There’s nothing that makes me wanna holler much more than an anatomically perfect patient for tummy tuck who smokes!

Last week I saw two patients in one day who were both absolutely anatomically perfect patients for tummy tucks.  They were both done with child bearing, they were both thin and both had abdominal muscle separation and loose jelly belly skin and they both had c-section scars.  This kind of patient makes me almost droll at the thought of how straight forward their surgery would be, how much improvement they would have and, most of all, how happy theywould be with their surgical result.

That was the ectacsy part of the consultation and now for the agony part.  Both of these patients were long time and dedicated smokers.  And that made them very, very poor candidates for tummy tuck regardless of their favorable anatomy.

The issue with smoking is the damage that smoking does to blood vessels.  With many procedures such as tummy tuck, face lift, breast lift and some body lifts, the blood supply of the skin is stressed because the skin must be peeled up for a distance either to remove extra skin or to alter structures under the skin.  Peeling the skin up cuts many, many small vessels that provide circulation to the peeled up area and that area is then dependent on a secondary blood supply for post-operative healing.   In a smoker, that secondary blood supply is not reliable and the chance for the peeled up skin dying is much higher than a non smoker.  We surgeons have a fancy name for things that die – necrosis and it’s a word I loath using in describing a post surgical wound in my post-operative notes.

So I had to deliver the two smokers that bad news that I could not operate on them until they were non smokers for at least three months and even then, they are still at increased risk for healing problems.   I am sure I am not the first doctor to tell them they should quit smoking but maybe, just maybe, if they want than tummy tuck enough, they will finally find the strength to kick the habit.

Seattle Plastic Surgeon blogs about the MYTH of local anesthesia being safer than general anesthesia.

General Anesthesia vs Local Anesthesia. The winner is???????????????

I would  like to dispel the myth that local anesthesia is somehow safer than general anesthesia.  There are some practices that use the “we only use local anesthesia” as a selling point to imply that their practice is  safer, more advanced or “less invasive”  than a practice that offers general anesthesia.  My advice is to really look into the anesthetic options and  not go with a physician who offers only local  anesthesia.

A physician who does only local may do only local because he/she is flying under the radar of state regulations for office surgery.  Office operating rooms that do not provide general anesthesia are often exempt from certification and/or inspection at the state or federal level.  Another reason for a physician  to do only local is lack of proper anesthesia equipment which (like everything else in the medical industrial complex) is expensive.  And yet another reason is that the only local physician cannot find and an anesthesiologist to work with him/her for various reasons or the only local physician does not have privileges to do the procedure in a hospital that can provide general anesthesia.   If you aren’t saying YIKES, you may want to go back and read this paragraph again.  Also, read this related blog.

Local anesthesia works great for many procedures.  I do some minor face, breast, body and lipo cases with only local.    In theese cases, I can keep the cost down, the patient comfortable, the recovery rapid and, unless I have used sedation, the patient can often drive him or herself home.  Sweet, huh?

But for many major or lengthy procedures, it is downright dangerous to use only local because the dose needed to provide comfort for the patient may exceed the toxic level.   All local anesthetics need to be administered within a safe dose and that safe dose varies with the area being injected, how fast it is injected, whether or not the local contains epinephrine and the size and health of the patient.    And the really scary part is that a local anesthetic overdose is often not evident until hours after the surgery has ended, when the patient is not longer in a doctors office, surgery center or hospital.  Patients can die from local anesthetic overdose.  This tragedy happened a couple of years ago in Bellevue, Washington at a clinic that only does local.  It this particular case, the patient kept complaining of discomfort during her extensive liposuction procedure and the doctor kept injecting local, way beyond the recommended dose.  He did not have an anesthesiologist there to help him keep the patient comfortable with intravenous sedation or general anesthesia or to help him keep track of how much local he was using.   She did not suffer the consequences of the overdose until hours after she left the office

There is no cosmetic surgery result so fabulous (or a price for that fabulous result so low) that  is worth dying for.  For my major cases, I really, really want to have an anesthesiologist there either to provide the general anesthesia or, in cases where I am injecting the local anesthesia, to provide sedation and monitoring and airway control (another topic and another blog) if needed.

Yes, the anesthetic equipment and anesthesiologists are expensive, and inspection by state and federal agencies are a hassle.   But the expense and hassle are well worth the safety that all patients, including cosmetic surgery patients, deserve.

Remember, better paranoid than sorry.  Thanks for reading.    Dr. Lisa Lynn Sowder.

Seattle Plastic Surgeon suffers from self inflicted post-surgical complication.

Seattle Plastic Surgeon is happy to be ACLS certified.

This week I saw a post operative patient in my office who happened to mention that her heart was racing and she felt a little weird.  I took a listen and indeed her heart was racing – about twice the normal heart rate!  

Given her excellent health, her middle aged female status and the fact that she is a bit of a stress and caffeine junkie (it takes one to know one), I made the diagnosis of paroxysmal atrial tachycardia also know affectionately as PAT. 

Then I had her do some things that are sometimes effective in breaking an episode of this abnormal heart rhythm.  I had her massage her carotid artery and bear down, like she was pushing out a baby.  And, thankfully, it worked.  She reverted into a normal rhythm and no longer felt weird.   She’s scheduled to see a cardiologist who can recommend further workup or treatment.

These things do not happen often in a plastic surgery office but when they do, I am so thankful that I take the time and effort to remain ACLS certified.  The ACLS classes require me to review the various protocols for cardiac problems and lately, also problems with stroke.  Treatment for some problems have remained the same since I took my first ACLS class in medical school over 25 years ago but treatment for many, many other problems seem to change every time I take a refresher course. 

One thing that always stays the same is the increase in my heart rate when I am taking one of the several in person and in real time tests managing simulated patients with an abnormal heart rhythm.    It is those simulated tests that allow me to “keep calm, think on my feet, and carry on”. 

I’m due to recertifiy this March and am looking forward to spending the better part of a weekend reviewing the stuff I know and learning the stuff I don’t.  I rarely put  this knowledge to work but when I listen to a patient’s heart and they are clipping along at 140 beats per minute, I’m glad it’s there when I need it. 

Thanks for reading!  Dr. Lisa Lynn Sowder

The Moon Walk, not everyone should try this.

Seattle Plastic Surgeon weighs in on the Dr. Conrad Murray verdict.

I remember clearly the day that Michael Jackson died.  I was operating at Seattle Surgery Center and the news went around the O.R. quickly as did speculation of his cause of death.  Drugs was at the top of my list.

As the story unfolded, we in medicine were blown away by the bizarre circumstances of Jackson’s death.  Propofol overdose.  What?  Propofol given by his private physician in his home.  You have got to be kidding.  How nuts is that???

This very sad story at least allows for some education of the public on the topic of Scope of Practice.   It is not a well known fact that there are no federal scope of practice laws and no state scope of practice laws in California, Washington (where I practice) or in most states.

What this means is that physicians with a medical license are not restricted as to what type of medicine they practice.  In the case of Dr. Murray, he was practicing anesthesia without training, experience or certification in anesthesia.  Yikes, huh?

The formally trained and board certified anesthesiologist with whom I work use Propofol all the time but they use it in an operating room with monitoring of the patient, control of the patients airway and with resuscitation equipment at hand.  Those essential ingredients were not available at Michael Jackson’s home.  Another thing lacking was Dr. Murray’s judgment.  It took him 20 minutes to call for help.

Something in plentiful supply was hubris.  Dr. Murray was in way, way over his head but did not recognize or admit his folly.    Hubris is also plentiful in ”cosmetic surgery”.  Over the past 20 years there has been a flood of non plastic surgeons physicians entering the field of “cosmetic surgery” through the back door.  These physicians have formal residency training in fields from radiology to ophthalmology to obstetrics/gynecology to emergency room medicine.  There are no laws that prevent these physicians from calling themselves cosmetic surgeons.

One reason for this flood is financial.   Twenty years ago there was a sea change in medical reimbursement and physicains have been squeezed financially by third party payers to the point where many physicains honestly can barely make it.   The “easy money” of “cosmetic surgery” is tempting.   Take a weekend course on liposuction or breast augmentation or buy this fancy, dancy laser!   But honestly, there is absolutely nothing easy about cosmetic surgery.  Many of these physicians (and their cosmetic patients) learn this the hard way.

Also, more and more surgery is being on in the private office setting.  One does not need hospital operating room privleges to operate in their own private O.R.  And even most state and federal regulations of outpatient operating rooms do not have requirements about the training and board certification of the physicans using the operating room.  The regulators are more concerned with the facility that the physicians who use it!  And in some states, an operating room can “fly under the radar” of all regulation because they use only local anesthesia.  And that topic is worth a whole blog of its own.

And, it gets even darker.  There are also at least a dozen “boards” and organizations that a physicain can join to give them credibility with potential patients.  Confusing?  Oh yeah.  On purpose?  Oh yeah.

So if you are looking for a plastic surgeon for a cosmetic procedure, don’t settle for a “cosmetic surgeon”.  If that surgeon were fully trained and boarded in plastic surgery, believe me, they would call themselves a plastic surgeon.   You can check to see if your” cosmetic surgeon” is a board certified plastic surgeon here.

 I know that I don’t know how practice radiology, opthalmology or ob/gyn or emergency medicine and I don’t try.  And I certainly know I don’t know how to Moon Walk.

Thanks for reading.  R.I.P. Michael.  Dr. Lisa Lynn Sowder

Meet Henrietta and Earl

My aussie/border collie/snapping turtle, Stella, just loves her Henrietta and Earl chew toys.  Henrietta emits a high pitched squeal when chewed.  Earl produces a realistic flatus-like sound.  Stella, Henrietta and Earl make for some great hilarlity – for about 30 seconds.

Henrietta and Earl do, however, have some redeeming qualities in that they are very useful for obesity education.

Henrietta has a problem with external obestiy.  Her excess fat is mostly external and distributed kind of all over – her hips, back, chest, upper thighs and tummy.  This fat is unsightly but not much of a health issue.

Earl, on the other hand, has the dreaded internal belly fat.  Earl, who has an inappropriately elevated level of self esteem, will say, “It’s muscle, not fat.  Feel it, baby, it’s hard.”  Well, it’s not muscle, Earl.  It’s belly fat and it puts Earl at risk for diabetes, high blood pressure, stroke, heart attack, etc.

Henrietta’s fat is best addressed with weight loss but it can also be addressed with breast and body contouring surgery.  Earl’s fat on the other hand can only be addressed with weight loss.  Surgery cannot remove Earl’s internal fat although Stella is doing her best to chew it off.

Thanks for reading!

Easily asmused Seattle Plastic Surgery, Dr. Lisa Lynn Sowder

Last week  I attended a “Culture of Safety” seminar at Seattle’s Swedish Medical Center.  I entered the lecture hall with a bad attitude thinking that there were more productive things I could be doing for the next three hours.  And, having quite the obsessive personality, I don’t need any help in keeping my patients safe.  I brought my Kindle to read while I kept my seat warm.

As per usual, it was a wrong assumption.   I was introducted to the “Swiss Cheese Theory of Error” and I’d like to share it with you.

Take a look at the slices of swiss cheese on the right.  These slices represent walls that have been constructed to prevent error.  The holes in the cheese represent holes in those walls that can let an error slip through.  Multiple walls make error less likely but the more holes, the more chance those holes will line up an let an error occur.

One wall that was recently added to surgery thoughout the United States is the “surgical time out” where, in the hustle and bustle of starting an operation, everyone agrees on the identity of the patient, the surgeon, the operation, the operative site,  any allergies, the antibiotics given and any anticipated issues.  When this time out is done correctly, it is a good wall.  When done incorrectly, it has holes.

We have out “surgical time out” printed out on the patient chart.  Sometimes patients are a little rattled when the nurse asks them their name, the name of their surgeon and what operation they are having.  It’s not that we don’t know!  We are just double checking and making sure this wall is one without holes.

Thanks for reading,

Seattle Plastic Surgeon, Dr. Lisa Lynn Sowder