In the operating room with Dr. Gustavo Gaspar Blanco


Dr. Gustavo Gaspar, plastic surgeon

Dr. Gustavo Gaspar, plastic surgeon

In the operating room with Dr. Gustavo Gaspar Blanco

Hospital de la Familia,

Mexicali, B.C.

Mexico

After interviewing Dr. Gaspar, he graciously invited me to join him in the operating room as an observer for several cases during the week.

Hospital de la Familia

As reviewed in the Mexicali! mini-guide to medical tourism, Hospital de la Familia is widely acknowledged as “the second best hospital in Mexicali.”  Much like the Hertz automobile rental campaign “We try harder,” the directors of Hospital de la Familia have embarked on an aggressive publicity campaign to attract patients and physicians to their facility.  This includes medical tourism – as Hospital de la Familia has partnerships with multiple brokers including PlacidWay and Planet Hospital.

Dr. Gaspar exclusively operates at Hospital de la Familia.

In the ORs at Hospital de la Familia

OR #3 is the plastic surgery suite.  It is spacious and well-lit with modern and functional equipment.  Along with a designated OR, Dr. Gaspar has an operating room team consisting of an anesthesiologist, an assistant surgeon, scrub nurse and circulating nurse.

Dr. Gaspar and his OR team

Dr. Gaspar and his OR team

Anesthesia is managed by Dr. Armando Gonzalez Alvarez.  He monitors the patient with due diligence and remains in attendance at all times.  He avoids distractions during surgery (like texting or excessive cell phone use) and remains patient-focused.

Dr. Gonzalez Alvarez, Anesthesiologist

Dr. Gonzalez Alvarez, Anesthesiologist

Dr. Binicio Leon Cruz, is a general surgeon who serves as Dr. Gaspar’s assistant surgeon during the case.  Monica Petrix Bustamante is the instrumentadora (scrub nurse), and she is excellent, as always*. She knows the surgeries, easily anticipates the doctors’ needs while maintaining surgical sterility and ensuring patient safety.

Monica prepares a prosthesis for implantation

Monica prepares a prosthesis for implantation

Adherence to international protocols

The majority of procedures are under an hour in length, which means that patients do not need deep vein prophylaxis during surgery.  The procedure (including site) and patient identity are confirmed prior to surgery with active patient participation before the patient receives anesthesia with both surgeons, nursing staff and the anesthesiologist in attendance.  Patients are then prepped and draped in sterile fashion, with care taken to prevent patient injury.

As with many plastic surgeons, Dr. Gaspar does not administer IV antibiotics for infection prophylaxis prior to the first incision.  Instead, all patients receive a course of oral antibiotics after surgery***.

Surgical sterility is maintained throughout surgery.  For the first case, after receiving adequate tissue preparation, since only limited liposuction is needed (for very specific sculpting), the patient receives manual liposuction (without suction) to prevent overcorrection or excess fat removal.  Despite having significant adhesions due to previous liposuction procedures, there is very minimal bleeding during the procedure.

Following the procedure, the patient is awakened, extubated and transferred to the recovery room for hemodynamic monitoring and adequate recovery prior to discharge.

Throughout the case, (and during all subsequent checks in the PACU), the patient is hemodynamically stable, and maintains excellent oxygenation.

The second case, is a breast augmentation revision – in a patient with a previous breast reconstruction after mastectomy for breast cancer.  The patient developed a capsular contracture which required surgical revision**.

Abdominoplasty

On a separate occasion, Dr. Gustavo Gaspar performed an abdominoplasty with minor liposuction of the “saddle bag” area at the top of the thighs.  For the abdominoplasty case, the patient received conscious sedation with spinal anesthesia.

While an abdominoplasty, “tummy tuck” is a much larger procedure, the case proceeded quickly (1 hour 15 minutes), and uneventfully.  There was very minimal bleeding, and excellent cosmetic results.

skin, and adipose tissue removed during abdominoplasty.

skin, and adipose tissue removed during an abdominoplasty

Gluteal augmentation (Gluteoplasty)

However, it was the gluteal augmentation case that attracted the most interest.  As mentioned during a previous interview, Dr. Gaspar is well-known throughout Mexico for his gluteal implantation technique.

Pre-surgical planning

Pre-surgical planning

Due to the proximity to the anus, and potential for wound infection and contamination, the area is prepped in a multi-step process, in addition to the standard surgical scrub.  A Xoban (iodine impregnated dressing) is applied to the area to prevent bacterial migration to the area around the incision.

For this procedure, Dr. Gaspar uses gluteal prostheses for intramuscular implantation.  Using one, small 3 cm incision, Dr. Gaspar dissects through the gluteal tissue to the muscle plane.  He then inserts the prosthesis and adjusts it into its final position.  When he has finished placing the implant, it is buried deep in the tissue and invisible.

after the implant is placed within the muscle it is invisible to the eye

after the implant is placed within the muscle it is invisible to the eye

He explains that by placing the prostheses in the intramuscular layer, the implants remain in a stable position, and are invisible to the eye and imperceptible to the touch.  (Even with movement and manipulation – there is no edge or pocket seen or felt after the gluteal prosthesis is placed).

The procedure is repeated on the opposite side.  Two small drains are placed, and the incision is closed.  The entire procedure has taken just 18 minutes.

incision and drains at the conclusion of surgery

incision and drains at the conclusion of surgery

Despite the speed by which Dr. Gaspar operates, he is meticulous in his approach. He frequently re-assesses during the procedure (particularly during bilateral procedures) to ensure symmetry of results.

*I frequently encountered Ms. Petrix during previous visits to the operating rooms at Hospital de la Familia during research and writing of the Mexicali book).

** Capsular contraction is one of the most frequently occurring complications of breast augmentation using breast prosthesis (implants).

*** this practice is somewhat controversial but the most recent surgical guidelines and literature on antibiotic stewardship suggest that pre-operative antibiotics may be unnecessary for some surgical procedures.

Thank you to the kind patient who graciously gave permission for publication of pre-operative, intra-operative and post-operative photographs on this site.

Additional readings: Gluteoplasty

The majority of publications originate in Latin America and Latin American journals (and are written in Spanish and Portuguese.)  Here is a small selection of open-access, English language journals.

Bruner, T. W., Roberts, T. L. & Nguyen, K. (2006).  Complications of buttocks augmentation: Diagnosis, management and prevention.  Clin Plastic Surg 33: 449 – 466.

Cardenas – Camarena, L. (2005). Various surgical techniques for improving body contour.  Aesth. Plast. Surg. 29:446-455.

Cardenas- Camerena, L. & Palliet, J. C. (2007).  Combined gluteoplasty: Liposuction and gluteal implants.  PRS Journal, 119(3): 1067 – 1074.  Part of a series on gluteal augmentation.

Harrison, D. & Selvaggi, G. (2006). Gluteal augmentation surgery: indications and surgical management.  JPRAS 60:922-928.

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What is a medico esthetico?


What is the difference between a medico estetico and a cirujano plastico?  The answer is more than just an issue of translation and semantics. We discussed this and several other issues during a visit to Clinica Plastic & Estetica Nova with Julio Casadiego, who works in the medical tourism sector here in Medellin at Colombia Travel Operator.  Mr. Casadiego works with many of the healthcare professionals here in Colombia to assist overseas traveler in making arrangements for medical travel and has done so since 2009.

The Clinica Plastica & Estetica NOVA

Carrera 48 #32B sur 30

Envigado, Antioquia

Tele: (4) 339 2300 EXT 125

Email: gerencia@clinicanova.com.co

Nova is an ambulatory surgery center and a center for aesthetics.  (Aesthetics is an umbrella term that encompasses other treatments outside of plastic surgery.)  This five-story facility houses several doctors offices, aesthetic treatment facilities (laser treatment area) other nonsurgical treatment areas (cellulite treatment, botox/ injectables etc.), a cosmetic dentist (Dr. Jorge Ivan Echavarria) specializing in crowns, dental implants, maxiofacial surgery, and orthodontics along with other cosmetic services such as teeth-whitening.

There is a small pharmacy as well as a full lab (for development of gel matrix in addition to performing blood analysis), and sterilization facilities along with an operating theatre and recovery unit.

There are three operating rooms; all of which are spacious and well-lit.  Each operating room has a full complement of fully functional and modern equipment and hemodynamic monitoring devices.  There are also several well placed ‘crash carts’ for potential emergencies.  The recovery room contains hemodynamic monitoring equipment with additional emergency equipment (just in case.)  Dr.  Diego Correa was my guide for a tour of the operating facilities and was happy to answer all of my questions.

He also reported that in the last year there have been just three cases of minor skin infections (the causative agent was normal skin flora).  He reports no serious infections or complications after surgery, and states that have been no instances of resistant bacteria or MRSA.

What is a Medico Estetico?

The literal translation of medico esthetico is aesthetics doctor, but a more accurate description would be a doctor who serves as an Aesthetics Consultant, or a doctor who performs nonsurgical aesthetics treatments. For a better understanding of this specialty, I spoke with Dr. John Jairo Monsalve Bedoya,  a medico estetico and general director at the Nova clinca.

A cirujano plastico is a ‘plastic surgeon’.  This is the surgeon who is trained to perform surgical procedures such as abdominoplasties, breast augmentation and similar types of procedures.

As he explained, the Aesthetics Doctor is a physician who specializes in the study of Aesthetic procedures.  Patients consult with this physicians as part of the initial consultation to help patients determine what procedures the patient needs or wants to achieve a desired result.  This is important in many cases when the patient knows what type of result they want (“I want to look younger”, for example) but may not know exactly what procedure is best to accomplish the results they want.

During the consultation, the doctor listens to the patient describe what they are looking for, collections medical history and other medical information as well as preferences.  Then the doctor discusses a range of procedures from injectables (botox, restalyne, gel matrix), and other non-surgical treatments (laser/ light therapies, mini-lift procedures) to larger, more invasive surgical procedures such as facial endoscopy, traditional face-lifts, eye lifts and other related procedures.

Finally, based on the information provided and the discussion with the patient and their family – the doctor recommends the procedures to accomplish the results the patients are seeking.

Once the patient has decided on their options, Dr. Monsalve, and his associate Dr. Correa begin the pre and post-operative treatment plan.  This plan is more than discussing payment, arranging a date for surgery, and a follow-up visit.  As Dr. Monsalve explains – it’s a process that encompasses the entire pre-operative period, surgery and recovery.

Patients undergo a compete physical examination, with blood work and cardiac testing as appropriate (usually EKG).  Patients are evaluated and treated by internal medicine physicians for any co-morbid conditions before meeting with the anesthesiologist for further evaluation.  (This is done to reduce risk of peri-operative and post-operative complications).   The degree of pre-surgical evaluation is related to the type of treatment – with more comprehensive evaluations for patients who elect to have surgical procedures with general anesthesia.

Intra-operative care is provided by the attending anesthesiologist with the initial post-operative recovery under monitored care in the recovery room.  But after the immediate recovery, patients aren’t simply discharged home.

The discharge planning / recovery phase is also governed by Dr. Monsalve and his team.  This includes a 24 hour call line, and home visits, as needed.  In fact, Dr. Monsalve encourages patients to call, saying, If a patient is having pain – they should call.. If they have questions or concerns, they should call.  It doesn’t matter what time it is.

Dr. Monsalve also encourages patients to consider aesthetics “a process- not just a surgery”.  He states that this treatment is a part of a patient’s life, and that using a philosophy of a process-based approach (rather than an episodic experience of pay – surgery – follow-up visit) results in a better patient experience, better outcomes and greater satisfaction/ happiness with the outcomes.  He believes that successful aesthetic procedures aren’t about  making people prettier, it’s about making people happier with themselves.

Medellin surgeons serving their community

During our discussion, we also talked about the many ways that local surgeons give back to their communities.  While this includes the more widely known programs such as Operacion Sonrisa, it also includes programs such as Gorditis de Corazon for post-bariatric procedures, Angeles por Colombia , a more generalized organization that recruits volunteers from all professions and areas of society (which operates under a philosophy of each one recipient then helps three others) as well as several other programs aimed at providing reconstructive surgery procedures to low-income Colombians.

Gel Matrix for skin rejuvenation

During our visit we also talked to Dr. Maria del Pilar Sanin, another medica estetica, who performs many of the non-surgical procedures offered at Nova.  She talked about Recombinant Plasma (approximate translation) which uses a gel matrix made for the patient’s own blood to improve the appearance and condition of the skin.

The origins of gel matrix: cardiac surgery

Having worked in cardiac surgery, this concept is not new – our perfusionist in Virginia often used the patient’s shed blood in orthopedic surgery to make a similar gel matrix that enhanced healing and reduced inflammation – particularly in patients with a history of poor wound healing.

Here at the clinica Nova, no major surgery is required.  Blood is taken, (by syringe) and placed into a centrifuge.  Now if you can remember back to high school biology – this causes the blood to separate into its components, buffy coat, platelets and red cell matter.  Then the doctor uses the platelet rich portion (which also contains fibroblasts, collagen, and other nutrients important to skin elasticity and wound healing).  This formula is then injected in small increments into the patient’s face to promote skin health and rejuvenation.  Since the material is made for the patient’s own body, (and unadulterated with preservatives or other chemicals) there is no possibility for allergic reactions or sensitivities to the ingredients.

Dr. Maria del Pilar Sanin reports that the healing time for this procedure is approximately four days, and that redness and inflammation at the sites of injections are common immediately after this procedure.  She states that the duration of the effects depend on the patient’s underlying skin condition, general health and age.  On average it lasts 1.5 to 2.0 years in most patients, but may not last as long in patients with extensive sun damage or deteriorated skin condition.

She recommends this procedure as a complimentary treatment to other non-surgical treatments for better overall skin condition/ health and a reduction in the appearance of wrinkles and fine lines.  She reports it is frequently used to treat the deepening of the naso-labial fold (the line that stretches from the nose to the corners of the mouth.)

Clinica Nova offers a wide-range of patient-centered aesthetic procedures and plastic surgery – all under one roof.

San Vicente at Rionegro: Hospital at the top of the hill


After interviewing Dr. Andres Franco, Chief of Cardiac Surgery over at Clinica Medellin, he invited me to tour San Vicente Fundacion’s Centros Especializados in Rionegro, Antioquia.

San Vicente Fundacion Centros Especializados in Rionegro, Antioquia

San Vicente Fundacion Centros Especializados in Rionegro, Antioquia

Rionegro is about 45 minutes from downtown Medellin but just a few miles from Jose Marie Cordoba airport (the international airport for Medellin.)  This makes this hospital well-positioned for domestic and international tourists.

San Vicente Fundacion

Vereda la Convencion, via Aeropuerto – Llanogrande, kilometre 2,3

Rionegro, Colombia

Tele: (574) 444 8717

Website: http://www.sanvicentefundacion.com

We’ve briefly mentioned the 100 million dollar facility in the past, as it was one of the first hospitals in Latin America to receive a “green” designation (Leed silver certification) for sustainability, water conservation, energy use, material and resource use, innovation and indoor environmental qualities.  To see San Vicente’s individual scores in each of these catagories, click here.  It was interesting to have the opportunity to see the facility for myself.

My guide for the visit was Ms. Flor Cifuentes, the chief nurse for cardiovascular surgery.  In addition to answering all of my questions and showing me around the facility, we talked about nursing.  We were joined by Ms.  Sandra Milena Velasquez, who is the care coordinator for the facility.

Nursing care at San Vicente

The three of us spent much of the morning talking about their vision of nursing at San Vicente.    Both nurses see the role of specialty nursing as being critical to the success of the facility, and the care of the patients.

I think they are interested in my viewpoint as both an outsider and as a nurse practitioner, a position that isn’t recognized in Colombia.  We all kind of sigh over this – as it’s apparent in any facility that nurses here have extensive education (usually five to six years for “Jefes” and often function in advanced roles (particularly in the operating room.)

Enf. Flor Cifuentes

Enf. Flor Cifuentes

Eco-friendly and patient friendly design

While four stories are visible to casual visitors, there are an additional four floors beneath the facility.  The subterranean floors are part of the eco-friendly design.

The hospital is beautiful, and surrounded by the lush greenery that characterizes the hills of Colombia.  There are several gardens stocked with aromatic plants as a sort of “tranquility space” for patients and families.

At 2600 meters (8,500 ft), Rionegro falls into one of the top ten hospitals for altitude (along with facilities in Bogota, Quito, Ecuador and La Paz, Bolivia).

The above ground areas are filled with light, with large windows.  Many of the patient rooms, including the ICU room have a ‘family space’ for family members to spend time with their loved ones.

The equipment was state-of-the -art.  The cardiac operating room was large, well-stocked.  There is a computerized system for everything from climate control to lighting, to cameras and monitors.  Touch screens abound.  Nitric oxide connections exist in all of the operating rooms.  A cell-saver rested in the corner next to the bypass machine (heart-lung machine) in an antechamber of the cath lab, just waiting to be called into service.

One of the operating rooms has been converted into an angiography suite (cardiac catheterizations, peripheral vascular procedures and neurology interventions) with a second room being constructed nearby.

There is a helicopter pad on the roof for more urgent arrivals.

Phase II

Evidence of ongoing construction was rampant – as the hospital begins a second stage of construction; for a Cancer Center, a Neurosciences center, a trauma center, plastic surgery center (plastic, maxiofacial and esthetics), Women’s Health, Neo-natal care and a Psychiatric care center.  It’s a pretty ambitious endeavor which will also add 400 beds to the facility.  (Currently, the Rionegro facility has 145 general beds, 14 ICU beds, 20 specialty beds and 20 ER beds.)

“Ghost Hospital”

Unfortunately, for investors – the two-year old facility was essentially empty.  Among healthcare professionals, many refer to the facility as a “ghost hospital” due to the low occupancy rates since it’s opening.

Only one of the five operating rooms was in use during my visit.  The pre and post operative areas were empty.  So was the four ambulatory procedure areas.

The ICU was half-full at best (4 to 5 patients).  The only area that showed evidence of life was one of the ‘regular’ patient floors.  Amazingly, even the emergency room was empty.

Hopefully, this is just growing pains for the hospital, which is the newest part of the well-established San Vicente Health System.

The San Vicente de Paul Health System

The Rionegro facility is part of the larger San Vicente de Paul Hospital System.  The San Vicente hospital in downtown Medellin has a long history of patient care and community service.  (The film below talks about the San Vicente Hospital System – but it’s a couple of years old, so the Rionegro facility was still in the development stage.)

Chapel on the main campus of San Vicente de Paul in downtown Medellin

Chapel on the main campus of San Vicente de Paul in downtown Medellin

San Vicente : Rionegro has several advertisements on YouTube about their facility, and is part of the San Vicente  channel on YouTube.  The majority of it is in Spanish but there are a few English language offerings.

For one of ads featuring the Rionegro facility, (Spanish version) – click here.   The hospital gave me a CD-ROM containing the English version, so a friend is uploading it to YouTube so I can show it here.

Checking in with Dr. Hector Pulido at Clinica General del Norte


After spending some time in my old neighborhood in Bogotá visiting friends and family over the holiday weekend – it was time for a quick trip to Barranquilla for another reunion, of sorts.  Dr. Hector Pulido, the Chief of Surgery at the Clinica General del Norte (and a long-time friend) invited me to Barranquilla to take a look around..

with Dr. Hector Pulido (left) and Dr. Barbosa in Cartagena (2010).

with Dr. Hector Pulido (left) and Dr. Barbosa in Cartagena (2010).

The City of Barranquilla: Colombia’s Golden Gate 

Barranquilla is the capital of the Colombian state (province) of Atlantico, and is the largest city within Atlantico.  Barranquilla is the fourth largest city within Colombia – after Bogotá, Medellin and Cali.  While population estimates vary greatly, the generally published estimate is around 1.6 to 2.4 million people*.  Much of Barranquilla’s historical importance is related to its position as the major port of Colombia.  This is reflected in Barranquilla’s continued growth and reputation today.

Barranquilla: More than Shakira and Carnival

While Barranquilla is widely considered to be Cartagena’s ugly big sister; it is also the coastal region’s more serious, intellectual and industrial side.   Excluding the internationally famous Carnival; among the Colombian coastal cities of Barranquilla, Cartagena and Santa Marta; Cartagena is viewed as being for play, Santa Marta for relaxation… But Barranquilla is viewed as the city where the work gets done..

That impression; of business-like efficiency and competency certainly held true during my tour of the main facility of the rapidly expanding Clinica General del Norte health system.

Clinica General del Norte

The Clinica General del Norte facility on Calle 70 is the main facility of the nine hospital network.  (There are 4 hospitals in Barranquilla itself, with several other hospitals in Cartagena and other coastal areas.)  The Calle 70 facility is also the biggest with 464 beds, and an anticipated addition of 300 beds in the works.

Care of the critically ill

Clinica General del Norte has 100 intensive care beds, with a dedicated coronary /cardiac intensive care, a burn unit, pediatric intensive care and a 24 bed neo-natal unit.  They also have an intensive care unit for patients requiring hepatic dialysis for patients with liver failure.  This last unit is of particular interest – since it is where Dr. Hector Pulido, as a general surgeon specializing in Liver, Biliary, Pancreatic Surgery and Transplant) cares for many of his more critically ill patients after surgery.

But no real chance to observe Dr. Pulido at work – at least, not today.. Just a quick whirl around the facility, accompanied by Yolanda Basto de Hossman, and Dra. Maria del Carmen – to the 14 operating rooms to check out the cardiac surgery room along with the updated and modern equipment, to  the neo-natal unit to talk to the Chief of Pediatrics, and see babies as young as 20 weeks gestation.

MRI/ CT scan and Angiography facilities

Dr. Pulido encourages them to show me everything (everything! he says) – so they do; the dual angiography suites, the 64 slice CT scanner with 3D reconstruction, to MRI – meeting and talking to staff along the way.  No PET/ CT yet but it’s on the way – they say – which will make this the only facility on the coast with such diagnostic capabilities. (They are building the structure to contain it as part of the new building being constructed in front of the existing facility).

But, of course, for me – it’s not enough.. I need to talk to the surgeons, spend some time with them; observing and talking to their patients – getting the feel and the rhythm of their practice.. I need to watch them in the operating room, and to know them – before I can be completely satisfied.

So even now, as Victor takes me back to the airport, I am thinking, questioning, planning.. “Are the rents very expensive near here?”, I ask.  “No” he says as he drives through the nearby small streets with gaily painted houses.. Well, then I think I have my answer.

Sunset in on the air field as I prepare to leave Barranquilla

Sunset in on the air field as I prepare to leave Barranquilla

Links for more information:.

City of Barranquilla  – government website

Official Colombia Travel page: Barranquilla

El Heraldo – news of the Colombian coast

Clinica General del Norte

*Local residents estimate the population at almost 4 million people in the metropolitan area