#64 – Zol Kryger, M.D.: Plastic surgery—common procedures, reducing risk, & picking the right doctor

Kryger notes that patients almost never ask about board certification — they ask how nice, confident, or empathetic the surgeon seems, and they weight price heavily. His own nurse, five years in his practice, chose a revision surgeon based on lower price rather than training. The Sunshine Act database (searchable online) shows every payment from pharmaceutical and device companies to physicians by name — useful to check before trusting a surgeon's opinion on implant type or device technology.

The textured-implant advantage in capsular contracture was a confound: European surgeons using textured teardrop implants were also using an inframammary incision that bypassed nipple flora, so the lower contracture rate was attributable to the incision, not the texture. A blinded study at a plastic surgery meeting showed surgeons correctly identified round vs. teardrop outcomes only 50% of the time — random chance — demolishing the claimed aesthetic advantage. Teardrop implants are also harder, require larger incisions, can rotate, and cost 20–25% more.

There is no mandatory reporting law requiring plastic surgeons to report ALCL cases to any registry. The voluntary ASPS PROFILE database mostly captures board-certified plastic surgeons, missing the large fraction of breast augmentations done by non-plastic surgeons. Women who had textured implants placed by a non-plastic surgeon are at highest risk and least likely to be followed up, because their provider may not be watching for the complication at all.

Kryger's 'Krieger test' for absolute indication: if a child asks the mother whether she is pregnant after a large meal, that is the clearest sign that diastasis and skin excess are significant enough to materially affect quality of life. Diastasis is not merely cosmetic — severely thinned fascial tissue allows intestinal movement to be visible through the skin. The diastasis repair closes the fascia (not the muscles themselves) over the midline, restoring a flat anterior abdominal wall. The hernia repair at the belly button is addressed simultaneously as a structural repair, not just a cosmetic one.

Kryger personally avoids large-volume liposuction: 'I try to avoid very large volume liposuction — that's where it becomes risky, where you're trying to suck up more than about ten pounds of fat at a time.' In unregulated settings, providers routinely remove 20–30 pounds in marathon 8-hour sessions; this is where the fluid-shift deaths and electrolyte crises occur. The cannula can also penetrate the diaphragm and enter the thorax (pneumothorax) or penetrate the abdominal wall into bowel when anatomic awareness lapses — these complications have been documented even in thin patients.

Kryger performs 20–30 per year — surgeons in Miami perform 4–5 per day and some do 7–8. At that volume, 'you cannot be maintaining the attention to anatomical detail that this procedure demands.' The USA Today expose on Miami BBL clinics documented deaths at facilities owned by non-physicians with criminal records, where unlicensed individuals were involved in performing the procedures. In Florida, until recent legislative changes, there were no restrictions on non-physician ownership of surgical facilities or on the credentials of physicians working there.

Kryger turns away 1–2 patients per day primarily because he does not believe surgery will help them. The most common turned-away case: overweight patients presenting liposuction as a weight-loss solution. He explains the ceiling on subcutaneous fat removal, the loose-skin risk, and the fact that 15 lbs lost through diet and exercise produces superior outcomes to 15 lbs suctioned. His closing pitch: 'Let's sit together right now and talk about how you could take the same amount of money, get a gym membership, hire a nutritionist, change your eating — you're gonna very easily lose 15 pounds that I would suck off, and you're going to be healthier, you're gonna look better.'

Kryger describes colleagues in his Los Angeles-area community — OB-GYNs, ER physicians, family practice doctors, and internal medicine doctors — who begin with Botox, add a laser, then progress to liposuction and breast augmentation. None of this is legally prohibited once they hold an MD. The patients most at risk are price-sensitive patients who do not know to ask whether the doctor trained as a plastic surgeon. Kryger's own nurse — who had been watching him work for five years — still chose to have a revision with a cheaper, less-qualified surgeon: 'Even in my community here in the Greater Los Angeles area hundreds and hundreds of physicians of all walks — gynaecologists, ER doctors, general surgeons, family practice doctors, internal medicine — who have no training or no knowledge whatsoever just decide I'm gonna start doing Botox.'

Kryger attended a plastic surgery panel where a Canadian surgeon, Elizabeth Hall-Finley, projected a single slide from the Sunshine Act database showing how much money each pro-textured panelist had received from implant companies — ranging from $150,000 to $3 million — then walked off stage without saying a word. A bacterial adhesion study found bacteria stick 70 times more readily to textured surfaces than smooth ones, which is mechanistically consistent with the higher ALCL and capsular contracture rates. The teardrop-shaped implants that were 100% textured have now been largely abandoned: a blinded study showed plastic surgeons could correctly identify round vs. teardrop-shaped results only 50% of the time — random chance.

Kryger has followed thousands of his own patients and found significantly lower contracture rates when using the inframammary fold incision. He now strongly advises against periareolar and transaxillary incisions: 'An incision through the armpit or through the nipple — you're making an incision in a location where there are more bacteria, and you're cutting through nerves both in the armpit and in the nipple, and studies show that there is a higher rate of pain and numbness and issues associated with going through those two sites.' The other key risk amplifier is early hematoma: blood is an excellent culture medium for the bacteria that seed at insertion, so early bleeding dramatically increases late contracture probability.

Kryger's own volume is 20–30 per year; Miami-based surgeons may do four to five per day, and some individuals he knows do seven to eight daily. At that volume, safety protocols cannot be maintained. The anatomical risk: the patient prone on the OR table in a flat position changes the depth of the gluteal venous plexus relative to surface anatomy. Bending the table 30 degrees (beach chair) moves the vessels deeper and reduces inadvertent cannulation risk — but this detail of table position requires formal surgical training to know. The plastic surgery societies have discussed placing a moratorium on the procedure.

Kryger frames this as the 'no free lunch' principle: 'If something has no risk, no recovery, no downtime, low cost — it has no result.' The same principle applies to PRP 'vampire facials': multiple HIV transmissions have been documented from clinics using inadequately cleaned harvesting equipment contaminated with blood from an HIV-positive previous patient. Permanent pigment damage from incorrectly calibrated lasers and chemical peels rounds out the minimally-invasive risk profile. The common denominator is unlicensed or undertrained operators in cash-pay, non-hospital settings.