The Role of Laser Therapy in Scar Management By Faraz Yousefian, DO, Graham Litchman, DO, MS and Chad Hinvor, MD, FAAD

The Role of Laser Therapy in Scar Management

By Faraz Yousefian, DO, and Graham Litchman, DO, MS and Chad Hivnor, MD, FAAD

Although scars may partially fade with time, the mark they leave behind are a constant reminder of the incident that initially caused the skin injury. Some of our patients are able to embrace these marks as a part of their identity, however, the majority endeavor to hide and treat these unpleasant and sometimes symptomatic cicatrices. Scar formation can have various etiologies of skin injury such as trauma, burn, gun powder, medical and surgical procedures, and occupational accidents which can lead to functional and psychological morbidities.1,2 In Texas, we encounter many patients with scars, especially in the veteran and oil field worker population, and we can improve their quality of life by offering a variety of available treatment options.

There are various forms of scars: contracture, depressed (atrophic), flat, keloid, raised (hypertrophied) and stretch marks. Scar formation or fibrosis is a normal physiological healing response that is primarily mediated by proinflammatory cytokines and transforming growth factors. There are six phases of wound healing: (1) rapid hemostasis; (2) appropriate inflammation; (3) mesenchymal cell differentiation, proliferation and migration to the wound site; (4) suitable angiogenesis; (5) prompt re-epithelialization (re-growth of epithelial tissue over the wound surface) and (6) proper synthesis, cross-linking and alignment of collagen to provide strength to the healing tissue.1,3 Scars may become painful, itchy or numb as nerve endings are often damaged initially, but these symptoms often improve over time.1,2,4

Educating patients on both injury prevention and proper wound care is paramount. Patients should promptly seek medical attention to minimize scarring – first and foremost by having a clinician evaluate for primary versus secondary wound healing options. Gently cleaning the wound with soap and water, keeping it moist with an ointment such as petroleum jelly, protecting it from sun exposure and maintaining adequate nutrition with high-quality proteins, Vitamin C and Vitamin D is essential for improving wound healing. The Patient Scar Assessment Scale and Observer Scar Assessment Scale are tools physicians can utilize to evaluate the scar before providing different treatment modalities such as polyurethane or silicone scar reduction patches, silicone gel, oral or topical tranilast (an inhibitor of collagen synthesis), pressure dressing, surgical excision, intralesional corticosteroids, intralesional 5-fluorouracil, cryotherapy, skin needling, subcision and/or laser therapy.2–5

There are numerous laser systems available that provide successful treatment of different types of scars with various etiologies. The detailed evaluation of individual patient and scar characteristics (location, size and type) is the foundation for prompt therapeutic planning such as non-ablative lasers for mild scars, and ablative lasers for deeper scars with reduced range of motion.6,7 There are many factors that are considered, such as the period after injury, depth, color, texture, symptoms, skin phototype, medicine usage and prior treatment to help select the best course of management. After careful assessment, Low-level Laser (LLL), Pulsed Dye Laser (PDL), Q-Ruby, Q- Alex and Q-YAG can be utilized to tackle the scar in multiple sessions.2,4–6 Initial treatment focuses on color; however, subsequent attention directed toward configuration of the scar allows the resurfacing process to provide improved skin elasticity, increased vascularization and overall symptom reduction.2,4,6

It should be noted that scars do not to be new to be considered for laser treatment. A dermatologist with expertise in lasers should be consulted for a careful scar assessment prior to constructing a plan for management. By utilizing intimate knowledge of the latest technology, including lasers, the medical and surgical skills of a licensed dermatologist will effectively provide the most appropriate treatment plan to improve the patient’s quality of life.

References 1. Guo S, DiPietro LA. Factors Affecting Wound Healing. J Dent Res. 2010;89(3):219-229. doi:10.1177/0022034509359125 2. Fu X, Dong J, Wang S, Yan M, Yao M. Advances in the treatment of traumatic scars with laser, intense pulsed light, radiofrequency, and ultrasound. Burns & Trauma. 2019;7(1):1. doi:10. 1186/s41038-018-0141-0 3. Acne scarring: A review and current treatment modalities - Journal of the American Academy of Dermatology. Accessed March 31, 2022. https://www.jaad.org/article/S0190-9622(08)00659-2/fulltext 4. Isotretinoin and Timing of Procedural Interventions: A Systematic

Review With Consensus Recommendations - PubMed. Accessed

March 31, 2022. https://pubmed-ncbi-nlm-nih-gov.uiwtx. idm.oclc.org/28658462/ 5. Iyengar V, Orengo IF. Surgical techniques for cutaneous scar revision. Journal of the American Academy of Dermatology. 2001;45(4):648. doi:10.1016/S0190-9622(01)70075-8 6. Xiao A, Ettefagh L. Laser Revision Of Scars. In: StatPearls. Stat-

Pearls Publishing; 2022. Accessed March 31, 2022. http://www.ncbi.nlm.nih.gov/books/NBK539686/ 7. Ohshiro T, Ohshiro T, Sasaki K. Laser Scar Management Technique.

Laser Ther. 2013;22(4):255-260. doi:10.5978/islsm.13-OR-20 Faraz Yousefian, DO is an intern at the Texas Institute for Graduate Medical Education and Research (TIGMER) in San Antonio, Texas. He is very passionate about mentoring nascent physicians and educating the general population about skin diseases and the steps they can take to prevent them. Dr. Yousefian is a member of Bexar County Medical Society.

Graham Litchman, DO, MS is a PGY-3 dermatology resident at St. John's Episcopal Hospital in New York. He was a Melanoma Clinical Research Fellow at the National Society for Cutaneous Medicine.

Chad Hivnor MD, FAAD is the Chief of Dermatology at South Texas Veterans Health Care System and clinical associate professor at Uniformed Services University Health Sciences and UT Health Science Center. He is also in private practice part-time in San Antonio. Dr. Hinvor is a member of the Bexar County Medical Society.

Understanding Long COVID

By Sean Rumney, Ashley Chakales and Monica Verduzco-Gutierrez, MD

In January 2020, SARS-CoV-2 was identified as the causative agent in an outbreak of pneumonia in Wuhan, China. In the last two years, our understanding of the clinical presentation of a SARS-CoV-2 infection has improved with acute disease classically resulting in the symptoms of severe upper respiratory infection.1

In addition to the symptoms of acute infection, a small portion of patients reported symptoms lasting for weeks to months after initial diagnosis. These patients, calling themselves ‘long haulers’ in some early reports, remained symptomatic weeks after PCR and lab studies showed evidence of no active infection with the virus. For some, symptoms of acute COVID infection might fail to improve, while others will report new or worsening symptoms weeks later in their disease course. While most COVID-19 patients make a full functional recovery, the health status of patients post-infection has been found to be lower than the general population.2 This pattern of symptoms has provided a challenge for primary care clinicians throughout the pandemic, as these chronic symptoms can prove difficult to manage, and in some cases can result in severe exercise intolerance and debility.

What is Long COVID?

Long COVID is defined as new or persistent clinical symptoms due to SARS-CoV-2 infection lasting for greater than 28 days.3 Different authors use different terms to describe the prolonged symptoms following COVID-19. Some of these include Long COVID, Persistent Post-COVID Syndrome (PPCS) by the CDC and Post-Acute Sequela of SARS-CoV-2 (PASC).3,4

What are the symptoms of Long COVID?

COVID-19 can produce systemic effects, thus Long COVID is associated with a wide range of symptoms. Prominent symptoms of Long COVID include fatigue, headache, dysgeusia, anosmia, shortness of breath, cough, chest pain, abdominal pain, myalgia, sleep disturbance, anxiety, depression, “brain fog” and cognitive impairment.3,5,6

What is the pathophysiology behind Long COVID?

The pathophysiology of Long COVID is unclear, however many symptoms have been attributed to a systemic inflammatory response following infection. In some patients, COVID-19 infection results in an inflammatory response characterized by the overproduction of proinflammatory cytokines. This period of pro-inflammatory response is compensated by an overproduction of anti-inflammatory factors, resulting in compensatory anti-inflammatory response syndrome (CARS).7 The production of these anti-inflammatory factors can progress to a persistent state of inflammation, immunosuppression and catabolism. This syndrome, called PICS, is seen in post-sepsis patients, and is characterized by immune dysregulation and inflammation, and shares similarities to manifestations of Long COVID. The differing inflammatory/anti-inflammatory responses in individual patients may be the cause of variable presentations of post-COVID syndromes. Fibrogenic cytokines are implicated in many known post-COVID complications including pulmonary fibrosis, and may be responsible for the CNS effects of Long COVID.8

Others suggest the delayed resolution of inflammation, autoimmunity and viral persistence may contribute to the pathogenies of Long COVID. Patients with Long COVID have demonstrated persistent elevation of interferons and proinflammatory cytokines post-infection, suggesting a delay in the resolution of inflammation and a consequent persistent systemic inflammation. The development of autoimmune response against self-tissue antigens is thought to contribute to the pathogenesis, as several studies have reported the presence of autoantibodies among COVID-19 patients.9

Who is at risk for Long COVID?

Long COVID can be found in patients with relatively mild initial infections to those with severe infections. Long COVID has been reported in pediatric, adult and geriatric populations. A study performed by the NIH that analyzed self-reported symptoms of individuals with a confirmed positive SARS-CoV-2 PCR attempted to categorize Long COVID symptoms. There were several predictive factors during initial infections that indicated a relative risk for developing Long COVID symptoms. Advanced age (>70 years old) and greater than five concurrent symptoms within the first week of COVID-19 infection were found to increase the risk of developing Long COVID symptoms. The most predictive symptoms were found to be, in order of risk: fatigue, headache, dyspnea, hoarse voice and myalgias. Comorbidities were not strongly predictive in the younger age group apart from a prior diagnosis of asthma, which significantly increased the chance of patients later reporting symptoms consistent with Long COVID.10

How is Long COVID managed?

Long COVID is diagnosed based on a patient’s history of COVID19 paired with the exclusion of other causes, as there is no one diagnostic test. A multidisciplinary approach in an assessment and treatment plan is recommended.

Fatigue and cognitive impairment are the some of the most commonly reported symptoms in patients with Long COVID.11 The American Academy of Physical Medicine and Rehabilitation published recommendations for the outpatient management of these patients, and states that patients should be evaluated for fatigue if symptoms do not improve within four weeks.12 Mild fatigue can be monitored by a provider, while functionally limiting fatigue may warrant further workup.

After a diagnosis of fatigue due to Long COVID has been made, treatment options may be discussed. As fatigue has shown a tendency to improve slowly over time, patients might choose to defer treatment. If the patient chooses to pursue treatment, an individualized plan can be built to help return them to baseline. Standard treatment plans include a structured and titrated return to activity plan, energy conservation strategies and encouraging healthy dietary patterns. Post-exertional malaise must be considered and screened for. Rehabilitation needs to be designed on an individual basis, as these patients will not benefit from these traditional therapy models.13

Pharmacologic treatment might be helpful in managing brain fog and chronic fatigue, and some clinics targeting Long COVID patients have prescribed antidepressants, cytokine inhibitors, leukotriene receptor antagonists, stimulants and antivirals. These treatment options have limited evidence through clinical trials and should be considered on a case-by-case basis after evaluation by a health care provider.

Two local post-COVID rehabilitation clinics run by Monica Verduzco-Gutierrez, MD through UT Health and University Health have promoted a holistic approach to the management of patients with Long COVID-associated cognitive impairment and fatigue. Energy conservation, titrated return to activity programs, and tailored cognitive rehabilitation are being used to aid recovery and return to function in these clinics.

References 1. Post-covid conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/long-termeffects/index.html. Accessed March 10, 2022. 2. Huang L, Yao Q, Gu X, et al. 1-year outcomes in hospital survivors with covid-19: A longitudinal cohort study. The Lancet. 2021;398(10302):747-758. doi:10.1016/s0140-6736(21)01755-4 3. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nature Medicine. 2021;27(4):601-615. doi:10.1038/ s41591-021-01283-z 4. CDC COVID-19 Response Team. Severe outcomes among patients with coronavirus disease 2019 (COVID-19) — United States, February 12–March 16, 2020. MMWR Morbidity and Mortality

Weekly Report. 2020;69(12):343-346. doi:10.15585/ mmwr.mm6912e2 5. Gupta A, Madhavan MV, Sehgal K, et al. Extrapulmonary manifestations of covid-19. Nature Medicine. 2020;26(7):1017-1032. doi:10.1038/s41591-020-0968-3 6. Graham EL, Clark JR, Orban ZS, et al. Persistent neurologic symptoms and cognitive dysfunction in non‐hospitalized Covid‐19

“long haulers.” Annals of Clinical and Translational Neurology. 2021;8(5):1073-1085. doi:10.1002/acn3.51350 7. Chippa V., Aleem, A., & Anjum, F. Post acute coronavirus (COVID19) syndrome. In StatPearls. StatPearls Publishing. 2022. http://www.ncbi.nlm.nih.gov/books/NBK570608/ 8. Oronsky B, Larson C, Hammond TC, et al. A review of persistent post-covid syndrome (PPCS). Clinical Reviews in Allergy & Immunology. 2021. doi:10.1007/s12016-021-08848-3 9. Mehandru S, Merad M. Pathological sequelae of long-haul covid.

Nature Immunology. 2022;23(2):194-202. doi:10.1038/s41590021-01104-y . Sudre CH, Murray B, Varsavsky T, et al. Attributes and predictors of Long Covid. Nature Medicine. 2021;27(4):626631. doi:10.1038/s41591-021-01292-y 11. Ceban F, Ling S, Lui LMW, et al. Fatigue and cognitive impairment in POST-COVID-19 syndrome: A systematic review and metaanalysis. Brain, Behavior, and Immunity. 2022;101:93-135. doi:10.1016/j.bbi.2021.12.020 12. Herrera JE, Niehaus WN, Whiteson J, et al. Multidisciplinary collaborative consensus guidance statement on the assessment and treatment of fatigue in postacute sequelae of SARS‐COV ‐2 infection ( PASC ) patients. PM&R. 2021;13(9):1027-1043. doi:10.1002/pmrj.12684 13. Twomey R, DeMars J, Franklin K, Culos-Reed SN, Weatherald J,

Wrightson JG. Chronic fatigue and postexertional malaise in people living with Long Covid: An observational study. Physical Therapy. 2022. doi:10.1093/ptj/pzac005

Sean Rumney and Ashley Chakales are medical students at the UT Health San Antonio Long School of Medicine.

Society.

Monica Verduzco-Gutierrez, MD is an accomplished academic Physiatrist and Professor and Chair of the Department of Rehabilitation. She is a member of the Bexar County Medical

Dermatologic Manifestations of Pregnancy

By Tue “Felix” Nguyen, Marie Vu and Cara Schachter

Introduction

There are many dermatologic conditions that occur during pregnancy which can appear distressing and affect our patients’ self-image and how they present themselves to the world. In this article, we will explore the following three common cutaneous conditions that affect pregnant women: 1) Striae Gravidarum 2) Telogen Effluvium 3) Melasma and Linea Nigra

Striae Gravidarum

Stretch marks, or specifically striae gravidarum (SG), is a skin condition that affects pregnant women during gestation. Common sites include the abdomen, breasts, medial upper arms, lower back, hips and legs.1 Initially, these lesions present as flat, reddish stripes (striae rubra) that over time fade, atrophy and appear more scar-like (striae alba) (Figure 1). The epidemiology of SG is not completely known, and its prevalence is estimated to be between 55 to 90%.2,3 Risk factors for SG include family history, personal history and race, which indicate that genetic factors play a significant role in the formation of SG in addition to metabolic changes that occur during pregnancy.2 The pathophysiology of SG is not fully understood and more research is needed. Current evidence suggests that because of a multifactorial process (including both physical and endocrine components), the elastic fiber network found within the dermis is damaged, yielding scars that appear as stretch marks.3,4,5 A very common inflammatory skin condition known as pruritic urticarial papules and plaques of pregnancy (PUPPP) is associated with SG and presents as itchy, edematous papules and plaques found on the abdomen originating from stretch marks.6 While SG is a benign condition, many women are bothered by their appearance and seek out methods to prevent and treat their scars. As of yet, preventative measures have limited success. A common remedy involves applying cocoa butter to the skin, but a study showed no effect on the appearance or development of SG.7 Current treatments available for SG include applying topical tretinoin or receiving non-ablative fractional laser therapy to improve the appearance of these scars.8 While there are cosmetic treatments available, it is important to address the stigma surrounding stretch marks to help improve patient selfconfidence.

Figure 1: Striae Alba8

Telogen Effluvium

Telogen effluvium is the excessive shedding of hair that occurs one to five months following pregnancy. This condition is common, as it affects between 40 to 50% of women in the postpartum period.9 In the normal hair cycle, each follicle on the human scalp cycles independently through three major phases including anagen (growth), catagen (transformation) and telogen (rest). The anagen phase accounts for approximately 90% of hair follicles, while <1% are in the catagen phase and 10% are in the telogen phase. The result of the telogen phase is marked by shedding of hair from the follicle. Telogen effluvium occurs when a larger proportion of hair follicles, about 7 to 35% more, enter the telogen phase. The mechanism is not completely understood; however, the theory of delayed anagen release may be related to postpartum telogen effluvium. The increase in estrogen during pregnancy is thought to prolong the duration of the anagen phase, thereby delaying the onset of the telogen phase. Hair loss is noted once this stimulus ends and the affected follicles enter the telogen phase. Thus, the most common period of hair loss occurs approximately three months after delivery when hormonal levels begin to normalize.10 Fortunately, the hair loss related to telogen effluvium is temporary and returns to normal within six to twelve months without medical intervention. It is recommended to eat a healthy and balanced diet, as well as use volumizing shampoo and conditioner to promote healthy hair until it regains normal fullness.11

Melasma and Linea Nigra

Hyperpigmentation may manifest itself in different ways during pregnancy, notably through melasma and linea nigra. Melasma is a hyperpigmented brown to gray-brown patch that typically presents in body areas with high amounts of sun exposure, especially the face (Figure 2). Although it may affect women of all ages, it is often associated with pregnancy, lending its name the “mask of pregnancy.” According to a multinational study across nine countries, 26 and 42% of melasma cases in 324 women occurred during or after pregnancy, respectively.12 Linea nigra, often referred to as a “pregnancy line,” is a hyperpigmented vertical line that com-

monly appears on the abdomen (Figure 3). Similar to melasma, linea nigra may affect women of all ages, but is often associated with pregnancy as the prevalence is greater than 90%. The pathogenesis of increased pigmentation related to pregnancy is not entirely understood but may be influenced by hormonal changes. Increased levels of estrogen and progesterone regulate stimulation of cells which produce pigment in the skin, thus leading to pigmentation changes. These changes may fade in the postpartum period; however, some women may have lasting results for years or even a lifetime. Although benign, these conditions can be bothersome and lead to women seeking dermatologic treatment. Hydroquinone is a common first treatment medication for hyperpigmentation, as it is a skin-lightening agent. To enhance skin lightening, dermatologists may also prescribe a second medication that includes a tretinoin or corticosteroid. Sometimes, a triple cream may be prescribed which contains hydroquinone, tretinoin and a corticosteroid all in one formulation. If medications are not successful in treating hyperpigmentation, procedures such as chemical peels, microdermabrasions, laser treatment or a light-based procedure may prove effective.13 Conclusion

Women experience physiologic changes throughout gestation that result in the development of peri- and post-partum dermatologic conditions. Many of these conditions are well-documented but the exact mechanism by which they occur is still poorly understood. Women affected by any of the aforementioned conditions should be evaluated by a dermatologist and establish routine follow-up care to best optimize their treatment.

References 1. MacGregor JL, Wesley NO. Striae distensae (stretch marks). In: Post TW, ed. Up-

ToDate. UpTodate; 2022. Accessed

February 13th, 2022. https://www.uptodate.com/contents/striae-distensaestretch-marks 2. Chang AL, Agredano YZ, Kimball AB.

Risk factors associated with striae gravidarum. J Am Acad Dermatol. 2004;51(6):881-885. https://doi.org/ 10.1016/j.jaad.2004.05.030 3. Goldsmith LA, Katz SI, Gilchrest BA, et al. Fitzpatrick’s Dermatology in General

Medicine. 8th ed. McGrawHill Medical. 2012 4. Cordeiro RC, Zecchin KG, de Moraes

AM. Expression of estrogen, androgen, and glucocorticoid receptors in recent striae distensae. Int J Dermatol. 2010;49 (1):30-32. doi:10.1111/j.1365-4632. 2008.04005.x 5. Watson RE, Parry EJ, Humphries JD, et al.

Fibrillin microfibrils are reduced in skin exhibiting striae distensae. Br J Dermatol. 1998;138(6):931-937. https://doi.org/ 10.1046/j.1365-2133.1998.02257.x 6. Chouk C, Litaiem N. Pruritic Urticarial

Papules And Plaques Of Pregnancy. In:

StatPearls. Treasure Island (FL): StatPearls

Publishing; August 6, 2021. 7. Buchanan K, Fletcher HM, Reid M. Prevention of striae gravidarum with cocoa butter cream. Int J Gynaecol Obstet. 2010;108(1):65-68. doi:10.1016/j.ijgo. 2009.08.008 8. Farahnik B, Park K, Kroumpouzos G,

Murase J. Striae gravidarum: Risk factors, prevention, and management. Int J Womens Dermatol. 2016;3(2):77-85. Published 2016 Dec 6. doi:10.1016/j.ijwd.2016. 11.001 9. Pregnancy and Hair Loss. American Pregnancy Association. Accessed February 13, 2022. https://americanpregnancy.org/ healthy-pregnancy/pregnancy-health-wellness/hair-loss-during-pregnancy/ 10.Bergfeld W. Telogen Effluvium. In: Post

TW, ed. UpToDate. UpTodate; 2022. Accessed February 13th, 2022. https://www.uptodate.com/contents/telogen-effluvium 11.Hair Loss in New Moms. American Academy of Dermatology Association. Accessed February 13, 2022. https://www.aad.org/public/diseases/hair -loss/insider/new-moms 12.Pomeranz MK. Maternal adaptations to pregnancy: Skin and related structures. In:

Post TW, ed. UpToDate. UpTodate; 2022.

Accessed February 13th, 2022. https://www.uptodate.com/contents/maternal-adaptations-to-pregnancy-skin-andrelated-structures 13.Melasma: Diagnosis and Treatment.

American Academy of Dermatology Association. Accessed February 13, 2022. https://www.aad.org/public/diseases/az/melasma-treatment 14.Melasma. Skin of Color Society. https://skinofcolorsociety.org/patientdermatology-education/1406-2/. Accessed February 22, 2022. 15.Linea Nigra. DermNet NZ. https://dermnetnz.org/topics/linea-nigra.

Accessed February 22, 2022.

Figure 2: Malesma 14

Tue “Felix” Nguyen, Marie Vu and Cara Schachter are medical students at UT Health San Antonio Long School of Medicine. Cara is a member of the BCMS Publications Committee.

2022 BCMS General Membership Meeting

University Health System hosted the Bexar County Medical Society members to a CME lecture presented by Dr. Allen S. Anderson, Chief, Janey & Dolph Briscoe Division of Cardiology, Director UT/UHS and Vascular Institute, UT Health San Antonio. Circle of Friends sponsors had the opportunity to interact with our physician leaders. The BCMS had Oakwell Private Wealth Management, UT Health SA Mays Cancer Center, iGenomeDX, Synergy Federal Credit Union, Elizabeth Olney, Edward Jones and TMAIT. Thank you to UHS for their continued support of physician development opportunities for BCMS members!

Above: Dr. Anderson giving his presentation on “Heart Failure Today: An Evolution in Understanding and Therapeutics.”

Right: Dr. Rajeev Suri, BCMS President and Dr. Allen S. Anderson, CME Lecture Speaker attend.

IN MEMORIAM: Douglas Wayne “Curly” Robinson Jr., MD

Douglas Wayne “Curly” Robinson Jr., MD was a general surgeon who practiced medicine for over 40 years. He was born in Gilmer, Texas, on November 12, 1947. Dr. Robinson graduated from the University of Texas Medical Branch at Galveston and completed his surgical residency at the University of Texas Health Science Center. He served as Chief Resident in 1978. After residency, Curly became a partner with General Surgical Associates and remained with them until his retirement in 2018. Dr. Robinson was married to his wife, Cynthia Kolb, for 52 years and had three daughters, 12 grandchildren and extended family members. He had a special bond with the “Liberty Boys” spanning 70 years.

Dr. Robinson was Doctor of the Year at Community Hospital in 1980, served on the Methodist Hospital System Board for five years where he was Chief of Staff in 1996, assisted Methodist Healthcare Ministries for 10 years, was a member and past president of the Aust Society, was a longtime member of the Texas Surgical Society and President in 2021 and was a member of the Bexar County Medical Society. He was an avid fisherman and hunter, and loved to hike, ski, play golf and spend time with his family. He was also a longtime member of Alamo Heights United Methodist Church, served on the Wesley Community Board, participated in the Canopus Club and loved attending the “Retired Doctor” lunches on Wednesdays. The Bexar County Medical Society extends sympathy to the family and friends of Dr. Robinson.

BCMS Ask a Doctor Event

The BCMS Ask a Doctor table at the National Public Health Week event held on April 7 was a tremendous success! The Bexar County Medical Society surveyed over 100 attendees about their COVID-19 vaccination status. Physicians were on hand to answer questions and got at least two unvaccinated attendees vaccinated. Several also received their boosters while there. A huge THANK YOU to Drs. Vincent Fonseca, Norys Castro Pena and Veronica Nieves-Garcia! BCMS has signed up for more fairs and events promoting our Find a Doctor program. If you are interested in volunteering, please call Chief Operating Officer Monica Jones at 210-301-4373.

Please ask your practice manager to use the Physicians Purchasing Directory as a reference when services or products are needed.

ACCOUNTING FIRMS

Sol Schwartz & Associates P.C. (HHH Gold Sponsor) Sol Schwartz & Associates is the premier accounting firm for San Antonio-area medical practices and specializes in helping physicians and their management teams maximize their financial effectiveness. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”

ACCOUNTING SOFTWARE

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward. Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

ATTORNEYS

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions” ASSETT WEALTH MANAGEMENT

Bertuzzi-Torres Wealth Management Group (HHH Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending and estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

BANKING

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Shawn P. Hughes, JD Senior Vice President, Private Banking 210-283-5759 shughes@broadway.bank www.broadwaybank.com “We’re here for good.”

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier 210-807-5581 brandi.vitier@thebankofsa.com www.thebankofsa.com

Synergy Federal Credit Union (HH Silver Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need.

Synergy FCU Member Services 210-750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

BUSINESS CONSULTING

Medical Financial Group (★★★ Gold Sponsor) Healthcare & Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller & past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems. Jesse Gonzales, CEO CPA, MBA 210-846-9415 information@medicalfgtx.com Linda Noltemeier-Jones Director of Operations 210-557-9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals”

CREDENTIALS VERIFICATION ORGANIZATION

Bexar Credentials Verification, Inc. (HHHH 10K Platinum Sponsor) Bexar Credentials Verification Inc. provides primary source verification of credentials data that meets The Joint Commission (TJC) and the National Committee for Quality Assurance (NCQA) standards for health care entities. Betty Fernandez Director of Operations 210-582-6355 Betty.Fernandez@bexarcv.com www.BexarCV.com “Proudly serving the medical community since 1998” FINANCIAL ADVISORS

Oakwell Private Wealth Management (HHH Gold Sponsor) Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community. Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113 SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner”

Elizabeth Olney with Edward Jones (HH Silver Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney, Financial Advisor 210-858-5880 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

FINANCIAL SERVICES

Bertuzzi-Torres Wealth Management Group ( Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending & estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Michael Clark, President 210-268-1520 mclark@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying. For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies. SWBC’s services supporting Physicians and the Medical Society. Michael Leos, Community Relations Manager Cell: 201-279-2442 Office: 210-376-3318 mleos@swbc.com swbc.com

HEALTHCARE BANKING

First Citizens Bank (HHH Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking. Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise”

Amegy Bank of Texas (HH Silver Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett EVP | Private Banking Manager 210-343-4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President | Private Banking 210-343-4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President | Private Banking 210-343-4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210-343-4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

HEALTHCARE TECHNOLOGY SOLUTIONS SUPPLIER

Nitric Oxide innovations LLC, (★★★ Gold Sponsor) (NOi) develops nitric oxide-based therapeutics that prevent and treat human disease. Our patented nitric oxide delivery platform includes drug therapies for COVID 19, heart disease, Pulmonary hypertension and topical wound care. info@NitricOxideInnovations.com 512-773-9097 www.NitricOxideInnovations.com

HOSPITALS/ HEALTHCARE FACILITIES

UT Health San Antonio MD Anderson Cancer Center, (HHH Gold Sponsor) UT Health San Antonio MD Anderson Cancer Center, is the only NCI-designated Cancer Center in South Texas. Our physicians and scientists are dedicated to finding better ways to prevent, diagnose and treat cancer through lifechanging discoveries that lead to more treatment options. Laura Kouba, Manager, Physician Relations 210-265-7662 NorrisKouba@uthscsa.edu Lauren Smith, Manager, Marketing & Communications 210-450-0026 SmithL9@uthscsa.edu Cancer.uthscsa.edu Appointments: 210-450-1000 UT Health San Antonio MD Anderson Cancer Center 7979 Wurzbach Road San Antonio, TX 78229 Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward. Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) TMA Insurance Trust is a full-service insurance agency offering a full line of products – some with exclusive member discounts and staffed by professional advisors with years of experience. Call today for a complimentary insurance review. It will be our privilege to serve you. Wendell England Director of Member Benefits 512-370-1776 wendell.england@tmait.org 800-880-8181 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

Guardian (★★★ Gold Sponsor) Live Confidently. Every financial dream deserves a well-crafted plan. Ned Hodge 210-332-3757 ned@nedhodge.com www.nedhodge.com | www.Opesone.com “Take care of today then plan for tomorrow”

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) With more than 20,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more. Kirsten Baze 512-658-0262 Kirsten.Baze@medpro.com www.medpro.com

ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group’s rating is AM Best A (Excellent). Mike Rosenthal Senior Vice President, continued on page 42 Visit us at www.bcms.org 41

Business Development 800-282-6242 MikeRosenthal@ProAssurance.com www.ProAssurance.com

INTERNET TELECOMMUNICATIONS

Unite Private Networks (HHH Gold Sponsor) Unite Private Networks (UPN) has offered fiber optic networks since 1998. Lit services or dark fiber –our expertise allows us to deliver customized solutions and a rewarding customer experience. Aron Sweet , Account Director 210-788-9515 aron.sweet@upnfiber.com Jim Dorman, Account Director 210-428-1206 jim.dorman@upnfiber.com Tammy Carosello, Account Director 210-868-0420 tammy.carosello@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

INVESTMENT ADVISORY REAL ESTATE

Alamo Capital Advisors LLC (★★★★ 10K Platinum Sponsor) Focused on sourcing, capitalizing, and executing investment and development opportunities for our investment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and financial restructuring (equity, debt, and partnership updates). Jon Wiegand, Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com

MEDICAL BILLING AND COLLECTIONS SERVICES

Medical Financial Group (★★★ Gold Sponsor) Healthcare and Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller and past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems. Jesse Gonzales, CEO CPA, MBA 210-846-9415 information@medicalfgtx.com Linda Noltemeier Jones, Director of Operations 210-557-9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals”

Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL PAYMENT SYSTEMS/CARD PROCESSING

First Citizens Bank (★★★ Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking. Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise”

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HH Silver Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.” MOLECULAR DIAGNOSTICS LABORATORY

iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases. Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”

MORTGAGES

SWBC MORTGAGE - THE TOBER TEAM (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying. For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies. SWBC’s services supporting Physicians and the Medical Society. Jon Tober, Sr. Loan Officer Office: 210-317-7431 NMLS# 212945 Jon.tober@swbc.com https://www.swbcmortgage.com /jon-tober

PROFESSIONAL ORGANIZATIONS

The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! Kevin Barber, President 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Medical Group Management Association (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Alan Winkler, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

Alamo Capital Advisors LLC (★★★★ 10K Platinum Sponsor) Focused on sourcing, capitalizing, and executing investment and development opportunities for our investment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and financial restructuring (equity, debt, and partnership updates). Jon Wiegand, Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com

Foresite Real Estate, Inc. (HH Silver Sponsor) Foresite is a full-service commercial real estate firm that assists with site selection, acquisitions, lease negotiations, landlord representation, and property management. Bill Coats 210-816-2734 bcoats@foresitecre.com https://foresitecre.com “Contact us today for a free evaluation of your current lease”

RETIREMENT PLANNING

Oakwell Private Wealth Management (HHH Gold Sponsor) Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community. Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113 SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner”

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Cindy M. Vidrine Director of Operations- Texas 210-918-8737 cvidrine@favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

2022 Ford Mustang Mach 1

By Stephen Schutz, MD

“When dinosaurs roamed the earth” is a popular expression that occurred to me often as I was enjoying the 2022 Ford Mustang Mach 1. This wonderful car might not be an actual dinosaur, but it is certainly facing extinction.

Too bad, because the latest Mach 1 is a joy to drive.

For the record, Ford, along with numerous other automotive manufacturers, has pledged to halt the production and sale of gasoline and diesel-powered cars in major markets by 2035. So there probably won’t be any new V8-powered Ford Mustangs for sale in a few years (I’d be surprised if any were offered for sale after 2025, candidly).

Thankfully, you can still buy V8 Mustangs now, and my recent experience with the best one currently available, the Mach 1, was exceptionally pleasant.

The best thing about the Mach 1 is undoubtedly its engine, the same 480HP 5.0L naturally aspirated V8 used in the (no longer available) Bullitt Mustang. Loud, revvy and seriously potent, this gem of a motor sings, especially highly in the rev range. And when paired with the stout Tremec 6-speed manual borrowed from the Shelby GT350 — OMG please don’t get the 10-speed automatic in this car! — it loves to boogie.

The best boogie-ing is found when you head out to a lightly traveled and twisty back road near you and GO. The engine springs to life, and you’ll find yourself shifting up and down through the gears more than necessary. And you’ll smile because, in 2022, this Ford is as fun to drive as any other new car on the market, regardless of price.

The manual transmission’s no-lift-shift and rev-matching features (for up- and downshifting, respectively) absolutely enhance the experience, by the way.

Despite its impressive athleticism, the Mach 1 is docile around town — although its loud exhaust note may annoy your neighbors — and quite comfortable on the highway. The relatively tall sixth gear helps keep the revs (and noise levels) down while cruising, something I wish the BMW M3/M4 and Subaru WRX STi were better at.

Is the Mach 1 the perfect automotive all-arounder? No. It’s tough to get in and out of, the rear seats are microscopic and there’s not much trunk space. And then there’s its fuel consumption problem noted below.

The exterior design is best described as the classic Mustang, updated. Deliberately evocative of the first- and second-generation fastback Mustangs, the current model manages to blend many contemporary styling cues with some retro touches in a way that even non-Ford fans would likely find attractive. The current generation Mustang dates back to 2015, and its look has aged very well for a seven-year-old design.

The same can’t be said for the Mach 1’s interior, which is starting to look old. The digital indicators and gauges are generally okay, although the dual screens ahead and to the right of the driver are smaller and more difficult to see than I’d like, and the whole thing just looks seven years old, which it is.

What would an ideal Mach 1 dashboard look like? Um, probably a lot like what you’ll find in the current Mustang Mach-E.

One observation that I’ve made about performance versions of other “normal” cars like the Subaru WRX STi also applies to the Mach 1: taking a $35,000 car and turning it into a $50,000 - $60,000 car for enthusiasts means that your fancy sports car ends up with a mostly entry-level interior. It’s not ugly or bad, but it’s not the same as what you’ll find in a $50,000 BMW or Audi either.

If you guessed that a 480HP V8 engine is not going to produce excellent fuel economy figures, you’d be correct. The Mach 1’s numbers are, gulp, 14MPG City/22MPG Highway.

Pricing starts at around $54,000, but loading it up with options can easily add $10,000 or more to the MSRP. My two cents on speccing your Mach 1: unless you plan to track your car, the $3,500 Handling Package (with its sticky Michelin Pilot Cup Sport 2 tires) and $1,600 Recaro seats are probably unnecessary.

Despite guzzling fuel and lacking a lot of space for people or things, the Mustang Mach 1 is Big Fun to drive and own. It’s one of the last cars you can buy with a V8 and manual transmission, and when it goes the way of the dinosaurs, it probably won’t come back. Get one while you can.

Note for readers: A trauma surgeon friend and I have launched an automotive podcast that may interest you. It’s called, “Cars on Call,” and it features discussions about a myriad of automotive subjects from two physicians’ perspective. It’s available on Apple, Spotify and other platforms, and I hope you give it a listen.

As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367), for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates.

Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the US Air Force. He has been writing auto reviews for San Antonio Medicine since 1995.

11911 IH 10 West San Antonio, TX 78230 Coby Allen 210-696-2232

Kahlig Auto Group

Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave. New Braunfels, TX 78130 Matthew C. Fraser 830-606-3463

Land Rover San Antonio 13660 IH 10 West San Antonio, TX Cameron Tang 210-561-4900

Kahlig Auto Group

North Park Mazda 9333 San Pedro San Antonio, TX 78216 John Kahlig 210-253-3300

Kahlig Auto Group

North Park Subaru 9807 San Pedro San Antonio, TX 78216 Raymond Rangel 210-308-0200

Audi Dominion 21105 West IH 10 San Antonio, TX 78257 Rick Cavender 210-681-3399

Northside Ford 12300 San Pedro San Antonio, TX Marty Martinez 210-477-3472

Kahlig Auto Group

North Park Lexus 611 Lockhill Selma San Antonio, TX Tripp Bridges 210-308-8900

Mercedes Benz of Boerne 31445 IH 10 West Boerne, TX James Godkin 830-981-6000

Kahlig Auto Group

North Park Subaru at Dominion 21415 IH 10 West San Antonio, TX 78257 Phil Larson 877-356-0476

Northside Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216 Charles Williams 210-912-5087 Chuck Nash Chevrolet Buick GMC 3209 North Interstate 35 San Marcos, TX William Boyd 210-859-2719

Northside Honda 9100 San Pedro Ave. San Antonio, TX 78216 Paul Hopkins 210-988-9644

Kahlig Auto Group

North Park Lexus at Dominion 25131 IH 10 W Dominion San Antonio, TX James Cole 210-816-6000

14610 IH 10 West San Marcos, TX 78249 Mark Hennigan 832-428-9507

Kahlig Auto Group

North Park Lincoln 9207 San Pedro San Antonio, TX Sandy Small 210-341-8841

Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX Al Cavazos Jr. 210-366-9600

Cavender Toyota 5730 NW Loop 410 San Antonio, TX Gary Holdgraf 210-862-9769

9455 IH 10 West San Antonio, TX 78230 Douglas Cox 210-764-6945

Kahlig Auto Group

North Park Toyota 10703 Southwest Loop 410 San Antonio, TX 78211 Justin Boone 210-635-5000