Thinking about going into cosmetic surgery? A warning story

This student is one who should know better.
The outcome was one of the range of possibilies that could have occured dispite technically normal performance of the procedure.
In no manner has she even posited that there was any deviation from normal good practices by her dermatologist in the performance of the procedure. She is merely dissatisfied with the result, one that she knew was possible and was willing to gamble upon in order to achieve her desired result.

Malpractice is not merely the wish for a better cosmetic result. It requres the doc to perform below the standard of care.

I agree with you on this. I assumed a medical error was made because of the behavior of the physician. I have never met a physician that pays out of pocket for follow up care for a patient in cases of a bad outcome. If you aren’t satisfied with a cosmetic procedure and the doctor did everything right, most docs are not going to volunteer to pay any future expenses you incur like this one did.

Another reason I was inclined to think the doc did something wrong was that she apologized profusely afterwards. When you start your clerkships in your third year of medical school, you learn that apologizing for a bad outcome to a patient is essentially legal suicide. It shouldn’t be like that, but it is. If no malpractice occurred, however, then I agree with the previous poster that no case should be filed.

I am an internist and I perform cosmetic laser procedures, including laser hair removal, like that described in this story.

It’s easy to see how a burn like this might happen, but it should not happen. Reasonable care with settings and handling of the laser handpiece should really prevent problems like this.

The physician factors that may have contributed:
1. Laser settings (Joues/Cm2, pulse length)
2. Inadequate cooling – most lasers use some sort of concurrent cooling to protect the skin. Was it on?
3. Overtreating the same region of skin – were too many pulses applied to the injured location?
4. Was the presence of photosensitizing agents investigated? (tetracyclines, diuretics, recent alpha-hydroxy acids, recent tanning – natural or artificial, photosensitive medical conditions)

Patient factors that may have contributed:
1. Failing to disclose the use of photosensitizing agents, tanning, or medical conditions
2. Failing to disclose a propensity to develop keloids (a relative contra-inidcation to laser hair removal)

The shame of this story is that the physician DID take responsibility, without having to be sued, and so forth, but then stopped taking the responsibility when the threat of a lawsuit was removed. The bright side of this story is that it demonstrates to the doubters that physicians DO take responsibility, it just doesn’t make the headlines and you never hear about it, until there is something to complain about. Shame on this dermatologist for not following through – had the demands become unreasonable at any time she could have argued about them – none of the demands described in the story seem to be unreasonable.

Since this is my story, I thought I should address a couple of things mentioned here in the comments.

First of all, I’m not a physician – I’m a medical student (2nd year). And I WASN’T a medical student at the time of the procedure, or I would have researched the risks myself – I was 18 years old, barely an undergraduate in my first semester of college, and I stupidly trusted my doctor, who told me that my skin may be a little pink after the procedure, but it should fade that evening. Of course the fine print said “scarring, death, etc.” as it always does. But every release form warns of the worst, doesn’t it?

As for my high school photo – I just happened to have that on my computer, which is why I used it as a comparison. It was one year before my surgery, and you can’t see the upper lip hair because it was taken at the end of August and I had a tan. The photo was not meant to be “manipulative”. It wasn’t excessively airbrushed either – that’s what I looked like.

And I didn’t fail to disclose the use of photosensitizing agents, tanning, or medical conditions; nor did I failing to disclose a propensity to develop keloids. I had no idea I had such a propensity – things that I’ve read since say that keloid scarring is most often seen in African-Americans.

What upsets me is not that I was burnt (which probably was faulty laser settings, due to the fact that the procedure hurt BADLY. And I have hereditary pancreatitis, so I know pain. This laser HURT. I almost asked her not to do the other side!) I was upset that my doctor seems to have taken advantage of my naivete. When I got the letter from her lawyer, I cried. I felt so, so stupid for believing her, for feeling that she had my best interests at heart. That hurt worse than the burn, truthfully – leaving a different kind of scar, you know?

I hope everyone here isn’t judging me too harshly, and I do appreciate Kevin for picking up my blog entry.

Of course the risks are to the patient. And of course risks are real, or why would anyone waste time talking about them.

As for covering subsequent surgeries, I have seen doctors willing to do revisions without charge where the patient is not happy with the initial outcome. It is commonplace in cosmetic practice to do this. For non-cosmetic surgeries, practices often do not do this. It is a good thing to do, and it maintains goodwill. I have also seen colleagues who have paid for revision work done by other doctors where that has been the preference of the patient. That can also be a smart thing to do.

This story involves an initial treatment with complications resulting in scarring and disfigurement. Deviation from acceptable care standards is not certain from the offered information. There were subsequent surgeries done by other doctors, a scar revision, then dermal fillers, and another revision all presumably in the interest of improving the cosmetic outcome of the initial procedure. Those procedures themselves carry risk, I am sure you appreciate.

I suppose one might ask how long a doctor who did the initial laser treatment could be expected to pick up the tab for repairs? Until the patient is satisfied enough and doesn’t want more surgery? Until other treating surgeons say to stop?
A lifetime? How much is enough? There is no answer, really. I am sure the treating doctor has already spent many more times the fee earned by the original procedure in trying to make this problem as right as it could be made (sure, trying also to avoid a suit and bad publicity) and yes, the consequences are borne disproportionately, the doctor sees the consequences only when she meets with her accountant; the patient gets reminded every time she looks in the mirror. Four years is a long time though, when it comes to cosmetic outcomes and revisions of revisions done not by the initial treating surgeon, but by second and third surgeons. And while no one wants to go around feeling marked by misfortune, there probably should be a point where the initial treating physician ought to be able to stop voluntarily paying for additional surgery. I do not think drawing the line at four years’ time was unreasonable. When you bought your initial procedure, you paid for surgical care for a surgery that had known risks. There is a professional, ethical and legal responsibility to provide for your postoperative care, which the dermatologist seems to have done, even going well beyond that. But that is not an unlimited obligation.

I have a few questions both to Kim and the doctors who do laser hair removal. As someone who had laser hair removal in the past and who plans to do it again because of a few hairs that popped up after a couple years or so.

Doesn’t the fact that procedure hurt badly a reasonable indicator that there was some error in the settings? This article states that excessive pain should be brought immediately to the attention of technician so that the settings can be adjusted. Kim, did you bring up your eccessive pain right away? Surely, if this was the case doctor had to adjust settings immediately?

I know that I had hardly any discomfort from laser hair removal, and that without any kind of numbing cream. My doctor used GentleLase.

I’m not going to respond to the person who refers to me as a scammer, with the demeaning moniker “Miss Kim”. That’s just ridiculous – I would expect a more intelligent and reasonable discussion from the readers here. But regarding this:

“And while no one wants to go around feeling marked by misfortune, there probably should be a point where the initial treating physician ought to be able to stop voluntarily paying for additional surgery.”

The thing that confuses me, though, is that she made the initial appointment for me to meet with the surgeon in Pittsburgh (before the statue of limitations) to schedule a surgery to bring my left upper lip down to make it more symmetrical – and gave me all indications that she would continue to cover my care until I looked as normal as possible. Or as close to what I looked like before the laser treatment, anyway. (This is always what she promised me, incidentally – I didn’t demand the plastic surgeon visits, the cortisone injections, etc. – they were her idea. She offered them immediately, when she saw my giant swollen face.) But then, when the four-year statue had passed (between my consultation with the surgeon and the actual surgery) her lawyer sent the letter and she refused to pay. And by that time, there was absolutely no legal action to be taken (I just wanted the $1400 surgery covered – it wasn’t easy for my family to afford. I wasn’t looking to make millions.) That’s what makes me think there’s something wrong there.

Y’all, I was just trying to tell my story – chronicle it on my blog so that I would always remember the details. I didn’t expect to draw this much vitriol from some people – especially if those of you who are so critical of me are physicians, who are supposed to be caring healers. I was 18 years old, I believed my doctor, I ended up horribly burnt with a scar. I don’t see how that’s my fault.

The previous post was brought to you by the makers of GentleLase.

I am the anon who mentioned it. I wish I haven’t mentioned the name of the laser. I truly don’t know much about other types of laser and I have no connection to the company. For all I know it was not the type of laser but the skill of my doctor.

HOW LONG DOES IT TAKE TO READ THE BLOG i POSTED ON dEC-06-2006 IN REGARDS TO MEDICAL MALPRACTICE THAT WAS SPURRED BY KIM’S STORY-
I TOLD OF MY STORY WITH MEDICAL MEDIOCIRTY- YET i CANNOT FIND IT ANYWHERE– PLEASE IF YOU FIND IT SEND IT BACK TO ME AT:
AQUAMAN182D@EARTHLINK.NET

I know this woman. I am a doctor. I can’t believe that after seeing the pictures, untouched, of an 18 year old woman with facial disfigurement, that anyone has the right to critique the patient! Yes, all procedures have risks – this case of substandard care was artificially absolved as follow-up care for a major burn with keloid scarring was remediated. However, the patient did trust that the ethically correct move was being made in this regard and the physician mocked her by dropping all guilt as soon as “time for a lawsuit is up!” This is an outrage and a sadness to a profession. Knowing the patient’s character and decency, I assure you that the blog is meant as a warning, not as a critique among all physicians. It is also meant as a testament to the standard of care of which SHE chooses to practice after medical school.