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Looking Forward

I always admire your editorials in PSP. It will be interesting to see how diversification plays out (“Looking Forward,” PSP, January 2006, page 8). From an economic standpoint, plastic surgeons expanding into allied fields may make sense.

The flip side is that the physician who positions himself as a “jack of all trades” will see his clinical skills in all of his “trades” diminish. The medical world today, even within a single specialty, is too complicated, complex, and challenging to get one’s hands around all of it and maintain superior skills and knowledge.

Medicine advanced when specialization took hold. The one truth is that the most specialized physicians or surgeons tend to be the most capable. The generalist can never match the specialist, and the specialist can never match the superspecialist.

Dollars are another story. It will remain for the practitioner-businessperson to decide whether he or she wishes to be at the top of the clinical-competence totem pole, or just another business owner with a variety of product lines.

Savvy patients ask us, “Doctor, if you or your spouse or child had this condition, to whom would you go? Would it be the physician-as-businessperson, or the most specialized one you know?”

This is not a criticism of their path in life. Bless them.

My point is that younger physicians should realize that as they expand their professional or business scope, they will fall behind clinically. You cannot have it both ways.

Keep the good stuff coming.

Robert Kotler, MD, Beverly Hills, Calif
rkotler@pacbell.net


Drainage Following Liposuction

I offer this counterpoint to the recent description of the novel technique “drainage following liposuction” (PSP, January 2006, page 48).

I believe that the author may have overstated the problem of postliposuction swelling, pain, and bruising. In my hands, using the standard superwet technique and infiltration solution, I have rarely experienced the degree of echymosis that the author shows. Furthermore, in patients who undergo liposuction limited to the abdomen (as in the author’s example), rarely can I recall a patient complaining of significant swelling or pain.

A single-suture closure of my two entrance wounds still allows dependent drainage of residual tumescent fluid. When we plastic surgeons struggle to place our stab incisions in hidden locations (for example, the panty line), it seems incongruous to riddle the entire abdominal wall with a shotgun blast of small incisions, however small they may be.

To be effective, the incisions must logically penetrate through the dermis and superficial fat layer (that many of us preserve) and extend into the deeper flat plane to stand any chance of tapping into the tumescent solution. I note that the photo of the soaked dressing demonstrates drainage only inferiorly—the same as achieved with my time-honored technique—while the superior portion of the author’s dressing is still dry!

Respectfully,

John L. Baeke, MD, Overland Park, Kan
jbaeke@parkplaceusa.net