Saturday, November 21, 2009


Medical skin care can be a confusing array of skin care products, some of which are more "hype" than science.  The Europeons have been in the skin care buisness for decades, and they have shown us the importance of caring for the skin on a daily basis to promote long term skin vitality. 

Key Points to Skin Care
Should be done at least daily, but even better -
morning and night.

1.  A gentle but through cleaning of the skin
2.  A toner to prepare the skin for exfoliation
3.  An Exfoliation Agent (such as a Retinoid or Glycolic Acid) to remove the
     outer layers of the skin and promote healthy regeneration
4.  Plenty of moisture into the skin
5.  A moisturizer to hold the moisture in

We can certainly help you with your skin care needs, using professional products that address your specific skin condition.


Approximately 6 million people suffer from chronic wounds, and the medical community is using multiple technologies to address this difficult problem. Why do people develop wounds, and why do some wounds not heal and become chronic wounds?  There are many etiologies of chronic wounds.  Diabetics are slow to heal because of small vessel disease and sensory disturbances, especially in the feet. Paraplegics develop chronic wounds because of lack of sensation and un-relieved pressure, which in turn "cuts off" the blood supply leading to "pressure sores". Shearing of skin during transfer can also be a factor.  Peripheral vascular disease (P.V.D.) can lead to chronic wounds due to lack of blood supply. Venous stasis disease can lead to lower extremity tissue break-down because of pooling of blood products in the tissues.  Cigarette smoking and nicotine products compromie healing because of their vaso-constrictive properties. Patients with immuno-compromise such as Acquired Immunity Deficiency Syndrome (AIDS) show poor healing capabilities.  Certain medications can also reduce the body's immune defense (such as steroids) and adversely affect wound healing. Some infections can cause significant tissue necrosis and lead to chronic wounds.

Many wounds will heal with time if given proper wound care.  The important principles of wound care include removing all unhealthy and/or devitalized tissues, removing any foreign bodies in the depth of the wound (such as wires and screws), controlling infection, off-loading any pressure on the wound, and providing the proper balance of hydration to the tissues. In the past, it was thought that we needed to let wounds dry out and scab in order to achieve healing. We now know that a wound will heal better in a moist envirnoment.  There are many wound-care dressings that are used to ensure the proper balance of moisture in a wound.

Topical growth factors have received much attention in the last several years as a way of speeding up the healing process. Hyperbaric Oxygen Therapy (H.B.O.) has been shown to improve healing in many patients by "super-saturating" the tissues with 100% oxygen.  This increased oxygen level stimulates new blood vessel  formation.  It also allows more white blood cells and antibiotics to reach the wound which help fight infection.  Electrical stimulation to a wound can be beneficial in some situations. Negative pressure wound therapy (N.P.W.T.) has been a gigantic leap in the treatment of chronic wounds. A sponge dressing is placed on the wound which incorporates negative pressure applied 24/7.  This negative pressure "sucks out" unhealthy fluids, stimulates granulation tissue (one of the first steps in healing) and shrinks the wound in all dimensions. One of the more popular units is called the V.A.C. (Vaccum Assisted Closure).  A new ultrasound treatment called Mist Therapy (Celleration of Eden Prairie, MN) has been developed to promote healing. Ultrasonic energy has been used in the past with varying degrees of success.  This new device that looks like a plant mister sprays saline droplets on the wound that carry ultrasonic energy. The ultrasonic energy dilates blood vessels and stimulates new vessel formation which increases blood flow and oxygen into the tissues.

Plastic Surgeons are an integral part of the wound care team.  They provide conservative care with some of the above mentioned tecniques, but also perform surgery to close wounds.  Many of these surgical procedures involve muscle flaps to bring in a new blood supply to the wound or micro-vascular transfer of tissue to promote healing. Chronic wounds are a challenging problem and require much skill and expertise.  Patients need to realize that this can be a long and slow process. 

Sunday, November 15, 2009


I title this "Health System Reform" instead of health care reform. The system needs revamping to reduce the obstacles that doctors face daily in trying to provide quality care for our patients. Government mandated paperwork for hospitals and doctors is taking away from valuable quality time with our patients. Insurance paperwork, administrative burdens and hassles, both private and government, require attention. Reforms in the insurance industry that expand choice of affordable coverage and eliminate denials for legitimate medically indicated care need to be addressed. In addition, insurance company denials for pre-existing conditions, and cancelling policies because patients get sick (and require treatment with state-of-the art technology), should be eliminated. If insurance companies want to pay their CEO's millions of dollars yearly, that's their choice, but please, take care of the patients that have paid their premiums. Medical liablity reforms must be included in any reform to reduce the cost of defensive medicine. Patients deserve the right to choose their physician, and this needs to be a part of any system reform. Health care decisions need to remain in the hands of patients and physicians, not insurance companies or government bureaucrats. Can we afford health insurance coverage for all Americans? - I do not know the answer to that question.

                      CBO says Senate healthcare bill costs $849 billion.
(ABC World News (11/18, story 2, 00:30, Gibson) reported, "On Capitol Hill, after weeks of delay, Senate Democrats" released "a cost estimate on their healthcare reform bill. The total cost is pegged at $849 billion over ten years." )

Ideally, it would certainly be nice, but the hassles and waste associated with any government run entity may not be the answer. The Senate bill is over 2000 pages, and probably not read nor understood by most of the Senators. The latest "political genius" from Washington is a 5% tax on cosmetic surgery procedures as part of the Senate's so-called health care reform. This is a tax that disproportionately targets women in every socioeconomic level. This type of law was enacted in New Jersey a few years ago. After unmet expectations, it was considered a failure and the original author of the bill introduced and shepherded a repeal of the tax which was unanimously approved by the Legislature but vetoed by Governor John Corzine. These taxes are arbitrary and difficult to administer because many times cosmetic and reconstructive procedures blend together.

Doctors have always, and will continue, to take care of people regardless of their ability to pay. If patients without insurance present to the emergency room for any condition, hospitals and physicians are required by law to take care of them. This is a financial burden, but never-the-less, it is our responsibility to take care of those in need with the very best care possible. Patients certainly need to take responsibility for their health and destiny. If they can afford to have insurance, they should choose to be covered. Addressing self imposed destructive behaviors (smoking, obesity, alcohol & drug abuse, etc.) will also lessen the burden on the system. End of life decisions and the large amount of health care dollars that are spent in certain terminal conditions need to be looked at closely, maintaining compassion and dignity in any decision. In conclusion, health care system reform needs the wisdom from physicians and their patients to guide the politicians in formulating the correct policies.

Wednesday, November 11, 2009


I am constantly asked about minimally invasive procedures with short scars, "thread lifts", "barbed sutures", mini-lifts, etc. Most of these procedures can be done in a short period of time, produce little bruising and swelling, and involve minimal "down-time". It sounds great, and certainly if these procedures would work, I would be signing up immediately. In most cases, these procedures do not produce results that last for more than a few months. These procedures are advertised extensively, mostly by non-board certified plastic surgeons because they can be done in an office setting with very little surgical training.
In order to get excellent and long lasting results with facial rejuvenation, more extensive surgery is needed. The Neck Lift is a common procedure that addresses the laxity in the lower face and neck. One of the more distressing aspects of aging that can be noticed even in the 30 and 40 year old age group, is laxity in the lower face, jowls, loss of definition of the jaw line and sagging in the neck. Pertinent points related to the neck lift involve the following:
(a) Excess fat in the neck is removed
(b) The muscle laxity in the neck and the deeper loose tissues in the face are tightened. This deeper tightening of tissues is critical in getting a natural and long-lasting result.
(c) A natural and conservative re-draping and removal of neck and facial skin.
(d) Incisions under the chin, in front of and behind the ears, and extending into the posterior hairline
(e) Be prepared for at least 2 weeks of bruising and swelling before you are back to work and social activities
(f) Numbness in the face and neck and tightness in the neck will resolve but may take several months.
(g) Heavy and prominent nasal labial folds (the folds running from the corner of the nose to the corner of the lip) are difficult, if not impossible, to correct. Although short-term improvement may be noted, it is difficult to achieve long lasting improvement no matter what technique is used.

The facelift is an extension of the above procedure into the mid face and temporal region.

Forehead lifting addresses the upper third of the face and can be done in several variations. The traditional forehead lift achieves four goals: elevation of sagging eyebrows, improving heavy creases between the eyebrows (glabella wrinkles), improves transverse forehead wrinkles, and some tightening of the excess upper eyelid skin. Be prepared for 2 weeks of "down-time" and prolonged numbness (maybe even permanent) in the forehead and extending into the scalp.

Eyelid Surgery addresses excess skin, excess fat and muscle laxity in the upper eyelids (Upper Blepharoplasty) and excess fat (puffiness) in the lower eyelids (Lower Blepharoplasty). We are limited as to how much we can improve wrinkles in the lower eyelids with this technique. If we try to pull the skin too tight and remove too much skin to try to achieve eradication of all wrinkling, this will produce too much tension on the lower eyelids and cause a pulling down (ectropion). A better technique for excessive lower eyelid wrinkling is laser resurfacing. Be prepared for 2 weeks of "down-time" and even longer to achieve the optimal result in terms of swelling around the eyes. I recommend a pre-operative visit to an opthalmologist prior to eyelid surgery to rule out any underlying eye disease.

Facial Resurfacing falls into four categories:
(1) Dermabrasion (Sanding): A diamond burr is used to "sand" away the outer layers of the skin
(2) Chemical Peeling: A chemical acid is applied to the skin to burn away the outer layers. Depending on the type of acid used will depend on the depth of the peel. Common acids include Glycolic Acid ("light peels"), Trichloracetic Acid -T.C.A. (medium depth peel) and Phenol Acid(Deep peel).
(3) Laser Resurfacing: Uses laser energy to remove the outer layers of skin. There are a variety of lasers available for facial resurfacing. Depending on the skin type and degree of sun damage and wrinkling dictates the laser of choice.
(4) Radiofrequency (R.F.): Uses radiofrequency energy to treat the skin surface. This may be helpful in certain cases of red and pigmentary skin problems.

In summary, facial rejuvenation continues to be popular in many age groups to address the affects of genetics, sun damage and aging tissues. My philosophy is to address the most problematic areas and the areas that concern the patient. A "shot-gun" approach addressing the entire face is usually not necessary in the typical patient.


Using Web for health information said to be risky.
In a column in the Washington Post (11/10), Carolyn Butler writes on "cyberchondria, loosely defined as the baseless fueling of fears and anxiety about common health symptoms due to Internet research, or, as I like to think of it, Googling oneself into a state of absolute, clinical hysteria over every last pain, itch and strange freckle on your body. Apparently, I'm not alone." Researchers at Microsoft found recently that "about two percent of all the Windows Live searches were health-related." Of those "users who engaged in at least one such query during the study, roughly one-third 'escalated' their subsequent web surfing to focus on far more serious...conditions." Problems can "arise when people turn to a broad web search to diagnose their ills," and Butler notes that "the Medical Library Association has some great tips for evaluating health research online."

Saturday, November 7, 2009


I strive to promote ethical, exceptional surgical and medical care for my patients. Proper pre-operative evaluation and diagnosis is essential in picking the correct procedure, or just as important, realizing that a surgical procedure is not necessary. Even though many patients think they need cosmetic surgery, many do not, and only require a gentle reassurance that they do not need, nor should they expect, to look like that model on the cover of "Cosmopolitan Magazine". Medical ethics should take top priority and should be in-grained in the minds of any cosmetic surgeon, plastic surgeon or for any other medical doctor. The Hippocratic Oath teaches us "First do no Harm". In order to abide by this oath, we must first realize that we are not "supermen" and we all have limitations. This applies to surgery and life in general. We need to have proper training in any procedure, not a week-end course. We need to use innovation to solve problems and be flexible in our thinking. As a plastic surgeon, I want to stay involved in the care of hospital patients and support my colleagues in other specialities when they have patients with problems requiring plastic surgical expertise. We need to continue to enhance our craftsmanship in order to do the very best for our patients. Continuing medical education is critical in maintaining our edge, no matter what field we are in. There will always be set-backs in life and in plastic surgery. By maintaining trust, balance and always having a eye toward the end result, these set-backs can be energized into a positive victory. Let the hard work and fun begin!


Getting together with colleagues at a recent plastic surgery meeting emphasized the proud and long tradition of Plastic and Reconstructive Surgery. Going back to World War I, and progressing through our current conflicts around the world, plastic surgeons have been on the "front lines" of surgical care and research. Pioneer plastic surgeons such as Sir Harold Gilles, Ralph Millard, John Converse, Joseph Murray, Paul Tessier, just to mention a few, have made a tremendous impact on innovations, teaching and transforming lives. As in any profession, "We stand on the shoulders of the giants who have gone before us". These pioneer plastic surgeons, along with many more, have been an inspiration to me and fostered my love for plastic surgery. It was my good fortune to have spent 2 years in Miami, Florida training with Dr. Ralph Millard, a world renowned plastic surgeon known for his reconstructive skills and cosmetic excellence. He is best known for his cleft lip and palate innovations, and devised the rotation advancement lip closure for babies born with this unfortunate condition. This technique is considered the "gold standard" around the world for closure of cleft lips. He has written numerous books and hundreds of articles on a wide variety of topics in plastic surgery, and many of his ideas and techniques have revolutionized the field of plastic surgery. In one's life, there are at best a handful of people that truly influence and transform an individual and challenge one's potential. My Dad would be on the top of that list, a wonderful man who spent 91 years on this earth, exemplifying the highest degree of ethics, care for others and kindness. My high school basketball coach, Mr. Al Belaire, and my current minister at First Presbyterian Church, Dr. James Miller are also on my list. I could write a long blog on the positive influence these people have had on my life. Without a question, Dr. Ralph Millard, my mentor in plastic and reconstructive surgery, has influenced and transformed my professional life and thinking. Not only was Dr. Millard a master in the operating room, accomplishing unbelievable feats on very difficult cases. but he was a stern teacher imparting the "principles of plastic surgery" - making you "think on your feet" when faced with very difficult reconstructive and cosmetic problems. In a future blog, I will talk more about these principles, because they not only apply to plastic surgery, but can be used in any profession. It was also rewarding to train with S. Anthony Wolfe, a cranio-facial surgeon who trained in Paris with the "father of cranio-facial surgery", Dr. Paul Tessier. As a plastic surgeon, I feel blessed to practice a wonderful profession, and have the ability and talent to provide outstanding cosmetic and reconstructive care for my patients. I truly stand on the shoulders of those giants and walk in the path promoting the proud tradition of Plastic Surgery.

Thursday, November 5, 2009


Several years ago, the Federal Trade Commission began to interfere with medical ethics by allowing medical doctors to advertise. Advertising has become a common modality in promoting medical practices, hospitals, drugs, procedures, etc. with the goal of educating and informing the public. One must realize that anyone can pay a fee and advertise and promote themselves. As my mentor, Dr. Ralph Millard has written, "A good reputation is gained by good results, by honest and dedicated service to patients and by respect of colleagues and patients. This takes time and has to be earned. Advertising is available immediately to anyone willing to pay for it, regardless of their skill or training. Many plastic surgeons that advertise claim merits unearned, skills not present and results never attained". The public must realize that there is no state or national law that limits a doctor as to what he can do in his office facility. We do have strict hospital by-laws that prevent inadequately trained doctors from performing procedures in a hospital or accredited out-patient ambulatory facility. Success in any career calls for special talent and specific training. There are no short-cuts when it comes to plastic surgery.

Tuesday, November 3, 2009


New technologies in suction lipectomy were discussed recently in Seattle at the American Society of Plastic Surgery meeting. The ASPS membership is composed of board certified plastic surgeons from the U.S.A. and around the world. The theme of this meeting was "East meets West", and presentations from China and other far east countries were highlighted. Much of the investigation resolves around the best technique to "break-up" the fat cells before they are suctioned, and what, if any, technology will assist in tightening the overlying skin. One of our problems that we constantly have to deal with is skin redraping. In essence, how well will the skin tighten after the underlying fat is removed. If skin elasticity is not good, the patient will end up with loose and redundant skin. Traditional liposuction is still the "gold standard" when comparing different technologies. This is done with small cannulas in a setting of tumescence (infiltrating saline into the fat prior to suctioning). The technique involves manually breaking up the fat with to and fro movements or using a power assisted device (P.A.L.) in which the cannulas are vibrated through the tissues. Ultra-sonic Assisted Lipoplasty (using internal ultrasonic energy to break up the fat cells) was initially thought to be beneficial in tightening skin but it has not shown to be that much better than traditional liposuction. Although it was a "hot procedure" starting in the late 1990's, it has not shown to give the skin tightening that we originally anticipated, and thus, it has become less popular. Laser Assisted Lipoplasty (using laser energy to lyse the fat cells) is the "buzz word" today. Various laser devices (SmartLipo; SlimLipo and many more) are being marketed to the public and to a wide variety of "cosmetic surgeons"as the device of choice for suction lipectomy. Various laser wavelengths are being investigated to try to find the optimal wavelengths to breakup the fat and also tighten the overlying skin. The most frustrating problem in the moderate to large volume liposuction cases is skin tightening and re-draping. It does not do any good to suction fat if the end result will result in loose and unattractive skin. The verdict is still out on the Laser assisted devices. Water jet liposuction is a new technology that uses a high powered stream of water to break up the fat cells. It is still under clinical trials, and from my initial analysis of the results and the data, I do not see this as being a better alternative. More clinical trials will have to be completed on this device. Radio-Frequency (R.F.) assisted liposuction uses radio-frequency waves to break-up the fat cells. This is still under investigation. Non-invasive techniques for fat reduction such as external ultrasound and injection lipolysis are under clinical trials. The theory with External Ultrasound is that energy placed on the surface of the skin will breakup the underlying fat. Injection Lipolysis uses various solutions injected into the fat to dissolve the fat cells. These are still under investigation and the final word is not yet written. Initial enthusiasm and "hype" is always a problem with any new technology. As a board certified plastic and reconstructive surgeon, my job is to evaluate and to make sure the scientific data shows a benefit and is safe before embarking on a new, expensive technology. I will keep you updated as data accumulates.

Monday, November 2, 2009


The medical term for the flu is influenza. It is a contagious viral infection affecting the nose, throat, airways and lungs. There are three types of influenza viruses: A, B, C. Type A is the most common and causes most of the serious illness and epidemics. The H1N1 ("swine flu") is a new type A virus that seems to be more severe and is causing disease all over the world. The viruses are different than what causes the common "cold" or the "stomach flu". Transmission of these viruses is from person to person by sneezing or coughing. Touching surfaces that are contaminated can be another source. Frequent hand washing and covering your mouth when coughing and sneezing is important. People are infectious from one day prior to the development of symptoms and up until five days after becoming sick. New vaccines against the flu viruses are created yearly because these viruses change yearly. Flu vaccines for injection are created from killed virus and therefore cannot transmit the virus. It stimulates your body's immune system to offer protection. This flu season, in addition to the normal flu vaccine, a separate vaccine against H1N1 is becoming available. Vaccines are your best defense against the flu. Another approach is to use anti-viral medications. These anti-virals have to be given within 48 hours of the first symptoms. Anti-virals should not be used in place of the flu vaccines.
In the U.S., seasonal influenza kills more than 36,000 people & hospitalizes 200,000 yearly.
This information comes from the Journal of the American Medical Association and the Centers for Disease Control (


Board certification is an important but somewhat confusing issue for the public to understand. To become a board certified plastic surgeon (we are not talking about a so-called "cosmetic surgeon"), one must complete 4 years of medical school, 5 years of a surgical residency and at least 2 years of a plastic surgery fellowship. Once these basic requirements are met, you have to accumulate multiple cases and experience, and then pass vigorous written and oral examinations which include case reviews. Only then is a plastic surgeon granted board certification or "diplomat" status by the American Board of Plastic Surgery, the only board recognized by the American Board of Medical Specialities to certify board certification. It is up to you to research the credentials of doctors or dentists claiming to be plastic surgeons or "cosmetic surgeons". Some of these doctors even claim "board certification". The bottom line, do your "home-work" and make sure your plastic surgeon is board certified by the American Board of Plastic Surgery. We are fortunate to have some very excellent and well trained board certified plastic surgeons in Tulsa.

Sunday, November 1, 2009


I feel strongly that photos of my patients should not be shown on the world wide web for public viewing. It is a matter of privacy and decency! This is an especially sensitive issue when we are dealing with photos showing intimate parts of the anatomy!  The current trend of flooding the web with naked bodies does not honor the anatomical form. I know prospective patients want to see before and after photos.  I will show them in the privacy of my office.  Remember that posted images on the web can be re-touched and misleading for marketing purposes. Surgical outcomes will vary in patients because of differences in the anatomy and healing.


Breast Augmentation is still a hot topic. Our recent American Society of Plastic Surgery meeting in Seattle was attended by board-certified plastic surgeons from around the world. Multiple panels, courses and scientific presentations covered various aspects of breast implants and techniques. The infra-mammary incision is still the most popular. The incision through the umbilicus has fallen out of favor. A 3 cm. incision for saline implants and a 6 cm. incision for silicone implants is typical. To reduce scar tightening around the implants (capsular contracture) and to improve mammographic visualization, the submuscular position is preferred. The one exception would be a patient with early breast ptosis -a better shape and contour can be obtained if the implants are placed above the muscles (submammary position). Saline filled and Silicone gel filled implants are both popular options. Silicone implants have the advantage of a softer feel and a more natural look. There is also less chance of wrinkling with silicone. In very thin patients with minimal breast tissue, the silicone implants give a better result. The cohesive gel implant is not yet approved by the F.D.A. for general use in the U.S.A. I will keep you up-to-date on this exciting breast implant. Breasts implants come in different sizes, shapes and projections, as well as textured vs. smooth surfaces. In order to achieve a "custom fit" for a natural result, the pre-operative and intra-operative sizing process is critical. This involves the patient's individual anatomy, chest wall dimensions, skin elasticity, and patient desires. In summary, breast augmentation is still a "hot commodity" with a high patient satisfaction level, minimal "down-time" and few complications.