INDIANA UNIVERSITY MEDICAL CENTER DIVISION OF PLASTIC SURGERY MERIDIAN NOTE PATIENT NAME: Lucille Iacovelli DATE: 2-21-01 Lucille is a 48 (my correction: 51) year old female who presents for consideration for facial surgery. She has significant aesthetic facial surgery history. In 1997 she underwent an initial facelift followed 6 weeks later by a rhinoplasty both of which were performed by the same surgeon in Boston. According to her, her postoperative course was complicated after by tremendous facial swelling which she feels occurred due to the use of the tumescent technique for hydrodissection of her facelift. Her subsequent rhinoplasty was then followed by an inordinate amount of facial swelling which resulted very quickly and a considerable of postoperative skin elasticity of which she has never recovered. i have had the opportunity before today of to have discussions with her several times by email and by phone as well as l have received a 2 inch thick portfolio of facial photographs which documents in great detail and number her preoperative to her postoperative course to the present time. Therefore I have had some significant insight into her problem before today. When asked to list the areas that bother her in order of priority she has come up with the following list which includes: 1 . The down turning and stretched out look of her commissures which creates a significant postoperative difference in her smile. 2. The feeling that she has excess skin and that the skin is not really attached to the underlying bone. I believe this represents the fair amount of skin elasticity that she has. 3. She is bothered by the appearance of her eyes and neck which appears to be relatively straightforward aging concerns. 4. The sunken appearance to her cheek and lateral facial areas. On examination she has well-healed preauricular scars which go in the standard fashion with exception of that they run in front of the tragus and they block out the hairline running with step excision running horizontally across the preauricular hairline and then in front of the temporal hairline just above the level of the lateral canthus. Palpation of her overall skin demonstrates that it is fairly thin and there is not a lot of substance of soft tissue, particularly in the lateral facial area to the ,underlying bone. She has very prominent nasolabial crease with falling over the superior skin. Her overall skin quality is modestly thin and she has a fair amount of pitied acne scars throughout the cheek areas as well as multiple areas of hyopigmented scars throughout the neck areas. After a 2-hour discussion with her we both agreed to an overall treatment plan. This includes an initial nasolabial fold excision with simultaneous corner of the mouth lift. She has read a great deal particularly about these procedures and is well aware of the resultant scars of which she is very willing to accept. A second stage would then be, followed by a full facelift with platysmal plication through a submental incision of which she has not had before. In addition, she did ask about and showed an article connecting the lateral canthal incision from the lower blepharoplasties to her temporal line. She feels that this is a good procedure and is willing to accept the scar in an effort to get rid of more the skin in this direction. Having discussed this her this is not an unreasonable request given that the distance between the 2 is only about 15 mms. While it is an unusual place to place a scar, she has researched this out and has found an article which does report it being done. She again is aware of the resultant scar, is aware according the article that the majority of the patients were not happy with result, and she still desires to precede with it. l agreed that l would consider this option on an lntraoperative basis and would use it only if l felt the redundant skin in that area would merit the scar and could be improved by its placement. After our very lengthy discussion, l have asked her to put more thought into it and then get back to me in regards to scheduling. She is interested in scheduling the first stage within the next several weeks. Barry L.. Eppley, M.D., D.M.D.
http://groups.msn.com/LosingFace/dreppleysresponse.msnwhttp://groups.msn.com/LosingFace/aftertheoperation.msnwhttp://groups.msn.com/LosingFace/immediatedenial.msnwhttp://groups.msn.com/LosingFace/dreppleysoperativereport4182001.msnwhttp://groups.msn.com/LosingFace/omittedmostimportantpartofoperation.msnwhttp://groups.msn.com/LosingFace/neveransweredthisormanyotherquestions.msnwhttp://groups.msn.com/LosingFace/emailtodreppleyoneyearlater.msnwhttp://groups.msn.com/LosingFace/mystoppaymentdreppleycutshislosses.msnwhttp://groups.msn.com/LosingFace/dreppleystalentfortwistingthetruth.msnwhttp://groups.msn.com/LosingFace/confidentialitynotatmeridianplastsurgcenter.msnwhttp://groups.msn.com/LosingFace/dreppleyplaysblamethevictim.msnwhttp://groups.msn.com/LosingFace/yourwebpage3.msnwhttp://groups.msn.com/LosingFace/expertsquestiondreppleyshighinfectionrate.msnwhttp://groups.msn.com/LosingFace/massachusettsgeneralhospitalresidentsclinic.msnwhttp://groups.msn.com/LosingFace/documentationofphotographs.msnwhttp://groups.msn.com/LosingFace/documentationofmyappearance.msnwhttp://groups.msn.com/LosingFace/opinionsfromexperiencedradiologists.msnwhttp://groups.msn.com/LosingFace/evaluationofbrilliantradiologist.msnwhttp://groups.msn.com/LosingFace/entspecialistconfirmsdrdoaksopinionandmore.msnwhttp://groups.msn.com/LosingFace/modifiedbariumswallow.msnwhttp://groups.msn.com/LosingFace/mbsreportbyspeechpathologist.msnwhttp://groups.msn.com/LosingFace/mbs503and1203.msnwhttp://groups.msn.com/LosingFace/consultationwithpulmonaryspecialist.msnwhttp://groups.msn.com/LosingFace/followupreportfrompulmonologist.msnwhttp://groups.msn.com/LosingFace/entreport02july2004.msnwhttp://groups.msn.com/LosingFace/entreportjuly162004.msnwhttp://groups.msn.com/LosingFace/april2002reportofconsultationwithsurgeon.msnwhttp://groups.msn.com/LosingFace/comparisonofxrays.msnwhttp://groups.msn.com/LosingFace/myexperienceatmghresidentsclinic.msnw
Friday, November 30, 2007
MGH part 2
Senior surgeons received my presentation of the problem with intimidating remarks and negative body language. They did everything but snicker and sneer. I asked why my under eye area had a sunken appearance, Dr. Constable response was: "What did you expect?". I told him I did not expect the muscle to be tightened and shortened the way it was; that I expected Dr. Driscoll to do exactly what he assured me he was going to do. When I pointed out the laxity of the neck, jowl and above the nasolabial fold, Dr. Donelan said: "You certainly look better than the pre-ops; you have a great facelift" and "How do you like your nose?" I told him I loved my nose, but did not bargain to cut it off to spite my face. This meeting convinced me to never again meet with this group of doctors without a witness present or tape recording the conversation.
I voiced all of my concern about the area where hydrodissection was used seemed to have a thinned and lax quality. I explained my belief that hydrodissection may require a longer healing time before the insult of another surgery with a high degree of potential for causing edema from the breaking of nasal bones. I said that if it were considered routinely safe to do a rhinoplasty ( not a tip plasty only) 8 weeks after a face lift, then perhaps the mechanics of dissecting with a solution under pressure has a different effect on tissue adhesion than sharp instrument dissection. This was dismissed by all as "having nothing whatsoever" to do with the healing of the facelift . I was told that my facelift would lookexactly the same, even if I had NOT had a rhinoplasty. I have heard this countless times from all the doctors at MGH . If so, then there must be serious problem with the facelift.
After they conferred, Dr. Driscoll said they had nothing to offer for improvement and all agreed I had a great facelift. He suggested I was unhappy with other areas of my life and was projecting that attitude on to the results of my surgery. I told him there was nothing in my life other than my displeasure with the results of my surgery and my concern that the problem from the swelling was more serious than they were willing to admit.
During the next several weeks, I consulted with three plastic surgeons outside MGH. One told me he could do a tuck up and submalar implants, which would improve the hollow appearance of my cheeks, and the platysma should be tightened with a different plication technique. He said he thought there was too much fat removed from under my eyes and was surprised when I said no fat was removed. He said nothing could be done about the eye area. When I asked about the stretching of the skin from the edema post-rhinoplasty and the use of tumescent dissection he said he never uses it due to its causing distortion that makes it difficult to determine what things will look like with the redraping of the skin. He had no comment on whether the skin appeared stretched. He only said there was laxity that might be improved by a tuck up.
My next consult was with a surgeon I had seen in 1996 about laser resurfacing. I also saw him in January, after the facelift and before the rhinoplasty. At first he thought my facelift looked good . He was surprised about my having the rhinoplasty so soon. I asked what he thought about the swelling and stretching of skin. I explained my theory about the tumescent, etc... I expressed my frustration at being unable to get at the source of the condition of my face.
He examined my face thoroughly, had me activate different muscles and contort my features while he tested and stretched the skin in different directions. He did this all over my face, neck and even around my eyes. He looked thoughtful, but hesitated to give me an opinion.. I expressed my frustration with my inability to obtain straight answers about this when I absolutely knew what happened. I am an accurate observer of my own healing process. I promised I would not involve him or mention his name in connection with any disagreement I may have with the doctors at MGH if he would give me his honest opinion. He said my results were "bizarre" and if my account was accurate, he could think of no other explanation for this than exactly what I related. He also said he would never consider doing a rhinoplasty after a facelift in less than 6 months. His remark about my theory regarding the tumescent possibly taking longer to heal before another surgery was "I think you are on to something".
This doctor is Chief of Plastic Surgery at a major teaching hospital. His opinion of the possibility of further surgery making an improvement was cautious. He personally would be concerned as to the unpredictability due to the apparent changes and would not attempt anything himself. I am grateful for his honesty. It has also made me face the possibility that I may have to remain like this for the rest of my life, which I find unbearable. As time passes it gets noticeably worse, and it has only been not quite a year. What will I look like 6 months or a year from now?
I understand the ethical issues surrounding a surgeon's critical analysis of another doctor's work. Different surgeons have their own ways of doing things and cosmetic surgery techniques are in a class of their own as far as what is acceptable. Obviously there are limitations to which one must adhere for the patient's safety, however, the nature of this specialty allows a certain degree of "artistic license". I have never heard a doctor criticize another work except in a courtroom as an expert witness or among themselves. There the financial aspect to be considered in shedding unfavorable light on the entire specialty of cosmetic surgery. Why is it you never hear about patients like me? It is not because there are so few of us, but because most are hiding; they meekly take their ruined faces and lives and go away. They are too devastated and exhausted to engage themselves in the pursuit of holding the responsible parties accountable. I have been on the receiving end of good and bad cosmetic surgery. Before my experience at MGH, I was one of the greatest advocates of the beneficial effects that cosmetic surgery can have on a person's well being.
My next consult said he thought I would get an improvement only from doing another full face and neck lift. I asked him what he thought of the stretching from the rhinoplasty and his opinion of the tumescent technique involvement, he said he uses large volumes of anesthesia, but not introduced into the tissue under pressure as I described, so reserved comment. He said I know my own face better than anyone, and he always listens to what the patient thinks and says because they usually will tell him exactly what is wrong. He found my description 'graphic' and I felt he understood what I was attempting to put forth without any problem. . I voiced my concern about the possibility that the skin may respond to surgery in an unpredictable manner, and he told me of the usual risks, but felt comfortable with the fact that I healed so well form all my previous operations and would be willing to proceed if I wished. The estimated cost of this surgery is $8,000.
I have been concerned about my ability to communicate these details from the start, since the doctors at MGH always left me feeling as though what I was trying to explain was so extraordinary as to be impossible. I felt intimidated by their attitude of my description being so extreme as to be taken with a grain of salt. I am not doing this to prove I am right, I am doing this because I feel I deserve an explanation. I have suffered visible damage that has caused me emotional devastation, and their denial has largely contributed to my distress
At my meeting with Dr. Driscoll on March 12, 1998, as I was leaving the clinic I remembered one more question I had forgotten to ask, and so walked back to the conference room where he was seated at the table, making notations in my medical record. I asked him about the bunching of the muscle under my left eye and the bruise that had remained all this time. He picked up a sheet of color slides and held them up to the light to show me the area before surgery. These were the photos taken in the OR and I could see that most of them had been taken during the procedure, and the first few just before I was placed on the table. There were about 24 slides in this plastic protector . Iwas able to discern some of the stages of the operation, but did not look at them long enough to see each one individually, as Dr. Driscoll held them up while I looked.
I later wrote to him asking if I could have copies of these photos and never received a reply. I wanted these photos because I felt it would help any surgeon I might see in the future determine exactly what was done and assist them in any attempt at revision surgery. I feel the photos will help me in proving the damaged areas of my face directly correspond with the undermined areas. You cannot help but recognize this if you examine my face. I have shown show them how the skin balloons out even if you stretch it to its maximum and seen their faces suddenly take on a puzzled look, then the quick control of their features as their minds register that something is very wrong with what they are looking at. I am familiar with this "look"; I have seen iton the face of the doctor I worked with many times. It is the expression the patient hardly ever perceives as trepidation, but that's exactly what it is.
One of my consultants did not think the undermining went down as far as the nasolabial line. I knew it did, but did not have the operative report at that time. He thought becausethe skin was loose and folded over when I smiled was due to the undermining not including that area. I can understand his thinking this way, since he also did not believe my face had swelled to the extent I described. If anything, my description has been on the conservative side, since I myself still cannot believe that experience. Only my landlady saw me at the worst point and she said she will never forget it. Her recollection is more dramatic than mine. She is willing to sign any testimony as to witnessing my condition. She is a responsible intelligent person whose judgment is beyond reproach
I voiced all of my concern about the area where hydrodissection was used seemed to have a thinned and lax quality. I explained my belief that hydrodissection may require a longer healing time before the insult of another surgery with a high degree of potential for causing edema from the breaking of nasal bones. I said that if it were considered routinely safe to do a rhinoplasty ( not a tip plasty only) 8 weeks after a face lift, then perhaps the mechanics of dissecting with a solution under pressure has a different effect on tissue adhesion than sharp instrument dissection. This was dismissed by all as "having nothing whatsoever" to do with the healing of the facelift . I was told that my facelift would lookexactly the same, even if I had NOT had a rhinoplasty. I have heard this countless times from all the doctors at MGH . If so, then there must be serious problem with the facelift.
After they conferred, Dr. Driscoll said they had nothing to offer for improvement and all agreed I had a great facelift. He suggested I was unhappy with other areas of my life and was projecting that attitude on to the results of my surgery. I told him there was nothing in my life other than my displeasure with the results of my surgery and my concern that the problem from the swelling was more serious than they were willing to admit.
During the next several weeks, I consulted with three plastic surgeons outside MGH. One told me he could do a tuck up and submalar implants, which would improve the hollow appearance of my cheeks, and the platysma should be tightened with a different plication technique. He said he thought there was too much fat removed from under my eyes and was surprised when I said no fat was removed. He said nothing could be done about the eye area. When I asked about the stretching of the skin from the edema post-rhinoplasty and the use of tumescent dissection he said he never uses it due to its causing distortion that makes it difficult to determine what things will look like with the redraping of the skin. He had no comment on whether the skin appeared stretched. He only said there was laxity that might be improved by a tuck up.
My next consult was with a surgeon I had seen in 1996 about laser resurfacing. I also saw him in January, after the facelift and before the rhinoplasty. At first he thought my facelift looked good . He was surprised about my having the rhinoplasty so soon. I asked what he thought about the swelling and stretching of skin. I explained my theory about the tumescent, etc... I expressed my frustration at being unable to get at the source of the condition of my face.
He examined my face thoroughly, had me activate different muscles and contort my features while he tested and stretched the skin in different directions. He did this all over my face, neck and even around my eyes. He looked thoughtful, but hesitated to give me an opinion.. I expressed my frustration with my inability to obtain straight answers about this when I absolutely knew what happened. I am an accurate observer of my own healing process. I promised I would not involve him or mention his name in connection with any disagreement I may have with the doctors at MGH if he would give me his honest opinion. He said my results were "bizarre" and if my account was accurate, he could think of no other explanation for this than exactly what I related. He also said he would never consider doing a rhinoplasty after a facelift in less than 6 months. His remark about my theory regarding the tumescent possibly taking longer to heal before another surgery was "I think you are on to something".
This doctor is Chief of Plastic Surgery at a major teaching hospital. His opinion of the possibility of further surgery making an improvement was cautious. He personally would be concerned as to the unpredictability due to the apparent changes and would not attempt anything himself. I am grateful for his honesty. It has also made me face the possibility that I may have to remain like this for the rest of my life, which I find unbearable. As time passes it gets noticeably worse, and it has only been not quite a year. What will I look like 6 months or a year from now?
I understand the ethical issues surrounding a surgeon's critical analysis of another doctor's work. Different surgeons have their own ways of doing things and cosmetic surgery techniques are in a class of their own as far as what is acceptable. Obviously there are limitations to which one must adhere for the patient's safety, however, the nature of this specialty allows a certain degree of "artistic license". I have never heard a doctor criticize another work except in a courtroom as an expert witness or among themselves. There the financial aspect to be considered in shedding unfavorable light on the entire specialty of cosmetic surgery. Why is it you never hear about patients like me? It is not because there are so few of us, but because most are hiding; they meekly take their ruined faces and lives and go away. They are too devastated and exhausted to engage themselves in the pursuit of holding the responsible parties accountable. I have been on the receiving end of good and bad cosmetic surgery. Before my experience at MGH, I was one of the greatest advocates of the beneficial effects that cosmetic surgery can have on a person's well being.
My next consult said he thought I would get an improvement only from doing another full face and neck lift. I asked him what he thought of the stretching from the rhinoplasty and his opinion of the tumescent technique involvement, he said he uses large volumes of anesthesia, but not introduced into the tissue under pressure as I described, so reserved comment. He said I know my own face better than anyone, and he always listens to what the patient thinks and says because they usually will tell him exactly what is wrong. He found my description 'graphic' and I felt he understood what I was attempting to put forth without any problem. . I voiced my concern about the possibility that the skin may respond to surgery in an unpredictable manner, and he told me of the usual risks, but felt comfortable with the fact that I healed so well form all my previous operations and would be willing to proceed if I wished. The estimated cost of this surgery is $8,000.
I have been concerned about my ability to communicate these details from the start, since the doctors at MGH always left me feeling as though what I was trying to explain was so extraordinary as to be impossible. I felt intimidated by their attitude of my description being so extreme as to be taken with a grain of salt. I am not doing this to prove I am right, I am doing this because I feel I deserve an explanation. I have suffered visible damage that has caused me emotional devastation, and their denial has largely contributed to my distress
At my meeting with Dr. Driscoll on March 12, 1998, as I was leaving the clinic I remembered one more question I had forgotten to ask, and so walked back to the conference room where he was seated at the table, making notations in my medical record. I asked him about the bunching of the muscle under my left eye and the bruise that had remained all this time. He picked up a sheet of color slides and held them up to the light to show me the area before surgery. These were the photos taken in the OR and I could see that most of them had been taken during the procedure, and the first few just before I was placed on the table. There were about 24 slides in this plastic protector . Iwas able to discern some of the stages of the operation, but did not look at them long enough to see each one individually, as Dr. Driscoll held them up while I looked.
I later wrote to him asking if I could have copies of these photos and never received a reply. I wanted these photos because I felt it would help any surgeon I might see in the future determine exactly what was done and assist them in any attempt at revision surgery. I feel the photos will help me in proving the damaged areas of my face directly correspond with the undermined areas. You cannot help but recognize this if you examine my face. I have shown show them how the skin balloons out even if you stretch it to its maximum and seen their faces suddenly take on a puzzled look, then the quick control of their features as their minds register that something is very wrong with what they are looking at. I am familiar with this "look"; I have seen iton the face of the doctor I worked with many times. It is the expression the patient hardly ever perceives as trepidation, but that's exactly what it is.
One of my consultants did not think the undermining went down as far as the nasolabial line. I knew it did, but did not have the operative report at that time. He thought becausethe skin was loose and folded over when I smiled was due to the undermining not including that area. I can understand his thinking this way, since he also did not believe my face had swelled to the extent I described. If anything, my description has been on the conservative side, since I myself still cannot believe that experience. Only my landlady saw me at the worst point and she said she will never forget it. Her recollection is more dramatic than mine. She is willing to sign any testimony as to witnessing my condition. She is a responsible intelligent person whose judgment is beyond reproach
My expeirence with mgh
Important note: The following was written long before I had revision surgery by Dr. Eppley in 2001. I was distressed over the deterioration of my appearance after surgery at MGH. My pre-op photos, opinions of family and friends prove this. Any normal woman would be distraught at having her attractive face ruined. While my distress after the MGH surgery was justified, it did not prevent me from engaging in physical activity. I still enjoyed excellent health. The MGH surgery injured my appearance by causing permanent tissue damage. Dr. Eppley's "revision" surgery in 2001 destroyed my health, leaving me with serious, debilitating, life threatening medical conditions. After experiencing BOTH types of injury, I wish to emphasize that no degree of destruction of one's APPEARANCE ONLY can destroy one's life as does the loss of GOOD HEALTH. Before Dr. Eppley's surgery, I was still able to enjoy the most important things in my life.. working out doors, having a healthy, functioning body capable of enjoy breathing, swallowing, moving normally..AND FREE OF PAIN. You can adjust to the loss of your pretty face and STILL enjoy life. You CANNOT enjoy ANYTHING when you are suffering physically each and every day . The most important message I wish to convey in sharing my experience is NEVER PLACE YOUR GOOD HEALTH AT RISK simply to improve your appearance!! If you think your appearance makes you unhappy, you do not KNOW what TRUE misery is like until destruction of your ability to walk, eat, breathe, makes appearance the LAST OF YOUR CONCERNS. If you think the nightmares happen to OTHER people, you are WRONG. If you are able to laugh, breathe, swallow, talk, walk.. all the things you take for granted when you are not thinking about the way you look, then you are more fortunate than you know. Do not risk the most precious thing in life.. a body that does not NEED an operation to relieve pain or disease.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~THE FOLLOWING IS AN ACCURATE ACCOUNT OF MY EXPERIENCE AT THE PLASTIC SURGERY RESIDENTS CLINIC OF MASSACHUSETTS GENERAL HOSPITAL
I had a full facelift and lower blephroplasty on November 24, 1997 at the Plastic Surgery Residents' Clinic of Massachusetts General Hospital. At my first consultation on 10-16-1997, I was interviewed, examined and medical history taken by the Chief Resident, Dr. Daniel Driscoll, clinical instructors and other residents. After the doctors conferred, Dr. Driscoll said he could perform my facelift under the supervision of Dr. Eugene Courtiss. The resident surgeon's fee was $1,000 and the OR fee was $889... a full facelift under the supervision of a professor of plastic surgery for less then $2,000. Clinical photos were taken and the surgery was scheduled.
Dr. Driscoll went to great lengths to satisfy my need for information regarding technical details of the procedure. I emphasized that my decision to undergo surgery was based on my knowledge of specific details and he seemed comfortable with this. I made it clear to all that I intended to become actively involved in decisions about what I would allow to be done to my face. Nobody objected to my expectation of having this kind of control over my operation.
Some of my questions were: Exactly where would the incision be placed; would it extend into the hairline, would drains be placed in the neck, what type and size suture would be used, etc. We discussed doing a lower blephroplasty which he agreed to discuss with Dr.Courtiss. He explained the risk of extropion in removal of too much skin. He drew a diagram showing how the skin bunched under the eye from a facelift incision and how the side burn could be spared by placing an incision above and behind it in the hairline to get the desirable degree of elevation and drape of the skin. We both agreed that doing less was better than too much. I admired his reasoning in regard to technique for achieving optimal results tempered with caution and conservatism.
Dr. Driscoll assured me I could call him any time to discuss things further and remarked on my being a well informed patient. I asked if I would need pre-op blood work. He said no, but I him to order a CBC, PT and PTT at Cape Cod Hospital and he agreed. The results were normal. Dr. Driscoll asked if I would mind coming in again, during the next week, for him to present my case to a visiting professor. I agreed, and so had the benefit of reviewing everything in more detail. I felt I was in good hands.
I called him a few days before the surgery for a prescription for clindamycin and asked if we would be doing the blephroplasty. He had not checked with Dr. Courtiss, but was concerned about the time involved in the facelift, estimating it to be a 6 to 6 1/2 hours, and the bleph would increase this by another 1 1/2 hours. He said he planned to work slowly and was concerned about my being under sedation and undergoing a procedure of that length.
My medical records showed I was in the OR from 8:45am to 12:05am, exactly 3 hrs. and 20 min. start to finish for both facelift and bleph. I knew Dr. Driscoll could not have made such a great miscalculation and I learned afterward that he did not execute the procedure as we had planned, which accounted for the discrepancy in time.
He was able to do both procedures in this brief time because he used tumescent anesthesia injected under pressure, of which I was not informed. When I questioned him about this, he said he had to defer to Dr. Courtiss' instruction. I feel this was a breach of my trust. He knew the importance I placed on having full knowledge of the procedure beforehand,
I was a guinea pig without my knowledge or consent. I had faith in Dr. Driscoll's ability to carry out the procedure as we had planned. I based my consent on information we discussed at length, the reason for all my questions, taking of notes and phone calls. There was no medical reason to deviate from our original plan. I was not expecting the use of tumescent technique, knew nothing about it in regard to facelift, was not informed before hand, and would never have consented to its use. Due to the lack of information available in the literature and the fact that most surgeons rarely use it, I believe a high probability exists for unforeseen complications. I am convinced by my personal experience that a longer healing time is required after the use of tumescent technique before a subsequent procedure can safely be performed.
The blephroplasty technique Dr. Driscoll used on my lower lids was not what he described in our meeting. I had only excess skin, but a good snap response, yet he used a technique that would have been appropriate for a much older patient with a poor snap response. He removed 1mm of skin and the swelling from the rhinoplasty has stretched the scar out to a greater degree that 1mm. Every surgeon who has seen my eyes says that too much fat was removed, yet no fat was removed. The sunken appearance is a combination of the inappropriate bleph technique and the equally inappropriate SMAS elevation which bunched under the outer aspect of the eye. I complained about the eyes on my first follow up visit, but did not feel it was unsightly. Overall, I was pleased with the result of the facelift and expressed my satisfaction to Dr. Driscoll. In spite of my shock at the use of the tumescent technique and dissatisfaction with the appearance of the lower eyelid hollows, I had an easy and rapid recovery.
I had several weeks before return to work in April as a gardener. I inquired about a rhinoplasty and how soon it could safely be done. I was told it could be done 8 weeks after the facelift. My rhinoplasty at the same clinic was scheduled for January 28, 1998 with the new incoming senior resident, Dr. Melissa Schneider. Upon learning that Dr. Joel Feldman, "facelift specialist" , would supervise my surgery, Any uncertainty I felt about having the rhinoplasty too soon after the facelift was dispelled, I figured it MUST be safe if such a highly regarded facial plastic surgeon as Dr. Feldman was involved in this decision.
I tolerated the procedure well, but on the 2nd day post-op had extensive swelling of the eyes, mid-face and neck. I called Dr. Schneider and reported the degree of swelling. I also noted that there was a difference in the quality of the skin undermined in the facelift from adjacent areas which were swollen but not involved in the facelift. These included a small area in the center of my neck, under my chin, the sides of my nose, and about 1" lateral to the facelift incision. These small, well defined areas did not stretch as did the remainder of the face undermined in the tumescent facelift. I knew there was a serious problem this early on.
I was extremely concerned that the skin involved in the facelift would permanently stretch because the edema was extreme. My instinct was to put a light compression bandage under the chin to keep the area from stretching, but when I asked Dr. Schneider about this she replied with an emphatic NO! My landlady was the only one who saw me at this time and though I took some pictures with her camera, they did not come out. There are no photos to document the extent of the swelling, but I do have a signed statement from my landlady. Dr. Schneider did not take photos on my visit with her 1 week post op when there was still a considerable degree of swelling.
My instinct told me that there was a relation between this extensive swelling as the quality of that skin and the use of hydrodissection (tumescent technique) in the facelift. After the rhinoplasty, my skin lost its adhesion to the SMAS layer beneath. It was as if something had "let go".
A few days before the rhinoplasty I had a dental appointment at Tufts. They could not take regular x-rays because I was unable to open my mouth due to the taught skin and muscle from the facelift. I was barely able to put a thin probe between my front teeth for a Panex x-ray. I was still using a child's toothbrush. Immediately after the rhinoplasty all the taught skin/SMAS that prevented me from opening my mouth were so stretched, I could easily open my mouth wide. Before the rhinoplasty I was not able to smile a full smile due to the facelift, and was careful not to overly animate my facial muscles so my facelift would heal properly. Right after the rhinoplasty I was able to smile widely without any tight feeling. Post-op edema from the rhinoplasty tracked into the dissected planes of the facelift, compromising the new adhesion. This adhesion essentially holds the facelift in place. Some surgeons call this "favorable fibrosis". The only tight feeling that remained was from the internal sutures, which remained intact, except in the platysma, where I could feel the suture had torn through on the right side.
Expressions of perplexed incredulity were plastered on the faces of the doctors at MGH when I described what happened and showed them how drastically different the skin reacted to traction than the areas not involved in the facelift.. . Two general surgeons and one ENT specialist I spoke to were not surprised and thought it would have been a miracle NOT to stretch out only 8 weeks after the facelift. These doctors are friends; I did not consult with them professionally, however, they are still surgeons and familiar with the healing process of the body.
I called Dr. Schneider several times during the first week, telling her I feared something was terribly wrong and could not imagine skin going back to its normal state after being stretched to such an extent. She offered to see me in the clinic on Friday, but there was nothing that could be done for it anyway. She said it was "impossible" that skin can remain stretched out after swelling. When I questioned this she used the following analogy: (exact words) "The chances of your facelift being stretched out are like the chances that a stop light will turn purple rather than red". She called Dr. Feldman, who supervised my rhinoplasty. He said he had never seen permanent stretching of skin from this. On my first follow up a week after the surgery, I was still considerably swollen and bruising had developed along the nasolabial, jowl and neck areas. I was told by several surgeons that they never heard of a neck swelling from a rhinoplasty, let alone developing bruising. The bruising followed the exact areas of dissection in the face/neck lift. This is where the blood settled and followed the path of least resistance. This does NOT happen in a rhinoplasty. The face and neck were swollen to a greater extent at this point than ever it was after the facelift, and was very lax.
I saw Dr. Schneider again 2 weeks post-op for the removal of the splint. May face was still swollen, and I was aware that a rhinoplasty can take up to one year for complete resolution of the swelling. I was pleased with the rhinoplasty, though still concerned about the skin laxity and peculiar appearance of my face when smiling, as there was no adhesion of the skin/SMAS to the deep muscles of expression. Dr. Schneider said she would get as much input from other doctors as she could. She took lots of photos, smiling and in repose. As the edema subsided over the next several weeks, there was a laxity in all the areas undermined by hydrodissection. Dr. Schneider arranged an appointment for me in the clinic with the group and Dr. Driscoll March 12, 1998. Dr. Schnieder did not attend this meeting.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~THE FOLLOWING IS AN ACCURATE ACCOUNT OF MY EXPERIENCE AT THE PLASTIC SURGERY RESIDENTS CLINIC OF MASSACHUSETTS GENERAL HOSPITAL
I had a full facelift and lower blephroplasty on November 24, 1997 at the Plastic Surgery Residents' Clinic of Massachusetts General Hospital. At my first consultation on 10-16-1997, I was interviewed, examined and medical history taken by the Chief Resident, Dr. Daniel Driscoll, clinical instructors and other residents. After the doctors conferred, Dr. Driscoll said he could perform my facelift under the supervision of Dr. Eugene Courtiss. The resident surgeon's fee was $1,000 and the OR fee was $889... a full facelift under the supervision of a professor of plastic surgery for less then $2,000. Clinical photos were taken and the surgery was scheduled.
Dr. Driscoll went to great lengths to satisfy my need for information regarding technical details of the procedure. I emphasized that my decision to undergo surgery was based on my knowledge of specific details and he seemed comfortable with this. I made it clear to all that I intended to become actively involved in decisions about what I would allow to be done to my face. Nobody objected to my expectation of having this kind of control over my operation.
Some of my questions were: Exactly where would the incision be placed; would it extend into the hairline, would drains be placed in the neck, what type and size suture would be used, etc. We discussed doing a lower blephroplasty which he agreed to discuss with Dr.Courtiss. He explained the risk of extropion in removal of too much skin. He drew a diagram showing how the skin bunched under the eye from a facelift incision and how the side burn could be spared by placing an incision above and behind it in the hairline to get the desirable degree of elevation and drape of the skin. We both agreed that doing less was better than too much. I admired his reasoning in regard to technique for achieving optimal results tempered with caution and conservatism.
Dr. Driscoll assured me I could call him any time to discuss things further and remarked on my being a well informed patient. I asked if I would need pre-op blood work. He said no, but I him to order a CBC, PT and PTT at Cape Cod Hospital and he agreed. The results were normal. Dr. Driscoll asked if I would mind coming in again, during the next week, for him to present my case to a visiting professor. I agreed, and so had the benefit of reviewing everything in more detail. I felt I was in good hands.
I called him a few days before the surgery for a prescription for clindamycin and asked if we would be doing the blephroplasty. He had not checked with Dr. Courtiss, but was concerned about the time involved in the facelift, estimating it to be a 6 to 6 1/2 hours, and the bleph would increase this by another 1 1/2 hours. He said he planned to work slowly and was concerned about my being under sedation and undergoing a procedure of that length.
My medical records showed I was in the OR from 8:45am to 12:05am, exactly 3 hrs. and 20 min. start to finish for both facelift and bleph. I knew Dr. Driscoll could not have made such a great miscalculation and I learned afterward that he did not execute the procedure as we had planned, which accounted for the discrepancy in time.
He was able to do both procedures in this brief time because he used tumescent anesthesia injected under pressure, of which I was not informed. When I questioned him about this, he said he had to defer to Dr. Courtiss' instruction. I feel this was a breach of my trust. He knew the importance I placed on having full knowledge of the procedure beforehand,
I was a guinea pig without my knowledge or consent. I had faith in Dr. Driscoll's ability to carry out the procedure as we had planned. I based my consent on information we discussed at length, the reason for all my questions, taking of notes and phone calls. There was no medical reason to deviate from our original plan. I was not expecting the use of tumescent technique, knew nothing about it in regard to facelift, was not informed before hand, and would never have consented to its use. Due to the lack of information available in the literature and the fact that most surgeons rarely use it, I believe a high probability exists for unforeseen complications. I am convinced by my personal experience that a longer healing time is required after the use of tumescent technique before a subsequent procedure can safely be performed.
The blephroplasty technique Dr. Driscoll used on my lower lids was not what he described in our meeting. I had only excess skin, but a good snap response, yet he used a technique that would have been appropriate for a much older patient with a poor snap response. He removed 1mm of skin and the swelling from the rhinoplasty has stretched the scar out to a greater degree that 1mm. Every surgeon who has seen my eyes says that too much fat was removed, yet no fat was removed. The sunken appearance is a combination of the inappropriate bleph technique and the equally inappropriate SMAS elevation which bunched under the outer aspect of the eye. I complained about the eyes on my first follow up visit, but did not feel it was unsightly. Overall, I was pleased with the result of the facelift and expressed my satisfaction to Dr. Driscoll. In spite of my shock at the use of the tumescent technique and dissatisfaction with the appearance of the lower eyelid hollows, I had an easy and rapid recovery.
I had several weeks before return to work in April as a gardener. I inquired about a rhinoplasty and how soon it could safely be done. I was told it could be done 8 weeks after the facelift. My rhinoplasty at the same clinic was scheduled for January 28, 1998 with the new incoming senior resident, Dr. Melissa Schneider. Upon learning that Dr. Joel Feldman, "facelift specialist" , would supervise my surgery, Any uncertainty I felt about having the rhinoplasty too soon after the facelift was dispelled, I figured it MUST be safe if such a highly regarded facial plastic surgeon as Dr. Feldman was involved in this decision.
I tolerated the procedure well, but on the 2nd day post-op had extensive swelling of the eyes, mid-face and neck. I called Dr. Schneider and reported the degree of swelling. I also noted that there was a difference in the quality of the skin undermined in the facelift from adjacent areas which were swollen but not involved in the facelift. These included a small area in the center of my neck, under my chin, the sides of my nose, and about 1" lateral to the facelift incision. These small, well defined areas did not stretch as did the remainder of the face undermined in the tumescent facelift. I knew there was a serious problem this early on.
I was extremely concerned that the skin involved in the facelift would permanently stretch because the edema was extreme. My instinct was to put a light compression bandage under the chin to keep the area from stretching, but when I asked Dr. Schneider about this she replied with an emphatic NO! My landlady was the only one who saw me at this time and though I took some pictures with her camera, they did not come out. There are no photos to document the extent of the swelling, but I do have a signed statement from my landlady. Dr. Schneider did not take photos on my visit with her 1 week post op when there was still a considerable degree of swelling.
My instinct told me that there was a relation between this extensive swelling as the quality of that skin and the use of hydrodissection (tumescent technique) in the facelift. After the rhinoplasty, my skin lost its adhesion to the SMAS layer beneath. It was as if something had "let go".
A few days before the rhinoplasty I had a dental appointment at Tufts. They could not take regular x-rays because I was unable to open my mouth due to the taught skin and muscle from the facelift. I was barely able to put a thin probe between my front teeth for a Panex x-ray. I was still using a child's toothbrush. Immediately after the rhinoplasty all the taught skin/SMAS that prevented me from opening my mouth were so stretched, I could easily open my mouth wide. Before the rhinoplasty I was not able to smile a full smile due to the facelift, and was careful not to overly animate my facial muscles so my facelift would heal properly. Right after the rhinoplasty I was able to smile widely without any tight feeling. Post-op edema from the rhinoplasty tracked into the dissected planes of the facelift, compromising the new adhesion. This adhesion essentially holds the facelift in place. Some surgeons call this "favorable fibrosis". The only tight feeling that remained was from the internal sutures, which remained intact, except in the platysma, where I could feel the suture had torn through on the right side.
Expressions of perplexed incredulity were plastered on the faces of the doctors at MGH when I described what happened and showed them how drastically different the skin reacted to traction than the areas not involved in the facelift.. . Two general surgeons and one ENT specialist I spoke to were not surprised and thought it would have been a miracle NOT to stretch out only 8 weeks after the facelift. These doctors are friends; I did not consult with them professionally, however, they are still surgeons and familiar with the healing process of the body.
I called Dr. Schneider several times during the first week, telling her I feared something was terribly wrong and could not imagine skin going back to its normal state after being stretched to such an extent. She offered to see me in the clinic on Friday, but there was nothing that could be done for it anyway. She said it was "impossible" that skin can remain stretched out after swelling. When I questioned this she used the following analogy: (exact words) "The chances of your facelift being stretched out are like the chances that a stop light will turn purple rather than red". She called Dr. Feldman, who supervised my rhinoplasty. He said he had never seen permanent stretching of skin from this. On my first follow up a week after the surgery, I was still considerably swollen and bruising had developed along the nasolabial, jowl and neck areas. I was told by several surgeons that they never heard of a neck swelling from a rhinoplasty, let alone developing bruising. The bruising followed the exact areas of dissection in the face/neck lift. This is where the blood settled and followed the path of least resistance. This does NOT happen in a rhinoplasty. The face and neck were swollen to a greater extent at this point than ever it was after the facelift, and was very lax.
I saw Dr. Schneider again 2 weeks post-op for the removal of the splint. May face was still swollen, and I was aware that a rhinoplasty can take up to one year for complete resolution of the swelling. I was pleased with the rhinoplasty, though still concerned about the skin laxity and peculiar appearance of my face when smiling, as there was no adhesion of the skin/SMAS to the deep muscles of expression. Dr. Schneider said she would get as much input from other doctors as she could. She took lots of photos, smiling and in repose. As the edema subsided over the next several weeks, there was a laxity in all the areas undermined by hydrodissection. Dr. Schneider arranged an appointment for me in the clinic with the group and Dr. Driscoll March 12, 1998. Dr. Schnieder did not attend this meeting.
email just before surgery
The following e-mail exchange between Dr. Eppley and myself is only one of many during the many months he and I corresponded before my revision surgery. The entries posted here may not appear in the proper chronological order and MOST of our the detailed messages have been lost from my AOL account due to corrupted AOL software. The entire contents of the screen name I reserved exclusively for e-mail exchange with Dr. Eppley was lost with the screen name. Copies of these interchanges were sent to another of his patients with whom I had a long time e-mail exchange, but this woman is not longer communicating with me. However, I assume she and Dr. Eppley still have this information saved on their own computers.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Date: 04/16/2001To: beppley@iupui.eduCC: Mchlewlsn
Dear Dr. Eppley:
Thank you for the call last Friday. Our talk did address my concerns,however, there remains one factor that cannot be determined until I actually meet with you on Wednesday when you have the opportunity to do a hands-on examination my face again.
I know it is impossible for you to determine exactly how much "tightening" is feasible until you actually perform the operation as well as consideration of my age, condition of my skin, aberration in tissue from previous surgery, individual capacity for healing, etc. With that understood, I would like to stand in front of a mirror and have you actually pull up the skin on both sides of my face (sort of like what I did in the video) to give me an idea of how much you think you can lift the neck and lower face and the vectors of tension involved. I need you to feel the unyielding quality of this skin/SMAS (?), appreciate the severity of its hypoelastic condition and the manner in which placing sufficient tensionto create an improvement while I am smiling stretches my mouth out to a grotesque degree while in repose.
I'm not sure I explained that very well, but I guess I need to see how far it is possible to effect a change to determine whether the surgery can accomplish enough change to make it worth the undertaking. I apologize for not bringing this up when we met, but there is a degree of change that I feel will make the financial, physical and emotional sacrifice of surgery worth while, as opposed to an improvement that is so slight as to be disappointing. Dr. Eppley, I do not have unrealistic expectations and know you cannot promise results, but I do not plan to have another facelift again and I want this one to accomplish the maximum degree of improvement because it will be my last.
It may help you understand if I tell you something about my financial situation. The money for this surgery is my entire life's savings. As you are aware from my medical records, I have narcolepsy and while I am able and fortunate enough to work at a job that allows me the flexibility to work "around" the inconvenience posed by this disorder, I do receive SSI disability and medical insurance because I have no material assets. It hastaken me 3 years and an advance in pay to save the money for this surgery and though I realize there are no guarantees, I would like to feel secure in being able to attain a certain degree of improvement, or at least have the odds on my side.
I realize that the financial status of a patient is not something any doctor feels is his concern, particularly with cosmetic procedures that are deemed a "luxury" , but sometimes it's helpful to know how important these things are to patients who are willing to sacrifice all they have in order to recapture some degree of what they consider a more "normal"appearance. If I had not experienced the problem after the rhinoplasty I would have happily continued living my life without wanting to undergo another surgery to "improve" anything else.
I have chosen you to perform my surgery over the other surgeons who have offered to do so because I believe you understand my problem and how I feel about it better than they and I feel comfortable in expressing myself to you and trust your skill and experience. I know you want me to be satisfied with the results and that you place as much importance onour understanding the possibilities and limitations involved as I.
I think we are on the "same page" and have been from the beginning, but I would feel better knowing that should you find the possibilities more limited upon examining me Wednesday, that I may have the option of doing the nasolabial excision and corner lip lift as an alternative to the major surgery we have planned.
Dr. Eppley, I believe we WILL go ahead with the big operation, but I still have this thing in my mind about the SMAS being stretched out as well as the skin and as many ways as I have pulled and lifted this face in front of a mirror myself, I cannot get the neck and jaw line defined enough without stretching my mouth out to the sides of my face! (I hope that made you laugh!) I see the success of this operation involving: 1.) the readhesion of the tissue plane that has been "loosened or detached" from the deeper muscles (whether that is skin or SMAS, will the dissection have to be on that plane to form a fibrosis and thus "reattach?) and 2.) being able to tailor the "excess" in such a way that it drapes in as natural a manner as its condition allows. If this involves direct excision and scars, that is quite acceptable to me. I would readily accept the scars to obtain the better contour.
I have even thought about the possibility of a Z plasty for the neck if the skin is stretched out in a way that only a direct excision would address. I know that would involve another procedure, but isn't it the same principle involved in the nasolabial area where you have the "parachute" effect of the tissue which may not be improved through lifting through the face/neck lift incision? Can the platysma plication/plasty be addressed in this fashion? I haven't read anything about Z plasty in this area.. just a few abstracts, but no complete articles.
I apologize for this long letter. I hope I haven't discouraged you from wanting to operate on me. I think I am just giving voice to all my last minute concerns to clear the slate for Wednesday. I hope you will not misunderstand anything I have said as a reluctance to move forward.
Thank you for all your time and understanding, Dr. Eppley, I truly appreciate it more than you know.
Lucille
PS: I have attached a diagram of the platysma transection I mentioned on the phone that you did not receive in my last e-mail.
http://groups.msn.com/LosingFace/emailjustbeforesurgery.msnw
Dear Dr. Eppley:
Thank you for the call last Friday. Our talk did address my concerns,however, there remains one factor that cannot be determined until I actually meet with you on Wednesday when you have the opportunity to do a hands-on examination my face again.
I know it is impossible for you to determine exactly how much "tightening" is feasible until you actually perform the operation as well as consideration of my age, condition of my skin, aberration in tissue from previous surgery, individual capacity for healing, etc. With that understood, I would like to stand in front of a mirror and have you actually pull up the skin on both sides of my face (sort of like what I did in the video) to give me an idea of how much you think you can lift the neck and lower face and the vectors of tension involved. I need you to feel the unyielding quality of this skin/SMAS (?), appreciate the severity of its hypoelastic condition and the manner in which placing sufficient tensionto create an improvement while I am smiling stretches my mouth out to a grotesque degree while in repose.
I'm not sure I explained that very well, but I guess I need to see how far it is possible to effect a change to determine whether the surgery can accomplish enough change to make it worth the undertaking. I apologize for not bringing this up when we met, but there is a degree of change that I feel will make the financial, physical and emotional sacrifice of surgery worth while, as opposed to an improvement that is so slight as to be disappointing. Dr. Eppley, I do not have unrealistic expectations and know you cannot promise results, but I do not plan to have another facelift again and I want this one to accomplish the maximum degree of improvement because it will be my last.
It may help you understand if I tell you something about my financial situation. The money for this surgery is my entire life's savings. As you are aware from my medical records, I have narcolepsy and while I am able and fortunate enough to work at a job that allows me the flexibility to work "around" the inconvenience posed by this disorder, I do receive SSI disability and medical insurance because I have no material assets. It hastaken me 3 years and an advance in pay to save the money for this surgery and though I realize there are no guarantees, I would like to feel secure in being able to attain a certain degree of improvement, or at least have the odds on my side.
I realize that the financial status of a patient is not something any doctor feels is his concern, particularly with cosmetic procedures that are deemed a "luxury" , but sometimes it's helpful to know how important these things are to patients who are willing to sacrifice all they have in order to recapture some degree of what they consider a more "normal"appearance. If I had not experienced the problem after the rhinoplasty I would have happily continued living my life without wanting to undergo another surgery to "improve" anything else.
I have chosen you to perform my surgery over the other surgeons who have offered to do so because I believe you understand my problem and how I feel about it better than they and I feel comfortable in expressing myself to you and trust your skill and experience. I know you want me to be satisfied with the results and that you place as much importance onour understanding the possibilities and limitations involved as I.
I think we are on the "same page" and have been from the beginning, but I would feel better knowing that should you find the possibilities more limited upon examining me Wednesday, that I may have the option of doing the nasolabial excision and corner lip lift as an alternative to the major surgery we have planned.
Dr. Eppley, I believe we WILL go ahead with the big operation, but I still have this thing in my mind about the SMAS being stretched out as well as the skin and as many ways as I have pulled and lifted this face in front of a mirror myself, I cannot get the neck and jaw line defined enough without stretching my mouth out to the sides of my face! (I hope that made you laugh!) I see the success of this operation involving: 1.) the readhesion of the tissue plane that has been "loosened or detached" from the deeper muscles (whether that is skin or SMAS, will the dissection have to be on that plane to form a fibrosis and thus "reattach?) and 2.) being able to tailor the "excess" in such a way that it drapes in as natural a manner as its condition allows. If this involves direct excision and scars, that is quite acceptable to me. I would readily accept the scars to obtain the better contour.
I have even thought about the possibility of a Z plasty for the neck if the skin is stretched out in a way that only a direct excision would address. I know that would involve another procedure, but isn't it the same principle involved in the nasolabial area where you have the "parachute" effect of the tissue which may not be improved through lifting through the face/neck lift incision? Can the platysma plication/plasty be addressed in this fashion? I haven't read anything about Z plasty in this area.. just a few abstracts, but no complete articles.
I apologize for this long letter. I hope I haven't discouraged you from wanting to operate on me. I think I am just giving voice to all my last minute concerns to clear the slate for Wednesday. I hope you will not misunderstand anything I have said as a reluctance to move forward.
Thank you for all your time and understanding, Dr. Eppley, I truly appreciate it more than you know.
Lucille
PS: I have attached a diagram of the platysma transection I mentioned on the phone that you did not receive in my last e-mail.
http://groups.msn.com/LosingFace/emailjustbeforesurgery.msnw
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