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Practicing civic medicine

Article-Practicing civic medicine

When she was 13, Susan E. Downey, M.D., accompanied her father, a rehabilitation physician, on a six-week volunteer mission trip to Mysore, India. She and her brothers watched as their father, Dr. John Downey, helped a colleague set up a hospital-based rehab facility.

"I remember seeing my dad being able to change things. With his skills and knowledge, he set up a center that would help change these people's lives.

"We all got a first-hand glimpse of what could be done, and I think that started us on this path," she tells Cosmetic Surgery Times.

The younger Dr. Downey, a board-certified plastic surgeon and voluntary faculty member at University of Southern California, says through plastic surgery, she works to change lives — especially when working with massive weight loss patients and during frequent voluntary trips to Third World countries to treat children's deformities.

Dr. Downey, who practices in Los Angeles, did not plan to focus on treating post-weight loss patients, although she did research early in her education studying obesity and fat metabolism. The area of specialization sort of "fell into her lap".

How it started

It was 1990 and Dr. Downey took numerous skin tags off a woman who had bariatric surgery and was part of a bariatric support group.

"She told everyone in the support group that I was the only one to go to. Her bariatric surgeon had just started doing the procedure, and he came to me and said, 'My patients want you to operate with me.' It started a long relationship," Dr. Downey says. "(Colleagues) would make fun of me when I went off to do these procedures."

There was no blueprint for planning cosmetic surgeries for patients who had lost 100 pounds or more.

Patients would approach Dr. Downey with their ideas and Dr. Downey would proceed, learning along the way from experience and by exchanging ideas with colleagues on the American Society for Plastic Surgery's (ASPS) Bariatric Taskforce.

"It was learning as you went, and it still is," she says.

One of the biggest lessons that doctors have learned about these patients in the last 15 years, Dr. Downey says, has been accepting the fact that post-massive weight loss patients are different than traditional plastic surgery patients.

"I think these patients are different from the standard cosmetic patient coming in for a tummy tuck, just as pediatric patients are different from adult patients," she says. "You have to approach them differently; you have to stage them differently; you have to anticipate other procedures being done in the future; you have to anticipate how what you are doing in one area will affect what you are doing in another area."

And it can take years to achieve these patients' goals, according to Dr. Downey. She uses the analogy of renovating a home — tackling what you dislike most first; then doing more in a year or two.

"I am operating on people now that I started operating on seven and 10 years ago," Dr. Downey says.

The dangers inherent in these patients deserve attention, according to Dr. Downey. Seroma formation, for example, is more prevalent in this population; recurrent laxity of the skin is more prevalent in the formerly obese than in those who have a tummy tuck done after having three children. Patients who have had bariatric surgery often have unique nutritional and absorption challenges.

While the work is more complex, the rewards are great, Dr. Downey says.

"As plastic surgeons, we like to take someone who has some physical problem that we can then fix — whether it is a breast cancer patient, and we can restore her breast, or someone who has excess skin who has lost 150 pounds. To me, that is what plastic surgery is all about," she says.

The patients tend to be extra grateful, she says, and they often are willing to accept less than perfect results, including extensive scarring.

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