Sent: Monday, October 06, 2003 2:06 AM
To: barry.zide@med.nyu.edu
Subject: I AM AN EXPERT IN ANYTHING YOU WANT
Dear Dr. Zide:

Regarding
your mention of the surgeon who sued his patient for  posted her
morphed photos on the Internet: Is the surgeon from Boston?  Is this
the Feldman v. Iacovelli case?

Just curious.
_______________________________________________________________________
Subj: RE: I AM AN EXPERT IN ANYTHING YOU WANT
Date: 10/6/2003 12:22:08 PM Eastern Standard Time
From: barry.zide@med.nyu.edu

Subj: Potential revision surgery
Date: 04/21/2000
To: zideb01@popmail.med.nyu.edu

Dear Dr. Zide:

I
was referred to you by Diane from NH, on whom you performed a revision
on her navel from a previous tummy tuck.   She had wonderful things to
say about you and encouraged me to consult you about my problem.
 
I  
had unfavorable results from facial surgery performed 3 years ago and
would greatly appreciate your reviewing my pictures and operative
reports to determine whether some improvement may be possible.  I
realize it is difficult to form an opinion without the benefit of an
examination of my face, but this seems like a good place to start.

I
had a full facelift and lower blephroplasty on 11/24/97 followed by a
rhinoplasty 8 weeks later on 01/28/98.  The results of the facelift at
8 weeks was favorable, however, I experienced severe swelling after the
rhinoplasty.  All areas undermined in the facelift and lower bleph
seemed to stretch and the tissue has never returned to its previous
integrity, as is apparent in the photos.

I have attached a
series of photos to this message.  I appreciate your taking the time to
review my material and look forward to hearing from you.

Sincerely,
Lucille M. Iacovelli
(operative reports attached)
________________________________________________________________________
Subj:  Re: Potential revision surgery
Date: 04/22/2000 1:13:47 PM Eastern Daylight Time
From: zideb01@popmail.med.nyu.edu (Barry M. Zide M.D.)

I know both attending surgeons very well,so you must have been done as a
clinic patient at the hospital .In some of tour pictures your head is down
so it's hard to say what the problem really is .I might have done your nose
differently,but it's not bad.I guess I would have to see you. Have you lost
a lot of weight?
________________________________________________________________________
Subj: Re: Potential revision surgery
Date: 04/24/2000
To: zideb01@popmail.med.nyu.edu

zideb01@popmail.med.nyu.edu writes:
> >you must have been done as a clinic patient<<
Yes, I was.

>>I might have done your nose differently,but it's not bad<<
I
actually like the  way my  nose turned out, since I did not want it to
look very different.    However,  I did not expect that cutting off my
nose would spite my face in such an unattractive manner..

>>Have you lost a lot of weight?<<
No,
I have gained almost 20 lbs over the past 2 years and weigh more than I
ever have in my life at 135 lbs.  My weight never fluctuated more than
5 lbs over the past 25 yrs.. I was 118 lbs at the time of my surgery.

Dr. Zide, I know you will have to examine me to properly evaluate the situation, but here's my take on what happened: 
The
facelift involved a sub cutaneous and extended sub SMAS dissection,
executed by hydrodissection under high pressure.    the  newly forming
adhesion of the facelift  were "broken" or compromised from severe
swelling after the nose job.

This tissue never returned to its
previous state and I am now left with a loose "sack" of SMAS and skin
which is no longer attached to the underlying muscles of expression. 
Thus, the distortion of my smile and other facial animation.  Please
note the platysma and parotid fascia has stretched  and because it
still maintains the firm quality  characteristic of this tissue, with
animation, it pulls downward rather than upward when I smile.  I can
"feel" the lack of attachment to the deeper muscles. Where the lower
face would normally pull upward with smiling, it pulls downward or
opposite than it did before the swelling of the rhinoplasty.  It is
difficult to describe or visualize without the benefit of examination. 

Things like swallowing and chewing cause pain in the r.
platysma area.  Actually there is constant pain of some degree present
in that area.  I do not have any motor never damage.  The drooping
corners of the mouth are caused by a profound laxity of all the lower
face due to the permanent stretching of this tissue.

Dr. Zide,
it is my belief that two things caused this damage: 1.) the rhinoplasty
was performed too soon after the facelift and  2.) the use of tumescent
technique in the facelift causes changes in the mechanical properties
of the skin and SMAS that does not occur with conventional dissection.
Therefore, the insult of the subsequent nose job caused swelling that
ay not have occurred with conventional dissection. 

Unfortunately,
I did not take pictures of my face during the period of severe
swelling.  My first instinct was to put a compression bandage under my
chin and/or wrap my face in a similar manner as it was after the
facelift.  However, my surgeon emphatically told me NOT to do this!  On
the second day my neck was swelled out to the degree that it was wider
than the rest of my face, with the weight of the edema pulling down the
corners of my mouth and giving my head a triangular appearance, with my
neck forming the base of the triangle.  (No exaggeration!) 

I
do have sensory nerve damage and could probably sustain a dissection of
my face without benefit of anesthesia.  Once again, this is in all
areas in which hydrodissection was used.  They did not take any pre-op
photos smiling, so I had to rely on snap shots for comparison.  The
earliest picture I have after the rhinoplasty in which there is still
some residual swelling is 3 1/2 weeks later.   I will send these to
you, if you would like to see them.
 
I have yet to find a
surgeon who uses this high pressure introduction of anesthetic solution
to dissect tissue planes in facelifts.  They all say it creates so much
distortion  as to make the rearrangement of tissue difficult to judge. 
When I explained my theory to the surgeons who operated on me they 
snickered and said it was impossible. A few surgeons whom I have
consulted  said they thought the of the distortion was due to
inappropriate vectors of tension.  I agree it gives that appearance, 
however, that is not the etiology of my condition.

There isn't
much written about tumescent technique used in facelifts, and nothing
about the physiological changes of the tissue.  I was able to pull up
one article about some cases of palperbal cutis laxa after rhinoplasty 
that was published in French.  I am having it translated now, but think
it probably will describe the hyperelastosis  is due to  swelling of
the eye area with the tissue sustaining permanent stretching.  Does
this not make sense?  Now, to carry logic one step further, doesn't it
seem all the more probable for a facelift that has had only 8 weeks to
heal would be susceptible to  permanent stretching from the insult of
another facial surgery?

 I have given this much thought and
research.  I never received an explanation as to what happened or why.
.  I was repeatedly told I had a "better than average" result and my
facelift would have healed like this with or without the rhinoplasty. 
In the same breath I was told I must have BDD to think I don't look
better after the surgery than before.  To this, I can comment that it
does not take a rocket scientist or a plastic surgeon to see my face is
sagging and stretched more AFTER these operations than before. 

I
would be interested in making an appointment to see you if you can
maintain an open mind regarding my case and not discount my theory
simply because you have never seen or heard of anything like this
before.  If things are as I believe, there will be limitations to be
considered in a revision surgery and I would want us to be on the same
wavelength as to what is wrong as how to correct it.

Thank you for taking the time to read this!  I appreciate it more than I can say.

Best regards,
Lucille Iacovelli
__________________________________________________________________________
Date: 04/24/2000 12:06:26 PM Eastern Daylight Time
From: zideb01@popmail.med.nyu.edu (Barry Zide)

I don't buy all the theories .the only thing to do is go forward. Have you
seen Dr. Feldman. You should because he was the attending
__________________________________________________________________________
Subj: Re: Potential revision surgery
Date: 04/24/2000

zideb01@popmail.med.nyu.edu writes:
>>I don't buy all the theories<<
What would be your guess as to the laxity?

>>the only thing to do is go forward<<
I agree... however doesn't the nature of the problem influence the strategy for correction?

>>Have you seen Dr. Feldman. You should because he was the attending<
Yes, I have.  He said he has nothing to offer.
_______________________________________________________________________

Subj: Re: Potential revision surgery

Date: 04/25/2000 12:06:26 PM Eastern Daylight Time
From: zideb01@popmail.med.nyu.edu (Barry Zide)

I haven't seen the problem yet

____________________________________________________________________
Subj: Re: Potential revision surgery
Date: 05/04/2000

zideb01@popmail.med.nyu.edu writes:
>> I haven't seen the problem yet<<

I'm
confused by this answer, Dr. Zide.  Have you seen all the pictures
posted in my hotmail account, or just the picture file I attached to my
previous e-mail?  The problem is most evident with animation, however
it is very noticeable in all the post op pictures.  (pictures attached)

I
did go back to see Dr. Feldman through the resident's clinic. The first
time they said I looked fine, even though I obviously did not.  I also
have persistent pain in the platysma on the right side.  I wrote to Dr.
Feldman and he responded by saying something may be possible to improve
my appearance in repose, but I would never have my "old" smile back.  I
then made several attempts to meet with him and because this had to be
handled through the resident's clinic, I was stonewalled at every
attempt. When I called his office I was told he would not communicate
with me except through the clinic, which was impossible.  I told his
secretary I was willing to pay his full consultation fee if he would
see me as a private patient, but was told that once operated on in the
clinic, he will not accept you as a private patient. 

Quite
frankly, I find the operation of the resident's clinic at Mass General
to be lacking in organization. the left hand doesn't know what the
right hand is doing and at this point, I don't want any of their hands
touching my face again!

I was told that you were the best facial
plastic surgeon in NY.  I have read many of your papers and think you
are brilliant.  I respect the fact that you do not agree with my
theories regarding the etiology of my poor results.  I am convinced
that my case is more complex than it appears and cannot be appreciated
without the benefit of an examination.  If you and I can come to some
agreement that the laxity of the lower face is more pronounced than
before the facelift, then I would like to make an appointment to see
you.

Dr. Zide, I really appreciate your time and help more than I can say.

Sincerely,
Lucille Iacovell
__________________________________________________________________________
Subj:  Re: Potential revision surgery
Date: 05/05/2000 9:25:11 AM Eastern Daylight Time
From: zideb01@popmail.med.nyu.edu (Barry Zide)

You definitely look different,and I don't know how to explain it

October 21, 2003

Robert M. Goldwyn, M.D.
1101 Beacon Street  - Suite 6E
Brookline, Massachusetts 02446

Dear Dr. Goldwyn:

I recently received a copy of an editorial published in the July 2003 issue of Journal of Plastic & Reconstructive Surgery titled "I Am an Expert for Anything You Want" by Barry Zide, M.D.   The article was accompanied by this personal note: "Lucille - Thought you would be interested in seeing the comments made about you."

The following paragraph was highlighted:

"What about what recently happened to one of our most esteemed colleagues? The surgeon was supervising fine residents in a cosmetic procedure, which went well. Little did they know that the patient had a huge body-image disorder. Postoperatively, the patient took her preoperative pictures, put them next to her "morphed" postoperative ghoulish pictures, and published them on the Internet. The doctor had to get a lawyer to obtain an injunction to stop her, but he lost business, money, and stature in the interim. Of course, the patient had to pay nothing."

The individual who sent this editorial did not ask if these comments were in reference to me; she knew.  My identity was evident without the use of my name.  As editor of this prestigious journal, I wish to inform you that Dr. Zide's comments are libelous. I demand that you publish an apology and retraction of these statements in the next issue of JPRS to go to print.

The following evidence proves the libelous nature of Dr. Zide's statements:

1. Letter from Richard Maclone, professional photographer, documents his examination of original negatives, prints and Internet images, revealing no evidence of digital manipulation or "morphing". (exhibit 1)

2. Statement by Karen E. Crosby, my former landlady, verifies herself as  photographer of the pictures in question and attests to the fact that the photographs were accurate representations of my true appearance at the time they were taken.  (Exhibit 1)

3. Copy of court order obtained by Joel J. Feldman, M.D. et. al. and Massachusetts General Hospital which prohibits me from publishing misleading photographs of my face and neck on the Internet and elsewhere.   My photographs were not misleading and were never removed from the Internet.  I assume Dr. Feldman and his attorneys are aware that I refused to remove these accurate and informative photographs, yet they have not challenged my ongoing publication of these pictures.  I have included copies of the Internet photos.  (exhibit 2)

4. In April 2000, I sent the same collection of photographs to Dr. Zide for his review and opinion regarding my surgical outcome.  As his e-mail responses show, he never mentioned any suspicion of "morphing" of the same photographs which he calls "ghoulish" in his editorial.  I find his use of such a term interesting, as I was repeatedly told by doctors at MGH that my results were "better than average".  In light of the documented authenticity of my photographs, I find such diverse opinions regarding my post surgical appearance incredulous. (exhibit 3)

5. Regarding Dr. Zide's unsubstantiated comment of my having a "huge body image disorder", I have enclosed fee quotes from six board certified surgeons; (five certified by ABPS and one by AAFPRS).  I consulted these doctors about surgical revision of my poor results from operations at MGH Residents' Plastic Surgery Clinic.   All of these doctors were aware of my surgical history and willing to operate on me, as their fee quotations prove.  Is it possible for all six experienced surgeons, whom I assume are aware of the incidence of BDD in patients seeking revision surgery, would have unanimously overlooked signs of "a huge body-image disorder"?  Would they all agree to operate on a patient they thought might be suffering from such a disorder?    Or would they have offered a surgical correction for what they observed was clearly a poor surgical result?  Please note the dates of these proposed procedures, some as early as May and June and October 1998, hardly enough time for signs of aging to manifest after a facelift performed in November 1997.  Therefore, it is reasonable to assume that these doctors found the poor quality of my results justification for revision surgery in less than one year. (exhibit 4)

6. E-mail was recently sent to Dr. Zide regarding his editorial, asking if his comments regarding the woman who posted her photos on the Internet and was sued by one of his "esteemed colleagues" referred to the Feldman v. Iacovelli case.  He responded that the article was meant for surgeons only, that he purposely did not use names, but would discuss the involved parties only with people he trusted.  As my receipt of this article proves, he did not have to use names in order for my identity to be known.  (exhibit 5)

7. Dr. Feldman's lawsuit and the details of the case were widely disseminated in the media.  The story was picked up by AP and literally appeared throughout the world.  A simple Google search of "surgeon sues patient" generates a long list of links in which my name appears along with Dr. Feldman's. (Exhibit 6).

An act of libel does not require the individual's name be spelled out if their identity is recognizable.  Dr. Zide and JPRS have acted in a negligent and irresponsible manner through malicious publication of false and damaging misinformation about me. Perhaps Dr. Zide or you, as editor, should have checked with the Court on the status of Dr. Feldman's complaint before carelessly publishing libelous statements.   Medical journals do not become outdated, but are permanent sources of reference for all physicians; therefore the damage to my credibility must be amended in JPRS to my satisfaction.   In his editorial, Dr. Zide implies that readers, assumed plastic surgeons, are aware of "what happened" to their "esteemed colleague".  Undoubtedly, that awareness is directly due to the extensive media coverage of Dr. Feldman's lawsuit against me.  It is reasonable to assume that most plastic surgeons would recognize my name if it were to appear in their appointment schedule.
 

I am a single woman living on at poverty income level.  I have learned that "justice" can be bought with power
and financial wealth I do not possess.  Dr. Feldman, Massachusetts General Hospital and their attorneys can and do "buy" as much "truth" as they find necessary to silence someone like myself, who must act in
her own defense without benefit of money and power.

Due to lack of financial resources and physical disability resulting from my revision surgery in April 2001, I was unable to legally defend myself against Dr. Feldman's accusations in a court of law.  He won his restraining order by default.  The court order does NOT prohibit publication of accurate, unaltered, true representations of my post operative appearance on the Internet or anywhere else and I will continue to display my pictures as a public service and warning to those seeking cosmetic procedures of the consequences they may face if they assume their surgeons will act responsibly in the event of a problematic outcome.     Many accusations included in Dr. Feldman's complaint are outright lies, including the statement that his patient cancelled her surgery because she was upset by my pictures.  This woman contacted me and explained the cause of her
emotional upset  was in reaction to Dr. Feldman's pejorative reference to me.  She said she did not care if he was the best surgeon in the world; she did not want a doctor operating on her who would make
disparaging remarks about any patient.  Dr. Feldman lost his patient due to his own actions, not mine.  Dr. Feldman's refusal to meet with me in a timely manner as advised by my therapist and primary care
physician and his ultimate refusal to perform my revision surgery after I had expressed my trust and confidence in him, forced me to seek the opinions of total strangers on the Internet regarding my surgical
outcome. If the doctors at MGH had treated me with the honesty and respect I deserved, I would never have had reason to take such measures.

One picture is worth a thousand words.  Mine speak volumes and will continue to do so. I demand you publish a retraction of Dr. Zide's comments, including an apology and explanation of the facts in a prominent place in your publication.  I demand immediate restoration of my credibility regarding the veracity of my pictures. 
Finally, I ask that you view the enclosed video on CD which includes a review of the same "ghoulish" pictures by a prominent facial plastic surgeon.  You will see that every surgeon does not share Dr. Feldman's
opinion.

I look forward to and expect a response to my request within the next 10 days.

Respectfully,

Lucille M. I acovelli

cc: Barry Zide, M.D., D.M.D.
Department of Surgery (Plastic Surgery)
New York University Medical Center
550 1st Avenue
New York, N.Y. 10016

Barry Zide, M.D., D.M.D.
Department of Surgery (Plastic Surgery)
New York University Medical Center
550 1st Avenue
New York, N.Y. 10016

barry.zide@med.nyu.edu

I AM AN EXPERT IN ANYTHING YOU WANT

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

There
is a Yiddish word that you and every other plastic surgeon needs to
know, and that word is "mishigas," which can be freely translated as
the craziness that you experience from patients and some colleagues.
When you do mostly aesthetic surgery, you are transformed into a major
mishigas magnet, but doing reconstructive surgery does not confer
natural immunity from this affliction. I will expound with examples.

Certain
patients always say the same thing, given an equal opportunity. For
instance, yesterday I was taking preoperative pictures of a patient's
knees and medial thighs for liposuction. The camera was 3 feet away and
aimed right there, and she said, "You're not getting my face in that
picture, I hope." And a couple of days ago, a patient was sent to me
with a diagnosis of malignant melanoma (thin); only the small biopsy
site was visible, as the primary lesion had been excised. I did the
usual wide excision of the biopsy site, and while dropping said tissue
in the container, I was asked, "Did you see anything?" as if I operate
at a molecular level. My buddy, John, told me of a patient who was
waiting outside the operating room in a stretcher prepared for his
facial surgery. John asked, "Any last questions?" At that juncture the
patient responded with, "You're not gonna cut me, are you?" Now, these
examples relate more to neuroses and fears than to bad behavior.

What
about what recently happened to one of our most esteemed colleagues?
The surgeon was supervising fine residents in a cosmetic procedure,
which went well. Little did they know that the patient had a huge
body-image disorder. Postoperatively, the patient took her preoperative
pictures, put them next to her "morphed" postoperative ghoulish
pictures, and published them on the Internet. The doctor had to get a
lawyer to obtain an injunction to stop her, but he lost business,
money, and stature in the interim. Of course, the patient had to pay
nothing.

And
then there is the influence of the media that leads patients to ask,
"How many of these procedures have you done?" We would not be in this
business if we did the same procedure every day, as do many general
surgeons. Besides, each patient needs something special. What is the
correct way of responding?

My series has not been published yet.
Somewhat less than 1000.
Our office is so busy we do not have exact data.

No one ever told me how many of anything I had to do to become an expert.

And
what about the patient who wants to see preoperative and postoperative
photographs that you do not have? My latest ploy for that is great:
"The new HIPAA, the Health Insurance Privacy Act (my translation),
which ensures patient confidentiality, does not allow us to show those
pictures anymore. I wish I could, though; they were impressive, really."

The
methods by which I try to keep a patient from going elsewhere
unnecessarily do not go beyond this petty, nebulous presentation of
data. Some of my colleagues, though, are downright creative. I saw a
patient who had a poorly performed chin implant, and she told me her
doctor's name. She also told me that her insurance had paid for the
surgery entirely. I actually got the patient to get the operative note,
which her original doctor's receptionist or the insurance company
provided. I just wanted to know what type of implant I was dealing
with, but the operative note was a dictation for cancer surgery of the
chin with a flap reconstruction. I called the doctor, whom I knew, and
flat-out asked, "What were you thinking by doing this? You could put
your license on the line with fraud like this!" His response was, "Gee,
Barry, I guess my office nurse dictated that for me." Are you kidding?

A
colleague of mine constantly has his name in the news and magazines.
After recent newspaper exposure of his supposed expert genius, a public
relations firm called me and asked me if I wanted more patients. I
asked her who her clients were, and she freely supplied that doctor's
name. But when I bumped into that surgeon at a recent meeting and
commented to him how effective his P.R. seemed to be, he said " I don't
use P.R.; my office manager calls the press sometimes without me even
knowing." Are you kidding?

I
know a surgeon in town, Dr. Blank, who was fired from the residency
and, fortunately, found another program in which to finish his
training. He opened an office, calling it the Dr. Blank Surgical
Center. So now he advertises in a magazine with his name, under which
he titles himself "Chief of Plastic Surgery" and "Director of the <st1:place><st1:PlaceName>Blank</st1:PlaceName> <st1:PlaceName>Surgical</st1:PlaceName> <st1:PlaceType>Center</st1:PlaceType></st1:place>." Are you kidding?

A
terrific scam has been going on for years here in this teeming
metropolis. A very attractive woman suggests in the advertisement that
she is familiar with the varying areas of expertise of only the best
doctors in the city. The ad goes something like, "Let me find exactly
the right plastic surgeon for your specific needs." The intimation is
that she has a profile of all of us when, in fact, a single elderly
plastic surgeon in town pays her for each ad-referred patient, who goes
only to him. Now that's effective marketing (and completely misleading
and spurious).

Cosmetic
surgery becomes more technically demanding every year, but only if you,
the doctor, decide to be more daring from what you learn. We all jumped
on the mid-face lift through the eyelid bandwagon and then off again. A
lot of us jumped on the ultrasonically assisted liposuction bandwagon
at outrageous prices, and some jumped off. On the one hand, the patient
screams for the next newest thing and some of us run to become the
first, sic, the early experts. If that pays off, they may go on TV, and
then their magazine ad can say, "as seen on TV" or "as discussed on
'The View.'" The latest craze, and definitely mishigas at the red-alert
level, is this "short scar face lift." Did not we all use these shorter
scars when previous face lift patients wanted a touch-up? Is this not
just doing less work behind the ear in younger patients who probably
did not need much postauricular work? But, now, some of us, the new
experts, capitalize on the term short scar as if a new operation had
just been invented. Am I wrong on this?

At
this point in my career, I feel reasonably skilled at surgery, adept at
staying out of trouble, and reasonably able to deal with most
situations. I refer some hand or breast cases that my colleagues do
better than I. But, still, many come to me seeking "the expert." Now I
go with the flow. If the technique is something I know I can do, I say,
"I can do that very expertly-no problem," and then I wonder if they'll
book. It's mishigas to worry about it.

P.S.: Thanks to Doug Roth for a great title!

Read my letter to Editor of JPRS regarding libelous statements about me:

Facing criticism

Cosmetic surgeon sues over postings by a former patient

By Anne Barnard, Globe Staff, 9/24/2002

It's
not every day that a doctor sues his patient, but Dr. Joel J. Feldman,
a face-lift specialist and former board member of the American Society
of Aesthetic Plastic Surgery, felt that he had no choice.

Lucille
Iacovelli, a gardener from Cape Cod, had posted dozens pictures of her
face on the Internet, showing what she called bad results from cosmetic
surgery that Feldman supervised at Massachusetts General Hospital. The
last straw came in March, when a South Shore woman walked into
Feldman's office at Mount Auburn Hospital, brandished Iacovelli's
photographs, and canceled her surgery.

Feldman sued Iacovelli
for defamation in Suffolk County Superior Court, contending she had
purposely contorted her face in the photos and subjected him to
''public scandal, infamy, and disgrace.'' In May, he won a court order
requiring her to remove any misleading photos or defamatory statements
from the Internet; the case is pending.

Feldman v. Iacovelli
is an extreme case, but it highlights sensitive issues in cosmetic
surgery, where every procedure is optional, success is subjective, and
patients wear the results on their faces. And it points to new
anxieties in the doctor-patient relationship: When can doctors shut
down criticism with legal action, and when does patient empowerment
veer into harassment?

Iacovelli, 52, who lugs around an
accordion file of medical journal articles on plastic surgery, said
Feldman was trying to silence her after she went public with concerns
she could not get addressed within medicine. She said it made sense to
use a medium increasingly used both to advertise and to critique
cosmetic procedures, the Internet.

''Originally, I admit, I
wanted to name and shame them,'' she said of Feldman and other doctors
involved in her care. ''Now I want to warn other people: This is a
dangerous business. If something bad happens, you may never be able to
get any answers.''

But Iacovelli's case is complex. Her
surgeons suspect she suffers from a psychological disorder that
distorts her view of her body and of surgical results they say are
normal. Before the court order, a Suffolk County judge already had
barred her from contacting Feldman or the two younger surgeons who did
her face lift and nose job, Dr. Daniel N. Driscoll and Dr. Melissa R.
Schneider. That ruling came after she sent letters, saying they should
''rot in hell'' and offering to mail them her severed head after her
death so they could dissect it and find out what went wrong.

The
dispute comes amid a push for more openness about bad medical outcomes.
State medical boards, including Massachusetts', have posted more
malpractice and discipline records on the Web. Nonprofit organizations
rate doctors; one group, Public Citizen, compiles a list of
''Questionable Doctors.'' Patient Web sites, overflowing with chat
about ''good'' and ''bad'' doctors, have proliferated, especially in
cosmetic surgery, an out-of-pocket business where every doctor's
livelihood depends on good reviews from patients.

But doctors
fear that the information could be taken out of context, misinterpreted
by laypeople, or used as a vehicle for revenge by disgruntled patients,
regardless of the merits of a case.

''There has to be some
outlet for patient discussion,'' said Driscoll, 38, who performed
Iacovelli's face lift and worries that she will unfairly damage his
Newton-based practice. ''But there's a lot of room for
misrepresentation.''(You can say that
again!  Like breach of informed consent, and doctors' tossing out lies
to patients as medical fact, because they think patients will not know
the difference.  I did.) 

At the same
time, observers of cosmetic surgery say the balance of power still
rests with doctors, and that it is hard for patients to get objective
evaluations of surgeons' work.

Joan Kron, who
writes Allure magazine's Scalpel News column and has covered cosmetic
surgery for 10 years, said there is lots of biased information on such
Web sites as Faceforum.com. But most of it, she suspects, is not
criticism but praise, planted by doctors' office assistants or friends.

Criticism of doctors is ''even smaller than a
drop in the bucket'' in the sea of promotional Web sites that helped
triple the number of annual cosmetic procedures between 1997 and 2001,
said Deborah Sullivan, an associate professor of sociology at Arizona
State University and the author of ''Cosmetic Surgery: The Cutting Edge
of Commercial Medicine in America.''

''The vast majority of media coverage of cosmetic surgery is nothing more than an infomercial,'' said Sullivan.

Between
Iacovelli's Web campaign and her doctors' court filings, her medical
record has become unusually public. Court records and interviews with
Iacovelli, Driscoll, and Feldman paint a complex picture:

Iacovelli
had two surgeries at Massachusetts General Hospital, both performed at
discounted rates by surgical residents, under the supervision of senior
doctors. Driscoll did the face lift in November 1997, supervised by a
senior doctor who has since died; eight weeks later, Schneider did the
nose job as Feldman looked on.

At first, Iacovelli was
pleased; pictures show her beaming, with a smooth neck and face. Later,
she grew dissatisfied. The pictures she posted on the Web, taken a year
after surgery, seem to show her neck looking wrinkled again. (my note:  My neck was not sagging and "wrinkled" BEFORE the facelift; clearly visible in Dr. Driscoll's pre-op photos)

Feldman
said her pose exaggerated the problems; Iacovelli denies it. Feldman
says face lifts that start to sag after a year are within the spectrum
of expected results, especially on patients with Iacovelli's ''stretchy
skin''; (my note:  facelifts do not
create unsightly sagging not present BEFORE the facelift, making the
patient appear 20 years OLDER in one year.  The comment about "stretchy
skin" is LUDICROUS.  Why is this so called "stretchy skin" confined
ONLY to the areas undermined in the facelift?  Skin on my forehead and
chin, untouched by surgery, is certainly not sagging.)  Iacovelli believes her face sagged because the second surgery came too soon after the first.

Iacovelli
wanted to sue, but a lawyer told her he could not get an expert witness
to back her argument. Her psychotherapist, Ted Powers of Plymouth,
urged Feldman to meet with her about corrective surgery, according to a
letter Iacovelli showed the Globe. But an MGH psychologist diagnosed
her with body dysmorphic disorder - in which patients with an
unrealistic body image seek excessive surgeries - and prescribed
therapy instead. (my note: 
They deceived their own therapist.  They never told her anything about
my case or showed her a single pre-op photo showing the damage.    Any
normal, attractive woman would be distressed at such results.  I agreed
to see the MGH therapist in good faith.  They never informed me that
she was a BDD specialist.  My every interaction with MGH was tainted
with DECEPTION by its doctors and attorneys.)

Still, Feldman said, he almost contacted her: (Then why didn't he?)''All I wanted to do was make her happy.''(He
initially denied that anything was wrong, in the single meeting I
had with him in October 1998, 8 months after my rhinoplasty.  I had to
wait 6 MONTHS before he finally met with me, and even this was only
"granted" after written requests. ) But he pulled back when her letters became frightening. (letters
written after ONE YEAR of respectful written requests to meet with him,
complying to his demand that I meet with the MGH therapist, even though
the initial agreement was that I go to MY OWN therapist.  Of course,
they didn't like what MY therapist had to say, which was, essentially,
that I was justified in my distress at their stonewalling and failure
to address my concerns. After meeting with Dr. Wilhelm, the MGH BDD
therapist, and realizing I had been duped (as was she) regarding the
purpose of the meeting, I DID send the following note:)  ''Enjoy
your [smile] while you still can,'' she wrote to all three doctors.
''It may be permanently wiped off your face when you least expect it.''
(which is EXACTLY what THEY did to ME. 
They ruined my smile and made it grotesque.  That particular note
began:  "A SMILE IS A PRECIOUS THING"   They ruined mine when I LEAST
EXPECTED IT.  Why should they consider my remark FRIGHTENING? They DID
wipe my smile off MY face", so, of what does that make THEM guilty?)
Iacovelli,
who is known as The Flower Lady at a golf club in Mashpee, where she
works as a gardener, says she never would have turned violent.

Barred
from contacting the doctors, Iacovelli moved her campaign to the Web.
And when Boston Magazine named Feldman a top surgeon, she said, she
slipped her pictures into copies ''in every newsstand, in every Stop
& Shop - everywhere!''

Meanwhile, she had a third surgery
in Indiana, which left her face and neck looking smooth but, she says,
left her with painful neurological problems. And the Mass. General
doctors moved on, viewing the case as a reminder to screen their
patients carefully. Their lawyer, William J. Dailey III, said they
always had Iacovelli's interests at heart. (
They had one interest only.. in never admitting they did anything wrong
and protection of their reputation, while they engaged in every
underhanded, sleazy tactic to discredit me with their LIES)

But
after a patient's daughter went online to look up Feldman's address,
and found Iacovelli's photos instead, he decided to sue to defend ''my
reputation and the caring that I've given to my patients.''(This
woman contacted me and said she canceled her surgery with Dr.
Feldman because she was  distressed at the disparaging remarks he made
about me.. calling me "crazy Lucille" and worse.  She told me she
didn't care if he was the best surgeon on earth.  She would never allow
a doctor operate on her who displayed such disrespect for ANY patient
as he did for me.) 

After the court order this
summer, Iacovelli took down the chat-room postings. But the photos can
still be found in a Hotmail account that anyone can access if Iacovelli
gives them the user name and password.
_____________________________________________________________________

Anne Barnard can be reached at abarnard@globe.com.

ERIC E. JOHNSON, M.D., P.C.

INTERNAL MEDICINE & CARDIOLOGY

MEDICAL CENTER AT THE PARK

45 RESNIK ROAD - SUITE 202 /

PLYMOUTH, MA 02360

February 11, 2000

Lucille Iacovelli

P0 Box 92

Osterville, MA 02655

Dear Lucille:

    I do recall that on February 24, 1999, during your visit, l did call

Dr. Feldman's office and he was unavailable.

I know that I left your number and asked that they call you back.

Sincerely,

Eric F. Johnson, MD

EFJ:db

February 24, 2000

Eric E. Johnson, M.D.
45 Resnick Road
Plymouth, MA  02360

Dear Dr. Johnson:

During my visit with you on February 24, 1999, you called Dr. Joel Feldman on
my behalf.  His secretary told you he was unavailable and you informed
her that you would like Dr. Feldman to meet with me as soon as possible.

Do you have a note of this written in my medical record?  If not, do you
recall making this phone call in my presence?  If so, would you mind
sending me a note that you did, indeed, make this call and that you
never received a return phone call from Dr. Feldman regarding this
issue?

I apologize for the inconvenience of this request.  I merely want to document the
fact that after seeing me,  it would have been in my best interest for 
Dr. Feldman  to meet with me face to face and that you did attempt to
facilitate this meeting.  I am grateful for all your help.

Most sincerely,

Edward M. Powers, Ph.D.
 P.O. Box 1050
 Plymouth, MA 02360

February 24, 1999

   Re: Lucille M. Iacovelli
       10/18/49

Dear Dr. Feldman,

  
l am writing at the request of the above named client to advise you of
her decision to undertake a course of outpatient psychotherapy with me
for treatment of depression.

 As you are aware, Ms. Iacovelli is experiencing adjustment problems
following cosmetic facial surgeries performed at the Mass. General Hospital.
l find her current depression to be largely reactive in nature. It appears essentially
attributable to her dissatisfaction with the outcome of the aforementioned
surgical experiences and the subsequent challenges shehas had to confront
in an effort to get her medical grievances redressed.

 It seems to me that it would be in all parties' best interests if Ms. Iacovelli
met with you to discuss her current surgical options. Thus far, the client has
been consistent in expressing to me her openness to undergoing such
corrective procedures as you may recommend. Given the delays that have
been experienced to date, a timely consultation with her would be advisable. Should
surgical correction be proposed, Ms. Iacovelli impresses me as one who
is psychologically prepared to undertake such a course without undue
emotional complications.

l currently foresee Ms. lacovelli's continuing participation in Outpatient
psychotherapy as the medical experience goes forward. If I can be of any additional
assistance in this effort please feel free to contact me.

   Sincerely,
   Edward M. Powers, Ph.D.

cc: Lucille M. Iacovelli
      Eric E. Johnson, M.D.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Please note the DATE of this letter, written nearly one month BEFORE Dr. 
May's phone message asking me to bring documentation of my emotional
suitability for surgery.. Another interesting note regarding Dr. May's
reference to "Dr. Wilhelm" AND "Dr. Sabine"..  Sabine Wilhelm, Ph.D. is
ONE PERSON! She is THEIR OWN THERAPIST! When you read Dr. May's phone
message, you will know what I mean when I say: At Mass General,  the
left hand doesn't know what the right hand is doing.

They insisted I see a therapist, so I did..  Dr. Ted Powers and I  had
established a very good rapport.   His letter to Dr. Feldman  clearly
states his condfidence in  my emotional suitability for revision
surgery.  He also attributes the source of my depression is  DELAY of
MGH doctors to address my problem.

In my sincere effort to do everything possible to accommodate their
wishes, (against the better judgment of my  primary care doc and nurse
practitioner) I agreed to be evaluated by  THEIR therapist,  Dr. Sabine
Wilhelm.  They never provided Dr. Wilhelm with a single note about my
case, nor inform her regarding their proposal.   

The paper trail is too extensive for me to post every bit of written
evidence, proving,  unequivocally,  the deceit and stonewalling in
which they engaged, to prevent my holding them to their original
agreement that Dr. Feldman would perform my revision surgery. 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
The Post-Meeting “Wear-You-Out” Syndrome
in Cosmetic Surgery
Rod J. Rohrich, M.D.
Dallas, Texas

Events
occur every day within a practice that can literally “wear you out.”
Life can seem hard at times, even when all is well. At this time in my
life, with a toddler and an infant at home, it has become even more
important to minimize those events that disrupt my day. We hope we can
learn from each other’s mistakes to find solutions for the everyday
practice of plastic surgery. However, patients with unrealistic
expectations are only one part of our daily challenge. What’s
frustrating and perplexing is when a technique is presented at an
educational meeting (intentionally or unintentionally) that sounds
appealing, yet is filled with potential problems when incorporated into
our practices. We return home to try the new procedures only to
discover they really do not work. The result is the “wear-you-out”
syndrome: a dissatisfied patient wearing you out with an unforeseen
postoperative problem from a procedure that was supposed to work well
by all reports.

At our national meetings, one occasionally hears about techniques that have an incredibly
steep
learning curve and probably do not work, and if they do work, the
results are unexpected, sometimes surprising, and often not
consistently reproducible. It is difficult to incorporate new
procedures into your practice if you do not have the same experience
and expertise as the individual who presented this new technique or
refinement. If the presenter
fails to clearly define the learning
curve or explain the number and percentage of complications, this can
pave the way for big problems. For instance, the surgeon who has just
learned to perform liposuction or a face lift technique cannot
immediately incorporate some advanced technique into his/her practice
just by watching an expert present the procedure. We should attempt to
make this clear in our teaching courses.

Everybody shows his or
her best results and many minimize the complication rate and learning
curve at meetings, seminars, and symposia.Perhaps this is human nature,
but it isnot acceptable. Even though a procedure hasbeen demonstrated
time and time again, it is not proper to minimize its risks and
complications.Do not tell us it works every time. In myown experience,
the role and use of fat injectionsin facial cosmetic surgery is a
classic example Fat injections have been touted to b the cure-all,
end-all for all types of problems,
especially facial aging. My
personal experience with the use of facial fat grafts and fat
injections has been dismal, particularly when using fat injections for
orbital rim blending of the cheek-lid interface. The results from this
technique have worn me out from the perspective of patient complaints.

A word of caution: do not go home and incorporate a new procedure into your arsenal
until you are very sure it works. Here are several thoughts to help avoid the post-meeting
“wear-you-out” syndrome in your practice:

1. Do not be the first to use a new technique or technology or the last to give it up.
2.
Be sure highly respected, experienced surgeons or a surgeon you know
and trust is using and praising the procedure or technique before you
attempt it.
3. Seek advice from the surgeon with the most experience and expertise using the same or similar techniques.
4.
Call the surgeon who described the technique and put him/her under
scrutiny. Does this really work? When does it not work? What are the
author’s revision and complication rates?
5. Optimally, observe the new technique or rejuvenation procedure. See if the actual
procedure is the same as presented. Ask to see follow-up patients if possible.
6. After you have performed 5 to 10 procedures using the new technique or technology,
provide the author with your own feedback and follow-up on what works and does not work for you.
7.
Listen to your patients and follow them closely when you change a
procedure or add a new technique to your armamentarium. Ask the hard
questions. Is this new technique really improving your results?
8.
Beware of the technique that continues to be “modified” significantly,
especially 1 year after its introduction as the latest and greatest in
plastic surgery. Obviously, something is not working properly if it
requires constant revision even in the hands of the “experts”!
9. Be wary of those who are never in doubt when asked about a procedure they are advocating. They may often be in error.
10.
Most complications relative to a new technique or technology occur
within 2 to 3 weeks after an educational meeting. This is a very
important statistic to remember!

In conclusion, do you find that your patients are “wearing you out” about their result from a
procedure
you are trying? If so, stop! Do not take everything you hear at a
meeting as established fact. Analyze your results, compare them to old
and new techniques, and formulate a plan that works best for you and
your patients.

Rod J. Rohrich, M.D.
Co-editor, Plastic and Reconstructive Surgery
Department of Plastic and Reconstructive Surgery
UT Southwestern Medical Center
5323 Harry Hines Boulevard, Suite E7.210
Dallas, Texas 75390-9132
rod.rohrich@utsouthwestern.edu
1044 PLASTIC AND RECONSTRUCTIVE SURGERY, September 15, 2001