Renaissance Plastic Surgery

Breast reduction is a procedure that, as its' name implies, reduces the size of breasts that are too large and too heavy. It is performed to relieve the severe back, neck and shoulder pain associated with large, heavy breasts. Ideally a woman will have this surgery before the weight of her breasts cause secondary changes in her spine, such as herniated discs, which cannot be reversed.

Breast reduction is seldom cosmetic because the goal is to relieve pain and it has a very high success rate, a position supported by extensive research and The American Society of Plastic Surgery. Given these facts, one might think that insurance companies would be sympathetic to the plight of this group of women who are living in pain. However, if you did entertain such a thought, you would be sadly mistaken. Breast reduction is the #1 plastic surgery procedure that is rejected by insurance companies.

Why would insurance companies deny approval for surgery? The answer is that any surgery successfully denied is an expense that never happens, and they make more money.

Why pick on breast reduction? That one is easy. This group of women are an easy target. Breast reduction does improve appearance so it can be, and often is, labeled as cosmetic. Most women are overweight, and insurance companies will allege that if the patient would lose weight the problem would go away. Enlarged breasts are not the only cause of back and neck pain, making it difficult to prove that heavy breasts are the cause.

Consider a conversation I had with a nurse at a medical management company in Indiana, whose job it is to approve or deny insurance claims for one of the school districts. I was responding to a letter denying approval for breast reduction for one of my patients.

The explanation in the letter was: "The documentation does not support conservative treatment was optimized." This was in spite of a letter I sent documenting that this patient had been taking pain medicine for two years and had also had physical therapy. Here is how it went, not word for word, but very close.

"I received your letter but there was no information on what this patient could have done, or didn't do, that caused this denial. How are we to know what she needs to do to obtain approval if you don't tell us."

"That's not our policy."

"Then how are we supposed to find out?"

"You could try conversation."

"I thought that was what we were having. So you can tell me now."

"How do we know that this is the cause of her back pain. There are lots of causes of back pain. And she should see a therapist or a chiropractor for her pain."

"But I told you that she saw a therapist and didn't improve."

"How do we know she saw the therapist for back pain. People go to therapists for lots of reasons."

At that point I knew I was in a virtual "rat's maze" and there was no way out. I asked to speak with the medical director and I have a phone appointment with him next week. I guess this type of work keeps them very busy.

Everything in insurance is ultimately a "numbers game" and this is no exception. What I described is a typical set of roadblocks thrown in front of a patient. The insurance companies do allow for appeals, and second appeals, and third appeals. Unfortunately, most patients either become exhausted or do not have the knowledge (since so much of it is withheld) to navigate the system. They simply give up, and that is how the "numbers game" works. If ten patients are denied breast reduction and only two take it to the third appeal, even if they are successful the insurance has a savings of 80%. Who can blame them. They have a responsibility to their shareholders, and no one ever died from heavy breasts.

The systematic denial of breast reduction surgery is a symptom of a much larger problem: the incentive each insurance company has to withhold care. The solution is to change the system so the incentives do not work against the patient, against you. Politics being what it is, it is hard to imagine a solution that will not favor the insurance industry and their well-paid lobbyists. In the meantime, I am left to helping my patients overcome this abuse, one battle at a time.

If you have ever considered plastic surgery, chances are you have spent a great deal of time thinking about the end result that you hope, or expect, to get. But what about the plastic surgeon? What do you expect from him, or her? What is reasonable and what is unrealistic?

It is reasonable to expect him to ask you about your goals, and to listen. A quick tip is if he doesn't write anything down, he probably isn't listening. Patients walk in and out the door all day and none of us are smart enough to commit to memory each individual patient's goals. On the other hand, listening is not the same as saying Yes to everything you request. Sometimes you may think a certain procedure will get you to where you want to go, but it won't and it is our job to explain why. You are not just paying for a procedure. You are paying for expertise and surgical judgment, and you have a right to expect it.

It is also reasonable to expect your plastic surgeon to care, not just before your surgery but after it as well. Ask to speak to an old patient and ask if she felt as important after her surgery as she did before she signed up. Did they respect her time and did they have time for her after her surgery? If you really want to find out about your surgeon, speak to a patient who had a problem or complication. After all, we all get them. It is the ability to reassure a patient and work through a complication to a good result that truly separates the best plastic surgeons. This is one instance where the cream rises to the top.

What about guarantees? Should plastic surgeons guarantee their work? The short answer is no. The human body and its' healing properties are too complex to guarantee a specific outcome. If your plastic surgeon does guarantee a result, be careful. The only things we can really guarantee are a commitment to do our best work and honesty. And you have a right to expect those two guarantees.

If your surgery does not turn out the way you had hoped, what will happen? If you are disappointed because your result is not perfect, then you probably never should have had surgery in the first place because no surgical result is ever truly perfect. But if there is a problem that could be corrected, it is reasonable to expect your plastic surgeon to try. Most surgeons will not charge an extra surgical fee to correct a problem but you may incur some charges related to operating room fees and this would be reasonable on their part.

Hopefully, you have thought through most of this in one form or another but if not, now would be a good time. If you are convinced that your plastic surgeon is caring, honest, listens, and puts forth his best effort, odds are that you are in good hands. This is not a guarantee, but you know all about that by now anyway.

Here it is, as advertised, an honest, no-frills assessment of the most popular diets out there. I'm sorry that it won't be all-inclusive or the final word on this topic, but it will give you enough information to sort out what would work best for you.

Before we begin, you need to be acquainted with two concepts. The first is the Glycemic Index GI), a ranking of foods based on how much they increase your blood sugar. Foods with a high Glycemic Index cause a rapid rise in blood sugar. Your body responds by making more Insulin, which moves the sugar (glucose) from the bloodstream into the tissues and lowers your blood sugar. The problem is that the end result, low blood sugar, makes you feel hungry and even though you don't need food, you will eat more.

The second concept is that fat is not inherently bad. Fat makes you feel full and satisfied longer compared with carbohydrates because it is digested slower. If you feel full you probably won't eat as much.

Now let's look at some diets. There are a variety of so-called starvation diets (less than 1,000 calories a day), which are often liquid diets or ones that require drinking tons of water or ice tea. You can strike all of them off the list because they are designed to fail. If your body feels that it is being starved, it will go into a survival mode and burn calories very slowly, trying to conserve fat to avoid the end result of starvation: death. When you go off the diet, which is inevitable, your body will be so efficient that most of the calories will be stored as fat. As you can see, the logic of this type of diet is simply backwards.

The original Atkins Diet was based on no carbohydrates but as much fat and protein as you could eat. It worked because the body normally uses carbohydrates for energy. Once the body's stored carbohydrates are depleted, it becomes a fat-burning machine. Four eggs for breakfast and two cheeseburgers for lunch were fair game and you still lost weight. There were no highs and lows in blood sugar and it was easier to get full and stay full. But the carbohydrate craving was awful.

Critics of the Atkins Diet pointed to the liberal intake of saturated fats, known to cause heart disease. There was also concern that fat-burning resulted in a high concentration of ketones in the bloodstream (The ketones replace glucose as your main energy source). However, other than bad breath and a small risk of dehydration if you don't drink enough water, this hasn't been much of a problem.

The new version of the Atkins Diet begins with a low intake of carbohydrates, 20 grams a day (equivalent to about half a bagel), in what is called the induction phase. It acknowledges the value of unsaturated fats, found in foods such as olive oil and fish, and recommends a balance of saturated and unsaturated fats. Calories and portions are not restricted. In phase two, called Ongoing Weight Loss, carbohydrates with a low Glycemic Index are gradually added back, increasing them by 5 grams a week until you reach a point where you are no longer losing weight. This becomes the daily maximum amount of carbohydrates you are allowed to consume and constitutes phase three, the maintenance phase.

The South Beach Diet is surprisingly similar to the Atkins Diet. It is different in that it places more emphasis on avoiding bad fats (saturated fats), not a surprise since it was written by a cardiologist. Like the new version of Atkins it also distinguishes between good and bad carbohydrates based on the Glycemic Index. It has three phases and, like Atkins, carbohydrates are restricted in the first phase, although it does not appear quite as strict because carbohydrate grams are not counted. Unlike Atkins, meats that are high in saturated fat are also restricted. It doesn't count calories but it does recommend controlling portions. In phase two carbohydrates with a low Glycemic Index are added but portions are still small enough so you continue to lose weight. Phase three is a maintenance phase when your goal weight has been reached and it continues to emphasize unsaturated fats and low Glycemic Index carbohydrates.

Any comparison of the Atkins and South Beach Diet is entirely subjective. Personally, I like the Atkins Diet better because it is more fun. If I have to almost completely give up carbs, then at least let me have sausage with my eggs and a cheeseburger. In the short term, I would be more likely to stay on the Atkins Diet. Once some of the carbs have been added back in, it would be easier to cut back on the saturated fats, which are the ones we all like the best but need to control in the long run for health reasons. But, and this is a major but, I would choose the South beach Diet if I had heart disease or any risk factors for heart disease. The Atkins Diet would also be a little easier to follow, at least for me, because it tells you how much carbohydrate you can eat. For the final maintenance phase they both look pretty healthy. Both diets give a passing nod to exercise as being important but don't spend much time talking about it.

On the down side, giving up carbohydrates is not fun. You will crave carbs and in the beginning, you will feel like crap with no energy. But this will pass and you will see results. If you don't like eggs you are in trouble at breakfast because the alternatives don't sound anything like breakfast to me. The other meals are easier to manage. I think both are easier than calorie counting because most of the low calorie foods are not much fun either and at least this way you don't have to be hungry all of the time.

A third option can be found in the book "Body for Life". This approach emphasizes small, frequent meals, or three meals and three snacks a day. The meal plans mostly consist of the good, or low Gycemic Index, carbohydrates and low fat meats and protein sources. Portions are controlled but calories are not counted. This plan is unique in that one day a week you are allowed to eat whatever you want and as much as you want. It also considers the diet as one of a three-prong approach to weight loss. The other two are cardio, or aerobic exercise, and strengthening to add muscle mass. The program calls for each type of exercise three times a week and one day of rest.

The "Body For Life" program is very effective if you include the exercise and strengthening. Probably the most important aspects of the diet are small, frequent meals and avoidance of the 'bad carbs' to control hunger and sugar cravings.

It would be unfair to have even a limited discussion of diets and not include 'Weight Watchers', a weight loss program that has been in the diet business longer than any of the others. Their system is essentially based on portion control and calorie counting through a support group. It must work or they wouldn't be so successful but it is hard and slow, mostly because low calorie diets cause your body to burn calories more slowly.

Where does plastic surgery fit in with dieting? The answer is, it depends. If you have a goal weight that will give you the shape you want, then plastic surgery is not part of the equation. If you know that no matter what you weigh, you will always have stubborn fat deposits, such as "love handles" or "saddlebags", then liposuction may help you achieve your goals. If you have excess skin and stretched out abdominal muscles from either pregnancy or massive weight loss, then you would more likely be a candidate for a tummy tuck or abdominoplasty. Once again, it depends on your goals.

This is likely one of the longest blogs I will ever write but dieting is a huge topic and I wanted to do it justice. So how do you proceed from here? I strongly believe that everyone should incorporate the strengthening and aerobic exercise protocol from the 'Body For Life' book. It will increase your metabolism and make any diet far more successful. As for choosing a diet, I would recommend that you avoid calorie counting unless it is within a structured group setting such as Weight Watchers. The other diets have a lot of similarity and I have tried to outline the differences. Ultimately you will have to "pick your poison" based on what you think would be most likely to work for you.

Good luck, but in the long run luck will have nothing to do with it.