New regulations out of Alabama

Earlier this summer, Alabama’s State Board of Medical Examiners (BME) pumped the brakes on the widely unregulated service of elective IV therapy according business and health care law firm Byrd Adatto. Under Alabama law, IV therapy constitutes the practice of medicine, meaning only a licensed physician, physician assistant (PA), nurse practitioner (NP), or midwife may diagnose, assess, and prescribe IV hydration therapy.

This means registered nurses, who can legally administer IV therapy, are not qualified to prescribe IV therapy and the use of “standing orders” (pre-written prescriptions that RNs can follow without consulting the provider) does not meet the legal requirements. The regulations for IV therapy vary by location, but as more states begin to follow Alabama’s lead, tighter regulations may be soon to follow.

Currently in California, the law states that IV therapy must be rendered through a medical corporation, and at least 51% of the practice must be physician-owned. Despite physician ownership, don’t be surprised if, similar to Alabama, the doctor, NP or PA must eventually prescribe treatment in California. In many places, IV therapy businesses are entirely staffed or even owned by RNs. With new state and federal regulations forthcoming, many of these businesses will potentially be out of compliance due to lack of oversight by a licensed provider.

Why is this important?

Ultimately it comes down to patient safety. IV fluids and added supplements have the potential to interact with other meds or even worsen existing medical conditions. For example, a patient with congestive heart failure (CHF) – a condition where a weak heart is already overloaded with too much fluid – should not have a seemingly harmless bag of IV fluids!

When we first discussed the idea of offering IV hydration in our office, this was one of my top concerns as a nurse practitioner. Can I order medications that can potentially be dangerous without seeing (virtually or in-person) the patient myself? I want to know their medical history, what surgeries they’ve had, what medications, supplements, and over the counter meds they take – all the details I need as a provider to determine if IV hydration is appropriate.

Because of this, I review each patient’s intake forms, verify their medical information, and conduct a brief assessment prior to treatment. For IV therapy, our patients come into the office and everything is done in person; for injections that can be self-administered, the entire visit can be conducted virtually, with live step-by-step instruction and visual confirmation of safe technique.

One size fits all?

There is no “one size fits all” for anything in medicine, even for something that may seem simple as a bag of IV fluid. Our safety-focused approach to IV hydration not only keeps us fully compliant with regulations, it allows us to provide customized care to each patient based on their individual needs. As with all medical treatment, we advise patients to do their research when seeking IV hydration therapy to ensure there is appropriate medical oversight of the business. Your health and safety, and those around you depend on it… even if the laws and regulations in your area haven’t kept up.

More Information

Check out our website to learn more about IV hydration therapy or click here to schedule a live or virtual evaluation today!

By Jennifer Cooper, MS, APRN, AGACNP-BC

Click here for the original blog post written by Jennifer Cooper for BuildMyHealth.

The post New Regulations for IV Hydration Therapy Coming Your Way! first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

BIA-SCC and BIA-ALCL

Breast implant associated squamous cell carcinoma and breast implant associated anaplastic large cell lymphoma are very rare. In fact, the incidence of these disease processes is not measured in annual rates. They are so rare that the case count is measured by the number of cases that have ever occurred in history. Understanding personal risk is important when recognizing this low incidence.

According to the American Society of Plastic Surgeons, there are 16 cases reported in the literature for BIA-SCC ever. In regards to BIA-ALCL, there are approximately 400 confirmed cases in the United States and a total of 1,227 worldwide as of August 2022.

BIA-SCC is a very rare but potentially aggressive tumor that appears to be associated with the scar that forms around any type of implant (knee implant, breast implant, etc), and in the case of breast implants, from the breast implant capsule. Because there are so few cases, it is not possible to determine what factors increase patient risk for BIA-SCC prior to their breast augmentation.

BIA-ALCL is a lymphoma or lymphoproliferative disease process. More information is available here. Below you can review a comparison of these two entities based on an overview from the American Society of Plastic Surgeons. Some information may be technical and more appropriate for your healthcare provider but it also offers the consumer insight into the language you may need to understand the full scope of these disease processes.

What is it?

BIA-SCC
Breast implant-associated squamous cell carcinoma (BIA-SCC) is a very rare but potentially aggressive, epithelial-based tumor that appears to emanate from the breast implant capsule. Pathology shows sheets of squamous cells lining the capsule in nests and bundles. BIA-SCC can exhibit highly invasive properties including spread to lymph nodes, local tissues and distant sites, such as muscle and bone.

BIA-SCC is not a cancer of the breast tissue itself.

BIA-ALCL
Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an uncommon and treatable type of T-cell lymphoma that can develop around breast implants. BIA-ALCL can exhibit highly invasive properties, including spread to lymph nodes, local tissues and distant sites.

BIA-ALCL is not a cancer of the breast tissue itself.

Lifetime Risk

BIA-SCC
Unknown.

BIA-ALCL
The current lifetime risk of BIA-ALCL varies widely (e.g., estimates of 1:2,207-1:86,029 based upon variable risk with different manufacturer types of textured implants. More recently, cumulative risk over 20 years in breast reconstruction patients implanted with Biocell devices was estimated at 1:100 (Cordeiro et al, 2020).

Age at presentation

BIA-SCC
55.8 years (range 40-81)

BIA-ALCL
55.3 years (range 28-84)

Average length since initial implantation

BIA-SCC
Average length since initial implantation 22.74 years (range 11-40 years)

BIA-ALCL
10.32 years (range 0.08-41 years)

Implant Surface

BIA-SCC
In case reports, BIA-SCC has been reported in patients who have had smooth and/or textured implants.

BIA-ALCL
No cases of BIA-ALCL have been confirmed in patients who have only had smooth implants in case series, case reports or registries. However, it is not possible to exclude the appearance of BIA-ALCL in association with smooth implants at this time. The FDA states that all confirmed cases worldwide either have a history of a textured device or an incomplete clinical history available for review.

Implant Type

BIA-SCC
BIA-SCC has been associated with both silicone and saline implants in aesthetic as well as reconstructive patients.

BIA-ALCL
BIA-ALCL has been associated with both silicone and saline implants in aesthetic as well as reconstructive patients.

Presentation

BIA-SCC
Delayed seroma (fluid collection), unilateral swelling, pain, erythema, often capsular contracture

BIA-ALCL
Delayed seroma, unilateral swelling, pain, erythema, sometimes capsular contracture

Extracapsular spread at presentation

BIA-SCC
80% at presentation

BIA-ALCL
28% at presentation

Typical Pathology

BIA-SCC
Squamous cells in sheets with varying degrees of atypia and metaplasia and at least one focus of SCC.

BIA-ALCL
Lymphoma with mass confined to single area on capsule.

Diagnostic Assessment

BIA-SCC
Send fluid collection sample to lab for testing of CK 5/6+ protein; p63+; Flow cytometry + for squamous cells and keratin

BIA-ALCL
Send fluid collection sample to lab for testing of CD30+ protein; ALK-; Flow cytometry + for T-cells

Imaging

BIA-SCC
Ultrasound to evaluate for fluid around the implant +/- aspiration; MRI with and without contrast to evaluate capsule to rule out mass; PET-CT for extent of disease, if present.

BIA-ALCL
Ultrasound to evaluate for fluid around the implant +/- aspiration; PET‐CT is performed following a positive diagnosis. Mammograms are not helpful for evaluating lymphoma but are important for the evaluation of breast cancer.

Treatment

BIA-SCC
Official treatment recommendations will need to be based on emerging data. At present, it appears that explantation with complete (en bloc) capsulectomy will provide the best outcomes.

Based on existing case reports, it appears that incomplete resection of BIA-SCC can result in early and/or aggressive recurrence.

BIA-ALCL
In the majority of cases, explantation with complete (en bloc) capsulectomy is curative. Incomplete capsular resection has been associated with both recurrence and significantly lower survival. Rare patients will present with more advanced disease and may require radiotherapy and chemotherapy. Treatment approach should follow international guidelines established by the National Comprehensive Cancer Network (NCCN) for BIA-ALCL. Current treatment recommendation is for bilateral complete capsulectomy and implant removal, as a small number of women have had contralateral disease found incidentally.

Chemotherapy / Radiation Therapy

BIA-SCC
Patients treated within these cases did not appear to respond.

BIA-ALCL
Responds to Brentuximab plus CT.

Reporting

BIA-SCC
The FDA recommends that any suspected or confirmed cases of SCC, lymphomas, or any other cancers around the breast implant be reported to the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database and the device manufacturer. To submit a case to the MAUDE database, which collects medical device reports (MDRs) of suspected device-associated deaths, serious injuries and malfunctions, visit www.accessdata.fda.gov.

BIA-ALCL
The FDA recommends that any suspected or confirmed cases of BIA‐ALCL be reported to the PROFILE registry, the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database and the device manufacturer. To submit a case to the MAUDE database, which collects medical device reports (MDRs) of suspected device-associated deaths, serious injuries and malfunctions, visit www.accessdata.fda.gov. To report a case to PROFILE, go to ThePSF.org/PROFILE.

Patient Counseling and Informed Consent

BIA-SCC
BIA‐SCC should be discussed with any patient considering breast implants as part of the informed-consent process.

BIA-ALCL
BIA‐ALCL should continue to be discussed with any patient considering breast implants as part of the informed-consent process.

American Society of Plastic Surgeon/Plastic Surgery Foundation Recommendations

Prior to implantation of any breast implant, plastic surgeons should provide patients with the manufacturer’s patient labeling, the FDA-required patient decision checklist and any other educational material to best discuss the benefits and risks of breast implants.

Preoperative workup is essential. All patients presenting with a late seroma should have fine needle aspiration (FNA) and cytology testing. Specimens should be sent for immunohistochemistry including CD30, ALK, CK 5/6, p63 and flow cytometry to look for T-cells, squamous cells and keratin.

All patients presenting with a late seroma should undergo a breast ultrasound and MRI with and without contrast. If disease is confirmed, a PET-CT should be considered prior to surgical intervention. A thorough preoperative work-up allows for potentially the most appropriately planned, single-stage surgery with the greatest chance of success for cure.

Consider the possibility of BIA-ALCL, BIA-SCC and other lymphomas when treating a patient with late-onset, peri-implant changes. If you have a patient with suspected BIA-ALCL or BIA-SCC, refer them to experts familiar with the diagnosis and treatment of BIA-ALCL and BIA-SCC.

At surgery, collect fresh seroma fluid, representative portions of the capsule, and specific pathology requests to rule out both BIA-ALCL and BIA-SCC.

Diagnostic evaluation should include cytological evaluation of seroma fluid or mass with Wright Giemsa stained smears and cell block immunohistochemistry/flow cytometry testing for cluster of differentiation (CD30) and Anaplastic Lymphoma Kinase (ALK) markers, as well as Cytokeratin 5/6 (CK 5/6) and p63.

Flow cytometry should include instructions to look for T cells, squamous cells, and keratin.

All confirmed or suspected BIA-SCC data should be entered into the PROFILE Registry (Data entry mechanism forthcoming).

Data for all patients with seroma should be entered into the National Breast Implant Registry (NBIR).

Click here for the original blog post written by Dr. Jonathan Kaplan for BuildMyHealth.

The post Update on Breast Implants first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

But as with many devices or medications, it is being used for a purpose other than what it is approved for. This isn’t illegal. It’s considered an off-label use. Consider BOTOX® Cosmetic. Doctors routinely administer it to consumers for the 11’s in between the eyebrows, forehead and crow’s feet. But it’s also used off-label for the lip flip or sweaty palms. Not illegal but not was it was cleared for, but since it provides a safe treatment for those off-label uses, it’s considered kosher.

However, heat-based devices to tighten the skin aren’t always safe, especially in untrained hands. These heat-based devices like Renuvion/J-Plasma can cause burns under the skin. In fact, that’s what the FDA reported. The agency received reports such as “serious and potentially life-threatening adverse events with use of this device for certain aesthetic procedures,” including some that have required treatment in an intensive care unit. The statement does not mention whether any cases were fatal.”

The Medscape article goes on to mention second- and third-degree burns, infections, changes in skin color, scars, nerve damage, “significant bleeding,” and “air or gas accumulation under the skin, in body cavities, and in blood vessels.” The last one, “air or gas accumulation” refers to terms you may be more familiar with like “gas gangrene” or “necrotizing fasciitis” aka infections from flesh-eating bacteria. Yes, this is serious stuff.

The reason I do not and will not offer this heat-based device to my patients is the same reason I avoided other heat-based devices like laser lipo. This clever sounding name describes using heat in the form of a laser to melt fat and then suck it out through a metal cannula. The heat from the laser was also promoted to tighten skin. But as you can see below and in this article that I wrote for a peer-reviewed publication, it also caused strange contractions of skin as well as 2nd and 3rd degree burns. To be clear, the photos below are not due to the heat-based Renuvion/J-Plasma device but from a related heat-based “laser lipo” device.

I know it sounds petty to say “I told you so.” But after years of the company attempting to get me to buy their equipment or patients asking if I offer J-Plasma (great marketing, I can’t argue that point), I feel vindicated that I avoided this class-action lawsuit.

Click here for the original blog post written by Dr. Jonathan Kaplan for BuildMyHealth.

The post I told you so (warning, graphic photos) first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

Greg:
Hey, this is Greg from Big Bay Mornings on 997 Now, and I’m here with a Board Certified plastic surgeon Dr. Bae. Good to see you again, Dr. Bae.

Dr. Bae:
Hey Greg.

Greg:
How’s it going?

Dr. Bae:
Going well, going well. I just want to point out that that is an awesome man-cave with those UT colors.

Greg:
Thank you. You look at that and look at my Longhorn thing back there. Yeah.

Dr. Bae:
And are you familiar with the actual name of the color? That type of orange?

Greg:
Burnt orange? How could I not be? I went to University of Texas.

Dr. Bae:
It’s actually burnt sienna. Yeah. It’s burnt sienna.

Greg:
That’s not what we say at UT. Here, I even have this for you, Dr. Bae, look at that. Hook ’em. I know you went to, not really a rival school, but close, close to University of Texas. You went to LSU.

Dr. Bae:
No, no. Well, for medical school, but I actually went to UT Austin for undergrad. We were a few years off though.

Greg:
Yeah.

Dr. Bae:
You’re getting confused, but it’s all right. Age does that to people.

Masks are coming off!

Greg:
Listen, don’t try to say I’m the older one here, but anyway. All right. I’ve got a question. Speaking of UT, since we both went there, I have this handy dandy mask. See my UT mask. I’ve got it all.

Dr. Bae:
Looks like a jockstrap, but okay.

Greg:
I’ve got those two, but I won’t go get it for you. I got the mask for you. I’m not going to get the jockstrap for you.

Dr. Bae:
And don’t get them mixed up and don’t get them mixed up putting the jockstrap on your face.

Greg:
I don’t know. In my world, that could be kind of exciting, but anyway, we better get back on track before we get in trouble here. Speaking to these masks though, we might not have to wear them forever. We are turning a corner here with the pandemic. Now, of course, we want people to keep wearing their masks right now. But I mean, one of the things that I kind of like about wearing the mask is it covers some of the things I don’t like about my face and the waddle, and maybe any imperfections, but that’s your specialty to fix these kinds of things.

Dr. Bae:
Yeah. I mean, it looks like things are getting a little bit closer back to normal. I mean, the CDC said this week that if you’re vaccinated, you can be inside with other people that are vaccinated and you could even be with other people that are unvaccinated as long as they’re not high risk. So the time of starting to remove masks is happening now. I mean, it is according to the CDC, I know that each state has different rules, but it’s happening. People are starting to take off masks and then you’re going to be able to start to see maybe the thin lips, the jowling, the full neck.

Greg:
I’m going to see the COVID-19, the COVID 19 that everybody gained.

Options for the lower face

Dr. Bae:
Right. So if anybody starts to get a little uncomfortable with that, people are still able to work from home so you can go get treatments and still recover from home, so that’s still pretty convenient, but yeah. When it comes to the lower face that was covered by a mask, yes, you can get lip fillers if you want. If you want to plump those up. If you have jowling, maybe just slight jowling, you can actually do liposuction along the whole neck, along the jaw line that can help with jowling.

Options for the neck

Dr. Bae:
If you have really bad jowling, then you need more of a facelift, but that’s obviously a bigger step for some people. And then when it comes to the neck, lots of different things, you can do surgical and nonsurgical. As far as the neck goes, if you have a little bit of folders here, there’s something called Kybella that will melt the fat, but keep in mind it will make your neck swell up like a bullfrog for about a week afterwards.

Greg:
Then you’ll need the mask again.

Dr. Bae:
That’s true. You’ll need the mask again. The other option is CoolSculpting, which it just freezes the fat and then the fat dies. The nice thing about CoolSculpting is that it doesn’t cause that big bullfrog swelling for the week after the treatment, so that’s good.

The SIMI Neck Lift

Dr. Bae:
And then if you really want to take it a step further, if you have a little bit of misplaced skin here, then you can do a surgical treatment, like I offer that I developed and I got published for. It’s called the SIMI neck lift, single incision, minimally invasive neck lift, where we just make one incision here, we undermine the skin, tighten up the skin here. And it avoids those big incisions behind the ears where you would normally remove excess skin. But for the patients who really do have that big turkey gobbler neck, have skin that they got to get rid of, then yeah, you would need to do a full neck lift for that, where you make those incisions behind the ears and remove the skin. So lots of options out there.

Greg:
And I have personal experience with this because my friend, Anna, she flew from Dallas. She came all the way from Texas to get her semi neck lift with you, Dr. Bae, And she absolutely is overjoyed with it. She loves the results.

Dr. Bae:
Well, thank you very much for the referral, Greg. You’ll get a little discount the next time you come in. Not that you are getting anything.

Greg:
I’m coming. I’m coming. You see this, I’m coming. Get your needle ready. Get that Botox ready for me.

Dr. Bae:
It’s ready. You’ve got a bottle of Botox with your name on it.

Greg:
Thank you, Dr. Bae. That’s good. All right.

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post The masks are coming off! What will they reveal?! [video] first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

The origin of Dr. Bae

Greg:
I got a couple things I want you to clear up for me. The two biggest questions I get. Number one, is Dr. Bae your real name? And when I go to the office, what’s the name I’m looking for on that thing?
Dr. Bae:
That’s a great question.
Greg:
Yeah.
Dr. Bae:
Yeah. When you show up to our office building is the 2100 Webster Building here in San Francisco in Pacific Heights. And yes, if you’re coming into the building and you’re looking on the marquee looking for Dr. Bae, you will end up at a Korean doctor’s office. You will not end up in my office. So you need to be looking for Jonathan Kaplan, K-A-P-L-A-N.
Dr. Bae:
But the reason we came up with Dr. Bae… I shouldn’t say “we”. Got to give a shout out to Dr. Miami and his CEO, Rosie. They had the idea for calling me Dr. Bae because I’m in the San Francisco Bay area, but it’s B-A-E, not B-A-Y, just to be a little more hip for the millennials.
Greg:
There you go.
Dr. Bae:
But, yeah. So look for Jonathan Kaplan. But it is funny how everybody when they come in, the patients and the families, they all refer to me as Dr. Bae. And I’m not sure they know what my real name is, and that’s fine. As long as they’re in my office and we’re having a good time, and I’m taking good care of them, it’s all good.

What makes someone Board Certified?

Greg:
Jonathan Kaplan or Dr. Bae. You can find him both ways. And Dr. Bae, here’s the other thing I wanted to ask you. I say it all the time, board certified plastic surgeon. What exactly does that mean? And what’s the difference between a plastic surgeon and a cosmetic surgeon?
Dr. Bae:
All right, yeah, this is a big can of worms that you’re opening up, but it is important. So, for the patient, if you’re going to somebody for a particular procedure, you want to make sure that they are board certified in the thing that they are doing on you. So for example, if you’re going to an orthopedic surgeon for a cosmetic liposuction procedure, that’s not a good idea. If you’re going to an orthopedic surgeon, you want them board certified in orthopedic surgery, and you’re doing an orthopedic procedure, that makes sense.
Dr. Bae:
The thing is, and this really comes down to money, is that over the last decade, as insurance reimbursements have gone down and doctors aren’t getting paid enough, a lot of them are looking for other alternative sources of revenue. So you’ll see ER doctors or OBGYNs looking for alternative sources of revenue, which means going outside of insurance and going to cash pay. And one of the things you can do that’s cash pay is cosmetics.
Dr. Bae:
So that’s why you really got to be looking for somebody that is not just doing cosmetics, but actually is board certified in plastic surgery. Or if they’re doing something on your face, you know that they’re a facial plastic surgeon or that they’re a dermatologist. You can find that stuff out on their website. But it’s tricky because-
Greg:
[crosstalk 00:02:53]. Yeah, what I was going to say is, just because you can stitch me up when I go to the emergency room doesn’t mean you necessarily are qualified to do my liposuction. And so, people need to be careful about that. You want somebody who specialized and went to school for plastic surgery like you did.
Dr. Bae:
Right. And so the thing is, saying they’re a cosmetic surgeon, that’s not really the same thing as saying that they’re a board certified plastic surgeon. And I’m not saying that anybody that says that they’re a cosmetic surgeon doesn’t have some technical ability to do a good job. I’m just saying that if it’s truth in advertising, let’s be honest about it.
Dr. Bae:
The thing is, anybody can say they’re a cosmetic surgeon. If they’re an ER doctor, OBGYN, and they’re doing Botox or liposuction in their office, they can actually call themselves a cosmetic surgeon. They’re not necessarily board certified in that in a way that’s recognized by the American Board of Medical Specialties. You might think, “Well, that’s illegal. If they’re an orthopedic surgeon, OBGYN, or an ER doctor, how can they do cosmetic procedures in their office?”
Dr. Bae:
It’s not technically illegal. They just may not have gone through the formal training that you are thinking they went through. Like, yes, they did med school. Yes, they did at least one year of residency training. But they might not have gone through a plastic surgery training program, or a dermatology training program, or facial plastic surgery. So you just have to look on their website to read. And if they say they’re just a cosmetic surgeon, then they may not be telling you everything. Maybe they were a primary care doctor first.

Do your research!

Greg:
The key here is do your research.
Dr. Bae:
Correct.
Greg:
Do your research before you do anything. You don’t want a podiatrist doing your facelift.
Dr. Bae:
And you don’t want me doing your bunions. It’s not an unreasonable thing. It goes both ways.
Greg:
I’ll let you try. I’ll let you try. All right. Well, thanks, doc… Oh.
Dr. Bae:
Yeah, yeah, no. I was just going to say… Yeah, you’re trying to cut me off, man. All I was going to say is that if people have questions about this, it is very complicated and we just touched the surface of it. If people have questions about if this person is board certified in plastic surgery, or dermatology, or facial plastic surgery, you can direct message me on my Instagram, which is Real Dr. Bae, R-E-A-L-D-R-B-A-E. Not B-A-Y. If you direct message me and you say, “This is the doctor I want to know more about,” I can direct message you back and tell you what I think as far as their board certification. I’m not going to talk badly about the doctor one way or the other. I’m just going to state the facts of what I see on their website.
Dr. Bae:
The other option is you can go to our YouTube page, which isn’t as memorable a YouTube page. It’s youtube.com/pacificheightsps, as in Pacific Heights Plastic Surgery. If you go to that YouTube page, we have a video on there about how to look at a doctor’s website to determine what they’re board certified in. And a lot of people just, again, just type in a doctor’s name in the comment section. I get that message, and then I reply to them about what I think that that doctor’s board certified in based on what I see on their website.
Dr. Bae:
So if you’re feeling lazy and you don’t want to do all the research yourself, you just message me the doctor’s name, and I can get the information back. Again, I am not badmouthing anybody in the process. I am just stating what I see on their website.
Greg:
I was going to say, then you don’t have to do the research. Let Dr. Bae do the research for you. He’ll do it all. All right.
Dr. Bae:
What else do I have to do?
Greg:
All right, now go edit this video, Dr. Bae. Thanks.
Dr. Bae:
Thanks. Great seeing you.

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post Bae Break: The meaning behind “Board Certified” [video] first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

Greg:

Hey. This is Greg here with board certified plastic surgeon, Dr. Bae, This time via video. I love this. I love this new look you got going on here, Dr. Bae.

Jonathan Kaplan:

Thanks. Appreciate you joining me. This is going to be our new vlog, Bae Break Example thing that we’re going to roll out and see how it goes. But I appreciate you working with me. We’ll hopefully work out all the kinks in this first pilot episode.

Greg:

Yeah. I’m super excited. And you can also sort of give me a consult to at times via video. You can tell me if I need a touch up here or there, when I do this.

Jonathan Kaplan:

Except that everybody else can see this video. So they’ll see the few imperfections you have, let’s be honest, the very few imperfections.

Greg:

But see? That’s okay. I can have them, because you can fix them.

Jonathan Kaplan:

That’s true. Fair enough. Fair enough. Point taken. Touche.

Three Vaccines

Greg:

All right. Well, I know what you do for a living is do things like this, help me look better, but you also know quite a bit about what everybody’s talking about. It’s the different vaccines for COVID. And we just had our latest one come out. Johnson & Johnson hit the Bay Area recently. But there are some differences and everybody wants to know between Johnson & Johnson, the Moderna, Pfizer. And some people have even suggested, “Ooh, do I want to get the Johnson & Johnson?” So fill us in and tell us what’s your best advices.

Jonathan Kaplan:

Yeah. So go through whatever website you can or whatever, Walgreens, Rite Aid. Do your best to kind of just sign up as soon as you can, as soon as your tier opens up. And don’t worry about which vaccine it is. They’re all life-saving vaccines. Yes, there are three that you hear about in the news, the Pfizer, the Moderna, the Johnson & Johnson. And yes, there is maybe higher effectiveness for Pfizer and Moderna, 94 1/2% versus 95%. Moderna’s 94.5%. Pfizer’s 95%. but don’t let that scare you, that Johnson & Johnson, the published report, [inaudible 00:01:57] from 66 to 71%, because it’s all about what they’re measuring there. The thing to keep in mind is while yes, maybe Pfizer and Moderna will keep you from getting a milder case, whereas that might get past the Johnson & Johnson vaccine, the thing that really keep in mind is that all three of them, after about two to three weeks after you’ve gotten any three of those vaccines, that you will not be hospitalized statistically speaking and you will not die if you catch COVID.

Jonathan Kaplan:

So that’s what’s really important, is that these are lifesaving vaccines that will keep you out of the hospital. Doesn’t matter what those percentages are that you may be hearing on the news. So please, whichever opportunity you get, whichever vaccine you get the opportunity to get, like I was saying, sign up, get that vaccine, go take that vaccine, the one that’s available to you tomorrow. Take it. Don’t say, “Oh, I’m going to wait for the Pfizer,” because you just never know when you’re going to get a chance to get that vaccine if you don’t take the chance when you have it.

Greg:

That’s true. And every day without a vaccine is a day that you could possibly encounter COVID. And so you don’t to have to go through that. And something you brought up and I just want to emphasize is I believe it’s 100% of the studies for all three nobody died, nobody went to the hospital under these vaccines. So it’s going to keep you from getting super sick, no matter which one you take.

Where we were just a year ago

Jonathan Kaplan:

Right. I mean, it’s so insane to think that we have three vaccines not even a year after the first shelter in place order was put in place in the United States, which happened to me in San Francisco. So that was March 16th, 2020. We’re not even to March 16th yet and we’ve got three fully-functional vaccines, that like you said and like I’ve said and which you can never reiterate it enough, it will keep you from dying and will keep you from getting hospitalized. Because that’s the thing, is if you say, “Oh, well, you know what? I want to wait for the Pfizer one,” well, let’s say that’s two weeks away and you go and you get a mild case or what you hope is a mild case of coronavirus, but then you get hospitalized and you get put on a ventilator, maybe you survive, great, but if you would have just gone with the Johnson & Johnson vaccine, which is supposedly around 66%, you would have completely avoided the hospital, you would have avoided being on the ventilator. So it seems very obvious to me.

Jonathan Kaplan:

The benefit also of this Johnson & Johnson vaccine is it is one shot. The other two are two shots. But they are looking to see if you get a… They’re doing another study of the Johnson & Johnson vaccine, that if you get a second booster shot, kind of like what you’re doing with Pfizer and with Moderna, that that will actually get your levels up to where the Pfizer and Moderna vaccines are. So they’re still studying that. But either way, if you can avoid being in the hospital, why take the chance and wait on another vaccine?

mRNA vs other technology

Jonathan Kaplan:

The other thing that’s really I find interesting about the different vaccines is people talk about, “Oh, well, I’m not sure about Pfizer and Moderna because their messenger RNA vaccines,” which nobody knows what that means. I don’t know why you all of a sudden they’re drawing a line in the sand that, “Oh no. No messenger RNA vaccines.” It’s just that that is a newer technology. Or excuse me, I should say it’s a technology that’s been around for 20 years. Just this is the first time it’s been used as a vaccine. And there was some concerns about fertility. All of that is unfounded. There’s no evidence of that.

Jonathan Kaplan:

So whether it’s a message RNA vaccine or whether it’s the Johnson & Johnson vaccine, which is a vector-based vaccine, you have to become an epidemiologist of virologist to understand any of this, but just believe that smarter people than all of us have done the research and these things are safe. The FDA has viewed these things as safe. And even though they just came out a few months ago, 100s of 1000s of people were included in the studies for all three vaccines and now millions of people have gotten these vaccines in the United States. So they are safe. They really are.

How to get your vaccine!

Greg:

All right. If you haven’t already, get online now, find all the websites, there’s several of them, where you can sign up to get in line to get your vaccine. You can’t just wait around and think you’re going to get a phone call from somebody. You’ve got to go online and be proactive. You can go to your doctor’s website. You can go to a lot of different other websites that you can search and Google, but it’s important to find out where your tier lies, get signed up and get your vaccine.

Jonathan Kaplan:

And what’s kind of cool, and this isn’t technically skipping the line, because obviously I would never encourage that, but if you go Google Dr. B, B as in boy, Dr. B vaccine, it’s a website.

Greg:

[crosstalk 00:06:15].

Jonathan Kaplan:

And maybe you’ve heard… You’re shaking your head. You’ve heard about it? Yeah.

Greg:

Yes.

Jonathan Kaplan:

It’s a website that will let you know if there’s a place where they’re going to have to throw away some vaccines at the end of the day that they don’t have enough people who scheduled or signed up and they’re going to have to throw them out anyway. And so you sign up for that. My boxing instructor, Magic Sean Hall, give him a shout on Instagram, he went last Thursday to the Oakland Coliseum and was able to get a vaccine because of the fact that he signed up on that website and they were going to throw it out. He’s definitely not in the right tier yet, but because they were going to throw it out, it’s totally legit. And he went and got it.

Greg:

Absolutely. The more shots we get in the arms, it doesn’t matter. We would much rather it get into an arm than get thrown away. So you can also show up the Moscone Center on a random Saturday, if they have extras, people don’t show up. That’s another thing. There are no-shows. So you could try it. You could try to show up somewhere. Be polite. And if they have it and it’s going to get thrown away, they will give it to you. Okay. Well, Dr. Bae, this is all great information. And if somebody maybe wants to see you for your real specialty, which is making us all look and feel better, I know you’ve done that for me and 1000s of others in the Bay Area, tell them how they can reach you.

Learn more

Jonathan Kaplan:

Yeah. It’s very easy. On Instagram or on Snapchat, they can message us, direct messages us, at realdrbae, R-E-A-L, D-R, B-A-E, not B-A-Y. And they can also go to our website, which is realdrbae.com. And we have a price estimator on there, a chat bot where you can check pricing, because I know that’s always… Ultimately, everybody’s question is how much does it cost? So we make it very easy for people to check pricing before they come in for the consultation, so nobody experiences any sticker shock.

Greg:

He can definitely help you get rid of that COVID-19 that you’ve gained, if that’s what you’re looking to do or-

Jonathan Kaplan:

[crosstalk 00:08:01] we all gained.

Greg:

Or any wrinkles, because you’ve been worried for a year and a half. Thank you so much, Dr. Bae. It’s been a pleasure.

Jonathan Kaplan:

Always a pleasure, Greg. Thanks so much for joining me.

The post Bae Break: Discussing the Three Vaccines [video] first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

Facial fillers and the COVID vaccine

First off, it’s not usual to have a reaction to a vaccine. Any vaccine. There’s nothing special about the COVID vaccine in that respect. The preservatives used in vaccines, such as polyethylene glycol (PGE)(used in skin creams and other self care products) can cause a reaction in some people. Typically recipients that are already susceptible to allergic reactions for one reason or another.

In fact, many documented cases of allergic reactions to the vaccine, facial filler patients or otherwise, were consumers that carry an EpiPen because of their risk of having an allergic reaction. That should tell you something about their innate susceptibility to allergens in general. This is different than the vast majority of the population.

Currently, the theory is that people who have had facial fillers, that can contain PGE, develop antibodies to PGE and once they receive the vaccine, which also contains PGE, their immune response “attacks” the fillers, causing facial swelling. For the record, this attack by the immune system is actually a good sign you have a strong, appropriately reacting immune response.

What happens to facial filler patients that have a reaction to the vaccine?

So for those people that have a reaction to the PGE in a vaccine, they have have facial or lip swelling in the area of the facial fillers. But that’s it. The reaction is easily treated with antihistamines like Benadryl, Claritin or Allegra. Oral or an injectable steroid will help tamp down the reaction as well.

The important thing to remember is that no one has had a serious reaction in the case of facial fillers. So if you’ve had facial fillers and are considering not getting the vaccine, please reconsider. This is a risk – benefit decision. And the benefit of getting the vaccine and avoiding an active COVID infection far outweighs the risk of have some facial swelling after facial fillers.

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post Facial fillers and the COVID vaccine first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

The Vice Presidential debate last week may seem like forever ago. But who can forget Kamala Harris’ statement that she would accept a vaccine from the FDA but not from President Trump. Whether you heard it or not, it’s still nonsense. This has nothing to do with politics and everything to do with the scientific method and science in general. So don’t let Kamala scare you.

Don’t let Kamala scare you from taking a vaccine

The development and approval of a vaccine is not, nor has it ever been, solely under the discretion of the President. There is a cacophony of public and private partnerships involved. Currently there are four drug companies that are in the final Phase 3 trials of a COVID-19 vaccine. Translation: they’re providing the vaccine to tens of thousands of volunteers throughout the world to ensure the vaccine is both safe and effective.

After each phase of any drug trial, the FDA reviews the data to determine if the drug company can proceed to the next phase and final approval after the third phase. Consider all of the researchers, doctors, nurses, statisticians that take part in these studies. If there were any shortcuts, someone within this entire process would blow the whistle.

And with so many involved, there are simply too many people standing in the way of a President imposing their will to magically approve a vaccine over everyone’s objections. While Vladimir Putin did that in Russia, this isn’t Russia. So for Kamala to say she would accept a vaccine from the FDA but not from the President is ridiculous. The truth is that approval is predicated on the drug companies, the FDA and the President signing off on it. Does that mean she won’t take the vaccine because the President was ultimately involved? Actually, what she does personally is immaterial.

Why her comments are so irresponsible

The real issue, the real harm is that she has lent credence to the thousands (or millions?) of Americans that have reservations about taking the vaccine. For either founded or unfounded reasons, some have concerns about the safety of the vaccine. With her irresponsible comments, they can now follow their instincts to forego the vaccine. Albeit for completely unscientific, nonsensical reasons.

By promoting a conspiracy that Trump will single-handedly approve the vaccine, she is no better than anti-vaxxers that believe vaccines lead to autism, a widely debunked theory. Some may believe her comments were hyperbole. That she didn’t really mean it. Unfortunately, being the Jenny McCarthy of the Democratic Party and scaring the populace from getting the vaccine, and producing herd immunity, is unforgivable.

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post If a vaccine is approved, don’t let Kamala scare you from taking it! first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

$300 per day penalty – is it enough?

If hospitals miss the deadline to place shoppable services on their website, a $300 per day penalty will be levied. But if your facility makes hundreds of millions of dollars on average, maybe $300 per day is just a rounding error?!

I’m not suggesting they should fine hospitals a higher dollar amount. Because in truth, providing all of the various types of pricing (bundled rates, cash rates, negotiated rates) for 300 shoppable services , while totally doable, will take a great deal of time. It also depends on the effort hospitals will put forth. Will they just list a huge readable database of pricing along with each procedure? Or will they make it more user friendly and searchable.

Time will tell whether any, some or most hospitals meet the deadline. In the meantime, we will always have pricing available and searchable on our website.

Video: Background to the Trump Price Transparency Rule

Physicians and outpatient facilities: this affects you too!

Physicians, surgery centers and independent practitioners need to get ahead of the curve. Don’t wait for hospitals and insurers to list your rates. Price transparency, when done correctly, can be a customer service satisfier. Whether it’s providing the consumer the bundled rate, the negotiated rate or the cash rate for their healthcare services, the consumer will find it much easier to determine their costs through the physician’s site rather than a clunky hospital or insurer’s site. So don’t think this only affects hospitals. Consumers will expect price transparency from you too!

Dr. Jonathan Kaplan is a board-certified plastic surgeon based in San Francisco, CA and founder/CEO of BuildMyBod Health, a price transparency-lead generation platform. You can watch him operate and educate @realdrbae on Instagram, Snapchat and TikTok.

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post Will a $300 per day penalty bring hospitals in line? [video] first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

Anaplastic large cell lymphoma (ALCL) vs Breast implant associated illness (BIAI)

Compared to BIAI, it’s “easier” to determine if someone has ALCL. They’ll present with a late onset fluid collection or seroma around their breast implants (most typically textured implants), 1 to 20 years after surgery. And when sent to the lab, that fluid collection will test positive for the CD30 protein or negative for the anaplastic lymphoma kinase (ALK) protein. ALCL is treatable, and cure is possible, with removal of the implant and surrounding scar tissue when performed early. Again, the most encouraging aspect of ALCL is that it is diagnosable and treatable.

While BIAI and ALCL are similar in that they both seem to affect patients with textured implants, they are very different in other ways. For example, BIAI has many vague symptoms also associated with other disease processes, including those not involving breast implants. Symptoms that women commonly report are fatigue, anxiety, foggy thinking, memory loss, headaches, muscle pains and even hair loss and skin rashes. A caring sympathetic doctor would not dispute that a patient is feeling these symptoms. But this is not enough to make the diagnosis of BIAI.

BIAI is difficult to diagnose for two reasons. First, there’s not always a physical symptom like seroma formation. And secondly, there’s currently no diagnostic lab test, as in the case of ALCL. However, in an exceptional case, I had a patient with BIAI that actually had physical symptoms and a positive lab test. But a word of caution. The lab tests referenced here are not specific to BIAI and are certainly not diagnostic of BIAI in the same way CD30 is diagnostic of a symptomatic patient with ALCL.

A BIAI patient with symptoms and lab abnormalities

A previously healthy, thin, fit, female patient of mine had breast augmentation with 320cc round-base, shaped, textured implants in April of 2016. Approximately 6 months after surgery, she started to experience rashes (see photo), extremely high blood pressure (168/110) and numerous food allergies (gluten, dairy, alcohol, coffee) which would lead to more rashes.

Her hands would turn white and purple, a sign of Raynaud’s disease (see photo) – changes she never experienced prior to breast augmentation. Soon after, she started to experience muscle weakness and a sensation that her legs were very heavy. Upon going to the ER, her lab tests showed very high levels of creatine kinase (CK). This is an enzymatic protein found in the heart, brain, skeletal muscle, and other tissues. It is released into the bloodstream when there is damage to those tissues. Measuring high levels of CK is  a common test for someone actively experiencing a heart attack. CK levels are high when there is damage to the heart muscle because coronary arteries are clogged and the heart isn’t receiving enough oxygen.

Despite a high CK level, there was no reason to suspect she was having a heart attack. She was young, had no chest pain and no changes on EKG. But they were concerned that elevated CK levels, whatever their cause, could damage the kidneys, as is possible in rhabdomyolysis. Rhabdo, for short, is the rapid breakdown of muscle tissue and release of proteins into the bloodstream. The large amount of proteins can damage the kidneys and cause acute renal failure.

While the doctors had not yet diagnosed the cause of the elevated CK protein in the blood, they worried about its effect on the kidneys. In an overabundance of caution, she remained in the hospital for 3 nights with IV fluids to help flush out the CK protein before it could damage the kidneys, which was successful.

Unsure of the cause of her full body symptoms, she dramatically shifted her lifestyle. This included alcohol cessation, which she already used in moderation beforehand, and avoidance of foods that could cause any bodily inflammation.

After another admission to the hospital in July of 2019 (3 years after surgery) because of weakness, muscle wasting and an elevated creatine kinase level of 411 U/L (normal is 24-173 U/L), she decided the implants were the underlying cause of these symptoms and made the decision to remove them.

In November of 2019 (3+ years after implantation), I removed the implants and the surrounding scar tissue (capsulectomy). Since then, her rashes, Raynaud’s and all other symptoms have disappeared. As of January 2020, 2 months after implant removal, her creatine kinase level returned to the normal range.

So what does it all mean?

This represents one of the few examples in the literature when demonstrable physical symptoms (rash and Raynaud’s disease) in combination with a lab test, both had resolution after removal of implants. And while resolution of elevated lab tests and symptoms should be seen as a success after implant removal in patients experiencing BIAI, the true success remains elusive.

What we need is a preoperative antigen test that can predict, with a high degree of certainty, that if someone gets implants, their body may react to the implants and enter a sustained, chronic phase of inflammation. And if the patient is found to be “reactive” to such a test, they wouldn’t get implants.

Testing like this is not unheard of within aesthetic medicine. For example, one component of the dermal filler Bellafill is bovine collagen. Because some patients can have a reaction to bovine collagen, they receive a skin test one month before Bellafill treatment. If they have a skin reaction, they are not a candidate for this long-lasting dermal filler. Similarly, if someone would have a reaction to some future “breast implant antigen” test, they would not be a candidate for breast augmentation.

Conclusion

For those who believe no one should get breast augmentation until the development of such a test, that is an unreasonable approach. There are millions of women around the world who currently have breast implants and over 400,000 undergoing the procedure for cosmetic or reconstructive reasons each year.  And with a relatively small percentage experiencing ALCL or BIAI, the benefits of breast augmentation greatly outweighs the risks. While continuing to provide this service to women for cosmetic reasons or for reconstruction after mastectomy, we should also continue to develop prognostic techniques to avoid augmentation in the few patients that will have very real adverse reactions.

And for those few patients that do have symptoms after implantation, luckily there’s treatment. They can be potentially cured with explantation (implant removal) and capsulectomy.

Dr. Jonathan Kaplan is a board-certified plastic surgeon based in San Francisco, CA and founder/CEO of BuildMyBod Health, a price transparency-lead generation platform. You can watch him operate and educate @realdrbae on Instagram, Snapchat and TikTok.

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post The difficulty in diagnosing Breast Implant Associated Illness (BIAI) first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

COVID cases increase

But telling schools, sports (without spectators), salons and other indoor businesses to remain suspended isn’t a long term plan. Sure you can attempt to mitigate the spread by not participating in large crowds like protests, enclosed bars and restaurants. You can wear a mask around others, social distance and wash your hands. But despite these measures, the rate of infections will continue to ebb and flow.

What we have to understand is this is a pandemic that is here to stay. Everyone is quick to mention the end of the pandemic will arrive when a vaccine is available. But even if a vaccine is approved, we have to hope it’s effective against all strains of this novel coronavirus.

There’s also the issue of distributing the vaccine. What makes you think you’ll be the first to get it? It’s almost certainly going to the elderly and institutionalized first. Your cohort, whomever you may be, is probably third or fourth in line!

So we need to prepare for the long haul here. We will continue to see surges come and go across the country and around the globe. Often revisiting locales that already experienced surges before. And that means the public has to avoid the temptation of demanding that everything, including schools or sports, shut down the moment one person, or three, get infected. This situation demands tolerance when members of our community test positive, because that is an inevitability. Remember, the realistic goal we set for ourselves from the outset was to flatten the curve, not eliminate it.

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post As COVID cases increase, so too must the public’s tolerance for them first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.

After the protests in June, and celebrations involving Memorial Day and July 4th weekends, we’re seeing an inevitable surge associated with mass gatherings. This leads to a continuing shelter-in-place, reducing travel plans and working from home for the foreseeable future. These mass gatherings and changes in consumer behavior are leading to a surge in both coronavirus and cosmetic surgery. What’s the connection?

Coronavirus and Cosmetic Surgery are surging

This phenomenon of increasing cosmetic surgery along with an increase in the coronavirus was recently highlighted in this article.

Since March, consumers are home, on ZOOM, seeing their reflection more than ever before. Naturally, some will see things they want to address. Like Botox or fillers for wrinkles.

They’re also realizing this is the best time to get that Mommy Makeover or other procedures they’ve been considering. With trips cancelled, that frees up more disposable income. And with the ability to work from home after a procedure, it’s easy to avoid questions from coworkers about why you were “out” or what you had done. If you just had a Brazilian Butt Lift, you won’t have to explain why you’re sitting on a pillow!

This increase in cosmetic surgery isn’t isolated. Across elective surgery websites, including BuildMyBod.com, where consumers can check pricing on outpatient services, traffic is up 73.4%! So while not everyone is getting cosmetic surgery or other elective procedures, they’re certainly considering it.

Think of a sales funnel. More consumers are entering the top of the funnel and checking pricing. As more folks enter the funnel, more will progress through the funnel, ask questions, schedule consults and then book surgery.

Safeguards with coronavirus and cosmetic surgery are surging

With the increasing surge in both coronavirus and cosmetic surgery, new safeguards are necessary. For plastic surgeons that perform cosmetic surgery at hospitals, their ability to operate is being curbed. As discussed here, cosmetic surgery is slow to start for several reasons at hospitals. Most significantly, the need for hospitals to make up lost revenue with better paying elective cases like orthopedic procedures.

But for outpatient surgery centers or office-based operating rooms, surgeons are performing a great deal of cosmetic surgery. To keep those patients safe, patients are undergoing COVID testing in the community prior to surgery. And in some offices, like ours, we perform an antibody test the morning of surgery.

While the coronavirus is a serious ongoing pandemic, it’s becoming increasingly clear that the end is not in sight. Therefore, we must mitigate the risks and move forward with our lives as safely as possible. That includes accommodating patients that want non-essential procedures such as cosmetic surgery. And based on web traffic and bookings, they’re clearly on board.

Click here for the original blog post written by Dr. Kaplan for BuildMyBod.

The post Why coronavirus and cosmetic surgery are surging first appeared on Plastic Surgeon San Francisco | Pacific Heights Plastic Surgery.