Tuesday, February 28, 2012

The Issues About General Anesthesia Sedation versus Local Anesthesia

Falls in Argentina photo by Dr. Robert Yoho


 We have many times emphasized in our information on our website and to our patients that we think that the light sedation that we use, which does leave the patient without any memory of the procedure, is by far the best way to go. Confusion arises with this because using pure local anesthetic the way a lot of people do, including the rapid facelift and the weekend facelift surgeons, often leaves the patients terrified and there is some pain involved. Our anesthetic, on the other hand, leaves the perception of general anesthetic, with no memory of the procedure in 99.9% of the cases, and we feel the risks are minimized and the discomfort is also minimized. Very little post anesthetic reaction occurs, with the chance of nausea, vomiting, and other bad feelings from the anesthetic being minimized.

General anesthetic is used by many well-meaning and well-trained surgeons who just haven’t found out just how to achieve good sedation without using all those heavy drugs. General sedation also requires an anesthesiologist to put the tube in the throat, and the attendant risks of general anesthesia. These surgeons generally have been trained in a hospital and are used to doing things just one way. They don’t understand and haven’t taken responsibility for the anesthesia care of their patients.

Dr. Yoho, on the other hand, as a Board-certified emergency room physician, is confident about his ability to manage patients who are sedated and his ability to give them a comfortable experience. This has been well-established after tens of thousands of cases of experience. Dr. Yoho gets as many cases as a lot of anesthesiologists get each year. We do use local anesthetic if the patient requests it as a sole or single agent for the pain relief, but we don’t usually recommend it. We recommend at least a touch of relaxation medicine and more likely our version of the single medication sedation technique that we advocate, have perfected, and have published articles in medical literature about. You can read more at DrYoho.com. You can read Dr. Yoho’s original article about this technique, which has been adopted by many surgeons across the country.

An additional advantage of your anesthesia at Dr. Yoho’s office is that you save money. Not only are the medications much less expensive than medications used for general anesthetic, but the extra expense of an anesthesiologist is avoided. Instead of an anesthesiologist, we have a fully licensed physician’s assistant who is competent to administer this medication and has been doing it for many thousands of cases. Dr. Yoho is also involved and we watch you very carefully with the standard monitoring technique that’s used in a surgery. The very cheapest of these medications, which are the Morphine/Demerol class drugs, are not used, and our technique does cost us a little more than this, but it’s much cheaper to make you comfortable using these modern medications than it is to have the anesthesiologist use a gas anesthesia or the many different drugs that are typically administered in general anesthesia.

Wednesday, February 22, 2012

All About The Total Makeover

Robert Yoho, MD playing with his daughter

Generally, facial procedures are done “all in one.” In other words, facelifts, eyelids, cheek implants, chin implants, noses, and laser resurfacing are often performed at the same time. This has been the traditional approach and is felt to be reasonable by the medical community. 

 However, the “total body makeover” where all this facial work is done and then breasts and liposuction are all performed together we think represents an extreme risk. One of the problems with this involves anesthesia time, which increases the problems with blood clotting and other medical issues related to the anesthesia. Surgeries over a couple of hours to us seem relatively unreasonable, although sometimes our facial surgery or breast lift will extend three hours or a little more.

So beware of the “total makeover.” We think that it’s easier for you and makes more sense to approach these things stepwise, thus getting to know the quality of your surgeon and the quality of the results bit by bit.

Tuesday, February 14, 2012

Am I A Surgical Candidate?

Dr. Yoho and friends in Argentina.

You are a surgical candidate if a number of things come together. First of all, you have to be psychologically ready for a surgery. Sometimes these things are stressful and sometimes they’re not, but you have to be willing to undergo the stresses of the possible complications for any of these given surgeries, however unlikely they are. Most cosmetic surgeries are comfortable and their post-operative recovery for most people is very modest, however. 

Second, you need to have good physical characteristics for the surgery that you desire. The doctor will help you understand just what kind of result you are likely to expect. For example, a woman with medium-sized breasts and a lot of breast tissue can get spectacular results with breast implants in most cases. A woman with long, skinny breasts sometimes needs reconstructive surgery and some of these surgeries come out better than others. Liposuction works very well for people with a lot of fat just under the skin surface, but doesn’t work at all for people with fat underneath the muscle wall. 

Of course, you need to be able to afford the procedure, and you need to be able to take the time off. If you are too busy to take the time off, many of the noninvasive procedures we do can, over time, make improvements that are as significant or nearly as significant as the invasive procedures. For example, our fractionated laser repeated several times can produce a fantastic result, and if you stay out of the sun and use Fallene sunscreen from drugstore.com (for example) and Retin-A over a year or two, you can get a fantastic result that rids you of wrinkles and really in many ways is as good as the invasive procedure which requires the two-week recovery and the possibility of more complications. 

Fillers can approximate a facelift for the right individual, replacing the fat and restoring the contours and form of the aging face to a younger contour, and when performed in conjunction with Botox and the resurfacing modalities, can be spectacular indeed. But the noninvasive procedures, remember, can be easily as expensive as the invasive procedures and require coming back to the office a lot.


Friday, February 10, 2012

The Insanity of the Modern Tummy Tuck

Trinidad beach scene-by Dr. Yoho. Nothing to do with tummy tucks.
I am concerned about the fact that the Los Angeles tummy tuck has become synonymous with plastic and cosmetic surgery in some contexts. The fact is that this operation is not indicated in most cases. A tummy tuck or abdominoplasty is a major surgery which has a fatality rate of one in 3,000, according to the best medical literature we have. Older studies had a fatality or death rate of one in 625 surgeries. The patient is cut all the way from hip to hip. The fat and skin is separated from the muscle. The muscle is usually tightened, and a large portion of skin and excess fat is removed and then the patient endures a recovery which can last for many months.

Modern liposuction can accomplish many of these goals and for most patients it is the preferred alternative, even for very overweight patients. Recovery from liposuction is very modest compared to a tummy tuck. The death rate for liposuction may be as low as one in 50,000. Although after a liposuction with a large patient, some saggy irregular skin is to be expected, the skin shrinks to a much greater degree than most people would expect. It’s not like cutting and pasting a paper bag. The skin is the magic organ of the body, and just like after a pregnancy, after a liposuction the skin shrinks a great deal. Particularly helpful in this regard is the irritation that is produced by the liposuction process itself. This irritation or injury process accelerates and helps the shrinkage of the skin.

Nothing is perfect. Liposuction can produce irregularities, and just like abdominoplasty, major complications can occur. However, let the reader imagine the number of hospitalizations, major blood losses, and blood clots to the lungs and legs that occur with tummy tucks versus liposuction. It’s a ratio of ten to one or greater with the much safer procedure being liposuction.

Large-volume liposuction, or removal of more than five liters of fat, has become a standard and much safer procedure for the modern surgeon and the contemporary patient. We believe that this can be accomplished safely and efficiently in our hands, using our techniques, with a very modest risk. These surgeries result in very gratifying results, and if extra skin remains after the procedure and the patient is willing to have a secondary touch-up procedure, this can be removed much more easily than when the patient presents with all the fat to begin with. In other words, a second relatively inexpensive surgery can make a result with a smaller scar and less risk of major problems after a liposuction than trying to do it all at once. Particularly risky is the practice of doing a large liposuction and cutting skin out at the same time. This procedure can result in areas of skin death or problems of other kinds, including infection or sometimes other problems.

My firm belief is that liposuction under general anesthesia, particularly large-volume liposuction under general anesthesia, is connected with a much higher risk. My technique involves sedation and local anesthetic combined with two operating professionals who remove the fat rapidly and expose the patient to a much shorter operating time and less medication.

So if your surgeon recommends a tummy tuck, shop this around and be sure this is what you want. Look at pictures online and see Los Angeles cosmetic surgery website in particular to see if there is another part to this story that you haven’t heard.

 Be careful out there.

______________________


Robert Yoho, M.D.


Saturday, February 4, 2012

Fat Transplant Problems and Opportunities

Fat transplant has become an increasing trend in the last few years. Transplantations can be performed on various areas, including to buttocks, face, and breast. Buttocks fat transplant is done in Dr. Yoho’s office almost every week. We’ve had experience that may extend to a thousand patients. We have seen very few complications with it because the fat is sterile. It’s kept sterile through the use of enclosed containers and is transplanted almost immediately back into the patient’s own tissues. However, when the volume of fat is increased to large quantities, the risks of problems become higher and higher because the buttocks’ blood vessels and supporting structure can only take so much of the new material before areas of fat become isolated and susceptible to infection. We have seen this in several cases where very large quantities of fat were used. The result is a prolonged recovery and an unhappy patient, intravenous antibiotics and procedures to wash whatever fat we can out of the buttocks. For this reason, we’ve limited our volume to a sensible amount and don’t claim to produce very full buttocks with one procedure. That said, repeat procedures can be done and improvement is progressive.

Facial fat transplant, of course, has been of great interest to the cosmetic surgeon for at least 15 years. Transplant of tiny amounts of fat to the cheek areas around the brow, the lips and chin, and even the muscles of the jaw produce very pleasing results if done carefully and by an experienced surgeon. It’s a bit tedious, but the tiny amounts of fat transplanted make for very smooth results. The problem here is that in the case of massive weight gain later, sometimes the patient ends up with a very fat face. This fat transplant to the face, if done properly, is permanent or at least very, very long-lasting. The general rule of thumb is that what you see is what you get after about three to four months.

Breast fat transplant is a very different kind of procedure. We do perform breast fat transplant and have experience with hundreds of cases, but it basically doesn’t work in breasts that are very, very small, because the breast can’t support and give nutrition to the new fat if there’s not much breast to begin with. For larger breasts, breast fat transplant is successful and can make them even larger. The most important point for the potential patient is to understand that they’ll never get an increase in size anything like a breast implant. However, if this is successful, breast fat transplant produces natural results and rarely any mammogram changes. The fear of the mammogram changes looking like breast cancer is generally misplaced, although I suppose it’s possible. The mammogram changes that show breast cancer are relatively characteristic of breast cancer, and any breast surgery can produce calcification and scarring that is visible on a mammogram that doesn’t look like breast cancer. That said, the small possibility of a biopsy for breast fat transplant in the future mistaken for breast cancer must be factored in by the potential patient. We’ve actually never seen, in our practice, abnormal mammograms after breast fat transplant. They always seem to come back “interval increase in breast size with no apparent other change.” 

In any case, there are risks and the patient should be aware of it all before fat transplant. This article isn’t complete and you need to speak with Dr. Yoho about your specific situation and he can tell you what to expect and what the potential problems are for your case and your body type. Please visit Dr. Yoho's main website for more information on many types of cosmetic procedures. Here, you can also find contact information to make an appointment for your complimentary consultation.