Talking with Dr. Juan David Betancourt Parra, plastic surgeon


I met Dr. Betancourt Parra at IQ interquirofanos while observing surgery with Dr. Luis Botero,. Dr. Betancourt was friendly, and immediately amendable to an interview but it took a little while to coördinate our schedules.

In person, he reminds me a bit of Dr.Carlos Ochoa Gaxiola, the kind and talented Mexican surgeon who graciously permitted me to study with him at Hospital General de Mexicali for several months while writing the Mexicali book.

Maybe it was his laid-back and open conversational style, or the braces on his teeth, giving him a bit of boyish charm that belies his years of experience.  Maybe it was his enthusiasm for his work, but whatever it was, I found the discussion to be especially informative and interesting.

Aesthetic plastic and reconstructive surgery

Dr. Betancourt is a plastic surgeon in Medellin.  He performs a wide range of aesthetic and reconstructive plastic surgery including corporal (body) and facial procedures such as rhinoplasty (nose), face-lifts, blepharoplasty (eyelid lift), breast augmentation, liposuction etc. but his true love is post-bariatric surgery procedures.

He also performs reconstructive surgery such as breast reconstruction after breast cancer.

Post-bariatric practice

Post-bariatric surgery is a subspecialty area of plastic surgery (reconstructive surgery).  Many of these patients have lost very large amounts of weight (100+ pounds) and have large amounts of sagging, drooping and excess skin.

This skin is more than aesthetically displeasing – it can also contribute to the development of skin irritations such as intertriginous dermatitis and infections.   It is particularly prone to causing problems for females – due to an excess build up of moisture, and friction in the genital areas.  It can also make simple tasks like showering, getting dressed and cleaning after using the bathroom difficult.  Patients sometimes have to “tuck” loose skin from the abdomen into support garments to prevent this skin from slipping down to their thighs.  This excess of skin (and the resultant movement/ friction) can prevent people from participating in normal activities like exercise.

The psychological impact of the appearance of, and the challenges of daily living can be extremely distressing – especially for someone who have spent months or years trying to lose weight.

The group of procedures used to treat this problem is called “Body contouring”.  For the majority of patients – this body contouring process will require several months and several separate surgeries.

Body Contouring

One of the primary procedures for body contouring is called a “lower body lift/ /belt lipectomy/ torsoplasty”.  This is actually two separate but very similar techniques; with the belt lipectomy being a modified lower body lift procedure.  However, they are often grouped together to simplify discussions about body contouring procedures.   The lower body lift or belt lipectomy is usually one of the first procedures as part of the reconstructive process after massive weight loss.

This procedure is the core procedure – which removes the majority of excess skin and tissue which is usually in the abdominal/ torso area.  This is a dramatic and large surgical procedure which I liken to “the open heart surgery of plastic surgery.”  This procedure can take 2 to 6 hours, and often requires a 1 to 2 night hospital stay.

The remaining procedures are more of a ‘fine tuning;, as they are smaller procedures with lesser effects as they are aimed at smaller, more specific areas of the body.  These procedures include brachioplexy to remove excess skin (aka “batwings”) from the upper arm/ bicep area, reduction mammoplasty to remove excess skin and drooping from the breast area, or a thighoplasty, to remove excess skin from the thighs/ upper legs.

One year minimum wait after bariatric surgery

Dr. Betancourt requires a minimum of one year after bariatric surgery before patients begin considering body contouring procedures.

This is important for two reasons:

1. Patient’s weight should be stable prior to performing surgical procedures.

2. This period gives patients a chance to adjust to their new weight.  Several studies have demonstrated that it may take months to years to adjust the mind’s eye (mental image) to a person’s actual appearance.

For an excellent article by Salwar & Fabricatore (2008) on the psychological considerations for patients after massive weight loss – click here.

Mirror versus mind’s eye

This is why many people literally “do not see” recent changes in our weight / appearance (particularly subtle/ small changes) when looking in the mirror.  However, as time passes, the mind’s perception of our image/ appearance usually changes to accommodate changes in our ‘real’ appearance – whether weight loss/ gain, signs of aging (fine lines, wrinkles) or even the loss of a limb or appendage.

photo from uhs.uk

photo from uhs.uk

When the mental / mirror image “mismatch” is dramatic, long-lasting, accompanied by depression/ anxiety or leads to dangerous practices like anorexia, hypergymnasia or self-mutilation – it is called body dismorphic disorder (BDD).  Patients who have successfully adjusted to their new size and appearance are much more likely to have realistic expectations, be satisfied with surgical outcomes and be able to maintain their weight over the long-term.

Dr. Betancourt explained that he enjoys the intellectual challenges of caring for post-bariatric surgery patients for several reasons.  These patients, often differ greatly from the majority of plastic surgery patients due to the presence of multiple co-morbid conditions relating to their previous obesity.   Patients may also have body image issues following the initial bariatric surgery as they adjust to their new bodies.  These patients may require multiple procedures for a complete reconstruction, making treatment a somewhat lengthy process.

Dr. Betancourt states that this is what makes it so gratifying; to be able to provide patients with dramatic body changes, help improve their self-image and enable patients to successfully adjust to their new lives.  He also finds it very rewarding because of the high level of patient satisfaction after these procedures.

These patients account for approximately 1/3 of his practice.

Education and Training

Dr. Betancourt has been a plastic surgeon for twelve years.  For eleven years, he worked in a public hospital, Manuel Uribe Angel in Enviagado, providing reconstructive surgery services to all patients at all socio-economic levels in Antioquia, Colombia .  For the last several years, he has devoted a significant portion of his practice to the sub-specialty of post-bariatric surgery.  He has attended several post-bariatric surgery conferences to learn new techniques and exchange ideas with many of the leaders in the field including Dr. Alaly (USA),  Jean François Pascal (France) and Dr. Ricardo Baroudi (Brazil).

Dr. Betancourt attended medical school at Universidad CES (University of Health Sciences) and graduated in 1993.  He is currently a professor at CES.

He competed in general surgical residency at the public hospital, Hospital Ipiranga in Sao Paulo, Brazil before completing his plastic surgery fellowship at the Universidad Santo Amaro, (in Sao Paulo, Brazil).

He is a member of the Colombian Society of Plastic Surgery (SCCP), as well as the Brazilian Society of Plastic Surgery.

Dr. Betancourt speaks Portuguese and English in addition to his native Spanish. He reports some trepidation with his English but was readily able to communicate with me without difficulties.

Dr. Juan David Betancourt Parra

Torre de Especialistas Intermedica 

# 1816

Calle 7 No.39 – 137

Medellin

Tele: 352 0264

Email: plasticjdb1@une.net.co

Website: www.plasticjbd.com

International Patients

While the majority of Dr.Betancourt’s patients are from the local area, he does see international patients. After an initial contact by email, or via his internet page, Dr.Betancourt solicits a complete medical history including previous surgical reports (from previous bariatric or plastic surgery procedures) and current photos.  Patients will also need to have blood work, and EKG as part of the pre-operative evaluation.  Additional studies may be needed depending on the individual’s history and diagnostic test results. (Patients may be referred to Internal Medicine specialist, as needed).

Following the on-line/ email communications, patients will be seen, for an in-person consultation and full physical examination. Dr. Betancourt’s office will make arrangements for a translator and companion to accompany the patient, as needed.  With the patient’s assistance, a full surgical treatment plan will be designed at that time – which discusses how many surgeries and what the anticipated timeline and recovery will be.

As discussed above, the torsoplasty/ belt lipectomy is usually the first procedure performed, often followed by reduction mammoplasty/ mammoplexy.

With the torsoplasty, patients are usually hospitalized for 1 to 2 nights.  They are encouraged to be active and ambulatory as soon as possible after surgery to prevent post-operative complications such as thrombosis and pneumonia. Dr.Betancourt usually engages private nurses to assist patients following their discharge from the hospital.

Sufficient recovery from return travel usually requires 3 weeks, and is monitored by Dr.Betancourt.

Dr. Betancourt also provides psychological / counselling referrals as needed for patients.

Additional References / Reading and Resources on post-bariatric surgery

* Recommended reading:  Langer V, Singh A, Aly AS, Cram AE. (2011).   Body contouring following massive weight loss. Indian J Plast Surg [serial online] 2011 [cited 2013 Aug 11];44:14-20. Available from: http://www.ijps.org/text.asp?2011/44/1/14/81439

Excellent article with general overview of the issues and procedures with before and after photographs.

* Recommended reading:  Shrivastava P, Aggarwal A, Khazanchi RK. Body contouring surgery in a massive weight loss patient: An overview. Indian J Plast Surg [serial online] 2008 [cited 2013 Aug 11];41:114-29. Available from: http://www.ijps.org/text.asp?2008/41/3/114/43607

Additional Readings

Distressing skin problems” – a 2011 first person story about skin problems after massive weight loss from the UK paper, Daily Mail.

Aldaqal SM, Makhdoum AM, Turki AM, Awan BA, Samargandi OA, Jamjom H. (2013).   Post-bariatric surgery satisfaction and body-contouring consideration after massive weight loss.  N Am J Med Sci. 2013 Apr;5(4):301-5. doi: 10.4103/1947-2714.110442.

Giordano S, Victorzon M, Koskivuo I, Suominen E. (2013).  Physical discomfort due to redundant skin in post-bariatric surgery patients.  Plast Reconstr Aesthet Surg. 2013 Jul;66(7):950-5. doi: 10.1016/j.bjps.2013.03.016. Epub 2013 Apr 9.  [free full text not available].

Song AY, Rubin JP, Thomas V, Dudas JR, Marra KG, Fernstrom MH. (2006).  Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring). 2006 Sep;14(9):1626-36. [no free full text available].

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Plastic surgery trends: Latin America leads the way


Just posted a new article over at Examiner.com based on a series of interviews with local plastic surgeons here in Medellin, Colombia.

The article summarizes the newly emerging trend of ‘less is more‘ meaning smaller breast implants, less fat grafting, and more sculpting liposuction, and Botox..

As we discussed in a previous post – the evolution of beauty ideals is a continuous process – and can change dramatically over the course of a decade.  So after the ‘I like big butts’ and porn-star ideals of the 1990’s and lush, voluptuous 2000’s, is it much of a surprise that plastic surgery is heading towards a more athletic idea (of sculpted abs) and smaller, less dramatic curves?

So, consumers, keep in mind – as you consider procedures – less is more, and what’s beautiful today – may be considered excess tomorrow.. Try to find a procedure/ ideal/ and outcome that suits you, and your body – instead of conforming to an ever-changing ideal..

 

 

 

Talking with Dr. Ruy Rodrigo Diaz, plastic surgeon


Dr. Rodrigo Diaz is a plastic surgeon at the Clinicas de Las Americas in Medellin.  He primarily specializes in facial plastic surgery (rhinoplasty, blepharoplasty, forehead surgery, facial endoscopy, face-lifts and fillers) and breast surgery (augmentation/ reduction).  He reports that he receives most of his clients by work of mouth but does see a significant percentage of medical tourists.

photo (30)

The majority of his patients are private practice (self-pay) patients but he does see patients from many of the major Colombian health care insurance plans such as Colseguro, Liberty, Sur America, Colsanitas.  While American insurance companies do not traditionally cover elective cosmetic procedures, it is worth investigating with your insurer as many of the larger plans such as Blue Cross/ Anthem now have ancillary plans for cosmetic procedures.

Dr. Diaz has been a practicing plastic surgeon for thirty years, and a professor of plastic surgery at the Universidad de Antioquia for the past 12 years.  He attended the Universidad de Antioquia medical school and completed his plastic surgery residency there as well.

Like all Colombian surgeons profiled here at Latin American Surgery.com, he is a member of the Colombian Society of Plastic, Aesthetic and Reconstructive Surgery.  He is also a member of the American Society of Plastic Surgeons (ASPS) and the International Society of Plastic, Reconstructive and Aesthetic surgery.

Pre-operative process

As we talk, he reviews the pre-operative process for his patients. “It usually starts with an email from the patient,”he states.  Then he solicits a complete medical history from the patient, including medications, past surgeries, social habits (smoking, drinking etc), current and past medical problems (like hypertension) and family history.  This also includes photographs so he can best determine exactly what procedure(s) they will need, plan the procedure and discuss anticipated results.

If they have a single problem (like high blood pressure), then he sends the patient for a complete medical evaluation.

All smokers are required to quit at least 2 months before the procedure, and Aspirin (and other anti-platelets) must be discontinued 8 days before the scheduled procedure.

Out-of-town patients are encouraged to bring another adult with them, and additional translators are provided as needed.

Plan for adequate recovery time

One of the things he stresses heavily during our interview is the need for medical tourists to allocate adequate time to the recovery process before returning to their home country.  This is something that has been brought up in previous interviews with other surgeons, as well but bears repeating.  Even smaller surgeries require adequate healing time, so the idea of a ‘weekend surgical makeover’ should be dismissed from the minds of potential clients.

Most important aspect is post-operative care

The time necessary for adequate healing is usually 15 days to three weeks depending on the procedures.  This period is also important for surgeons to be able to detect small problems such as delayed healing before it becomes a bigger problem.  “It is better for me to see an incision that isn’t healing right away so I can treat it immediately, then for the patient to put it off – and then seek treatment weeks later when it is a much larger problem.”

Another reason he encourages patients to not to rush home, is that surgeons in their home countries may be unwilling to care for patients who have surgery elsewhere.

Patients take priority

Dr. Diaz prides himself in providing excellent post-operative care. All patients have his cell phone, and he encourages them to use it for all and every question or concern – day or night.  “If they need me, I am here.”

And – don’t worry, if you are hesitant to call him – he is going to call you anyway, just to check in and make sure you are doing well, and your pain is controlled.  He calls all of his patients the day after surgery, and continues to check-in and see patients frequently during the first weeks after surgery.

“My patients always take priority, even after they return home.  If I have a patient Skyping me in the office – well, that takes priority over other things because I know what a hassle it is for them.”

He speaks English fluently but reports he continues to take weekly classes in English and American culture.  He feels that it is impossible to have a complete understanding and good communication of his clients without understanding the culture.

Trends in facial plastic surgery

During his lengthy plastic surgery career, Dr. Diaz has seen a lot of trends come and go in aesthetics. He reports that one of the main trends he has seen over the last few years, is a trend for lesser facial procedures such as facial endoscopy, eyelid surgery or use of fillers by his clients versus a full face-lift. He states the reasons are multiple. Patients want to avoid the dreaded “plasticized / surgerized” artifical appearance that has been highly visible in popular media such as American reality shows, and prefer more subtle results, so his patients tend to seek treatment earlier, just a lines and folds appear.  While many of these treatments are temporary like fillers or laser re-surfacing, the results are more natural and aesthetically pleasing.

Secondly, patients want to avoid the longer downtown involved with a larger procedure like a face-lift which may have residual bruising, or swelling for several weeks.  These patients want to be refreshed and back in the office quickly.

Lastly, as he reflects on his career and the ‘style’ of plastic surgery – he reports that for many of his clients (particularly Colombian client), the focus is so heavily on the body (breast and buttock augmentation) that the face is secondary in consideration.

Dr. Ruy Rodrigo Diaz

Calle 32 No 72-28

Clinica de Las Americas, 4th floor

Medellin

Tele: 345-9159

Email: rdiaz@une.net.co

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.

In the operating room with Dr. Luis Botero, plastic surgeon


Please note that some of the images in this article have been edited to preserve patient privacy.  

Today, Dr. Luis Botero has invited me to observe surgery at IQ Interquirofanos in the Poblado section of Medellin.  He is performing full-body liposuction and fat grafting of the buttocks.

Dr. Luis Botero, in the operating room

Dr. Luis Botero, in the operating room

The facility: IQ Interquirofanos

Interquirofanos is located on the second floor

Interquirofanos is located on the second floor

IQ Interquirofanos is an ambulatory surgery center located on the second floor of the Intermedica Building across the street from the Clinica de Medellin (sede Poblado).  The close proximity of this clinic to a hospital is an important consideration for patients in case of a medical emergency.

The anesthesiologists estimate that 90% of the procedures performed here are cosmetic surgeries but surgeons also perform gynecology, and some orthopedic procedures at this facility.

The are seven operating rooms that are well-lit, and feature modern and functional equipment including hemodynamic monitoring, anesthesia / ventilatory equipment/ medications.  There are crash carts available for the operating rooms and the patient recovery areas.

There are fourteen monitored recovery room beds, while the facility currently plans for expansion.  Next door, an additional three floors are being built along with six more operating rooms.

Sterile processing is located within the facility with several large sterilization units.  There is also a pharmacy on-site.  The pharmacy dispenses prosthetics such as breast implants in addition to medications.

The only breast prosthetics offered at this facility are Mentor (Johnson & Johnson) and Natrelle brand silicone implants (Allergan).  In light of the problems with PIP implants in the past – it is important for patients to ensure their implants are FDA approved, like Mentor implants.

In the past seven years, over 31,000 procedures have been performed at Interquirofanos.  The nurses tell me that during the week, there are usually 30 to 35 surgeries a day, and around 15 procedures on Saturdays.

Prior to heading to the Operating Room:

Prior to surgery, patients undergo a full consultation with Dr. Botero and further medical evaluation (as needed).  Patients are also instructed to avoid aspirin, ibuprofen and all antiplatets (clopidogrel, prasugrel, etc) and anti-coagulants (warfarin, dabigatran, etc.) for several days.  Patients should not resume these medications until approved by their surgeon.

Complication Insurance

All patients are required to purchase complication insurance.  This insurance costs between 75.00 and 120.00 dollars and covers the cost of any treatment needed (in the first 30 days) for post-operative complications for amounts ranging from 15,000 dollars to 30,000 dollars, depending on the policy.   All of his clients who undergo surgery at IQ Interquirofanos are encouraged to buy a policy from Pan American Life de Colombia as part of the policies for patient safety at this facility. International patients may also be interested in purchasing a policy from ISPAS, which covers any visits to an ISPAS-affiliated surgeon in their home country.

Today’s Procedures: Liposuction & Fat Grafting

Liposuction – Liposuction (lipoplasty or lipectomy) accounts for 50% of all plastic surgery procedures.   First the surgeon makes several very small slits in the skin.  Then a saline – lidocaine solution is infiltrated in to the fat (adipose) tissue that is to removed. This solution serves several purposes – the solution helps emulsify the fat for removal while the lidocaine-epinephrine additives help provide post-operative analgesic and limit intra-operative bleeding.  After the solution dwells (sits in the tissue) for ten to twenty minutes, the surgeon can begin the liposuction procedure.  For this procedure, instruments are introduced to the area beneath the skin and above the muscle layer.

During this procedure, the surgeon introduces different canulas (long hollow tubes).  These tubes are used to break up the adipose tissue and remove the fat using an attached suctioning canister.  To break up the fat, the surgeon uses a back and forth motion.  During this process – one hand is on the canula.  The other hand remains on the patient to guide the canulas and prevent inadvertent injury to the patient.

fat being removed by liposuction

fat being removed by liposuction

Due to the nature of this procedure, extensive bruising and swelling after this procedure is normal.  Swelling may last up to a month.  Patients will need to wear support garments (such as a girdle) after this procedure for several weeks.

Types of liposuction:

In recent years, surgeons have developed different techniques and specialized canulas to address specific purposes during surgery.

Standard liposuction canulas come in a variety of lengths and bore sizes (the bore size is the size of the hole at the end of the canister for the suction removal of fat tissue.)  Some of these canulas have serrated bores for easier fat removal.

Ultrasound-assisted liposuction uses the canulas  to deliver sound waves to help break up fat tissue.  These canulas are designed for patients who have had repeated liposuction.  This is needed to break up adhesions (scar tissue) that forms after the initial procedure during the healing process.

Laser liposuction is another type of liposuction aimed at specifically improving skin contraction.  This is important in older patients or in patients who have excessive loose skin due to recent weight loss or post-pregnancy.  However, for very large amounts of loose skin or poor skin tone in areas such as the abdomen, a larger procedure such as abdominoplasty may be needed.

During laser liposuction, a small wire laser is placed inside a canula to deliver a specific amount of heat energy to the area (around 40 degrees centrigrade).  The application of heat is believed to stimulate collagen production (for skin tightening).  Bleeding is reduced because of the cautery effect of the heat – but post-operative pain is increased due to increased inflammatory effects.  There is also a risk of burn trauma during this procedure.

There have been several other liposuction techniques that have gone in and out of fashion, and many of the variations mentioned are often referred to by trademark names such as “Vaser”, “SmartLipo”, “SlimLipo” which can be confusing for people seeking information on these procedures.

Fat Grafting

Fat from liposuction procedure to be used for buttock augmentation

Fat from liposuction procedure to be used for buttock augmentation

Fat grafting is a procedure used in combination with liposuction.  With this procedure, fat that was removed during liposuction is relocated to another area of the body such as the buttocks, hands or face.

In this patient, Dr. Botero injects the fat using a large bore needle deep into the gluteal muscles to prevent a sloppy, or dimpled appearance.  Injecting into the muscle tissue also helps to preserve the longevity of the procedure.  However, care must be taken to prevent fat embolism*, a rare but potentially fatal complication – where globules of fat enter the bloodstream.  To prevent this complication, Dr. Botero carefully confirms the placement of his needle in the muscle tissue before injecting.

Results are immediately appreciable.

fat being injected for buttock augmentation. (Photo edited for patient privacy).

fat being injected for buttock augmentation. (Photo edited for patient privacy).

The Surgery:

Patient was appropriately marked prior to the procedure.   The patient was correctly prepped, drapped and positioned to prevent injury or infection.  Ted hose and sequential stockings were applied to lessen the risk of developing deep vein thrombosis.  Pre-operative procedures were performed according to internationally recognized standards.

Sterility was maintained during the case.  Dr. Botero appeared knowledgeable and skilled regarding the techniques and procedures performed.

His instrumentadora (First assistant), Liliana Moreno was extremely knowledgeable and able to anticipate Dr. Botero’s needs.

Circulating nurse: Anais Perez maintained accurate and up-to-date intra-operative records during the case.  Ms. Perez was readily available to obtain instruments and supplies as needed.

Overall – the team worked well together and communicated effectively before, during and after the case.

Anesthesia was managed by Dr. Julio Arango.   He was using an anesthesia technique called “controlled hypotension”.  (Since readers have heard me rail about uncontrolled hypotension in the past – I will write another post on this topic soon.)

Controlled Hypotension

However, as the name inplies – controlled hypotension is a tightly regulated process, where blood pressure is lowered to a very specific range.  This range is just slightly lower than normal (Systolic BP of around 80) – and the anesthesiologist is in constant attendance.  This is very different from cases with profound hypotension which is ignored due to an anesthesia provider being distracted – or completely absent.

With hypotensive anesthesia – blood pressure is maintained with a MAP (or mean) of 50 – 60mmHg with a HR of 50 – 60.  This reduces the incidence of bleeding.

However, this technique is not safe for everyone.  Only young healthy patients are good candidates for this anesthesia technique.  Basically, if you have any stiffening of your arteries due to age (40+), smoking, cholesterol or family history – this technique is NOT for you.  People with high blood pressure, any degree of kidney disease, heart disease, peripheral vascular disease or diabetes are not good candidates for this type of anesthesia. People with these kinds of medical conditions do not tolerate even mild hypotension very well, and are at increased risk of serious complications such as renal injury/ failure or cardiovascular complications such as a heart attack or stroke.  Particularly since this is an elective procedure – this is something to discuss with your surgeon and anesthesiologist before surgery.

The patient today is young (low 20’s), physically fit, active with no medical conditions so this anesthesia poses little risk during this procedure. Also the surgery itself is fairly short – which is important.  Long/ marathon surgeries such as ‘mega-makeovers‘ are not ideal for this type of anesthesia.

Dr. Julio Arrango keeps a close eye on his patient

Dr. Julio Arango keeps a close eye on his patient

However, Dr. Arango does an excellent job during this procedure, which is performed under general anesthesia.   After intubating the patient, he maintained a close eye on vital signs and oxygenation.  The patient is hemodynamically stable with no desaturations or hypoxia during the case.  Dr. Arango remains alert and attentive during the case, and remains present for the entire surgery.  Following surgery, anesthesia was lightened, and the patient was extubated prior to transfer to the recovery room.

He also demonstrated excellent knowledge of international protocols regarding DVT/ Travel risk, WHO safety protocols and intra-operative management.

Surgical apgar score: 9  (however, there is a point lost due to MAP of 50 – 60 as discussed above).

Results of the surgery were cosmetically pleasing.

Post -operative care:

Prior to discharge from the ambulatory care center after recovery from anesthesia the patient (and family) receives discharge instructions from the  nurses.

The patient also receives prescriptions for several medications including:

1. Oral antibiotics for a five-day course**. Dr. Botero uses this duration for fat grafting cases only.

2. Non-narcotic analgesia (pain medications).

3. Lyrica ( a gabapentin-like compound) to prevent neuralgias during the healing period.

The patient will wear a support garment for several weeks.  She is to call Dr. Botero to report any problems such as unrelieved pain, drainage or fever.

Note: after some surgeries like abdominoplasty, patients also receive DVT prophylaxis with either Arixtra or enoxaparin (Lovenox).

Follow-up appointments:

Dr. Botero will see her for her first follow-up visit in two days (surgery was on a Saturday).  He will see twice a week the first week, and then weekly for three weeks (and additionally as needed.)

* Fat embolism is a risk with any liposuction procedure.

**This is contrary to American recommendations as per the National Surgical Care Improvement Project (SCIP) which recommends discontinuation within the first 24 hours to prevent the development of antibiotic resistance.

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.

Sanabria, breast implant

Medellin Plastic Surgeons: Aristizobal Aramburo thru Gomez Botero


Medellensa (or women from Medellin) are considered some of the most beautiful women in the world.  However, they often have had some help.  Plastic surgery is wildly popular in Medellin, Colombia and much of Latin America, and standards of beauty are based on a voluptuous physique with large breasts, small waist and an (often) exaggerated caboose.  Actress Sofia Vergara, of Barranquilla is a classic example of Colombian beauty ideals, which have spread into popularity to the United States.  Many North Americans and Europeans seeking this look come to Medellin for the city’s famed plastic surgeons.

Of the 650 members of the Colombian Society of Plastic, Aesthetic and Reconstructive Surgery, 98 members are located in the Medellin area. Using this directory, I attempted to contact surgeons for interviews.  When e-mail addresses were not available, I contacted surgeons thru the Colombian Society website, when that option was available*.  If the surgeons listed a website, contact was also attempted via website.

Alphabetical listing – compilation is ongoing as I continue efforts to contact and interview plastic surgeons in the city.

Luis Fernando Aristizobal Aramburo

Calle 7 #39-290  Office # 1216 Cl Medellin

Medellin

Tele: 266 9823

Email: aristi01@epm.net.co

Emailed 7/4/2013, no reply.

Joaquin Aristizabal

No email or internet contact information available

Edgar Alonso Becerra Torres

Calle 6 Sur #43 – 200

Office # 1001

Sector Poblado

Medellin

Tele: 268 – 1132

Email: consultorio1001@une.net.co

Website: esteticaedgarbecerra.com

Emailed 7/4, and used contact form at site, no reply.

Carlos Alberto Betancourt Madrid

No contact information provided

Juan David Betancourt Perra

Calle 7 #39- 197 Torre Intermedica

Piso 13, Office # 1816

Medellin

Tele: 352 – 0264

Email: plasticjdb1@une.net.co

Website: www.plasticjdb.com

Emailed 7/4, no reply.  Met in person at the Clinica Interquirofanos 7/13/2013.

Specializes in post-bariatric surgery procedures.  Interviewed August 2013.  To read the interview, click here.

Rafael Ivan Botero Botero

Clinica Las Vegas Fase II

Office # 370

Medellin

Tele: 311 9167

No email provided.

Contacted via Society website on 7/4

Lists fluency in English and Spanish.

Luis Fernando Botero Guiterrez

Cra. 25A # 1-31  Parque emp. El Tesoro

Office # 907

Medellin

Tele: 448 – 6030

Email: luchobot@gmail.com

Emailed 7/4, responded immediately.

Lists English and French in addition to Spanish.  Following correspondence, I interviewed Dr. Botero at his office.  The interview with Dr. Botero can be seen here.  You can read about my visit to the operating room here.

Juan Botero Londono

No contact information provided

Jenny Carvajal Pareja

Calle 2 Sur #46 – 55

Office 266  Fase II

Medellin

Tele: 444 – 1312

No email provided

Contacted via society site 7/4*

J. Mario Castillon Montoya

Clinica Medellin Fundadores

Office #1003

Medellin

Tele: 511-6634

No email provided

Contacted via society site 7/4*

Diego Alberto Castillon Munoz

Calle 54 # 46 – 27 (Clinica Medellin)

Office # 1003

Medellin

Tele: 511 -6634

Email: dacastillon@une.net.co

Emailed 7/4, no reply

Reports on the society website that he speaks English and French in addition to native Spanish.  Shares office with Mario Castillon.

Oscar de Jesus Chica Gutierrez

Calle 2 Sur #46 – 55

Office 235

Medellin

Tele: 311 – 6344

Email:  oscarchica1@hotmail.com

Emailed 7/4, no reply.

Camilo Correo Herrera

No contact information provided.

John Emiro Cortes Barbosa

Calle 33 # 74E – 80 Cl. Medellin

Tele: 250 – 3941

Cell: 315 – 343 – 6898

Email: jamanta@hotmail.com

Emailed 7/4

Speaks English.

Jose Ivan Cortes Hernandez

Calle 38A # 80 – 72 Apto. 216

Cuidadela Laureles

Medellin

Tele: 412 5803

No email ontact provided.

David Ricardo Delgado Anaya

No contact information available

Ruy Rodrigo Diaz

Calle 32 # 72 – 28 Clinica Las Americas

Medellin

Tele: 345 – 9159

Email: rdiaz@epm.net.co

Emailed 7/4.   Interviewed July 18, 2013.  To read more about the interview, click here.

Jenny Maricela Diaz Cortes

Cra. 48B # 15 Sur 35

Aguacatala 2

Medellin

Tele: 321 0539

Cell: 317 639 7501

No email.  Contacted on 7/4 using society form*.

Gonzalo Diaz Palmett

Calle 2 Sur # 46 – 55

Office # 450

Medellin

Tele: 268 – 0158

Email: sdiaz@une.net.co

Emailed 7/4,no reply.

Andres Diaz Romero

Diag 75B # 2A – 80

Office # 421

Torre Medica Clinica Las Americas

Medellin

Tele: 345-9159

Email: cplastica@hotmail.com

Emailed 7/4 no reply received.

Clemencia Duque Vera

Diag 75B # 2A – 80

Office # 419

Torre Medica Clinica Las Americas

Medellin

Tele: 345-9159

Email: duqueclemencia@hotmail.com

Emailed 7/4, no reply received.

Alberto Echeverry Arango

Diag 75B # 2A – 80

Office # 422

Torre Medica Clinica Las Americas

Medellin

Tele: 345 – 9160

Email: albertoecheverry@yahoo.com

Emailed 7/4, no reply.

William Echeverry Duran

Calle 1A Sur # 43A – 49

Office # 206, Edificio Colmena

Medellin

Tele: 311 – 0555

No email.  Attempted contact via society site on 7/4*.

Francisco Fabian Eraso Lopez

Cra. 45 # 1 – 191

Torre 1 Apto 1607

Torres Patio Bonito

Medellin

No telephone, no email provided

Attempted contact via society site on 7/4*

Julio Cesar Eusse Llanos

Calle 7 # 39 – 197

Office # 908

Medellin

Tele: 444-5464

No email.  Attempted contact via society form 7/4*

Sabrina Gallego Gonima

Calle 2 Sur #46 – 55  Fase I

Office # 528

Medellin

Tele: 311 – 6780

Email: sgallegog@gmail.com

Emailed 7/4, no reply.

Lists English and French in addition to Spanish.

Monica Maria Garcia Gutierrez

Calle 33 # 42B – 06

Office 1220

Torre Sur San Diego

Medellin

Tele: 262 – 3915

Email: monicamg@une.net.co

Emailed 7/8.

Rodrigo Gaviria Obregon

Carrera 25B $ 16A Sur – 211

Biofarma

Medellin

Tele: 317 1626

Email: Rodrigo.gaviria@biofarma.com.co

Email bounced.

Julio Alberto Giraldo Mesa

Carrera 25A # 1 -31

Office 716

Parque emp. El Tesoro

Medellin

Tele: 317 4478

Cell: 311 333 4061

No email listed, emailed through society website on 7/8*.

Profile states he speaks English and Portuguese in addition to Spanish.

Lists plastic surgery education at Hospital Barata Riverio – Rio de Janiero, Brazil.

Martha Elena Gomez Botero

Calle 2 Sur # 46 -55

Clinica Las Vegas

Medellin

Tele: 268-3818

Email: megomezbotero@hotmail.com

Emailed 7/8.

Dr. Gomez specializes in maxiofacial surgery and hand surgery.

** the website  email form for the Colombian society of plastic surgeons does not appear to be working. I have contacted the society regarding this issue.