Talking to Dr. Juan David Londoño, plastic surgeon


Dr. Juan David Londoño, plastic surgeon

Dr. Juan David Londoño, plastic surgeon (photo provided)

Dr. Juan David Londoño is a plastic surgeon here in Medellin who specializes in body procedures such as liposuction, abdominoplasties and breast augmentation.

He shares an office with Dr. Jorge Aliro Mejia Canas in the Forum building, next to the Santa Fe shopping mall in the upscale Poblado neighborhood.

He is also one of just a handful of surgeons here who specialize in hair restoration.

Dr. Londoño attended medical school at the Universidad de Antioquia, graduating in 1995.  He completed his plastic surgery residency at the same institution and completed his training in 2003.  While he trained in both reconstructive and aesthesthic plastic surgery, he states that he prefers aesthetic surgery because of the close relationship it entails with patients.

Today we talked primarily about Hair Restoration procedures because it’s his favorite procedure, and one I don’t know much about.

Patience is the key, he states as he explains the ins and outs of hair restoration treatments.  Patience was certainly the order of the day as he carefully and graciously explained the principles of hair transplantation to me.  Patience is necessary he explains, as in, there is no ‘quick fix’.  Hair restoration techniques have evolved with the development of newer procedures but it remains a painstaking process.

Not just for male pattern baldness

While people traditionally think of this treatment as exclusively for male pattern baldness, women also undergo hair restoration in cases of thinning hair.  People can also use this treatment to restore hair to other areas of the body such as the eyebrows (or as commonly publicized in Turkey) for beard restoration.

Treatment options

As Dr. Londoño explains, there are a range of treatments available for the treatment of hair loss, such as male pattern baldness, or thinning hair.  While these treatments run along a continium of scalp massage –> medications  –> surgery; these treatments can also be used to compliment each other.

Probably the best well-known treatments are the medications such as topical applications of minoxidil  (Rogaine) or oral (finesteride) Propecia tablets.  Many people are familiar with these medications due to long-standing and widely viewed pharmaceutical advertisements in the early and late 1990’s.   Both of these medications were originally developed to treat other conditions (hypertension and BPH) and hair growth was quickly noted to be a frequently occurring side effect.   These medications underwent additional clinical trials and study by the FDA before being re-formulated (as a topical spray), in the case of minoxidil, and re-marketed to treat hair loss.

However, these medications are less than ideal for treating a long-term problem like hair loss.  While the medications can prevent additional hair loss, in most cases – additional hair growth is modest and requires continued medical therapy (pills) to maintain.

Scalp massage, is believed to stimulate blood circulation in the scalp and improve the health of the scalp and hair.  It is also quite pleasant for most people.  However, the results of scalp massage as a sole treatment are minimal at best when it comes to the treatment of alopecia.

Surgical methods of hair restoration

The original surgical methods of hair transplantation (or hair restoration) are more widely known for their limited results.  “Hair plugs” refer to the artificial appearance due to the technique of implanting a group of hair in one area, with the finished results often having a row-like appearance (like a doll).

More modern techniques include the strip method, and the most recent technique called Follicular Unit Extraction (FUE).

With the strip method a small area of scalp on the back of the head (where hair is usually the densest, and has the greatest longevity) is surgically removed in a long strip.  The scalp is then sutured closed, leaving a small linear scar.  The area of scalp, and hair follicules are then used for implantation.  By taking a portion of the scalp, the surgeons are able to ensure that the critical portion of the hair shaft – the root is preserved.  This root is needed for hair to survive and grow after implantation.

With the newer Follicular Unit Extraction, each hair, including the root is extracted using a 1mm punch biopsy technique.  (This is like a skin biopsy punch but much smaller.)  Since each root is extracted individually, this is a painstaking and time consuming process.  He reports that depending on the degree of hair loss, the length of the sessions and the results desired by the patient – determines the number of sessions a person will need.   Since this procedure requires multiple sessions, some patients elect for shorter sessions but require a higher number of sessions since this is often more convenient for the schedules of working people.

The first treatment is usually done to re-establish the natural hairline.  Subsequent treatments are needed to fill in areas of hair loss.

For patients who have very little remaining head hair, hair can be taken from other parts of the body.  In general, surgeons use hair from areas (like the so-called “fringe area”) where hair persists despite months or years of hair loss.  These areas are less likely to have hair that will succumb to the processes that caused alopecia in these individuals.

There are newer methods of FUE which use a more automated process, but as Dr. Londoño explains this often incurs a higher cost – and does not improve the outcomes (but does shorten the process somewhat.)  He has the Artas Robot to assist him with the process, (if needed), but cautions readers not to be fooled by surgeons advertising the latest and greatest machinery.  We digress into a conversation about general plastic surgery and the widespread advertising of specifically trademarked (and very expensive) equipment such as SlimLipo, Ultrasound and Vaser.

It’s more about the surgeon than the tools

He cautions consumers not to be fooled into thinking that having the most expensive equipment equals the best surgeon as often these devices are employed only to attract customers and command more expensive prices.  As we discussed in a previous post, these devices were designed for specific uses that may not even be needed for many clients.

Why should patients pay for ultrasound-assisted liposuction when standard liposuction will be equally effective in their case? That’s kind of how he feels about the hair transplant robot.  He has it – and he will use it if he needs it, but it isn’t for everyone.

Results take time

Results of this procedure are not immediate.  The scalp takes time to heal from the transplant procedure, and the newly implanted follicules need to adjust to the transplantation process.   Usually, the initially transplanted hair sheds – leaving living, hair producing roots behind.  These hair roots will then grow new hair as part of the normal hair growth cycle.  But hair takes time to grow – so many patients won’t see the full results of their procedure for up to six months afterwards as the hair grows in to the patient’s normal length.

Costs of the procedure

The near universal standard for hair restoration at many facilities is a dollar a hair.  When you consider that the average (full) head of hair contains 100,000 hairs – the potential costs of this procedure* can be daunting.  However, Dr. Londoño does not apply a “one price fits all” approach to his patients.  Instead his assesses the client, their restoration needs (a small area versus the entire coronal area), the amount (and type) of treatments involved, and the expected results before determining a price.  It is a more personalized and individualized accounting that may not suit some medical tourists who are looking for bargain basement prices however, it seems a better practice.

Dr. Londoño, hair transplant specialist

Dr. Londoño, hair transplant specialist

Dr. Juan David Londoño

Calle 7 sur N. 42-70

Edificio Fórum Poblado,

consultorio 511

Medellin, Colombia

Telé: 448489 or 3140478

Email: ciruplas2@une.net.co

Website: www.cirplalondono.com

Speaks primarily Spanish.

*Generally patients would only need a small fraction of this number for hair restoration.

References and Resources

Khanna M. (2008). Hair transplantation surgery.  Indian J Plast Surg. 2008 Oct;41(Suppl):S56-63.  An excellent overview of the procedures used in hair transplantation with photographs depicting these techniques and results.

Rashid RM, Morgan Bicknell LT. (2012).  Follicular unit extraction hair transplant automation: options in overcoming challenges of the latest technology in hair restoration with the goal of avoiding the line scar. Dermatol Online J. 2012 Sep 15;18(9):12.  The authors compare automated FUE extraction (and limitations) with manual extraction.

Note: the feature photograph(on the front page) has been heavily edited (by me) to depict a gentleman with a receding hairline.  This model actually has a lovely head of hair, but I did not want to use the photo of a real person without permission.  (This photo is open source). This photo is for article art only and is not an attempt to dupe or trick readers.  It is my policy to always disclose when photos have been altered from the original image.

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Talking with Dr. Jhon Jairo Berrio about vascular disease and Prostaglandin E1


XXIX Congreso Latinoamericano de cirugia vascular y angiologia

Santa Cruz de la Sierra, Bolivia

Dr. Berrio, Vascular Surgeon, Tulua, Colombia

Dr. Jhon Jairo Berrio is  the Chief of Vascular Surgery at the Clinica San Francisco, Tulua, Colombia, which is a small community outside of Cali.  He attended medical school in Colombia, completing his general surgery residency at Hospital clinics for Carlos.  He completed additional training at New York University and he completed his vascular surgery residency in Bogota at the Hospital de Kennedy  and trained under the instruction of Dr. Albert Munoz, the current president of the Association of Latin American Vascular Surgery and Angiography (ALCVA) .  He does a range of vascular procedures such as aortic aneurysm repair, fistula creation as well as endovascular surgery but his favorite procedures are limb salvage procedures such as aorto-femoral bypass, femoral-popliteal bypass and other treatments designed to prevent amputation.

He is here in Bolivia giving a presentation on the use of Prostaglandin E1 for critical ischemia / and last chance limb salvage.

Today we are talking to Dr. Berrio about the use of prostaglandin E1 (Iloprost/ iprostadil) for peripheral vascular disease (PAD).  In the past, we have used a myriad of treatments including statins, pentoxifylline, clopidogrel and even quinine for the prevention and relief of claudication symptoms.  However, all of these previous agents are designed for early PAD and are only minimally effective at treating later stages of disease.  Treatment of severe disease (rest pain or ulceration/ ischemia wounds) has been limited to stenting (angioplasty) and surgical revascularization – but this strategy often fails for patients with microvascular disease (or disease that affects vessels that can not be operated on.)

Last effort at Limb Salvage in critical ischemia

No – Prostaglandin E is not some magic ‘panacea’ for peripheral vascular disease.  There is no such thing – but it is a medication in the treatment arsenal for vascular surgeons – and it has shown some promising results particularly in treating limb-threatening ischemia.  In fact, the data goes back over 20 years – even though most people in the United States have never heard of it.  That’s because prostaglandin E1 is more commonly used for other reasons in the USA.  It is a potent vasodilator, and in the US, this medication is often used in a different (aerosolized form) for primary pulmonary hypertension.  It is also used for erectile dysfunction.  Despite a wealth of literature supporting its use for critical ischemia it is not currently marketed for such use in the United States – and thus – must be individually compounded in a hospital pharmacy for IV use.  Supplies of this medication in this form are often limited and costly.

Intravenous Prostaglandin E1

This medication offers a desparately needed strategy for patients with critical ischemia who (for multiple reasons) may not be surgical candidates for revascularization and is a last-ditch attempt to treat ‘dry’ gangrene and prevent amputation and limb loss.  Since more than 25% of all diabetes will undergo amputation due to this condition – this is a critical development that potentially affects millions of people.  (Amputations also lead to high mortality for a variety of reasons not discussed here.)

What is Prostaglandin E1?

As mentioned above, prostaglandin E1 is a potent vasodilator – meaning it opens up blood vessels by forced the vessels to dilate.  This brings much-needed blood to ischemia tissue (areas of tissue dying due to lack of blood.)

Treatment details:

A full course of treatment is 28 days.  Patients receive 60 micrograms per day by IV.

Patients must be admitted to the hospital for observation for the first intravenous administration of prostaglandin E1.  While side effects such as allergic reactions, rash or tachycardia are rare – since this medication is given as an IV infusion, doctors will want to observe you for the first few treatments. The most common side effect is IV irritation.  If this occurs the doctors will stop the infusion and dilute it further to prevent discomfort.  Once your treatment has been established, doctors may arrange for you to have either out-patient therapy at an infusion center, or home health – where a nurse comes to your house to give you the medication.

The surgeons will evaluate your legs before, during and after treatment.  If the ischemia or rest pain are not improving, or worsen during treatment – doctors may discontinue therapy.

Prostaglandin E1 therapy is compatible with other medications for PAD such as clopidogrel, aspirin, pentoxifylline and statins, so you can continue your other medications for PAD while receiving this treatment.  However, if you are taking nitrates such as nitroglycerin, (Nitro-dur, Nitropaste) or medications for pulmonary hypertension or erectile dysfunction – please tell your surgeon.

In Colombia, the average cost of the entire course of treatment (4 weeks of daily therapy) is 12 million Colombian pesos.  At today’s exchange rate – that is  a little under $ 7000.00  (seven thousand dollars, USD).

While this is a hefty price tag – it beats amputation.  In some cases, arrangements can be made with insurance companies to cover some of the costs.  (Insurance companies know that amputation-related costs are higher over the long run, since amputation often leads to a lot of other problems due to decreased mobility).

Additional Information about Dr. Berrio:

Dr. Jhon Jairo Berrio, MD

Vascular surgeon

Calle 414 – 30

Buga, Colombia

Tele: 236 9449

Email: vascular@colombia.com

Speaks fluent English, Espanol.

References/ Additional information about peripheral arterial disease (PAD) and prostaglandin e1

Pharmacotherapy for critical limb ischemia  Journal of Vascular Surgery, Volume 31, Issue 1, Supplement 1, January 2000, Pages S197-S203

de Donato G, Gussoni G, de Donato G, Andreozzi GM, Bonizzoni E, Mazzone A, Odero A, Paroni G, Setacci C, Settembrini P, Veglia F, Martini R, Setacci F, Palombo D. (2006).  The ILAILL study: iloprost as adjuvant to surgery for acute ischemia of lower limbs: a randomized, placebo-controlled, double-blind study by the italian society for vascular and endovascular surgery.  Ann Surg. 2006 Aug;244(2):185-93.  An excellent read – even for novices.

S Duthois, N Cailleux, B Benosman, H Lévesque (2003).   Tolerance of Iloprost and results of treatment of chronic severe lower limb ischaemia in diabetic patients. A retrospective study of 64 consecutive cases .  Diabetes & MetabolismVolume 29, Issue 1February 2003Pages 36-43

Katziioannou A, Dalakidis A, Katsenis K, Koutoulidis V, Mourikis D. (2012).  Intra-arterial prostaglandin e(1) infusion in patients with rest pain: short-term results.  Scientific World Journal. 2012;2012:803678. Epub 2012 Mar 12.e Note extremely small study size (ten patients).

Strecker EP, Ostheim-Dzerowycz W, Boos IB. (1998).  Intraarterial infusion therapy via a subcutaneous port for limb-threatening ischemia: a pilot study.  Cardiovasc Intervent Radiol. 1998 Mar-Apr;21(2):109-15.

Ruffolo AJ, Romano M, Ciapponi A. (2010).  Prostanoids for critical limb ischaemia.  Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006544.

Volteas N, Leon M, Labropoulos N, Christopoulos D, Boxer D, Nicolaides A. (1993).  The effect of iloprost in patients with rest pain.  Eur J Vasc Surg. 1993 Nov;7(6):654-8.

In the operating room with Dr. Enrique Davalos Ruiz, Neurosurgeon


Dr. Enrique Davalos Ruiz, Neurosurgeon

Spent the morning in the operating room with Dr. Davalos.  As we discussed in a previous post, Dr. Davalos is one of just a few neurosurgeons here in Mexico to specialize in both adult and pediatric neurosurgery procedures.  He performs a wide range of procedures such surgery for cerebral tumors, spinal bifida, hydrocephalus, trauma, spinal surgery and epilepsy.  But one of the procedures he is best-known for here in Mexicali is the surgical repair of craniosynostosis.  However, if you’ve ever watched this intricate procedure – ‘repair’ really isn’t the word that comes to mind to describe the procedure.  ‘Rebuild’ is much more appropriate.

Craniosynostosis is a congenital cranial deformity caused by the premature fusion of the cranial sutures.  (These sutures allow for the babies head to be slightly compressed during natural childbirth).  Many new moms can attest that their neonate’s head was temporarily ‘squashed’ looking at birth, but normalize over the first few days as the bones relax into their natural position.  In normal development, these sutures (or ridges where the bones come together) are not yet fused  – and fuse over the first few months of life.

When the bones that comprise the skull fuse early, it can result in a significant cranial abnormality.  (Luckily, in most cases of [primary] craniosynostosis – the patient’s brain functions normally despite this.)

To treat this surgically, Dr. Davalos had to essentially rebuild part of the skull (the coronal sections of the parietal and frontal bones).   He did this by removing and reshaping the skull in separate sections and then rejoining the pieces to conform to a more natural shape.  (As a someone who sews, it reminded me of lacing a corset to get curved shaping).   In a child of this age – the bones should fuse/ heal within approximately six weeks – with no long term limitations for activities.

Sterility was maintained during the case, and everything proceeded in a rapid and appropriate fashion.  Anesthesia was proficient during the case, with excellent hemodynamic stability and oxygenation.

Dr. Davalos beveling a portion of the skull

Dr. Enrique Davalos Ruiz, MD

Pediatric and Adult Neurosurgery specialist

Calle B No 248

entre Av. Reforma and Obregon

Zona Centro

Mexicali, B. C.

In the OR with Dr. Ramos & Talking with Dr. Enrique Davalos Ruiz, Neurosurgeon


Interesting day today – as I travelled across a wide range of specialties in just a few short blocks.  I started out this afternoon in thoracic surgery with the good doc seeing patients in clinic, then off to IMSS to watch a Whipple procedure (pancreatoduodenectomy) with Dr. Gabriel Ramos.   (The Whipple procedure would be the ‘open heart’ surgery of the general/ oncology surgery specialty – it’s a complex, complicated and involved procedure – so, naturally, I loved every minute of it!)

Dr. Gabriel Ramos & Dr. Maria Rivera

Some of you will recognize the absolutely delightful Dr. Maria Rivera from one of our pictures last week (on facebook) – in which she was an absolute stunner.

Not an everyday photo – but then that case was pretty breathtaking too – (when I finish writing about it, I will post a link.)

Dr. Elias Garcia Flores, who I met briefly last week was there too.. (Of course, I didn’t recognize him since he had a mask on this time.)

Unfortunately, I couldn’t stay because I had a previous appointment to interview Dr. Enrique Davalos Ruiz, a local neurosurgeon.  He turned out to very charming and interesting..

He’s the only neurosurgeon specializing in pediatric and adult neurosurgeon for all of Baja California and Sonora.  (I’ll write more about him soon – I am hoping to head to the operating room with him next week.) He’s pretty busy working at IMSS and Hospital General de Mexicali, in addition to private practice but he didn’t seem to mind taking time to talk to me.

In the operating room with Dr. Martin Juzaino


This post is a little overdue since I was out of town for a few days.. I missed the 115 degree temps and I missed Mexicali too..

Dr. Juzaino (left) and Dr. Rivera

Usually, I go to surgery after I’ve spoken to the surgeon, and talked to them for a while but in this case – I had heard of Dr. Juzaino (after all – he practices at Hospital General de Mexicali) but couldn’t find a way to contact him – he’s not in the yellow pages, and no one seemed to have his number..

So I just hung out and waited for him when I saw his name on the surgery schedule. He was supernice, and invited me to stay and watch his femoral – popliteal bypass surgery.  Case went beautifully – leg fully revascularized at the end of the case.   Patient was awake during the case but appeared very comfortable.

intern during surgery

There was a beautiful intern in the surgery – her face was just luminous so I couldn’t resist taking a picture.  Unfortunately, I didn’t get her name, and no one recognizes her because of the mask – so I am hoping some one from the OR recognizes her here.. I’d like to send her a copy of the picture.. (and get permission to post it..)

Saw Lupita Dominguez – who in the role of nursing instructor that day.  She is always so delightful – I need to get a picture of her with out the mask so all of you can see her -besides being an outstanding nurse, and nursing instructor,  she is just the friendliest, sweetest person with cute freckles to boot.. (I am very envious of people with freckles..)

On another note entirely, here’s some more information about the ethical implications of transplant tourism for my interested readers as follow up to my Examiner.com article.  It’s a video of lectures by one of the leading ethicists and transplant surgeons, Dr. Delmonico.. (yes, like the steak.)

Dr. Marco Sarinana and Dr. Joel Ramos,Bariatric surgeons


Busy day yesterday – spent the morning shift with Jose Luis Barron over at Mexicali General..  Then raced over to Hospital de la Familia for a couple of general and bariatric cases.

The first case was with the ever charming Drs. Horatio Ham, and Rafael Abril (who we’ve talked about before.)  with the always competent Dr. Campa as the anesthesiologist.   (Seriously – Dr. Campa always does an excellent job.)

Then as we prepared to enter the second case – the director of the hospital asked if I would like to meet Dr. Marco Sarinana G. and his partner, Dr. Joel Ramos..  well, of course.. (Dr. Sarinana’s name has a tilde over the first n – but try coaxing that out this antique keyboard..)

So off to the operating room with these three fellows.  (This isn’t my usual protocol for interviewing surgeons, etc. but sometimes it works out this way.)  Their practice is called Mexicali Obesity Solutions.

Dr. Marco Sarinana and Dr. Joel Ramos, Bariatric surgeons

Dr. Alejandro Ballesteros was the anesthesiologist for the case – and everything proceeded nicely.

After that – it was evening, and time to write everything down!

Today should be another great day – heading to IMSS with Dr. Gabriel Ramos for a big case..

Dr. Gabriel Ramos, Oncology Surgeon


Dr. Gabriel Ramos, Oncologic Surgeon

Been a busy week  – (Yea!) but now that it is the weekend, I have a chance to post some more pictures and talk about my day in the operating room with Dr. Gabriel Omar Ramos Orozco. 

Despite living in a neighboring apartment, interviewing Dr. Ramos proved to be more difficult than anticipated.  But after several weeks, I was able to catch up with the busy surgeon.

Outside of the operating room, he is a brash, young surgeon with an off-beat charm and quirky sense of humor.  But inside the operating room, as he removes a large tumor with several cancerous implants, Dr. Gabriel Ramos Orozco is all business.

It’s different for me, as the interviewer to have this perspective.  As much as I enjoy him as a friendly neighbor – it’s the serious surgeon that I prefer.  It’s a side of him that is unexpected, and what finally wins me over.

Originally from San Luis Rio Colorado in the neighboring state of Sonora, Dr. Ramos now calls Mexicali home.  Like most surgeons here, he has a staff position at a public hospital separate from his private practice.  It is here at IMSS (Instituto Mexicano del Seguro Social) where Dr. Ramos operates on several patients during part of the extended interview.

Operating room nurses at IMSS

During the cases, the patients received a combination of epidural analgesia and conscious sedation.  While the anesthesiologist was not particularly involved or attentive to the patients during the cases, there was no intra-operative hypotension/ alterations in hemodynamic status or prolonged hypoxia.

Dr. Ramos reviewed patient films and medical charts prior to the procedures.  Patients were prepped, positioned and draped appropriately.  Surgical sterility was maintained during the cases.  The first case is a fairly straight forward laparoscopic case – and everything proceeds rapidly, in an uncomplicated fashion.  45 minutes later, and the procedure is over – and Dr. Ramos is typing his operative note.

Dr. Gabriel Ramos in the operating room

But the second case is not – and Dr. Ramos knows it going in..

The case is an extensive tumor resection, where Dr. Ramos painstakingly removes several areas of implants (or tumor tissue that has spread throughout the abdomen, separate from the original tumor).

The difference between being able to surgical remove all of the sites and being unable to remove all of the gross disease is the difference between a possible surgical ‘cure’ and a ‘de-bulking’ procedure, Dr. Ramos explains.  As always, when entering these surgeries, Dr. Ramos and his team do everything possible to go for surgical eradication of disease.  The patient will still need adjunctive therapy (chemotherapy) to treat any microscopic cancer cells, but the prognosis is better than in cases where gross disease is left behind*.  During this surgery, after extended exploration – it looks like Dr. Ramos was able to get everything.

“It’s not pretty,” he admits, “but in these types of cases, aesthetics are the last priority,” [behind removing all the tumor].  Despite that – the aesthetics after this large surgery are not as worrisome as one might have imagined.

The patient will have a large abdominal scar – but nothing that differs from most surgical scars in the pre-laparoscopy era.  [I admit I may be jaded in this respect after seeing so many surgeries] – It is several inches long, but there are no obvious defects, the scar is straight and neatly aligned at the conclusion of the case – and the umbilicus “belly-button” was spared.

after the successful removal of a large tumor

As I walk out of the hospital into the 95 degree heat at 11 o’clock at night – I admit surprise and revise my opinion of Dr. Ramos – he is better than I expected, (he is more than just the kid next door), and he deserves credit for such.

*This may happen due to the location of metastatic lesions – not all lesions are surgically removable.  (Tumor tissue may attach to major blood vessels such as the abdominal aorta, or other tissue that cannot be removed without seriously compromising the patient.)  In those cases, surgeons try to remove as much disease as possible – called ‘de-bulking’ knowing that they will have to leave tumor behind.