiología. Noviembre 27 – Diciembre 1, 2001. Revista Colombiana de Cardiología, 2001, Vol. 9(2): 238.
23. Giraldo, N., Franco, S. Fernández H., Escobar A., Ramírez, C., Vallejo, C., Castro H. Endarterectomia Coronaria del tronco principal izquierdo. Departamento de Cirugía Cardiotorácica, Clínica Medellín. CES Medicina Vol. 16 # 1, página 39-44. Enero-Marzo 2002.
24. Franco, S., Giraldo, N., Fernández H., Escobar A., Ramírez, C., Vallejo, C., Castro H. Cierre tardío del esternón en el manejo del sangrado mediastinal post cirugía cardiaca. Departamento de Cirugía Cardiotorácica, Clínica Medellín. CES – Medicina. Vol. 16 # 1, página 27-34. Enero-Marzo 2002.
25. Franco, S., Giraldo, N., Fernández H., Escobar A., Ramírez, C., Vallejo, C., Castro H. Cambio valvular mitral con preservación total del aparato valvular: Técnica quirúrgica, resultados y seguimiento. Departamento de Cirugía Cardiotorácica, Clínica Medellín. CES Medicina. Volumen 16 # 1, página 9-18. Enero-Marzo 2002.
26. Franco S, Giraldo N, Escobar A, Fernández H, Vallejo C, Ramírez C. Cambio valvular mitral con preservación total del aparato valvular: técnica quirúrgica, resultados y seguimiento. Revista Colombiana De Cardiología. 2003. pp. 368 – 74
27. Giraldo N, Franco S, Escobar A, Fernández H, Vallejo C, Ramírez C. Cierre tardío del esternón en el manejo del sangrado mediastinal post cirugía cardiaca. Revista Colombiana De Cardiología 2003. pp. 95 – 99
28. Escobar A., Giraldo N., Franco S., Jaramillo J., Orozco A. Taquiarritmias supraventriculares postcirugia cardiaca con y sin el uso de circulación extracorpórea. En : CES Medicina Volumen 17 # 1, Enero-julio 2003, Pgnas 23-31
29. Echeverri JL, Gonzáles M, Franco S., Vélez LA. Ruptura traumática de la aorta. Reporte de dos casos y revisión de la literatura. Medicina Crítica y Cuidados Intensivos. Enero – Junio 2004, 2 (1) : 31-35
30. Franco, S. Giraldo, N., Gaviria, A. et al. Aneurismas y seudoaneurismas de injertos venosos coronarios. Revista Colombiana de cardiología, Vol. 11 # 8, Abril 2005. Pgna 401- 404.
31. Franco, S.; Uribe, W.; Velez, JF. et al. Tratamiento quirurgico curativo de la fibrilacion atrial mediante tecnica de ablacion con radiofrecuencia monopolar irrigada : resultados a corto y mediano plazo. Revista Colombiana de Cardiologia. 2007. Vol 14, # 1. Pnas 43 – 55.
32. Escobar, A., Franco,S., Giraldo,N., et al. Tecnica de perfusion selectiva cerebral via subclavia para la correccion de patologias del arco aortico. Revista Colombiana de Cardiologia Volumen 14, numero 4, agosto 2007. P 232-237
33. Franco, S.Tratamiento quirurgico de la fibrilacion atrial. Revista Colombiana de Cardiologia – Guias de Diagnostico y Tratamiento de la Fibrilacion Auricular. Vol 14, Suplemento 3, Octubre 2007. P. 133 – 143.
34. Franco, S. Velez, A., Uribe, W., Duque, M., Velez, JF, et al. Tratamiento quirurgico de la fibrilacion atrial mediante radiofrecuencia. Revista Medica Sanitas 2008, Volumen 11, Numero 1, pgnas 8 – 20. Febrero – Abril, 2008.
35. Franco,S., Herrera, AM., Atehortua, M. et al. Use of Steel bands in sternotomy closure : implications in high-risk cardiac surgical population. Interactive CardioVascular and Thoracic Surgery 8 (2009) : 200-205.
36. Franco, S.Tratamiento Quirurgico para el manejo de las arritmias ventriculares. Guias Colombianas de Cardiologia. Artitmias Ventriculares y Muerte Subita. Revista Colombiana de Cardiologia. Volumen 18, Suplemento 1. Pgnas 160 – 163. Febrero 2011.
37. Miranda, A. ; Franco, S.,; Uribe, W. et al. Tromboembolismo Pulmonar Masivo de Alto Riesgo. Medicina ( Buenos Aires), 72 : 2012; Pgnas 128-130.
38. Miranda, A., Duque, M., Franco, S., Velasquez, J. et al. Tromboembolismo Pulmonar Masivo. Indicaciones de Cirugia – Reporte de caso. Revista Colombiana de Cardiologia. Volumen 19, Suplemento 1. Marzo de 2012.
39. Franco, S.; Eusse, A.; Atehortua, M., Vélez, L., et al. Endocarditis Infecciosa : Análisis de Resultados del Manejo Quirúrgico Temprano. Revista Colombiana de Cardiologia. Volumen 19, Suplemento 1, pgna 66. Marzo de 2012.
40. Franco, S.; Bucheli, V.; Atehortua, M., Vélez, L.; Eusse, A et al. Tratamiento Quirurgico : El “Gold Estándar” en el manejo de los defectos del septum interauricular. Revista Colombiana de Cardiologia. Volumen 19, Suplemento 1. Marzo de 2012.
41. Franco, S.; Atehortua, M., Vélez, L.; Castro, H., et al. Anomalías coronarias del Adulto. Origen anómalo de la arteria coronaria izquierda de la arteria pulmonar (ALCAPA). Reporte de caso. Revista Colombiana de Cardiologia. Volumen 19, Suplemento 1, pgna 61. Marzo de 2012.
42. Franco, S.; Atehortua, M., Vélez, L.; Castro, H., et al. Metástasis cardiaca de carcinoma anaplasico de tiroides. Reporte de caso. Revista Colombiana de Cardiologia. Volumen 19, Suplemento 1, pgna 70. Marzo de 2012.
43. Franco, S.; Giraldo, N.; Atehortua, M., Vélez, L.; Castro, H., et al. Endarterectomia coronaria del tronco principal izquierdo : Seguimiento a 15 años. Reporte de caso. Revista Colombiana de Cardiologia. Volumen 19, Suplemento 1, pgna 66. Marzo de 2012.
44. Franco, S.; Atehortua, M., Vélez, L.; Castro, H., Bucheli, V.; et al. Implante de válvulas biológicas : evaluación de libertad de reoperación por deterioro valvular estructural. Revista Colombiana de Cardiologia. Volumen 19, Suplemento 1, pgna 69. Marzo de 2012.
45. Miranda, A. Franco, S. Uribe, W., Duque, M. et al. Tromboembolismo Pulmonar Masivo de Alto Riesgo Asociado a Foramen Ovale Permeable. Medicina (Buenos Aires) 72 : 128 – 130. 2012.
46. Franco, S.Criterios Para la Selección de Una Protesis Cardiaca. Rev Fed Arg Cardiol. 2012; 41(3): 156 – 160.
Special topics in Cardiac Surgery: (Monographs)
1. Franco Sergio. Manejo Básico Inicial del Paciente Con Trauma CortoPunzante En: Monografía. Hospital San Vicente de Paúl – Prado (Tolima) 1989.
2. Franco S; Montoya A. Transplante Pulmonar: Indicaciones, Criterios de Selección y rechazo, Técnica Quirúrgica, Manejo de Donante y receptor, Complicaciones. Protocolo para la realización de transplante pulmonar en nuestro medio. Comité de transplantes de corazón y pulmón. 1996. Clínica Cardiovascular Santa María, Biblioteca Médica – Facultad de Medicina, Universidad Pontificia Bolivariana
3. Giraldo N., Franco S., Estudiantes X Semestre Instituto de Ciencias de la Salud – CES. Tratamiento Quirúrgico de la Endocarditis Infecciosa. Monografía. Investigación realizada en la Clínica Cardiovascular Santa Maria. Publicación Monográfica. Enero 1997.
4. Franco S. Safenectomía Videoendoscópica. Realización de video con descripción de la técnica quirúrgica. Descripción Monográfica. Departamento de Cirugía Cardiovascular. Unidad Cardiovascular Clínica Medellín. Diciembre de 1997.
5. Franco S., Giraldo N., Fernández H. Tratamiento Quirúrgico de la Enfermedad Pulmonar Obstructiva Crónica. Cirugía de Reducción de Volumen Pulmonar. Monografía, Departamento de Cirugía Cardiovascular – Unidad Cardiovascular Clínica Medellín. Octubre 1999.
6. Franco S., Escobar A. Trauma de Tórax. Revisión del tema. Monografía. Departamento de Cirugía Cardiovascular / Unidad Cardiovascular Clínica Medellín. Octubre de 1999.
7. Franco S., Jaramillo J.C. Cirugía en el paciente con Angina. Consenso Nacional sobre el Manejo de la Angina de Pecho. Sociedad Colombiana de Cardiología. Bogota, 11-12 agosto 2000.
8. Franco, S. Fibrilación Atrial: Tratamiento Quirúrgico. I Actualización del Consenso Nacional Sobre Fibrilación Atrial. Capitulo de Electrofisiología, Sociedad Colombiana De Cardiología. Abril 2002.
9. Franco, S, Jaramillo JS, Vélez JF, Castro H. Infecciones Mediastinales. Monografía. Departamento de Cirugía Cardiovascular. Hospital Departamental Santa Sofía de Caldas, Manizales. Mayo de 2003.
10. Guias Colombianas de Cardiologia. Fibrilacion Atrial – Guias de bolsillo.
Duque, M, Marin, J, ed. Franco, S. Cirugia de fibrilacion atrial. Sociedad Colombiana de Cardiologia y Cirugia Cardiovascular. 2008.
11. Franco, S. Long-Term Effectiveness of HIFU on Atrial Fibrillation in High Risk Valvular Surgery Patients. A Clinical Interview from Epicor- Cardiac Ablation System – St Jude Medical. March 2009.
What is the difference between a medico estetico and a cirujano plastico? The answer is more than just an issue of translation and semantics. We discussed this and several other issues during a visit to Clinica Plastic & Estetica Nova with Julio Casadiego, who works in the medical tourism sector here in Medellin at Colombia Travel Operator. Mr. Casadiego works with many of the healthcare professionals here in Colombia to assist overseas traveler in making arrangements for medical travel and has done so since 2009.
The Clinica Plastica & Estetica NOVA
Carrera 48 #32B sur 30
Envigado, Antioquia
Tele: (4) 339 2300 EXT 125
Email: gerencia@clinicanova.com.co
Nova is an ambulatory surgery center and a center for aesthetics. (Aesthetics is an umbrella term that encompasses other treatments outside of plastic surgery.) This five-story facility houses several doctors offices, aesthetic treatment facilities (laser treatment area) other nonsurgical treatment areas (cellulite treatment, botox/ injectables etc.), a cosmetic dentist (Dr. Jorge Ivan Echavarria) specializing in crowns, dental implants, maxiofacial surgery, and orthodontics along with other cosmetic services such as teeth-whitening.
There is a small pharmacy as well as a full lab (for development of gel matrix in addition to performing blood analysis), and sterilization facilities along with an operating theatre and recovery unit.
There are three operating rooms; all of which are spacious and well-lit. Each operating room has a full complement of fully functional and modern equipment and hemodynamic monitoring devices. There are also several well placed ‘crash carts’ for potential emergencies. The recovery room contains hemodynamic monitoring equipment with additional emergency equipment (just in case.) Dr. Diego Correa was my guide for a tour of the operating facilities and was happy to answer all of my questions.
He also reported that in the last year there have been just three cases of minor skin infections (the causative agent was normal skin flora). He reports no serious infections or complications after surgery, and states that have been no instances of resistant bacteria or MRSA.
What is a Medico Estetico?
The literal translation of medico esthetico is aesthetics doctor, but a more accurate description would be a doctor who serves as an Aesthetics Consultant, or a doctor who performs nonsurgical aesthetics treatments. For a better understanding of this specialty, I spoke with Dr. John Jairo Monsalve Bedoya, a medico estetico and general director at the Nova clinca.
A cirujano plastico is a ‘plastic surgeon’. This is the surgeon who is trained to perform surgical procedures such as abdominoplasties, breast augmentation and similar types of procedures.
As he explained, the Aesthetics Doctor is a physician who specializes in the study of Aesthetic procedures. Patients consult with this physicians as part of the initial consultation to help patients determine what procedures the patient needs or wants to achieve a desired result. This is important in many cases when the patient knows what type of result they want (“I want to look younger”, for example) but may not know exactly what procedure is best to accomplish the results they want.
During the consultation, the doctor listens to the patient describe what they are looking for, collections medical history and other medical information as well as preferences. Then the doctor discusses a range of procedures from injectables (botox, restalyne, gel matrix), and other non-surgical treatments (laser/ light therapies, mini-lift procedures) to larger, more invasive surgical procedures such as facial endoscopy, traditional face-lifts, eye lifts and other related procedures.
Finally, based on the information provided and the discussion with the patient and their family – the doctor recommends the procedures to accomplish the results the patients are seeking.
Once the patient has decided on their options, Dr. Monsalve, and his associate Dr. Correa begin the pre and post-operative treatment plan. This plan is more than discussing payment, arranging a date for surgery, and a follow-up visit. As Dr. Monsalve explains – it’s a process that encompasses the entire pre-operative period, surgery and recovery.
Patients undergo a compete physical examination, with blood work and cardiac testing as appropriate (usually EKG). Patients are evaluated and treated by internal medicine physicians for any co-morbid conditions before meeting with the anesthesiologist for further evaluation. (This is done to reduce risk of peri-operative and post-operative complications). The degree of pre-surgical evaluation is related to the type of treatment – with more comprehensive evaluations for patients who elect to have surgical procedures with general anesthesia.
Intra-operative care is provided by the attending anesthesiologist with the initial post-operative recovery under monitored care in the recovery room. But after the immediate recovery, patients aren’t simply discharged home.
The discharge planning / recovery phase is also governed by Dr. Monsalve and his team. This includes a 24 hour call line, and home visits, as needed. In fact, Dr. Monsalve encourages patients to call, saying, If a patient is having pain – they should call.. If they have questions or concerns, they should call. It doesn’t matter what time it is.
Dr. Monsalve also encourages patients to consider aesthetics “a process- not just a surgery”. He states that this treatment is a part of a patient’s life, and that using a philosophy of a process-based approach (rather than an episodic experience of pay – surgery – follow-up visit) results in a better patient experience, better outcomes and greater satisfaction/ happiness with the outcomes. He believes that successful aesthetic procedures aren’t about making people prettier, it’s about making people happier with themselves.
Medellin surgeons serving their community
During our discussion, we also talked about the many ways that local surgeons give back to their communities. While this includes the more widely known programs such as Operacion Sonrisa, it also includes programs such as Gorditis de Corazon for post-bariatric procedures, Angeles por Colombia , a more generalized organization that recruits volunteers from all professions and areas of society (which operates under a philosophy of each one recipient then helps three others) as well as several other programs aimed at providing reconstructive surgery procedures to low-income Colombians.
Gel Matrix for skin rejuvenation
During our visit we also talked to Dr. Maria del Pilar Sanin, another medica estetica, who performs many of the non-surgical procedures offered at Nova. She talked about Recombinant Plasma (approximate translation) which uses a gel matrix made for the patient’s own blood to improve the appearance and condition of the skin.
The origins of gel matrix: cardiac surgery
Having worked in cardiac surgery, this concept is not new – our perfusionist in Virginia often used the patient’s shed blood in orthopedic surgery to make a similar gel matrix that enhanced healing and reduced inflammation – particularly in patients with a history of poor wound healing.
Here at the clinica Nova, no major surgery is required. Blood is taken, (by syringe) and placed into a centrifuge. Now if you can remember back to high school biology – this causes the blood to separate into its components, buffy coat, platelets and red cell matter. Then the doctor uses the platelet rich portion (which also contains fibroblasts, collagen, and other nutrients important to skin elasticity and wound healing). This formula is then injected in small increments into the patient’s face to promote skin health and rejuvenation. Since the material is made for the patient’s own body, (and unadulterated with preservatives or other chemicals) there is no possibility for allergic reactions or sensitivities to the ingredients.
Dr. Maria del Pilar Sanin reports that the healing time for this procedure is approximately four days, and that redness and inflammation at the sites of injections are common immediately after this procedure. She states that the duration of the effects depend on the patient’s underlying skin condition, general health and age. On average it lasts 1.5 to 2.0 years in most patients, but may not last as long in patients with extensive sun damage or deteriorated skin condition.
She recommends this procedure as a complimentary treatment to other non-surgical treatments for better overall skin condition/ health and a reduction in the appearance of wrinkles and fine lines. She reports it is frequently used to treat the deepening of the naso-labial fold (the line that stretches from the nose to the corners of the mouth.)
Clinica Nova offers a wide-range of patient-centered aesthetic procedures and plastic surgery – all under one roof.
Medellensa (or women from Medellin) are considered some of the most beautiful women in the world. However, they often have had some help. Plastic surgery is wildly popular in Medellin, Colombia and much of Latin America, and standards of beauty are based on a voluptuous physique with large breasts, small waist and an (often) exaggerated caboose. Actress Sofia Vergara, of Barranquilla is a classic example of Colombian beauty ideals, which have spread into popularity to the United States. Many North Americans and Europeans seeking this look come to Medellin for the city’s famed plastic surgeons.
Of the 650 members of the Colombian Society of Plastic, Aesthetic and Reconstructive Surgery, 98 members are located in the Medellin area. Using this directory, I attempted to contact surgeons for interviews. When e-mail addresses were not available, I contacted surgeons thru the Colombian Society website, when that option was available*. If the surgeons listed a website, contact was also attempted via website.
Alphabetical listing – compilation is ongoing as I continue efforts to contact and interview plastic surgeons in the city.
Lists English and French in addition to Spanish. Following correspondence, I interviewed Dr. Botero at his office. The interview with Dr. Botero can be seen here. You can read about my visit to the operating room here.
No email listed, emailed through society website on 7/8*.
Profile states he speaks English and Portuguese in addition to Spanish.
Lists plastic surgery education at Hospital Barata Riverio – Rio de Janiero, Brazil.
Martha Elena Gomez Botero
Calle 2 Sur # 46 -55
Clinica Las Vegas
Medellin
Tele: 268-3818
Email: megomezbotero@hotmail.com
Emailed 7/8.
Dr. Gomez specializes in maxiofacial surgery and hand surgery.
** the website email form for the Colombian society of plastic surgeons does not appear to be working. I have contacted the society regarding this issue.
All plastic surgeons listed (for Colombia) are members of the Colombian Society of Plastic, Aesthetic and Reconstructive Surgery.
Dr. Luis Botero during a tour of the new El Tesero ambulatory surgery clinic
Dr. Luis Fernando Botero Gutierrez
Carrera 25A #1 -31
Edificio Parque emp. El Tesoro
Office # 907
Medellin, Colombia
Tele: 448 – 6030
Email: luchobot@gmail.com
Website:currently under revision
It is fitting that one of Medellin’s most prominent plastic surgeons shares the same last name as one of Colombia’s most (but not related) famous artists – since plastic surgery requires considerable artistic vision from its practitioners. While Fernando Botero’s classic works depict a more fleshy, voluptuous and sumptuous view of the world, Dr. Luis Botero spends much of his time doing the opposite: slimming and smoothing his clients with the judicious application of the latest liposuction techniques.
Quirofanos El Tesoro
His office is located next to the El Tesoro mall, in one of the most affluent parts of the city, but that will soon change with the August opening of a large ambulatory surgery clinic within the upscale shopping center. Dr. Botero is a large part of the vision behind the 15-million dollar surgery center, which will also house the 150 physician offices from multiple specialties (including 21 plastic surgeons).
Trilingual surgeon
Dr. Botero speaks English and French fluently in addition to his native Spanish. Much of this is due to his training. After attending medical school at the Universidad de Antioquia here in Medellin and practicing as a general medicine physician for four years – he headed to Europe for specialty training in plastic surgery.
He attended the Free University of Brussels (Universite Libre de Bruxelles) in Belgium for his plastic surgery residency before moving to the University Henri Poincare (now University of Lorraine) in Nancy, France for four years to complete fellowships in maxiofacial surgery, plastic surgery of the face and separate training in hand and microsurgery and upper limb surgery. He spent an additional year working as a plastic surgeon in France. He also spent time in Singapore (National University Hospital) with Dr. Robert Pho and Taipei, Taiwan (Chang Gung Memorial Hospital) as a visiting fellow.
He returned to Colombia 12 years ago, and has been working as a plastic surgeon in Medellin ever since.
He is currently the president of the Antioquia chapter of the Colombian Society of Plastic, Aesthetic and Reconstructive surgery as well as holding memberships in Belgian Society of Plastic Surgery and the Group for the Advancement of Microsurgery (GAM). He is also a member of the International Society of Aesthetic Plastic Surgery (ISAPS) and the Latin American Federation of Plastic Surgery (FILACP).
He is the official physician for the French Embassy office in Medellin.
Current practice in Medellin
Despite his extensive training, his current practice is almost exclusively aesthetic surgery (rather than reconstructive, micro or hand surgery). He performs a combination of facial and body procedures including facial endoscopy, and reports that like almost all plastic surgeons, around fifty percent of his practice is liposuction.
While the majority of his practice are women, he estimates that around 15% are male clients. The most popular procedure for his male patients are blepharoplasty (eye-lid lift), mandibular liposuction (chin) and corporal liposuction (body).
He is patient, pleasant and very likeable. We talk about current trends in plastic surgery, cultural attitudes regarding plastic surgery and the anticipated opening of the new clinic. During our walk through the mall after a tour of the new clinic – we are greeted by two of his former patients who are pleased to see him. One young lady ruefully shrugs with a shy smile while showing off her advanced pregnancy, as if acknowledging that she will be back soon.
Hopefully, we will follow Dr. Botero to the operating soon.
Fashion + Beauty are intrinsically tied together. Sometimes it’s hard to tell where one ends and the other begins… (This is the more in-depth discussion from an article published on Examiner.com)
Fashion as the evolution of beauty
Fashion is the evolutionary arm of our concepts of Beauty.. While ad campaigns talk about ‘timeless beauty”, in reality, the standards of beauty are constantly evolving, changing, expanding.. This has occurred throughout recorded history.. with dramatic examples of idealized beauty in ancient Rome, feudal Japan, China and the noble houses of Europe. With that in mind – the evolution of beauty over time has more impact on (mainly) women, but also economics, surgery and technology.
Changing and conforming to beauty ideals throughout time
Since the earliest of times, we’ve used cosmetics, clothing, and even surgery (yes, surgery) to change our looks to conform to the beauty standards of that time/ place/ culture. With the advent of the internet age, ‘global beauty’ is the concept that cultural differences in beauty ideals are breaking down and becoming enmeshed into a single universal ideal.. While my fellow writers could (and have written) millions of words on the sociological and psychological aspects of attempting to fit into a ‘beauty ideal’ – I am not interested in discussing the ethics, moral or personal beliefs of independent individuals nor shall I attempt to impose those opinions on readers.. What I want to know, and to see – (and be able to watch and identify) as these beauty ideals morph and change.
So – I am heading to fashion week 2013 here in Medellin with high hopes.. Medellin has long been a leader in fashion, beauty and plastic surgery – and I want to see what’s trending now – and what’s coming next. Not so much interested in the styles of the clothes, as I am, in the bodies beneath the clothes, and how the clothes showcase or encase certain areas of the bodies.. Is the focus on hips and buttocks this year, or is it swan-like necks and slim backs? High rounded breasts or sleek arms and shoulders?
A brief history of Fashion (and Beauty)
In the last century alone – we’ve seen dramatic sweeping changes in beauty ideals.. From the corseted Gibson Girl with her sweeping locks to the androgynous flat chested flappers with eton crops – the pendulum of beauty swings bag and forth..
As flappers out grew their short locks, styles in the 1930’s featured more natural but subdued curves.. to the mannish shoulders and aggressive features of our 1940’s gals.. Back to the softly overblown 1950’s pin-ups.. as the swinging sixties came in – so did Twiggy.. slim boy-like 70’s to anorexic 80’s with icons like Jane Fonda.. The 90’s heralded the rise of J. Lo, and the voluptuous figure once more.. But what comes next?
We’re heading off to Colombia Moda 2013 this month to see if we can spot the latest trends in beauty (and plastic surgery)
because you need someone who is objective (and informed) that is looking out for you, the patient..
In this article, at International Journal of Medical Travel, Kevin Pollard talks about the need for regulation of medical tourism in cosmetic surgery. I wholeheartedly agree – in fact, Mr. Pollard and I conversed about this very topic in a series of emails last week.
After all – it is why I do what I do, and publish it here for my readers. The industry does need to be regulated – medical tourism companies shouldn’t pick providers by “lowest bidder” and patients need to be protected (from unsanitary conditions, bad surgeons, and poor care). But what form will this regulation take?
Will it be Joint Commission certification – which covers facilities and not the physicians (and their surgical practices themselves)?
Will it require facilities to pay a lot of money for a shiny badge?
Or will it be someone like me, low-key and independent, going into facilities at the behest of patients; interviewing surgeons and actually observing the process and talking to patients?
and ultimately – will this be done in a fair, open and honest way? Or it is really a witch hunt led by disgruntled American and British plastic surgeons? Will they bother to discriminate between excellent surgeons and incompetent ones who will it be by geography alone?
Chairman discourages medical tourism, stating that medical tourists are victims of inferior care
The strongly-voiced piece accused surgeons outside of European and North America of providing inferior medical care, inadequate pre-operative evaluations and operating in substandard facilities.
States bad outcomes wouldn’t happen at home
In his editorial, Dr. Niechajev provides anecdotal evidence of a botched procedure that occurred in Asia, and stated that “such a tragic outcome” of [procedure cited] “is highly unlikely had the patient not been a medical tourist.” Dr. Niechajev cites these concerns, not as a surgeon losing business to his competitors but states that he is concerned about the costs of caring for patients with possible complications once they return home.
Not limited to national borders
His concerns don’t stop at national borders, Dr. Niechajev also suggests that surgeons limit themselves to their immediate local vicinity. What this may mean for a rural patient requiring extensive reconstructive surgeon is not addressed by Dr. Niechajev.
Statements based on limited data
He bases the majority of his opinions on the shoulders of Dr. Ritz, the Australian National Secretary for Health, who cites one specific incident as the trigger for changing Australian legislature to prohibit this practice. Additional evidentiary support of gross episodes or a mass epidemic of malpractice by international surgeons appears to be limited to 11 cases in the United Kingdom. No other data was cited.
International Society debating the issue; Niechajev recommends financial sanctions against patients
These concerns have the officers of ISAPS considering changing the code of ethics of the organization to discourage the practice of medical tourism by its member surgeons. However, Dr. Niechavej does not seem content to stop there, instead he advocates for governmental announcements advising the public about “increased risks associated with medical tourism” and that “surgery overseas practically means that they [patients] are giving up all their rights.” He also advocates for financial penalties for patients who experience post-operative complications after surgery overseas, stating, “No preventative measure is as effective as hitting someone’s purse.”
Colombian plastic surgeons respond
In an exclusive interview with the President of the Colombian Society of Plastic Surgery, he answered many of the allegations by Dr. Niechajev.
Regarding Dr. Igor Niechevaj’s statements on the lack of regulations and substandard facilities in countries that are popular medical tourism destinations, the President of the Colombian Society of Plastic, Esthetic and Reconstructive Surgery, Dr. Carlos Enrique Hoyos Salazar replied that, “All facilities, and hospitals in Colombia are regulated by the Ministry of Health. There are minimum standards that must be met. Any facilities that are interested in participating in the medical tourism business have additional standards and qualifications for certification by national agencies. Anesthesiologists, and medical doctors are required to have additional training to perform pre-operative evaluations for International plastic surgery patients”.
Reports safety and patient protections for medical tourists
He refutes claims that patients receive minimal post-operative care before returning home. In addition to medical advice from Colombian physicians, he cites agreements with Colombian and international airlines to encourage international patients to stay a minimum of 15 days after their surgical procedures to ensure optimal recovery.
Additionally, several plastic surgeons specializing in medical tourism and medical tourism companies offer ‘complication policies’ to pay for any expenses a medical tourist may incur in both the destination and home country should they develop complications post-operatively. In fact, an advertisement for one of these policies shares space with Dr. Niechevaj’s article. These policies effectively negate one of Dr. Niechevaj’s (and Dr. Ritz’s) strongest arguments, that medical tourism incurs costs in the home country when patients develop post-operative infections or other problems after returning home.
ISAPS Chairman defending his own wallet?
When asked about Dr. Niechevaj’s position on medical tourism and possible changes to the ISAPS code of ethics, Dr. Hoyos stated, “This is not right. This has nothing to do with the quality of surgery in Colombia and other countries. This is about the expensive costs of surgery in Europe and the United States. If a surgery costs $6,000 (USD) over there and only $3,000 – $3,500 in Colombia, then those doctors are losing money due to medical tourism.”
Good and Bad is a global phenomenon
As we’ve pointed out here on our site (and related work) – good and bad surgical outcomes are certainly not limited by geography, and Dr. Niechajev certainly seems to paint the rest of the world with a wide brush with his call to action.
A more reasonable, and fair response would be continue to encourage work such as mine – using outside, independent and unbiased observers to evaluate surgeons wishing to participate in medical tourism.
In an ideal world, companies such as Blue Cross/ Blue Shield who wish to broaden their international physician base would hire independent medical professionals to review surgeons who wished to be included under their health plan. This way both consumers and third-party payers would have more information before patients went ‘under the knife’ so to speak.
Patients wouldn’t be shuttled to surgeons who submit the lowest bid (to insurance companies, and private parties) but to surgeons whose qualifications had been authenticated. All parties would know about the quality of hospital facilities, anesthesia, pre-operative evaluation and post-operative care.
Doing my part
Readers know that I do what I can, in a very small way, to add to the body of knowledge about the quality and care of patients who receive treatment from the surgeons who consent to let me observe, evaluate and report my findings.
Now we just need this on a large-scale, multi-national level.
No, not the World Health Organization (WHO), but another entity entirely, ISAPS.
Plastic surgeons in Mexico gather for a demonstration of techniques for breast reconstruction. Mexico is currently ranked #5 for number of plastic surgeries
International Society of Aesthetic Plastic Surgery (ISAPS) recently published survey data ranking Colombia at 11th for volume according to the most recent statistics (2011) available. 211,879 total procedures were reported. Colombia currently ranks #27th globally in population with a 2013 estimated population of 47 million. Considering the modest population size of Colombia this statistic may reflect both Colombian cultural expectations and the growing trend of medical tourism.
Countries that perform the most cosmetic surgery procedures***:
1. United States: 1,094,146
2. Brazil: 905,124
3. China: 415,140
These top three nations also represent a total population of 1.86 billion people. Brazil, in particular is also widely known as the medical tourism destination of choice for plastic surgery.
Plastic surgery in Colombia
Of the 211, 879 procedures, 65,075 or 30.7% were breast enhancement procedures. Liposuction accounted for 23% of all cosmetic surgical procedures.
Dr. Reyes, a plastic surgeon in Bogota, Colombia operates on a patient
Questionable study results due to lack of participation
However, the accuracy of the data collected by a joint American – Brazilian team is questionable given the low percentage of participation by licensed member surgeons. Out of 20,000 eligible ISAPS member surgeons, only 996 participated in the organization’s survey. Additionally, of the .04 percent of surgeons reporting their surgical practices, 43% (431 surgeons) were based in the United States. Of the remaining 565 surgeons represented the remainder of the worldwide plastic surgery community, 172 of these participants were from Brazil. The final statistics provided for each country are based on estimates extrapolated from a representative sample from survey responses received.
Are the results any surprise, given the players? But then again, maybe these results will encourage more Latin American surgeons (and surgeons in other countries) to participate more fully in the academic activities of their specialty societies.
*Mexico was also in the top five with 299,835 procedures.
***As an interesting aside, the island nation of Japan ranked fourth.
I am still working on several posts – but in the meantime, I wanted to post some photos from my visit to the operating room with Dr. Wilfredy Castaño Ruiz, one of the thoracic surgeons at Hospital General de Medellin.
Readers may notice that some of the content of my observations of the operating room have changed.. In reality, the reports haven’t changed – I have just chosen to share more of the information that I usually reserve for the books since I probably won’t get time for a “Medellin book”. So, if you are squeamish, or if you don’t want to know – quit reading right about now…
It was a surprise to meet Dr. Wilfredy Castaño Ruiz because it turns out we’ve already met. He was one of the fellows I encountered during one of my early interviews in Bogota, with Dr. Juan Carlos Garzon Ramirez at Fundacion Cardioinfantil.
Since then (which was actually back in the early spring of 2011), Dr. Castaño has completed his fellowship and come to Medellin.
Dr. Wilfredy Castaño Ruiz, thoracic surgeon at Hospital General de Medellin
Yesterday, I joined him in the operating room to observe a VATS decortication. The case went beautifully.
Dra. Elaine Suarez Gomez, an anesthesiologist who specializes in cardiothoracic anesthesia managed the patient’s anesthesia during the case. (This is important because anesthesia is more complicated in thoracic surgery because of such factors as double lumen intubation and selective uni-lung ventilation during surgery).
Anesthesia was well-managed during the case, with continuous hemodynamic monitoring. There was no hypotension (low blood pressure) during the case, or hemodynamic instability. Pulse oxymetry was maintained at 98% or above for the entire case. Surgical Apgar: 8 (due to blood loss**)
Monitors at HGM are large and easily seen from all areas of the OR
Dr. Wilfredy Castaño Ruiz was assisted by Luz Marcela Echaverria Cifuentes, (RN, first assist*). The circulating nurse was a very nice fellow named Mauricio Lotero Lopez.
Enf. Luz Echaverria assists Dr. Wilfredy Castaño Ruiz during surgery.
*”Registered nurse” is not terminology common to Colombia, but this is the equivalent position in Colombia, which requires about six years of training.)
** In this particular case, the surgical apgar of 8 is misleading. The anesthesia was excellent, and the surgery proceeded very well. However, due to the nature of surgical decortication (for a loculated pleural effusion/ empyema) there is always some bleeding as the thick, infected material is pulled from the lung’s surface. This bleeding was not excessive for this type of surgery, nor was it life-threatening in nature.
The answer is “NO” for several disfigured patients in Australia, who later found out that a loophole in Australian licensing laws allowed Dentists and other medical (nonsurgeons) professionals to claim use of the title of ‘cosmetic surgeon’ without any formalized training or certification in plastic and reconstructive surgery (or even any surgery specialty at all).
In this article from the Sydney Morning Herald, Melissa Davey explains how dentists and other nonsurgical personnel skirted around laws designed to protect patients from exactly this sort of deceptive practice, and how this resulted in harm to several patients.
As readers will recall – we previously discussed several high-profile cases of similar instances in the United States, including a doctor charged in the deaths of several patients from his medical negligence. In that case, a ‘homeopathic’ and “self-proclaimed” plastic surgeon, Peter Normann was criminally indicted in the intra-operative deaths of several of his patients. The patients died while he was performing liposuction due to improper intubation techniques.
But at least, in both of the cases above – the people performing the procedures, presumably, had at a minimum, some training in a medical/ quasi-medical field..
Surgeon or a handyman
More frightening, is the ‘handyman’ cases that have plagued Las Vegas and several other American cities – where untrained smooth operators have preyed primarily on the Latino community – injecting cement, construction grade materials and even floor wax into their victims.
How to protect yourself from shady characters? In our post, “Liposuction in a Myrtle Beach Apartment” we discuss some of the ways to verify a surgeon’s credentials. We also talk about how not to be fooled by fancy internet ads and the like. (Even savvy consumers can be fooled by circular advertisements designed to look like legitimate research articles as well as bogus credentials/ or ‘for-hire’ credentials*. )
*We will talk about some of the sketchy credentials in another post – but the field is growing, by leaps and bounds..More and more fly-by-night agencies are offering ‘credentials’ for a hefty fee (and not much else.)
Now that’s a mighty long title – for a very small section of medical tourism, which alternates in generating world-wide headlines and being swept quietly under the rug.
Bathtub full of ice
Everyone has heard ‘urban folklore’ regarding the unwary/ drunken/ duped young man who goes looking for sex, and wakes up in a bathtub full of ice.. Conventional wisdom is that these tales serve as a modern-day fairy tale with an underlying moral message. In this case – cautioning young people against the vices of alcohol/ drugs and anonymous/ promiscuous sex.. If only the truth were really just such a cautionary tale. But, as readers know, the truth is considerably darker – involving the exploitation and even outright murder of citizens around the world to feed the organ trade.
(For the first-person account from a Chinese doctor involved in organ harvesting, click here. )
This division of medical tourism, “Transplant tourism“, is the sanitized term for organ selling, or diversion of transplantable organs to wealthy consumers (outside of the formal donor networks like UNOS).
Transplant tourism/ murder for organs is making headlines again this week as Taiwanese legislators try to ban the practice among their citizens and residents. The Taiwanese lawmakers are trying to prevent the practice of wealthy patients (and companies making money from the sale of organs/ transplantation) using China as a ‘spare parts’ playground.
As widely reported over the last several years – China has become notorious for widespread ethical violations, including the murder (execution) of political prisoners for organ sales and transplantation to wealthy buyers. Many of these political prisoners are people accused of such crimes as the practice of the religion, Falun Gong, or for expressing ideas that challenge the traditional Chinese culture or current government practices.
Not illegal in the United States
Unfortunately, despite multiple scientific, medical, governmental papers and sporadic media coverage of this issue – it is not illegal for Americans to engage in this practice, nor for American companies to offer transplantation services based on these practices. (It is illegal for organs to be sold in the USA, but not for people to travel to engage in these practices.) While the United Nations, New Zealand, Australia and now, Taiwan have begun addressing this practice – the US government remains silent.
Protecting citizens from the wealthy foreigner
Other nations, like Pakistan have acted to try to prevent their citizens from becoming donor sources for wealthy foreigners. Just today, a new law was passed to prevent organs obtained in Pakistan from being given to non-Pakistani residents. While these laws will not eliminate the practice outright, these countries and their citizens have taken a moral and legal stance against the practices. Now, it’s our turn.
The Ugly Side of Medical Tourism – a related post with links to scholarly articles and media reports regarding transplant tourism in China and Latin America.
Patients with passports – another post on law, ethics and medical tourism discussion focused on the publication of a book by the same title. Includes links to several articles by Dr. Delmonico – the foremost expert on illegal organ transplantation.
Was it a medical mistake/ an accident of fate / or…. was it the Cocaine? An inquest is held on the intra-operative death of an Irish medical tourist..
In a recent inquest, the wife of an Irish tourist who died while undergoing liposuction with a well-known Colombian plastic surgeon talked about her husband and his decision to pursue plastic surgery with Dr. Ricardo Lancheros Pedraza.
In a published story by Gareth Naughton of the Irish Independent, the wife of Pierre Christian Lawlor detailed her husband’s decision to undergo cosmetic surgery with the Bogotá surgeon due to unhappiness with his physique.
During her testimony, she also conceded that her husband had taken cocaine in the days and hours immediately prior to surgery – despite being advised specifically to refrain from smoking, alcohol or taking medications.
In a story published in Irish Central – Ms. Andrea Galeano, the Venezuelan-borne wife of Mr. Farrell reported that her husband had taken cocaine on several occasions after arriving in Bogotá for his surgical procedure.
Mr. Farrell is believed to have died from intra-operative myocardial infarction (heart attack during surgery).
Additional Information
This Daily Mail article from 2012 describes how the use of cocaine can cause heart attacks, and sudden cardiac death.
The file download for the latest radio program, “Know before you go” with Ilene Little is available. It’s from the Christmas broadcast with Dr. Freddy Sanabria.
Dr. Sanabria joined us to talk about his experiences, and his clinic in Bogotá, as well as his ongoing projects and patient safety protocols. It was nice to be able to share some of my observations from my visits to his operating room.
We recently mentioned Dr. Denise Crute, an American neurosurgeon in a November blog post, Wrong-sided surgery. We quoted News of the Weird as our source, with the original source being ABC channel 7 news. We mentioned her story to illustrate the importance of safety checklists in the operating room. It would have stopped there, but now we’ve received a threatening letter from a lawyer in Phoenix, Arizona representing Dr. Crute. (Since we last heard that she was practicing in New York – the Arizona lawyer must be for my benefit. I wonder if she would have hired a Colombian lawyer if she realized that’s where I spend the majority of my time.)
Harming her reputation?
Her lawyer claimed that by republishing this information that I am liable for damages caused by the harm to her reputation.
In my opinion, she’s blemished her reputationall on her own (but I’ll let you read the letter for yourself).
To make it easy on everyone – I’ve also linked to my original post, which was a quote from Mr. Shepherd, who stands by his story.
In my defense – Truth is the truth
I think my statements are fair, accurate criticism, particularly given the known facts of the case. Now, the last thing I want to do is report something erroneously. After all, I stake my reputation on my honesty and integrity, so if I have made a mistake – I will freely admit it – and will happy display it in ALL CAPS here on the blog. Not only that, but I will happily travel out to see Dr. Crute and interview her for the blog, so she can set the record straight – if it needs correcting. But I can’t be cowed by an angry surgeon looking for an easy target.
Litigious behavior doesn’t change the facts
Notably, the lawyer’s letter doesn’t even address the accuracy of the claims against her. But I did see her own personal blog, where she has a one page statement addressing the charges, so I will link to it here. In it she claims to have been the victim of a one-person driven witch hunt.
Yes, that could happen – but the breadth and width of the charges (hundreds) and the collaborating witnesses in the statements argues against it in this case.
Now, the initial report to the medical board may very well have been the result of professional jealousies, or whatever, as Crute and her legal team claim. But there are so many charges – with multiple supporting witnesses that it seems highly unlikely.
Her main argument is against the neurosurgeon that helped the medical board evaluate the claims. She chalks up his decisions and statements against her behavior to competition, since she is the superior surgeon, apparently. Fine, but that doesn’t account for the majority of charges which have nothing to do with actual surgery – but with the ethics of her practice. (You don’t have to be a neurosurgeon to know that altering a patient chart and falsifying data is wrong.)
Another point to consider:
But it also may have also taken another neurosurgeon who was finally bold enough to speak up against repeated, repeated and repeated episodes of unprofessional, dangerous and injurous behaviors.
In fact, a recent poll of 24,000 physicians demonstrates the reluctance of doctors to criticize their colleagues. The Medscape 2012 Ethical Dilemma Survey results showed that just 47% of physicians would caution a patient about a colleague they felt was practicing ‘substandard’ medicine.
While her statement makes it sound like these sort of complaints against providers and surgeons are common – they really aren’t.
While it may seem so for Dr. Crute (and neurosurgeons do have a high rate of malpractice), for another colleague, several nurses and the surgeon’s own PA to make these statements about Dr. Crute to a medical board means that it was more that a personality conflict.
Not having her license stripped away is not proof of innocence. In most states, medical boards offer disgraced physicians the opportunity to inactivate their licenses. It’s similar to hospitals (and other organizations) allowing doctors, CEOs and such, to resign instead of being fired outright. This practice has been clearly established and well-documented in several notable cases.
Doctor’s story led to changes in the Colorado Board of Medicine
But it’s more than that – attacking my blog for using well-publicized and reprinted information (available at multiple sources) to illustrate a discussion here on patient safety, just seems to me like bullying, especially when there are twenty other articles about Dr. Crute on much larger websites with a lot more viewers. So I also contacted Mr. Ferrugia and Mr. Shepherd (of News of the Weird) to see if they, too, had been contacted by Dr. Crute and her legal team. No, they haven’t.. Just me.
This makes me suspect that this entire letter/ episode is just an attempt to bully someone smaller and less powerful, and that’s what makes me angry. This would have been a good opportunity for Dr. Crute to rectify the record, if that’s truly the case (especially since legal action and media coverage appears to have ramped up in the last few days with more and more articles over the last week) but she doesn’t appear interested in that. (If she had, we would be seeing retractions from the other writers involved).
But – check out her site, read her defense, and let me know what you think. It is also worth noting that despite all the ‘glowing’ quotes she has on her website, she doesn’t appear to be operating on patients in her new position.
I’m not sure that the fact that she volunteers or donates supplies to Central America holds any relevance to the discussion – but she put it out there, so I’m reporting it.
documents related to medical practice
In the meantime, I stand by my statements in reference to safety checklists, etc. that a ‘time-out’ for patient safety can prevent many of these errors that are documented in the original papers, such as in 2004 when she performed wrong-sided brain surgery – which she is accused of, along with then attempting to cover-up in her documentation (and actually had the gall to say that the patient “marked” the wrong-side.) The patient had a right subdural hematoma (and according to the notes on page 7 of attached document) – was in no condition to consent/mark or otherwise make any medical decisions.
Read the original documents – and see if it paints a portrait of someone who did whatever she wanted, when she wanted and thought that she could get away with it – like when she failed to come see an emergency surgical consult at night*. She gave a telephone order for intubation, and still didn’t bother to come see this critically injured patient. Then, after it was too late – came by at 7 am in the morning, and back-dated her notes. (Yes, patient died). Unfortunately, there is no checklist to address such an ethical lapse.
But in the spirit of honesty and integrity, and in pursuit of the truth, I have contacted the reporter of the original story, John Ferrugia to see if there have been any story updates, retractions or corrections. (Mr. Ferrugia also provided the supporting documents.) I also offer Dr. Crute the opportunity to give a statement here. She knows how to contact me, and apparently she’s reading the blog.
But – this isn’t what my blog is really about – so we will get back to our regular topics, like surgical checklists and surgical apgar scoring – on our next post..
(Out of respect for patient privacy – I’ve done my best to crop the patient ‘bits’ from the photo.)
Spent some time last week with Dr. Alberto Martinez of Med-Sports Orthopedic Clinic here in Bogotá. Dr. Martinez specializes in arthroscopic surgery of the hips, knees and shoulders. As we talked about before, shoulder surgery is its own subspecialty in orthopedics due to the increased complexity of this joint.
We talked a bit about hip arthroscopy,which is still a relatively new procedure in orthopedics and the fact that one two surgeons in Bogota are currently performing this procedure.
Arthroscopy is the orthopedic minimally invasive counterpart to general surgery’s laparoscopy or thoracic surgery’s thoracoscopy. It involves insertion of a camera and several tools through small (1 cm) incisions in the skin. Arthroscopy itself has been used in orthopedics for many years but it is just now making inroads in hip procedures.
I’ll be publishing an upcoming article based on my observations over at ColombiaReports.com
Spent the afternoon with Dr. Alberto Munoz, Vascular Surgeon. He invited me over to Clinica Palermo to watch surgery for a carotid body tumor, which is almost exclusively a high-altitude condition.
We previously met in Santa Cruz de la Sierra (Bolivia) at the annual conference of the Latin American Association of Vascular Surgery and Angiography. Dr. Munoz is the current President of the organization.
Since the majority of cases of this condition are diagnosed and treated in Latin America (in the high altitude cities of Mexico City, Bogotá, Quito and La Paz) one of the goals Dr. Munoz is working on is compiling a database of carotid body tumor cases, and creating a surgical consensus (or guideline) for the treatment of this condition.
Right now, there is no formal data collection process to keep track of all the different surgeons operating for this condition at different hospitals – so the true incidence of this condition isn’t really known. Having a database to collect all the data would also make it easier for surgeons to track and publish their findings and outcomes. Since both vascular surgeons and ENT surgeons operate for this condition – a lot of the experts for this condition aren’t even in contact with each other to share information.
Dr. Munoz, operating
Since I created a thoracic surgery database (for a similar purpose), we talked about this a bit while waiting for the patient to be brought to the operating room.
More importantly, this database would give surgeons an opportunity to publish their data – for the benefit of others in the specialty as well as the patients. (Wouldn’t you, as a patient want to see someone like Dr. Munoz, who has operated on numerous patients with this condition versus a North American surgeon, who may see just a few cases, if any, during his/her entire career?)
The database would allow surgeons to quantify their cases, as well as report and calculate their surgical outcomes.
(I’ll publish more about the actual operating room experience over at Colombia Reports.com)
Interview at noon today with Traveling for Health – where you can call in and ask questions.. You can find the show here. Don’t worry, if you miss it – you can hear it in the archives next week.
While I have written several books about surgery and surgeons in Colombia, much of this information I’ve obtained from my research has been consigned to sitting on the shelves of various bookstores.
But, now with the help of Colombia Reports, I am hoping to change that. As I mentioned in a previous post, Colombia Reports.com and it’s founder, Adriaan Alsema have been amazingly supportive of my work, ever since they printed my first article on Cartagena in 2010.
Since returning to Colombia, I have kept in touch with Colombia Reports while we discussed ways to bring more of my research and work to the public. Colombia Reports is a perfect platform – because it serves a community of English-speaking (reading) individuals who are interested in/ and living in Colombia. With this in mind, Colombia Reports has created a new Health & Beauty section which will carry some of my interviews and evaluations.
It is an ideal partnership for me; it allows me to bring my information to the people who need it – and continue to do my work as an objective, and unbiased reviewer. We haven’t figured out all of the details yet – but I want to encourage all of my faithful readers to show Colombia Reports the same dedication that you’ve shown my tiny little blog, so that our ‘experiment’ in medical tourism reporting becomes a viable and continued part of Colombia Reports.
This is more important to me that ever – just yesterday as I was revisiting a surgeon I interviewed in the past (for a new updated article), I heard a tragic story that just broke my heart about a patient that was recently harmed by Dr. Alfredo Hoyos. While I was unable to obtain documents regarding this incident – this is not the first time that this has happened.
Previous accusations of medical malpractice against this surgeon have been published in Colombian news outlets including this story from back in 2002.
The accusations are from Marbelle, a Colombian artist regarding the intra-operative death of her mother, Maria Isabeth Cardona Restrepo (aka Yolanda) during liposuction. These accusations were published in Bocas – which is part of El Tiempo, a popular Colombian newspaper, in which the singer alleges that Dr. Hoyos was unprepared, and did not have the proper equipment on hand to treat her mother when she went into cardiac arrest during the surgery.
story about the death of one of Dr. Alfredo Hoyos’ patients.
Now – as many of you remember, I interviewed Dr. Alfredo Hoyos back in 2011, and followed him to the operating room, giving me first hand knowledge of his surgical practices.
Readers of the book know he received harsh criticism for both failure to adhere to standard practices of sterility and patient intra-operative safety (among other things.) I also called him out for claiming false credentials from several plastic surgery associations – and notified those agencies of those claims.. In the book, readers were strongly advised not to see Dr. Hoyos or his associates for care.
But – as I mentioned, my book is sitting lonely on a shelf, here in Bogotá – and in the warehouses of Amazon.com and other retailers.. So, people like that patient – didn’t have the critical information that they needed..
This is where Colombia Reports – and I hope to change all that. So in the coming weeks, I am re-visiting some of surgeons we talked to in 2011, and interviewing more (new) surgeons, more operating room visits..
As many long-time readers know, I spent several months trying to chase down Dr. Ernesto Andrade for an interview while writing the Bogota book, but only got a couple of minutes with one of his surgical interns – who was fairly dismissive.. Despite repeated requests, phone calls and emails were not returned.
Several months ago, I was contacted by Dr. Andrade on LinkedIn, the professional networking site, and he asked if I would interview him. I was pleased, and explained that I would be in Colombia soon – and would be happy to talk to him (and gave the date when I would arrive.) Now after repeated emails, and even an office visit – it looks like I am getting the same run around.
Often when I fail to make contact with someone I would like to interview – I chalk it up to missed / miscommunication (maybe staff never forwarded messages, etc.) but this is clearly something else entirely.
So while I apologize to the many readers who have asked for more information about Dr. Andrade – there is little more that I can do at this point.
Spent part of yesterday back in the operating room with Dr. Sergio Abello. Dr. Abello is an orthopedic surgeon who specializes in foot and ankle surgery. (He also have a specialized computer system in his office for truly customized orthodics).
Dr. Sergio Abello de Castro, Foot & Ankle Center
It was a chance meeting in the hallway, but as always, with the gracious and genial surgeon – it led to the operating room. He apologized, “it’s just a small case,” but everything went perfectly.
Dr. Sergio Abello (right) with orthopedic resident, Dr. Juan Manuel Munoz
Patient was prepped and draped in sterile fashion, with no breaks in sterile technique. Case proceeded rapidly (previous surgical pins removed).
The was no bleeding or other complications.
Yvonne (left), surgical nurse
Anesthesia was managed beautifully by Claudia Marroqoon, RN – with a surgical apgar of 10. The patient received conscious sedation and appeared comfortable during the procedure. There was no hemodynamic instability or hypoxia. Oxygen saturation 100% for the entire duration of the case.
I went back to see Dr. Luis Torres, thoracic surgeon and spent the day in the operating room with him for a couple of cases. He is a very pleasant, and friendly surgeon that I interviewed last week. Dr. Torres just recently returned to Bogotá after training in Rio de Janeiro for the last several years at the Universidade de Estado de Rio de Janeiro. He completed both his general surgery residency and thoracic surgery residency in Rio after graduating from the University de la Sabana in Chia, Colombia. (He is fluent in Spanish and Portuguese).
I spent some time out in Chia last year with the Dean of the medical school (and thoracic surgeon, Dr. Camilo Osorio).
The first case was a sympathectomy for hyperhidrosis. I’ve written more about the surgical procedure over at Examiner.com, and I will be posting more information about the procedure – potential candidates and alternative treatments over at the sister site.
The second case was more traditional thoracic surgery – a wedge resection for lung biopsy in a patient with lung nodules. **
In both instances, cases were reviewed prior to surgery, (films reviewed when applicable – ie. second case) and visibly posted in the operating room. Patients were sterilely prepped, draped and positioned with surgeon present. Anesthesia was in attendance for both procedures – and hemodynamic instability/ desaturations (if present) were rapidly attended/ addressed / corrected.
Dr. Torres utilized a dual-port technique for the sympathectomy, making 1 cm incisions, and using 5mm ports. Each side (bilateral procedure) was treated rapidly – with the entire procedure from initial skin incision and application of final bandaids taking just 35 minutes.
Dr. Torres, performing VATS
The second case, proceeded equally smoothly, and without complications. There was no significant bleeding, hypoxia or other problems in either case. Surgical sterility was maintained.
** Both patients were exceedingly gracious and gave permission for me to present their cases, photographs etc.
Just as the second case ended – Dr. Ricardo Buitrago arrived – and performed a sympathectomy on one of his patients – using a single-port approach. (I am currently working on a short YouTube film demonstrating both of these techniques.)
I hope everyone is enjoying some of the changes in format – after all the wonderful experiences I had writing the Mexicali book, I thought I would start incorporating more local culture and content in the blog when I am in Bogotá. (I have always enjoyed Bogotá – but my writing tended to be rather dry and uni-focal so from now on, I’ll try to include more local information about the city since I am in the midst of it all.)
Barbie display at Andino Mall, Carrera 11 No 82-01
It doesn’t mean that I am any less interested in crucial issues in medical tourism, quality measures or surgery – I just won’t focus on these topics exclusively.
I spent yesterday over at Clinica de Marly with Dr. Ricardo Buitrago to watch one of his robotic surgery cases. They’ve been doing robotic surgery over at Marly for several years – but Dr. Buitrago just started the first robotic program in thoracic surgery in Colombia. (Previously the robot was used exclusively for urology and gynecology surgery).
Robotic surgery with Dr. Ricardo Buitrago
Dr. Buitrago trained with the renown robotic (thoracic) surgeon, Dr. Mark Dylewski – and has been a thoracic surgeon for over 20 years so it is always interesting to watch one of his cases – robots or no robots..
Just published a new article about robotic-assisted thoracic surgery over at the Examiner.com along with photos and a short film clip that shows the robot in action. I am working on a longer film that provides a better look at what robotic surgery really is/ what it entails.
Colombian Culture & Cuisine 