In this episode of Botox and Burpees, host Sam Rhee invites Dr. Lawrence Tong, a renowned plastic surgeon from Toronto, to discuss the tragic passing of 31-year-old Brazilian influencer Ana Bárbara Buhr Buldrini @anabmusi following cosmetic surgeries traveling from Mozambique to Istanbul, Turkey.
They explore how the transactional nature of trading surgical procedures for social media exposure potentially compromised standard safety protocols from allegedly partying with the surgeon before surgery to operating late at night and possibly ignoring basic safety measures like NPO status.
The conversation delves deep into what makes cosmetic surgery safe – proper patient preparation, medication disclosure, facility standards, and the risks of multiple procedures. Both surgeons emphasize that while excellent doctors exist worldwide, patients must conduct thorough due diligence when seeking treatment abroad.
Whether you're considering cosmetic surgery at home or abroad, this episode provides vital information to help you make informed decisions that prioritize safety over cost. Remember - if a surgical deal seems too good to be true, corners are likely being cut somewhere, and the price may ultimately be your safety.
#BotoxAndBurpees #MedicalPodcast #PlasticSurgery #PatientSafety #MedicalTourism #SurgerySafety #CosmeticSurgery #HealthAndWellness #PlasticSurgeons #SurgeryStories @botoxandburpeespodcast
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:05):
Hello and welcome to another episode of Botox and
Burpees.
I'm your host, sam Rhee, and Ihave with me special guest Dr
Lawrence Tong from TorontoCanada.
What's your Instagram handleagain, larry?
Speaker 2 (00:18):
At Yorkville Plastic Surgery at Yorkville Plastic
Surgery.
Speaker 1 (00:22):
One of the most talented plastic surgeons I know
trained with him at Universityof Michigan.
He's killing it for all facetsof plastic surgery and, as I
mentioned in our previousepisode, our esteemed podcast
Three Plastic Surgeons and aFourth is currently on hiatus,
so I thought I'd bring Larry onBotox and Burpee so we could
(00:43):
talk about a very tragic storythat just recently happened.
There was a 31-year-oldinfluencer, anna Barbara
Bohr-Boldrini, who died after aseries of cosmetic procedures in
Turkey, and her circumstancesin terms of her passing is
pretty tragic, and I think thatthere's a lot that we can learn,
(01:04):
both as surgeons and patients,in terms of unpacking this to
make sure that our patients aresafe and that plastic surgeons
are following best practices interms of what they do.
So, before we get into it,larry, if you could give us our
disclaimer?
Speaker 2 (01:22):
My pleasure.
So this show is forinformational purposes only.
Treatment and results may varybased upon the circumstances,
situation and medical judgment.
After appropriate discussion,Always seek the advice of your
surgeon or other qualifiedhealth provider with any
questions you may have regardingmedical care.
Never disregard professionalmedical advice or delay seeking
advice because of something onthis show.
(01:42):
So tell us about thecircumstances with Anna Barbara.
All right medical advice ordelay seeking advice because of
something on this show.
So tell us about thecircumstances with Anna Barbara,
all right so Barbara Baldriniis a was a 31 year old female
influencer from Brazil, and sheand her husband had traveled to
Istanbul, Turkey, to have aseries of cosmetic procedures
(02:03):
with the understanding that shewould be promoting the hospital
where she was having the surgery.
It's reported that thesurgeries that she underwent
were breast augmentation,rhinoplasty and liposuction,
although they did not elucidatehow much liposuction was done,
which might be important.
The surgery occurred on June15th and it's reported that this
(02:26):
occurred hours after her andher husband had quote-unquote
partied with the surgeon who wasperforming the procedure.
The husband states that theprocedure ended at 11 pm, which
is, in my opinion, sort of lateto end surgery, and the
assistants told him that she wasrecovering from anesthesia and
(02:49):
showed him a photo of herrecovering, but then, sadly, one
hour later, the surgeon cameout and told him that her heart
was beating slowly, whileanother surgeon told him that
she had died.
It's reported that she had diedof cardiac arrest and obviously
the husband is very upset aboutthis and he's saying that she
(03:14):
was not prepared adequately forthe surgery.
One of the things that he notedwas that she was not NPO, which
means she had still beeningesting food prior to surgery
and that her surgery had beenmoved up, actually two days
(03:34):
earlier than was scheduledbecause of quote unquote
scheduling issues.
So there are pertinent topicsthat we should discuss, but it
is important to note that we donot know the entire story and
all the facts about whathappened, so some things are
unclear.
But this discussion is aroundimportant topics surrounding
(03:58):
this tragedy how things shouldideally take place, and you know
what are the particular issuesregarding having surgery in a
foreign country, having socialmedia mixed in with the aspect
of having surgery, and safety insurgery.
(04:21):
So I'll start off with talkingabout the fact that she had a
cardiac arrest.
That's how it's been reportedin the news.
There has not been furtherinformation about that, but
there are, you know, tragically,times when this can occur, and
(04:43):
so, as a patient, you might bewondering well, you know, what
can I do to minimize that risk?
Because you know, with allsurgery, there's going to be the
potential for complications.
There's no way to get around it.
But there are things that canbe done to, you know, minimize
the risk, and there are thingsthat the surgeon is responsible
(05:07):
for, but there are also thingsthat the patient has some
responsibility in as well.
Absolutely.
Speaker 1 (05:17):
And you mentioned, there are always risks
associated, potentially, withsurgery, and choosing the right
people that you feel comfortablewith to perform your anesthesia
, to perform your surgery, playsa large part of it, and that's
something that we might talkabout in terms of how she
(05:38):
traveled, how she chose thisparticular group or surgeon.
But you're right, there arethings that patients can do also
to make sure that they staysafe during the procedure as
well as after.
So what are some of the thingsthat people should know about in
terms of trying to stay safe?
Speaker 2 (05:59):
So one of the things that you know every patient is
told before they have surgeryand if our viewers have ever had
surgery they probably told younothing to eat or drink after
midnight.
Then that's often referred to asNPO after midnight, and there's
a reason for that and that thereason for that is because when
(06:21):
you are put under generalanesthesia is because when you
are put under general anesthesiayou should have an empty
stomach.
If you've eaten just before youhave anesthesia and you have
food in your stomach, the riskis that you might aspirate.
Aspiration means the food fromthe stomach comes up through
(06:43):
your esophagus and then goesback down into your lungs, which
can cause pneumonia and you candie from that.
So that is a very basic thingthat every surgeon will instruct
you to do, and so it'simportant.
If a surgeon instructs you tonot eat or drink after a certain
time period, you should reallyfollow that advice, because that
is very, very important and ingeneral, unless it's an
(07:06):
emergency, if we know about apatient who's eaten, who's ate
or drank before surgery, we will, you know, we will cancel their
case for that day because thesafety aspect is that important.
Speaker 1 (07:19):
Absolutely.
I have known people who havenot been truthful about that and
they put themselves at enormousrisk because those stomach
contents, if they go into yourtrachea, into your lungs, it's
very acidic.
This stuff is all filled withyour stomach acid and you're
going to have huge problems, asyou mentioned, with pneumonia,
(07:43):
with lung damage, potentiallydeath.
And if you wonder, well, howabout trauma surgery or some
situation where people are notwithout empty stomachs, well
then the anesthesiologistsperform a slightly riskier type
of procedure called rapidsequence intubation, where they
(08:05):
are trying to minimize that riskof people aspirating stomach
contents into their lungs.
So that's something that Ihaven't.
I mean, I can't remember thelast time I saw a rapid sequence
intubation I think it wasprobably residency on the
general surgery service ontrauma, like that's sort of what
, and that's not a greatsituation to be in.
Speaker 2 (08:28):
How do you and that is not something that you should
be doing in a cosmetic practicethat?
is exactly right, you shouldnever be in that situation.
So any kind of you knowintubation should have the
proper protocol in place andhaving the steps in place before
doing the surgery.
So I think that if it's truethat that patient did not follow
(08:51):
NPO before the surgery, I wouldnot have done that surgery.
What else so related to that isactually, you know, some of the
drugs that you take that apatient might take.
So one of them is Ozempic.
So Ozempic is very popular,especially amongst the cosmetic
(09:12):
surgery population, and one ofthe things that Ozempic does is
it slows down gastric emptying.
That means the rate at whichfood leaves your GI system is
slowed down a lot.
And if you are taking Ozempic,even if you have stopped eating
the night before, that isgenerally not enough time to
(09:34):
minimize your risk of aspiration.
So some people are on Ozempicand because it's to the point
where it's so commonplace, theymight not even mention that
they're taking it, or they'remaybe taking an Ozempic sort of
copycat and they don't thinkit's really like taking a drug.
(09:54):
So if you are on Ozempic, youdefinitely need to tell your
surgeon that you are on it,because we usually stop that
medication about two or eventhree weeks before a patient
goes under general anesthesia.
Speaker 1 (10:08):
Yeah, and there's so many variations.
Now there's Zepbound, monjaro,you name it.
There are so many differentGLP-1 type agonists that, like
you said, and a lot of them arejust intermittent injections,
they're not daily pills oranything.
So people might even forgetthat this is quote, a drug that
might affect their procedure.
(10:28):
And you're right, I probablysee.
Now I don't know what would yousay.
I would say maybe for my bodycontouring.
I would say at least a third ofthose patients are on some sort
of, or have tried a GLP-1agonist.
Speaker 2 (10:41):
Yeah, I don't know if the number is that high in my
practice, but it is somewheremaybe in my practice around 10
or 15 percent, something likethat.
So it's not unusual at all.
Diuretics so diuretics is amedication that you take to get
(11:10):
rid of fluid in your body and itis primarily used for patients
with high blood pressure orheart disease.
But patients also take it tomake themselves look thinner so
that they don't look soquote-unquote bloated.
And using that medicationmesses with your fluid balance
and can mess with yourelectrolyte imbalance.
So it's also very important toinform your physician if you're
(11:35):
taking that kind of medication.
And there are other kinds ofdrugs that are not
pharmaceuticals but recreationaldrugs that are important for
you to tell your doctor, such asyou know if you use cocaine.
That is a very high risk thingto take if you're having surgery
in the near future.
Speaker 1 (11:58):
Yeah, it's funny, we have several menstrual cramping
medications in our household,mainly because not for me, but
for other members of myhousehold, like my daughter and
I looked at the ingredients anda lot of them contain diuretics.
So not only do they containsome sort of pain medication for
(12:22):
menstrual cramping, but theyalso have these pretty powerful
water treatments to addresswater retention, and so people
might not even think a Midol ora Pamprin or something like that
is a real medication.
But yes, definitely you got tolet your surgeon know, because
(12:44):
if you're dehydrated and you gointo a procedure, that could
definitely adversely affect yoursystem.
Speaker 2 (12:53):
Yes.
And then the last thing is yourgeneral medical history.
It's actually pretty commonthat patients don't tell me what
cosmetic procedures they've hadwhen they come in, and then
when I look at them, I can youknow.
When I examine them, I can tellthem and, if that's okay, did
you have this done?
You know they have a scar orsomething like that which makes
it obvious.
So having prior surgery affectshow your surgeon may approach
(13:19):
any future surgery, especiallyif it's in the same area.
So I think that's importantbecause in general it's not
going to be as easy the secondor third time as it was the
first time, and you should youknow for your own safety and
interest.
You should tell your surgeon ifyou've had surgery before in
those particular areas and, inaddition to that, if you have
(13:39):
any other medical conditions,especially related to your lungs
or your heart, or you knowstrokes or history of anesthetic
complications or blood clots.
All those things are veryimportant.
So I guess it's very, it's very, very important that you be
(14:02):
truthful with your surgeon,because it's only going to help
you in the long run.
Speaker 1 (14:09):
It can be embarrassing to disclose
everything to somebody, but inthese cases I think people have
to take their.
You know, be courageous, telleverything, and sometimes people
forget.
I cannot like.
Last week I had someone whocame in for a tummy tuck forgot
everything, and sometimes peopleforget.
I cannot like.
Last week I had someone whocame in for a tummy tuck forgot
that she had liposuction.
(14:29):
We screened her twice, wetalked to her on the phone, then
my medical assistant talked toher before I saw her and it was
only after about 15 minutes oftalking.
She's like oh yeah, by the way,I also have liposuction, in
addition to, you know, whateverhysterectomy or gallbladder
surgery or whatever else shetold us about.
So, yeah, like, take, take asecond and sort of think about
(14:54):
your medical history.
I know you feel like you knowall this stuff is not something
that is that important, but itis very, very, very, very
important for you to get thebest results for your outcome.
Speaker 2 (15:09):
Yeah, I think you tell us what you've had or what
your history is, and we'lldecide if it's important or not.
Speaker 1 (15:16):
Right.
So what else do you want totalk about with Boldrini right
now?
Speaker 2 (15:20):
All right.
So I want to talk about peoplewho go to other countries to
have surgery, often known asmedical tourism.
So in general, there are issuesrelated to that, and that's not
to say that every foreigncountry is bad compared to North
(15:47):
America.
And you shouldn't go tointernational surgeons, because
there are many, many excellent,well-trained, world-renowned,
you know, respected surgeons.
But patients have to do theirdue diligence because it's not
(16:09):
the same as in North America.
I think that, in my opinion,north America has the highest
standards for physician trainingand for regulation and
licensing of facilities andlicensing of facilities.
And so you know, if a patientis thinking about medical
(16:29):
tourism, they have to be extracareful in choosing who they're
going to and what countrythey're going to.
And you just have to look atall of those things From a
training standpoint.
In the United States and Canada,plastic surgeon trains from
anywhere from five to sevenyears and then goes to have
(16:53):
board certification, which is arigorous type of examination to
make sure that the surgeon issort of up to snuff to do the
surgery.
Surgeons in the United Statesand Canada have to operate in an
accredited facility.
That means a place where theydo the surgery which has
(17:17):
standards, that is, you know,recognized by certain regulatory
groups.
And in North America, you know,each jurisdiction has a strong
medical board, which means thatthey conduct surgeon licensing
(17:38):
and patient complaints andinvestigations.
So patients have, you know,strong legal system and
protections with surgery, and soin other countries not all of
these safeguards are in place.
Speaker 1 (17:51):
I think there are two things I think about when I
think about these types ofissues associated with medical
tourism.
The first is is you'reabsolutely right, there are
great surgeons everywhere, butthe biggest thing that I have
seen for patients who gosomewhere outside of their own
country for surgery is cost.
It is generally expensive inNorth America to have aesthetic
(18:17):
surgery procedures, and sothey're looking for a cheaper
way of doing it, and that isvery popular for a lot of types
of procedures, especially hairtransplantation.
In Turkey, what Ms Baldriniwent through, there was
something like 2 millionvisitors that went to Turkey
(18:40):
last year in 2024.
Speaker 2 (18:42):
That's like $12 billion and the reason is is
that the cost so two millionpeople who went for surgery, you
mean.
Speaker 1 (18:49):
Yes, two million people went for surgery and it
was like a $12 billion industryin Turkey right now for medical
tourism, and so the cost is sucha powerful draw factor for so
many people.
But that doesn't mean that youare absolved of your
responsibility of finding theright person.
In fact, it's probably evenmore so, and the issue is is
(19:10):
that a lot of it is based on, uh, social media or other issues,
like I understand that peopledon't want to delve into the
regulatory or certification sortof aspects of stuff very boring
, not exciting, doesn't make anydifference like and and I agree
it doesn't necessarily.
if people will argue thatdoesn't mean that that person is
(19:32):
a great surgeon, that is true.
Just because you have yourdriver's license does not mean
you're a great driver.
However, you probably are goingto be a safer driver than
someone who does not have theirdriver's license in general.
So there are some minimumstandards there.
That's what you can think of itas, and then you have to find
someone that you think is goingto do a great job, but social
(19:53):
media from someone 5,000 milesaway is probably not going to
give you necessarily an accuratepicture.
I don't know how Ms Baldrinipicked this particular surgeon.
Some negative publicity orincidents was literally trading
(20:18):
procedures for social mediaexposure.
And how do you feel about thatas a plastic surgeon?
Speaker 2 (20:27):
Well, it's sort of a slippery slope because once you
have that aspect involved, it'snot the norm, that aspect
involved it's not the norm, andsometimes you don't treat the
patient as your typical patient,which is something you should
absolutely not do.
You should be treating patientsall you know, equally, with the
(20:51):
same degree of safety, with thesame protocols.
Safety with the same protocols.
Because if you deviate fromthat, that's when you run the
risk of you know complicationshappening, such as you know
(21:14):
having you know drinks orpartying with the patient prior.
The surgeon might have feltthat you know this is something
to gain favor, or you knowsomething that that surgeon
probably would not have done ifit was just a sort of a regular
patient that he was going to doon a Tuesday.
And so it's an issue becausethe incentive is very strong.
(21:38):
When you have somebody who isan influencer and this patient
had, I think, 800,000subscribers then that draw can
be something that clouds yourjudgment.
Speaker 1 (21:54):
Absolutely I.
Always it makes me wonder, likeyou said, they are providing
their services for free.
Did that alter how they managethis particular patient, why
they push this patient two dayssooner, why they, you know,
didn't weren't allegedlyconcerned about the NPO status
(22:15):
of this patient, like all ofthose things are are brought
into question when you look atthe transactional nature of this
surgeon patient relationshipwhich, as you said, is that's.
That's very concerning.
I don't, I've never, ever donesomething like that and I I
don't think I would ever want todo something like that.
(22:38):
But even if you did, let'ssuppose were a surgeon who did
something like this.
Like you said, that patient hasto be treated just like every
other patient, whether they'repaying zero or a million dollars
, whatever it is like thattreatment has to be top-notch
regardless.
Speaker 2 (22:57):
Yes, and another issue with medical tourism is
from a logistic point of view.
What if you have a complicationafter you've flown back to the
United States?
What if you're not happy withhow the procedure has turned out
?
With how the procedure hasturned out, those things are
(23:19):
difficult to treat, even in mypatients who maybe come from
cities further away or even fromdifferent provinces.
It is exponentially moredifficult when it's in a
different continent and you know, unless you're Turkish, you
don't even understand thelanguage.
There's a big language barrieras well with that.
(23:40):
So if a patient is going toconsider having surgery, as you
said, price is a big driver, butyou have to think about the
whole picture.
If you end up having acomplication and you need
surgery, then you're eitherstuck with accepting the
(24:02):
appearance that you don't like,or you have to take a plane back
to Turkey, if they're evenwilling to do more surgery on
you, or you have to find asurgeon where you live and then
at that point your savings fromthe original surgery are
probably erased and you'reprobably paying more than would
have if you just had the surgerydone in North America.
Speaker 1 (24:23):
You're 100 percent right.
I have seen multiple versionsof medical tourism patients
either to Florida or to theDominican Republic, latin
America, dominican Republic,latin America.
And, it's funny, most of themwon't go back again, so they've
(24:45):
done it once and then after thatthey will find someone who is
closer to them.
So there are very few patientsI've seen who go multiple,
multiple times back.
Most of the experiences areadverse to some degree either
results, the way they weretreated, the difficulty with it.
You know all of those, you knowthe logistics, like all of
(25:05):
those things are.
It sounds great on paper andthen when they actually go
through it, most patients haverelated yeah, you know, and they
will.
It's so funny cause I'll say,oh, how was the experience?
And they'll say, oh, it wasgreat, and I said, okay, well,
so then why don't you go backfor your next procedure with
them?
And they're like oh, and thenlike some variation of some
(25:28):
excuse comes up and I can tellit's hard for them to own that.
Maybe that wasn't the best ideafor them to have done that, own
that.
Maybe that wasn't the best ideafor them to have done that, and
I'm not pressing them on it,but it is interesting to hear or
see so many patients who'vetried it once but then won't try
it again.
So there's something to thatfor sure.
Speaker 2 (25:49):
Yes, Now I'll also take the flip side of that.
We are seeing the patients whohave problems.
There may be many, many, manypatients who've gone through the
experience and haven't had anyissues, so we never see them
True.
Speaker 1 (26:02):
Very true.
I'm biased, for sure, in termsof what I see.
Speaker 2 (26:09):
One thing that I want to touch on is having multiple
procedures in one setting.
So this patient had rhinoplasty, breast augmentation and
liposuction.
I think one of the thingsthat's important to find out and
learn about this is how muchliposuction did this patient
(26:32):
have?
Because out of those procedures, I think liposuction is
actually the one that has themost potential to cause
physiologic problems in theperioperative period.
How do you feel about that?
Speaker 1 (26:49):
I agree.
I think there can be a lot offluid shifts, volume changes,
with large volume liposuctionthat might potentially need to
be managed.
I think if you're doingposition changes in the
operating room with liposuctionand the patient is under general
anesthesia, that's always achallenge.
(27:09):
I don't think peoplenecessarily think of liposuction
as an arduous or complicatedprocedure but, like you said, it
really depends on the situation.
Speaker 2 (27:25):
That's right, because what patients see is this
little couple tiny incisions.
It's not like some long scar,like a tummy tuck.
So they will equate that to asort of easier or smaller
procedure.
But there are a lot of fluidshifts and for the viewers who
(27:46):
don't know, there's actually aguideline or a limit that the
American Society of PlasticSurgeons puts out as to how much
liposuction you can do in onesetting, and that number is five
liters.
So you know, five liters is apretty large amount and once you
hit five liters therecommendation is that you have
to hospitalize the patient.
(28:06):
And that's because it's beenshown that the complication rate
goes significantly higherbeyond five liters.
So in my practice I never gobeyond five liters.
I try to stay away from thatnumber as much as possible.
And if a patient comes in andthey want to do multiple areas
of liposuction and I think it'sgoing to hit more than five
(28:27):
liters, then I will have adiscussion with them beforehand.
They can either choose to breakit up into two procedures or
we'll get as far as we can andthen before we you know well,
before we get to, or once we'regetting close to that five liter
mark, we will stop.
And then you know, do the restof it at a later date.
Speaker 1 (28:46):
In Florida, I think it's even more restrictive in
terms of doing an abdominoplastyplus liposuction.
I think they restrict theliposuction lipoaspirate to like
one liter with a tummy tuck orsomething like that, just
because they've had so manycomplications in Florida with
large volume liposuction andthen probably other procedures.
(29:07):
So you're right In this case,what they called a Bob lift,
breast augmentation, liposuction, rhinoplasty none of those
procedures themselves areparticularly of issue in and of
themselves, and I have I mean, Iwill say I've never done a bod
lift, I've done breastaugmentation, liposuction in one
(29:29):
sitting.
What are your criteria in termsof combo procedures and when
patients want multiple thingsdone at one time, like how do
you, what are your guidelines orhow do you advise patients on
that?
Speaker 2 (29:45):
So I would say that there's no one specific way you
evaluate it, but in general, oneof the more important things is
how long the surgery is goingto take.
More important things is howlong the surgery is going to
take.
So if a person wants you knowfive procedures done and you
sort of look at it and it'sgoing to be like 10 hours, then
I'm not going to do all thosethings in one sitting.
(30:08):
And that's because the longerthe surgery is, the more
physiologic changes start tooccur.
The patient starts to get thebody temperature starts to drop,
there's more blood lossassociated with it, there's more
fluid shifts associated withthat.
So timing is one thing.
(30:29):
Also, you don't want yoursurgeon to be like exhausted
when they're starting your youknow fourth procedure.
You want your surgeon to befresh and you know I don't want
to your surgeon to be fresh andyou know I don't want to operate
when I'm exhausted either.
So time is one of them.
Also, combination surgeries,where you're going to be really
(30:50):
impeding on their ability toheal postoperatively, I think is
an issue.
For example, if you're doingbrachyplasty, which is arm lift,
and then bilateral verticalthigh lift, which is basically
long incisions on the legs andlong incisions on the arms that
can maybe really impede on thembeing able to move around or do
(31:12):
self-care and hygiene aftersurgery.
So sometimes I will have adiscussion with them.
Sometimes there are practicalreasons, like if I'm doing a
tummy tuck which involves anincision, big incision on the
front, and they also want aBrazilian butt lift, which is
fat ejection in the butt.
(31:33):
That's not a practicalcombination because after the
surgery the patient has tobasically lie on their back and
be sort of the V position sothey don't put too much stress
on the endoplasmic incision.
But then you don't want them tobe sitting on the fat because
that's going to impede on howmuch of the fat will survive
with the BBL.
(31:55):
But I think the main thing isyou know timing.
I also look at blood loss,although traditionally cosmetic
surgery does not have a lot ofblood loss unless you're dealing
with somebody who's bloodreally really large and can
somebody want to contouringprocedures.
So blood loss is another factorto look into.
And then of course, overallhealth status.
Speaker 1 (32:14):
I'm discussing this assuming a healthy patient but
if a patient is older or frailor has systemic medical issues
(32:34):
such as diabetes and things likethat, it's probably is a
challenge in terms of recovery,in terms of positioning.
They end up getting like bodypillows and sort of like on
their side like kind of curledup, and it's not optimal.
You really have to work with apatient to try to get that to
work, but it is always achallenge.
But I agree with you, for meit's operative time.
(32:56):
I mean I was just thinkingabout it when you mentioned it
in this case, I can't rememberthe last time I was operating at
11 pm, like maybe, like I meanthat wasn't in the ER, like or
some kind of like trauma case,like when was the last time you
did an elective case at 11 pm?
Honestly, never, Never Right.
Speaker 2 (33:31):
There's a reason we should not be operating on
elective people at 11 pm, and ifyou are, either you are the
busiest plastic surgeon outthere and you have inexhaustible
energy, or or maybe you startyour day at four o'clock in the
afternoon, or something likethat.
Speaker 1 (33:38):
Yeah, Maybe you're Dracula and you're keeping odd
hours, but on the other I mean,listen, every hospital I've been
to, surgical start time isusually seven 30.
Like we're early morning typepeople.
Uh, the other thing is is haveyou ever partied with a patient
ever prior to any procedure?
Maybe not even the day before,but like ever.
Speaker 2 (33:59):
I have not.
Speaker 1 (34:00):
I have ever partied with a patient ever prior to any
procedure, maybe not even theday before, but like ever, like
I mean, listen, when I was aresident and all that, like
that's a totally differentsituation.
I was 20, in my 20s, I hadlimited, more limited
(34:23):
responsibilities, but as but asan attending, like it's not
awesome, especially for thesetypes of procedures to be out
late at night.
It's so.
It's always funny because Ialways have a patient or two who
will like look at me verycarefully before a surgery and
be like how are you doing?
Are you good?
(34:43):
You have a good night's sleep,do you feel?
Do you feel good?
And I'm always like dude, itwas like I'm a little bit hung
over.
Right, Like that's what I shouldsay, right as a joke, but no, I
mean, I'm always like dude it'smore important for me to feel
good about this than you evenknow.
Like I can't stand not beingoptimized for my procedures, and
(35:05):
so that just makes no sense tome really.
Speaker 2 (35:10):
All right.
So in closing, you know somepatients might wonder OK, well,
if I am going to, if I'm deadset on going out of the country
because I can't afford it anyother way, what are some of the
criteria we should try to lookat if we're choosing a surgeon
outside?
So I have a few that I'velisted here and maybe you can
(35:36):
give some comments on that.
So number one find a reputableplastic surgeon.
Speaker 1 (35:42):
Reputable meaning what?
That they have a millionfollowers on Instagram.
Speaker 2 (35:46):
No, I would say, you know, ideally, american Board of
Plastic Surgery is certified,but it's sort of that, something
equivalent to that in theirhome country, maybe
internationally known,well-published, with multiple
years of experience.
You know, the pitfalls is thatthere may be difficulty to
(36:07):
actually know what thesecredentials are because of
language barriers and, you know,lack of some degree of
transparencies.
Number two facility standards.
Any comments on?
Speaker 1 (36:22):
that yes.
So I don't know how much duediligence you can do for a
facility thousands of miles away.
But yeah, I would assume thatTurkey does have some sort of
(36:49):
regulatory body.
That't be hard for them to findout that a center down there is
not QA certified or haswhatever appropriate
certification.
Speaker 2 (37:00):
Probably you could do something similar for the
country that you're in Right, ormaybe like a larger center,
like a well-known hospital thatthey're at.
That's right, so something likethat.
Just do some diligence on thefacility and then you know who's
doing your anesthesia Ideallyan anesthesiologist and then you
(37:24):
know if not an anesthesiologist, some sort of equivalent to a
nurse anesthetist, some sort ofequivalent to a nurse
anesthetist Barring that if it'smaybe a small procedure, like
at least a nurse administeringsome seduction.
You don't want to be in asituation where the surgeon is
also the person giving youranesthesia.
You want your surgeon to befocused and concentrating on the
(37:47):
surgery and the surgery alone,not also giving something to
knock you out while they'redoing it at the same time.
Speaker 1 (37:57):
If you're doing something big, for sure, if
you're doing IV sedation orgeneral anesthesia, something
more than, say, light sedationit's very important to have
someone who's trainedappropriately, and that's really
hard to find out.
I'm sure that if you ask thesepeople who does your anesthesia
(38:22):
for you, they may give you anykind of answer, and so you know
that that's a tough one.
Yeah, hopefully they'll say ananesthesia off chest and then
one one one would hope, butyou're right Um the way that the
, the surgeon, helps to uh makesure your anesthesia is safe.
Is is critical.
Speaker 2 (38:43):
Yeah, uh, make sure that you know when, when they go
through your consultation, thatthey ask you about your full
medical history, want some bloodwork, maybe EKG, and, as
necessary, get clearance fromyour other doctors, like if you
have some sort of you know heartcondition arrhythmia or you're
on some blood thinners.
(39:03):
You know all those types ofthings are important, are
important.
You know they should be settingrealistic expectations and
really not trying to sell youthe surgery.
They should be telling you howit is, what the complications
are, what the expected outcomesare, based on your particular
(39:25):
anatomy and you know and yourhealth status.
And you know you should bemaybe a little bit concerned if
they think, oh, everything'sgoing to be great, it's going to
be fine, and they don't talkabout any of the potential
downsides to surgery.
Speaker 1 (39:43):
Yeah, I think the biggest thing is and I've heard
this time and time again withpatients who've had not awesome
experiences is that they feltlike there was no due diligence
on the surgeon's part.
They blew through the priormedical history, they blew
through any health issues ormedications and they had some
(40:05):
other person pressuring them toput a deposit down right away
for their procedure.
Like if, if that person isn'tactually taking any time to to
know you as a potential patient,that's a red flag, like you
better not just walk, but youbetter run away from that place,
because every surgeon out therethat is worth their weight and,
(40:29):
as a surgeon, is going to tryto avoid complications, make
sure it goes smoothly, and thenumber one way that we can do
that as surgeons is to know ourpatients.
Make sure we know all of theirmedical history, know everything
that they've talked about.
We just talked about that likebeing truthful, like that's
critical, and if a surgeondoesn't even bother to take the
(40:50):
time to do that before takingyour money, that's that's a huge
problem.
Speaker 2 (40:55):
All right.
And then the last thing is makesure you you portion enough
time to recover before you leave.
Make sure you at least see thepatient and have your stitches
removed before you leave.
I mean, we see patients, we getcalled all the time.
Oh, I had surgery here, Can youtake my stitches out?
I was wondering why they didn'tjust stay a few extra days and
(41:19):
get their stitches out.
That's not just to get thestitches out.
You want the surgeon to see tomake sure you're not having an
infection, your wounds arehealing properly, you're not
having some sort of complicationthat you might not be aware of.
Speaker 1 (41:33):
That is universal.
I can't my office staff have astanding policy.
Now, if someone wants some sortof follow-up after a procedure
that they've had somewhere likein Florida or another country
like that's a hard, no, likethat's a hard, no, like that's a
hard pass.
And the funny thing is is a lotof these surgeons that are from
(41:55):
a distance will instruct theirpatients get on the plane, fly
back.
You can find someone to do this.
It's very simple.
They just have to, like takeout some sutures or do something
like that's part of theirstanding post-op instructions.
And I'm like sutures or dosomething like that's part of
their standing post-opinstructions.
And I'm like, wow, like who hasthe balls to do something like
(42:19):
that?
Like that's crazy, um, to notactually know or care, uh, about
the outcome of your patient inany way.
Speaker 2 (42:23):
Yeah, and, and I just thought of something you know
getting on a plane after you'vehad a major surgery, that
increases your risk of havingDVT, especially if you're doing
some sort of transcontinentalflight.
So you know, if you're going todo it, at least stay there to
recover to a pretty good extentbefore you decide to come back
home.
Agreed, 100%, all right.
(42:45):
So in summary, red flags ifyou're going out of the country
to do surgery.
Red flags are, you know,inadequate board certification
or trainings or equivalent tosomething like American Board of
Plastic Surgery If theprocedure is done in an
unlicensed facility or maybesometimes in a hotel.
(43:07):
Having multiple procedures donein one setting for example,
getting a BBL, a tummy tuck,lipo 360 and breast augmentation
lift in one setting that isprobably not a smart strategy to
go with Very short post-opstays.
So make you know, make surethat your surgeon is going to
see you afterwards to make sureyou're okay before you leave.
(43:28):
No anesthesiologist, especiallyin any of these standard
procedures that require you togo into general anesthesia or
even deep sedation.
Smaller procedures maybe it'sacceptable If the clinic refuses
to answer detailed questionsbeforehand.
Or maybe you know you want toknow more about it and they sort
(43:50):
of gloss over all the potentialrisks and complications.
And then, lastly, if the priceis too cheap, if the price seems
too good to be true, you knowthey have to be cutting corners
in some aspect.
Speaker 1 (44:07):
Larry, that's such a great summary.
Agree with a thousand percentwith everything you just said.
I think everyone who'sconsidering something similar to
what Miss Boldrini did shouldtake that to heart.
Yeah, 100% agree and make surethat they avoid such a tragic
(44:56):
potential risk.
100% agree, yeah, thank you somuch, larry.
Until next time, man.
Hello and welcome to another episode of Botox and
Burpees.
I'm your host, sam Rhee, and Ihave with me special guest Dr
Lawrence Tong from TorontoCanada.
What's your Instagram handleagain, larry?
Speaker 2 (00:18):
At Yorkville Plastic Surgery at Yorkville Plastic
Surgery.
Speaker 1 (00:22):
One of the most talented plastic surgeons I know
trained with him at Universityof Michigan.
He's killing it for all facetsof plastic surgery and, as I
mentioned in our previousepisode, our esteemed podcast
Three Plastic Surgeons and aFourth is currently on hiatus,
so I thought I'd bring Larry onBotox and Burpee so we could
(00:43):
talk about a very tragic storythat just recently happened.
There was a 31-year-oldinfluencer, anna Barbara
Bohr-Boldrini, who died after aseries of cosmetic procedures in
Turkey, and her circumstancesin terms of her passing is
pretty tragic, and I think thatthere's a lot that we can learn,
(01:04):
both as surgeons and patients,in terms of unpacking this to
make sure that our patients aresafe and that plastic surgeons
are following best practices interms of what they do.
So, before we get into it,larry, if you could give us our
disclaimer?
Speaker 2 (01:22):
My pleasure.
So this show is forinformational purposes only.
Treatment and results may varybased upon the circumstances,
situation and medical judgment.
After appropriate discussion,Always seek the advice of your
surgeon or other qualifiedhealth provider with any
questions you may have regardingmedical care.
Never disregard professionalmedical advice or delay seeking
advice because of something onthis show.
(01:42):
So tell us about thecircumstances with Anna Barbara.
All right medical advice ordelay seeking advice because of
something on this show.
So tell us about thecircumstances with Anna Barbara,
all right so Barbara Baldriniis a was a 31 year old female
influencer from Brazil, and sheand her husband had traveled to
Istanbul, Turkey, to have aseries of cosmetic procedures
(02:03):
with the understanding that shewould be promoting the hospital
where she was having the surgery.
It's reported that thesurgeries that she underwent
were breast augmentation,rhinoplasty and liposuction,
although they did not elucidatehow much liposuction was done,
which might be important.
The surgery occurred on June15th and it's reported that this
(02:26):
occurred hours after her andher husband had quote-unquote
partied with the surgeon who wasperforming the procedure.
The husband states that theprocedure ended at 11 pm, which
is, in my opinion, sort of lateto end surgery, and the
assistants told him that she wasrecovering from anesthesia and
(02:49):
showed him a photo of herrecovering, but then, sadly, one
hour later, the surgeon cameout and told him that her heart
was beating slowly, whileanother surgeon told him that
she had died.
It's reported that she had diedof cardiac arrest and obviously
the husband is very upset aboutthis and he's saying that she
(03:14):
was not prepared adequately forthe surgery.
One of the things that he notedwas that she was not NPO, which
means she had still beeningesting food prior to surgery
and that her surgery had beenmoved up, actually two days
(03:34):
earlier than was scheduledbecause of quote unquote
scheduling issues.
So there are pertinent topicsthat we should discuss, but it
is important to note that we donot know the entire story and
all the facts about whathappened, so some things are
unclear.
But this discussion is aroundimportant topics surrounding
(03:58):
this tragedy how things shouldideally take place, and you know
what are the particular issuesregarding having surgery in a
foreign country, having socialmedia mixed in with the aspect
of having surgery, and safety insurgery.
(04:21):
So I'll start off with talkingabout the fact that she had a
cardiac arrest.
That's how it's been reportedin the news.
There has not been furtherinformation about that, but
there are, you know, tragically,times when this can occur, and
(04:43):
so, as a patient, you might bewondering well, you know, what
can I do to minimize that risk?
Because you know, with allsurgery, there's going to be the
potential for complications.
There's no way to get around it.
But there are things that canbe done to, you know, minimize
the risk, and there are thingsthat the surgeon is responsible
(05:07):
for, but there are also thingsthat the patient has some
responsibility in as well.
Absolutely.
Speaker 1 (05:17):
And you mentioned, there are always risks
associated, potentially, withsurgery, and choosing the right
people that you feel comfortablewith to perform your anesthesia
, to perform your surgery, playsa large part of it, and that's
something that we might talkabout in terms of how she
(05:38):
traveled, how she chose thisparticular group or surgeon.
But you're right, there arethings that patients can do also
to make sure that they staysafe during the procedure as
well as after.
So what are some of the thingsthat people should know about in
terms of trying to stay safe?
Speaker 2 (05:59):
So one of the things that you know every patient is
told before they have surgeryand if our viewers have ever had
surgery they probably told younothing to eat or drink after
midnight.
Then that's often referred to asNPO after midnight, and there's
a reason for that and that thereason for that is because when
(06:21):
you are put under generalanesthesia is because when you
are put under general anesthesiayou should have an empty
stomach.
If you've eaten just before youhave anesthesia and you have
food in your stomach, the riskis that you might aspirate.
Aspiration means the food fromthe stomach comes up through
(06:43):
your esophagus and then goesback down into your lungs, which
can cause pneumonia and you candie from that.
So that is a very basic thingthat every surgeon will instruct
you to do, and so it'simportant.
If a surgeon instructs you tonot eat or drink after a certain
time period, you should reallyfollow that advice, because that
is very, very important and ingeneral, unless it's an
(07:06):
emergency, if we know about apatient who's eaten, who's ate
or drank before surgery, we will, you know, we will cancel their
case for that day because thesafety aspect is that important.
Speaker 1 (07:19):
Absolutely.
I have known people who havenot been truthful about that and
they put themselves at enormousrisk because those stomach
contents, if they go into yourtrachea, into your lungs, it's
very acidic.
This stuff is all filled withyour stomach acid and you're
going to have huge problems, asyou mentioned, with pneumonia,
(07:43):
with lung damage, potentiallydeath.
And if you wonder, well, howabout trauma surgery or some
situation where people are notwithout empty stomachs, well
then the anesthesiologistsperform a slightly riskier type
of procedure called rapidsequence intubation, where they
(08:05):
are trying to minimize that riskof people aspirating stomach
contents into their lungs.
So that's something that Ihaven't.
I mean, I can't remember thelast time I saw a rapid sequence
intubation I think it wasprobably residency on the
general surgery service ontrauma, like that's sort of what
, and that's not a greatsituation to be in.
Speaker 2 (08:28):
How do you and that is not something that you should
be doing in a cosmetic practicethat?
is exactly right, you shouldnever be in that situation.
So any kind of you knowintubation should have the
proper protocol in place andhaving the steps in place before
doing the surgery.
So I think that if it's truethat that patient did not follow
(08:51):
NPO before the surgery, I wouldnot have done that surgery.
What else so related to that isactually, you know, some of the
drugs that you take that apatient might take.
So one of them is Ozempic.
So Ozempic is very popular,especially amongst the cosmetic
(09:12):
surgery population, and one ofthe things that Ozempic does is
it slows down gastric emptying.
That means the rate at whichfood leaves your GI system is
slowed down a lot.
And if you are taking Ozempic,even if you have stopped eating
the night before, that isgenerally not enough time to
(09:34):
minimize your risk of aspiration.
So some people are on Ozempicand because it's to the point
where it's so commonplace, theymight not even mention that
they're taking it, or they'remaybe taking an Ozempic sort of
copycat and they don't thinkit's really like taking a drug.
(09:54):
So if you are on Ozempic, youdefinitely need to tell your
surgeon that you are on it,because we usually stop that
medication about two or eventhree weeks before a patient
goes under general anesthesia.
Speaker 1 (10:08):
Yeah, and there's so many variations.
Now there's Zepbound, monjaro,you name it.
There are so many differentGLP-1 type agonists that, like
you said, and a lot of them arejust intermittent injections,
they're not daily pills oranything.
So people might even forgetthat this is quote, a drug that
might affect their procedure.
(10:28):
And you're right, I probablysee.
Now I don't know what would yousay.
I would say maybe for my bodycontouring.
I would say at least a third ofthose patients are on some sort
of, or have tried a GLP-1agonist.
Speaker 2 (10:41):
Yeah, I don't know if the number is that high in my
practice, but it is somewheremaybe in my practice around 10
or 15 percent, something likethat.
So it's not unusual at all.
Diuretics so diuretics is amedication that you take to get
(11:10):
rid of fluid in your body and itis primarily used for patients
with high blood pressure orheart disease.
But patients also take it tomake themselves look thinner so
that they don't look soquote-unquote bloated.
And using that medicationmesses with your fluid balance
and can mess with yourelectrolyte imbalance.
So it's also very important toinform your physician if you're
(11:35):
taking that kind of medication.
And there are other kinds ofdrugs that are not
pharmaceuticals but recreationaldrugs that are important for
you to tell your doctor, such asyou know if you use cocaine.
That is a very high risk thingto take if you're having surgery
in the near future.
Speaker 1 (11:58):
Yeah, it's funny, we have several menstrual cramping
medications in our household,mainly because not for me, but
for other members of myhousehold, like my daughter and
I looked at the ingredients anda lot of them contain diuretics.
So not only do they containsome sort of pain medication for
(12:22):
menstrual cramping, but theyalso have these pretty powerful
water treatments to addresswater retention, and so people
might not even think a Midol ora Pamprin or something like that
is a real medication.
But yes, definitely you got tolet your surgeon know, because
(12:44):
if you're dehydrated and you gointo a procedure, that could
definitely adversely affect yoursystem.
Speaker 2 (12:53):
Yes.
And then the last thing is yourgeneral medical history.
It's actually pretty commonthat patients don't tell me what
cosmetic procedures they've hadwhen they come in, and then
when I look at them, I can youknow.
When I examine them, I can tellthem and, if that's okay, did
you have this done?
You know they have a scar orsomething like that which makes
it obvious.
So having prior surgery affectshow your surgeon may approach
(13:19):
any future surgery, especiallyif it's in the same area.
So I think that's importantbecause in general it's not
going to be as easy the secondor third time as it was the
first time, and you should youknow for your own safety and
interest.
You should tell your surgeon ifyou've had surgery before in
those particular areas and, inaddition to that, if you have
(13:39):
any other medical conditions,especially related to your lungs
or your heart, or you knowstrokes or history of anesthetic
complications or blood clots.
All those things are veryimportant.
So I guess it's very, it's very, very important that you be
(14:02):
truthful with your surgeon,because it's only going to help
you in the long run.
Speaker 1 (14:09):
It can be embarrassing to disclose
everything to somebody, but inthese cases I think people have
to take their.
You know, be courageous, telleverything, and sometimes people
forget.
I cannot like.
Last week I had someone whocame in for a tummy tuck forgot
everything, and sometimes peopleforget.
I cannot like.
Last week I had someone whocame in for a tummy tuck forgot
that she had liposuction.
(14:29):
We screened her twice, wetalked to her on the phone, then
my medical assistant talked toher before I saw her and it was
only after about 15 minutes oftalking.
She's like oh yeah, by the way,I also have liposuction, in
addition to, you know, whateverhysterectomy or gallbladder
surgery or whatever else shetold us about.
So, yeah, like, take, take asecond and sort of think about
(14:54):
your medical history.
I know you feel like you knowall this stuff is not something
that is that important, but itis very, very, very, very
important for you to get thebest results for your outcome.
Speaker 2 (15:09):
Yeah, I think you tell us what you've had or what
your history is, and we'lldecide if it's important or not.
Speaker 1 (15:16):
Right.
So what else do you want totalk about with Boldrini right
now?
Speaker 2 (15:20):
All right.
So I want to talk about peoplewho go to other countries to
have surgery, often known asmedical tourism.
So in general, there are issuesrelated to that, and that's not
to say that every foreigncountry is bad compared to North
(15:47):
America.
And you shouldn't go tointernational surgeons, because
there are many, many excellent,well-trained, world-renowned,
you know, respected surgeons.
But patients have to do theirdue diligence because it's not
(16:09):
the same as in North America.
I think that, in my opinion,north America has the highest
standards for physician trainingand for regulation and
licensing of facilities andlicensing of facilities.
And so you know, if a patientis thinking about medical
(16:29):
tourism, they have to be extracareful in choosing who they're
going to and what countrythey're going to.
And you just have to look atall of those things From a
training standpoint.
In the United States and Canada,plastic surgeon trains from
anywhere from five to sevenyears and then goes to have
(16:53):
board certification, which is arigorous type of examination to
make sure that the surgeon issort of up to snuff to do the
surgery.
Surgeons in the United Statesand Canada have to operate in an
accredited facility.
That means a place where theydo the surgery which has
(17:17):
standards, that is, you know,recognized by certain regulatory
groups.
And in North America, you know,each jurisdiction has a strong
medical board, which means thatthey conduct surgeon licensing
(17:38):
and patient complaints andinvestigations.
So patients have, you know,strong legal system and
protections with surgery, and soin other countries not all of
these safeguards are in place.
Speaker 1 (17:51):
I think there are two things I think about when I
think about these types ofissues associated with medical
tourism.
The first is is you'reabsolutely right, there are
great surgeons everywhere, butthe biggest thing that I have
seen for patients who gosomewhere outside of their own
country for surgery is cost.
It is generally expensive inNorth America to have aesthetic
(18:17):
surgery procedures, and sothey're looking for a cheaper
way of doing it, and that isvery popular for a lot of types
of procedures, especially hairtransplantation.
In Turkey, what Ms Baldriniwent through, there was
something like 2 millionvisitors that went to Turkey
(18:40):
last year in 2024.
Speaker 2 (18:42):
That's like $12 billion and the reason is is
that the cost so two millionpeople who went for surgery, you
mean.
Speaker 1 (18:49):
Yes, two million people went for surgery and it
was like a $12 billion industryin Turkey right now for medical
tourism, and so the cost is sucha powerful draw factor for so
many people.
But that doesn't mean that youare absolved of your
responsibility of finding theright person.
In fact, it's probably evenmore so, and the issue is is
(19:10):
that a lot of it is based on, uh, social media or other issues,
like I understand that peopledon't want to delve into the
regulatory or certification sortof aspects of stuff very boring
, not exciting, doesn't make anydifference like and and I agree
it doesn't necessarily.
if people will argue thatdoesn't mean that that person is
(19:32):
a great surgeon, that is true.
Just because you have yourdriver's license does not mean
you're a great driver.
However, you probably are goingto be a safer driver than
someone who does not have theirdriver's license in general.
So there are some minimumstandards there.
That's what you can think of itas, and then you have to find
someone that you think is goingto do a great job, but social
(19:53):
media from someone 5,000 milesaway is probably not going to
give you necessarily an accuratepicture.
I don't know how Ms Baldrinipicked this particular surgeon.
Some negative publicity orincidents was literally trading
(20:18):
procedures for social mediaexposure.
And how do you feel about thatas a plastic surgeon?
Speaker 2 (20:27):
Well, it's sort of a slippery slope because once you
have that aspect involved, it'snot the norm, that aspect
involved it's not the norm, andsometimes you don't treat the
patient as your typical patient,which is something you should
absolutely not do.
You should be treating patientsall you know, equally, with the
(20:51):
same degree of safety, with thesame protocols.
Safety with the same protocols.
Because if you deviate fromthat, that's when you run the
risk of you know complicationshappening, such as you know
(21:14):
having you know drinks orpartying with the patient prior.
The surgeon might have feltthat you know this is something
to gain favor, or you knowsomething that that surgeon
probably would not have done ifit was just a sort of a regular
patient that he was going to doon a Tuesday.
And so it's an issue becausethe incentive is very strong.
(21:38):
When you have somebody who isan influencer and this patient
had, I think, 800,000subscribers then that draw can
be something that clouds yourjudgment.
Speaker 1 (21:54):
Absolutely I.
Always it makes me wonder, likeyou said, they are providing
their services for free.
Did that alter how they managethis particular patient, why
they push this patient two dayssooner, why they, you know,
didn't weren't allegedlyconcerned about the NPO status
(22:15):
of this patient, like all ofthose things are are brought
into question when you look atthe transactional nature of this
surgeon patient relationshipwhich, as you said, is that's.
That's very concerning.
I don't, I've never, ever donesomething like that and I I
don't think I would ever want todo something like that.
(22:38):
But even if you did, let'ssuppose were a surgeon who did
something like this.
Like you said, that patient hasto be treated just like every
other patient, whether they'repaying zero or a million dollars
, whatever it is like thattreatment has to be top-notch
regardless.
Speaker 2 (22:57):
Yes, and another issue with medical tourism is
from a logistic point of view.
What if you have a complicationafter you've flown back to the
United States?
What if you're not happy withhow the procedure has turned out
?
With how the procedure hasturned out, those things are
(23:19):
difficult to treat, even in mypatients who maybe come from
cities further away or even fromdifferent provinces.
It is exponentially moredifficult when it's in a
different continent and you know, unless you're Turkish, you
don't even understand thelanguage.
There's a big language barrieras well with that.
(23:40):
So if a patient is going toconsider having surgery, as you
said, price is a big driver, butyou have to think about the
whole picture.
If you end up having acomplication and you need
surgery, then you're eitherstuck with accepting the
(24:02):
appearance that you don't like,or you have to take a plane back
to Turkey, if they're evenwilling to do more surgery on
you, or you have to find asurgeon where you live and then
at that point your savings fromthe original surgery are
probably erased and you'reprobably paying more than would
have if you just had the surgerydone in North America.
Speaker 1 (24:23):
You're 100 percent right.
I have seen multiple versionsof medical tourism patients
either to Florida or to theDominican Republic, latin
America, dominican Republic,latin America.
And, it's funny, most of themwon't go back again, so they've
(24:45):
done it once and then after thatthey will find someone who is
closer to them.
So there are very few patientsI've seen who go multiple,
multiple times back.
Most of the experiences areadverse to some degree either
results, the way they weretreated, the difficulty with it.
You know all of those, you knowthe logistics, like all of
(25:05):
those things are.
It sounds great on paper andthen when they actually go
through it, most patients haverelated yeah, you know, and they
will.
It's so funny cause I'll say,oh, how was the experience?
And they'll say, oh, it wasgreat, and I said, okay, well,
so then why don't you go backfor your next procedure with
them?
And they're like oh, and thenlike some variation of some
(25:28):
excuse comes up and I can tellit's hard for them to own that.
Maybe that wasn't the best ideafor them to have done that, own
that.
Maybe that wasn't the best ideafor them to have done that, and
I'm not pressing them on it,but it is interesting to hear or
see so many patients who'vetried it once but then won't try
it again.
So there's something to thatfor sure.
Speaker 2 (25:49):
Yes, Now I'll also take the flip side of that.
We are seeing the patients whohave problems.
There may be many, many, manypatients who've gone through the
experience and haven't had anyissues, so we never see them
True.
Speaker 1 (26:02):
Very true.
I'm biased, for sure, in termsof what I see.
Speaker 2 (26:09):
One thing that I want to touch on is having multiple
procedures in one setting.
So this patient had rhinoplasty, breast augmentation and
liposuction.
I think one of the thingsthat's important to find out and
learn about this is how muchliposuction did this patient
(26:32):
have?
Because out of those procedures, I think liposuction is
actually the one that has themost potential to cause
physiologic problems in theperioperative period.
How do you feel about that?
Speaker 1 (26:49):
I agree.
I think there can be a lot offluid shifts, volume changes,
with large volume liposuctionthat might potentially need to
be managed.
I think if you're doingposition changes in the
operating room with liposuctionand the patient is under general
anesthesia, that's always achallenge.
(27:09):
I don't think peoplenecessarily think of liposuction
as an arduous or complicatedprocedure but, like you said, it
really depends on the situation.
Speaker 2 (27:25):
That's right, because what patients see is this
little couple tiny incisions.
It's not like some long scar,like a tummy tuck.
So they will equate that to asort of easier or smaller
procedure.
But there are a lot of fluidshifts and for the viewers who
(27:46):
don't know, there's actually aguideline or a limit that the
American Society of PlasticSurgeons puts out as to how much
liposuction you can do in onesetting, and that number is five
liters.
So you know, five liters is apretty large amount and once you
hit five liters therecommendation is that you have
to hospitalize the patient.
(28:06):
And that's because it's beenshown that the complication rate
goes significantly higherbeyond five liters.
So in my practice I never gobeyond five liters.
I try to stay away from thatnumber as much as possible.
And if a patient comes in andthey want to do multiple areas
of liposuction and I think it'sgoing to hit more than five
(28:27):
liters, then I will have adiscussion with them beforehand.
They can either choose to breakit up into two procedures or
we'll get as far as we can andthen before we you know well,
before we get to, or once we'regetting close to that five liter
mark, we will stop.
And then you know, do the restof it at a later date.
Speaker 1 (28:46):
In Florida, I think it's even more restrictive in
terms of doing an abdominoplastyplus liposuction.
I think they restrict theliposuction lipoaspirate to like
one liter with a tummy tuck orsomething like that, just
because they've had so manycomplications in Florida with
large volume liposuction andthen probably other procedures.
(29:07):
So you're right In this case,what they called a Bob lift,
breast augmentation, liposuction, rhinoplasty none of those
procedures themselves areparticularly of issue in and of
themselves, and I have I mean, Iwill say I've never done a bod
lift, I've done breastaugmentation, liposuction in one
(29:29):
sitting.
What are your criteria in termsof combo procedures and when
patients want multiple thingsdone at one time, like how do
you, what are your guidelines orhow do you advise patients on
that?
Speaker 2 (29:45):
So I would say that there's no one specific way you
evaluate it, but in general, oneof the more important things is
how long the surgery is goingto take.
More important things is howlong the surgery is going to
take.
So if a person wants you knowfive procedures done and you
sort of look at it and it'sgoing to be like 10 hours, then
I'm not going to do all thosethings in one sitting.
(30:08):
And that's because the longerthe surgery is, the more
physiologic changes start tooccur.
The patient starts to get thebody temperature starts to drop,
there's more blood lossassociated with it, there's more
fluid shifts associated withthat.
So timing is one thing.
(30:29):
Also, you don't want yoursurgeon to be like exhausted
when they're starting your youknow fourth procedure.
You want your surgeon to befresh and you know I don't want
to your surgeon to be fresh andyou know I don't want to operate
when I'm exhausted either.
So time is one of them.
Also, combination surgeries,where you're going to be really
(30:50):
impeding on their ability toheal postoperatively, I think is
an issue.
For example, if you're doingbrachyplasty, which is arm lift,
and then bilateral verticalthigh lift, which is basically
long incisions on the legs andlong incisions on the arms that
can maybe really impede on thembeing able to move around or do
(31:12):
self-care and hygiene aftersurgery.
So sometimes I will have adiscussion with them.
Sometimes there are practicalreasons, like if I'm doing a
tummy tuck which involves anincision, big incision on the
front, and they also want aBrazilian butt lift, which is
fat ejection in the butt.
(31:33):
That's not a practicalcombination because after the
surgery the patient has tobasically lie on their back and
be sort of the V position sothey don't put too much stress
on the endoplasmic incision.
But then you don't want them tobe sitting on the fat because
that's going to impede on howmuch of the fat will survive
with the BBL.
(31:55):
But I think the main thing isyou know timing.
I also look at blood loss,although traditionally cosmetic
surgery does not have a lot ofblood loss unless you're dealing
with somebody who's bloodreally really large and can
somebody want to contouringprocedures.
So blood loss is another factorto look into.
And then of course, overallhealth status.
Speaker 1 (32:14):
I'm discussing this assuming a healthy patient but
if a patient is older or frailor has systemic medical issues
(32:34):
such as diabetes and things likethat, it's probably is a
challenge in terms of recovery,in terms of positioning.
They end up getting like bodypillows and sort of like on
their side like kind of curledup, and it's not optimal.
You really have to work with apatient to try to get that to
work, but it is always achallenge.
But I agree with you, for meit's operative time.
(32:56):
I mean I was just thinkingabout it when you mentioned it
in this case, I can't rememberthe last time I was operating at
11 pm, like maybe, like I meanthat wasn't in the ER, like or
some kind of like trauma case,like when was the last time you
did an elective case at 11 pm?
Honestly, never, Never Right.
Speaker 2 (33:31):
There's a reason we should not be operating on
elective people at 11 pm, and ifyou are, either you are the
busiest plastic surgeon outthere and you have inexhaustible
energy, or or maybe you startyour day at four o'clock in the
afternoon, or something likethat.
Speaker 1 (33:38):
Yeah, Maybe you're Dracula and you're keeping odd
hours, but on the other I mean,listen, every hospital I've been
to, surgical start time isusually seven 30.
Like we're early morning typepeople.
Uh, the other thing is is haveyou ever partied with a patient
ever prior to any procedure?
Maybe not even the day before,but like ever.
Speaker 2 (33:59):
I have not.
Speaker 1 (34:00):
I have ever partied with a patient ever prior to any
procedure, maybe not even theday before, but like ever, like
I mean, listen, when I was aresident and all that, like
that's a totally differentsituation.
I was 20, in my 20s, I hadlimited, more limited
(34:23):
responsibilities, but as but asan attending, like it's not
awesome, especially for thesetypes of procedures to be out
late at night.
It's so.
It's always funny because Ialways have a patient or two who
will like look at me verycarefully before a surgery and
be like how are you doing?
Are you good?
(34:43):
You have a good night's sleep,do you feel?
Do you feel good?
And I'm always like dude, itwas like I'm a little bit hung
over.
Right, Like that's what I shouldsay, right as a joke, but no, I
mean, I'm always like dude it'smore important for me to feel
good about this than you evenknow.
Like I can't stand not beingoptimized for my procedures, and
(35:05):
so that just makes no sense tome really.
Speaker 2 (35:10):
All right.
So in closing, you know somepatients might wonder OK, well,
if I am going to, if I'm deadset on going out of the country
because I can't afford it anyother way, what are some of the
criteria we should try to lookat if we're choosing a surgeon
outside?
So I have a few that I'velisted here and maybe you can
(35:36):
give some comments on that.
So number one find a reputableplastic surgeon.
Speaker 1 (35:42):
Reputable meaning what?
That they have a millionfollowers on Instagram.
Speaker 2 (35:46):
No, I would say, you know, ideally, american Board of
Plastic Surgery is certified,but it's sort of that, something
equivalent to that in theirhome country, maybe
internationally known,well-published, with multiple
years of experience.
You know, the pitfalls is thatthere may be difficulty to
(36:07):
actually know what thesecredentials are because of
language barriers and, you know,lack of some degree of
transparencies.
Number two facility standards.
Any comments on?
Speaker 1 (36:22):
that yes.
So I don't know how much duediligence you can do for a
facility thousands of miles away.
But yeah, I would assume thatTurkey does have some sort of
(36:49):
regulatory body.
That't be hard for them to findout that a center down there is
not QA certified or haswhatever appropriate
certification.
Speaker 2 (37:00):
Probably you could do something similar for the
country that you're in Right, ormaybe like a larger center,
like a well-known hospital thatthey're at.
That's right, so something likethat.
Just do some diligence on thefacility and then you know who's
doing your anesthesia Ideallyan anesthesiologist and then you
(37:24):
know if not an anesthesiologist, some sort of equivalent to a
nurse anesthetist, some sort ofequivalent to a nurse
anesthetist Barring that if it'smaybe a small procedure, like
at least a nurse administeringsome seduction.
You don't want to be in asituation where the surgeon is
also the person giving youranesthesia.
You want your surgeon to befocused and concentrating on the
(37:47):
surgery and the surgery alone,not also giving something to
knock you out while they'redoing it at the same time.
Speaker 1 (37:57):
If you're doing something big, for sure, if
you're doing IV sedation orgeneral anesthesia, something
more than, say, light sedationit's very important to have
someone who's trainedappropriately, and that's really
hard to find out.
I'm sure that if you ask thesepeople who does your anesthesia
(38:22):
for you, they may give you anykind of answer, and so you know
that that's a tough one.
Yeah, hopefully they'll say ananesthesia off chest and then
one one one would hope, butyou're right Um the way that the
, the surgeon, helps to uh makesure your anesthesia is safe.
Is is critical.
Speaker 2 (38:43):
Yeah, uh, make sure that you know when, when they go
through your consultation, thatthey ask you about your full
medical history, want some bloodwork, maybe EKG, and, as
necessary, get clearance fromyour other doctors, like if you
have some sort of you know heartcondition arrhythmia or you're
on some blood thinners.
(39:03):
You know all those types ofthings are important, are
important.
You know they should be settingrealistic expectations and
really not trying to sell youthe surgery.
They should be telling you howit is, what the complications
are, what the expected outcomesare, based on your particular
(39:25):
anatomy and you know and yourhealth status.
And you know you should bemaybe a little bit concerned if
they think, oh, everything'sgoing to be great, it's going to
be fine, and they don't talkabout any of the potential
downsides to surgery.
Speaker 1 (39:43):
Yeah, I think the biggest thing is and I've heard
this time and time again withpatients who've had not awesome
experiences is that they feltlike there was no due diligence
on the surgeon's part.
They blew through the priormedical history, they blew
through any health issues ormedications and they had some
(40:05):
other person pressuring them toput a deposit down right away
for their procedure.
Like if, if that person isn'tactually taking any time to to
know you as a potential patient,that's a red flag, like you
better not just walk, but youbetter run away from that place,
because every surgeon out therethat is worth their weight and,
(40:29):
as a surgeon, is going to tryto avoid complications, make
sure it goes smoothly, and thenumber one way that we can do
that as surgeons is to know ourpatients.
Make sure we know all of theirmedical history, know everything
that they've talked about.
We just talked about that likebeing truthful, like that's
critical, and if a surgeondoesn't even bother to take the
(40:50):
time to do that before takingyour money, that's that's a huge
problem.
Speaker 2 (40:55):
All right.
And then the last thing is makesure you you portion enough
time to recover before you leave.
Make sure you at least see thepatient and have your stitches
removed before you leave.
I mean, we see patients, we getcalled all the time.
Oh, I had surgery here, Can youtake my stitches out?
I was wondering why they didn'tjust stay a few extra days and
(41:19):
get their stitches out.
That's not just to get thestitches out.
You want the surgeon to see tomake sure you're not having an
infection, your wounds arehealing properly, you're not
having some sort of complicationthat you might not be aware of.
Speaker 1 (41:33):
That is universal.
I can't my office staff have astanding policy.
Now, if someone wants some sortof follow-up after a procedure
that they've had somewhere likein Florida or another country
like that's a hard, no, likethat's a hard, no, like that's a
hard pass.
And the funny thing is is a lotof these surgeons that are from
(41:55):
a distance will instruct theirpatients get on the plane, fly
back.
You can find someone to do this.
It's very simple.
They just have to, like takeout some sutures or do something
like that's part of theirstanding post-op instructions.
And I'm like sutures or dosomething like that's part of
their standing post-opinstructions.
And I'm like, wow, like who hasthe balls to do something like
(42:19):
that?
Like that's crazy, um, to notactually know or care, uh, about
the outcome of your patient inany way.
Speaker 2 (42:23):
Yeah, and, and I just thought of something you know
getting on a plane after you'vehad a major surgery, that
increases your risk of havingDVT, especially if you're doing
some sort of transcontinentalflight.
So you know, if you're going todo it, at least stay there to
recover to a pretty good extentbefore you decide to come back
home.
Agreed, 100%, all right.
(42:45):
So in summary, red flags ifyou're going out of the country
to do surgery.
Red flags are, you know,inadequate board certification
or trainings or equivalent tosomething like American Board of
Plastic Surgery If theprocedure is done in an
unlicensed facility or maybesometimes in a hotel.
(43:07):
Having multiple procedures donein one setting for example,
getting a BBL, a tummy tuck,lipo 360 and breast augmentation
lift in one setting that isprobably not a smart strategy to
go with Very short post-opstays.
So make you know, make surethat your surgeon is going to
see you afterwards to make sureyou're okay before you leave.
(43:28):
No anesthesiologist, especiallyin any of these standard
procedures that require you togo into general anesthesia or
even deep sedation.
Smaller procedures maybe it'sacceptable If the clinic refuses
to answer detailed questionsbeforehand.
Or maybe you know you want toknow more about it and they sort
(43:50):
of gloss over all the potentialrisks and complications.
And then, lastly, if the priceis too cheap, if the price seems
too good to be true, you knowthey have to be cutting corners
in some aspect.
Speaker 1 (44:07):
Larry, that's such a great summary.
Agree with a thousand percentwith everything you just said.
I think everyone who'sconsidering something similar to
what Miss Boldrini did shouldtake that to heart.
Yeah, 100% agree and make surethat they avoid such a tragic
(44:56):
potential risk.
100% agree, yeah, thank you somuch, larry.
Until next time, man.
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