Blog — Notes of a Plastic Surgeon

Welcome to my blog. I am a plastic surgeon in Seattle and have been in private practice since 1991. I've seen more than a few interesting faces and cases through my years spent in the exam room, the operating room and the emergency room. And I have an opinion on just about everything relating to plastic surgery (and a lot of unrelated stuff). If you like my blog, let me know. Thanks for reading! Lisa

Category: This Makes Me Cranky.

A cancelled operation is like an empty airliner taking off.

October 14th, 2015 — 2:58pm
blog empty airline

An empty airline is almost as sad and an empty operating room.

Yesterday I had to cancel a case.  This patient was having a tummy tuck and I do not do tummy tucks on smokers.  She showed up for her surgery and confessed that she indeed had not completely quit smoking but was only smoking about 5 cigarettes a day.  Even that relatively small amount of nicotine puts her at significant risk for major healing problems and also puts her at risks for anesthesia problems because of airway irritability and increased secretions.

Soooo……………………we canceled her surgery, much to her disappointment.  This lady had arranged for time off work, child care, a caregiver for herself etc.  I don’t blame her for being disappointed and I have to say that I was a little disappointed too.  I had assembled an anesthesiologist, two registered nurses and a surgical tech not to mention my operating room.   And there we were, ready to go with no patient.  Canceling a case is sort of like flying an empty airliner around.  Lots of overhead but no paying passengers.

I am grateful that this patient was honest with us about her smoking.  I would much rather have an empty airliner on my hands than a surgical complication.  We got her rescheduled for after the first of the year and this time, I think she will take the no smoking instructions more seriously.

Thanks for reading and please don’t smoke.  Sometimes it can just ruin a good case.                                                                                                                                                                                    Dr. Lisa Lynn Sowder

Patient Safety, This Makes Me Cranky., Tummy Tuck

ICD-10. It’s heeeeeeeere.

October 1st, 2015 — 10:30am
Don't worry Barbie. There's an IDC-10 for that squirrel encounter!

Don’t worry Barbie. There’s an IDC-10 for that squirrel encounter!

Today, October 1, 2015, is the day that doctors have to switch from ICD-9 to ICD-10 diagnosis codes.  Up until today, we doctors had to rely on a mere 18,000 ICD-9 codes to describe patient diagnoses.  Doctors rely on these mandatory codes for reimbursement from insurance companies.  Years ago, when I was doing a lot of insurance work, I had many of these codes memorized.  A couple of examples of ICD-9 codes I used a lot were 611.1 for overly large breasts, 173.30 for skin cancer and 873.50 for a gnarly dog bite to the face.

The new federally mandated version, ICD-10 expands the number of codes to around  from 18.000 to 140,000 codes.  That’s a lot of codes!

Here are a few examples I might possibly need to use for cases I see in the emergency room when I am on call:  Walked into a lamppost, initial encounter W22.02XA.  And if that patient walks into the lamppost again, ICD-10 has it covered:  “Walked into a lamppost, subsequent encounter, W22.02XD.  And for that occasional patient who suffers a burn while waterskiing: V91.07XA.  I occasionally treat animal bites and in the bird department I am covered.  There are 72 codes which cover ducks, macaws, parrots, geese, turkeys and chickens.  And if the chicken bite occurs in a chicken coop, there is an add on code for that!   And if it’s a squirrel bite, of course there is a code.  But what is it something other than a bite?  There’s a code for “other encounter with a squirrel.”  Doesn’t that just make your imagination run wild???

And sometimes, I’ll see a patient late at night in the ER who along with their chicken bite and/or lamp post  injury presents with a bizarre personal appearance (R46.1) and/or a very low level of personal hygiene (R46.0). I hope they don’t take it personally because in the middle of the night, both those codes just may apply to me!

I have to keep reminding myself that the feds who mandate this stuff are from the government and they are here to help.   Sometimes I just have to scratch my head.   I wonder if there is a code for that??????

Disclosure:  I borrowed heavily form an article in the Wall Street Journal written by Anna Wilde Mathews for this topic.

Thanks for reading!  Dr. Lisa Lynn Sowder

Financial Issues, Government and Politics, This Makes Me Cranky.

Correct diagnosis is the cornerstone of proper treatment.

June 15th, 2015 — 1:27pm

blog correct diagnosisI saw a patient this week that really drove home the importance of diagnosis before treatment.  In plastic surgery, diagnosis is usually very straight forward and can be made from across the exam room or sometimes even from across the street.  Common diagnoses in my practice include large breasts, saggy breasts, small breasts, asymmetrical breasts, saggy abdomen, big saddlebags, jowls, saggy eyelids …… you get the idea.  But sometimes I will see a patient whose diagnosis requires something more than a history and physical examination.

This particular patient was a lady in her early 60’s who had a breast lift some 15 years previously.  She presented with an ulcerated area on her right nipple that had been present for over 6 months.  She was convinced it had something to do with her breast lift surgery although the ulcerated area was well away from any of her well healed and almost invisible breast lift scars.  I am convinced that her ulceration is a rare and treatable form of breast cancer called Paget’s disease.

She had seen a half dozen alternative provides who all offered some sort of treatment be it supplements, special salt baths or special ointments.  Guess what?  Nothing worked and none of these providers had a diagnosis.  They were treating an unknown problem with ineffective therapy.  If you know me well, you know that this sort of thing makes me really, really cranky.  This lady had spent a lot of money and delayed a definitive diagnosis by 6 months.

I referred this patient to a breast cancer surgeon for a biopsy which will reveal her diagnosis and allow her to get proper treatment.  I never cease to be amazed by the hubris of some members of the “alternative” medical community.  They don’t know what they don’t know.

Thanks for reading.  Dr. Lisa Lynn Sowder

General Health, Ineffective, My Plastic Surgery Philosophy, This Makes Me Cranky.

Very effective sunblock blocked by the FDA.

June 10th, 2015 — 11:33am


Border patrol K-9 unit trained to sniff out illegal sunscreen.

Sparky is especially trained to sniff out illegal sunscreen. Woof.

This is an article from the May/June 2015 King County Medical Society Bulletin.  It’s a little long and technical but just hang onto that attention span and read it!

Packing a Sunscreen Souvenir

Tourists Grab UVA Treatments Common Elsewhere, Illegal Here

By Barbara K. Gehrett, M.D.

Some international travelers are returning with pharmaceutical souvenirs – new UVA sunscreens available in Europe, Canada, Mexico, and other countries and not yet approved in the United States.

Ninety-five percent of the solar UV radiation that reaches earth is UVA.  It has a wavelength between 320 and 400 nanometers and is present during all daylight hours, summer or winter, cloudy or clear.  UVA passes through glass and penetrates deep into skin.  It is responsible for more damage to basal keratinocytes in the epidermis than UVB.

Most UVB damage occurs in the superficial layer of the epidermis, producing suntan, sunburn, and aging skin.  Protection from UVB with sunscreens reduces the risk of non-melanoma skin cancers.

Two short-acting, barrier-type UVA sunscreens have been approved for use in the U.S.  These are zinc oxide and oxybenzone.  Dermatologists argue that their protection is limited and requires repeated application because they break down quickly.

Ecamsule is a longer-acting “chemical filter” made by L’Oreal and is one component of a U.S. approved lotion, Mexoryl.  The FDA turned down the application to release ecamsule as an over-the-counter UVA sunscreen, although it has been available in Europe since the late 1990s.  It is regulated there as a cosmetic, which has a different standard than the drug category it falls into in the U.S.  All sunscreens in Europe must give both UVA and UVB protection.

Eight UVA sunscreen products have been languishing in line (one since 2003) for FDA consideration.  Congress and President Barack Obama attempted to pressure the FDA by passing the Sunscreen Innovation Act in December of 2014.  This new law requires the FDA to issue an approval or disapproval ruling within 60 days of receiving a complete application for sunscreen.   All eight of the new UVA sunscreens were expeditiously disapproved by the FDA early in 2015.

The FDA wants long-term data on safety before approval will be given.  Typically this means two Phase 3 clinical trials, which are expensive and time-consuming.  It is possible ;that future data on skin cancer protection from other countries would move the agency.  Or perhaps ;the procedural review taking place at the agency will result in a different set of criteria for sunscreens.

In the meantime, U.S. travelers stocking up on sunscreen  when they are outside the country are violating the Food, Drug and Cosmetics Act by importing unapproved drugs.  According to WebMD, the FDA does not generally pursue violators, unless the quantities involved are egregious.  One other work of warning:  online purchases should be made with caution, because of international counterfeiting of drugs.

Thanks for reading!  And keep using that lousy U.S. approved sun creen.  It’s better than nothing.   Dr. Lisa Lynn Sowder

General Health, Government and Politics, Skin Cancer, Skin Care, This Makes Me Cranky.

Another fake top surgeon racket.

October 28th, 2014 — 2:28pm
blog top breast surgeon

You too, for some $$$, can hang one of these on your wall. No qualification necessary. Just $$$. You can send an email to to arrange for payment.

Yet another bogus TOP DOC award I could hang on my wall but won’t. 

Here is the cut and paste of an email I received today from one Daniel Singh.

“You Have Been Nominated – Join the Top Breast Surgeons in America

Only 5 Plastic Surgeons will be chosen per state to be showcased

Please reply back to this email and we will have detailed information sent to you regarding this exciting opportunity to showcase your practice as one of the Best of the Best in Breast augmentation and reconstruction.

Thank you for your time in advance. is not a credentialing organization.  It is not a surgery association.  It is nothing but a website to promote their bogus awards that are sold to doctors to display in their offices to impress unsuspecting patients.   Do I seem cranky today?  I am because this kind of nonsense makes me cranky.  Check out this blog for more of Cranky Dr. Sowder.
Thanks for reading!  Dr. Lisa Lynn Sowder


Patient Beware, This Makes Me Cranky.

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