Hawking Surgery

“Hawking” surgery makes me grumpy.
Glossing over the risks involved with surgery to promote your product makes me grumpy.
E! Reality Show is “hawking” plastic surgery as part of the prize package for brides in their new show “Bridalplasty.” 

Over Diagnosis of Breast Cancers

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Are breast cancers over-diagnosed?  If so, how often?  Those are the questions looked at by the systematic review of incidence reported data/articles done by Karsten Juhl Jørgensen & colleagues.  Their results are published online in the June 9th issue of the British Medical Journal.   Their review shows an estimated 52% over-diagnosis of breast cancer.

The researchers’ objective was to estimate the extent of over-diagnosis.  Screening for breast cancer is meant to detect lethal cancers earlier.  Unfortunately it also detects harmless ones that will not cause death or symptoms. As it is not possible to distinguish between lethal and harmless cancers, all detected cancers are treated. Over-diagnosis and overtreatment are therefore inevitable.

They begin their review of incidence reported data from 7 years before routine screening programs were implemented and 7 years after full screening was implemented.  They included screened and non-screened age groups.  Data was available from United Kingdom; Manitoba, Canada; New South Wales, Australia; Sweden; and parts of Norway.

This data came from a PubMed search (May 2006) which yielded 2861 titles, 2546 of which were not relevant.  That left 315 articles which were evaluated. Four were included as core articles and one was added when the search was updated in April 2007, presenting data from the United Kingdom; Manitoba, Canada; New South Wales, Australia; Sweden; and parts of Norway.  A meta analysis was done on the data.

Looking at the United Kingdom data, they found that the screening program began in 1988 for women aged 50-64.  National coverage began by 1990.  The screening was expanded to women aged 65-70 in 2002.   There was a 41% higher than expected rate of invasive cancer found in women aged 50-64 during the 1993-1999 period with no compensatory drop during the 7 yrs after full screening was implemented.  This is interpreted as over diagnosis of breast cancer.  This chart (photo credit) shows the incidence of invasive breast cancer per 100,000 women in UK.

This same trend was found in the data from the other countries.  Combining the data, the researchers estimated 52% over diagnosis of breast cancer in a populations of women who are offered organized mammography screening.  That amounts to one in three breast cancers being over diagnosed.

We need improved screening methods to decrease this number to less than 10% over-diagnosis.   Each “un-necessary” surgery for one of the over-diagnosed cancers puts the patient at risk for complications.  Not to mention the increased cost to the healthcare system of each country.

REFERENCE

Overdiagnosis in publicly organised mammography screening programmes: systematic review of incidence trends; BMJ 2009;339:b2587;  Karsten Juhl Jørgensen, researcher, Peter C Gøtzsche, director

A Few Other Breast Cancer Related Posts

Breast Self Exam (BSE) (October 2008)
Mammograms (October 2008)
Breast Cancer Screen in Childhood Cancer Survivors – An Article Review (February 2009)
Indications for Breast MRI – an Article Review (March 2009)

Unused Prescription Medications

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

As regular readers of my blog know recently my family lost my mother (May) and my sister lost her husband (March).  Both times we were left with many unused prescription drugs at their respective homes.  What do you do with these?  What do you do with ones you or a family member have left when switched to another drug?

This topic was also brought up on twitter recently by  lesmorgan.

• Handling a family request to donate dialysis meds after a death. Is it correct that Kaiser pharmacy has no post-death return policy?
• @rlbates thanks for the comment. that's the usual answer, but some institutional systems do have giveback programs, unsure on Kaiser.
• http://www.dhss.mo.gov/Drug... DHSS FAQ on medication donations in Missouri. Regulations vary by state.
• http://bit.ly/aeAfv California law on recycling meds after SB 798
• http://www.ciwmb.ca.gov/HHW... California medical waste disposal location finder. Handy!
• @striving4more My understanding is that laws vary by state, I'm updating my own FAQ on the issue now.
• @striving4more Best general advice is to ask the pharmacy that dispensed the meds to advise on prevailing law, which also varies by med.

I tried to take my brother-in-law’s to the pharmacist downstairs in the building my office is in.  They were not allowed to take them for recycling.  Their advise to me and to others who ask was to empty the pills into a plastic bags with cat litter, then throw that bag into your regular trash.  I did the bag/cat litter thing, but put my into my “medical waste” trash at the office.  I don’t like the thought of those drugs ending up in my drinking water, but I also find the waste sad.  I wish there were a way to donate them to charity clinics legally.  It’s much easier to donate or “recycle” the unused prescription drugs when someone dies in a nursing home or hospice.  It’s almost impossible if the drugs have made it into someone’s home cabinets.  Most states are similar to California and make no recommendations on the ones that I wanted to donate or recycle (the ones at the departed’s home).

SUMMARY

California Senate Bill 798, signed into law by Governor Schwarzenegger in September 2005, authorizes a county to establish a program to collect unused prescription medications from nursing homes, wholesalers, and manufacturers and redistribute them to low-income, uninsured people. (A copy of the law is attached. )

Here is a post I did early in my blogging days, May 2007 – Unused Medicines.

As I have begun to find more ways to recycle and conserve waste in my home and office, I have found that it is no longer acceptable to “flush medication” down the drain. I was taught in medical school (graduated in 1982) to educate patients to dispose of out-of-date medications (old Tylenol, aspirin, cough syrups, etc) and unused prescription (either couldn’t take them due to side effects or failed to take all of the antibiotics or HBP medication was switched) by flushing them down the toilet. That is no longer a good idea. But the information out there is not clear as to the new guidelines.

I found that the Senior Care Service website still tells our elderly and their care givers to flush the out-of-date or unused medication. I found little help at my own state’s Cooperative Extension Agency’s website on medication disposal, but it is very helpful for other household chemicals.

The two best sites I found were the American Pharmacy Association and the White House Drug Policy. Both of these give clear instructions [ Federal Guidelines ]

How Not to Do Buttocks Enhancement

 Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one.

In this day and age when physicians are facing being rated like the local plumber or restaurant on Zagat, it astounds me that anyone would allow a non-physician to perform cosmetic enhancement “injections” in their home.  That seems to be what women in Florida have done to the detriment of their health (ABC Action News).

Two women who wanted cosmetic injections to enhance their bottoms are now recovering in a Town N' Country Hospital with severe infections. 

Deputies say Andrea Lee and Zakiya Teagle thought they were getting injections that were safe and would provide them with the appearance they wanted.  Instead, the person who injected them apparently is on the run and detectives want to find her.

Hillsborough County Sheriff's office says Sharhonda Lindsay of Tampa is wanted for practicing medicine without a license. A warrant for her arrest was issued Monday.

They say Lindsay injected the women's buttocks several times and was paid hundreds of dollars for her efforts.   But after leaving her home, the two were in so much pain and had to go to the hospital for treatment.

On Monday night, one of the two women was in critical condition after her kidneys stopped functioning.

While there are safe ways to cosmetically enhance buttocks, silicone injections is not one of them.  Silicone injections into soft tissue in the United States has been illegal for many years now.  Silicone injections into the face and breasts were once used for enhancement in those areas, but led to many disfiguring problems.

When liquid silicone is injected into soft tissue (face, breasts, buttocks) it can migrate to other areas.  The body often reacts to the silicone by forming benign tumors called siliconomas.

Good physicians won’t do liquid silicone injections.  They will use fat injections.  They will do buttock implants.

Safe methods for buttocks enhancement include:

Micro-fat grafting

Buttock Reduction/Contouring

Gluteal Implants

Buttock Lifts

Combination of the Above

It is important to go to a well trained plastic or cosmetic surgeon.  Do not go to a friend who offers to do the injection in their home.

Sources

List of Legal Injectable Fillers (FDA)

Suture for a Living post on Buttocks Enhancement

Patient Question – Options for Payment/Coverage of Surgery

 Updated 3/2017 -- all links (except to my own posts) removed as many no longer active and it was easier than checking each one.

The same person who asked the questions here, had more questions regarding how to pay for (self/insurance) procedures that remove the excess skin after weight loss.

Insurance Coverage

If you are “lucky” then you have insurance coverage, but as I wrote about here that is not likely.  For most (hesitate to say all, as I have not read all policy booklets), define cosmetic surgery this way:

Cosmetic Procedures -- services are considered Cosmetic Procedures when they improve appearance without making an organ or body part work better. The fact that a person may suffer psychological consequences from the impairment does not classify surgery and other procedures done to relieve such consequences as a reconstructive procedure."

So without a medical reason (ie major skin issues, repeated infections, such a large pannus that it interferes with mobility, etc) then the surgery to remove skin from the abdomen, arms, breasts, etc will always be defined as cosmetic.   If you have any of those medical issues, be sure you have them documented by your family physician or surgeon who did your lap band or gastric bypass.  It’s not enough for you to simply say, you have had the skin issues and dealt with them yourself for five years.  That won’t help me help you get coverage.  I can not say it enough, make sure it is documented.

Indigent Care Coverage
Most states have a program similar to Colorado’s (pdf file)

The state does not have sufficient resources to pay for all medical expenses for persons who are indigent.

The state must allocate available resources in order to increase access to primary care among Colorado’s indigent population.

So once again, you will need to prove that it is a medically necessary issue that the surgery will improve or correct.  If it is, there will need to be documentation.

Medical Schools / Residency Programs
There are no programs that I know of or could find with a google search that allows it’s plastic surgery residents (USA) to perform reduced fee or free surgery just for the training.  If anyone knows differently, please, let me know.

Credit/Financing
Physicians and hospitals take most credit cards these days.
Then there are many companies out there that will gladly loan you money with different interest rates and 1-5 yr pay back plans.   A few of them include:
Capital One Healthcare Finance
Care Credit
Med Loan Finance
Reliance Finance Company
Surgery Refinancing

Medical Tourism
Not one I really want to advocate, but it is an option.  It is well known that the cost of surgical procedures in other countries is much less than in the United States.  However, please, be very careful if you take this route.



When you have multiple procedures you need or want to have done, it will often be necessary to stage them for your own health safety (for reasons such as length of surgery, estimated blood loss, etc).  So if you can only pay for one procedure, which would it be.  That in my humble procedure is often the place to start.  It is not always the same place we (patient and I) would start, if there are no issues with money (none of my patients fall in this category). 

Insurance/Healthcare Thoughts

 Updated 3/2017--all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I've been struggling to get a patient's insurance company to give consent for a panniculectomy. I have not been successful. I have appealed the initial reject. It was rejected a second time. There reasoning:

Upon reviewing the submitted information, I have determined that at this time "Excision, excessive skin and subcutaneous tissue; abdomen, infraumbilical panniculectomy" is not a covered benefit under the benefit plan. This determination is based upon the following plan language, found on pages (s) 74 and 125 of the member's Certificate of Coverage or Summary Plan Description:

"Excluded ..... Cosmetic procedures, including cosmetic surgery expenses, supplies, appliances and drugs, except for reconstructive surgery to repair accidental injury

Cosmetic Procedures -- services are considered Cosmetic Procedures when they improve appearance without making an organ or body part work better. The fact that a person may suffer psychological consequences from the impairment does not classify surgery and other procedures done to relieve such consequences as a reconstructive procedure."

I thought I had made it clear, both times, that this proposed panniculectomy was to be done at the request of the patient's dermatologist as the patient's chronic skin rashes/infection in the lower abdominal skin roll could not be treated adequately with conservative methods. How is the treatment of the patient's skin infection/hygiene issues cosmetic?

It seems to me that this patient's insurance company is failing him. This seems to be a recurring theme in recent weeks in the blog world. Check out the recent post and comment section by TBTAM -- In Case You Were Wondering If Health Care is Broken.

Also check out When an MD says Yes and Insurance says NO by Healthcare Today, September 9, 2008

If a credentialed provider determines a specific course of action is reasonable for medical therapy it is amazing that insurance companies can countermand that judgment. Providers may be working as patient advocates, but clearly insurance companies are looking out for their own selfish bottom line. Not a new revelation as most of us would agree.

Hospitals in Hands of Voters

Updated 3/2017--all links removed as many are no longer active and it was easier than checking each one.

I posted this over at Med-Politics Blog and am now re-posting here with the outcome of the vote added at the end.

This is one of the headlines on the front of my local news. The article can't be read there without a subscription, but can be read here in full as it was reprinted on the AARP website.

Statewide, at least 11 small community hospitals receive some community support, typically in the form of sales taxes or millages, said Paul Cunningham, senior vice president for the Arkansas Hospital Association. Most of them have had local taxes approved within the last five or six years.

Nationwide, community hospitals are struggling under the weight of low reimbursement rates, high levels of charity care, increasing demand from an aging population, and difficulties recruiting doctors and other medical personnel to rural areas, said Rick Wade, senior vice president with the American Hospital Association.

I think this will only become ever more common as reimbursements are lowered or not paid (never events). For all those who feel that medical care is a right and not a privilege, how do you propose to prevent hospitals and clinics from closing due to lack of funding? It doesn't really matter about coverage, if there is no access, does it? Massachusetts is finding that out.

I don't have the answers. I have never aimed to get rich on the backs of folks who need my care, but I like to be able to pay my bills. I like to be paid a fair "wage". I will never be paid as the ousted CEO's (nor do I think I should) of Fannie Mae and Freddie Mac have been, but neither have I ever made what the public thinks I do.

Update on the vote outcome:

The vote outcome didn't make the front page of the paper. It was on the 3rd page of the B (or Arkansas) section of the paper in the Wednesday paper, but it was above the fold. Once again, I can't link the the newspaper article as you need a subscription to read it.

The 85-yr Hot Spring County Medical Center will stay open. The county voters over-whelming approved a 5-year, one-half percent sales tax. (4,844 for and 633 against)

Voters in Chicot County also approved a sales-tax increase to support Chicot Memorial Hospital in Lake Village. Theirs is a 5-year, 1 percent sales tax. (1,244 for, 586 against)

A Surgeon's Outburst

 Updated 3/2017--all links removed as many are no longer active and it was easier than checking each one.

I'd like to comment on the recent Boston Globe article on surgeons' outbursts and also on Maggie Mahar's post, Surgeons and Other Physicians: A Cultural Divide.  Both seem to be painting surgeons as the ogres or bullies of the medical community.  I'd like to think that I am neither.  There are better examples of surgeons than the Alex Baldwin character in the movie Malice. 

I agree it is not good form or good for the patient for these outbursts to occur, but generalizing to the point that most of your readers would think that 90% or more of surgeons behave this way is wrong. I have never thrown any equipment and rarely gotten angry to point of raising my voice or screaming in the OR. Each time I did, the nurse told me I was right.

I have witnessed some of the examples given in the article. Yes, those surgeons should be counseled and most likely should even be required to go to anger management classes. BUT maybe the reason for their anger should also be sought.

Was the faulty equipment putting the patient at risk? It is very frustrating to try three pair of scissors before you get one that will cut tissue or to have the electrocautery machine not work so the circulating nurse (bless her) has to go find one that does. Perhaps the hospital is at fault for not updating and replacing defective instruments and equipment.

Did the surgeon have to finally say "no more" to extraneous people entering the room? I have done that a few times. Someone comes in looking for a piece of equipment stored in the room you are working in (why wasn't it taken to the other room before my surgery got started?). Someone comes in to ask where such and such is (usually a new person who hasn't been properly oriented). My tolerance is such that I can take several (justified) interruptions in one case, but there is always a tipping point. Raising my voice to get the crew who is supposed to be helping me with my case refocused is my way of dealing with it, not throwing things. Still I would prefer to not have the issue.

Did the surgeon have to ask the nurse (or another crew person) to make their personal calls later? I have had to do this a few times, especially now that everyone has a cell phone. I try to be considerate when that person has a loved one in the hospital and are trying to get updates. Still, if they can't focus on their work (someone else's loved one) then maybe they should have taken the day off.

Those are just a few examples. I agree that we should never throw anything in the OR, but I do expect the equipment the hospital provides to work. I do expect the personnel they use to be professional and properly trained. I think of myself as part of the team, but that means we ALL have to put the patient first and work together.

Now let me give you some better examples of surgeons

• Dr. Eli Blumfield (played by Alan Arkin) from the movie The Doctor.  The one that William Hurt's character picked to do his surgery.   He was not only a great surgeon, but a good person.
• Benjamin Franklin "Hawkeye" Pierce (Alan Alda) from MASH, don't recall ever seeing him throw anything in the OR.  He mostly directed his anger at the policy makers, not the OR staff or patients.
• BJ Hunnicutt (Mike Farrell) from MASH, a gentle soul who missed his wife and daughter.  He didn't disrupt the OR with temper tantrums either.
• Sherman T Potter (Harry Morgan) from MASH, who kept Hawkeye and the others in line.  A good surgeon and administrator.
• Dr Richard McCarthy (real-life orthopedic spine surgeon) who was featured in an episode of Extreme Surgery back in 2004.  I was a medical student when I first meet him at Arkansas Children's Hospital.  He is a very good surgeon and a gentle man.  He is very highly regarded by all -- administration, nursing staff, colleagues, patients, etc.  I tried to find the episode link so you could see him in action, but failed.
• Dr. Sanjay Gupta, neurosurgeon and CNN correspondent.  Though I have never been in an OR with him, he doesn't seem as if he would be the type to throw tantrums.
• Dr Bruce Campbell, ENT and fellow blogger.  I have not been in the OR with him either, but you get the sense of a someone who is respectful and civil when reading his posts.
• David A. Kappel, MD, a plastic surgeon in Wheeling, WV.  I was influenced by him as a general surgery resident.  Someone who is very good at what his does, treats his OR crew well, and is a wonderful human being.
• Dr Dale Morris who was a general surgeon here in Little Rock, AR for years.  He has retired and is missed.  He was/is a very kind and skilled surgeon who always treated everyone well.

Let me also say that I am blessed to have had several good nurses and OR scrubs over the years teach me how to work as a team.    To name a few -- Jeannette Murphy, Vivian Mitchell, Joe Roe, Becky Bennett, and on and on.

You may also want to read this article from the WSJ and it's comments from last month on "Better Hospital Manners by Mandate".

The Right Thing

I did a precertification for a patient. The precert was for breast reduction surgery. My office had reminded the patient prior to her initial visit that my office was not in her insurance network. We asked her to check her policy to see if she had out-of-network benefits as we didn't want her to get "stuck" with the bill, as it were. My office balance bills, but tries to be up front about costs.

I did the initial visit, reviewed why she felt she needed a breast reduction, did the exam, took measurements and photos, and then after she left sent a letter with documentation (photos, etc) for the precertification.

She received the letter (copied to my office) below which states that she meets her insurance requirements for the surgery. It then clearly states "If Dr Ramona Bates performs the surgery it will not be eligible for reimbursement."

She called to schedule the surgery for early September. I called her back and reminded her that if I did the surgery her insurance would not cover it (not the surgeon, not the surgery center, not the anesthesia, none of it).

"Would you still like me to do your surgery or would you like me to try to find someone in your network?"

"Well, I would really like to have my surgery in September. Do you think you could get me in to see someone soon enough that I could have it done then?"

"I'll try, but I can't guarantee that you might not have to consider a different time for the surgery."

So I called Dr PS1. He is in her network, but can't see her for the initial office visit until September and probably can't get the surgery scheduled until November or December.

Tried Dr PS2. This one, like my office doesn't participate in her insurance network.

Tried Dr PS3 and hit the jackpot for her! They can see her in a week and most likely get her scheduled (since the precert is already done) in early September.

I then called her back and told her the news. "Thank you Dr Bates. I don't know how I can ever really thank you."

 

Medical Tourists

Updated 3/2017-- all links removed as many no longer are active. 

The first or second year I was in practice I received a call from Dr Gaspar Anastasi. He had been the head of my plastic surgery residency while I was at Boston University Hospital. He was calling to ask me to do follow up for him on an otoplasty patient who lived in Arkansas. I readily agreed. In fact, I was honored that he would ask.

These days we think of the medical tourist as someone who goes to another country (ie. from the USA to Singapore for an operation), but in some ways the same issues may arise when the patient simply goes out-of-state to have a procedure done. They are not always ready, willing, or able to go back for follow up. This is especially true if a complication arises, be it small (missed stitch) or large (wound infection). They may have used up all their vacation time and not want to take the days off for travel.

I have had patients come to me from Nevada, Arizona, Texas, Louisiana, Tennessee, and Mississippi. Usually because they have family that lives here. They plan on staying with them while they recover. Still, I ask the ones who are more than 3 hours away if they are willing to stay around 10-14 days after surgery before agreeing to do the procedure. I ask them if they are willing to return if the need arises or if they have a local physician who is willing to help out. I try to make them think about what could happen. Even the ones who live closer I try to outline the follow up that will be expected.

There is a nice article in this month's Contemporary Surgery Journal discussing the ethics of caring for/refusing to care for a patient who comes to you with a complication after having their surgery elsewhere. You can read it here (may have to register).

A former patient presents with general malaise and reports having had low-grade fever. The examination is unremarkable, but laboratory tests indicate an infection not isolated to an organ system. Groin and blood cultures are positive for MRSA.

A while ago you diagnosed an abdominal aortic aneurysm in this patient, but she went to India for aortic endograft placement. You are considered an authority on graft infection. What should you do?

A. Tell her to return from whence she cometh.
B. Alert the media to the problem of cheap international medical care.
C. Advise the patient to sue in International Court.
D. Care for her as you would any patient.
E. Tell her that once a patient leaves your care, she leaves permanently.

My answer is D. Though I wish the patient would come to me for the entire "package", I would do what needed to be done. I would prefer to meet them before the initial surgery, but we don't always have that luxury. I would prefer that I could try to get them to do their care (if it is available, though specialized care is not always) closer to home or at least at a distance they are more willing to travel as needed. I would prefer that the surgeon call me and let me know that he would like me involved in the postop care.

Is it possible that this concept of international travel for surgery is here to stay? Most likely. So maybe the patient should find a "local" surgeon who would be willing to do the postoperative care when they return. The patient could then give their "international" surgeon the name, address, phone number, and e-mail address of the "local" surgeon so that information could be communicated and care coordinated.

What would your choice be?
Article:

The Medical Tourist Whose Outcome Went South; Contemporary Surgery, Vol 64, No 6, pp 290-291; James W Jones, MD PhD, MHA (This article was condensed from: Jones JW, McCullough LB. What to do when a patient’s international medical care goes south. J Vasc Surg. 2007;46;1077-1079.)

Toad Suck Festival

 Updated 3/2017-- photos and all links removed as many no longer active.

There is a small community in Arkansas that sits on the Arkansas River named Toad Suck. It is near Conway. In 1982, Conway began holding a festival to raise money for scholarships to help local students further their education. Over the years the festival has raised over $500,000 for local students to attend Central Baptist College, Hendrix College, University of Arkansas Community College at Morrilton, and the University of Central Arkansas. CBC, Hendrix, and UCA are all colleges located in Conway, Arkansas. The festival is the first weekend of May (this year May 2-4th).

What does "Toad Suck" mean anyway?

Well, The answer is quite simple...
Long ago, steamboats traveled the Arkansas River when the water was at the right depth. When it wasn't, the captains and their crew tied up to wait where the Toad Suck Lock and Dam now spans the river. While they waited, they refreshed themselves at the local tavern there, to the dismay of the folks living nearby, who said: "They suck on the bottle 'til they swell up like toads." Hence, the name Toad Suck. The tavern is long gone, but the legend and fun live on at Toad Suck Daze.

The festival has grown to include multiple sports events: basketball, golf, 5K/10K, bicycling, and softball. There are free music concerts. This year some of the bands featured are: Hwy 5, Riverbilly, Blake Shelton , Ben Coulter, Culpepper Mountain Band, FreeVerse, KickBack, The Blue Meanies, Shaw Blades .

 

Each year they sell T-shirts, lots of food and craft vendors, and there are toad races. This year as in the past few years there has been some difficulty finding the toads (don't confuse them with frogs). The article below may help explain why the numbers are decreasing.

There is a nice article on Amphibians (frogs, salamanders, and others) slipping into oblivion in Defenders (a conservation magazine of Defenders of Wildlife). You can read it online here. The photo below is of a female marsupial frog and her offspring and is from the article. The article states that amphibians are the most threatened group of animals in the world.

It Costs How Much?

Do you remember this splint that I was told to wear (and did for a week) when I had acute olecranon bursitis? Well, I got my bill recently and was shocked by how expensive the splint was! If I had been told how much it was going to be, I swear I would have left without it. I would have used the "soft" elbow pad and made myself a plaster splint to protect my elbow from being bumped for that week. Here's the breakdown of the medical bill. For some reason, all of the charges had been billed to insurance EXCEPT the splint charge. I asked that it be submitted.

Service	Description of Service	Charge	Insurance Allowed	Patient to Pay
99204	Office/New Patient	$229.02	$140.38	$140.38
73070	X-Ray Exam	$73.92	$33.12	$33.12
97760	Orthotic (OT)Management	$40.00	$36.00	$36.00
L3763	Rigid Elbow Splint	$773.33	???	???

"My Worst Nightmare"

Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

Recently I have had to deal with a patient who refers to herself as my "worst nightmare". I knew she would be difficult before I ever did her surgery. She had warned me that she always had a lot of pain and it was difficult to control. I knew she would need more TLC than most patients.

I always call outpatients the night of surgery. It helps me sleep better and hopefully them/their families too. The night of her surgery (and I have learned to double check phone numbers where they will be), I called three separate times over a 2 hour period to two numbers. No one answered any of them. I left a message that "If there are any problems tonight, please, have me paged through the Medical Exchange at ****. I will check on you again in the morning." That night it was quiet.

I called her the next morning and this time she answered.
"I'm in so much pain."

After going through a list of questions to make sure there were no other issues (no undue swelling, no fever, etc), "Have you tried taking the Xanax with the Percocet?"

"No. I didn't know I could do that."

I had written the Xanax prescription after seeing how she dealt with the pain in the recovery room. Nothing we tried had seemed to make her comfortable until we tried it. I mean nothing including morphine. And physically she appeared okay.

I explained that she could. That the Xanax would help her nerves and help her rest. "So why don't you try that. I'll call you again tonight." She agreed.

I called back that night (Friday). Things seemed to be better. Saturday was quiet. Sunday, just past noon, the pager goes off. I called the number.

"Dr. Bates, it's your worst nightmare. The pain is horrible and I don't have any pain medicine left."

I go through the same list. No undue swelling, no fever, etc. So I offer to call in some Darvocet (and do so). I don't offer to meet her and write a new script for the Percocet. I don't suggest that she go to the ER. Two hours later, the pager goes off again. Same patient.

"Dr. Bates, I'm so sorry. It's your worst nightmare again. I don't know what to do. The pain is so bad."

This time I firmly tell her that she will have to tough it out until tomorrow (Monday) as I can't phone anything stronger in for her. She will have to make due with the Darvocet. (By my count, the Percocet should have lasted her until Monday or Tuesday).

Nothing more from her until first thing Monday morning when she calls the office. "Dr. Bates, it's your worst nightmare. I am in so much pain."

"You are no where near my worst nightmare, but we won't go there. Why don't you come into the office so I can see you. You will have to come into the office before I give you anything more for pain."

She comes in. Her exam is benign. She is healing as expected. I touch the operative area gently--she flinches. I leave it and keep talking to her. She visibly relaxes, as the time passes. I keep up a constant patter. I remove her stitches and tape the incision. I deliberately touch the area again with slightly more pressure. This time there is less flinching. I keep talking to her. Then one more time palpate the area. This time pointing out how she allows me to do so.

I give her one more script for Percocet and Xanax. I caution her to take them as prescribed, not more often. I bring up the young actor, Heath Ledger, who recently "overdosed" on prescription medications. She says she didn't realize you could take too many. She did fine from that visit on.

So for her I think that much of her pain was in her head. I think she "thought" she hurt more than she "actually physically" did. I don't mean to belittle her pain, but she had had a few bad experiences with pain, so she ANTICIPATED that each new event would be as bad or worst. I think that "fear" adds to her pain.

I try to get patients to realize that there will be pain, but that each day will get a little better. I don't try to make "light" of it, but to get them to distract themselves. Or to "reassure" themselves that it is not a permanent state. Postoperative pain (I know there are exceptions) is not a permanent state. It will go away.

As far as being my worst nightmare--not even close. Some of my "worst" nightmares would include an abdominoplasty patient dying of a pulmonary embolism (PE) 2-4 weeks after surgery, any patient getting toxic shock (was consulted after the fact on a patient once who needed a gastrocnemius flap to cover her knee joint after surviving TSS post-knee surgery), or this.

Or if we're talking non-patient related then this (snakes wrapped around you).

Elbow (Olecranon) Bursitis

Odd topic for a plastic surgeon. Maybe. Maybe not when it's the plastic surgeon who has the problem (olecranon bursitis). That's right, earlier this week, (truly out of the blue) I set my left elbow down on the desk while writing a note. I noticed it was kind of sore/tender. Ignored it, but as the day went on it became more so. I went to the full length mirror in one of the exam rooms so I could really look at it. Red, swollen, no breaks in the skin. I didn't recall any trauma to my elbow. None of that "I hit my funny bone" stuff that makes you take notice. I still ignored it for another day as I had no elevated temp. It got worse. I called up one of the hand surgeons I had done my fellowship with back in 1989-1990. He is an orthopedic trained hand surgeon. He worked me into his busy schedule. The x-rays of my elbow were pristine. No joint abnormalities, no bone spurs, no hairline fractures, nada. That's good, but then what set off my elbow bursa? He wasn't any more sure than I was. He put me on antibiotics (red, warm to touch) and had his therapists make me a splint. He wanted to put me on an anti-inflammatory, but Aleve (helps my joints, etc) gives me severe esophagitis. Severe--burns from the posterior tongue all the way to the stomach.

Damn, I hate this splint. It's amazing the elbow motions you take for granted and the shoulder can only move in so many ways.

• I hold the phone with my left hand, so my right is free for taking notes. Can't do that with the splint on.
• Can't scratch my nose or much of any area above the waist, front or back, with my left hand with the splint on.
• Tough to reach into the washer to pull out clothes with the left arm. Hadn't realized that I used my left arm for that more than the right (interesting).
• Can't scrub in for a case with the splint on.
• Not sure it would inspire confidence in me if patients saw me using it

Okay, I love the splint for these reasons:

• Keeps me from knocking my elbow on the washing machine, the car door, the table top, etc
• Able to wash dishes with the splint on (started to put this in the neutral or hate column, but recalled my Thanksgiving post and couldn't do it)

Neutral about the splint for these reasons:

• Able to use the keyboard while wearing the splint.
• Able to walk my dog in the splint fairly normally.
• Did manage to do some quilting (both hand and machine) with the splint on.
• Did manage to drive my car (safely) with the splint on.

Interesting insights, but Thank God it's not my right!!! I will honestly admit I don't wear the splint full time, but do think I have done better than 50%. My elbow is improving quickly (not as fast as the bursitis appeared but). Also, the elbow joint will get stiff if not moved. I have tried to be (and think I have) careful of not banging it or putting any pressure on it when the splint is off. I don't sleep with it on, I'm afraid I might accidentally hit my husband with it.

Here are a couple of sights with more information (medical) on elbow bursitis:
Elbow Bursitis -- American Association of Orthopedic Surgeons
Olecranon Bursitis; Patrick M Foye MD and Todd P Stitik MD; eMedicine Article, November 22, 2006

Suitability

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

There are definable risks and benefits in every surgical procedure. This risk/benefit ratio is particularly important for the cosmetic or aesthetic patient. This patient starts out "well" and will be put into a temporarily "unwell" state to ultimately help them "feel better".

Most training programs do not teach "patient selection" and not everyone is born with the "sixth sense" that will help you know who might not be a good candidate for the procedure requested.

Patients I need to watch for when doing aesthetic procedures
Inflated Expectations

• Patient tends to be "deaf" to any attempt to educate them as to what their surgery will entail.
• They seem to have difficulty digesting the fact that there any major procedure carries some degree of inherent risk.
• Will use the results of computer imaging as a warranty, rather than the possibility intended. Computer imaging does not take into account healing quirks, skin thickness/elasticity, etc.

The Demanding Patient

• The patient who brings you celebrity photographs with modifications that they want you to duplicate even though the celebrity is a completely different body type (apple vs pear).
• The patient who brings you a picture of themselves with overlays of the changes they would like. If they can be made to understand that the human body is not clay, but tissue that heals with scars (sometimes predictable, but not always) then this can be a good start to a discussion.
• The patient who demands no scar. Plastic surgeons are not magicians. When skin it cut, there is always a scar.

The Surgiholic

• Patients who have had multiple (There does not seem to be a good number to put here. Is three too many or is six?) previous aesthetic surgeries.
• The patient who had multiple surgeons for their previous surgeries. You will be compared to Dr. X.

Marital or Family Disapproval

• Yes, the adult patient seeking aesthetic surgery does not require anyone's approval or consent, but ... Secrecy from a spouse or significant other can add stress for both the patient and the surgeon. Someone will need to know how to care for them in the postop period. It helps if they know what was done.

Capitulation

• The other side of the coin. No patient should be pushed into surgery to please someone else. That other person may not be around in five years, whether by divorce, separation, or death. Will the patient still be glad they had the procedure?

Incompatibility

• There are some people with whom you just don't feel comfortable. This may be for a variety of reasons. And it may be true from the patient side also. Both may be "nice" people, but may not be comfortable with each other.

Body Dysmorphic Disorder

• In its simplest definition, it is an obsessive preoccupation with a slight, imperceptible, or actually nonexistent anatomic irregularity to the degree that it interferes with normal adjustment within society.
• This disorder may be present in varying degrees. It is the most common aberrant personality characteristic seen by the plastic surgeon.
• When postoperative dissatisfaction occurs (and in most cases, it will), it almost always is based on what the patient understood rather than what was actually said.

The bottom line is: Not everyone is a candidate for aesthetic surgery. Nor is it possible to eliminate every possibility of dissatisfaction or conflict that might arise. Here are some suggestions for doctor and patient

First

• Surgeon--Be a complete physician, not just a skilled technician.
• Patient--Be a partner in your care. Give a full and honest medical/surgical history. Don't leave out any medications. What you do when recovering often will have major impact on the final result.

Second

• Surgeon--Avoid hyping your "unique" talent.
• Patient-- Be honest about your reasons and expectations.

Third

• Surgeon--Strive to maintain good communication and rapport with your patient. Listen.
• Patient-- Do your part in maintaining that good communication and rapport. Listen. If you don't understand, say so. Have your surgeon try to explain in another way.

Fourth

• Surgeon-- Be honest about your skills. We are all better at some procedures than others.
• Patient -- Let your surgeon refer you to someone else, if they feel it is in your best interest. Don't "massage" his/her ego to try to get them to do it (I only want you to do it. I feel so comfortable with you. I know you are the best.)

References
Recognition of the Patient Unsuitable for Aesthetic Surgery; Aesthetic Surgery Journal, 2007 Vol 27, No 6, pp626-620; Gorney Mark MD
Streamlining Cosmetic Surgery Patient Selection-Just Say No!; Plastic & Reconstructive Surgery, 104(1):220-221, July 1999; Rohrich, Rod J. M.D.
Of Chickens and Red Flags; Plastic & Reconstructive Surgery, 112(2):684-685, August 2003; Edelstein, Jerome M.D.
Dr. Vazquez Añón's last lesson; Aesthetic Plastic Surgery, Volume 2, Number 1 / December, 1978, pp 375-382; Ulrich T. Hinderer
Body Dysmorphic Disorder and Cosmetic Surgery; Plastic & Reconstructive Surgery, 118(7):167e-180e, December 2006; Crerand, Canice E. Ph.D.; Franklin, Martin E. Ph.D.; Sarwer, David B. Ph.D.
Body Dysmorphic Disorder: Diagnosis and Approach; Plastic & Reconstructive Surgery, 119(6):1924-1930, May 2007; Jakubietz, Michael M.D.; Jakubietz, Rafael J. M.D.; Kloss, Danni F. M.D.; Gruenert, Joerg J. M.D.
Inspired by
Everything Health's -- 2008 Resolutions for Patients and Doctors

Breast Swelling as a Medication Side-effect

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

A patient called last week upset that a drug, domperidone, she has been taking for her GI problems has enlarged her breasts. She had a breast reduction done several years ago (not one I did, I did some scar revision work for her), so this did not make her happy. She came in to talk about redoing her breast reduction. The enlargement is asymmetrical with one being much larger (about 1 bra cup bigger) than the other. This is not a complaint that plastic surgeons hear very often. I was not sure what to tell her regarding insurance. I told her that she will need a mammogram (her yearly is due anyway) to rule out something non-medication related. If the mammogram is normal, I think this will be a case where it would be good to do a pre-approval letter (or medical necessity letter) in advance unless she just wants to take her chances or pay out-of-pocket. It's tough enough getting insurance companies to pay for a breast reduction. Even though legit, I'm sure they will need convinced that a woman might need a second one.

Here are a few more commonly used drugs known to have this side-effect (swollen breasts, breast enlargement, or gynecomastia):
Carbemazepine (TEGRETOL®)
Cimetidine (Tagamet)
Chlorpromazine (Thorazine)
Clomipramine hydrochloride (Anafranil)
Doxazosin (Cardura, Cardura XL)
Dutasteride (Avodart)
Estrogens (including most birth control pills)
Ethosuximide (Zarontin)
Haloperidol decanoate
Methdilazine Hydrochloride (active ingredient in Dilosyn)
Methyldopa (Aldomet)
Metoclopramide (Reglan)
Nilutamide (Anandron^®, Nilandron^®)
Risperidone (Risperdal)
Sustiva (efavirenz, EFV)

Here is a list of drugs (according to the Physician Desk Reference) that can cause gynecomastia as a side effect. The risks are generally very low for male breast enlargement from these medications, but breasts in men can be a cause for embarrassment. [And often women don't mind a small (if symmetrical) enlargement.] Don't forget that some medications may be very important for your other medical problems.

Review of Medical Expenses

My friend who incurred the self-inflicted gun shot wound to his right forearm has gotten his medical bills. I ask him to allow me to review them. I was interested in what was billed and what the insurance company actually allowed. Notice how long it has taken to get everything (well not everything--ambulance services still pending review) through insurance review (late August until today). Here is the breakdown.

Service Rendered		Billed	Insurance Allowed	Patient Responsibility
Ambulance-- ALS Emergency Mileage ALS Pulse Oximetry IV Supplies Disposable Supplies		$488.00 $146.25 $36.00 $42.00 $42.00	* Still waiting	* Still Waiting
Hospital ER		$836.32	$459.98	$459.98
X-Ray Reading		$28.00	$12.18	$12.18
Generic Pain Med		$4.06	$4.06	$4.06
Secondary Wound Closure (done in office)		$650	not actually billed (maybe $356 on hosp % reimburse)	not actually charged (maybe $356 as based on ER reimbursement)
At home dressing supplies		not covered by insurance $30.06	not covered $30.06	$30.06 (Coban, guaze, etc)
Total Expenses		$2,302.69	$862.28*	$862.28*

My friend has a Medical Savings Account so has a high deductible ($5700). The insurance coverage did decrease his actual out-of-pocket responsibility by "not allowing" $392.16 (more depending on the ambulance bill outcome). This is also money that the hospital and ambulance service did not receive. I know he is grateful for the savings. I, however, also see the other side. A reduction of nearly 50% seems absurd. Is the medical community really overcharging that much? Or are we charging fairly to cover the expenses of the hospital/office? Just as Wal-Mart has a built in "padding for loses" for each item sold (covers losses due to theft /shop lifting), the hospitals/offices need to be able to have the same "padding" to cover the services that aren't paid for by the patient (under-payment by Medicare/Medicaid, no insurance, simply doesn't pay, etc).

Poststernotomy Mediastinitis and Repair

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

In the United States, mediastinitis most commonly occurs in the postoperatively. It occurs in 1-2% of patients who have a sternotomy. Most of these patients are cardiac surgery patients (more than 300,000 cases per year in the US). Most of these are coronary bypass patients rather than heart valve or transplant patients. Some other causes of mediastinitis, other than postoperative, include 1) esophageal perforation; 2) trauma, especially blunt trauma to the chest or abdomen; 3) tracheobronchial perforation, due to either penetrating or blunt trauma or instrumentation during bronchoscopy; 4) descending infection following surgery of the head and neck, great vessels, or vertebrae; 5) progressive odontogenic infection (Ludwig angina); 6) mediastinal extension of lung infection; and 7) chronic fibrosing mediastinitis due to granulomatous infections. (photo credit)

Mediastinitis is a life-threatening condition with an extremely high mortality rate if recognized late or treated improperly. Although small in proportional terms (one out of one hundred post-sternotomy), the actual number of patients affected by mediastinitis is substantial (1% of 300,000 equals 3000). This significantly increases mortality and cost.

Even though poststernotomy mediastinits is considered by the Department of Health and Human Services as a "never event" it will still occur. Hopefully, it will decrease to a much smaller (though I doubt ever be a "never") in number event. Prevention guidelines—The CDC surgical site infection prevention guidelines are backed by evidence based medicine. 

Risk factors for the development of mediastinitis postoperatively include the following:

• Bilateral internal mammary artery grafts
• Diabetes mellitus
• Emergency surgery
• External cardiac compression (conventional cardiopulmonary resuscitation)
• Obesity (>20% of ideal body weight)
• Postoperative shock, especially when multiple blood transfusions are required
• Prolonged bypass and operating room time
• Reoperation and/or Reexploration following initial surgery (check out Grunt Doc's post)
• Sternal wound dehiscence
• Surgical technical factors (eg, excessive use of electrocautery, bone wax, paramedian sternotomy

TREATMENT
Medical

Most patients have already received prophylactic antibiotics, usually a first-generation cephalosporin. Very broad and deep antibiotic coverage that includes Pseudomonas species (20% are gram negative) and methicillin-resistant S aureus (20% are MRSA) is needed. Culture results should then guide antibiotic use as multiple regimens are available for use with patients who have mediastinitis. Therapy is usually prolonged, ranging from weeks to months (4-6 weeks of therapy is adequate for most patients). Nutritional support is often necessary. This may be enteral or hyperalimentation.

Surgical options for mediastinitis after cardiac surgery
Effective treatment for simple sternal dehiscence without infection is rewiring the sternum. This usually yields reasonable long-term results. Cultures should be taken to exclude active infection in the cases of sternal dehiscence.

Failure to adequately debride and sterilize the mediastinum during the first reoperation is the most common cause of repeat postoperative mediastinitis. Options for mediastinitis after cardiac surgery are immediate closure after sternal debridement, delayed closure after sternal debridement, and sternal irrigation after sternal debridement. Each has its advantages and disadvantages. The best strategy for accomplishing this depends on the duration of the infection, the condition of the mediastinal structures, and the experience of the surgeon. Below is a diagram of the main pathways for treatment selection as per the presenting wound as per Dr. Norman Schulman (reference 3).

Most surgeons prefer to leave the wound open for subsequent debridement efforts after initial sternal reexploration. In this case, the wound is packed daily until it appears clean with adequate granulation tissue. At this point, muscle flap closure is achieved. The workhorse flap is the unipedicled pectoralis major muscle flap. It is based on its primary blood supply from the acromioclavicular axis. By detaching the muscle from its sternal, rib, humeral, and medial clavicular attachments and separating it from the clavicular head of the deltoid, it can usually be extended to the level of the xiphoid. Back cutting the superior medial segment of the pectoralis muscle for a distance of 4 to 6 cm maintains its blood supply and permits it to be tucked into an upper manubrial dead space. Distal closure at the level of or below the xiphoid is accomplished by approximating the upper medial ends of the rectus sheath with large no. 1 sutures. (photo credit)

Although many closures are accomplished with a single pedicled pectoralis flaps both muscles may be used if necessary on their respective pedicles to provide extensive coverage for the heart and the sternal defect and particularly exposed grafts. Many bypass patients have had the left and on occasion the right internal mammary arteries taken, thus limiting the use of “turnover” pectoralis flaps, which rely on perforators from these arteries. The rectus muscle is very hardy and can provide excellent coverage of sternal defects, especially those involving the lower sternal areas.

Recently, vacuum-assisted closure has been used alone or in conjunction with muscle flap closure for mediastinitis in an attempt to decrease the incidence of this bleeding.

The lack of a bony anterior sternal wall may be unacceptable to some patients and has prompted some surgeons to attempt sternum-sparing procedures, even in more advanced cases. This is often a difficult decision, requiring excellent surgical judgment. Advanced cases of sternal osteomyelitis are extremely difficult to cure, and most patients with muscle or omental flaps do very well from a functional standpoint.

Vacuum-Assisted Closure Photo credit.

Vacuum assisted closure (also called vacuum therapy, vacuum sealing or topical negative pressure therapy) is a sophisticated development of a standard surgical procedure, the use of vacuum assisted drainage to remove blood or serous fluid from a wound or operation site. A piece of foam with an open-cell structure is introduced into the wound and a wound drain with lateral perforations is laid on top of it. The entire area is then covered with a transparent adhesive membrane, which is firmly secured to the healthy skin around the wound margin. When the exposed end of the drain tube is connected to a vacuum source, fluid is drawn from the wound through the foam into a reservoir for subsequent disposal.

The plastic membrane prevents the ingress of air and allows a partial vacuum to form within the wound, reducing its volume and facilitating the removal of fluid. The foam ensures that the entire surface area of the wound is uniformly exposed to this negative pressure effect, prevents occlusion of the perforations in the drain by contact with the base or edges of the wound, and eliminates the theoretical possibility of localised areas of high pressure and resultant tissue necrosis. 

References

Part II, Department of Health and Human Services Centers for Medicare & Medicaid Services ; 42 CFR Parts 411, 412, 413, and 489 Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule --surgical infections

Mediastinitis by Dale K Mueller, MD--eMedicine article

Sternal Wound Reconstruction: 252 Consecutive Cases. The Lenox Hill Experience; Plastic & Reconstructive Surgery. 114(1):44-48, July 2004; Schulman, Norman H. M.D.; Subramanian, Valavanur M.D.

Chest Reconstruction, Sternal Dehiscence by Sanjay K Sharma, MD--eMedicine article
Bipedicle Muscle Flaps in Sternal Wound Repair; Plastic & Reconstructive Surgery. 101(2):356-360, February 1998; Solomon, Mark P. M.D.; Granick, Mark S. M.D.

Use of the Omentum in the Management of Sternal Wound Infection after Cardiac Transplantation; Plastic & Reconstructive Surgery. 95(4):697-702, April 1995; Wornom, Isaac L. III M.D.; Maragh, Hallene M.D.; Pozez, Andrea M.D.; Guerraty, Albert J. M.D.

Mechanisms Governing the Effects of Vacuum-Assisted Closure in Cardiac Surgery; Plastic & Reconstructive Surgery. 120(5):1266-1275, October 2007; Malmsjo, Malin M.D., Ph.D.; Ingemansson, Richard M.D., Ph.D.; Sjogren, Johan M.D., Ph.D.

An introduction to the use of vacuum assisted closure by Steve Thomas, PhD--World Wide Wounds

Panniculectomy vs Abdominoplasty

Updated 3/2017-- photos and links removed as many no longer active.

You’ve had your gastric bypass and have lost over 100 lbs. Now you have "all this loose, saggy skin that just hangs" and you have "rashes under the fold all the time". Will your insurance pay for a tummy tuck? Probably not what you are thinking of as a tummy tuck. They may pay for a panniculectomy, but not an abdominoplasty. So let me try to tell you the difference between the two. Photo from article (see below).

Panniculectomy is the removal of the loose (excess) skin and fat tissue below the belly button (umbilicus). Nothing is done to the (possible/probable) loose skin above the belly button. It is strictly to help remove the overhanging skin that is trapping moisture and creating a hygiene and chronic rash problem. It is not meant to improve your overall body shape.

An abdominoplasty is the removal of the loose (excess) skin and fat tissue from the abdomen (stomach area) with transposition of the skin around the umbilicus (the belly button doesn’t usually get moved, the skin around it does) and often tightening (plication) of the abdominal muscles. This creates a more pleasing shape as it addresses the entire abdomen. It is not just a functional surgery, but a cosmetic one.

Look at the above photos. The one on the left with minimal upper body excess skin might get both the functional and improved body shape (cosmetic result) with the panniculectomy. The one on the right would still have the "upper" skin roll as this is from skin above the umbilicus. So by definition, the panniculectomy would not do anything to improve this. The insurance company (see the California BC restrictions) would probably not be persuaded to make an exception for a full abdominoplasty which is what she would need. Chances are this person gets skin irritation below the upper roll also. Frustrating, isn’t it?

Prior to this year (2007) when a surgeon coded the surgical procedure for a panniculectomy or an abdominoplasty the same code was used. This made it difficult (without reading the operative note) to truly tell what had been done.
CPT 15831 Excision, excessive skin and subcutaneous tissue (including lipectomy);abdomen (abdominoplasty)

As of this year the coding has changed which makes it more clear to an insurance company what has been done for the patient. Perhaps it will also help clarify for the patient that a "cosmetic tummy tuck" is not what they will get (unless they are willing to pay the difference) when a panniculectomy is done. The new codes are:
CPT 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
CPT 15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)
Use 15847 in conjuction with 15830

To know whether your insurance policy will help you out with this issue, check your policy or call your insurance provider. Here is BC of California’s policy on the issue. Here is Cigna's. Many insurance companies have similar policies. Some consider it all cosmetic.

Photo--A Classification of Contour Deformities after Bariatric Weight Loss: The Pittsburgh Rating Scale; Plastic & Reconstructive Surgery. 116(5):1535-1544, October 2005; Song, Angela Y. M.D.; Jean, Raymond D. M.D.; Hurwitz, Dennis J. M.D.; Fernstrom, Madelyn H. Ph.D.; Scott, John A. M.S.; Rubin, J Peter M.D.

Tips for Finding a Good Bra Fit

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Tips for finding your proper bra size:

First put on the best fitting, unpadded bra you own. If necessary pin the straps up to bring the breasts to the correct level. Get a tape measure and either measure yourself or have a friend measure you. The general rule of thumb for all measuring is: less than ½”, round DOWN, more than a ½”, round UP. So if your measurement is 32 ¼”, call it 32.

1. The first measurement is taken under the bust. You want to hold the tape snugly, but not tight. You will add either 4" or 5" to this measurement to make it an even number. This is the "band size" for the bra size.
2. Next measure the circumference above the bust under the arms (upper bust).
3. Measure the full bust circumference (nipple level). Make sure the tape measure is straight. Do not let the tape droop in the back.
4. Subtract measurement 2 (upper bust) from measurement 3 (full bust). Each inch difference is a bra cup size. For example, 1" corresponds to an A cup, 2" to a B cup, 3" to a C cup.

Second, you must try on bras. As we women know, there are variance between different styles and manufactures, so now you take your measurements and go try on different styles. Find the bra style that feels and looks best on you. You want the area between the cups to touch or almost touch the chest wall (no big air gap). The bra is not a sling for the breasts. They should be supported by the whole bra, not hanging from the straps.

Women with augmented breasts (implants) may find it more difficult to find a good fit as the implant shape may alter the way the bra fits. Because of this two plastic surgeons developed a bra designed for the augmented breast. "Le Mystère No.9 is a collection of innovative, designer bras incorporating patented technology so as to compliment the unique changes in shape and size that occur after a breast augmentation. Le Mystère has created the only bra on the market designed specifically for augmented women that fits true to size. You will no longer have to go up one cup size to accommodate the increased depth of your breast, since the design of the No.9 garments has taken into account all of the anatomic changes that occur after your breast enhancement. Now it’s easy for you to find a superior fitting bra for your post augmentation breasts. Look no further, Le Mystère No.9 is here!"

Resources:
Teen Health--Finding the Right Bra
Sandra Saffle, Nordstrom's top bra fitter for Oprah's Bra Fitting Tips
Sew Sassy Fabrics (if you want to make your own)