There's a really interesting demonstration of facial aging you can see in a "Where are they now?" slideshow in former supermodels of the 1970's, 1980's and 1990's you can see here. Here's a representative sample of a few different "vintages" which I think show some of the signs of aging that creep onto all of us as we age. The lifestyle of many models in terms of diet, sun-exposure, smoking, drug use, and depression clearly play a role in some of the exaggerated changes you might see in some of these beautiful people.

Christy Turlington, (age 43) multiple Vogue cover model of the early 1990's.You see the early loss of midface volume of the cheek and hollowed areas around the lower eyelid.

Janice Dickinson, (age 56) one of the 1st supermodels of the late 1970's early 1980's. You see a striking loss of volume of the face with sun-damage related changes to the skin. She's also had a number of well-publicized issues with substance abuse and depression which are known factors in early facial aging. Animation lines and fine wrinkles around the eyelid and mouth become more prominent.

Twiggy (age 62) the waif-like icon of mid 1960's swinging London fashion scene. Twiggy demonstrates the fact that it's hard to grow old when you're frozen in time in pop culture as the "It" girl of 1966. Her interval photos demonstrate all the changes you see from volume loss, sun damage with discoloration, and a gradual change of the heart-shaped "Ogee" curve of the youthful face and cheek to a flattened and round shape.

The women in the story are still striking, but do show some exaggerated changes of the aging face that we see in consultation in the office frequently. The single biggest things you can do to slow down facial aging are common sense steps like to avoid sun, not smoke, and maintain a steady weight and diet.

Rob

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There is an overwhelming amount of skin care products on the market, and it can get kind of confusing to patients and doctors about sorting out hype from substance. At the end of the day I think you've got to keep it simple and try to minimize the number of steps and products that people use.

At a basic level you need to consider 3 things to be essential

• a gentle daily cleanser (which can be something cheap)
• a restorative agent(s) to improve or maintain your skin
• protection from the sun

There's a whole bunch of peripheral products addressing pigmentation (toners, hydroquinone products, etc...) that serve niche roles as well.

I've become a fan of the Neo Cutis line of products for two reasons
1. it's reasonably priced for medical grade skin products
2. you can do a lot with a very simplified regimen

The gimmick with NeoCutis is a substance called "PSP" which is a proprietary protein derivative of sorts derived from fetal skin cells. This PSP ingredient is common to their different product lines in different concentrations and with some other additives. For men, their gel-based, "Biogel"
is a very easy single product that men can use without overwhelming our simple brain or making us feel overly metrosexual. Highly recommended and one tube will last 3 months or so, pretty reasonable for $120-150 dollars. Neocutis makes a more concentrated PSP product eye cream which is also great. As I understand it, a lot of people just use it for their whole face. It seems to work well and be very tolerant to people even with sensitive skin.

I'm not here to pimp for that particular company, but I think they make a value-based product line that is very simple. If you combine one of their PSP products with an OTC gentle cleanser, Retin A (or another retinoid-like product), and some sunscreen you suddenly have a fairly formidable combination for less then $200-250.

rob

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That was a heck of the title, eh? My little pun on the "6 P's" ;)

Of all medical diseases, few are surrounded by as much politics as breast cancer. After all, who doesn't want to advance the treatment of breast cancer? The problems arise when feel good political ideas triumph over evidence based medicine and you end up with legislation which is almost sure to cause as many problems as it solves.

Enter the boldly titled "Breast Cancer Education and Awareness Requires Learning Young Act of 2009" (EARLY Act) introduced by Rep. Debbie Wasserman Schultz (D-Fl). For whatever reason, Rep Schultz is one one of the single most obnoxiously partisan members of congress and gets on my every last nerve when I come across her on television. Schultz's bill seeks to spend $45 million over five years to start educational campaigns that would include promoting regular breast self-exams to secondary school students, even though the this has been proven ineffective and quite possibly harmful in clinical trials.


Breast self-examination may seem an innocuous and intuitive way to assist the self-detection of breast cancer except for the fact that IT DOES NOT WORK when applied on large populations of non-selected women. All young women have dense lumps and bumps in their breasts tissue which represent fibrous breast tissue or benign cysts that become symptomatic with their menstrual cycles. Recommending breast self-exams to this group of women will cause fear, many expensive negative imaging studies, false-positive results of various screenings, and many unneeded biopsies.

There's some math you need to think about with these younger women. The probability that a woman who is age 15 years will develop invasive breast cancer by age 40 years is less than one-half of one percent (0.497%). This can be compared to a 5% probability that a 50 year old woman will develop breast cancer by age 70 years (5.62%). The American Cancer Society reports that during 2000-2004, only 5% of new cases and 3% of breast cancer deaths occurred in women under 40 years of age. For women aged 20-24, there were only 1.4 cases per 100,000 women. The goal of an effective screening program is to find disease and save lives. Unfortunately, at the end of the day there is no effective method of detecting breast cancer in a healthy population of women under 40.

Other then family history, we're currently left with little other then some of the expensive genetic tests (like BRCA1 & BRCA2)to try and select out people for closer surveillance. Despite the strong association between BRCA mutations and breast cancer (where as many as 85% would be expected to develop invasive breast cancer), only 5-10% of all breast cancer patients have BRCA1 or BRCA2 mutations. This again gets back to the difficulty in effective screening.

Leslie Bernstein PhD of the City of Hope Hospital in California published an open letter to legislators considering this bill to explain why this is a poorly aimed directive and likely to cause more problems then it solved. The letter can be read here. A better public policy goal in my opinion would be to mandate insurers and Medicare to cover breast MRI for screening in high risk women.

Rob

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This past week the FDA had some hearings to discuss the issues of dermal fillers (like the popular Juvederm, Restylane, Sculptura, & Radiess) and BOTOX. The use of such products has exploded in recent years and we've seen some real complications reported. The majority of such problems are usually minor and transient as most of these products degrade or wear off. However, there are some products whose effects are permanent (like some of the micro-silicone injectables which aren't used in the US) or last up to several years (like Radiess or Sculptura).

The FDA presented data on over 800 patients who suffered reactions after injection with dermal fillers between 2003-2008. There have been no deaths reported to the FDA, but almost 80% of the patients required follow-up treatment of some sort. Most of these were minor swelling and redness (which isn't really a complication, but expected IMO). However, the FDA also received reports of "serious and unexpected" problems, including facial, lip and eye paralysis, disfigurement, vision complications and some severe allergic reactions.

Most troublesome complications of these fillers are those injected around the eye to fill the hollow "tear trough" that develops under the lower lid with aging. Injections in that area offer a solution that cannot be reliably fixed surgically as the changes are produced from a combination of atrophy of the cheek bone (malar complex), deflation of the fatty tissue of the orbit/cheek, and thinning of the skin rather then something descending and producing loose skin. The thin skin of the lower lid is unforgiving for imprecise injection of dermal fillers as it shows each and every irregularity. In addition, inadvertent injection into a blood vessel in this area has been associated with embolic phenomena to the eye which can produce blindness. Natasha Singer, the NY Times go to girl for cosmetic surgery articles wrote a nice summary up last week (see here).

Not directly addressed at this hearing was the hornet's nest of exactly who is actually doing these procedures, particularly those indications that are still "off label" for the injectable. (Natasha, if you're reading this BTW that subject is screaming for an feature by you....Rob) To this point, states have been reluctant to engage the issues about qualifications and credentialing for doctors performing aesthetic medicine or surgeries. It strains common sense to allow people who are un or undertrained to perform these types of procedures. IMO, if you're not trained in lower eyelid surgery (a la an opthomologist, plastic surgeon, or ENT surgeon) you don't have much business pushing injectables or fat grafting that area - it's that finicky! In many other states, physicians are not even required to do these procedures themselves but are free to delegate them to low level providers or nurses.

Rob

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A big Cheers(!) to our colleagues 'across the pond' who are encouraging more professionalism in the business of cosmetic Plastic Surgery.

The British Association of Aesthetic Plastic Surgeons (BAAPS) has made a position statement that digitally enhanced pictures of bikini-clad women in writhing poses should be banned in advertisements as they mislead patients about expected results. BAAPS has singled out one chain of cosmetic clinics for particularly egregious promotion, pointing to an ad by the West One Clinic franchise which used models in advertisements that are "anatomically impossible".

Below is the wasp-waisted model with gi-normous breasts that apparently started this discussion. It clearly looks to me like she's been "morphed" with Photoshop to narrow her waist in relation to her trunk.


A second promotion offers a £250 ($462.55 USD by today's exchange rate) discount to customers as an incentive to have the surgery quickly, while a third offers a "lunchtime facelift", which arguably plays a little fast and loose by with downtown and recovery for short-scar facelift procedures.

This education that BAAPS is not a call per se for limiting all cosmetic surgery procedures, but rather it is a desire to see a more safe, thoughtful, and informed process take place when someone is considering surgery. It is impossible to remove unrealistic body images from pop culture, as both men and women strive for whatever form is popular in their era. What we do owe patients are frank discussions about the limits and morbidity of surgery minus the "magic brush" function of computer photo editing.



Rob

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There's an op-ed piece in today's Wall Street Journal by one Betsy McCaughey which has my blood pressure up. The article titled, "Hospital Infections: Preventable and Unacceptable" implies that any hospital acquired infection was preventable and should be remedied with class action lawsuits.

For someone who's bright like Ms. McCaughey, she shows little insight and understanding apparently into what drives and perpetuates many different types of infections. Nobody disagrees that common sense steps like hand washing and protocols for invasive intravenous (IV) access maintenance are important in limiting infections, it is both a dangerous and disingenuous idea to suggest that a goal of ZERO is attainable. It is impossible to achieve a failure rate of 0% for system or process, particularly one with infinite numbers of variables (as with a human population of patients). Unlike a Toyota, no two models of the human assembly line are exactly alike (even identical twins gradual accumulate differences due to environmental exposure).

Patients with more comorbities are going to have higher infection rates PERIOD. An overweight, diabetic, smoker (a frequent demographic for vascular disease patients in my neck of the woods) who has open heart surgery has more problems then others and an increased infection rate is more attributable to the patient's behavior rather then the hospital. Obese patients and smokers have higher rates of problems after elective plastic surgery (like breast reconstruction or reduction for instance)as well for that matter. You can be sure at some point, hospitals (and doctors) will be looking at patient demographic data to exclude higher risk patients from treatment at their facility whatsoever.

In referring to a list of "never events" recently laid out by Medicare for which they will not cover the cost of complications she blithely writes

"No wonder Medicare calls these infections "never events" Why should jurors reach a different conclusion in a lawsuit."

This coming from a bureaucrat and politician is hard to take. While we should always strive to be perfect, it's important to realize that there are processes which we can all agree on to attain low and reproducible rates of infection.

For a related writing here on Plastic Surgery 101 see the post "Medicare announces they won't pay for complications - How the F*** is this going to work?" that I wrote last year.


Cheers!
Rob

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Doh!

Sometimes our terminology and analysis comes out of our mouth without thinking about how people may internalize it. So I'm at this event the other night celebrating my new partner's addition to the practice, and I made the innocent mistake of telling someone I thought they had a little bit of a "witch's chin" when they were asking me about what they didn't like about their own chin.




Big mistake!I think I've now scarred that girl for life as she's now fixated on it! While I was implying a subtle chin feature that only someone like me is going to pick up on, she's imagining I've called her the wicked witch of the west. That awkward moment has inspired today's sermon on chins.

Cartoons characters such as Andy Gump and Broom Hilda the Witch are best known for their exaggerated facial features. In Plastic Surgery we have borrowed these characterization helping us to describe features with the “Andy Gump Syndrome” or the “Witches Chin Deformity.”




An Andy Gump deformity is produced from not reconstructing the jaw bone (mandible), most commonly when cancer surgeries in that area require removal. In 2008, such mandible problems are treated by taking a piece of your fibula (a lower leg bone) and doing microsurgical reconstruction to transplant it to the jaw. I did about a dozen of those in my training and it's an elegant surgery. As I don't do microsurgery in practice or work at a hospital where such large ENT cancer surgeries are performed, I hopefully will never be asked to do something like that again!

A "witch's chin" deformity describes either an excess of fat and/or drooping of said fat on the projecting part of you chin. The surgical correction involves removing the bulk and suspending it to the bony part of your chin. Seen below is a representative picture of the condition and a graphic of one of the operations to fix it.















For all you ever wanted to know about witch's appearences in pop culture throught history, check out the neat "Sexy Witch Blog" from Australia.

G'day mates!
Rob

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Now that you've been roped in with a salacious post title, the answer is kind of boring and mundane.

So what do they have in common? Trademark issues.

This type of Lesbian on lesbian action involves the tiny Aegean Sea island of Lesbos, home to the ancient Greek poet, Sappho, who famously praised romantic love between women 2700 years ago and gave us the origin of the term lesbian, has been threatening to sue to protect it's name from being used by Gay rights groups.

Similar to other old world cities, and most often involving foodstuff or liquors, these areas do have some legal claims on words derived from the area if they've trademarked them in a concept known as "protected designation of origin".


Image Source: Slap Upside the Head Blog.

Think of things like

• champagne - which can only come from certain areas of France


• Bourbon whiskey - which has to come from Kentucky and be distilled a certain way


• Roquefort cheese - cheese must be made from milk of a certain breed of sheep, and matured in the natural caves near the town of Roquefort in France, where it is infected with the spores of a certain fungus that grows in local caves (Ick!)


• Budějovický Budvar beer from the Czech Republic city of Budweis which had brewed a budweiser (literally a "beer from Budweis") style of beer since the 13th century, had a 20 year lawsuit settled with American corporation, Anheuser-Busch Co. over their popular Budweiser brand. This Czech beer, praised by beer aficionados, is now available in the USA as the brand, Czechvar. (Good stuff!)

The concept of trademarking surgical procedures has caused a little controversy in recent years. In particular, a number of facelift variations have been given catchy monikers like QuickLift, ThreadLift, S-lift, MACS lifts, E-Z lift, Lifestyle lift, etc.... Some surgeons have even had enough gumption to send cease & desist letters claiming intellectual property violations for surgeons performing these procedures. They were actually asking for royalties to do these operations.

The "Lifestyle Lift", a minor variation of the "short scar" facelift procedures has been commercialized by a chain of clinics and is advertised heavily in print and media. There have been an inordinate number of complaints (see here) among patients with these clincs which may represent who is doing the surgery (often not plastic surgeons at these clinics) rather then some inherant flaw in the technique. You can get OK results in very modestly aged faces with these procedures, but I get the impression it's being used on people that need "real" facelifts. A popular variation (and one I like), the MACS lifts, is a little more powerful tool for trying to get by with shorter scars on some of these patients.

This practice goes against a long history of our profession disseminating ideas & innovations around the world. Cosmetic surgery is probably one of the only industries where businesses publish and lecture on their trade craft for free! In addition, many of these "new" surgeries have been described many times before if you know where to look. John McGraw, the father of modern reconstructive surgery, has quipped "If you think you've invented some new operation in Plastic Surgery, you probably haven't looked in German surgery journals from the 1920's!"

Rob

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There's a front page story in today's Wall Street Journal, "Hospitals Demand Cash Upfront From Patients" (login required) outlining the increasingly common practice of hospitals demanding pre-payment for services to be rendered.

I've been noticing this locally for awhile as well. As the amount of "bad debt" has been soaring from patients defaulting on their obligations which are the co-pays, deductibles, & any other part of the cost they're responsible for on their insurance. The really disturbing anecdote in the story surrounding a leukemia patient being treated at MD-Anderson Cancer Center in Houston is a painful reminder of the schizophrenic nature of American healthcare where we try to balance patient care and healthcare economics. It's stories like this that just convince me more then ever that we're hearing the death rattle of our traditional system as we move to some universal healthcare system.

Sympathy aside however, patients do need to understand their financial obligations under their insurance plans. One of the least fun things to do in medicine is to start sending collection notices to patients for unpaid charges from office visits or surgery. As you'd predict, it's much harder to get patients to pay after services are rendered then it is prior. There are very common misperceptions among many patients about how, when, and how much we're reimbursed for services.

I can still remember a massive weight loss patient after gastric bypass refusing to pay her co-payment of $1000 to our office for removing her excess abdominal skin (a panniculectomy or tummy tuck) because she felt like the $700 her insurer paid for 4 hours work and half a dozen post-op visits was enough. I'm a softie on many of these cases and we waive charges frequently (particularly on breast cancer reconstruction, which is a passion of mine) but we've had to become much more attentive to this issue as we see more kinds of cases creeping up.

Rob

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A nerdy public policy-wonk post today!

Despite a surprisingly brief blurb on the AP wire & broadcast news media, there was a very important move last week by the Supreme Court of the United States (SCOTUS) about the future of health care in this country. The court refused to hear an appeal by the American Association of Retired Peoples (AARP) about a companies ability to terminate health care benefits when a retired former employee becomes eligible for Medicare at 65. The AARP is one of the most powerful political lobbies in the United States, and this is a pretty big defeat for them.
The court's action upholdsa a rule adopted last year by regulators that says the "coordination of retiree health benefits with Medicare" is exempt from the anti-age-bias law.


This case has pitted the interests of younger employees and unions against retirees over the dwindling budget for job-related benefits. In recent years, many employers have pulled back from providing these kind of benefits to their retirees because of the soaring cost obligations. But until Monday it had been unclear whether it was illegal to use a worker's age -- in this instance, 65 -- to trigger a reduction in benefits.

"In some cases, it's become a millstone around their necks," said Jack Kyser, chief economist of the Los Angeles County Economic Development Corp. "Corporations aren't all heartless, but in many cases, you're competing with multinational corporations that don't have quite the obligations that domestic firms have."

This decision not to hear the appeal is interesting because it's going to grease the skids for a large shift of healthcare obligations from the private sector to the feds. As I remained convinced that we're quickly moving towards "Medicare for all" as the eventual American adoption of universal health coverage, the incorporation of more people under it's existing umbrella seems another move in that direction.


Rob

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From the Palm Beach Post comes the tragic death of Florida teen, Stephanie Kuleba, from a rare allergic reaction to inhalation anesthetics called malignant hyperthermia (MH). Wikipedia describes it succinctly as a idiosyncratic reaction that "induces a drastic and uncontrolled increase in skeletal muscle oxidative metabolism which overwhelms the body's capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if untreated."

There's really no way to screen for this process and a patient can die quickly. Most surgeons and anesthesiologists may go their entire career and never see a true case of it. I was talking to one of my colleagues the other day about office based surgery and he said he was unlikely to return to doing that after seen a near fatal MH on a cosmetic surgery case he was doing in an ambulatory surgery center adjacent to a hospital.

I'm not sure what the take home message from this is. It's such a rare event that it's hard to justify having exotic protocols at all times in low risk procedures. Most office surgery suites maintain a supply of Dantrolene, a medicine to treat MH which is almost $2500 per dose and must be restocked often to stay current. There's plenty of adverse events more common then MH, but we don't have aortic balloon pumps or cardiac bypass machines routinely laying around for that. It already sounds like that the family has hired an attorney who is already assuming an aggressive posture in his comments to the media so I'm sure we'll see some legal proceedings even if perfect care for MH was instituted.

Rob

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You know you're having a bad week when you end up as a featured celebrity on Awful Plastic Surgery. Britt Eklund, former James Bond uber-chick, agent Mary Goodnight from 1974's "The Man With the Golden Gun" (the definitive Roger Moore-era Bond picture for my money), was the guest of honor last week with Awful Plastic Surgery zeroing in on her "trout pout" from over augmented lips. Poor Britt is still stinging from being voted in Entertainment Weekly (here) as the "6th Worst Bond Girl" in 2006 (Denise Richards character, Dr. Christmas Jones, the hot pants wearing nuclear physicist takes top honors for "The World Is Not Enough" BTW)

In 2007 that is usually achieved with an off the shelf filler like Juvederm or Restylane, while in years past it would have been collagen, fat grafts, or the occasional Gore-Tex implant.

Yeah, I guess her lips are pretty noticeably enlarged, but it was probably the least of her features that I zoned in on. She's got a very instructive feature on facial aging. Take note of her upper eyelids from her 20's versus her late 50's.

In her youth, she has full eyelids with very little upper lid skin showing. Presently, she has fairly hollowed out lids and lots of eyelid skin visible. These changes can happen naturally, but they're also the byproduct of classic upper lid blepharoplasty surgery. Many patients come in with the idea that a youthful eye should show lots of lid skin, such that they can apply lots of eyeshadow in that area.

Survey fashion magazines and take note of the models eyes. You'll see the same phenomena in that a youthful lid is full, quite often low, and shows little skin. We've undergone dramatic reinterpretation of oculoplastic procedures in recent years to recognize the actual problems. Gone is the axiom of taking as much skin, muscle, and fat so as to make the lid completely flat, even when the patient requests it. Many eyelid super specialists like Dr. Steve Fagien from Boca Raton,FL (the most elegant and logical speaker on this for my money) have gone to minimalist approaches resecting tiny amounts of skin, while using fat redraping,fat grafts, or fillers to augment the area.

Rob

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The American Board of Plastic Surgery has released it's 2008 data on it's most recent board-certification testing applicants. Board certification takes passing both a written exam followed by an oral examination in the next 1-2 years.

The failure rate for each exam traditionally hovers around 20% (19.6% for the written and 21.4% for the orals in 2007), which is highest among all the surgical specialties certification processes, and continues to reaffirm the general opinion that the ABPS exam is the most difficult to pass. Another thing to keep in mind is that due to the intense competition for training spots, even those 20% who failed either exam were likely among the top-performing students in their medical school classes (for those who were in "integrated" programs where you start out of medical school) or in their prerequisite surgical residencies.

You can check your doctor's board-certification status for free at the American Board of Medical Specialties (ABMS)site (click here). The ABMS is the American gold-standard for physician accredidation and is what people are referring to when they talk about "board certification". Please note that organizations like the American Academy of Cosmetic Surgery, The American Board of Cosmetic Surgery, and the American board of Cosmetic Gynecology(?)are not (and likely will never) be recognized by the ABMS.

The celebrity blog, Knifestyles of the Rich and Famous (LOVE that name!) had a post in December, "Doing Due Dilligence", (click here to read), which gives a little overview for the laypeople on this topic that's worth reading.

Rob

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The first major casualty in the American experience with mesotherapy has arrived with reports that FIG, the first franchised mesotherapy clinic company, is closing it's doors in the wake of hundreds of complaints from unhappy clients.

FIG had operated over a dozen clinics in seven states that promoted a package of mesotherapy injections, costing almost $2,000 per body part, to reduce fatty deposits on the thighs, abdomen, buttock, and neck. Its clinics reportedly performed over 100,000 mesotherapy-style treatments across the nation.

Now all this doesn't mean that mesotherapy can't or doesn't work, but it clearly shows what happens when you put the cart in front of the horse with new technology or techniques. It's to the credit of the Plastic Surgery Education Foundation that they've taken the lead in trying to study the safety and efficacy of standardized regimens for these injection lipolysis treatments. The inaction of other medical groups who have dabbled in this is disturbing.

Hopefully this will temper the enthusiasm for people experimenting with these kinds of injections until we have more information. Remember that the active components of all these treatments are cyto-toxic medications being used in a way far from their accepted indications.

Rob

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A study was presented at our major Plastic Surgery meeting in Baltimore which came to the conclusion that breast-feeding did not cause ptosis (drooping) of the breasts.

While I haven't seen the published manuscript yet, I find this conclusion somewhat implausible clinically and flawed based on the thumbnail descriptions of the methods of study used.

The researchers interviewed 132 women who consulted for a breast lift or breast augmentation. The women were, on average, 39 years old; 93 percent had had at least one pregnancy, and most of the mothers--58 percent-- had breastfed at least one child. Also evaluated were the patients' medical history, body mass index, pre-pregnancy bra cup size, and smoking status.

The results suggested no difference in the degree of breast ptosis (the medical term for sagging of the breast) for those women who breastfed and those who didn't. However, researchers found that several other factors did affect breast sagging, including age, the number of pregnancies, and whether the patient smoked.

Quantifying something as subjective as this is hard to do under most circumstances (and I give the doctor's credit for writing something interesting), but unless you study these women prospectively (rather then retrospective as was done here) and get better characterization of their baseline breasts size/shape, skin quality, body weight, and breast tissue tone (ie. firm vs fatty) then you really can make no valid conclusions about their hypothesis.

You get breasts that hang for a number of reasons including:

• gravity (no explanation needed!)


• thinning of the skin with age


• attenuation of the internal soft tissue support of breast tissue (aka Cooper's Ligaments)


• "tissue expansion" phenomena from weight gain or engorgement during lactation

Now in re. to ptosis and lactation, the tissue expansion effect is what I'd say predominates. Now as a lactating breast will be swollen for a longer time, it's pretty intuitive and obvious that it's going to affect the breast shape more. I'm skeptical from this intuitive POV plus an (occupational) observational basis on this idea that there's no difference after breast feeding.

One of the more common sub-groups in the breast augmentation or breast lift group are women in their early or mid 30's who present with "involutional ptosis" (our fancy words for saggy breasts after pregnancy). During my residency at the University of Louisville (KY), I can remember spending time with one of my favorite surgeons, Dr. Marc Salzman, who was kind enough to let me accompany him during his cosmetic surgery consults. There was a pretty girl ~ 33 years old who came in, and when describing what she did not like about her breast declared, "Dr. Salzman, after having my babies, my breasts now look like Squidworth's nose!". He was kind of puzzled by her comment, but I burst out laughing aware (due to having small children) that Squidworth is Sponge Bob Squarepant's boss on the popular cartoon show.

Pictured below is Squidworth. And you know what? Her breast looked exactly like Squidworth's nose. :)

Rob

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Just thinking about the human body today.....

Reports in the medical literature continually reinforce my belief that it's nearly impossible to outsmart mother nature in terms of the bodies inflammatory response. The inflammatory response is critical to your bodies compensatory mechanisms for stress or infection, but it has a tendency to go haywire and (apparently) make things worse. Billions of research dollars have been invested in characterizing (and manipulating) this cascade of biochemical processes. Every time we think we've figured out the big picture, eventually we are humbled by the bodies' "counter offensive".

In an international study (summarized awhile back here ) comparing bare metal versus the fancy new metal stents coated with medicines to inhibit re-occlusion of the artery showed dramatic increases in post procedural deaths as these patients were followed out from their procedure. When these drug-eluding stents were first introduced in 2003, they became the fastest-selling medical device in recent history despite being nearly 400% more expensive then the older bare metal stents.

We've witnessed a lot of similar outcomes in the trauma and septic response literature as multiple stages of the inflammatory cascade are suppressed or modulated, only to come back with a vengeance thru alternate "work around" pathways that must exist somewhere in the body.

When you see diagrams of what we think the immune response looks like, it is a frighteningly busy graphic. Despite millions of man hours in labor and billions of research dollars, complete understanding of these processes is elusive.

Rob

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The tabloids are in overdrive digging up dirt on the surgeon who performed Kanye Wests' mother's surgery. The surgeon in question was kind of a minor media figure, having hosted some TV shows on plastic surgery. In an instant, this doctor's career has been reduced to "the guy who killed Kanye's mom" which is kind of sad.

Still to be determined is what exactly was the cause of death?

The implication being circulated is that she should not have been done as an outpatient surgery. That's a judgment call, but it's one that has to take into consideration her age, medical comorbidities, type of proposed surgery, and length of surgery. Her surgery was apparently almost 8 hours long, which while longer then you like, is certainly not outside the vague notion of "standard of care". Publicized cases like this tend to lead to reactionary measures, and I would not be surprised with some fallout in California as to how office surgery is regulated.

A woman her age (almost 60) who dies shortly after this kind of surgery would make me think of a few things

1. Did she have a post-operative heart attack( MI)?


2. Did she have hypovolemic shock from intra-operative or post-operative bleeding?


3. Could she have had toxicity from lidocaine (a local anesthetic) used in high volume liposuction?


4. Did she get nauseated, throw up, and subsequently go into respiratory arrest from aspiration?

There's a couple of less likely things that can happen, but they usually don't present quite like Mrs. West's case. Those would be pulmonary embolism (a blood clot which migrates to the lungs & usually happens a few days later), bowel perforation (usually has a more gradual onset of sepsis), and acute necrotizing infections (usually from Streptococcal group A or B bacteria).

Post operative deaths are rare, but tragic. They reportedly occur in only one of 51,459 cosmetic procedures, according to the journal Plastic and Reconstructive Surgery. It's been suggested that number may actually slightly under-represent the problem as not all deaths get reported accurately. For example, a study a few years ago by some dermatologists claiming no deaths from high volume office-based liposuction cases performed by dermatologists flew in the face of numerous anecdotal reports by General & Plastic Surgeons having to deal with major complications which showed up in the hospital from some of these same dermatologists.

Rob

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There's an interesting philosophic debate being played out in a lawsuit in New Jersey over an insurance companies refusal to pay for a patients breast reconstruction surgery. You can read the news wire story here.

Short Version: Patient has double mastectomies with saline implant reconstruction almost 15 years ago. One of her implants deflates, and her insurance company is refusing to now pay for a conversion to a reconstructive procedure using her own tissue.

Replacement of her implants with either saline or silicone implants (which they would agree to cover) would be able to be performed quickly and done as an outpatient surgery with little morbidity. The type of surgery she wishes to have covered, a DIEP flap (deep inferior epigastric artery perforator) is a complex microsurgical procedure (where tissue from her abdomen is transferred to her chest wall) which would involve a long, expensive operation and a number of days in the hospital.

Last fall I profiled a case in People magazine where such a DIEP flap was performed on identical twin sisters, with one twin's abdominal tissue transferred to the other's breast. You can see that story here "Breast Reconstruction Using Your Twin."

What are the issues involved with this as I see it:

1. Should breast reconstruction after mastectomy be covered?

Well that issue was settled a number of years ago via federal legislation, the Women's Health and Cancer Act (WHCA) of 1998, ensuring that reconstruction was a mandatory obligation of insurers.

2. Should all types of reconstructive surgery be covered?

Again, that's part and parcel of the WHCA, which includes reconstruction after mastectomy for benign disease, usually done for painful cystic breast tissue.

3. In a scenario like the one involved here, should someone have the right to demand complex and expensive surgery when less expensive options are available?

I'm conflicted here. It does not seem completely outrageous to me for this company to deny this request or at least ask the patient to pay part of the balance difference given the particulars as I understand them. She had an acceptable reconstruction with implants, and needs a quick & relatively inexpensive surgery to maintain her result.

In other countries with state-funded ("universal") health care programs, I suspect there's no way in hell this would be approved. In an era of cost-containment, all health care costs are going to be scrutinized and there will be hard choices to make. Luxuries like exotic breast reconstruction almost two decades after the initial surgery seem hard to justify in that context.

Rob

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I was interviewed awhile back for San Francisco's American Sexuality magazine which finally came to print. The article "Plastic Surgery and the New Standard, Unnatural Beauty" can be read by clicking here.

My contribution to this had to do with the question of:

1. Whether we're becoming a society of have & have-not's for plastic surgery along class lines




2. Whether we're in an era of unprecedented beauty standards

I made two observations.

One - that rather then becoming more exclusive, the access to cosmetic plastic surgery has never been more readily accessible to the masses. Decades ago, there were only a handful of providers who catered mostly to the very well-to-do. Now we have many different kinds of doctors doing "cosmetic medicine" of all types at historic discounts with low-interest financing available from multiple sources. The cost of theses procedures is historically low and are frequently offered in convenient retail-like environments.

Two - "unnatural" standards of beauty have always existed and I'm not so sure that what passes now (BOTOX'd foreheads, laser "Brazilian" hair removals, breast implants, etc...) are more radical things that have been done since time immemorial (infant head molding, feet binding, corsets ("wasp waists"), neck stretching, tattooing, ritual scarring/piercing). In fact, there's kind of been some pushback towards less radical surgical and non-surgical treatments towards less obvious and more natural results.

Rob

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In what I guess passes for peer-reviewed literature in the UK, a London surgeon has proclaimed to have identified the perfect breast. The model mammary has a nipple that points slightly up, and an upper breast pole just a bit smaller than the bottom half. Apparently UK surgeon, Dr. Patrick Mallucci, spent many hours "poring over photos of topless models in lads magazines and tabloid newspapers" to come up with this theory.

While observing the "ideal" (as defined by cultural norms) is an ok way to make some general observations about beauty, I'd take issue that "laddie mags" (STUFF, Maxim, etc....) and pornography are the best reference point. A disporportionate number of models in those mediums have had breast augmentations which changes your whole frame of reference for comparison. The ideal augmented breast should approach the ideal un-augmented breast, which most (don't flame me here) would point to as the symetric nulliparous (prior to childbearing) breast with little ptosis (droop) that possesses some degree of upper pole fullness. This is pretty much what Dr. Mallucci describes, but I take some contention to his methods and conclusions. Most women will never have this kind breast naturally, but "good" breast surgery can move someone closer to it. The ideal breast shouldn't be pointed to one that does not and cannot exist in nature, ie. Baywatch circa 1996.


Who has the "best breast" according to this doctor? The "why exactly am I famous again?" model/singer/personality, Caprice Bourret

And the worst? The world's most famous soccer mom, Victoria (Posh Spice) Beckham

I'd agree that Ms. Beckham's result isn't the best, but thin women have a hard time hiding all but the most modest implants. She would have done better with smaller and narrow implants, and would have been ideal for the anatomically-shaped gumy bear devices (form-stable high cohesive silicone gel devices like the Inamed 410 or Mentor CPG).

But picking 36 year-old Caprice Bourret as the best "natural" breast shape (as described by this doctor in the article)? She's got a classic over-sized, over-round result you get from big implants (again that Baywatch thing). She's claimed in the past not to have had extensive plastic surgery, but I find that implausible.

Do you?



While it may in fact be a result that both earns Ms. Bourret a great deal of attention and be one that many women think they want, it's a setup for multiple future complications. That tissue just won't maintain that result for any length of time.


Rob

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