How to choose a plastic surgeon

Choosing the right plastic surgeon is not easy! Check out this link via HauteBeauty to learn some tips!

https://hauteliving.com/hautebeauty/641879/how-to-choose-the-right-surgeon-according-to-the-experts/

HauteLiving Plastic Surgery Discussion

In case you missed our live discussion, you can watch the replay here!

Learn more about Upper Blepharoplasty!

See my most recent post on HauteLiving!

(Reproduced below)

HB: What is a Blepharoplasty?

Your eyes are the most captivating features of your face. Over time, extra skin above the lids tends to sag and can become puffy giving you a tired, aged appearance. If the excess skin sags enough, it can also block vision. This is why Upper Eyelid Blepharoplasty is one of the most commonly requested surgeries in the United States. Upper Eyelid Blepharoplasty is a procedure to remove the excess skin and weight off your lids. There are, however, many ways and techniques to remove the extra heaviness, and it’s best to consult with an Oculofacial Plastic Surgeon.

HB: How does an Upper Eyelid Blepharoplasty work?

Upper eyelid surgery requires precision and very fine incisions that follow the natural creases and contours of the eyelids. There is no “one-size fits all” technique, but rather an individualized and custom approach for each patient. The natural eyelid crease is identified and then the right amount of skin to remove is marked. This is critical to make sure there is enough skin left behind so patients can still blink normally and close their eyes. The extra skin is then excised. Sometimes, extra fat is either moved around or completely removed. It is important not to cut out too much fat, so the eye sockets don’t look too hollowed out. The skin is then closed very carefully with stitches. This procedure can be done at a surgery center with light sedation or in clinic with local anesthesia. Removing this excess skin and fat from the upper lids can result in a youthful, rested appearance!

HB: Who is the best candidate for this procedure?

Upper Eyelid Blepharoplasty is a great option for any adult looking to rejuvenate their eyelids. Common problems this procedure can fix include: extra skin in the upper eyelids that causes them to feel heavy, the disappearance of the upper eyelid crease, tired or sad appearance, obstructed vision from eyelid skin, bulging in the lids, and lack of an upper eyelid crease.

HB: What does recovery look like?

Recovery from surgery is usually quick and without any significant pain. I generally ask my patients to take it easy, with no bending, heavy lifting, or straining, for 1 week, after which there are no restrictions. Most patients feel pretty good and can go back to work if they want within a couple days; however, bruising and swelling can sometimes up to 1-2weeks. Use lots of ice and cool compresses in the first 2-3days, use over-the-counter pain medicine like Acetaminophen, and apply a small amount of antibiotic ointment for the first week. After that, keep the incision moisturized with Vaseline or Aquaphor so the scar heals well.

Top 5 Facial Rejuvenation Trends For 2020

The new year has arrived and like many others, you’ve committed to a new you! Just doing a little editing on your face- be it erasing fine lines, softening furrows, evening out patchy spots, tightening loose skin- can make you look and feel more refreshed and ready to tackle your goals. Fortunately, there are many treatments with minimal downtime!

Top 5 Trends

For Facial Rejuvenation

1. Injectables:

These include injections of botulinum toxins such as Botox, Xeomin, and the new trendy Jeuveau; as well as, hyaluronic acid fillers, like Juvederm and Restylane. Botulinum toxins work by blocking signals from nerves to muscles. The injected muscle can no longer contract. When used correctly by a well-trained physician, this can cause wrinkles to soften and relax. It is mostly used on forehead lines, fine wrinkles around the eyes, glabellar/frown lines, and necklines. Botulinum injections are relatively affordable, have very few risks, and have practically no downtime. Hyaluronic acid fillers are injected under the skin and can treat many cosmetic concerns. They are great for filling fine vertical lines around the mouth, add more volume to lips, restore fullness to hollowing cheeks and eyes, and better defining the jawline. Hyaluronic acid fillers are eventually absorbed by the body. These also offer quick recovery, with low risks.

“It is always important to choose a well-qualified, board-certified physician. All procedures have some risk, but you can mitigate the risk by choosing a physician who is well-trained and has knowledge in these treatments.”

2. Lasers and Light:

Lasers have numerous indications. Lasers can remove moderate and deep wrinkles, dramatically improve skin tone, texture, and tightness. Deep, ablative lasers remove outer layers of the skin, often require anesthetic injections or light sedation to keep a patient comfortable, and have a longer recovery. Non-ablative lasers leave the outer layers of the skin intact and target deeper layers. Often times, these treatments only require topical anesthetic creams/gels and have a quicker recovery. Photorejuvenation with light therapy is also becoming a more popular, non-invasive technique to improve tone and tighten skin. Phototherapy, like Intense Pulsed Light (IPL) or BroadBand Light (BBL), also targets cells with specific colors, or chromophores, within the skin, and offers a very quick recovery. Both lasers and light therapy are great for improving skin tone, getting rid of acne, removing broken blood vessels, clearing sun damage, and tightening skin.

3. Radiofrequency:

Radiofrequency works by targeting deep skin tissue with radiofrequency (RF) energy, which generates heat and results in new collagen and elastin production. RF treatments are great for tightening sagging skin anywhere on the body, and many of these treatments can be done quickly and without any downtime.

4. Microneedling:

Microneedling devices deliver a series of controlled wounds beneath the surface of the skin. This triggers the body’s own natural collagen and elastin production to help rejuvenate the skin. This minimally invasive procedure can be combined with radiofrequency or platelet-rich plasma (PRP) for a stronger effect. This technique is also great for treating acne scars, sun spots, fine lines and wrinkles, large pores, and uneven skin tone.

5. Surgery:

Sometimes, surgery is the best option! Newer surgical techniques can result in long-lasting results with minimal scar, and can certainly be combined with any of the above for complete facial rejuvenation. Blepharoplasty, for example, is a relatively straightforward, popular procedure to address heavy lids and rejuvenate the eyes. Other procedures can include brow lifts, lid lifts (ptosis repair), mid-facelifts, lower eyelid blepharoplasty, or even full facelifts. While surgery has a longer recovery, it can still be performed very safely with outstanding results by qualified surgeons.

Many of these treatments are minimally invasive, or non-invasive and effective in rejuvenating your face. Although low-risk, convenient, and effective, it is always important to choose a well-qualified, board-certified physician. All procedures have some risk, but you can mitigate the risk by choosing a physician who is well-trained and has knowledge in these treatments. A new year brings new opportunities to feel and look better!! Now is a great time to consider facial rejuvenation as there many new technologies and devices out on the market that are non-invasive and can produce noticeable changes. Talk to your physician to find the best options for you! Happy New Year, Happy New You!

Lower Eyelid Rejuvenation

Here’s a recent interview about Lower Eyelid Rejuvenation and Blepharoplasty, reposted from HauteBeauty:

HB: What is a Lower Eyelid Blepharoplasty and how does it work?

There are two ways to get to the fat in your lower eyelids. The best way, in order to avoid lower eyelid retraction, is to go through the inside of your lower eyelid. Once the fat is exposed, it is excised and/or reshaped to smooth out the lid-cheek transition. A small amount of skin under your lashes is sometimes removed, and the corner of your lids can be tightened. Lower eyelid blepharoplasty can also be combined with many other procedures, such as laser resurfacing, fat transfer, upper eyelid blepharoplasty, face lift, eyelid lift, or brow lift.

HB: Do you prefer it to other methods?

There are many ways to help improve the appearance of your lower eyelid bags. Over the counter creams, lotions, and serums can moisturize your skin to help improve the appearance of fine wrinkles, but the results are not lasting. Laser resurfacing can help improve the look of lower eyelid bags, but again this really targets the skin and does not change the underlying fat that often causes a lumpy, bumpy appearance. Other options to mask lower eyelid bags include fillers, which can help smooth the lid to cheek transition. Fillers are a temporary solution as they last only a year or so, and some patients can develop swelling in the lower lids that will require the filler to be dissolved.

Lower eyelid blepharoplasty involves cutting out or reshaping the fat in your lower eyelids. This procedure really is the foundation for smooth, natural, youthful lower eyelids and is longer lasting than any other technique. Combining lower eyelid blepharoplasty with any of the above techniques can help you look more refreshed and youthful.

HB: Who is a good candidate?

Lower eyelid blepharoplasty is a great option for many patients looking to reduce their lower eyelid bags. You first want to seek out an Oculofacial Plastics and Orbital expert, who completed an ASOPRS fellowship, to see if you are a good candidate; but generally speaking, patients, who are otherwise healthy and have lower eyelid bags due to fat and not just edema or swelling, are good candidates. Medical causes for swelling around your lids should also first be ruled out.

HB: What does recovery look like?

After lower eyelid blepharoplasty, patients can expect to have bruising and swelling that could last a couple weeks, but they generally feel better within a couple days. I also ask patients to take it easy for 1 week with no bending, heavy lifting, or straining; and, no swimming for at least 2 weeks.

HOLIDAY SPECIAL!!

The holiday season can be stressful. Take a moment to treat yourself and prevent new wrinkles! For a limited time, schedule an appointment with me for 20% off all wrinkle- slaying products (Botox, Xeomin, Jeuveau) and get a free consultation for cosmetic surgery.

What's Your Favorite Sense??

This week in JAMA Ophthalmology, I came across an article that tried to value different senses. It was a small study, and there may be some bias as the authors themselves were part of an eye health department; however, it came to what I feel was the predictable conclusion: sight was the most valued sense.

The study surveyed 250 participants in the UK. The group comprised mostly of women (56.4%), and the average age was 50 years old, but included people 22 years and older. The vast majority of the study group did not have any family history of vision impairment. They included the following 8 senses in their questioning: sight, hearing, touch, smell, taste, balance, temperature, and pain. How would you rank these in order of most to least favorite? For me, the top choice is simple… My rankings would be as follows: Sight, Balance, Hearing, Taste, Touch, Smell, Pain, Temperature.

The study also looked at Time Tradeoff. Participants were essentially asked: How many years of perfect health would you give up in order to maintain your sight (or these other senses)? This could also be rephrased as: How many years of perfect health would you prefer compared to 10 years of life with complete vision loss (or other sense)? The results were quite astounding!

“ “The time tradeoff exercise indicated that, on average, participants preferred 4.6 years (95% CI, 4.2-5.0) of perfect health over 10 years without sight and 6.8 years (95% CI, 6.5-7.2) of perfect health over 10 years without hearing (mean difference between sight and hearing, 2.2 years; P < .001).””

On average, people chose 4.6 years of perfect health compared to 10 years of complete vision loss. The second most valued sense was hearing as people chose 6.8 years of perfect health compared to 10 years of complete hearing loss. Even more interesting, 15% of people chose death over living 10 years with complete vision loss (compared to just 6% choosing death over complete hearing loss). While it’s important to keep in mind that this is just one small study that may not reflect the general population, the findings here seem to be reinforced by a couple other studies out there.

“As physicians in this economically tightening environment, we have to demonstrate objectively our value to the population. It is no longer enough simply to have patients say they like us.”

So what does this all mean? To me, this reinforces the value that my field of Ophthalmology brings to people. We value our vision and the health of our eyes so much that we would give up a lot to preserve our sight. From a personal standpoint, I’m grateful to be in a field that helps make a significant difference. Nobody really understands what we do (either as Ophthalmologists or Oculoplastics experts) until they need us and by then, vision could already be damaged.

From business and healthcare policy standpoint, I see a significant disconnect. First of all, it seems a little ridiculous to me that eye health is not universally covered. Vision care, from eye glasses to cataracts to other complex surgeries, should be a basic covered service because it has such a profound impact on people’s lives. The US system right now has just a patchwork of insurance options to cover eye health with many gaps in care. Imperfect vision not only affects one’s quality of life, but there is also an economic impact with loss of productivity

Secondly, all physician specialties have generally seen a cut in their reimbursements, but as policymakers, we should ask ourselves, what does the public value, and how should limited resources be distributed? As physicians in this economically tightening environment, we have to demonstrate objectively our value to the population. It is no longer enough simply to have patients say they like us.

Although I’m biased, I think it’s clear what the public values. People are willing to give up nearly 5 years of their life over a 10-year period to have good vision. That’s pretty remarkable.

Free Tuition?! A step towards better medical education!

NYU recently joined the ranks of few other medical schools that offer their students reduced loan burdens and an even smaller, elite group of medical schools that offer completely free tuition. This is fantastic news for medical students, and we can only hope that other institutions begin to offer similar deals to their students!

Medical education is a huge business and is expensive. While I cannot comment on exactly the resources it takes to train a competent physician, I imagine it's a lot. Medical liability itself must be particularly expensive in our litigious society, but also the costs to hire lecturers and practicing physicians to teach must be significant. The large administrations, bureaucracy, and facilities at many training institutions also have significant costs that someone needs to pay. So to have NYU, in one of the most expensive cities in the world, take a bold step to free their students from the shackles of educational debt deserves tremendous credit!

“To not consider the financial or economic consequences of your career decisions is short-sighted.”

I had a wonderful experience in medical school at Case Western in Cleveland and wouldn't trade it for anything. I was taught by the best, had access to amazing faculty, unparalleled opportunities, and was able to work/learn along side the most wonderful and brightest people. Yet looking back, I do wonder if the debt was worth it. Over $200,000 in medical education debt, to which I have not made a dent being on a trainee's salary for the last 5+ years. In order to keep up with the interest rates and even touch the principal, I would have to make payments of more than ~$1,500-$2,000 per month in after-tax dollars... on an average pre-tax salary of ~$55,000-$65,000 per year. The math just doesn't add up. This also means I haven't been able to save for retirement (and thus have lost out on a decade of compounding interest growth), create a safety-net fund, save for a house, plan for future child expenses... all those things that one should really begin in their late 20's and early 30's. 

My mentors and faculty would say that you should choose a field solely based on interests, while ignoring the potential reimbursements as a specialist. This is foolish. To not consider the financial or economic consequences of your career decisions is short-sighted. It makes little financial sense to not be a specialist with potential for higher reimbursement when you have so much accumulated debt. And I wonder if this factored into my class' residency decisions, where a significant number chose specialties like radiology, orthopedics, etc. Even among those that chose internal medicine or pediatrics, anecdotally, it seems most continued to further specialize. I wonder how finances/economics played into our decision-making, even on a subconscious level. 

“A lower medical education cost gives you the freedom to truly make the decision based on your passion. ”

Healthcare Implications: By reducing the debt burden, more people will consider going into medicine in the first place. It removes a significant financial barrier in order to attract the brightest students, regardless of their ability to pay. This benefits everyone. More trainees may also consider primary care, which could certainly use more physicians. In the long-term, a stronger primary care force would help maintain a healthier population and reduce overall costs.  

“If you work hard and score well on standardized testing, you will still likely get the residency you want, regardless of how much tuition you paid.”

Student Implications: Students have a tough decision to make when it comes to where to go and what field to choose. I would argue that it's better to go to an institution that you feel is a good fit AND has the lowest costs. Accrediting organizations like the LCME, AAMC, and AOA have stringent requirements, so most medical schools are pretty good. If you work hard and score well on standardized testing, you will still likely get the residency you want, regardless of how much tuition you paid. A lower medical education cost gives you the freedom to truly make the decision based on your passion.

There's little I would change about my journey as that is what led me to this moment. It's important to remember: Fulfillment in medicine comes not from the remuneration, but instead the intellectual challenge and gratification of helping another human being. If you're solely interested in money, perhaps a career in finance or starting a business is better. But this debt is a real burden. Physicians are certainly well compensated once they finish all their training, but these salaries are deceiving when you take into account the opportunity costs, length of education, shortened careers, lack of retirement investments, and lack of general savings. Previous generations of physicians may have done extremely well financially, but the economic reality today is much different.

Medical education benefits greatly from reduced physician debt burdens. Students can focus on learning and practicing medicine, instead of worrying about crushing debt. The brightest, most talented students may also be more likely to consider academic careers, where reimbursements are lower. Having happier, financially secure physicians to teach and lead future generations of physicians creates a positive cycle that benefits not only future students, but also patients. 

Kudos to the likes of Cleveland Clinic, NYU, and the few other medical schools that have found a way to reduce this burden on their students! It's a HUGE upfront cost, but an investment that will lead to more competitive and diverse applicants, happier trainees, less burdened physicians, and ultimately better healthcare for everyone.

View fullsize

Beyond Burnout and the Business of Medicine

This week in JAMA, Dr. Catherine Humikowski penned a wonderful article about physician burnout that I think is worth a read. Over the last few years, we've started to see research and personal exposés on physician burnout. We have seen in the news the tragic stories of suicides across all levels of training, from medical school to late career physicians. In response to these events, there have been more resources, usually in terms of counseling, available to trainees. There has also been a greater acknowledgement that mental health is critical to a physician's well-being, and therefore by extension, our patients' well-being. However, this hardly seems enough as we continue to hear what our colleagues and current trainees face.

We choose a medical career not because of a business decision, but rather we hope to make a difference in others' lives. We are, and hope to continue to be, intrigued by the science, restored by the humanity, enlightened and entertained by our patients, challenged in every aspect, and driven to perfection. Yet we cannot escape the reality that the system is broken. Bureaucracy and administrative requirements dictate our practice, and profits have become the underlying driver of the field. 

“Medicine could stand to drop the attitude that we are somehow immune to the same basic physiology we have devoted our lives to understand.”

— Catherine Humikowski, MD

One great point that Dr. Humikowski highlights is that, "Burnout infers insufficient energy from within, as if one's spiritual well were too shallow, or constitution too weak." Like most residents now, I sat through a lecture in my residency every year on burnout. The conclusion was that we need to be more resilient, that indeed the fault lies within us for these overwhelming feelings. It fails to acknowledge the systemic or institutional issues that drive physicians to burnout. Just as Dr. Humikowski discussed in her article, we too were lectured on the importance of self-care, yet we face the reality of actual institutional policies contradicting this very notion. I recall in my own residency the challenges and fear I had to request a few hours off to see a doctor or dentist for my own health. How many residents out there encounter this kind of anxiety? Do training programs have actual defined policies in place? As residents, we genuinely strive to provide the best care we can to best of our abilities, often to the detriment of our own health. Dr. Humikowski mentions, "If any industry should care for the caretaker, it's ours. But we have not done it well." I, and countless other physicians who leave the profession for other fields, couldn't agree more.

There is no simple solution to physician burnout, but progress needs to be made, and large healthcare institutions that train and hire physicians have an opportunity to be at the forefront. Taking cues from other large corporations that have improved productivity and employee satisfaction, residency programs and large hospitals can offer (as Dr. Humikowski mentions) paid sick leave, child care, and maternity/paternity leave. In addition, they should also provide great and affordable health insurance coverage (I've trained/worked at literally the best institutions in the country, that provided the worst, most complex health insurance), a competitive 401K (to help make up for a decade of lost earnings), and student loan relief (the average physician graduates with over $190K of debt). Although capped at 80-hour work-weeks due to ACGME requirements, the reality is that many residents continue to approach nearly 100-hour work-weeks. How about offering pay commensurate to hours worked?

It's important to acknowledge that medicine is a business. On the business side, this means more costs and lower short term profits, which is why there will be a reluctance to make substantial change. Instead, trainees and physicians will likely be offered more online modules, counseling, and seminars because talk is cheap. Real progress requires a strong will and upfront capital investments. Yet these investments will pay off in the long-term as more people choose the profession, become more productive, and opt to stay in it for as long as possible. I would anticipate with some common sense changes, burnout would be less. For substantial changes to be made, trainees and physicians need to understand how business decisions drive medicine.

At the end of the day, Dr. Humikowski says it best, "Medicine could stand to drop the attitude that we are somehow immune to the same basic physiology we have devoted our lives to understand. We must cultivate balance around us and among us, not just within us."

ASOPRS SPRING 2018 Meeting (Part II)

Not only did I give a talk on surgical complications, I presented some original research to a crowd of the brightest, most talented oculofacial and orbit surgeons in the world. It was such a blast having this presentation accepted to this great meeting in Austin, TX!

My research here looked at very severe cases of orbital cellulitis caused by a specific group of bacteria that generally live in body anyways. These bacteria, Group F Streptococcus, are notorious for causing very bad abscesses in the head, face, and neck. My research showed that there are some signs on CT scans that could suggest an infection by this terrible bacteria. If this is seen, physicians should consider moving fast and maybe even take the patient to surgery very quickly to prevent some very bad complications. Fortunately, we found that if physicians act fast and treat appropriately, the outcomes are good, vision is saved, and most patients get better.

Stay tuned for the final paper......