Hollywood Plastic Surgeon, Dr. Frank Ryan

Hollywood plastic surgeon to the stars, Dr. Frank Ryan, died this last week in a single car accident that was apparently the result of texting while driving. A while ago I had commented on some of his surgeries on Heidi Montag. He was a good surgeon involved with a, to put it mildly, unstable patient in Heidi Montag. And I think that even he, in the end, had told her no more, especially with respect to her breast augmentation. He was a board certified plastic surgeon, a UCLA graduate like me and did good work. There are too many surgeons out there who don’t do good work. There are the many pretenders, the  faux plastic surgeons, these are the get-rich-quick surgeons who are entering the profession in droves because there is no reimbursement in conventional medicine. Dr. Ryan was one of the doctors inside plastic surgery doing his best work for his patients.

This is not necessarily a eulogy to Dr. Ryan but more of a commentary on the tragedy of his death. All of our lives are becoming much more complicated. Because of the nature of business today, plastic surgeons are spending a great deal of time on their websites their blogs their Facebook or Twitter and who knows what else will be coming down the road. If the news reports are true, Dr. Ryan’s death was caused by his tweeting while driving on a fairly dangerous road. Once we become addicted to our electronic media they are a constant part of our lives. Multitasking is also something that many of us feel obligated to do because there just isn’t enough time in the day. This combination of factors, keeping up with his twitter, multitasking and being distracted seems to have led to his untimely death. There are several things that we can take away from this tragedy first and most obvious texting while driving kills. There was a ubiquitous sign poster in the 1960s that said speed kills. This was obviously referring to the drug not velocity. Nowadays texting kills. A friend of mine was almost killed recently when he narrowly averted a head-on collision because a girl in the opposite lane was texting while driving 65 miles per hour on a two-lane highway, didn’t have a clue, and then lost control of her car. She hit the side of his car, spun out and ended up in the hospital, lucky to be alive. She said, “I wasn’t texting, I was reading a text,” which, of course, is texting. Don’t text and drive, it’s just that simple.

The other thing that this incident does is it gives us pause for reflection about how complicated our lives have become. Are we spending more time with our computers, laptops and iPhone’s then we are with the people we love. Are we tweeting, facebooking and texting more than talking and sitting with these people? The pace of life seems to accelerate every year just a little bit. Like the lobster in the stew pot, we don’t even know we are being boiled until it’s too late. This may be a good time to reevaluate all our relationships with our machines, how dangerous they are at times and how much of our lives they consume. Life is short and you never know when your number is going to come up, take time while you still have a chance to enjoy it. The second to last of Frank Ryan’s tweets was, “After 25 years of driving by, I finally hiked to the top of the giant sand dune on the pch west of Malibu. Much harder than it looks!  Whew!”

Dr. Frank Ryan's last tweet: "Border collie jill surveying the view from atop the sand dune."

Then he posted a picture of his dog at the top of the sand dune while driving away. It is a sad irony that it would be the high-tech sharing of a moment he stole away from his hectic schedule to enjoy actually living, that would end his life.

There’s even a $7,000 entry-level course being taught for anyone with an M.D. degree to learn how to perform breast augmentation. At the end of this weekend course, someone with only modest surgical skills could learn how to balloon up the breast tissue as you would for liposuction, and do a very limited pocket under the breast and over the muscle for a large incision in the breast fold and then put an implant in and sew it up.

What does surgical judgment, experience and aesthetic judgment count for?  By the time I had started my cosmetic breast practice, I had performed hundreds of a much more difficult procedure: breast reconstruction. This gave me a great deal of experience with the sub muscular pocket and the beginnings of the concept of the muscle brassiere. In addition, with breast reconstruction, you are usually trying to match and adjust the opposite side.

So is judgment and experience important?  Just this last week, among the other cases cited were breast cases: bilateral and augmentation, unilateral augmentation, and then a mastopexy bilateral Salt removal and replacement bilateral implant removal incised exchange.

Just as an outline of the process of breast augmentation and lift:

1. Preoperative marking
2. General anesthesia
3. Incisions
4. Making the sub muscular pocket with muscle support
5. Placement of a sizer to expand the pocket to fit the breast implant
6. Sit the patient up for visual assessment for shape and volume
7. Make necessary adjustments to the size
8. Temporary sutur breast lift
9. Sit up for assessment
10. Remove sutures
11. Second temporary breast lift
12. Sit patient up for assessment
13. 3rd Temporary breast lift
14. Set up okay just markings
15. Remove skin
16. Suture closures
17. Set up for final check of finished lift and augmentation to make sure it is aesthetically correct.

These steps were for a complicated major breast lift and augmentation with asymmetry.  There are many different surgical steps with a lot of decisions to be made at every step. The reason you can’t just throw some markings and then cut on the dotted line is for every change in volume, there are changes in dimension according to the skin tension. This is different according to every person.

There’s a lot more to cosmetic breast augmentation, breast lifts and breast surgery than just putting a little bag under the skin. Cosmetic breast surgery has a steep learning curve that takes years to master.  This is especially true if one is performing symmetry surgery or revision surgery, which is complicated three-dimensional surgery.  It is definitely not for the gynecologist with time on his hands who has just taken a weekend course.

There is a disturbing trend in medicine where internists, family doctors, gynecologists and other specialists are offering to do plastic surgery procedures as a way of making a little cash, “on the side.”  Dermatologists and E.N.T. (ear, nose & throat) doctors are expanding into areas where they have little or no training.  Because of this, complications are escalating like never before.

I know someone who went in for a yearly checkup and found her internists now owned a roomful of lasers next-door and was promoting their use.  The largest liposuction clinic in my community is run by an internists and an emergency room doctor.  Family practice doctors are opening, “med spas.”   Some E.N.T. doctors are beginning to perform breast augmentation surgery and gynecologists are doing face-lifts. What’s going on?

A recent article in Plastic and Reconstructive Surgery by Matthew Camp, titled Who is Providing Aesthetic Surgery? A detailed examination of the geographic distribution and training backgrounds of cosmetic practitioners in Southern California put some insight into this question.

So what is going on?

Medicine is hard-pressed for fair reimbursement by health insurance companies.  Despite any statements to the contrary, it is likely going to get worse in the future.  More and more doctors will be attempting to supplement their income by offering plastic surgery procedures in which they have little or no training.

Plastic surgery is literally the only cash business left in medicine, especially if you include hair transplants, laser hair removal, varicose veins, and all noninvasive treatments under that umbrella.

Individual magazines devoted to different specialties routinely promote, “boosting your income by adding cosmetic services.”  Medical meetings also promote one-day workshops in different procedures and technologies.

Makers of cosmetic products and devices are actively promoting their goods to non-plastic surgeons as a way of expanding their markets.  Moreover, those that are not intentionally marketing to these doctors are none-the-less bound by law to sell to these doctors if the doctor orders from them.  This is because in California, a medical doctor has a license that entitles him or her to do anything they see medically fit in the office.  He can do brain surgery, heart surgery, or sex changes.  If something goes wrong, let the lawyers sort it out after the fact.  There is no restraint of trade for physicians.  Hospitals monitor doctors and only allow them to have privileges for those procedures in which they have actual training and/or certification.  This is why most of these practitioners who are expanding their offerings work only in their offices where they are completely unsupervised and unregulated.

The economic situation that is leading gynecologists to start offering facelifts is also placing very young plastic surgeons, just out of school, in a difficult situation.  Therefore, they are vulnerable to being scooped up by franchise corporations that have catchy names and usually offer one specialty procedure at what they suggest is a discount price that an established and experienced plastic surgeon cannot compete with. The reality is that in most cases they are at or very near regular market prices for these procedures.  These “McFacelift” shops or “LipoKing” franchises perform procedures with pressure on the doctors and staff to do as many per day and as fast as they possibly can.  To quote from the Camp article, “the development of aesthetic practices with individual providers are considered to be interchangeable and replaceable is becoming ever more prominent.”  This is particularly the case among the “medispas.” The practices are often named after a geographic location with the cachet of affluence such as Rodeo Drive, Beverly Hills or La Jolla.  In these practices, or perhaps better described as “mills,” the practitioners are employees of the corporate owner of the clinical facility and are pushed to produce revenue.  The divorce of the practice from the name of a responsible physician has the potential to have a profound impact on the doctor-patient relationship and how patients select a provider.

Therefore, as the Romans said, “caveat emptor;” Let the buyer beware. This is especially true in California since there is essentially no enforcement by the medical board, which has recently been stripped of most of its funding.  Many complaints and many bodies must pile up before anything will be done.  Any doctor can do virtually anything in his office and will not be stopped until there are large numbers of complaints or he kills or maims a patient.  It is amazing that we require such tight restrictions on many other fields such as airline pilots.  What is happening is the equivalent of allowing someone who knows how to fly a single engine plane to go ahead and sit at the controls of 747, bringing it down for a landing into a major metropolitan area without any training.  Do you want the professional airline pilot with a complete education or someone who had a one-day course in the 747 before he takes your life into his hands? On the flip side, I am a trained plastic surgeon who has had thousands of hours of training and experience in plastic surgery but I have also had some training in many other aspects of medicine.  Legally, I can perform brain surgery and heart transplants in my own operating room, but would I be your best choice if you needed these procedures?  What if I were to offer to do the surgery at a discount?  …Yeah, I didn’t think so.

If you’re considering a plastic surgeon, do what the caterpillar did.  Ask, “who are you?”  “Are you board-certified?”  “Are you board-certified in plastic surgery?”  “How many of these procedures have you done?”  “How long have you been providing this procedure?”  “Do you have hospital privileges?  Or is plastic surgery just another way to boost your income.”  Or, “are you a cosmetic surgeon” which is essentially a meaningless term since there is no recognized Board of cosmetic surgery.

Caveat emptor. Do your homework and trust your gut feelings.  If you feel unsure or apprehensive, regardless of whom the person is, move on.  Plastic surgery is not like having your hair done.  Some people spend more time researching a vacation then researching a plastic surgeon, don’t be one of them.