I am Huay-Zong Law, Clinical Director of the International Craniofacial Institute, and Board Certified Plastic Surgeon in Dallas, TX. I have operated in Haiti, Guatemala, and Taiwan, and spent a year at the CDC. I perform a full range of cosmetic ...

How close are we to knowing the cause of cleft palate/lip and hopefully finding ways to prevent it?

That's an interesting question. Certainly we know genetics can play a role, and we see generations of patients come through with grandparents, parents, and now the children with a cleft.

At the same time, we see plenty of patients with zero family history, nothing abnormal with the pregnancy, and everybody is surprised at birth.

In one way, it's a bit like cancer - there are a lot of different cleft types and causes, so narrowing it down to a handful of causes is difficult.

There's great research being done at multiple centers, including UPenn and Seattle Children's. Here are a few pages with more information: CLAPA, CDC, ACPA, Pubmed article.

Thank you for that. As the mom of a kiddo with cleft lip and palate, no family history, had prenatal care, and normal pregnancy, I still wonder why. I reread my pregnancy journals to find some sort of cause. (We were trying to conceive which is why I had journals). I’ve just come to accept that we likely will never know what caused it. People often ask me if we had a family history. And when he was a baby I often wondered if people thought I caused it because of something I did or didn’t do during pregnancy.

You're welcome. Mom/dad guilt is already such a tough thing at baseline.

Overall, we spend more time with our children than our parents did (https://ourworldindata.org/parents-time-with-kids), working more (https://www.bls.gov/opub/mlr/2002/05/art2full.pdf), and even doing more housework (https://www.bls.gov/news.release/pdf/atus.pdf).

I see families where it feels like the mom has also taken the brunt of any issues with conception or problems with a baby's health, when there's more research coming out that paternal factors also play a large role.

Most often, though, it does just seem like random chance. A random ray of radiation from the sun that happened to tick an A to a T somewhere.

Genetic counseling can be helpful for some families, especially if you're thinking about having more kids, or for your kiddo before they go on to have kids themselves one day.

Um, wow. I think I may have gone to high school with you. Were you ever in the band by any chance?

Hahaha, yes. Band was awesome, and some of the best times of my life.

An anesthesiologist I work with is part of a clarinet choir, and I've considered trying to pick it back up to join them for fun. It would be like my time in an a capella group - quietly in the background.

Check your DMs. I have more to tell you.

😳

They totally just confessed to a murder and needed to get it off their chest and is hoping to use "Doctor patient privilege" in order to remain anonymous and free

It was pretty much this (*major* spoiler - go watch the movie first if you haven't seen it yet)

Edited: definitely the reveal of the movie. What's the statute of limitations on this? How long does a movie need to be out before you can talk about the ending openly?

Potential? It spoils the whole movie! But definitely go watch it :)

100% right. Edited!

Hi and thanks for doing this AMA!

1. When/Why did you chose to get into this line of work?

2. Did/do you have a mentor?

3. Are you family the book Breath by James Nestor? If so I might have a follow up question.

4. Would you be open to an interview for a related podcast?

​

1. When/Why did you chose to get into this line of work?

It's been a journey. I didn't consider medical school until I did a summer program after my junior year of college. This was set up through the UT Biomedical Engineering program. We were at MD Anderson Cancer Center / UT-Houston, and it was a bit of an immersion in different paths an MD can open up.

We did 2 weeks of gross anatomy with human cadavers, and then 8 weeks of rotations shadowing in the mornings in the hospital (OB, ER, pediatrics, general surgery, etc), and research in the afternoons. My research was on isolating fat stem cells to be able to grow them outside of the body, like for breast reconstruction. Throughout, we also had lectures in the morning that started at 630am, covering ethics, leadership, etc. It was intense, interesting, and eye-opening.

Then during medical school, we had a chance to rotate with orthopaedics or plastic surgery for a musculoskeletal focus. I ended up with plastic surgery, and got to see the crazy range of things the specialty has swallowed up. My first memory was of a guy who fell from a ladder and cut a tendon and couldn't straighten his finger. After he was numbed up, he watched Bad Boys 2 on the TV while the resident repaired the tendon and skin. And immediately he had full function again. So immediately gratifying.

After that, there were further rotations at WashU, and some visiting rotations I took to Taiwan, Irvine (CA), and Dallas. Tons of interesting problems and surgeries to try to fix the problem.

​

1. Did/do you have a mentor?

I'd say I have had many mentors who I have learned from, and continue to learn from. We certainly stand on the shoulders of giants, and I'm always humbled by how much I have learned from a lot of selfless teachers.

Most recently I'd say I lean on my partners the most - Drs. David Genecov and Carlos Raul Barcelo. Dr. Jeff Fearon is across the hall and has an open door, and I've called Drs. Steve Byrd, Craig Hobar, Richard Ha, and Jason Potter probably within the past year. I also learned a lot in residency from the amazing team there - truly more mentors than I could list out.

And then you look back at all those other steps along the way - Michele Follen from the mini-medical school experience, David Callahan and Denise Koo at the CDC, Will Ross, Alison Whelan and many more at WashU.

​

1. Are you family the book Breath by James Nestor? If so I might have a follow up question.

I haven't read it yet, but I'm always looking for more book recommendations! The tough part is carving out time to read it all. My bookshelf is like my whiskey collection - definitely grows at a faster rate than I can consume.

Current open books on the bedside table:

- Brandon Sanderson, Rhythms of War

- Michael Lewis, The Big Short

- Emily Oster, Cribsheet

Underneath those - waiting to be opened - are Jonathan Haidt's The Righteous Mind, and Kahneman's Thinking, Fast and Slow.

​

1. Would you be open to an interview for a related podcast?

Sure, always happy to chat.

As a mom to a 9 year old cleft lip & palate and cholesteatoma warrior, thank you. He is at 12 surgeries already, with more to come. We are grateful to live in the DC area and have access to many top specialists.

Are you part of a cleft team in Dallas?

Yes, the group I joined began with Dr. Ken Salyer many years ago at Medical City Dallas, and we are a part of the ACPA-approved center there. I'm fortunate to have stepped into a situation where many of the specialists we work with have decades of experience already working with cleft patients.

Patients and families can search here for cleft teams that have undergone the approval process with the American Cleft Palate Association. https://acpa-cpf.org/acpa-family-services/find-a-team/acpa-approved-teams/

Copying from the ACPA website, this does mean:

Teams must include: - Care coordinator who facilitates care and assists patients and families in understanding, coordinating, and implementing treatment plans - Orthodontist who straightens the teeth and aligns the jaws - Speech-language pathologist who assesses speech and feeding - Surgeon such as a plastic surgeon, an oral/maxillofacial surgeon, a craniofacial surgeon, or a neurosurgeon

Teams must also have access to: - Audiologist who assesses hearing - Geneticist who screens patients for craniofacial syndromes and helps parents and adult patients understand the chances of craniofacial conditions occurring again in their families - Nurse who helps with feeding and provides ongoing supervision of the child’s health - Otolaryngologist is an “ear nose and throat” doctor, or “ENT” - Pediatrician to monitor overall health and development - Pediatric dentist or other dental specialist such as a prosthodontist, who makes prosthetic devices for the mouth; - Psychologist, social worker, or other mental health specialist to support the family and assess any adjustment challenges or support needs - Other specialists necessary for treating specific aspects of complex craniofacial conditions

What procedure is surprisingly easier than the layman would expect?

Brow lift and a straightforward breast augmentation immediately come to mind.

We have a tendency in medicine to sometimes overcomplicate things with jargon and people publishing papers for a variety of reasons (publish or perish academics, trying to make a name for themselves, etc.).

A lot of surgical procedures do distill down to simple steps and principles quite a bit. But sometimes when you least expect it, surgery will humble you. Some people with lots of grey hair will tell you that the only surgeons with no complications are those that are not operating.

My buddy and I have been wondering about this for a long time. Why isn’t there a procedure to lengthen penis? There is so much money to be make. Or is there one?

Good question, and outside the scope of my training. I've heard of people treating buried penis syndrome (don't google that at work), but I haven't seen it done much less done it.

I have heard of people who do implants and fat transfer augmentation, and others who divide a suspensory ligament.

This seems to be a good review on the subject: https://www.nature.com/articles/ijir200814

Thank you for doing this! I only have one question that I've always wondered about... When I was 5 a german sheppard my sister was fostering attacked me and I got drug by my face down the back steps. As you can imagine, it was very traumatic for me.

My mother said that when I was younger there was nothing they could do about it because I was still growing. Im now in my mid 30s and though it doesn't bother me nearly as much and I am married, it's still the first thing I see when I look into the mirror.

It's only about 2 inches on my right side of my face ( left to everyone else ) and it has deformed my top lip some. Is there something I can do about it now or is it too late? Up until the last couple years thinking of the cost has made it impossible but I did learn that you can finance something like that right?

I'm sorry to hear about the trauma. My wife has a couple small scars from being bitten in the face, and we see a lot of bites in the Emergency Department all the time.

Once I get the blog going on my website, I'll definitely do a post early on about scar revision.

There are a lot of things we can do with old scars. It often depends on what the problem is, and how much you're willing to put up with.

If the scar is wide, depressed, discolored/thick, has a weird texture, or the lip misaligned, it would be worth talking about cutting out the scar and starting with a fresh repair. Early on, yes, you're still growing. And sometimes the tissue itself is damaged and won't heal well, no matter what you do.

I talk with my patients about keeping fresh repairs hydrated and protected from the sun. After 3-4 weeks, scar massage and silicone sheeting is helpful. And taking time off from strenuous activities and avoiding re-injuring the area is important, too.

Most offices will work with you financially. I know we have patients who are on a payment plan from surgeries over 10 years ago. Sometimes I will discount my fee on a case-by-case basis as well, particularly in cases of trauma and abuse.

Before I forget - other things out there like lasers, microneedling, fat grafting, and peels - all have roles, too, depending on the problem.

Oh, and some insurance companies will cover scar revision, especially in cases of trauma. Though typically they will require a functional problem (pain, bleeding, etc.) in addition to any cosmetic problem.

http://www.aetna.com/cpb/medical/data/1_99/0031.html

Here is a response to someone asking about my experience in Guatemala and Haiti:

Guate was with HELPS International in a couple places - Huehuetenango and Tejutla. Haiti was in Port-au-Prince with LEAP Global Missions.

The experience is always some of the most intense, memorable, and gratifying times I've had.

It's medicine distilled - people have a problem, you offer what you can to help them, and we get a thanks (and sometimes a bag of avocados). People will walk 10+ hours to see you, and then sleep on the floor for the chance to have surgery or be seen.

I've also studied Spanish in Guatemala in Xela, and spent some time traveling the country by chicken bus. The people I met were all very kind and gracious to me, and there are a lot of beautiful places that are a touch off the beaten path.

Haiti unfortunately was a little politically unstable, and I haven't had the chance to go back for a couple years because of the unrest. We worry about our patients there.

On a related note, Meds & Food for Kids is a great foundation (from what I've seen), working to help combat undernutrition and malnutrition in Haiti. The founder quit her job as a doctor in the US to bring a ready to use medical peanut butter to the area. They make it there, employ local staff, and seem to be trying to do things the right way.

There are issues with mission trips for sure, and consideration given to how much is medical tourism, how much is helping people, and whether those resources would be better served locally. Lots to unpack there for sure.

https://www.reddit.com/r/Dallas/comments/lj3gcd/i_am_huayzong_law_md_clinical_director_of_the/gn97j0d?utm_source=share&utm_medium=web2x&context=3

What is your take on 3D printed implants?

There's a wide range of them out there, with different applications.

I used some custom implants this past week based on 3D CT scans, and it was incredibly satisfying because the fit was impeccable.

For certain uses I'd say it should absolutely be the gold standard.

I'm keeping an eye on 3D printed scaffolds, that ideally would be seeded with and replaced by a person's own cells one day. Super cool stuff on the horizon.

Have you heard of the new evidence suggesting underdeveloped jaws/long faces are entirely due to our environment and not genetics? Aka lack of breastfeeding as a baby and the modern diet of softer foods. It’s kinda unraveling that the way our faces develop is more under our control than we thought

I haven't, and that is very interesting.

The human body is certainly dynamic and responds greatly to the environment.

At a 10,000 foot view, I'd expect some amount of nature and some nurture. Feel free to send over any particularly interesting studies. Maybe we can send to Emily Oster and she can update her book Cribsheet with a section about this.

Sawbones just an episode about this titled "Mewing" if you're into podcasts.

Such a great podcast, can't recommend it highly enough. Hilarious and informative. I don't keep up with every episode, but it's great to listen to while exchanging back rubs with the wife.

At what point do you recommend a therapist or psychologist for body image issues?

100% with transgender concerns.

We have a pediatric psychologist we work with, who helps a lot especially with our patients from about second grade through puberty, largely for our cleft and craniofacial patients.

Also, if I can't see what they're seeing, they're on their 2nd or 3rd+ surgery for the same issue, or it seems to be interfering with their life excessively.

I've been told therapy actually can be good for most everybody. I heard an ad for some online therapy the other day that had me intrigued, just as a way to bounce everyday things off of a trained professional and neutral person.

It stands out to me that you spent time at the CDC. What type of work/ learning did you do there?

It was an Applied Epidemiology Fellowship for medical students, which I don't think is offered any more. Kind of a mini-EIS training program for those interested.

I was considering going into Pediatrics and working with Big Data to try to solve public health problems. Things like Google Flu Trends and the work Hans Rosling does.

I enjoy making sense of the numbers, and translating that into improved health and policy. I also enjoyed the hands-on investigations.

There was a particularly nasty drug-resistant bacteria we went to Reno to investigate. The highlights included learning to play craps, and figuring out how to download all of the culture results from a lab onto a floppy disk, and importing it into a spreadsheet. The alternative was to take the piles of printouts and re-enter that data by hand.

We also had wonderful mentorship and teaching, with journal clubs, public messaging and speaking teaching, and 24/7 access to true experts in their fields.

It gave me an appreciation for the scientists who are apolitical and just trying to make the world healthier. I also came to understand inefficiencies and costs associated with government and bureaucracies.

Hi Dr. Law!

I recently underwent a stage 1 urethroplasty procedure for severe hypospadias. This is my second time going through this procedure, as the first time my buccal graft developed multiple strictures after about 9 years.

I'm also a Nurse Practitioner hoping to enter the field of urological surgery and I was wondering if you knew of any new research coming down the pipeline about other types of autografts or allografts that can be used for these types of procedures? Thanks!

Hello u/chippyda!

It seems every year they're coming out with new things made from cadaver skin, porcine bladder, shark/bovine cartilage, even neonatal foreskins. Hard to tell whether they're any better than the products already on the market.

There's some research about fat grafting and stem cells helping to remodel scars and improve blood flow. On the other hand, I've also seen reports of stem cells injected into a spinal canal that grew too vigorously and caused compression of the spinal cord. So I'm not sure I'd get into anything too experimental when you're dealing with high-value real estate.

Urology is a really cool field, and I'd defer to them on this question. They are truly the experts in their anatomic domain, and have an interesting practice (to me) with both clinical and surgical parts to it.

Have you ever had patients who wanted cosmetic surgery that would make them look undoubtedly more unattractive? What do you do in that case?

Oooh, interesting. I actually have not had that happen.

More common is someone coming in and asking for something changed that you really can't see what they're talking about. A nose that's crooked or deformed, perhaps. Or someone wanting a breast augmentation that's going to be way too big and cause more harm than good.

Usually I try to empathize, discuss their goals and expectations, and then tell them I don't think I'm good enough to achieve what they're looking for.

Happy, satisfied patients make the work worthwhile. That extra procedure and money just isn't worth the aggravation and lost sleep over whether you're doing the right thing with your life.

There are definitely people who want more filler in their lip that goes outside what I think looks good, and I encourage them to stay more conservative.

If they want bigger or aren't satisfied, I don't hear about it, but they also probably go find somebody who will do what they ask.

I've also had a few inquiries about transgender surgery, and that is very much a case by case basis.

What were some of the most complex and difficult plastic surgeries you have had to perform?

My partner helped separate conjoined twins, though that was before my time.

Microsurgical cases can be fairly complex. This involves dissecting tissue from one part of the body with its bloody supply, and hooking up that blood flow in and out in another area.

For instance, for jaw reconstruction after cancer or trauma, you can take the fibula, and fashion it into a mandible that can hold dental implants. Also for breast reconstruction, we can take the abdominal skin and fat, track the blood supply through the abdominal muscles and down towards the groin, and shape that tissue in the chest after hooking it up to the blood vessels running alongside your sternum.

Sometimes blood vessels are less than a millimeter in diameter, and the sutures used are much smaller than a human hair.

It would be fascinating to be a part of the face and transplant teams. They perform amazing feats of reconstruction. There's also a lifetime of complex medical care for those patients afterwards, so huge kudos to those teams pushing that frontier.

This may or may not be on your wheelhouse. What would make the cranial sutures on someone’s skull (middle aged, not losing weight) become significantly more prominent over a 1-month period?

Hm, interesting. Any significant and quick changes like that are usually worth having a doctor check you out. Especially if there is any pain, bleeding, headaches, or any other symptoms.

I've definitely removed a variety of growths - bone, fat, etc. - on the face and scalp that otherwise shouldn't be there. You may end up needing some imaging (CT, MRI) to help sort it out. Good luck!

Thanks. She lives with a doctor. Nothing raised—more prominent depressions. No other symptoms other than her chronic ones. Almost like the muscles over it are wasting, but nothing anywhere else. Strange!

Is it anything like cutis verticis gyrata?

Considering that you've operated in a number of countries, what do you think about people traveling to more affordable areas for treatment? Is the quality of care in the US actually worth the price?

I'm going to copy a reply from earlier on xpost. This does touch on the bigger questions of:

- why does health care cost so much more in the US?

- where could we cut costs without impacting outcomes? what is essential in healthcare, and what can we shed?

- are we willing to make tradeoffs to slide further down the socialism-capitalism scale (which we're already on)?

- what is sustainable long-term?

- are we willing to trade worse outcomes or worse safety for reduced cost?

- should other countries be paying more for their health care and medications? Is the US footing a disproportionate share of the bill?

​

Copying a reply from earlier on a xpost:

Costs are certainly higher in the US. From a population view, we know that medicine costs multiples more here than in other developed countries, with similar or worse outcomes for the population.

For individual surgeries, you're paying for a surgeon's fee, the facility, and for anesthesia care.

Surgeon's fee includes our cost of overhead (rent, staff, insurance, equipment, supplies, etc.), and anything we hope to take home. The facility costs include all of their staff and overhead, and same with anesthesia.

From what I can tell, all of the above costs more in the US, and it all adds up.

Part of the cost is going to be some of the safety regulations here. I know many people do go abroad to have surgery and have great outcomes. But I have treated people who come back and have problems (infections, wound healing problems, etc.) and are receiving treatment from a surgeon who wasn't there for the original operation. That means anatomically, there's a bit of a black box for understanding what type of implant or sutures were used, what areas the blood flow for healing may be intact or compromised, etc.

My middle kiddo was born with bi-coronal craniosynostosis, which was corrected surgically when she was 11months old. Her surgeon told me that a lot of what he does in these cases is a cross between carpentry and art. Do you feel like most surgeons in this specialty have to have more of that artistic sense, since a lot of what is done seems to be by feel?

I’ve also wondered how often craniofacial/plastic surgeons/etc see cases like that. He said it was the hardest he’d done, but she’s great now years later! Do you have a lot of occasions to really save people like that?

I have worked with excellent surgeons on both end of the spectrum. Some are very free-flowing, artistic, drawing circles by hand. Others measure everything down to a T, set a mathematical plan going in, and execute on that plan.

I've seen both ways work very well.

Plastic surgery is often like engineering. You're working with certain factors and variables, and you work off of some principles to try and get to an optimal solution.

Reshaping the skull definitely involves both carpentry and an eye for the aesthetic, trying to achieve balance and harmony.

For many reasons, bicoronal craniosynostosis is being seen less and less frequently overall. I think nutrition, less smoking and drinking, and prenatal screening all play a role. Patients are also more spread out.

In the beginning, there was really just a handful of craniofacial surgeons figuring it out as they went along. Dr. Tessier, Dr. Whitaker, Dr. Salyer, Dr. Ian Jackson, Dr. Daniel Marchac, Dr. Fernando Ortiz-Monasterio, Dr. Ian Munro, and Dr. Kawamoto all come immediately to mind.

Then each of them trained disciples, and now we're in a third and fourth generation trying to build on the lessons of the past.

That also means there are many more surgeons who have been trained to do these surgeries, and so the patients are dispersed.

We recently completed distraction on a child with bicoronal synostosis, and are planning another one right now. We're also fortunate to have Dr. Fearon in our center, and he attracts quite a few patients from all over the country and abroad, so I'm told we see more in our center than anywhere in the world. It helps tremendously when the nurses and staff are all experienced and familiar with the surgery and the recovery.

I'm glad your kid is doing well!! I've had a few kids come through who had surgery 15-20 years prior, and needed something to treat headaches or minor cosmetic issues. Hopefully yours is in the clear and can avoid any more surgery!

Hi there! Thanks for doing this.

I am almost 39, bra-free by choice, and don't plan on ever wearing one again. I am also childfree and sterilized, so I will never be pregnant or breastfeeding.

As I get older, I know someday that my C cup breasts will be more "obviously" not in a bra. Do you or other surgeons perform breast lifts without putting in implants? Would that give me a natural-looking result and eliminate (most) of the droop?

I've been somewhat lucky that, even if people can tell I'm not wearing a bra, it isn't "extreme," if that makes sense. But I know that can't last forever.

Breasts come in a wide variety of shapes and sizes, and each person (some men, too, with gynecomastia) has different goals.

Inevitably, gravity takes its toll as we continue to age. Usually there is some amount of deflation, and skin becomes thinner and more lax over time.

Now, some women prefer a lift alone, raising the volume of the breast back primarily above the fold, and repositioning the nipple and areola in an aesthetic position at the most projecting area higher on the breast. Other women want more volume in clothes, and don't want the scars involved with the lift.

Some women are good candidates for a lift plus filling with more volume, either in a single surgery or in two stages.

Adding volume can involve an implant (saline or silicone). I think increasingly more women are using their own fat rather than an implant. This involves liposuction to contour one area (like the waist, hips, or thighs), and then use that fat to augment the breasts.

The main downside is that additional time in surgery to do the liposuction, and the amount of volume that can be added is more modest, because that transferred fat needs to be spread out and in small enough aliquots to survive and develop its new blood supply. So sometimes women need to go through a 2 or 3 rounds of fat grafting to get to their goal.

Pros: it's your own tissue, you don't have to worry about an implant giving trouble over time, minimal incision if no lift, and you have the added effect of slimming the body so the bust-waist ratio changes more. Cons: less volume at the high end, gravity affects the fat more, longer surgery, and sometimes the fat doesn't survive and can turn into a small oil collection (seen more often when too much is transferred at once)

Thank you for your answer! I definitely don’t care about volume. I wish they were smaller actually so I wouldn’t have to worry about them as much. So maybe the lift alone would suit me best. I feel like adding an implant or fat would just make them bigger but not higher. Or does it do both because you add the implant or fat high up? Thank you!

Adding volume provides some lift - think about a deflated balloon with more air added to it. But the amount of lift for the nipple/areola is modest.

An implant does give you more volume superomedially - high along your cleavage. Fat grafting can do the same to target that area, but is going to be less powerful than the implant.

A lift can also reduce the volume a half of a cup to a full cup size, so that may actually be a great fit for your goals. Breast reduction actually falls along a continuum -- recently I removed nearly 5 pounds total for a young woman, and in the process helped shape and lift at the same time.

What do you think of the show "Botched?" How complicated are the procedures compared to the average plastic surgery?

I've only seen pieces of the show. The bits I saw turned me off, featuring people on their 15-20th surgeries, looking for more.

The types of patients I like to care for are pretty normal overall. Teachers are usually a joy to care for.

Secondary and tertiary+ surgeries are often harder, and I applaud anyone willing to take on those operations and those expectations. We just did a tertiary orthognathic case (breaking and moving the jaws to line them up), and it was one of the tougher surgeries I've done.

How in the world does silicon help with scarring after a plastic surgery, or any surgery? Is it supposed to hold in moisture? Should I be moisturize before using the silicone gel for it to work properly? I feel like none of the packaging explains what it actually does. I recently had a breast reduction and I feel like I have no idea if the silicone is doing a thing.

Hah, I know!!

This was on one of our exams one year, and it was struck from the exam and not counted.

Last I checked there's a lot of hand waving, people making up explanations, but it's not clear if it's none, one, or all of those explanations in part.

Could be pressure, hydration, electronegative charge, protecting from the sun, etc...

That said, that's really been the best thing people have found to work for scars. I hope your recovery is going smoothly!

Any tips for getting into medical school?

I had classmates from different majors and different paths. I interviewed alongside a general, I think, who was going back to go into medicine.

There are the basics - get good grades, do well on tests, try to clear the cutoffs where people get automatically cut before applications are really reviewed.

And then find things you're interested in and maybe have aptitude for. It's kind of like dating. There's some randomness involved, some amount that's on their end and nothing you could do differently. But if you continue working on your skills and experience, you can often persist into a spot, even with lower scores.

I know people who completed research after graduating college, and their work with a mentor showing up every day, doing good work, and being a team player got them a strong recommendation and made their application stand out.

Ultrasonic SMAS lifting, is this a real medical procedure or more of a scam? My dear wife wants her stomach area thinned and this is the procedure she have been recommended.

Ooh, good question. I'm always a little wary of devices, because they cost money to buy or lease, and the purchaser needs to use it to justify the costs.

In general, non-surgical interventions tend to have a mild to moderate effect, and have some potential downsides (look up paradoxical adipose hyperplasia for those trying to shrink fat). In the end, I tend to favor surgery to make the biggest difference in one go, for less cost than if you're going back multiple times for a non-surgical intervention.

That said, some people really don't want surgery, and are very happy with the change they do see with non-surgical procedures. They have their place, but I haven't been converted yet.

Are there any major risks are associated with Double jaw surgery if the patient is immunocompromised and has genetic lung disease ?

Super specific I know but just wanted to know because I may be getting DJS eventually

Hm, off the top of my head I'd be concerned about - any increased work of breathing with the swelling, and current lung capacity - chronic steroid use which will slow healing, and for which I'd recommend some Vitamin A supplementation if you can't stop the steroid - increased risk of infection

There would be a fair amount of working with your existing team of doctors to optimize everything possible ahead of time.

I’m expecting in June, 4 years ago I had a breast reduction (lollipop procedure) I’ve been told by my doctors that I may be able to breast feed but it’s unlikely. Do you have any insight into breast feeding post reduction?

The best reviews I've seen, and what I tell my patients, is that your ability to breastfeed shouldn't be affected.

Some percentage of women are unable to breastfeed at baseline, and a percentage will need to supplement with formula. Those percentages seem to be the same between women who have had a breast reduction, and those who have not. It's not a failure on the part of the mother nor the child; it's just physiology.

The only exception may be in the rare (but real) times when a free nipple graft is needed, when the blood flow is poor to the areola, and it has to be lifted off as a graft onto skin with better blood flow.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5648284/

https://pubmed.ncbi.nlm.nih.gov/19692299/

Our baby was diagnosed in utero (we’re due in June) with a left side cleft lip, it isn’t impacting the nose so they think it’s very small and only on one side. I’m terrified though. We’re hoping it’s just one surgery, but what are the odds our kid can grow up looking normal? How far has cleft lip surgery come over the years? Anything you can share is helpful. Also we’re in Vancouver. Would you happen to have heard anything about BC Children’s vs Sick Kids? I want to get the best possible plastic surgeon and we’re willing to move back to Ontario if the doctors are better.

Also, we were told that there’s a 90% chance the cleft lip is the only issue but there’s a 10% chance that there may be something else genetically wrong. I’m currently waiting for the results of the amniocentesis. Do you have any experience working with parents in these situations? I’m trying to hold hope with that 90% chance that there’s nothing else going on but I’m also terrified.

Most children with cleft lips grow up to have very normal lives!

Surgery has come a long ways. A scar is inevitable, and asymmetry will be a challenge over time as there will be differences in how each side grows over time.

Your child already has the most important thing in the world, with caring parents who are committed to doing everything they can to help them grow into the people they will become!

Yes, we see a number of parents for prenatal visits. We talk about any possible surgeries, and what those look like and when those would happen. More than anything I think we provide a piece of certainty that someone is in your corner and the child's corner. Then as needs come up and questions come about, we're available to help and teach in any way we can. Or we get you to the people who you need to see.

The most important thing will be the first few weeks. First - are there any other needs or workup like an ultrasound of the kidneys that needs to be done. Then figuring out whether you need to try any specialty bottles if there is a cleft of the palate.

We then tend to repair the lip and palate in the first year of life. Then you generally get a break until 7-9 years old for a bone graft if there is a cleft along the gums. And then sometimes jaw surgery and a rhinoplasty at full maturity (16-18 years of age).

I'm taking off for a bit to take over child care, but I will be back to continue with my thoughts on location!

Thank you so much for this.

Ok, about whether to stay local in Vancouver or head to Toronto.

I do know that Toronto is very well-regarded as a cleft and craniofacial center. I don't have any direct experience with the team there, nor the BC hospital. And I'm a little unsure how this would work for you within the medical system in Canada.

All that said, I'm all for trusting your gut. I would meet the BC team and give them a chance. It will make surgery, recovery, office visits, and long term follow-up much easier on you. The difference in surgical outcome (if any, and maybe better maybe not), may be totally offset by the travel stress and costs.

There are now many hundreds, if not thousands, of cleft and craniofacial trained surgeons. You may have a great one right next door.

Thank you for speaking plainly and for your support. I’ve been crying on and off since we found out, asking myself what I could have done better, how I can help this kid, and balling at every picture a friend shares of their perfect baby fresh into the world, knowing I won’t have that moment. So thank you, because honestly I haven’t known how or who to speak to about these things.

Hang in there! If anything, I find that parents totally fall in love with the cleft smile, and have a short adjustment after surgery to get used to the new smile.

You're going to be a great parent! What boils my blood are the parents who are a bit indifferent to their children and aren't invested in their well-being.

Parenting is definitely an adventure. The most gratifying and most frustrating thing I've ever done, bar none. Makes me appreciate my own parents (and all parents, particularly single parents) now being on the other side.

Have you ever encountered a request that was so outrageous that it would harm the patients physical health significantly?

A classic ethics issue we sometimes run into is what to do if someone refuses a blood transfusion, but they need it to survive? And what if it is a child, and the parent doesn't want them transfused?

Nothing else immediately comes to mind. We do always take the time to discuss the risks of surgery thoroughly, and try to make sure people understand fully how commonly they occur, and how bad it can be. I have had colleagues with healthy patients die from a blood clot after having elective surgery, even though every possible precaution was taken. It's devastating for everybody.

In the end, Aristotle's ethics are a solid starting point for me. 1) Beneficence - do good. 2) Non-maleficence - do no harm. 3) Autonomy - people make up their own mind. 4) Justice - treat everyone fairly and equally.

If the harms outweigh the benefits, I wouldn't offer surgery.

I’ve seen some grisly photos of facial injuries from WWI. They wore expertly crafted facial prosthetic masks that made them look almost completely normal. If you saw a similar injury in today’s world, would you be able to make them look normal again with just surgery? If so, what advances would have led to that?

photos of WWI facial injuries

Yes, WWI really gave rise to modern plastic surgery. Here's some interesting info about Dr. Blair who was the first chief of plastic surgery at WashU.

A lot depends on the degree of injury, and what structures are involved.

We have a few more tools at our disposal, perhaps most notable is microsurgery. That lets us takes vascularized bone and soft tissue from one part of a patient's body, and move it to another area. At some point you just don't have enough tissue in the area to reconstruct all of the necessary elements.

Prostheses have come a long ways, and sometimes they're still the best answer.

Distraction and tissue expansion are other techniques. You break a bone and gradually move it, with new bone growing in the fracture, and the soft tissue gradually expanding. We also use tissue expanders, which are like inflatable water balloons, to gradually stimulate skin and soft tissue to stretch and expand to give us more tissue to work with.

Most notably, face transplants may be the way to get the best result possible. That said, there's still quite a bit of work to do to figure out optimal transplant rejection medication regimens, or even if you can eventually wean somebody off of medication entirely.

I moved to Texas a few years ago and I see more male hormone treatment centers than doctors offices. What is wrong with native born Texas males and their testosterone levels? Is this a secret mecca for penis enlargement surgery too?

Hah! I've had a few people point out the flourishing of these offices.

I haven't looked into it myself, from either the doctor or the patient side.

I wonder how regulated that space is. And what kind of margins people receive on it.

Anecdotally, I have heard of people feeling better and rejuvenating their sex life. I have no idea about the risk profile there.

I'm pretty sure a mecca for penis enlargement wouldn't be able to stay under wraps for too long. It would certainly be a fast-growing field. They'd erect monuments.

What’s a remedy for old age spots appearing on the face and hands? I’m a 66 year old female.

Here's a list from the American Academy of Dermatologists: https://www.aad.org/public/cosmetic/age-spots-marks/get-rid-spots

• creams and lotions
• cryotherapy (freeze it)
• dermabrasion
• chemical peels
• lasers

Honestly, I'd start with a dermatologist to do a full skin check and make sure you don't have any areas concerning for skin cancer. After that, your options depend a bit on the areas, your skin type and baseline pigmentation, and any other medical problems you may have.

You may search for a cosmetic dermatologist or dedicated skin care center, as they'll have more options to offer than most general dermatologists.

I was born with undetected gastroschisis and was left with a hernia bump, a scar from the bump to my "belly button," and a star shaped scar from the feeding tube. Mom offered to look at cosmetic surgery when I was 18 (1995) but I always figured there wasn't much that could be done. How advanced is such cosmetic surgery in 2021? I'm too old to act, but I'm curious. Thanks.

Usually with scar revision you trade a gnarly-looking scar for a straight line or a designed Z or other shape depending on the area.

The secret sauce for most plastic surgery closures is repairing multiple layers meticulously.

Sometimes I see repairs that had just skin glue or sutures in the top of the skin. Skin takes about 6 weeks to reach 80% strength, and at 2 weeks is still barely at 50%. So after the skin glue falls off or the stitches come out, the skin will continue to widen. And if the muscle isn't repaired (like I've seen on a forehead), you can get a very wide scar as the edges pull apart.

Even if it's skin alone, depending on the area and the length, sutures on the inside of the skin (on the underside of the dermis) support the scar several weeks as it heals. If you leave sutures in the surface of the skin that long, you get little train tracks where the skin grows along the suture thread tract.

So that was a long-winded way of saying - the actual technique isn't much different than you would have seen 50 years ago. But you do still end up with a scar, just hopefully a much less noticeable one.

That's pretty much what I figured. The Dr. did a fantastic job on my primary scar and even took time to give me a "belly button," which is also why I haven't looked into surgery - he tried so hard it seems disrespectful.

That's very thoughtful and empathetic of you. Sometimes if people are unhappy with a pretty small bump or a scar that didn't heal perfectly, I'll offer to revise and try again under local anesthesia in the office for a minimal amount or nothing at all. It helps if people are kind and understanding.

Do you do any orthognathic surgeries? I know there tends to be a lot of overlap between surgical specialties but where would you draw a line between OMFS and plastics?

Yes, we do a fair number of orthognathic surgeries, many more than usual for plastic surgeons.

We do overlap a good amount with OMFS and with ENT as well. When we took trauma call in residency, we shared that call 1:1:1. Oral surgery is certainly better trained at any dental issues, and doing their own anesthesia. ENT with sinus and skull base, and head and neck cancer. Plastic surgeons tend to have more experience and exposure to cosmetic surgery, but that can vary quite a bit between training programs.

Back to your question - plastic surgery extends further anatomically, and with a few different tools in the bag surgically. I have also worked with fantastic oral surgeons with cleft and craniofacial backgrounds, with beautiful results I would be proud of myself.

Do you do Maxillomandibular advancement? I love that surgery because it cured my obstructive sleep apnea with 87 ahi to 0 ahi. If you do it, can you explain the challenges of it from a surgeons point of view?

That's an awesome result! Truly life-changing.

We do a fair amount for our cleft and hemifacial microsomia patients. Secondarily sometimes for obstructive sleep apnea, or other patients with jaws that don't quite line up.

The technical challenges include:

- preoperative planning and orthodontics, including making intermediate and final splints to guide the movement. The splints can make the surgery super smooth if they're on, or much more difficult if they're off.

- any previous scarring or surgeries, including patients with clefts. The jaws don't move as well, and the dissection can be more tedious.

- not accepting when something is off with the alignment or seating of the TMJ. It's easy to accept a subpar result after 4 or 5 hours of getting to an ok result. But it's not acceptable, and needs to be fixed.

- there are other anatomic issues, with people with more fragile bone, gaps where third molars used to be, nerves and teeth not quite where they usually are.

- if the movement is too great, the muscles and other soft tissue will fight the movement, and the body will try to push things back to where they were. Sometimes we use distraction, where you break the bone, and then slowly move it forward. This lets bone fill in the break gradually, and the soft tissue to gradually accommodate the movement. If you've seen Gattaca - that's what they do to the guy's legs to make him taller.

I was told by a plastic surgeon many years ago that meat-eaters heal better and scar less than vegetarians: Based on your own experience, and whatever evidence you've seen, do you agree that that's true?

I can't say I've seen enough vegetarians nor vegans in my practice to speak to that.

We do see problems with low protein or undernutrition causing delayed healing. If someone's protein levels (usually measured by one's albumin/prealbumin level) are known to be low ahead of surgery, we'll supplement protein to get the numbers up.

I usually recommend trying to eat plenty of protein (sometimes up to 1 gram of protein per kg of ideal body weight) and fresh fruits and vegetables, to try and have all of the building blocks in place to heal quickly and smoothly.

Here's some reading that seems reasonable: https://journals.lww.com/aswcjournal/Fulltext/2003/03000/Vegetarian_Diets_and_Wound_Healing.6.aspx; https://advancedtissue.com/2017/01/wound-care-concerns-vegetarians-vegans/

Have you worked with any Vascular Ehlers Danlos Syndrome patients? I would love to know about it if you have.

I think only one or two patients. I remember being very nervous about wounds not healing, and being as careful as possible. Everything healed from what I recall, but it's certainly been awhile.

How do you feel about modern surgeons being filthy rich and the health care industry facilitating an even higher level of capitalism for what should be a humanitarian cause? In your ideal world, should surgeons (financially) be in the top 10%? 1%? .01%?

You listed off a care team earlier that was many doctors and didn't even go into the nursing staff and support staff. How do you feel knowing that a simple overnight stay is five figures and it's relatively easy for a normal person to get six figures of debt for saving their life?

Oooh, this could be a whole post or dissertation in itself.

It gets into questions about:

- healthcare costs in the USA versus other countries, and the relative health outcomes

- access and choice

- are surgeons and other professionals (lawyers, accountants, etc) paid appropriately for their training and services?

- medical bankruptcy, and whether we should accept that as a society or to what degree

In my ideal world, you would see universal health access, particularly to primary care and life and limb-saving services first and foremost. Then you work down as you have the resources to life-lengthening and life-enriching services, perhaps measured by QALY.

There are ethical considerations for a two-tier system like most countries have, with a public option and additional private coverage, but that seems to be the best balance right now.

I'd have a bit of a beef with what I would consider obscene administrative costs, which have grown at an outsized rate. https://www.motherjones.com/kevin-drum/2019/06/join-me-on-a-dive-down-the-rabbit-hole-of-health-care-admin-costs/

Hospital and insurance company executives don't need to be making tens and hundreds of millions, imho. Physicians in some cases are definitely excessively focused on profits rather than health, and it makes most of us sick to our stomachs.

Hello! Our daughter suffered from craniosynostosis (frontal suture line). The corrective surgery was performed at Children’s in Dallas was Drs. Hobar and Sklar. :-) She is an exceptional adult with an MA in SPED - Learning Disabilities and Behavior Disorders.

We had no other similar issues within the families. Any new research on causes?

Ah, Dr. Hobar is such a treasure, as a surgeon, mentor, and role model. Dr. Sklar I met but can't say that I worked too much with him during my training.

I'm glad to hear your daughter is doing so well now! It takes a very special and patient person to do what she does, and I applaud her for it.

A lot of research is being done with genetics. This article says that 39 new genes have been identified just from 2015-2017!

Do you do the surgery for TMJ? My dr made it seem like it was a risky surgery with lots of possible outcomes.

We used to do more TMJ surgery at our center, but more recently have been working with our oral surgery colleagues to do surgery together. For exampled, for conditions like hemifacial microsomia, we sometimes need to replace the joint with a prosthetic, while also leveling and aligning one's occlusion with orthognathic surgery (i.e., breaking the upper and/or lower jaw and resetting it in a different position so that the teeth line up and are level).

what are the most common procedures people get?

Here's a rundown from our main society: https://www.plasticsurgery.org/news/plastic-surgery-statistics

Top 5 cosmetic surgeries:

1. Breast augmentation (300k)
2. Liposuction (265k)
3. Eyelid lift / Blepharoplasty (211k)
4. Tummy tuck / Abdominoplasty (123k)
5. Breast lift / Mastopexy (113k)

You can find more charts and graphs there depending on what you're looking for.

Did you ever eat at Clements hospital cafeteria? That place is the best.

Ha, yes. Surprisingly good. The chef at Medical City is great, too, if you're ever that direction. Lotsa Pasta is also a hidden gem in the medical office buildings at Medical City.

Wow, it's so cool to see an alum of BME on IamA! I'm currently a BME student at UT Austin.

Did anything from biomedical engineering help you down the line in med school or in your current practice? What was most memorable from your time during college?

Have you ever had ethical concerns with cosmetic procedures? (This is somewhat of a hot topic in this current era of social media and influencers!) How do you evaluate that a patient is fit for the surgery?

Tons of BME has been applicable, though I'm definitely biased.

Random things come up, like being asked in conference about different biomaterials. Definitely that summer program at MD Anderson was a huge leg up having gone through anatomy in a condensed way once already.

Mostly the thinking and social aspects I'd say. Problem solving, working with others, understanding principles and trying to apply them. Constantly random things pop up, like drug delivery with Peppas, transport engineering considerations with flow between two spaces and Poiseuille's formula, etc.

The degree does feel like it makes you a bit of a jack of all trades, master of none. But that equips you to tackle pretty much anything you want to do going forward. I think 1/3rd of our class went to medical school, 1/3rd grad school, and 1/3rd into industry. Eventually, I know some circled back to medical school later on, too.

The most memorable times were definitely the adventures with your friends and co-conspirators. I saw somewhere else on Reddit that it's a lot harder to make friends in your 30s, and that's true. In college, you have people all around you, within a few minutes walk, who will meet up on a moment's notice to throw a frisbee by the flagpoles, grab some Wendy's, or play Smash Bros. You're usually free in a lot of ways, without kids or spouses, to be very flexible with your time.

I also made liberal use of the chance to take P/F classes that don't apply to your degree requirements. Language, philosophy, PE classes, etc. Also some nerd nights with friends, when we'd get together, pretend we could taste subtleties in different wines, and teach and learn and discuss about most anything we wanted. It's really not the things, but the experiences and the people I miss.

What are good places/countries to get experienced plastic surgeons? How do you find a good plastic surgeon?

There are talented and amazing surgeons all over the world. I've heard of surgeons going to India and China, thinking they were going to do some teaching, and learning that those surgeons are leaps ahead of the Western surgeon.

A couple options in the US are to make sure your surgeon is board certified for plastic surgery here. The American Society of Plastic Surgery also has a directory.

Some personal referrals go a long ways, as does just a gut feeling after meeting and consulting with a doctor. Sometimes it's a good match; sometimes you can just tell it's not going to work out.

Do useful plastic surgeons look down on the cosmetic surgeons who only give people giant tits and fake asses? I'd imagine it's like turning your back on the hippocratic oath for sex, money, and fame.

Haha - I think that sentiment does run through some of the surgeons out there.

When we were working on our boards certification, there was some speculation that the all-cosmetic surgeons did have a tougher time because of that.

We all are trying to find our way to what will give us fulfillment with our professional and personal lives, though, and I try not to judge anyone else's choices. Should I have gone to Africa like Albert Schweitzer, and founded a hospital and worked there my whole life?

Can you fix my brow after my craniotomy messed it up?

Hard to say without seeing you in person, but generally yes, that's something that can be improved.

Didn’t you work with Dr. Genecov? I believe I’m met you before at a visit with Dr. Genecov and may have filled in when he wasn’t available.

Yes! We still work together, and operated together a couple of days this past week.

Do you have any advice for dark skinned folks that are especially prone to scarring when it comes to getting procedures done ? Also do you recommend getting a donut breast reduction if the persons size is currently an e cup ?

Some is expectation management. More pigment tends to correlate with darker, thicker scars that take longer to soften and mature.

The breast reduction technique can vary a lot between different surgeons. I'd have to defer to the surgeon who has examined you and discussed the procedure with you.

I'd want them to be confident they can remove enough volume to relieve your symptoms. Also to tailor the skin enough to give you an a beautiful breast.

Do you think the majority of US physicians are healers or capitalists?

Healers > Capitalists

Capitalists >> 0

​

Response copied from below:

Oooh, this could be a whole post or dissertation in itself.

It gets into questions about:

- healthcare costs in the USA versus other countries, and the relative health outcomes

- access and choice

- are surgeons and other professionals (lawyers, accountants, etc) paid appropriately for their training and services?

- medical bankruptcy, and whether we should accept that as a society or to what degree

In my ideal world, you would see universal health access, particularly to primary care and life and limb-saving services first and foremost. Then you work down as you have the resources to life-lengthening and life-enriching services, perhaps measured by QALY.

There are ethical considerations for a two-tier system like most countries have, with a public option and additional private coverage, but that seems to be the best balance right now.

I'd have a bit of a beef with what I would consider obscene administrative costs, which have grown at an outsized rate. https://www.motherjones.com/kevin-drum/2019/06/join-me-on-a-dive-down-the-rabbit-hole-of-health-care-admin-costs/

Hospital and insurance company executives don't need to be making tens and hundreds of millions, imho. Physicians in some cases are definitely excessively focused on profits rather than health, and it makes most of us sick to our stomachs.

Hi Dr. Law, gen surg resident here. Any favorite memories/ particularly great stories from residency at UTSW?

I was telling someone yesterday about my time as a PGY-2 on trauma surgery. Our PGY-4 was out for interviews in the early fall, and the 5 and attending were in the OR with a GSW. I end up having to field a multiple MVC event, with all the trauma bays full, and a patient clearly bleeding in her belly.

I leave the PGY 1 to handle the ER, and I find myself in the OR, about to ex lap a patient by myself. With scalpel in hand, the attending walks in and says, "what the F*** is going on here?"

There are other stories, some apocryphal stories, probably better shared over a drink some time.

Did you ever have a problem of unstable/shakey hands? If so how did you deal with it? Are there any solutions?

Sometimes under a microscope, small tremors are very apparent.

In that case, it can help to anchor and stabilize your hands, so that the bigger muscles are fully relaxed and supported.

Other than that, increasing sleep and cutting back on caffeine as broad suggestions are worth trying.

What is the most difficult surgery you have performed on a toe?

We actually spent a fair amount of time on podiatry.

Maybe it was removing a 6th toe, and using the bone as a source for grafting.

Could also be all the infected diabetic foot wounds that have a hard time healing.

There is also something called a toe-to-thumb transfer, where you can create a thumb by transplanting a toe to a hand. Also been done with the 1st and 2nd toes for the thumb and index finger. Never seen it, but it's a marvel of ingenuity.

Do you operate only on necessary corrections, and do you ever refuse and convince a patient that his/hers cosmetic surgery is not necessary and are only based in whatever is today's beauty trend?

I'm seeing more and more of people looking exactly the same.

Beauty is in the difference.

Yes. Generally I walk through the surgery, expectations, risks, and goals. If we're not on the same page, usually the patient will decline to come back because I tell them what I will and won't do, and can and can't achieve.

Though philosophically, who's to say my ideal of beauty is better than anyone else's?

(FWIW, I do and will always refuse to intentionally deform anybody, based on my standards.)

A good rule of thumb is whether I would be ok with a family member receiving it, after full understanding of the risks involved.

What's the occurrence rate of osteomyelitis in jaw bone from extensive dental decay? In addition, the development of mrsa, and by extension necrotizing fasc, in embedded staph infection of that bone?

Asking due to some personal experience and a seeming difficulty in finding similar case reports. Thank you for your time.

Yikes, I can't say I have that off the top of my head. Probably more often than we hear about, like how all the Florida Man things we learn about just because of their open records.

Unfortunately for that person that gets it, it's 100%.

I'm terrible at describing faces, happen to have a good reference on how to do so?

Hm, nothing immediately comes to mind. Maybe the photos in a developmental pediatrics book?

What is your experience with Microtia or performing one of the three techniques(Brent, Nagata, Reinisch) to correct the deformity?

Admittedly more limited than I'd like. The cases I've done myself have been together with my senior partner, who used to literally teach a course on it. It's the benefit of having very experienced and expert partners, both very willing to give up full days to passing on their lessons learned.

This experience has followed the Nagata technique using a patient's own cartilage to carve a new ear framework. The advantages include more durability to infection and trauma over time, and more resilience and lifeboats if there are issues with healing or exposure.

The Reinisch technique is attractive for avoiding a donor site on the chest, but in many hands seems to fall a little short of what he has achieved. This was the method I saw in my residency to mixed results. Several other surgeons I've worked with felt the complication rate was unacceptably high in their hands.

In Taiwan, the expert there (who seemed to do 3-5 days of just microtia reconstruction every week) said he was at about 50-50 rib cartilage vs. Medpor, and he left it up to the parents after discussing it with them.

It is one of the more amazing things we can offer, and one of the core areas I'd love to focus on really offering every possible option.

Hey, I'm impressed by your accomplishments and you should be proud. Not to take away from the work that these groups do, but I've worked in remote communities that have been visited by the Operation Smile team... They're pretty much abandoned post-op without any reliable followup. I trained in a trauma center so I'm ok dealing with some, but not most of these complications, but alot of these doctors who spend real time (years) with the communities are GPs. Can you comment on the risk/reward of operating on these patients, and the actual capacity they have to consent?

You're definitely right - there are issues with parachute teams that drop in and have no follow-up. Are the patients better off for it? How well can they consent given language barriers? How often are surgeons coming over and doing surgeries they don't do regularly, or try different techniques they otherwise wouldn't try at home?

I'm happy to say the teams I've been with go to the same places year after year, so there is continuity. There is also partnership with local doctors and teams to make sure the right things are happening at the right time for each patient (to the best of everyone's abilities), with as much understanding both directions as possible.

Thank you for doing this!

Is there a way you could that no of to safely perform facial feminization surgery on a patient with severe obstructive apnea?

Tough to say without seeing the patient and talking about specific goals. I'd probably be looking to get that apnea treated as the priority.

What percentage of people regret their cosmetic surgery, and in particular nose surgery? Asking for a myself.

My mum told me I might never be able to smell again if I get it too.

Based on this site, about 90% are happy with their result.

A lot depends on your goals and reasons.

The problem is when you're in that 10%, it's 100% for you.

Would you be happy if you had only partial improvement? Would you be happy with even full improvement? There are definitely times when you think this will change everything, but you discover it's not that much different in the end.

Take your time with the process, understand the risks, and make sure you have a surgeon who takes it as seriously as you do.

I wish I had access to a doc of your caliber where I live (rural PA).

What's your preferred solution to a "short" jawline/double chin? I have spent my whole life marveling at sharp, tight jawlines. As a 50 year old, I watch people's faces as they speak to me, and I find they sort of--peel nervously on their own necks while they talk to me. It's not like I can suck in what's under my slight chin.

Anyway. I'm older, and I'm going to probably droop way more (if my dad is any indication--but he has a beard to cover up his problems), and I could be really ready for a chin/jaw overhaul. Surgery does not terrify me at all.

Can you offer pointers or direct me a bit? Or--feel free to see, "that ship has sailed! You're skin is too old!"

50 years old is actually a good time for a lower face / neck lift.

The question is anatomically, what are the contributing factors, and what can be done about them.

Sometimes the bone can be moved forward, sometimes fat resected, and muscle and skin tightened.

I have seen some men do well with a direct neck excision / lift, with a scar directly in the middle of their neck like here.

Depending where you are in the state, I know there are great surgeons in Philly and Pittsburgh.

Some people have asked here about macillomandibular advancement/DJS/orthognathic. For someone who isn’t sure what their options are, generically speaking, who should a patient see first a plastic surgeon or maxillofacial surgeon? What types of things should a patient be looking for in terms of the back and forth with their doctor? For instance, is it beneficial to find a practice that implements 3D modeling and some of the new technologies. I apologize as I’m not sure of all the tools available to these practices. Thank you.

More important than the tech is the experience of the surgeons, and the quality of the orthodontist. You can try to get a sense of how many of these types of surgeries they do each year. In general, a maxillofacial surgeon tends to have more background and ongoing practice, though there are exceptions. We do more in our practice than most because of all of our cleft and other craniofacial patients.

Do you do skin reduction on excess skin? I live in Dallas and might come to you.

Yes, definitely. We work with several bariatric surgeons to help take care of patients after their weight stabilizes. This ranges from a panniculectomy to remove just the overhang at the waistline, to full tummy tucks, arm and thigh lifts, and face and neck lifts. It can be very satisfying for all involved. Safety regarding blood clots, optimizing any other medical problems, and limiting total anesthesia time are major considerations.

How's your esthetics business last year during covid?

In some ways surprisingly good. Maybe more people not traveling nor eating out, with more cash on hand. It will be interesting to see what the numbers end up looking like nationwide.

What does the future of treatment for full- thickness/ severe burns look like? Sorry if this falls more into the dermatology category.

I have done less acute burns since my time rotating with the Parkland Burn service. I think the principles are similar now, compared with many years ago. Some of the promised technology like taking skin from one's body, growing it and expanding the area, and grafting that back, are still dealing with problems of cost and durability.

For burns that are now healed, I have been doing some fat grafting and fractionated laser treatment, both of which help soften and remodel the thick, scarred tissue. Tissue expansion for expanding healthier skin to replace adjacent, burned skin can help but is definitely a process.

Microsurgery is also an option in some cases, to transplant some healthy skin to replace thick, scarred tissue, like for a contracture.

Of all the medical residencies, was plastic surgery the hardest to get accepted?

What separated your application from the other medical students?

I think plastic surgery is on the more competitive side for sure. A lot of the smaller specialties are more hit-or-miss. Some great candidates fall through the cracks just because of the fewer number of slots.

The biggest factor I'd say was actually rotating at that program. When everything else is fairly equal, that exposure and familiarity wins out. (Or, it can also definitively tank your chances. You really have to be on your A game.)

Hi! Thanks so much for doing this AMA.

Do you have any tips for medical students who are interested in plastic surgery and want to match into an integrated program in the future? Have you ever met someone who just "didn't have the hands" for it? And what are the things that you think you did right to stand out and match into such an amazing program?

- the applicant pool is crazy competitive objectively speaking, seeing it from the interviewing side

- grades, step score, AOA certainly help, at least to prevent from raising major questions about the ability to keep up with the material

- letters and recommendations can make a strong impression

- be yourself as you are on a good day. That goes for interview day and for rotations.

- don't sleep in and miss the first part of interview day... especially after it was noted you went out for more drinks after the pre-interview dinner reception

- rotate at several places, ideally places you would hope to match a priori. Often rotators are considered almost completely separately since there's more information to go off of, and it shows especial interest in the program.

- consider your backup plans. gen surg and reapply after a year? gen surg and go for fellowship after 5 years? research for 2 years and reapply year 2?

- there's luck and timing involved. Control what you can, do your best, work hard, play nicely in the sandbox. Don't show up the residents. First one in, last one out. Remember patient care comes first. And your co-rotators will be with you for life - take care of them, and they are likely as stressed or even more than you. You've made it this far - believe in yourself, but with humility. r/GetMotivated

What are some good books/sources that helped you learn how to study effectively?

A lot of trial and error. I learn best with problem solving and hands-on application. Alo teaching others. Other people are more visual or aural.

Hey Doc! I have 7th nerve dysplasia, mild paralysis L side of my face: on of the things I'm looking at is a procedure where they place a small gold leaf/weight in my L eyelid to help it close... I have a theory: I think if this procedure helps my blink rate, it will help with neuropathic and maybe some Nociceptive pain as well. My thought (uneducated but feeling it from inside) Is that nerve pathways & synapses are having to kind of reroute every blink/and this may give them a little short cut. Bonus question; If I have a legit gold leaf in my eyelid; I'd be totally reasonable for not responding to ANY friends or family unless they refer to me as "GoldenEye", right?

The gold weight does seem to help with symmetry, and I wouldn't be surprised if it helps with pain as well.

GoldenEye is still a great movie, and one of the best video games of all time. Prox mines for the win.

Do you have to check if the patient is ok mentally before performing cosmetic surgery? As some people go overboard as seen on r/botchedsurgeries

Not always, but that's always a concern. Sometimes a nurse or other office staff will let us know that a patient is sending off major warning vibes, and we'll end up declining to offer them surgery.

What is the youngest age you would personally do a rhinoplasty on and why?

Generally speaking, at the minimum after full skeletal maturity. For girls, this tends to be 15-16 years old, and for boys a little bit later. At the early end, it's very much an open discussion and feeling out how much understanding there is of the potential risks and benefits, that there is no pressure on the patient from another person (like a parent or boyfriend/girlfriend), and that expectations and maturity seem appropriate.

That said, for a cosmetic rhinoplasty, generally I'm more comfortable with someone at least in their 20s-30s, though there are plenty of 40-50 year olds who are definitely poor candidates.

Very rarely, we have younger patients, usually cleft or other craniofacial patients, who are getting excessively teased and it's a severe deformity. There's more risk of causing more scarring which can affect growth, and also needing more surgery in the future. This can sometimes be even in 6-7 year olds, and the most conservative approaches are used.

What do you drive?

A 20 year old truck. Been reliable through it all, and no ongoing payments.