The Evolution of the Cosmetic OB/GYN
Interview with Dr. Julio Cesar Novoa, M.D. by Flor Rodriguez

Ms. Flor Rodriguez is a freelance reporter working in the El Paso, Texas and Juarez, Mexico area. She has 10 years experience in media including: TV, radio, newspaper, weather girl, police reporter and health reporter. She currently resides in El Paso, Texas.
The Interview
Flor: Hello Dr. Novoa, thank you for agreeing to be interviewed.
Dr. Novoa: Thank you for inviting me.

Flor: Dr. Novoa, on your website you talk a lot about trying to make the public aware of what you call a "high rate of Cesarean Section (C/S)." Why do you consider this to be a problem?
Dr. Novoa: It's a problem when you realize that one in three women are being delivered by Cesarean Section (C/S). In cases of teen pregnancy and older patients, the rate can be as high as 50%. It is not just me that is worried about this problem, the National Institutes of Health (NIH), the Center for Disease Control (CDC), the World Health Organization (WHO), and the American Congress of Obstetricians and Gynecologists (ACOG) all say that we as obstetricians are not doing enough to keep the rate of C/S down. In some cases we are not only doing a bad job but a poor job.

Flor: So what would you describe as a "good number" for C/S? And would you mind telling our readers what is your C/S rate?
Dr. Novoa: I am concerned that half of all C/S are unnecessary. I agree with the recommendations of Healthy People 2010 and the World Health Organization, who recommend a 15% primary C/S rate. My primary C/S rate is 7% with an average number of deliveries between 30-50 babies per month. Since 1995, I have delivered over 5000 babies.

Flor: I understand that you are also a very strong advocate for the VBAC. What is VBAC?
Dr. Novoa: VBAC stands for Vaginal Birth After Cesarean Section. When a woman has previously had a C/S and becomes pregnant, she can request a VBAC and attempt to deliver her next child vaginally.

Flor: I have heard that VBAC is dangerous and should not be attempted and no one except you does them in El Paso. Is this true?
Dr. Novoa: Absolutely not. VBAC deliveries can pose a higher risk than either a spontaneous vaginal delivery or planned repeat C/S but they are not considered dangerous. As a matter of fact, the NIH, CDC , WHO and ACOG all encourage women to attempt a vaginal delivery after previous C/S if her doctor recommends it.

Flor: So why aren't more women attempting a VBAC?
Dr. Novoa: Because very few doctors are recommending it?

Flor: I don't understand, if so many organizations are recommending the VBAC, why aren't doctors doing more VBACs?
Dr. Novoa: There are generally three reasons why we aren't doing more VBACs. (1) There is a 1% chance that a VBAC can lead to a serious complication which can harm the mother or the baby. (2) It is not cost effective for a doctor to do a VBAC as compared to a repeat C/S. (3) Doctors don't want to lose revenue by referring a patient interested in a VBAC to a doctor that does.

Flor: Well, that sounds very surreal Dr. Novoa. Then why do you do VBACs? Obviously by looking at your credentials, you don't need to do them.
Dr. Novoa: I do them because I feel that women should be given as many options as possible regarding their bodies and their pregnancies. If my daughter or another family member asked me to help her with a VBAC, I would have to say, Yes. So in all good conscience, I could not deny the same service to my patients.

Flor: You say that it's not "cost-effective" to do a VBAC? What do you mean by that? Dr. Novoa: A scheduled repeat C/S takes about 15-20 minutes to perform. A doctor assisting in a VBAC is required by the hospital to be present on Labor and Delivery the entire time a patient is laboring which can take as long as 18 hours. Unfortunately, the vast majority of doctors cannot commit to this amount of time and be paid less than a Repeat C/S.

Flor: So during a VBAC, you stay with the patient for up to 18 hours in the hospital?
Dr. Novoa: Yes, once I assess the patient and we agree to try for the VBAC, I stay as long as it takes for a safe delivery.

Flor: As one of the busiest doctors in El Paso, how does staying 18 hours in the hospital for one patient affect your personal life and practice?
Dr. Novoa: It has a great affect on both. It demands a great deal of understanding from my patients, family and friends. But I honestly believe that the VBAC is an important option that must be offered. Until the hospitals change their policies or offer some kind of assistance to doctors willing to perform VBACs, I will just have to keep trying my best. My success rate with VBAC is 90%.

Flor: What do you mean by a 1% risk of a serious complication?
Dr. Novoa: It has been estimated that there is a 0.5-1% risk of the uterus opening where the scar from the previous C/S was performed and healed. However, when taking into consideration how often we do C/S for other reasons, I consider the risk to be acceptable as does the organizations I mentioned.

Flor: You have also said that there are OB/GYNs that don't refer patients to you. Could you elaborate?
Dr. Novoa: Since I specialize in the VBAC, we get a lot of patients transferring from other doctors. During our interviews, the majority of them tell me that their current doctor has told them that no doctor in El Paso is doing VBACs. This is simply not true and they know better. What they are doing by not properly informing their patients is unethical. There are other doctors in private practice offering VBAC and the University Hospital has an outstanding record regarding VBAC deliveries.

Flor: Changing the subject, I would like to talk about AWAKE surgery. Exactly what does that mean?
Dr. Novoa: AWAKE surgery uses tumescent or diluted lidocaine injected directly into tissue to anesthetize it which avoids the need for either oral, intravenous, intramuscular or General Anesthesia. Using this technique, I am able to perform Breast Augmentation, Liposuction, Tummy Tucks or Vaginal Rejuvenation Surgery using only tumescent lidocaine thus avoiding the risks, potential complications and expense of General Anesthesia.

Flor: I have watched your Breast Augmentation video on YouTube.com. It was very interesting. But why did you create it? Weren't you afraid of giving away trade secrets?
Dr. Novoa: I was the first doctor and I believe still the only surgeon in El Paso to perform AWAKE procedures in the manner it was originally designed. When I first started doing them in 2008, I received an incredible amount of criticism from my OB/GYN, Plastic Surgery and Anesthesiology colleagues. Despite their respective Board certifications, none had ever heard of or could even contemplate how to perform cosmetic surgery on a totally conscious patient. I created the video in order to show my colleagues and the general public how to do AWAKE Breast Augmentation and thus remove the veil of secrecy associated with it. I am very proud of the video. In a year and a half, it has been viewed over 60,000 times and is considered an instructional video on how to do AWAKE Breast Augmentation both nationally and internationally.

Flor: I understand that Congratulations are in order. My sources tell me that your most recent paper has been accepted for publication and that you are authoring two chapters in an upcoming breast surgery book.
Dr. Novoa: Thank you. Yes. I recently completed a journal paper based on my first 504 AWAKE Breast Augmentation surgeries performed in my Office Based Surgical Center. Since writing the paper, I have been invited to speak at three international conferences on the subject of AWAKE Breast Augmentation. I am very excited about the publication because the paper will finally dispel the unfounded criticism that AWAKE surgeries are inferior to procedures done under General Anesthesia. On the contrary, on the right patient, AWAKE surgery is incredibly safe and allows a patient to communicate her wishes during the entire surgical procedure.

Flor: So you mean that during surgery, a patient can actually see how large you are going to make her and she can make the final decision before you finish?
Dr. Novoa: Yes, using my technique, the patient is in no pain and can make an informed consent during the surgery. She looks in the mirrors and she is the one that makes the final decision on how big she wants to be.

Flor: Changing the subject one last time, I understand that you are the only surgeon in El Paso performing Vaginal Rejuvenation Surgery. What is Vaginal Rejuvenation Surgery (VRS)?
Dr. Novoa: As part of both my GYN and Cosmetic practices, I specialize in the management of sexual disorders of female patients, specifically with disorders affecting the ability of a woman to enjoy intercourse and to achieve orgasms. Part of this is associated with the relaxation of the vagina associated with childbirth. As a cosmetic gynecologist I am specially trained to "rejuvenate" the vagina back to virginal size and appearance to include the recreation of the hymen.

Flor: Does VRS really improve sexual satisfaction?
Dr. Novoa: It is only one factor in a larger picture of female sexuality. In combination with couples therapy, hormone supplementation, education in self-awareness and sexual techniques and surgical modifications of the vagina, a patient can significantly improve her level of sexual gratification.

Flor: It seems like you are continuously educating yourself and yet, isn't it true that you are neither Board Certified in OB/GYN or Plastic Surgery? If so, why not?
Dr. Novoa: This is correct. I am not Board certified in OB/GYN or Plastic Surgery. To answer the first part of your question, a licensed doctor in Texas is required to earn at least 24 Continuing Medical Education (CME) credits per year to maintain their license. In the past 3 years I have earned 1012 CME credits which I believe is the highest for any doctor in any specialty in El Paso. I am not Boarded in OB/GYN because I have a fundamental objection to the current policies of the American Board of Obstetrics and Gynecology (ABOG) in regards to both cosmetic surgery and the increasingly high rate of C/S. The ABOG does not recognize cosmetic gynecology and currently provides no avenue of credentialing for this new field of gynecology. Second, and more importantly, I feel that neither the ABOG nor ACOG is doing enough to fix the problem of the ever increasing rate of C/S, basically turning a blind eye to the problem. Think about it, if greater than 90% of OB/GYN doctors are Board certified but over half a million C/S per year may be unnecessary, what does this say about being Board certified? All Board certification says is that you passed a test, their test. It doesn't say anything about me as a doctor or surgeon. I stand by my record and am proud not to be Board certified. Until the Board makes its members more accountable, I choose not to be Board certified in OB/GYN.

In regards to being Board certified in Plastic Surgery. I am not nor do I claim to be a Plastic Surgeon. I am a Cosmetic Surgeon, having trained first as an OB/GYN and then continuing my training in cosmetic surgery. I am, however, working towards by Board Certification in Cosmetic Surgery through the American Board of Cosmetic Surgery (ABCS).

Flor: Speaking of your record, you post your monthly delivery statistics on your website (www.drnovoa.com). Why do you do this?
Dr. Novoa: I do it so that my patients and the general public can see exactly how many deliveries I do per month and what their outcomes are. It's all about being accountable. If ABOG and ACOG were to make their members more accountable, I believe we would see the rate of C/S cut in half within one year. So, I post my stats to do my part so that patients have an objective way of determining my practice numbers. And I think that my 7% C/S rate compared to 32% nationally, shows that I am doing a good job.

Flor: Well, that's all the time we have today. Any final comments?
Dr. Novoa: I believe that the Cosmetic OB/GYN is the natural evolution of the traditional OB/GYN, providing a level of expertise in the field of medicine which includes all facets of the female gender to include obstetrics, gynecology, sexual health and cosmetics. I am truly excited that I am able to stand in the forefront of this new and continuously developing subspecialty of OB/GYN.