#64 - Zol Kryger, M.D.: Navigating the sometimes shady world of plastic surgery—understanding potential complications of common procedures and how to reduce your risk by choosing the right doctor and asking the right questions
Dr. Zol Kryger, a board-certified plastic surgeon, discusses the alarmingly loose regulations in plastic surgery, leading to many procedures performed by non-certified doctors. He highlights serious complications, common misconceptions, and provides crucial questions to ask surgeons to mitigate risks and ensure proper care.
Deep Dive Analysis
12 Topic Outline
Introduction to Dr. Zol Kryger and Plastic Surgery Misconceptions
The Shocking Reality of Non-Board Certified Plastic Surgeons
Essential Questions to Ask Your Cosmetic Surgeon
Managing Complications and the Value of Two Surgeons
Breast Augmentation: Implants, Complications, and ALCL Risk
Breast Reconstruction Following Mastectomy
Tummy Tucks: Procedure, Risks, and Diastasis/Hernia Repair
Liposuction: Techniques, Risks, and the 'Wild West' of Practice
Brazilian Butt Lifts: High Risks and Ethical Concerns
Why Untrained Doctors Enter Cosmetic Surgery
Addressing Vanity, Insecurity, and Patient Selection
Risks of Minimally Invasive Procedures: Botox, Fillers, Lasers
6 Key Concepts
Capsular Contracture
This is the most serious long-term complication of breast augmentation, where the body forms an abnormal, hard, and contracting scar tissue capsule around the implant, causing pain and distortion. It can displace the implant higher, making the breast feel hard and look smaller.
ALCL (Anaplastic Large Cell Lymphoma)
A rare type of cancer associated with breast implants, specifically textured implants. It's a lymphoma that develops in the capsule surrounding the implant, potentially invading the breast tissue, and has a higher incidence with certain textured implants.
Diastasis Recti
A separation of the rectus abdominis muscles (six-pack muscles) that occurs, often after pregnancy, creating a gap in the midline. It results in a protuberant abdomen, especially after meals, and can be repaired during a tummy tuck.
Seroma
A common complication after a tummy tuck, involving the accumulation of fluid in the large space created by lifting the skin off the abdominal wall. It typically requires drainage and can be minimized with the use of surgical drains.
Fat Embolism
A highly dangerous complication of Brazilian butt lifts, where injected fat inadvertently enters veins in the buttocks and travels to the lungs. This causes a fat embolus, which carries a high risk of fatality, and is a major concern with this procedure.
Lidocaine Toxicity
A risk associated with liposuction, caused by overdosing patients with lidocaine, which is used to numb the area. Peak levels of lidocaine in the bloodstream occur 8-12 hours after the procedure, potentially leading to complications at home if not properly managed.
10 Questions Answered
A board-certified plastic surgeon has completed a rigorous 6-7 year residency focused on plastic surgery, including reconstructive surgery. In contrast, any physician with a medical license can legally perform plastic surgery procedures, often without formal training in the specialty, typically in office-based settings not regulated by hospitals.
Patients should ask about the surgeon's board certification in plastic surgery, their specific training for the desired procedure, how long they've been performing it, where they trained, if they have hospital privileges for that procedure, and their plan for managing complications, including potential costs.
The most common long-term complication is capsular contracture, where scar tissue hardens around the implant. A rarer but serious complication is ALCL (Anaplastic Large Cell Lymphoma), a type of cancer associated specifically with textured breast implants.
Women with textured implants should be aware of the low risk of ALCL and see their plastic surgeon annually. While most will be fine, they might consider periodic MRIs and should perform monthly self-exams to check for masses or significant swelling.
Round, smooth silicone implants placed under the muscle, through an incision underneath the breast fold, are generally considered the safest option. This approach aims to reduce the risk of capsular contracture and ALCL, and often results in a more natural look and feel.
A tummy tuck removes excess skin from the central abdomen below the belly button and typically tightens stretched abdominal muscles, often addressing diastasis recti (muscle separation) and umbilical hernias resulting from pregnancy.
Significant risks include fluid accumulation (seroma), electrolyte problems from fluid shifts, pulmonary edema, lidocaine toxicity from overdose, and, in severe cases, accidental puncture of organs like the lungs or liver, especially with large volume liposuction.
Brazilian butt lifts carry a high risk of fatal fat embolism, which occurs when injected fat inadvertently enters veins in the buttocks and travels to the lungs. This complication is difficult to treat and has led to multiple deaths.
Yes, responsible plastic surgeons frequently turn away patients, especially those seeking liposuction for weight loss, those with body dysmorphic disorder, or individuals who display red flags like badmouthing previous surgeons, as these patients are unlikely to be satisfied with surgical results.
These procedures are not without risk; for example, filler injections near the eyes have been linked to reported cases of blindness due to arterial obstruction. Lasers and peels can cause permanent pigment damage, and unsterile practices in procedures like 'vampire facials' have led to infections like HIV.
41 Actionable Insights
1. Prioritize Hospital-Privileged Surgeons
Choose surgeons who have hospital privileges for the specific procedure you need, as hospitals rigorously vet doctors’ training, expertise, and malpractice history, ensuring a higher standard of safety.
2. Research Plastic Surgeons Thoroughly
Approach the selection of a plastic surgeon with the same rigor as choosing a surgeon for heart or brain surgery, conducting thorough research to ensure you find the right, qualified professional.
3. Patient Due Diligence Critical
Since regulatory environments often lack restrictions on who can perform procedures, patients must take responsibility for thorough research and due diligence to ensure their safety and desired outcomes.
4. Understand MD Practice Scope
Be aware that in the U.S., any physician with an MD can legally perform any procedure, highlighting the critical need for patients to verify a doctor’s specialized training and board certification for the specific procedure they seek.
5. Ask About Complication Plan
Ask the surgeon for their detailed plan if complications arise, specifically inquiring about their hospital privileges for the exact procedure you are undergoing to ensure proper care.
6. Inquire Complication Incidence/Management
Ask plastic surgeons about the specific incidence rate of complications for your procedure and their detailed plan for managing each type of complication if it occurs.
7. Understand Complication Costs
Discuss and clarify with your surgeon how complications are managed from a cost perspective, in addition to the medical management, before undergoing a procedure to avoid unexpected financial burdens.
8. Choose Trained Filler Professionals
For filler procedures, ensure they are performed by individuals who are highly trained and experienced in the anatomy of the area, as improper injection can lead to severe harm, including blindness.
9. Skepticism for ‘No Risk’ Procedures
Apply the rule that if a procedure promises no risk, no recovery, no downtime, and low cost, it likely yields no significant or lasting result, and may even carry hidden dangers.
10. Prioritize Patient Well-being
Seek out healthcare providers who prioritize patient well-being and ethical treatment over financial gain, as this indicates a commitment to genuine care.
11. Seek Humble, Honest Surgeons
Look for surgeons who exhibit humility and honesty, especially regarding mistakes or complications, as this is a sign of a good and trustworthy practitioner.
12. Expect Doctor Honesty
Expect and seek honesty and open communication from your doctors, especially if a complication arises, as this fosters trust and better management of your health.
13. Choose Doctors Embracing Complications
Select doctors who openly discuss and ’embrace’ their complications, rather than hiding from them, as this indicates a commitment to learning and patient care.
14. Inquire About Surgeon Experience
Ask potential surgeons how long they have been performing a specific procedure and how they acquired their training for it, looking for extensive experience.
15. Verify Surgeon’s Training
Inquire about where a surgeon trained and in what specific medical field to ensure their background aligns with the procedure you are considering.
16. Request Patient Referrals
Ask the surgeon for referrals to previous patients who have undergone the procedure, allowing you to discuss their experience and satisfaction.
17. Review Before/After Photos
Request to see a surgeon’s before and after pictures of their work to evaluate their aesthetic results and skill, ensuring they align with your desired outcome.
18. Apply Surgeon Selection Questions
The questions for selecting a plastic surgeon are valuable and applicable to choosing any doctor for procedural medicine, including surgical and dermatologic procedures.
19. Minimize Anesthesia Duration
Recognize that longer anesthesia duration increases complication rates, so seek efficient surgeons, especially for larger procedures, to reduce your exposure.
20. Choose Surgeons Managing Complications
Select a surgeon who is capable and prepared to manage any complications they might create during a procedure, indicating comprehensive skill and responsibility.
21. Exercise Extreme Caution
Due to lax regulations and profit-driven practices in some areas of plastic surgery, patients must exercise extreme caution and conduct thorough research to protect themselves.
22. Patient Research Responsibility
Understand that the primary responsibility for researching surgeons and procedures falls on the patient, especially in less regulated cosmetic fields.
23. Use ASPS Website for Research
Utilize the American Society of Plastic Surgeons (ASPS) website as a valuable resource to gain knowledge about procedures and their associated risks before undergoing any cosmetic treatment.
24. Liposuction Not for Weight Loss
Do not consider liposuction as a primary method for weight loss, as it is designed for subcutaneous fat removal and not for addressing overall body weight or visceral fat.
25. Prioritize Diet & Exercise
For weight loss, prioritize diet and exercise over liposuction, as gradual weight loss leads to better health, appearance, and is a more effective use of resources.
26. Recognize Body Dysmorphic Disorder
Be aware of signs of body dysmorphic disorder (e.g., SIMON: single, immature male, overly narcissistic, fixated on a body part), and understand that counseling, not surgery, is the appropriate treatment.
27. Accept Surgical Refusal
Be prepared for a surgeon to decline a procedure if they believe it won’t address the root issue or is not in your best long-term interest, even if mechanically possible.
28. Avoid Badmouthing Past Surgeons
When seeking new surgical opinions, avoid immediately badmouthing previous surgeons, as this can be a red flag for new practitioners and suggest unrealistic expectations.
29. Be Aware of Filler Blindness Risk
Understand the severe risk of blindness associated with facial fillers, especially when injected near the eyes or in the forehead/eyebrow area, due to arterial obstruction.
30. Caution with Vampire Facials
Exercise extreme caution with ‘vampire facials’ (PRP treatments) due to reported cases of HIV transmission from inadequately cleaned and processed equipment.
31. Correct C-Section Scars
A tummy tuck procedure offers the additional benefit of correcting issues arising from C-section scars, such as scar tissue, indentations, or skin overhang.
32. Skepticism for ‘Magic Wand’ Fat Loss
Be skeptical of non-invasive fat reduction technologies like CoolSculpting that promise easy results, as their efficacy and safety are often questionable and may lead to contour irregularities or burns.
33. Understand Psychological Impact
Recognize that cosmetic procedures can address not only physical concerns but also significant psychological issues, potentially improving a patient’s self-perception and quality of life.
34. Seek Holistic Problem Assessment
Look for plastic surgeons who critically assess whether a problem can truly be fixed surgically or if it requires alternative treatments, indicating ethical practice and patient-centered care.
35. Reset Plastic Surgery Expectations
Understand that plastic surgery is a serious medical specialty, not a service where a ’technician’ can be summoned on a whim, and should be approached with appropriate respect for medical rigor.
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5 Key Quotes
The numbers are probably 90 to 95% of all plastic surgery done in the United States is not done by board certified plastic surgeons.
Zol Kryger
A lie can travel around the world faster than it takes the truth to put its shoes on.
Peter Attia
It's interesting that I probably only get asked about once a year by a patient, are you board certified in plastic surgery? People don't ask that.
Zol Kryger
I always said, if freezing the fat works, why are the Eskimos so fat?
Zol Kryger
If something has no risk, no recovery, no downtime, low cost, it has no result.
Zol Kryger