We are pleased to announce the availability of our new plastic surgery and cosmetic surgery forum on the Trinidad Institute of Plastic Surgery website.

The forum is moderated by Trinidad Institute of Plastic Surgery surgeons and physicians and intended to facilitate the discussion of plastic surgery and cosmetic surgery related topics.

Registered members of Trinidad Institute of Plastic Surgery are able to post on the forum, which also features a closed, private mailing system.

We see this enhancement as an opportunity to improve the user experience provided by our website and also facilitate interaction with our clients.

Naleenie Singh-Maharaj, RN, BSN, CCRN, TNCC, MHSA, MBA

CEO, Trinidad Institute of Plastic Surgery

Trinidad Institute of Plastic Surgery is proud to announce to availability of a multimedia telemedicine, virtual conferencing and virtual consultation service starting February 1, 2012.

The system made available by Bioengineering Associates, our US based management and healthcare consulting company, allows voice, video and chat interaction through a virtual private network server.

It is intended to provide patient and physician access to highly trained specialists in plastic surgery, hand surgery, burn surgery and craniofacial surgery with otherwise limited availability in Trinidad and the Caribbean. Telemedicine is expected to make a major impact on healthcare delivery in this decade.

In the initial phase Dr. Schleich, Chief of Plastic Surgery, Plastic, Hand, Craniofacial and Burn Surgeon, and Dr. Ramkissoon, Chief of Anesthesia and Specialist in Pain Management, will be available for interaction on this system.

Scheduling is possible on a 24/7 basis through Trinidad Institute of Plastic Surgery Global Access.

Naleenie Singh-Maharaj, RN, BSN, CCRN, TNCC, MHSA, MBA

CEO, Trinidad Institute of Plastic Surgery

So Pandora’s box was finally opened. The eventual worldwide recall of French Polyimplant Prothese (PIP) silicone breast implants puts a final exclamation mark behind what everybody knows but hates to admit – cheap is bad, to be cheap you have to cut corners to cut costs and cutting corners – such as using industrial instead of medical grade silicone (besides other substandard manufacturing practices such as inferior easily ruptured shells) – costs in the end.  An estimated 300000 women were implanted PIP silicone implants, mainly in countries with low level of medical care and deficient in plastic surgery training and acumen, such as Venezuela, Belgium, Poland, Czecheslovakia etc. It doesn’t stop in third world and quasi third world countries. UK surgeons  allegedly succumbed about 40000 times to the same error, French surgeons around 30000 times and Australians, Austrians and Germans line up right behind to match the price of their competitors down the road or across the border.

Like a knee jerk reaction comes the desire to blame somebody after the company PIP is not any longer available to take the fall having gone to bankruptcy  heaven months ago. What I am going to say now will not be popular, like any truth. No single entity is to blame, it is everybody’s and thus nobody’s fault.

Regulatory oversight  according to European Community standards over the manufacturing of a high risk medical device failed miserably. Nobody noticed for years that this crap did not conform any longer to the CE specifications and European Medical Device Directive ? Give me a break. Want to sue somebody over PIP implants – these are the people to start with wanting the company itself as a primary culprit. Without the CE label the device could not have been used legally in the European Community and close to 100000 women would likely have been spared the fate to agonize over the decision what to do now.

Blame the surgeons – always popular, and at least in this case partially correct. Any surgeon naive enough to make him or herself believe there is no difference between an implant costing around 200 USD per pair and one costing around 1500 USD/pair should voluntarily stop practicing because this degree of stupidity might affect all decisions he or she makes. But according to the CE label the 200 USD/pair joke was at least harmless, as this is what the CE label essentially means. It signifies safety, not much more, particularly does not imply any effectiveness. So in the mind of the naive a safe device was used, no less.

Now very unpopular – the consumer may have some responsibility for his/her decisions. You get what you pay for, literally, that is the essence of consumerism.  Cosmetic surgery is a luxury good and it has the price tag of a luxury good. Anything cheaper means corners have to be cut. Properly trained plastic surgeon, experienced, certified by a reputable specialty board (no, not the one in Santa Somewhere), with enough training, experience and judgment to know the difference between a good and a cheap implant, high end implants and equipment, respected hospital, first class anesthesiologist – all are on the same level as German luxury cars. And those don’t come at a price of some bamboo cart held together by dried spit, just ask your local dealer.  So no, the consumer was not cheated, consumers did what they do best, consume based on the number on the price tag of the good they desire, short sighted to what that number actually means. Consumers, who do not look beyond that number, will always get what they pay for, particularly in cosmetic surgery.

So what now – after all PIP implants may result in health related  problems ?

If there is any clinical evidence of  device failure, explantation or exchange are the only two options, like for any ruptured silicone implant regardless of the manufacturer. In my opinion explantation is aesthetically unfavorable, but the desire of the client should certainly take precedence. Without clinical evidence of device failure a more difficult situation arises. The options are watchful waiting, watchful waiting with imaging surveillance to screen for silent rupture (as mandated by the FDA for Allergan/Mentor silicone implants in the US) or prophylactic exchange/explantation of any and all PIP silicone breast implants. The speculation of French health authorities that breast cancer risk in women with PIP implants may be increased contradicts all biologic knowledge about silicone, is not substantiated by their data at the present moment and may not be a valid argument for prophylactic exchange/explantation at this time.

When data is lacking, opinion is abundant – so here are my five cents:  a woman having PIP implants obviously has a substandard device implanted, which will likely have to be exchanged or explanted at some time, even in the absence of clinically evident rupture at present. If the personal health related concerns of the woman are high enough I would advise exchange of implants for a high end device such as Polytech, Silimed, Mentor or Allergan. Explantation alone should be performed if the client is clear about the aesthetic consequences and absolutely does not desire implants any more.

View Healthgrades for Dr. Schleich here. Healthgrades is one of the better organized and objectively reviewed rating organizations in the US.

Dr. Schleich performed plastic surgery on me in early 2011, which comprised decompression of multiple nerves in the craniofacial region, reshaping of my skull as well as septo and rhinoplasty. While being done with techniques used in cosmetic surgery, the primary purpose of the entire procedure was to relieve my severe migraine headaches. I had been suffering for 17 years on a nearly daily basis from severe and sometimes incapacitating migraine attacks. I had been on various chronic medications to suppress the severity and frquency of those migraine headaches. Dr. Schleich had performed botox injections into several trigger points previously and I experienced significant, but temporary relief of migraine from botox. Dr. Schleich thus considered me a good candidate for the surgery. Dr. Schleich’s skill and professionalism are amazing. He is extremely honest about what the possibilities are as far as surgical outcomes. I felt confident that I would be in good hands, and now almost a year after surgery, I  am happy to report that I was absolutely right. My migraines have been relieved by more than 90%, and Dr. Schleich provided the best care I could possibly have imagined before, during and after the procedure. I have thanked him repeatedly, and do so again!

The consultation is an indispensable preliminary for everything else. It establishes the framework for counseling and the exchange of medical information – the famous benefits, risks and alternatives for any treatment. Cosmetic surgery is mainly the change/enhancement of parts of the human body. This is highly individual and has to be analyzed at least by “look and feel”, sometimes in more depth. So the client really has to meet with me. The only exception I make to this rule is for my international clients, where a phone consultation with pictures of the area where correction is desired is conducted prior to the client coming to Trinidad. This minimizes the surprises and possible disappointments in our experience and to date I have not yet been forced to change the operative plan based on findings at the preoperative visit that were not apparent during the phone consultation. But I am sure there is going to be a first here, too.

“Before treatment the gods have put diagnosis” – I forgot who said that, but it is an immutable truth. Without making a correct diagnosis the correct treatment plan cannot be formulated. At the consultation the analysis of the problem results in a diagnosis. From the diagnosis the possible treatments follows logically. A popular example is breast augmentation – sagging of the breasts to the degree incompatible with the placement of implants (even very projecting ones) has to be diagnosed as the treatment then becomes a lift, possibly with an implant. A close runner up is liposuction of the torso – areas of skin laxity and overdistension or underlying muscular changes in the abdominal wall should be treated differently than mild excess adiposity in the belly with tight muscles and skin for optimal outcomes, no matter how much “research” or “reading online” is done or what the friends say. Consciously choosing a suboptimal procedure despite having been educated to the contrary is certainly an option for a variety of reasons (cost, convenience, scars etc.) and it is part of the counseling and education aspect of the consultation to ponder upon the various trade-offs. As I am a perfectionist I occasionally reject performing suboptimal procedures, particularly if the likely result and the understanding of trade-offs exhibited by the client are to far off for my taste.

Once the treatment/procedure are determined it makes sense to talk about cost. Neither my office staff nor myself can give information about cost over the phone prior to completing a consultation. For the hypothetical “average procedure” hypothetical “average surgical fees” are posted in the cosmetic surgery price list, regardless of the applicability of the procedure to an individual situation. Anything more specific or detailed can only be done during a consultation.

So the answer to “What is the cost of … ?” is “Initially, everything costs the same – the consultation fee”.

I am thirty years old and have had large breasts from my teenage years.  It was really uncomfortable for me as my shoulder and back would hurt from the weight.  In addition, because of the size of my bust, I my choice of clothes was limited.  I became very conscious of my bust size, and sometimes got depressed, especially when I could not wear certain styles of clothes and could not fit into a swimsuit they way I would like to.  I decided to do some research concerning breast surgery and I found the Trinidad institute of Plastic Surgery.  I sent an email and got a response not before long.  Not long after that email, I was contacted via phone by Dr. Schleich who outlined the procedure of breast reduction to me, including the long term effects.  He was very professional at doing this, and right away I decided that I wanted him to perform the procedure for me. While in Dr. Schleich’s care, I felt safe, comfortable, and respected.  He took time to explain everything and was very professional.  After my surgery, I had professional follow up care done by Dr Schleich, and the results are amazing and life changing. He did an excellent job for me.  By breasts is smaller, firmer and youthful looking. I don’t even have to wear a bra if I don’t want to. The best part is that I can now fit into any clothes and swimsuit that I want to and the weight is gone. My body is more proportionate now.  It is now six months post surgery, and I am very happy and satisfied with the results. Moreover, my husband loves them.  I will recommend Dr. Schleich to anyone who wants to have this procedure done.  He has an amazing staff and he is excellent.  He is professional, and has years of experience.
Simone (Bridgetown Barbados)

I am 49 and had one delivery seven years ago by C-section which played havoc with my tummy. I was
left with quite a big roll of skin hanging apron-like which was very unsightly. I know I am a small-boned
person, but the size of my tummy meant I had to wear larger-sized clothes which were ill-fitting. I visited
with Dr. Schleich in January and he told me that no amount of exercise (I used a cross-trainer) would reduce
the tummy as the muscles were too stretched and slack. He suggested a full abdominoplasty with lipo
suction of the waist area which I had done in March 2011.
His bedside manner is great, friendly but professional and never once did I feel uncomfortable. The
reassurance combined with realistic assertions was good. Like all operations, it has risks after all,
including death. I liked the fact that he never glossed over these risks, but spelt them out so that I
understood everything before proceeding. After 2-3 weeks of pain and discomfort, the drains came out and
the pain started to decrease slowly but steadily as the tummy size reduced.
Now, almost three months later, the results are nothing short of astounding. I'm pain free and the
scar is healing nicely. I feel great, can exercise more, eat less because I dont feel the need to
over-indulge, feel healthier and as a bonus, my clothes fit well - my tummy is quite flat and actually looks
better than ever- I even have a waist now! I actually dropped two dress sizes (lost about 10lbs) and have had
to ditch a lot of clothes post-op! I could probably just about get away with a bikini now when before all I
wanted to do was just to avoid beaches and pools. Dr Schleich was extremely professional throughout the
process and willing to answer any questions/concerns posed. His follow ups were great and again done in
the most professional manner. I therefore have no hesitation in recommending his services.

Migraine headaches are common in young women and can be extraordinarily incapacitating requiring longterm treatment with medications. Similar to the account of the discovery of a cure we observe migraine headaches not infrequently in our Caribbean plastic surgery practice at Trinidad Institute of Plastic Surgery in younger women presenting for facial rejuvenation with Botox.

Chance plays a big role in medical progress. But luck only meets the prepared mind. A decade ago a plastic surgeon observed that migraine headaches in certain instances disappeared in women receiving Botox injections in the eyebrow and forehead area for cosmetic purposes. Systematic study of this phenomenon resulted in the hypothesis that compression of the forehead nerves by the eyebrow muscles may trigger migraine attacks. These very muscles (corrugators, depressors, procerus) are the target of cosmetic Botox injections. Nerve compression is eased and migraine attacks decrease in frequency and severity once the Botox effect relaxes the corrugators/depressor/procerus complex. However, once the Botox effect wanes after three to four months, headache severity and frequency increased again. Evidence supporting a trigger point/nerve compression theory accumulated when it became apparent that permanent nerve decompression by resection of the compressing corrugator muscles as done during forehead and eyebrow lifting and rejuvenation resulted in a permanent decrease of headache severity and frequency.

After this initial success some types migraine headaches remained unresolved. Further investigations suggested that persistent headaches were related to the location – side of the head and back of the head. Research identified several additional nerves being compressed by surrounding muscles. The process of Botox injections into the areas of compression and surgical decompression was repeated. If Botox injections improved the headaches then this improvement could be made permanent by surgical decompression.

The final bastion was located in the nose. Correction of deviation of the nasal septum during septoplasty and rhinoplasty succeeded in improving headache frequency and severity in conjunction with nerve decompressions.

The path to discovery also outlines a treatment plan for proven migraine headaches with a roughly seventy percent chance of permanently decreasing the severity and frequency of migraine headaches. After confirming the diagnosis, Botox injections are preformed in the dominant compression areas sequentially. If the injections result in improvement, surgical nerve decompression is suggested.

The operation is performed as a combination of a brow lifting technique (most of the time as keyhole surgery with the use of an endoscope), decompression of nerves on the back of the head under magnification through an incision covered by most female hairstyles and a septoplasty or rhinoplasty using invisible incisions inside the nose.

View Trinidad Institute of Plastic Surgery in Caribbean Beat Magazine issue 105 !