Saturday, November 21, 2009

Federal Health Care Reform - Concerns of the California Medical Association

November 21, 2009

Special Alert: Federal Health Reform

Today the United States Senate will vote on “cloture” to begin debate on health reform. CMA is opposed to the proposal currently before the Senate and has communicated our position and concerns to both California Senators. I and Immediate Past-President Dr. Dev GnanaDev will speak directly to Senators Feinstein and Boxer on Monday to make clear our concerns with the current proposal. In CMA’s view the current version does not improve patient care and could in fact, substantially harm the doctor-patient relationship. CMA is committed to working with our Congressional Delegation to substantially improve this legislation.

It is our hope that we will be able to support a final product that protects what currently works well for patients and fixes what is broken. The CMA Executive Committee and Board of Trustees will review any final legislative agreement and, with input from CMA member physicians, make a decision as to our final position.

Please stay tuned for more updates; CMA will provide a more detailed summary of our concerns shortly.

J. Brennan Cassidy, M.D.
CMA President

Monday, November 16, 2009

Research, Stem Cells and Microsurgery - Working toward growing breast tissue in the lab

The following describes exciting new research on "growing" breast tissue in the lab, using stem cells, tissue engineering and technology!

Breast 'regrowth' trial planned

Researchers in Australia plan to test a medical "scaffold" designed to stimulate natural breast tissue to regrow following surgery.

Doctors from the Bernard O'Brien Institute of Microsurgery in Melbourne, will test the technique next year in a trial involving six patients.

The team say that the permanent fat found in breasts can be grown inside this contoured scaffold. They claim to have successfully tested the device in pigs.

The results of that experiment were presented at a plastic surgery conference in Sydney. The researchers recently announced on the institute's website that they had received funding from the Australian government to carry out the human trial.

If this is successful, they hope to develop it into a breast reconstruction technique that avoids using silicone.

Breast scaffold

The teams says that when the "empty chamber" is implanted, fat tissue will naturally fill it to form a new breast.

It's at such an early stage, it is not yet clear whether it will work in people - Dr. Lesley Walker, Cancer Research UK.

This chamber will also contain a gel made using the patients' muscle cells to "induce fat tissue production".

Professor Anthony Hollander, an expert in tissue engineering from the University of Bristol in the UK, said the attractions of this approach were its simplicity and the fact that the tissue growth occurred inside the body.

"At the time of implanting the cells the surgeon redirects the vasculature of the body which keeps a good blood supply to the implant. That is in itself nothing new, but combining it with a cell implant is an interesting step," he said.

He said that the technological advance was the use of a biomaterial cage used to trap the cells in the right place.

In future, the team plan to make this cage biodegradable so it does not have to be removed.
"If it's tried and it works that will be a really nice approach," Professor Hollander said.
But he cautioned that there was "still some way to go".

"This procedure is first likely to be used on cancer patients," he said. "[The team will] have to be able to demonstrate a technique that guarantees that all the cancerous cells are removed and none are grown up in the process, so there is still some way to go."

Dr Lesley Walker, director of cancer information at Cancer Research UK, said: "We know that having a mastectomy can be a very difficult experience for many women and so research to try to improve breast reconstruction after surgery is important.

"[But] it's at such an early stage, it is not yet clear whether it will work in people. Even if this surgery proves to be effective, it will be a number of years before it can be used in the clinic."

Wednesday, November 11, 2009

The Jakarta Post Article - The Brave New World of Plastic Surgery

I was recently interviewed by San Francisco freelance writer, May-lee Chai, for an article in the Jakarta Post, Indonesia.

Click on the images for a full-size version of this article on Plastic Surgery.

Saturday, November 7, 2009

Local Heroes in Medicine: Women Pioneers that Shaped Medicine in San Francisco

The following is an article from the September 2009 San Francisco Medicine publication:

Local Heroes in Medicine

Pioneers that Shaped Medicine in San Francisco
by Nancy Thomson, MD

“Women should not be expected to write or fight or build or compose scores. She does all by inspiring men to do all.” —Ralph Waldo Emerson (1802–1882)

In 1948, when I started college at Stanford University, my physician father discouraged me from preparing for medical school, saying that I would take a man’s place, then marry and never practice. Lois Scully, MD, a San Francisco internist, Stanford graduate, and 1979 president of the American Women’s Medical Association, ran into the same bias at about the same time when the
Stanford physician who interviewed her told her to go home, marry, and have five children.

In the early 19th century, Lucy Stone (1818–1893) wanted a good education, but the only college in the world that accepted women at that time was in Brazil. Luckily, Oberlin University was founded in 1835 in Ohio, the first U.S. college to accept both women and African-American students. Stone enrolled and graduated in 1847. However, when it came time to seek a profession, the only field open to women was teaching. In 1849 (the year Elizabeth Blackwell graduated from Geneva Medical College in New York), Lucy Stone wrote, “We believe that if the system of educating females for physicians be generally adopted, a great amount of suffering and death will be saved.”

In fact, the number of female medical school graduates rose steadily from 1849 to 1900. By 1900 in Boston, women represented 18 percent of practicing physicians. However, by 1903 women’s participation in medicine began to decline, as most of the women’s medical schools established in the previous 50 years were closed or merged with male dominated schools, which continued to reject women applicants. This situation generally prevailed until the 1970s, when the feminist movement and antibias legislation brought about an increase in women attending medical schools.

In 1970, female admissions to medical schools were at 9.2 percent; in 1980 they had risen to 27.9 percent, and they are at almost 50 percent today. The decline in economic potential for physicians (which was historically one of the foremost motivations for male medical students) is given comparatively little importance by female students, who cite longtime interest in medicine and science, the desire to help others, and dissatisfaction with other types of work among
their reasons for choosing medicine.

The following time line highlights women’s place in the medical history of San Francisco.

Historical Time Line

From the time of landing at Plymouth Rock, women as well as men practice medicine in New England, often after an apprenticeship with a practicing physician. However, when American medical schools are established, they follow the European pattern of barring women from
seeking medical degrees.

Elizabeth Pfeifer Stone, the first woman to practice medicine in California, settles in San Francisco. Probably German-born and -trained, she previously practiced in New York.

University of California acquires Toland Medical School in San Francisco, and since U.C. is already coeducational, Lucy Maria Field Wanzer, a thirty-three year-old teacher, is accepted as its first female medical student. However, the dean suggests to her fellow students that they “make it so uncomfortable for her that she cannot stay.”

Charlotte Blake Brown applies to the San Francisco Medical Society for admission. Some members of the membership committee feel strongly that females are mentally, physically, and morally unfit to study medicine, let alone practice the profession. On advice of mentors, Brown
withdraws her application.

Following the model of Elizabeth Blackwell’s New York Infirmary for Indigent Women, Pacific Dispensary for Women and Children is founded by three women, all educated on the East Coast: Charlotte Blake Brown, Martha Bucknall, and Sarah E. Browne. This outpatient clinic, initially located at 510 Taylor Street, is intended to provide opportunities for women physicians to obtain internship experience.

San Francisco Medical College of the Pacific accepts its first female student, Alice Boyle Higgins, who graduates in 1877.

Having been admitted to the California Medical Society along with four other women in 1876, Lucy Wanzer becomes the first female member of the San Francisco Medical Society.

Founders of Pacific Dispensary create the first nursing school west of the Rockies. Its one-year course becomes a two-year curriculum in 1882.

The Pacific Dispensary moves to a new two-story building at California and Maple Streets and becomes Children’s Hospital. Interns and residents can be either male or female, but there are no men allowed on the medical staff.

Citizens of San Francisco raise money to build the Little Jim Building for pediatrics at Children’s Hospital.

One year after X-rays are discovered, Elizabeth Fleischman-Aschheim, an engineer, opens the first X-ray laboratory in California, at 611 Sutter Street.

William Randolph Hearst leads the campaign for the Eye and Ear Pavilion at Children’s Hospital.

Dr. Charlotte Blake Brown dies at age fifty-eight. Her daughter, Adelaide Brown, MD (1868–1933), carries on her mother’s work at Children’s Hospital but also serves on the Stanford faculty at Lane Hospital. She fights locally and nationally for clean milk, sanitary garbage disposal, maternal and child welfare, visiting nurse services, and clinics offering cardiac care and birth control.

The San Francisco earthquake forces the demolition of the 1887 Children’s Hospital building.

A new, four-story brick Children’s Hospital building opens at California and Cherry Streets.

The Contagious Disease Pavilion opens at Children’s Hospital, with money donated by William Randolph Hearst, to care for diphtheria, scarlet fever, measles, TB, and, later, polio.

Children’s Hospital affiliates with the University of California for the teaching of medical students.

The American Medical Association admits its first female member.

Henries Hagar Duggan, MD, becomes a pioneering medical anesthesiologist. She works at various hospitals but settles at Children’s for twenty-five years, retiring after the end of World War II.

UCSF pediatricians Mary Olney and Ellen Simpson found summer camps for children with diabetes.

Marian Yueh Mei Li arrives in San Francisco, having completed medical school in Shanghai. She eventually opens a private practice and becomes the first Chinese female ophthalmologist to practice in Chinatown.

Pediatrician Hulda Thelander establishes the Child Development Center at Children’s Hospital for children with cerebral palsy, developmental delays, and congenital defects.

Internist Roberta Fenlon, MD, becomes the first female president of the San Francisco Medical Society.

Dr. Roberta Fenlon becomes the first female president of the California Medical Association.

Linda Hawes Clever, MD, MPH, founds (and chairs) the Department of Occupational Health at California Pacific Medical Center. She is also the first female editor of the Western Journal of
Medicine and is the founder of RENEW, an organization to help fight professional exhaustion and dissatisfaction.

Children’s Hospital acquires St. Joseph’s Hospital.

Marshall Hale Hospital, formerly Hahnemann Homeopathic Hospital, merges with Children’s Hospital.

Children’s Hospital and Pacific-Presbyterian Medical Center merge to create California Pacific Medical Center (CPMC). CPMC joins the Sutter Health chain.

Judith M. Mates, MD (ob-gyn), becomes the second female president of the San Francisco Medical Society.

Toni J. Brayer, MD (internist), becomes third female president of SFMS and, in 1990, the first female chief of staff at California Pacific Medical Center.

Rita Melkonian, MD, FACOG (obgyn), becomes the fourth female president of the San Francisco Medical Society, with E. Ann Myers, MD (endocrinology), as the president-elect.

In closing, it’s interesting to note that in 1868, while debating the admission of women, the American Medical Association recorded this statement by Dr. Alfred Stille, prominent teacher of pathology:

“Another disease has become epidemic. The woman question in relation to medicine is only one of the forms in which the pestis mulieribus vexes the world. In other shapes it attacks the bar, wriggles in the jury box, and clearly means to mount upon the bench; it strives thus far in vain to serve at the altar and thunder from the pulpit; it raves at political meetings, harangues in the lecture room, infects the masses with its poison, and even pierces the triple brass that surrounds the politician.”

If only Dr. Stille could see us today. We’ve sure come a long way.

Nancy Thomson, MD, was a practicing anesthesiologist at Children’s Hospital from 1963 to 1985. In 1988 she received her master’s in public health from the University of California at Berkeley. From 1991 to 2000 she worked as the infectious disease officer and staff physician at San Quentin State Prison. Dr. Thomson currently serves on the editorial board for San Francisco Medicine and is the magazine’s obituarist.

Friday, November 6, 2009

All About Labiaplasty - Labia Minora Reduction


Labiaplasty is a surgical procedure which corrects excessively long, enlarged or redundant labia minora. Women who seek this surgical procedure may be self-conscious about hanging labial tissue, they may have asymmetric labias, or they may have pain or discomfort during sex, with exercise or sometimes just walking!

The purpose of labiaplasty is to surgically reduce excessive large labia minorae, to create symmetry when it is lacking, and to make the labia appear more cosmetically appealing. Occasionally excess tissue around the clitoral hood is also carefully trimmed, without any injury to the nerves that provide sexual stimulation.

Labiaplasty only addresses the labia minora (inner lips of the external genitalia of women). It does not generally affect the labia majora (outer lips), nor does it alter the vagina.


In order to ensure complete comfort and relaxation, we perform labiaplasty in the operating room, under a short and safe general anesthesia. Surgical loupes (microscope glasses) are always used to ensure the most meticulous possible repair.

The area to be trimmed is marked, and local anesthetic containing epinephrine (adrenaline) is injected to prevent bleeding and bruising during surgery, and to keep the area numb for many hours after surgery. Next, excess tissue is trimmed. A multiple-layer closure is then done (usually 2-3 layers of stitches) using all dissolving (absorbable) sutures. Antibiotic ointment is applied, and mesh panties with an absorbable pad are placed.

On average, surgery takes around an hour and a half to two hours. It is outpatient surgery - women can go home in a couple of hours, when they are awake and alert, without nausea and when they are eating and drinking well.


You can expect some mild discomfort requiring oral pain medication such as Tylenol or occasionally something stronger (Vicodin or Percocet) for a few days. Aspirin or Ibuprofen (Advil, Motrin) should be avoided as these can increase bruising or bleeding.

There will be some swelling and possibly bruising of the genital region. You can shower the next day, and will be advised to apply antibiotic ointment daily and wear a thin pad in your underwear in case of any spotting or bleeding.

If you have your period, use a pad instead of a tampon for your first 1-2 menstrual cycles to avoid irritation of the incisions while they are healing.

Most women take at least a few days off of work, or work from home during the first few days after surgery, when they are swollen and tender.

Sexual intercourse should be avoided for 3-6 weeks, or until the area is no longer swollen and tender. Aggressive physical activity should also be avoided for at least a week, as increasing your heart rate and blood pressure will bring more blood flow to the area and create more discomfort or swelling.

Some women describe intense itching (due to histamine release during healing), while others have very little discomfort at all after surgery. Keeping a small pillow in your purse can cushion the area if you are sitting on a hard surface during healing.

Like any incision, it takes at least 3-4 weeks for initial healing, and 6 months up to a year for the results to be absolutely final. Incisions are hidden in the natural crease. The area of surgery will eventually be very difficult to see, and there is usually very little scarring, as it involves a mucosal membrane (think about cuts to the inside of your mouth or gums, and how they have healed).

You will be seen back at your surgeon's office within a few days of surgery for an initial checkup, and then usually at 2-3 weeks, 6 weeks, 6 months and one year. All follow-up visits are covered by your surgery fees.

Most women find this operation liberating and are very satisfied with the results.


Any surgical procedure carries with it potential risks of anesthesia (nausea, headache, etc), the potential for bleeding, infection and wound healing problems. There will be temporary pain or tenderness, swelling, bruising, and numbness of the area.

Bleeding is controlled during surgery by a cautery pen that coagulates any blood vessels that are encountered. You likely be given a few days of prophylactic (preventative) antibiotics to help prevent infection. You should shower daily and ensure the area is kept clean after surgery.

Your labia may not be completely symmetric - this is the norm for most women. You can have temporary change in pigmentation (lighter or darker) while you are healing.


Women of all backgrounds, shapes and sizes, professions (including stay-at-home moms) and cultures seek labiaplasty! Many women are born with asymmetric or redundant labial tissue, which is normal for them! Sometimes after childbearing, labial tissue can become stretched, and following menopause, the area can droop more.

Labiaplasty is a private procedure that should not be viewed with embarrassment or shame! It is often an empowering experience that can improve a woman's body image and self-esteem.


Any surgical procedure includes a surgical fee, operating room or facility fee, and anesthesia-related fees. On average, the total cost can range between $4000 and $8000, depending on the complexity of the surgery, time needed for surgery, and other details specific to your unique anatomy.

Insurance does not usually cover labiaplasty. You can inquire with your insurance carrier about this benefit, but labiaplasty is usually viewed as cosmetic.


Smoking should be stopped for at least 6 weeks before any operation. Other health problems such as diabetes, heart disease, high blood pressure, or autoimmune disorders should be well-controlled before considering any surgery.

You should be cleared by your primary care physician for surgery, and have had routine preoperative tests (bloodwork, EKG), as appropriate based on your age and medical history. You should not be pregnant, and should not undergo surgery immediately before a major life event (give yourself at least 4-6 weeks to heal before a vacation, etc).

Avoid medications and herbs or nutritional supplements that can increase the risk of bleeding or bruising with surgery (aspirin, anti-inflammatories, vitamin E, fish oil, etc) - your surgeon will give you a comprehensive list of what types of things to avoid and for how long before and after surgery.

Sunday, November 1, 2009

Research pays off when choosing a breast implant surgeon

When you are considering breast augmentation, be sure to research both the procedure and your surgeon extensively.

Learn as much as you can about the procedure using online sources (visit reputable websites such as the American Society of Plastic Surgeons (ASPS) or the ASAPS website) that do not feature only one surgeon, and that provide data on national statistics and safety issues.

Visit a surgeon who is experienced with breast augmentation, and is Board-Certified by either the American Board of Medical Specialties or the Royal College of Physicians and Surgeons of Canada (these are the only two Boards recognized by the American Societies for Plastic Surgery and Aesthetic Plastic Surgery).

Write your questions down for your surgeon, and ask to see before-and-after photographs of typical (not just the best) patient results. Ask to speak to patients who have had the procedure before.

Do your homework! Ensure you have found a good fit with the surgeon in terms of personality, office environment, and aesthetic goals for the procedure.