Miami plastic surgeon tied to multiple deaths

Posted on May 16, 2016 by K Eckland

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.

Patient satisfaction scores vs. clinical outcomes: The Yelp! approach to surgery

Is your ‘cosmetic surgeon’ really even a surgeon?

Patient Safety & Medical Tourism

Liposuction in a Myrtle Beach apartment

Reason #6

Posted on August 5, 2015 by K Eckland

Reason # 6

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.

Source article:

Clary, Michael (2015). Penis ‘mutilated’ after surgery; ex-Boynton doctor from Tamarac accused. Sun Sentinel, August 2015.

Reason #146 – a cautionary tale

Plastic surgery safety & Buttloads of pain

Cement, Fix-a-flat and Superglue are not beauty aids

Is your surgeon really a doctor?

See the plastic surgery archives for even more articles.

Ebola and medical tourism

Posted on October 24, 2014 by K Eckland

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.

Related posts: Plastic surgery safety archives

Plastic surgery safety: Know before you go radio interview

Is your cosmetic surgeon really even a surgeon?

Liposuction in a Myrtle Beach apartment

It’s not vanity and it’s not easy: NHS agrees

Posted on July 13, 2014 by K Eckland

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.

More from the Diabetes & Bariatric Archive:

Life after bariatric surgery

Bariatric surgery and the family

Bariatric surgery and CV risk reduction

The Diabetes Pandemic

Part II

Diabetes as a surgical disease

Gastric bypass as a cure for diabetes

Days of Summer

Posted on June 15, 2014 by K Eckland

A cautionary tale for my on-line friends in another botched surgery case in Florida.

Let the buyer beware:

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.

Pennsylvania: William Charles Marrocco held a license in Pennsylvania for a brief two-year period between 1998 to 2000. This includes his period of medical residency training at Temple University Hospital.

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.

(official image from Colombia Moda / Inexmoda)

As many of you already know, I was able to attend last year – and got a fascinating glimpse into the fashion industry and the future of both fashion and consumerism.

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.

!Eres Absurdo!

Posted on April 11, 2014 by K Eckland

Eres Absurdo!

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:

Aortic Stenosis and Heinz 57 : (what is Aortic stenosis?)

Aortic Valve Replacement and the Elderly

Aortic Stenosis : More patients need surgery

Cardiac surgery and valvular heart disease: More than just TAVR

There is a whole separate section on TAVI/ TAVR.

The Sincelejo Diaries

Posted on March 30, 2014 by K Eckland

Sincelejo from the balcony

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 24^th 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.

**Pulling on his superman cape when needed.

Plastic surgery safety & Buttloads of Pain

Posted on January 24, 2014 by K Eckland

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.

Gluteal implants – Interview with Dr. Gustavo Gaspar

Fat transfer : Dr. Luis Botero

Update: February 2014

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.

Medical tourism on the heels of Obamacare

Posted on November 26, 2013 by K Eckland

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.

Health insurance and medical tourism

Posted on November 2, 2013 by K Eckland

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.

If you aren’t sure – do a little on-line research and call your insurer. Sometimes the insurer will even offer subscribers an incentive for traveling.

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

Posted on September 9, 2013 by K Eckland

Dr. Gustavo Gaspar, plastic surgeon

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 abdominoplasty.

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.

Bruner, T. W., Roberts, T. L. & Nguyen, K. (2006). Complications of buttocks augmentation: Diagnosis, management and prevention. Clin Plastic Surg 33: 449 – 466.

Cardenas – Camarena, L. (2005). Various surgical techniques for improving body contour. Aesth. Plast. Surg. 29:446-455.

Cardenas- Camerena, L. & Palliet, J. C. (2007). Combined gluteoplasty: Liposuction and gluteal implants. PRS Journal, 119(3): 1067 – 1074. Part of a series on gluteal augmentation.

Harrison, D. & Selvaggi, G. (2006). Gluteal augmentation surgery: indications and surgical management. JPRAS 60:922-928.

Start here…

Posted on September 7, 2013 by K Eckland

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..

I believe in full disclosure, so here’s my CV.

I think it’s important that this includes financial disclosure. (I am self-funded).

I’m not famous, and that’s a good thing.

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.

Reasons to write about medical tourism: a cautionary tale

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 talk about checklists – a lot..

The surgical apgar score

I look at the quality of anesthesia – and apply standardized measures to evaluate it.

Why quality of anesthesia matters

Are your doctors distracted?

Medical information

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.

What about hospital scores, you ask.. Just look here – or in the quality measures section.

Cultural Content

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..

Thank you for coming.

Talking with Dr. Gustavo Gaspar Blanco, plastic surgeon

Posted on September 6, 2013 by K Eckland

Dr. Gustavo Gaspar Blanco, plastic surgeon

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.”

To read more about Dr. Gaspar in the operating room.

Gluteal Implants versus Fat Grafting

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 a dangerous 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.”

About Dr. Gustavo Gaspar Blanco, MD

Plastic and reconstructive surgeon

Av. Madero 1290 y Calle E

Plaza de Espana, suite 17 (second floor)

Mexicali, B.C

Tele: (686) 552 – 9266

If calling from the USA: 1 (877) 268 4868

Email: gustavo@drgaspar.com

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.

Talking with Dr. Juan David Betancourt Parra, plastic surgeon

Posted on August 14, 2013 by K Eckland

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 practice

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.

Dr. Juan David Betancourt Parra

Torre de Especialistas Intermedica

# 1816

Calle 7 No.39 – 137

Medellin

Tele: 352 0264

Email: plasticjdb1@une.net.co

Website: www.plasticjbd.com

International Patients

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.

Aldaqal SM, Makhdoum AM, Turki AM, Awan BA, Samargandi OA, Jamjom H. (2013). Post-bariatric surgery satisfaction and body-contouring consideration after massive weight loss. N Am J Med Sci. 2013 Apr;5(4):301-5. doi: 10.4103/1947-2714.110442.

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].

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