December 18, 2017

Claude A. Hawkins, MD, FACS

Riverside Plastic & Reconstructive Surgery Specialists

During his 21 years of military service and two deployments to Afghanistan, Dr. Claude Hawkins not only helped repair the most complex and devastating injuries. He also learned to work daily with physicians of all specialties on an immense and varied caseload.

Now a retired Air Force Colonel, Hawkins has transferred those skills and commitment to multidisciplinary teamwork to Riverside Health System, where since 2014 he has handled a range of reconstructive procedures with a particular specialty in breast reconstruction.

“Treatment of breast cancer can be quite complex,” he says. “There are many decisions that have to be made, and part of my job as a reconstructive surgeon is to educate patients about their reconstructive options. I try to demystify the types of surgeries and choice of implants available, as well as to explain the new developments in the field so patients can make the best choices for their situations.”

Advances in implants and fat-grafting techniques have made reconstructions more cosmetically successful, he adds: “We’re on our fifth generation of silicone implants, with improvements in both the shell and the way the shell interacts with the gel. In addition, the ability to do liposuction to harvest fat and inject it around the breast can dramatically improve contouring and shape.”

Hawkins’ other focus areas include skin cancer resection and reconstruction; abdominal wall reconstruction; soft tissue surgery for face and hands; cranioplasty; complex wound and ulcer management; lower extremity reconstruction; and skin-reducing procedures after massive weight loss.

Long interested in science, Hawkins considered becoming a high school biology teacher but decided on medicine as an undergraduate at Indiana University. He completed his medical degree at Uniformed Services University in Maryland, followed by a residency in General Surgery at Wright State University in Ohio and a fellowship in Plastic and Reconstructive surgery at Oregon Health & Science University.

Just prior to starting at Riverside, he added a year-long fellowship at Georgetown University Hospital in Washington, DC, gaining additional experience in immediate reconstruction with tissue expanders and AlloDerm, reconstruction after nipple-sparing mastectomy, oncoplastic reconstruction, re-operative breast surgery, fat grafting and breast augmentation, mastopexy and reduction.

Hawkins’ military career earned him multiple awards, including a Bronze Star Medal for heroic or meritorious achievement or service. Stateside, he served as a Flight Surgeon at Andrews Air Force Base in Maryland; Chief of Plastic and Reconstructive Surgery at David Grant Medical Center in California, where he provided around-the-clock call for patients and instructed General Surgery, Transitional and Oral-Maxillofacial Surgery residents; and Commander of the Surgical Operations Squadron at USAF Hospital Langley in Hampton, where he was in charge of 219 personnel and directed operations for five operating rooms and the anesthesia department.

Early in his career, Hawkins served two years at Anderson Air Force Base Guam, where he chaired the Occupational Health Working Group. In 2007 and again in 2009, he deployed for six months to Craig Joint Theater Hospital at Bagram Air Base in Afghanistan, a facility that provided care for American troops, coalition allies and Afghan residents caught in the crossfire.

On his first deployment, Hawkins helped establish USAF Level III medical/trauma services and supervised 31 healthcare professionals who completed some 400 surgeries. On his second, he was the sole plastic surgeon at the U.S. Trauma Hospital, receiving referrals from 11 forward operating bases. He handled more than 320 major surgical cases, including limb salvage surgery with pedicled and free flaps, facial trauma repairs and major wound debridements.

Some patients stand out more clearly in his memory, such as an Afghan girl of no more than 10 who suffered severe burns and required multiple skin grafts on her face and upper body after a home kerosene heater exploded. Or an Afghan police officer whose nose was blown off by a bomb; Hawkins worked with an ENT surgeon on a reconstruction using a complex forehead flap procedure. “We were able to correct their disfigurements pretty significantly,” Hawkins relates.

Caring for injured American soldiers was especially emotional. Once, Hawkins watched a General pin a Purple Heart on a patient. “I still get choked up thinking about that,” he says. “These were really young kids, many in their early 20s, with multi-limb traumatic amputations and other serious injuries. You realize the capacity that human beings have to work through the worst situations and never give up.”

Hawkins’ other experience includes three years as a Staff Plastic Surgeon at Contra Costa Regional Medical Center in California. At Riverside, he is affiliated with multiple local hospitals and surgery centers. While about 80 percent of his work is reconstructive, he also performs cosmetic procedures such as breast and body contouring and Botox injections.

Additionally, Hawkins, a father of three, is studying for a Master of Business Administration at the College of William and Mary. There is a growing push for doctors to understand the business of medicine, he notes: “Providing excellent medical care while controlling costs is very important in hospital organizations. That’s the way you’re going to help the most people.”

In Hawkins’ specialty, helping the most people also requires working with neurosurgery, orthopedics, general surgery and other specialists on a regular basis. For him, that is a job perk.

“One aspect of reconstructive surgery that has always appealed to me is the multidisciplinary approach to patient care,” he says. “It’s truly a team effort where everyone puts different skills and experiences toward one goal: achieving the best possible outcome for each patient.”

William P. Magee, JR., DDS, MD, FACS

Past President, Magee-Rosenblum Plastic Surgery; Past Chief of Plastic Surgery and Director, Cranofacial Center, Children’s Hospital of the King’s Daughters; Co-Founder and Chief Executive Officer, Operation Smile Inc.

Photo Courtesy of Operation Smile

As the second of 12 children raised by a general practice physician, Bill Magee grew accustomed to both chaos and certainty. The chaos part is obvious – and probably why Magee’s father took him and his siblings on house calls to give his mother a small break.

The certainty was about medicine’s power to change lives. His father had an office at their home in Fort Lee, N.J., and lines of patients would grow outside as their doctor took time to comfort, educate and hopefully heal each of them. After church on Sundays, his dad would patiently answer questions from everyone who approached him.

Magee can’t say he knew he wanted to be a doctor immediately because, by his own admission, he wasn’t much of a student. But when he did opt to go into healthcare – a journey that would include dental and medical school, a specialty in pediatric reconstructive plastic surgery, and a charitable organization that has changed hundreds of thousands of lives worldwide – he knew why.

Photo Courtesy of Operation Smile

“That human aspect of medicine is always what has appealed to me, more than the scientific part,” Magee says. “We all need to love and be loved. In medicine, you have such a unique opportunity to show people love every day. You can take on their problems, relieve their anxieties, give them reassuring touches and tell them they’re beautiful.”

Magee, 73, has spent almost his entire career in reconstructive plastic surgery, rather than cosmetic. Since 2000, he has worked exclusively with children, repairing cleft lips and palates and major and minor craniofacial anomalies. In addition to his more than 40 years of service at Children’s Hospital of the King’s Daughters, Magee was President of Magee-Rosenblum Plastic Surgery in Norfolk.

In 1982, he co-founded Operation Smile with his wife and high school sweetheart, Kathy, a nurse. The nonprofit medical service organization, based in Virginia Beach, now has offices in 60 countries with more than 5,000 medical volunteers; it has provided free surgeries to 400,000-plus children with facial deformities. Most are from impoverished backgrounds and have endured years of teasing and exclusion due to their appearance.

Magee also has brought about 150 foreign children with extremely complex facial deformities to CHKD, where he was Chief of Plastic Surgery from 1982 to 2004 and Director of its Craniofacial Center until his retirement in January. If a child or family ever needed a place to stay, Magee would move his own five kids onto floor mattresses to free up their beds. “It was a great opportunity not only to help kids who were suffering but to ground my own children, who grew up in comfort,” he notes. He also gave patients his cell or home phone number so they could always reach him.

Magee graduated with a Bachelor of Science degree from Mount Saint Mary’s College in Maryland and earned a dental degree from the University of Maryland, followed by a medical degree from George Washington University. He trained in maxillofacial surgery during an externship in Zurich, Switzerland, before completing general surgery residencies at the University of Virginia and Norfolk General Hospital, a plastic surgery residency at Eastern Virginia Graduate School of Medicine, and a plastic surgery fellowship as a Fulbright Scholar in Paris, France. In addition, he has done short-term observational studies in Switzerland, Germany, Scotland and New York City. He has been Board certified in Plastic Surgery since 1979.

A passionate educator, Magee also has been active in teaching and publishing. He has trained doctors from around the world, as well as countless fellows through Eastern Virginia Medical School as an Associate Professor of Plastic Surgery. Patients have come from across the United States, too, regardless of their ability to pay. In fact, he estimates he handled about a quarter of his cases for free.

Magee retired from local practice this year, although he still logs 60 to 80 hours a week with Operation Smile. “It was tough to tell families that I was leaving, but I knew it was time,” he says. “There were a lot of hugs and tears.” Operation Smile organizes hundreds of trips annually and, to pass on a service ethos, now incorporates middle and high school students. Magee’s oldest child went on its very first mission, to the Philippines in 1982, when she was 13; all his kids since have traveled with the group. One of his sons later adopted a girl from Vietnam – a country where volunteerism has improved overall relationships with America – as one of his 14 grandkids.

“These students work 14 to 16 hour days and come back completely different people,” Magee notes. “Very quickly, they don’t see deformities – they see children. And for some of those kids, it’s the first time anyone has looked at them as ‘normal.’” Magee is quick to credit CHKD; his former partner, Richard S. Rosenblum, MD; Operation Smile staff and volunteers; and his wife and family for supporting his work. “I could not have done any of this on my own,” he stresses.

Photo Courtesy of Operation Smile

Throughout his career, Magee has embraced the detail-oriented aspect of reconstructive surgery, sharing that he has a long-time interest in construction and considered a career as an electrician as a teenager. So he’s excited about new, highly durable bone replacement materials; more precise, three-dimensional scanning equipment; and pre-formed polyethylene implants, which have improved cosmetic results and reduced the risk of surgical complications. “It’s dramatic, how they fit so exactly and snap right into place,” Magee marvels.

But the heart of medicine is always foremost in his mind: “My work is incredibly rewarding. I will continue as long as I feel I can add a benefit to these children’s lives.”

Lambros K. Viennas, MD, FACS

Chief, Division of Plastic Surgery, and Assistant Professor, Eastern Virginia Medical School; Chairman, Department of Plastic Surgery, Sentara Norfolk General and Leigh Memorial Hospitals

When visiting his dentist as a child, Lambros Viennas found the dental laboratory fascinating. The son of a carpenter, Viennas always enjoyed working with his hands, as evidenced by the clay models and art projects that filled his room. His dentist, he saw, could make teeth – crowns, bridges and dentures that gave patients the ability to chew and smile with confidence again.

Viennas’ elementary school dream job took him to dental school at the University of Maryland, where he discovered oral surgery. Then, during a subsequent residency in oral and maxillofacial surgery at Temple University Hospital, he encountered patients with head and neck cancers who required complicated reconstructive plastic surgeries to fix significant facial deformities.

“During our training, we had the opportunity to assist the plastic surgeons,” Viennas recalls. “Seeing what a difference those surgeons could make on the patients’ lives was a turning point for me. I wanted to have the skill set to be able to reconstruct any part of the body.”

Today, Viennas is responsible for all facets of plastic surgery at Eastern Virginia Medical School, helping everyone from cancer survivors, trauma injury or burn victims, people with excess skin after massive weight loss and patients seeking cosmetic rejuvenation procedures. He also is an important referral source for many local hospital- and community-based physicians, especially on complicated cases.

Reconstructive cases comprise a significant part of Viennas’ workload, with breast and facial reconstructions in oncology patients among his particular specialties. With improved technologies and advanced techniques such as skin substitutes, filler materials, fat grafting, microvascular tissue transfer and 3D computer imaging, the field of plastic surgery continues to evolve, giving patients more treatment options and improving outcomes.

Plastic surgeons now have a variety of methods to transfer a patient’s own tissue for reconstruction of the face, breast or other body parts. Complex cases sometimes require removal of tissue from one area to rebuild another – such as moving a muscle from the back to the head and then, under a microscope, connecting its small blood vessels there. “Skin substitutes are also being used to regenerate new skin without using the patient’s own tissues,” Viennas notes. “Hopefully, this technology and research will continue to develop and allow us to grow organs and other body parts in the future.”

In addition, new filler materials and fat grafting techniques have transformed the approach to improving the aesthetic outcomes of reconstructive procedures. If a patient has a depressed scar, for example, “filler material or fat grafts can be placed under the scar to improve the appearance,” Viennas states. “Recent observations by plastic surgeons have also noted rejuvenating changes of the overlying skin after fat grafting, which is currently being studied.”

Meanwhile, surgeons can pre-plan major reconstructions before an operation ever begins, using three-dimensional computer imaging and 3D prints. “That is especially helpful for facial reconstruction in trauma or cancer patients, because the technology allows you to determine the tissue requirements and the exact position for placement,” Viennas says.

While he has more tools than ever to help patients regain both form and function, Viennas also is a firm believer in the simple power of listening. “The challenge is that every case is different,” he says. “As a doctor, you need to understand and care about each person’s concerns and goals. Only then can you develop a tailored treatment plan and recommend the procedures with the best chance of success.”

Born to Greek immigrants who left their country after World War II decimated its economy, Viennas grew up in Baltimore and earned his medical degree from Hahnemann University School of Medicine in Philadelphia. He followed that with a general surgery residency at St. Agnes Hospital in Baltimore and a plastic and reconstructive surgery residency at Pennsylvania State University. He also completed international rotations in oral and maxillofacial surgery and craniofacial surgery at, respectively, hospitals in England and Australia.

Viennas joined EVMS Surgery in 2009 after more than 14 years in private practice in Baltimore, where he also was a Clinical Instructor at Johns Hopkins University. As the reconstructive plastic surgeon member of the EVMS Breast Center, he is able to evaluate women with their surgical oncologist. He also is affiliated with Sentara Norfolk General Hospital, Sentara Leigh Hospital and the Sentara Princess Anne Ambulatory Surgery Center, and he teaches surgical principles and techniques to medical students and residents on a daily basis as Educational Director of EVMS Plastic Surgery.

Rebuilding body parts lost to disease or trauma is so rewarding because patients stand to gain not only self-confidence but greater independence and overall health, Viennas notes. “The objective is always to achieve not only cosmesis, but both form and function. If you’re reconstructing the lips, for example, it’s critical to restore the skin’s cosmetic appearance, the mucosal lining inside the mouth and the muscle function so a patient can smile, speak, retain food when eating and avoid drooling.”

On the cosmetic side of plastic surgery, Viennas handles the gamut of common procedures, such as facelifts, brow lifts, blepharoplasties, breast augmentations and reductions, liposuction, body contouring and excess skin removal in weight loss patients.

Married to a pediatrician and father to two boys, Viennas is grateful that his childhood interest in dentistry was a steppingstone into the ever-evolving world of reconstructive surgery. “It’s always an exciting and innovative field,” he says. “I feel like I have the best job in the world.”

Dr. Melanie J. Wilhelm, DNP, CPNP

Pediatric Specialists

While Melanie Wilhelm spent 15 years as a Registered  Nurse, she often found herself discussing doses and diagnoses with doctors, which she recognized was not the norm.

Now, as a Doctor  of Nursing Practice, Certified Pediatric Nurse Practitioner and author, that experience as a nurse, and as a mom, “makes me a better provider,” said Wilhelm, who works at Pediatric Specialists in Norfolk, VA.

When her daughter Ashley-Kate struggled with asthma, she was frustrated no one seemed to be able to help her, she said. Wilhelm eventually found a Pediatric  Nurse Practitioner who specialized in asthma, and her daughter’s health dramatically improved under her care. “I started thinking about going back to school, and here I am.”

Her children are now grown — her son is 28, her daughter 22 —  but as a “parent in the other chair,” at medical offices, she learned to really understand the struggle patients and their parents often face.

She admits to being open with patients about her own parenting struggles. “Being vulnerable helps parents understand,” she said. “I’ve lived it. It’s not just my profession.”

Returning to school mid-career, Wilhelm became a nurse practitioner and then, eight years later, received her doctorate. A few years later she was on a vacation with her family in the Virgin Islands when an a-ha moment led to what she sees now as her life’s mission .

“I woke early to have some quiet prayer and meditation on the beach before the kids got up,” she explained. Watching the waves, she was overwhelmed with the beauty of nature. She got up to put her toes in the water and paused for a moment. “As I looked back, I saw my footsteps being washed away by the water. I felt God speak to my soul as I heard the words, ‘You’ve got to leave a deeper mark.’”

Wilhelm said she felt called to write a series of parenting books, “not just to help this generation of parents, but for subsequent generations of parents,” she said.

It took her about five years to release her first book, “Raising Today’s Baby,” which is peer-reviewed by physicians and offers medical recommendations and her experiences as a parent. The book covers topics from birth to one year, including feeding, bathing and medical questions. She is currently working on the sequel “Raising Today’s Toddler” scheduled for release in 2018.

Wilhelm also serves as Adjunct  Assistant Professor at Old Dominion University and writes a monthly column  for Tidewater Family Magazine.

Her focus in graduate school was childhood obesity, something she often faces in her medical practice . She teaches families to remember the numbers 95210: 9-10 hours of sleep, 5 fresh fruits and vegetables daily, less than 2 hours of screen time, one hour of exercise daily and zero sweetened drinks.

“These are difficult topics, but we need to take the time to address them,” she said. “I rest well knowing that I made someone else’s journey a bit easier in regards to childhood obesity. Progress can be slow, but I have seen it happen.”

You can view Dr. Wilhem’s blog at RaisingTodaysChild.com

 

If you work with or know a Physician Assistant or Nurse Practitioner you’d like us to consider, please visit our website – www.hrphysician.com or email holly@hrphysician.com

Shannon McCole, MD

Department of Ophthalmology, Eastern Virginia Medical School

After her 1994 graduation from Loyola University Chicago Stritch School of Medicine, Dr. Shannon McCole served her ophthalmology residency at EVMS.  “I was impressed by the level of excellence of the faculty and the warmth of the reception I got as a member of the ophthalmic community,” she says, “and I knew I’d get a lot of experience at a Level One trauma center.”

She liked the area so much that she decided to stay in Hampton Roads to join a private practice.  She was so dedicated to the program at EVMS that even while beginning her practice, she volunteered as a community faculty member.  She did that for five years, she says, adding, “I graduated from the program.  There were some aspects of the education program that we knew needed tweaking, and I felt that as a recent graduate, I was in a unique position to try to make the changes that needed to be made to fulfill the ever-increasing accreditation stipulations and regulations.”

After five years as community faculty, Dr. McCole came on as an associate program director – again as a volunteer.  “I enjoyed working with the residents – it’s fun to teach these bright, young, energetic kids who are hungry for knowledge in ophthalmology,” she says.  “It’s a really rewarding experience to do that.”

Assuming additional responsibilities as an unpaid volunteer was nothing new to Shannon McCole.  She’s gone as far as Peru and as near as Wise County, VA, on medical missions to provide basic eye care and glasses to people who have neither the access nor the resources to get them.   “People were in such desperate need for ophthalmologic services that they were camping out two or three nights to get a spot in line for the clinic,” she says.

Dr. McCole was ultimately asked to join the EVMS faculty full time as the Program Director for the ophthalmology training program, ending her volunteer status, but not her work on behalf of the poor and indigent.  “I’ve been trying to get my residents to get involved in RAM”, she says, referring to the Remote Area Medical team established in 1985 by Stan Brock as a way to deliver basic medical aid to people in the country’s inaccessible regions.  “EVMS does participate in RAM.  My residents have gone in the past, and hopefully they’ll go again next year as well.”

She’d like to strengthen her department’s volunteer efforts to do more international work but acknowledges the difficulty with a small program.  “We have so many patients in need to see here in the clinics,” she explains, “and it’s tough to pull faculty members and residents out to go on these longer missions. So we focus on doing things locally, like partnering with area Lions Clubs and working in the HOPES Clinic.”

Today, the former volunteer leads a very unusual department of ophthalmology, in that it is composed entirely of volunteer faculty members.  “It’s very rewarding now, as the Program Director and Chairman of the department, to bring all these ophthalmologists in the community together for a common cause, which is the educational mission of EVMS – and to provide eye care to those who would otherwise be left out.”

She adds, “At the EVMS Sentara Lions Sight Center, we are the largest provider of eye care for indigent patients in Eastern Virginia.”  Her team performs countless eye surgeries for underserved patients throughout Hampton Roads.  In addition, she personally performs cataract surgeries as charity procedures through the Lions Club.

She describes her inspiration: “Preserving or restoring a person’s ability to see is doing good for all of us, not just the individual.  When people have a disability because of their vision that could be prevented or treated, we’ve got to intervene and do something to help them.  We have a duty to serve them, which in turn helps us, both as a nation and globally, to keep people functioning so that they can continue to be contributing members of society.”

If you know physicians who are performing good deeds – great or small – who you would like to see highlighted in this publication, please submit information on our website – www.hrphysician.com or email holly@hrphysician.com

Laws to Guide Care Disputes under Advance Medical Directives

By William Charters and  Jeffrey Kiser

Advance Medical Directives provide the most definitive information – other than direct patient conversation, of course – about the course of a patient’s treatment. What happens, however, when a physician considers the treatment wishes of a patient or family to be inappropriate or unethical?

Congress provided a right for patients to make
predetermined decisions about their medical care when they passed the Patient Self-Determination Act in 1990.  Increasingly, however, the care that patients and their families want or demand is beyond what their physician deems appropriate.  Different states allow for varying degrees of discretion, and not everyone “legally” permits the same procedures or care.  Virginia, for example, does not recognize the Death with Dignity Act (or any other physician-assisted end-of-life program), but a nearby neighbor, the District of Columbia, does.  Knowledge of the particulars of the Virginia statutes provides a springboard for the analysis of what can or should be provided.

How about that circumstance where the treatment
demanded is considered unethical, immoral or inappropriate by the treating physician?  The Code of Virginia provides that an attending physician faced with an instruction to render care that he/she feels is medically or ethically inappropriate is not required to carry out the instruction (whether contained in an advance directive or not) but must first make every reasonable effort to explain his/her reasoning to either the patient or the decision-making authority under the advance directive.  Then within 14 days, the treating physician must make a reasonable effort to transfer the patient to another physician who is willing to comply with the patient’s request or the directive’s instruction.   Many facilities have a mediation process of sorts that helps to determine the medical appropriateness of care in conjunction with the physician and the patient or decision maker.

It is important to note, however, that this requirement does not extend to treatment the physician is physically or legally unable to provide.  More specifically, the Code directly states that “mercy killing or euthanasia” is not permitted, nor is any act that will “end life other than to permit the natural process of dying.”  These guidelines aim to help physicians maintain a level of professionalism and control over their practice but, most importantly, offer protection against professional malpractice and personal tort claims.

While these rules and the rest of Virginia’s Health Care Decisions Act offer aid and guidance, they are most effective when implemented on a proactive rather than reactive basis – as the old saying goes, an ounce of prevention is worth a pound of cure.  Take the time to educate yourself and your practice on the many facets of advance directives, and establish a protocol for how you and your employees will determine if an advance directive exists for any given patient.  Once you know that and determine who the “decision maker” is, be honest and straightforward about what you consider moral and ethical treatment, so that care can be transferred early on if there is likely to be a dispute.

William Charters

Jeffrey Kiser

William Charters, a member of Goodman Allen Donnelly, focuses his practice on providing advice, risk and litigation support to healthcare professionals and practices throughout the Commonwealth.  Jeffrey Kiser, an Associate with GAD, provides detailed and targeted guidance to individuals and groups for their end of life and asset protection plans.  goodmanallen.com

Expert Care: Riverside Specialty Practice Gives Local Women Access to a Fellowship-trained Breast Reconstruction Surgeon

Victoria McCarthy, RN (left) and Claude A. Hawkins, MD, FACS (center) discuss breast reconstruction with a patient.

Women who opt for breast reconstruction after battling cancer can turn with confidence to Riverside Plastic & Reconstructive Surgery Specialists in Newport News, now home to a board certified plastic surgeon with additional fellowship training in breast reconstruction.

The small practice is built around Claude A. Hawkins, MD, FACS, and his nurse Victoria McCarthy, RN. In close consultation with other Riverside specialists, Hawkins offers implant-based and autologous tissue reconstructions – the latter via a TRAM Flap or Latissimus Dorsi Flap procedure – in a caring and supportive environment.

“Breast reconstruction is not ever a one-size-fits-all specialty,” he says. “It really requires close scrutiny of each patient’s individual life situation, aesthetic goals and overall health, followed by precise attention to detail every step of the way.”

Hawkins, a retired U.S. Air Force Colonel, brings extensive operating room experience to Hampton Roads, including two tours as a reconstructive surgeon in Afghanistan. His advanced training culminated in a 12-month fellowship in Breast Reconstruction and Aesthetic Surgery at Georgetown University Hospital, which he completed just prior to his 2014 arrival at Riverside.

Under the late Dr. Scott Spear, Founding Chair of Georgetown’s Department of Plastic Surgery and Past President of the American Society of Plastic Surgeons, Hawkins studied a wide variety of basic and complex reconstructive techniques. He left with a highly-specialized layer of knowledge, well beyond his previous fellowship in Plastic and Reconstructive Plastic Surgery at Oregon Health and Science University.

“Additional specialty training will improve any surgeon’s ability to select and perform the best type of reconstruction for each patient,” Hawkins notes.

Most of Riverside’s breast reconstruction patients are cancer survivors, although a subset come with congenital anomalies such as tuberous breast deformity or severe asymmetry. Hawkins works with women of all ages, from 19 to well past 70. Advances in pre- and post-operative care and anesthesia have rendered procedures safer and more effective for a wider range of patients. He is affiliated with Riverside hospitals and surgery centers in Newport News, Hampton, Williamsburg and Gloucester.

Hawkins is careful to cover all reconstructive options at a patient’s earliest appointments, including choosing external prosthetics over any type of surgery. He also is upfront about what can be a lengthy, multi-step treatment and recovery process. Together with Nurse McCarthy, he steers and reassures his patients through any highs, lows or complications they might experience along the way.

“Guiding women to the right solution takes time, but it is so fulfilling,” he says. “A lot of cancer survivors don’t even realize that there are answers to that question of, ‘Will I feel whole again?’ Our goal is to create breasts that appear as natural and symmetrical as possible, so a woman can begin to feel comfortable with her body again. In the end, a vast majority of our patients experience that.”

About 80 percent of Riverside’s patients opt for implant-based reconstructions, most with silicone implants. Compared to autologous tissue reconstruction, the approach requires significantly shorter hospital stays and recovery time, often important considerations for women with families and jobs.

While soft tissue reconstructions have historically delivered superior outcomes, several improvements in implant-based surgery have leveled the playing field. Implant designs and materials have continued to evolve, while new fat-grafting techniques can add attractive contouring. Surgeons also can utilize Acellular Dermal Matrix, a material constructed from the collagen layer of cadaver skin, to create strong and bioresorbable internal anchors for implants.

“We really have begun to see equivalency of results, which has been a benefit to so many women,” Hawkins says.

Claude A. Hawkins, MD, FACS and his nurse Victoria McCarthy, RN

Still, autologous reconstruction remains the best choice for most patients who have undergone radiation therapy, as complications may arise from placing implants in irradiated fields. Those patients tend to select a TRAM Flap procedure, which moves a portion of the transverse rectus abdominis muscle, along with skin, fat and blood vessels, to rebuild breasts. The technique also offers some abdominal contouring, although it is not a cosmetic surgery and may not result in ideal scar placement.

A Latissimus Dorsi Flap Reconstruction, meanwhile, uses a smaller oval of tissue dissected from a patient’s back, near the shoulder blade. That can be a good option for women who have had a partial mastectomy, or lumpectomy, that caused a “dented” area of a breast, Hawkins states: “We are able to reshape those deformities quite effectively with that more limited amount of tissue.”

Medical expertise and technology are just part of the Riverside practice. McCarthy, who has worked with Dr. Hawkins for more than two years, says the two also emphasize an encouraging bedside manner.  She decided to become a nurse after working as a receptionist in an oncology department, where she scheduled chemotherapy appointments for nervous patients.

“I wanted to help women going through those very tough times,” she recalls. “Now, I get to see our patients so excited and confident about their results – maybe walking in wearing a shirt they thought they’d never wear again, with a big smile. It is just extremely rewarding.”

Dr. Hawkins, she adds, “has so much empathy for his patients. He sits down with them for as long as they need, listens to them, explains all their options, asks for their opinions and consults with other doctors whenever necessary.”

Beyond breast reconstruction, Riverside Plastic and Reconstructive Surgery Specialists also provides multiple other reconstructive and, cosmetic procedures. “No matter what they need, our patients are always at the heart of everything we do here,” Hawkins says. “We want them to feel like they’re part of a family.”

Riverside Plastic & Reconstructive Surgery Specialists is located at 12200 Warwick Boulevard in Newport News.

To reach the practice, call (757) 534-6380. Or, visit the website at riversideonline.com/hawkins

New Thinking About the Treatment of Obesity

…recognizing obesity as a multifaceted, chronic disease benefits patients who suffer from it

In August of 2016, the venerable Oxford Dictionary introduced its annual list of words being added to its modern language edition.  One of these words was “fat-shame.”  The addition was hardly surprising, as nearly everyone has witnessed the mocking and hurtful comments people make about the size and weight of other individuals.

What should come as more of a surprise is the August 3, 2017 headline of an article published on the website of The American Psychological Association: “Fat Shaming in the Doctor’s Office Can Be Mentally and Physically Harmful.”  The article reads in part, “Disrespectful treatment and medical fat shaming, in an attempt to motivate people to change their behavior, is stressful and can cause patients to delay health care seeking or avoid interacting with providers.”

Christa Black, PA-C

That the APA article was written in 2017 is particularly troubling in light of recent changes in thinking about obesity.  “As a medical community, we’re now viewing obesity as a chronic disease,” explains Christa Black, PA-C, with Bon Secours Surgical Weight Loss Institute, a comprehensive program that incorporates nutrition, exercise, pharmacological therapy and surgery as well.  Black, a member of the Integrated Health Executive Council of the American Society for Metabolic and Bariatric Surgery, adds “Those of us who’ve been caring for patients with this disease have known for years.  We’d see problem lists that begin with conditions like diabetes, sleep apnea, hypertension, depression, GERD and so on, and at the very bottom of the list would be obesity – when obesity should be listed as number one, with the other conditions listed as a, b, c, etc.  The chronic disease is the obesity – those other conditions are co-morbidities of obesity.”

Acknowledging obesity as a chronic disease represents a fundamental sea change.  In 2017, within the bariatric community, the very terminology used to diagnose these patients is changing.  Patients are no longer called obese; instead, they’re described as “having the disease of obesity.”

Jennifer Pagador, MD

Unfortunately, as the August 2017 APA article demonstrates, there remain providers who haven’t accepted the change.  “It’s been just within the last two years or so that the leading organizations, the CDC, the AMA and NIH, have regarded obesity as a disease that needs to be treated like any other chronic disease,” says Jennifer Pagador, MD, Medical Director of Seriously Weight Loss LLC.  “I have patients who come to see me and say they’ve tried to talk to their doctors, but all they’ve been told, time and time again, was to diet and exercise.  No support was offered, and these patients come to me feeling like they’re failures.”

Margaret Gaglione, MD

“The change in thinking probably had its origins in the treatment of the 1980s and ‘90s, when medications for weight loss were approved for a single 12-week regimen – a very short course of time,” says Margaret Gaglione, MD, of Tidewater Physicians Multispecialty Group.  “We don’t treat any other chronic disease like that.  Obesity is not a curable disease; it’s a multifaceted disease that’s both behavioral and physiological, that needs to be managed every day.”

David C. Lieb, MD

Genetics may play a role. There might be a genetic predisposition to obesity, says David C. Lieb, MD, an Associate Professor of Internal Medicine and Program Director of the Endocrinology Fellowship Program at EVMS.  “There are multiple genes that have been associated with the risk for obesity, and probably even changes in utero that increase that risk,” Dr. Lieb notes.  “There was a study published a number of years ago looking at mothers who got pregnant while they were obese, and later had bariatric surgery so they weren’t obese while pregnant with their second child.  There were differences in the risk of obesity in the two children.”  However, a study reported in the August 24, 2017 New York Times that examined “more than 10,000 mother-child pairs from birth to adulthood found that both maternal and paternal BMI were associated strongly with the metabolic traits of their children.”  The article adds that “since paternal BMI cannot impact the fetus during its development, this suggests that familial traits, rather than any programming of the fetus in the womb, are the explanation for metabolic abnormalities in the children of obese mothers.”

Dr. Pagador cites a Harvard study originally published in June 2009, which found that, “The strength of the genetic influence on weight disorders varies quite a bit from person to person. Research suggests that for some people, genes account for 25 percent of the predisposition to be overweight, while for others the genetic influence is as high as 70 to 80 percent. Having a rough idea of how large a role genes play in your weight may be helpful in terms of treating your weight problems.”  However, she emphasizes, “Just because you have a family history doesn’t mean you’re doomed.  You can mitigate the risk.”

And Dr. Lieb cautions, “I don’t know that we’re at a place yet where we can use any of this information to make predictions so clearly, but the potential is there.  And it continues to be studied.”

No matter the cause, obesity remains a growing problem in America. According to the Centers for Disease Control, more than one-third of US adults are considered obese, while about one in five school-aged children (ages 6–19) is classified as obese – a figure that has nearly tripled since the 1970s.  A 2014 study in The New England Journal of Medicine found that kids who were obese or overweight by 5 years of age were likely to carry that weight through adulthood.

William A. Hackworth, MD

Obesity is particularly problematic in children, says William A. Hackworth, MD of Riverside Gastroenterological Specialists.  “It’s certainly well understood that obesity affects health in many ways.  Most of the leading causes of death – heart disease, stroke, diabetes, cancer – are all at least in part secondary to obesity.  But for children and adolescents, it can be even more deadly: a recent study showed that being obese at the age of 17 can predict a patient’s risk of colon cancer at age 50.”  That long-term study, done at Tel Aviv University, included a large cohort with a minimum follow-up of 10 years, and found that higher BMI scores correlated with higher rates of rectal cancer as well.

Glenn Moore, MD

Virginia is 29th in the nation in terms of obese population, and Hampton Roads fares no better. In fact, according to the Virginia Department of Health, more than 550,000 residents of South Hampton Roads are classified as overweight or obese – or about 62 percent.  “I don’t think we have a definitive answer as to why that is, “says Glenn Moore, MD, a bariatric surgeon with Chesapeake Surgical Specialists.  “You see segments of populations that have higher obesity rates, and on a superficial level, I think our food preferences, our dietary habits, the availability of some foods, factor in.  People in cities eat differently than people in the country, and people in the South eat differently than people in California.”

Prevention is key.
“What I’d like to see is people attacking their weight problems before they get to the point where they need any of the more drastic options,” Dr. Moore says.  “I’d like to see these people seek help and get education and counseling, because it’s much easier to fix those things earlier than later.”  Dr. Lieb agrees: “Traditionally, many of us have focused on the complications of obesity, not spending time on the actual prevention of obesity.”

Dominique Williams, MD

Healthy You for Life: help for pediatric patients and their families.
For the children of Hampton Roads who are already experiencing the consequences of obesity, CHKD offers a program that helps them gain control of their weight and prevent future problems.  Dominique Williams, MD is Medical Director of CHKD’s Healthy You for Life, which was developed in 2001.  “These kids risk serious health problems, including diabetes, hypertension, depression and even self-esteem issues, just as adults do,” she says.  “And just as with adults, everybody wants to talk about it, everybody feels the sense of urgency, but they’re just not sure how to move that child to a place of doing something about the weight.”

Dr. Williams understands well the difficulty of such conversations, but with a BS and MPH in nutrition and recent Board certification in Obesity Medicine, she feels comfortable initiating them.  “The most important thing is that we deal with patients, not diagnoses,” she says.  “We humanize treatment as much as possible, always acknowledging that these are human beings who are struggling.  We encourage them to share their challenges and their barriers, and respect their vulnerability.  We acknowledge that subjecting themselves to treatment takes courage.”

The program works with parents and children together, focusing on all aspects of weight management, including diet and food planning, physical activity and emotional support.  There are medical clinic visits with yearlong follow-up and options for group fitness and health classes.  The Healthy You for Life Clinic is open to children aged 3 years and older who have a BMI greater than the 85 percentile for age and gender.

“The primary way to get into the program is referral from a physician, nurse practitioner or physician assistant,” Dr. Williams says.  “We make sure this is the best place for the child, and if it isn’t, we try to locate and connect them with resources that better suit their needs and interests.”

There are some adolescent patients who are so complex, whose lives are so impacted by the disease of obesity, Dr. Williams acknowledges, that surgical intervention is appropriate.  “In those cases, the child runs the risk of being overcome by their other diseases.  It becomes an all out war.  But there are several objective pieces of data or criteria that must be met, and it requires an established relationship with the patient and family.”

Treatment options.  
For morbidly obese adults, it’s statistically established that bariatric surgery is the most effective solution for rapid weight loss.  There are several options, including the once popular band surgery, but that has been largely abandoned by most surgeons across the country because it wasn’t seen as effective enough for most patients.  “What we do see more of now is the gastric sleeve,” Dr. Moore says, “and it’s a very good choice, sometimes a better choice for some people, but for many patients, gastric bypass is still the procedure of choice, because of its safety record and good long term results.  And gastric bypass is the best option for diabetics and patients with severe reflux.”

Not all patients are candidates for surgery, and many don’t want or can’t afford it, but do feel they need intervention of some kind.  For these patients, Dr. Hackworth offers the Reshape Balloon Procedure, a refinement of a similar technology that’s been used in Europe for about 20 years, successfully resulting in weight loss for tens of thousands of patients.

The procedure involves going into the patient’s stomach via endoscope to place two balloons, which are then inflated with fluid, Dr. Hackworth explains.  The balloons stay in the stomach and give the patient the feeling of fullness and satiety, while limiting the amount of food that can fit in the stomach.  “The Reshape differs from the original single balloon procedure in several ways,” he says.  “The traditional single balloon would sometimes pop and pass into the small bowel, where it could cause obstruction.  And the single balloon didn’t fit well because of the stomach’s J shape.  With the Reshape, the two balloons are tied together and placed to fit the stomach’s contours.  Using a smaller volume in each balloon, we’re able to achieve a higher overall volume.  If one of the balloons should pop, there’s virtually no risk of it passing into the small bowel and causing complications.  The other remains inflated.”

In the Seriously Weight Loss LLC program, the emphasis is on psychological management and intensive counseling to help patients modify their behavior, Dr. Pagador explains.  “Cognitive behavioral therapy is the foundation of treatment.  Some patients come with a history of childhood trauma, but many are just experiencing the stress of 21st century living: a hectic work schedule while trying to balance caring for small children and aging parents, etc.  Many self-describe as stress eaters or emotional eaters, depressed eaters.  We start with a minimum of an hour of counseling on lifestyle, stress management, and diet and exercise.”

Before any treatment is begun, patients have an EKG and bloodwork to identify any medical issues not immediately evident.  Medication, when used, is carefully regulated and monitored.  “The patient’s BMI must be 30, or 27 with one or more co-morbid conditions.  But we always start with lifestyle changes, with diet and exercise.”

To all of her patients, Dr. Pagador emphasizes that they have a chronic disease that will always need to be managed – regularly and for a lifetime for some patients, and occasionally for others.

Dr. Gaglione takes a similar approach with her patients at Tidewater Bariatrics, with a heavy emphasis on medical nutritional therapy.  She too reinforces that her patients are dealing with a chronic disease.  “Whether they choose a medically directed program like ours, or opt to have surgery, patients will still need to manage their disease state, just as diabetics or anyone with chronic hypertension do,” she says, “and even more so, because environmental control and what they’re surrounded by are critically important.”

For Dr. Gaglione’s patients, that involves learning and practicing new skills, and changing the patient’s relationship with food.  There are important tools like the well-known HMR program (Tidewater Bariatrics is the only full in-clinic HMR program in Virginia), which teaches structured eating, whether on HMR meals exclusively, or HMR prepared foods supplemented by fruits and vegetables chosen by the patient.

Once the weight is lost, “It’s important that patients understand that if they have a history of morbid obesity and they are no longer morbidly obese, they still have the disease,” Dr. Gaglione says. “It’s always going to be with them.”

Going forward.
Every physician and provider interviewed for this article agreed that it is time for the stigma – the fat-shaming too long attached to obesity, both within and outside the medical community – to disappear.  “As physicians, we all need to do a better job of focusing on the prevention of obesity,” Dr. Lieb says.

“Obesity is a stubborn problem,” Dr. Hackworth says.  “Surgery is not the solution for the disease itself.  In our program, patients receive nutritional and dietary counseling and exercise coaching.  They meet regularly throughout the year.  Weight loss doesn’t happen if the patient isn’t motivated and willing to make some changes.”

“It’s a complex, multifaceted disease,” Christa Black says, “and there’s no one-stop cure for it.  We’re at the point where we have to almost throw everything but the kitchen sink at each individual patient, to see what works.  It takes a multidisciplinary, team approach.  And thankfully, there’s a real paradigm shift happening now.”

Effectively Treat Chronic Pain by Treating Obesity

By Jenny L. F. Andrus, MD

Obesity is an epidemic in America.  As physicians, no matter if we are PCPs or specialists, we see a steady stream of obese patients., many of whom are obese.  Obesity causes or exacerbates many of the most common pathologies we observe, and chronic pain is no exception.

As an Interventional Pain Management Specialist, I see patients in my practice who suffer from chronic pain and obesity.  I utilize different methods of treating their pain, including interventional procedures, medications, Physical Therapy, and behavioral therapy.   For most patients, these are appropriate treatments.  However, weight loss may provide them with the most effective and long-lasting form of pain relief.  As physicians, we should be more proactive in addressing weight as part of our treatment plan.

Extra weight causing any level of obesity always equals problems for the human body, especially for the musculoskeletal system.  The muscles, joints and ligaments become stressed and sore.  Joint degeneration occurs, leading to less activity, weight gain and chronic musculoskeletal pain.  Back pain, arthritis, fibromyalgia, diabetes, and spinal issues all typically have obesity as a component.

There are several challenges to overcome.  The first is helping our patients understand the connection between obesity, pain and chronic illness. Those patients who have exhausted the easier treatment options and have not found relief may be easier to persuade about the benefits of weight loss.

Second, if losing weight was so easy, we would not have to address obesity with our patients.  Bu we do.  Are we helping our patients by offering resources, reading materials and medical direction on weight loss, or is prescribing a pill easier? Are we offering referrals to nutritionists or behavioral therapists so that they can address the reasons for consuming too much food, or do we look the other way?  Would bariatric surgery be the most expeditious remedy for our morbidly obese patients, or are we afraid to discuss that option in case we hurt someone’s feelings?

The federal government and the Commonwealth of Virginia have issued strict guidelines regarding the use of opioids because of the deleterious or potentially deadly effects they have on the health of those who take them.  However, obesity is a much larger health issue for Americans, affecting millions and costing billions of dollars to treat every year. It is time that we address the epidemic health issue of obesity as diligently as possible.

Many of you have seen the dramatic results that weight loss has on the health of your patients:  hypertension resolves, Type 2 Diabetes ends, GERD goes away, the risk for stroke, heart attack and cancers decrease…the list goes on and on.  Chronic pain patients who overcome obesity often report that their pain goes away completely or decreases substantially… something that might not happen with medication, surgery or other interventions.  Pain medications can be stopped entirely or reduced to a fraction of what the patient once required for analgesia.

Losing weight has so many benefits to the overweight/obese patient that I believe it should be a part of any comprehensive treatment and wellness plan, no matter your specialty.

Jenny L.F. Andrus, MD practices at the Orthopaedic and Spine Center in Newport News. She is Board certified in Physical Medicine and Rehabilitation and Pain Management. www.osc-ortho.com

Advances in Ankle Foot Orthotics (AFO’s)

By Matt Zydron, CPO

Ankle Foot Orthosis, also called AFO’s, have been around for decades. These braces work to restore function to the lower extremity. This helps patients with drop foot due to stroke, spinal cord injuries, multiple sclerosis, neurological conditions or other ankle instabilities (to name a few) decrease pain, increase or decrease range of motion, and ambulate more closely to normal gait.

In the past, AFO’s have primarily been fabricated from polypropylene-based plastic and other thermoplastics. While these materials have proven to be durable, lightweight, while allowing for customization, the profiles may be thick, uncomfortable, and limit a patient’s footwear choices.

The next generation AFO’s | Pre-preg carbon
A new process of pre-impregnating a carbon composite with a thermosetting resin is bringing improved applications for orthotic devices. Pre-preg AFO’s have several advantages over traditional, thermoplastic orthoses. Improvements include:

• Pre-preg carbon AFO’s are stronger than traditional, thermoplastic braces

• They have a thin, light profile which improves patient comfort and does not require accommodative shoes

• Pre-preg AFO’s provide a dynamic response, facilitating ambulation

• Carbon pre-preg has a high strength- to-weight ratio

• They provide completely customizable forefoot and spring flexibility configurations to tune the device to the exact specifications needed for the patient

The process of fabricating the carbon AFO’s can be done relatively quickly, getting patients up and walking more safely in a short amount of time.

First, a cast or 3D scan is made of the patient’s calf, ankle, and foot. Once the cast is modified, the pre-impregnated carbon composite fabric is cut into strips to create the calf band, strut, and foot plate of the AFO. After the carbon is fit into place, it is placed under vacuum and heated to cure the resin.  Finally, the edges of the AFO are smoothed on a grinding machine, and straps and padding are added.

Carbon pre-preg AFO’s are just one way that new materials are making their way into orthotic and prosthetic technology. Lighter, stronger materials are improving patient comfort and performance, which in turn improves patient outcomes.

Matt Zydron, CPO, is a graduate of Northwestern University’s Prosthetic and Orthotic Program, and received his undergraduate degree from Hampden-Sydney College. He is certified by the American Orthotic and Prosthetic Association and has been a practicing O&P clinician since 2002. www.reachops.com