John LoMonaco, MD, FACS, runs a state-of-the-art plastic surgery practice in a restored historic residence

Like most successful plastic surgeons, John LoMonaco, MD, FACS, owns a stylish house. However, the house in question isn’t where he lives—it’s the home of his thriving Houston practice. And what a home it is!

Built in 1917, meticulously restored, and distinguished by a structurally integrated façade of hand-hewn Texas limestone, the two-story former domicile is a local landmark that draws droves of admirers. Invariably, some end up as LoMonaco’s patients.

The house is located in the Hyde Park section of Houston, a mixed-use neighborhood of elegant old homes (most of them restored to mint condition), retail shops, and tony restaurants. LoMonaco snapped up the property while searching for a place to establish a medical spa. “I wasn’t thinking about office space,” he recalls. “But this old house had so much charm and good vibes that I thought, ‘Wow, this would be perfect for my office, too.’ ”

Practice Profile

Name: John LoMonaco, MD, FACS
Location: Houston, Tex
Specialty: Plastic surgery
Years in practice: 5
Patients per day: 10
New patients per year: 200 surgical consults; 250 nonsurgical treatments
Days worked per week: 5–6
Number of employees: 5
Office square footage: 4,200

Curb appeal was only the half of it. LoMonaco figured that, with the right touches, the interior could be made every bit as glorious as the exterior. “I wanted to create an atmosphere that patients would find comfortable and nonthreatening, just like in their own homes,” he says. “My thinking was that, if I could get prospective patients to feel more at ease when they first walked in the door, they would be more inclined to choose me as their plastic surgeon.”

LoMonaco has done a superb job of introducing just such an ambiance and minimizing the office’s clinical attributes. When you tour the 4,300-square-foot structure, you see hardwood flooring throughout (except in the high-traffic areas, where the floor is terrazzo tile), Persian rugs, pastel-hued walls, upscale window treatments, fine furniture, tabletop lamps with incandescent bulbs (even in the two examining rooms), and a working fireplace. “I personally selected many of the interior design elements and colors,” LoMonaco says. “I even welded the wrought iron on the gates and doors myself. My personal stamp is all over everything here.”

So is the stamp of the house’s first occupant: the man who built it, who was the owner of a Texas quarry—where all of that limestone came from. He constructed it as a one-story stuccoed bungalow, and added the second floor and the limestone façade around 1930. “His wife had gone back to her native Germany for a 6-month family visit; while she was away, he remodeled the house as a surprise,” LoMonaco relates.

LoMonaco bought the house in 2003. In the as-purchased condition, it was not suitable for use as a plastic surgery office and medical spa. Accordingly, it was necessary to pull out all of the ancient plumbing and wiring, then replace them with modern, up-to-code, commercial-grade materials. 

“Other than that,” he says, “the rest of the house was in very good shape and structurally sound. It had been very well-constructed.” The office occupies the ground floor, and the spa is upstairs.

Postbariatric Focus

As a plastic surgeon, solo-practitioner LoMonaco performs the usual gamut of aesthetic procedures, but mainly breast and body-contouring work—with an emphasis on postbariatric-surgery patients.

Almost all of his surgeries take place at one of two nearby hospitals. LoMonaco says he prefers using those (as opposed to independent outpatient centers), because the majority of body-contouring cases involving massive-weight-loss patients are complex, lengthy procedures that require a team approach and at least one postoperative night of inpatient skilled nursing.

“A hospital setting gives me all of the levels of care that I might need to access, including 24-hour x-ray services, labs, and pharmacy,” LoMonaco stresses. “I’m a lot more comfortable with that, and so are my patients.”

The relative handful of procedures he performs away from hospitals are minor ones, and they are conducted in his office. The office is equipped for laser procedures, photofacial work, chemical peels, and botulinum toxin Type A treatments.

Approximately 30% of LoMonaco’s caseload is reconstructive. “I still take those calls, just to keep things interesting,” he says, insisting that he has no desire to see his mix evolve to 100% aesthetic—unless every aesthetic case could be a postbariatric body-contouring job. “I could do those to the exclusion of everything else and still be happy, because they’re each so different in terms of the challenges involved,” he asserts.

It is fortunate that LoMonaco feels that way, given that he is seeing more and more of these patients. “I think postbariatric body contouring is going to emerge eventually as a new subspeciality,” he says. “The growth in the number of rapid-weight-loss patients will just about guarantee that. These are patients with needs unlike those of other types of aesthetic-surgery patients.

“For example, compared to the typical ‘tummy-tuck’ patient, the massive-weight-loss patient has skin that is more difficult to redrape and fit to the contours of the ‘new’ body, which means you often must perform the surgery in stages over a period of months to obtain the results you want.

“Also, there are psychological issues that arise from the fact that the postbariatric patient is seemingly a new person. The once-obese individual has to get accustomed to no longer being a societal castoff; this process often produces inner turmoil until the patient’s self-image catches up to the realities of his or her new body. So, you have to make sure the patient is in a good place psychologically before you start talking to them about plastic surgery.”

LeJour for Breast Lifts

A surgical technique that LoMonaco prefers to perform for his postbariatric patients is the LeJour breast lift, a short-scar procedure that simultaneously raises the position of the nipple and shortens and narrows the breast.

“The LeJour, along with other vertical techniques, has been the standard outside the United States for about a decade, but is only now catching on here,” he notes. “I like it because, with challenging weight-loss patients, it gives me a lot more flexibility in the operating room and results in a superior shape with less scarring. But it’s not a cookie-cutter or paint-by-numbers operation. The freehand markings can be a challenge, and that generates a rather steep learning curve.”

To promote faster healing following surgery, LoMonaco routinely sends postbariatric patients upstairs to the medical spa, where they receive lymphatic massage at the hands of certified therapists. “Postoperative swelling is the biggest complaint from patients for the first 3 months after major body-contouring procedures,” he says. “Lymphatic massage dramatically reduces that swelling and improves circulation. It makes a huge difference for the patient.”

On an “Ultrasound” Footing

Along similar lines, LoMonaco offers diagnostic and therapeutic ultrasound to find seromas. “Fluid collection is a complication that shows up in about 25% of patients who experience massive weight loss,” he explains. “I’ve encountered seromas often enough that it made sense for me to invest in this equipment.”

The ultrasound system LoMonaco owns is a portable model, about the size of a lunch box. It is simple to operate; however, LoMonaco says he experimented with it for several months before he was confident enough to fully incorporate it as a practice adjunct.

In addition to pinpointing seromas, the technology allows him to perform in-office guided drainage. “Previously, these pa­tients had to be referred to a radiology center,” says LoMonaco. “Now, we diagnose and perform drainage right here. That saves my patients and me enormous amounts of time, trouble, and expense.”

Another tool in LoMonaco’s armamentarium is digital imaging, which he finds is an efficient means of documenting his work. He has been taking digital pictures for several years and has accumulated a rather extensive archive. “The images are keyed so that they can be easily searched and quickly retrieved by patient name, patient type, or body region,” he says.

Importantly, the images he presents in consultation are of past patients whose ages and body types are similar to those of the prospective patient. “The temptation is to show the pictures of the gorgeous 21-year-old swimsuit model you worked on, because it makes you look so very skilled,” he says. “But the problem with ‘brag-book’ pictures is that they promote unrealistic expectations when you show them to the 39-year-old housewife who has had four kids.”

LoMonaco makes a point of seeing each patient two or three times before surgery. The first encounter with a patient serves as an occasion to impart information about the contemplated procedure.

“I don’t believe in closing the deal during the first encounter for the reason that I want the patient and me to get to know each other, to make sure we have the same expectations,” he explains. “Also, patients tend to be better satisfied with the results of surgery if they don’t feel like they were pushed into to going forward with it.”

However, LoMonaco’s authorization-seeking approach isn’t one of total passivity. After that first encounter, he ratchets things up a notch by actively striving to get patients back in for the second visit. One method he uses is to send prospects a follow-up letter 10–14 days later, inviting them to schedule an appointment for a serious chat about the proposed surgery. If that elicits no response, LoMonaco’s patient coordinator then contacts non-respondents by phone in a bid to address concerns that might be behind their hesitation.

The third encounter occurs after the patient authorizes surgery, and it is typically reserved for the day prior to the operation. On this occasion, LoMonaco performs markings for his more involved procedures (such as body lifts) in front of a full-length mirror. “This gives the patient the ability to provide feedback while I explain what the surgery will alter and what the realistic limits of that alteration are,” he says. “Again, it’s about good management of expectations.”

Wind at His Back

In Houston, everyone talks about the weather—especially hurricanes. Lately, the one they’ve been talking about most is this past summer’s Katrina, which changed a lot of lives in Houston and in New Orleans, just across the state line. But the hurricane that had the biggest impact on LoMonaco was Allison in 2001, which he credits with spurring him into private practice. “Allison destroyed the teaching hospital where I was working, the clinic where I saw patients, and the research facilities we used at the medical school, so I was out of a job.”

The fact is, LoMonaco had been contemplating entering private practice for some time prior to Allison; the hurricane merely jump-started and fast-tracked his transition from academia. LoMonaco officially hung out his shingle in 2001 by renting space in the office of another plastic surgeon. Two years later, he went completely on his own with the move into the Hyde Park historic home.

Hurricanes never caused much uprooting 250 miles north of Houston on the Dallas ranch where LoMonaco spent summers growing up—and where he showed an early interest in plastic surgery. “One of the chores on the ranch was cutting the horns off the cattle,” he says, adding that “it really bothered me when they weren’t cut symmetrically.”

As an undergraduate at Austin College in Sherman, Tex, he prepared himself for the artistic aspects of plastic surgery with a liberal-arts education that included an independent study of Renaissance architecture and sculpture in Florence, Italy. “The Italian Renaissance was all about form, symmetry, and clarity,” he offers. “Florence to me was the ultimate embodiment of art and science, and that pretty much defines what plastic surgery is to most of us.”

LoMonaco went on from there to medical school at the University of Texas Health Science Center in Houston. He completed a general surgery residency at the Texas Medical Center’s Memorial-Hermann Hospital and M. D. Anderson Cancer Institute, during which he participated in tissue-healing research and played a role in developing skin substitutes for burn victims.

This was followed by plastic surgery training, also at the Texas Medical Center, which included an accredited fellowship. Afterward, he spent 2 years as an assistant professor of plastic surgery at the Health Science Center and also served as the director of plastic surgery at Lyndon B. Johnson General Hospital there.

In total, LoMonaco has lived in Houston for more than 20 years. His personal residence today is just a limestone’s throw away from the Hyde Park office. But, frequently, new patients, as they walk in and begin marveling at the place, assume that the stately abode is where LoMonaco dwells.

“The most common question I’m asked is whether I live upstairs,” he chuckles. “I don’t mind that question. Believe it or not, I want people to think I live here. It just adds to the homey atmosphere, and helps make the patient more comfortable. If the patient is comfortable, I’m comfortable. That’s good for both of us.” PSP

Rich Smith is a contributing writer for Plastic Surgery Products.