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What Do Fake News, Healthcare And Plastic Surgery Have In Common?

Sen. Ted Cruz (R-Texas) and Sen. Bernie Sanders (I-Vt.) met on CNN on Feb. 7 to debate the future of health care in the United States. Some plastic surgeons watching the debate felt that Sen. Sanders mischaracterized the specialty when he brought up the cost of medical school and the shortage of primary care physicians.

During the debate, Sanders stated: “We need tens of thousands more doctors in this country. We have a major crisis in primary care. There are areas in urban America and in rural America where people literally can’t find a doctor to serve their needs. And one of the reasons – there are a number of reasons for that – one of them is, you go to medical school, you can come out hundreds of thousands of dollars in debt. And then you’re going to become a plastic surgeon, not doing primary care in an urban area or rural America.

The segment occurs at roughly the 1:13 mark of the debate video.

ASPS President Debra Johnson, MD, sent the following letter to Sen. Sanders’ office on behalf of all board-certified plastic surgeons. The goal of this response is to educate the lawmaker about the true depth and breadth of the specialty – and perhaps open the door to further discussions about plastic surgery’s vital role in the health-care system.


The Honorable Bernie S Sanders
332 Dirksen Office Building
United States Senate
Washington, DC 20510

Dear Senator Sanders,

As president of the American Society of Plastic Surgeons, I represent more than 7,000 board-certified plastic and reconstructive surgeons in the United States.

I thank you for your recent debate with Senator Ted Cruz regarding the fate of Obamacare and the future of American medicine.

Some of my members were offended by your remarks regarding plastic surgery. You were stressing the need for more primary care physicians, and bemoaning the fact that because medical school is so expensive, recent graduates refuse to enter primary care and instead choose “to become plastic surgeons.”

You may be stereotyping plastic surgeons as cosmetic “nip/tuck” doctors who cater to the wealthy. While some of my members do have practices that are cosmetic and lucrative, the vast majority of plastic surgeons are providing both aesthetic and reconstructive services in our communities.

We are the doctors called when a dog bites your child, when your brother-in-law accidently sticks his hand in the lawnmower, when your wife gets breast cancer and wants to consider her reconstructive options. We have been at the forefront of helping our wounded warriors reintegrate into society, by making their damaged limbs more functional, their faces more recognizable, their scars of war less noticeable.

Plastic surgeons have been and will continue to be incredible innovators in medicine, beginning with kidney transplantation (first performed by Nobel Laureate Plastic Surgeon Joseph Murray) and now moving into face and hand transplantation. Within our regenerative medicine laboratories, we are trying to grow whole body parts from stem cells, such that children born without an ear can be reconstructed more easily and effectively. We are working to solve the riddle of aging, to try and keep our human bodies healthy and viable as long as possible.

I firmly agree with you that healthcare is a right and not a privilege. A majority of my members believe in universal healthcare. I served in the National Health Service Corps, providing primary care to Native Americans, and I believe that medical school should be free in exchange for graduates providing primary care in underserved communities. Like many of my members, I volunteer free reconstructive surgery around the world, as it is an obligation to “pay it forward” for the privilege of having such a fabulous vocation.

Because I take care of some cash-paying cosmetic surgery patients, I can afford to continue operating on a three-month old infant with a cleft lip, doing my best to give her a result that she can carry without shame for the rest of her life. I do this despite the fact that I am rewarded only $210 by MediCal for this service. It is a sad state of affairs that despite spending twice as much on healthcare in this country, the vast majority is not spent on physician services. Burdensome regulation, overpricing by Pharma, one-time use waste in our hospitals, inappropriate overutilization of testing and imaging, as well as the for-profit health insurance system are all areas that should be evaluated for improved cost-effectiveness.

Members of the American Society of Plastic Surgeons are proud to serve as aesthetic and reconstructive surgeons. We are proud of the creativity and innovation we have brought to medical care. We hope to partner with you in the task of improving American medicine, and we would like to start that partnership through a conversation. If you would be willing to sit down and meet with leaders from the American Society of Plastic Surgeons, we will gladly come discuss the best path forward for American health care.

Thank you for shining a bright light on this issue.


Debra J. Johnson, MD FACS
President, American Society of Plastic Surgeons
Past-president, California Society of Plastic Surgeons
Director, American Board of Plastic Surgery
Clinical Professor of Plastic Surgery, UC Davis School of Medicine
Director, Sutter Cleft Lip, Palate, and Craniofacial Anomalies Panel


Round or Shaped Breast Implants?

During a typical consultation with a patient interested in breast augmentation, I discuss options including incision placement, pocket placement, and, of course, implant options.  Implant options include silicone versus saline, low, moderate versus high profile,  smooth versus textured surface, and round versus anatomic shape.  Women frequently are under the assumption that an anatomic shaped implant is better than a round implant, but is this actually true?  It has always been my experience and thus, my opinion, that if a prospective augmentation patient has at least some shape to her own breasts, that she merely needs enhancement of that shape, and therefore she can get a good result with a round implant.  And now I have a study that corroborates my experience. The following is hot off the press from my Plastic Surgery  specialty society’s recognized journal:

Round or ‘Shaped’ Breast Implants? Even Plastic Surgeons Can’t Tell the Difference

Looking at before-and-after photos, plastic surgeons and plastic surgical nurses can’t tell whether breast augmentation surgery was done using conventional round implants or newer anatomically shaped implants, reports a study in the January issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

At least in the specific group of patients studied, the results of breast augmentation using round versus shaped implants are indistinguishable, according to the new research, led by Dr. Carlos Rubi of The IMED Hospital Department of Plastic Surgery, Valencia, Spain. The results suggest that routine use of increasingly popular “teardrop-shaped” implants is not justified.

No Visible Difference in Results between Implant Types in Before-and-After Photos

In the study, 30 plastic surgeons and plastic surgery nurses reviewed preoperative and postoperative photos of 30 women who had undergone breast augmentation with round or anatomically shaped implants—15 patients in each group. The two groups were otherwise similar: all procedures were done using silicone implants, placed under the muscle (subpectoral), with an average implant size of about 300 cc.

For each set of photos, the surgeons and nurses judged whether the procedure was done using round or shaped implants. The goal was to determine if the aesthetic results of round versus shaped implants could be differentiated from each other.

For all observations, there was about a 50-50 chance that the surgeons and nurses could correctly identify the type of implant used. There was a lack of agreement not only between different raters, but also for individual raters comparing the same images several weeks later.

Plastic surgeons performed slightly better than nurses in identifying the type of implant—possibly because they could deduce which type would likely be recommended, based on the “before” photos.

Introduced recently, teardrop-shaped implants have become increasingly popular for breast augmentation surgery. “A widespread idea is that the anatomically shaped implants give more natural results than the round implants,” Dr. Rubi and coauthors write.

But the new study shows that even plastic surgeons and plastic surgery nurses cannot tell the difference between the final outcomes of breast augmentation with round versus shaped implants, in a group of patients with otherwise similar characteristics. The results add to a previous study that showed similar outcomes with the two implant types used for breast reconstruction.

The inability to tell the difference between implant types for breast augmentation questions the preference for shaped implants—especially since they cost more and carry a risk of complications related to implant rotation, compared to round implants. “The systematic use of anatomically shaped implants is not justified,” Dr. Rubi comments. “Natural results are achieved with both types of implants.”


KYBELLA® Now Available In Our Office!

KYBELLA® is the first and only injectable drug approved by the FDA (in 2015) “for the treatment of moderate to severe convexity or fullness associated with submental fat in adults”.  In lay terms, this drug improves the appearance and profile of moderate to severe fat below the chin, or “the double chin”.  KYBELLA® is deoxycholic acid (DOCA), a cytolytic drug, which, when injected into the tissue,  physically destroys the cell membrane causing lysis, i.e., permanent death to the fat cell so it can no longer store or accumulate fat, regardless if the origin of fat is genetic, weight gain or aging.

This is an office procedure involving multiple injections with a very tiny needle into the fatty area below the chin.  A topical anesthetic is applied beforehand for comfort.  Afterwards, an ice pack is placed to reduce swelling.  While normal activities may be resumed, because of the likelihood of swelling, social downtime for a few days is recommended.  The average treatment uses 2 to 4 vials, and the average patient requires 2-4 treatments at monthly intervals.  Once the result is achieved, further treatment is not necessary. This is a non-surgical alternative to liposuction in this area of the body!

The most common adverse reactions (>20%) include injection site edema/swelling, bruising/hematoma, pain, numbness, erythema/redness and induration/firmness.  Edema/swelling was reported as mild in 79.5%, moderate in 19%, and severe in 1.5%.  Ice packs, head elevation and time resolve this reaction.  Risks include frequent bruising/hematoma reported in 72%.  Marginal mandibular nerve injury resulting in an asymmetric smile was reported in 4%; spontaneous resolution occurred in a range of 1-298 days, median 44 days.  Dysphagia (difficulty swallowing) was reported in 2%; spontaneous resolution occurred in a range of 1-81 days, median 3 days.

Deoxycholic acid (DOCA) is a naturally occurring molecule in the body that aids in the breakdown and absorption of dietary fat.  Endogenous DOCA (that which normally circulates in the body) is a product of cholesterol metabolism and is excreted intact in the feces.  DOCA from KYBELLA® joins the endogenous bile acid pool in the liver circulation and is excreted along with the endogenous DOCA.

Before and after photos can be viewed at .

Castle Connolly’s “Top Docs” 2016 Recognition

Once again, I am honored to be selected as Castle Connolly’s “Top Doctors” in Plastic Surgery for 2016, as published in the Gulfstream Media Group’s publications (Jupiter Magazine, The Palm Beacher). Castle Connolly Medical Ltd. is a health care research and information company recognized for their established survey and research process.  Their team of researchers follow a rigorous screening process of doctors’ educational and professional experience to make selections.  Doctors do not and cannot pay to be selected and profiled as “Top Doctors”. This is my seventh consecutive year for this selection and I am humbled to be recognized. My goal has always been to provide exceptional, individualized care to improve the health and well being of my patients, both reconstructive and cosmetic.

Radiesse First Filler FDA Approved For Hands

       RADIESSE® is the first and only dermal filler approved by the FDA for correction of volume loss in the aging hands. Our office is pleased to be one of the first in the Palm Beach County area to offer RADIESSE® for hand rejuvenation. RADIESSE® provides an immediate volumizing effect and can help to reduce the prominence of tendons and veins in the hands, delivering smooth, natural-looking results that can last up to 1 year.  Treating the hands with RADIESSE® is a quick in-office procedure that can usually be completed in 30 minutes.
       In recent years, I’ve seen an increase in the number of patients who are seeking aesthetic treatments for their hands. The hands don’t lie- so even after providing a more youthful appearance of the face, a patient’s age can easily be given away by the appearance of his/her hands.  RADIESSE® allows me to restore the volume in the back of the hands, enhancing the appearance and the filler also provides the opportunity to treat both their hands and their face. With RADIESSE® for hands, I am able to provide an FDA-approved treatment for patients in my practice who are ready for this next step in their aesthetic regimen.
       In a randomized, controlled US trial, blinded evaluators reported that RADIESSE® improved the appearance of both hands in 75% of treated patients at 3 months. Importantly, 98% of treated patients also reported improvement in the appearance of their hands at 3 months. Improved aesthetic outcomes as measured on the Global Aesthetic Improvement Scale (GAIS) after initial and repeat treatments correlating with clinical improvement were demonstrated in this study, with all primary and secondary endpoints being met. Most adverse events were injection site reactions such as swelling, redness, pain and bruising, which were usually mild to moderate, short in duration (lasting about 1 week), and required no treatment. No severe device-related adverse events were reported that required treatment.

Plastic Surgery Medical Tourism

Plastic Surgery medical tourism is becoming more frequent.  In South Florida, I  hear of patients going to Costa Rico or other places outside of the United States for “cheaper” procedures.  Unfortunately, not infrequently, this can result in complications with which the patients find themselves facing the dilemma: who will treat the complication?  Typically, it is the local plastic surgeons who take on that responsibility, but not without cost to the patients.  I assume most Plastic Surgeons have a policy similar to mine, i.e., in the unlikely event that a post operative complication requires treatment, or when a result deemed unsatisfactory by both the patient and surgeon requires revision, surgical fees (not facility or anesthesia) are waived.  Patients who have their plastic surgery performed out of the country don’t benefit from this professional commitment to exceptional individualized care by their foreign surgeons.  The link below is an interesting example of Plastic Surgery medical tourism gone wrong in China.  Once again, the lesson learned is “cheaper is not always better“… or in other words, “you get what you pay for”.

“Top Doctors” Recognition By Castle Connolly!

Once again, I am honored to be selected as Castle Connolly’s “Top Doctors” in Plastic Surgery for 2015, as published in the Gulfstream Media Group’s publications (Gold Coast Magazine, Jupiter Magazine, The Palm Beacher, Boca Life Magazine). Castle Connolly Medical Ltd. is a health care research and information company recognized for their established survey and research process.  Their team of researchers follow a rigorous screening process of doctors’ educational and professional experience to make selections.  Doctors do not and cannot pay to be selected and profiled as “Top Doctors”. This is my sixth consecutive year for this selection and I am humbled to be recognized. My goal has always been to provide exceptional, individualized care to improve the health and well being of my patients, both reconstructive and cosmetic.

Lifestyle Lift No Longer Lighting Up Your Life……. Or Your Face

Nationwide cosmetic surgery chain Lifestyle Lift apparently has closed at least 40% of its clinics and may file for bankruptcy.  The corporation treats plastic surgery more like a commodity…the model is based on selling trademarked cosmetic procedures to physicians in return for patient referrals, marketing, and training.  They claim to offer less invasive, cheaper facelifts and a shorter recovery. “Real” Plastic Surgeons do similar procedures, but call them “mini-facelifts”.  Because “real” plastic surgeons have extensive training, their results are usually better with less scarring and longer lasting. This is just another example that “Cheaper is not always better!” See more information on the following links:

From Plastic Surgery SmartBrief (03/10/15):  Fast Face-Lift Firm Closes Clinics

Nationwide cosmetic surgery chain Lifestyle Lift has shuttered clinics and might file for bankruptcy. Office staff at a North Carolina clinic that closed said they are working for free to ensure patients get necessary follow-up care. WCNC-TV (Charlotte, N.C.) (3/5), WWSB-TV (Sarasota, Fla.) (3/6)




Cheaper Is Not Always Better!

If you think the cost of good Plastic Surgery is expensive, consider the cost of bad Plastic Surgery! This woman who was interested in enlarging her breasts opted against traditional breast augmentation surgery for a cheaper procedure….she choose silicone injections.  Cheap ended up costing the woman her breasts.  The old saying, “You get what you pay for” still rings true! Click on the following link for the story

Memorial Day Weekend…Honor Those Who Gave Their Lives For Our Freedom

Memorial Day Weekend is considered by many to be the kickoff to Summer. Before we start the celebrations, backyard barbecues and beach side picnics, I have 2 serious points to consider. One, let us remember to honor those who died to preserve our freedom. And the second, choose the right sunscreen.

Summer is right around the corner. And while you should use sunscreen every day of the year, it’s even more important during summertime, when the days are longer, the sun is stronger, and it’s easier to spend more time outdoors. When choosing sunscreen, be sure to read the label before you buy. US Food and Drug Administration regulations that went into effect in 2012 require the labels to follow certain guidelines. The guide below can help you understand the terminology.

Choose a sunscreen with “broad spectrum” protection. Sunscreens with this label protect against both UVA and UVB rays. All sunscreen products protect against UVB rays, which are the main cause of sunburn. But UVA rays also contribute to skin cancer and premature aging. Only products that pass a test can be labeled “broad spectrum.” Products that aren’t broad spectrum must carry a warning that they only protect against sunburn, not skin cancer or skin aging.
Make sure your sunscreen has a sun protection factor (SPF) 30 or higher. The SPF number is the level of protection the sunscreen provides against UVB rays. Higher SPF numbers do mean more protection, but the higher you go, the smaller the difference becomes. SPF 15 sunscreens filter out about 93% of UVB rays, while SPF 30 sunscreens filter out about 97%, SPF 50 sunscreens about 98%, and SPF 100 about 99%. No sunscreen protects you completely. The FDA requires any sunscreen with SPF below 15 to carry a warning that it only protects against sunburn, not skin cancer or skin aging.
“Water resistant” does not mean “waterproof.” No sunscreens are waterproof or “sweatproof,” and manufacturers are no longer allowed to claim that they are. If a product’s front label makes claims of being water resistant, it must specify whether it lasts for 40 minutes or 80 minutes while swimming or sweating. For best results, reapply sunscreen at least every 2 hours and even more often if you are swimming or sweating. Sunscreen usually rubs off when you towel yourself dry, so you will need to put more on.

Other ways to stay sun-safe

In addition to choosing the right sunscreen and using it correctly, follow these steps to help protect your skin from sun damage that can cause premature aging and skin cancer:

Cover up. When you are out in the sun, wear clothing and a wide-brimmed hat to protect as much skin as possible. Protect your eyes with sunglasses that block at least 99 percent of UV light.
Seek shade. Limit your direct exposure to the sun, especially between the hours of 10 a.m. and 4 p.m., when UV rays are strongest.
Avoid tanning beds and sunlamps. Both can cause serious long-term skin damage and contribute to skin cancer.