Breast reduction surgery presents an interesting issue when we're getting into an era where every health care cost is going to be scrutinized. As a society, is this a procedure we're going to be willing to commit major funding to? Currently there is a patchwork of indications that vary between different insurance companies as to what meets medical necessity for this operation.

In general, most insurers make you do extensive documentation of "conservative therapy" before even considering approval. I'm not sure what conservative management of big breast is exactly anyway! There are differing weight requirements for the tissue to be removed as well. Blue Cross of Alabama for instance requires a minimum of 500 grams (~1.1 lbs) per breast to be removed. Others use a sliding scale called the "Schnur Scale" to correlate appropriate weight removal to a calculation of your total body surface area (TBSA). The Schnur scale came from a paper by a plastic surgeon who was trying to quantify symptoms in his breast reduction patients.

The recommendations from that study by Dr. Schnur were perverted by insurers, written into policy guidelines, and are now used to exclude many patients from having breast reduction surgery. There now exists a great deal of literature showing that reductions much less then prescribed by insurance companies is effective in patients suffering from neck, back, and shoulder pain. In fact, a Finnish study suggests breast reduction surgery seems to improve the health-related quality of life indicators as much or more then surgeries for hip or knee joint replacement.These studies are dismissed by insurers as observational,flawed, or biased by greedy doctors, but if they could speak honestly they would explain that they don't want to open eligibility for the procedure to a whole new class of patients and cost themselves a great deal of money.

Apparently we're not the only country that is having issues on whether to cover breast reduction surgery. Hat tip!

A court in the German state of Hessen has ruled that insurance companies do not need to cover the cost of breast reduction surgery as having a large bust is not a medical problem. The decision means that insurers will only have to pay to correct breasts which are deformed.

The case was brought by a 38-year-old woman who suffered orthopaedic and physical problems due to the weight of her boobs. She had been advised by doctors to have breast reduction surgery.

But her insurance company didn’t see it as a necessity and therefore refused to cover the costs of the operation. It claimed she was suffering from back problems because she was overweight and that her physical discomforts would be reduced if she trimmed down weight and built some muscle up.

The court agreed with the insurance company and the big-breasted woman lost her case.

Two and a half years ago, the court in Hessen rejected the case of a woman who thought her breasts were too small. She wanted her medical insurance to cover a breast enlargement operation and claimed that she was physically harassed for her small boobs. The court declared then that small breasts are not an illness

Rob

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The insufferable (vaguely) plastic surgery -related drama, Nip/Tuck , has been terminated by the FX network. From the LA Times,

"When "Nip/Tuck" made its debut in 2003, it broke cable-viewing records and instantly distinguished itself with its stylized look, tongue-in-cheek tone, gorgeous stars and fresh take on America's obsession with beauty and youth. Those qualities earned it a Golden Globe for best drama, critical acclaim and water-cooler buzz that lasted for most of its first four seasons.

But when one of FX's signature series quietly wrapped last week on the Paramount lot, it did so without the usual fanfare associated with the end of a noteworthy show. In part, the silent send-off was because TV viewers won't see the "Nip/Tuck" finale, which finished shooting on June 12, for a long time, probably as late as 2011, making it tricky to publicize. Behind the scenes too, during the last week of production, there was an awkward sense that the end had already happened, since much of the crew had already moved to creator Ryan Murphy's new Fox musical, "Glee," last year, and Murphy himself was out of the country location-scouting for an upcoming movie.

....In the five seasons that have aired, the doctors, who are in their 40s, have almost died several times, slept with dozens of women, broken up their partnership a few times and dumped a dead body in the Florida Everglades. In the 19 new episodes, which will probably air over two seasons and may begin in January, the series will become even more operatic and dark, elements that, critics say, have diminished its pleasures over time.
"

Plastic Surgeons, will uniformly celebrate the demise of this tawdry show which did little to accurately portray or advance our field. While less offensive then Dr. 90210, The Swan, Miami Slice, and other "reality" shows, Nip/Tuck was painful to watch. Other then having supermodels throw themselves at me weekly, I just can't can't relate to this show ;)
(just kidding Honey!)

Rob

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According to iScrub, Plastic Surgery 101 is now the 3rd best plastic surgery blog on the web. I demand a recount :)

Writing a blog has been an interesting discipline. It can be real hard to come up with something that I think is worthwhile talking about. Unlike some medical related blogs which seem more like Twitter level entries, I try to put enough effort to make it worth coming back to. With the new office and little league consuming most of my free time, I haven't been able to be as consistent with output as compared to a few years ago. In the "draft bin" I've got nearly 50 blog posts or ideas that I've not gotten around to finishing.

For plastic surgery blogs, I'd really like to celebrate Dr. R.L. Bates' "Sutures for a Living". I have respect for the quality, consistency, and complete lack of self-promoting B.S. that Dr. Bates brings to her blogging. Toni Youn's "Celebrity Plastic Surgery" & Joe DiSala's "Truth in Cosmetic Surgery" blog are about the only other one's I check on from time to time. Joe's was the first blog out there, followed by myself and Toni a few years ago. Most of the other blogs by Plastic Surgeons are extensions of their marketing campaign with little interesting original writing.

Rob

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The United States is not alone in trying to come up with a way to ensure quality and standards among providers of cosmetic surgery and related procedures. The Independent (UK) wrote about this problem in Ireland and the U.K. last fall (see here) saying,

"Once you have a basic medical degree you need no specialist qualification in order to perform plastic surgery. A GP could do a breast augmentation in the morning, even though he had never seen it done or performed one -- and that is perfectly legal. The International Association of Plastic Surgeons (IAPS) members are trained in plastic, reconstructive and aesthetic surgery. Other people carry out procedures despite having no formal qualifications." One major concern of the IAPS is that of surgeons being flown in from abroad by private clinics and simply flying home after performing a procedure. "You would expect any other surgeon to be resident in the country in which he is practising," says Mr David O'Donovan, Secretary of the IAPS.

"Yet private clinics are shipping in surgeons who are not around when the patient needs aftercare, or complications arise. Some say their doctors are specialists, but they don't say what they're specialists in. For instance, a doctor performing breast surgery could, in fact, be a bowel specialist."

Similar stories can can found around the world from the United States, Australia, and other western countries. It certainly seems likely to get worse here as reimbursements for physicians are poised to take a big hit with whatever happens with American health care reform. There will be even more pressure for many doctors to encroach outside of their areas of expertise and become self-styled "Cosmetic Surgeons" or "Aesthetic Medicine" specialists.

Catering to this trend is the ever proliferating alphabet of organizations seeking to give some fig leaf of authenticity for doctor's credentials who have little or no formal training in some of the services they're now offering. (WTF is laser "vaginal rejuvenation" by the way?). One of the "cosmetic surgery boards" here in the United States has even had the nerve to suggest that their members are more qualified then Plastic Surgeons to perform cosmetic procedures and has railed against hospital medical staffs who have (quite rightly) not granted their hodge podge of members surgical privileges outside the scope of their accredited training.

For a Gynecologist's take on some of his colleagues trying to peddle themselves off as reinvented cosmetic surgeons, read this great post at "David's waste of bandwidth".

"Cosmetic surgery can kill people. It can maim and disfigure people. Just as I think surgeons should respect the procedures we do as gynecologists, we should respect the things they do, and only do them when we really have the training and judgment to proceed. No weekend course on ”cosmetic gynecology“ (whatever the f that is) is going to provide skills and judgment comparable to someone who is boarded in cosmetic surgery and plastic/reconstructive surgery. As it is, the folks who are boarded in cosmetic surgery are rightfully pissed at those cosmetic surgeons who are doing this without board certification or a decent background in plastic and reconstructive surgery. Why are we adding to this nonsense?

As an example in terms of judgment, you're mentioning the possibility of doing ”gspot injections“ (sic). This is inappropriate and has no place in modern practice, cosmetic surgery, gynecology or otherwise.

To my point exactly. We have no business doing this crap. I sympathize with those who do, and understand their motivation in terms of a cash business. But we're surgeons and professionals, NOT car dealers trying to make a fast buck. Or are we?"

It's not so far fetched to imagine a proverbial "Tom's Rhinoplasty Clinic" (an olde school South Park season 1 reference) popping up every block stamped with the seal of approval by ____________. (fill in the blank with bogus board certification du jour)

Rob

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Just like when your wife or girlfriend asks "Do I look fat in this?", it is surely the deadliest of traps when a cosmetic surgery patient asks you the open-ended "What do YOU think I need done?". Most Plastic Surgeons know not to take the bait with this question, but rather tease more out of the patient about what is concerning them.

A careless phrase or suggestion can produce both anger and anguish to a patient. I still think I'm getting pain from a voodoo doll for my inadvertent pointing out a "witch's chin" deformity to a patient (Long story, read here to get up to speed).

Vanity Fair magazine put this to the test when they had a writer go "undercover" on three consults for cosmetic surgery. (The article can be viewed here). One with a Manhattan Plastic Surgeon (whom I've actually heard of), one with an ENT trained "cosmetic surgeon" (who notably was sanctioned for defrauding Medicare in 2003 - Don't these people use Google?), and one osteopathic (a DO as opposed to an MD degree) surgeon who'd trained in an osteopathic plastic surgery residency.

Note: There is really nothing about Plastic Surgery as a discipline that is related to osteopathic tenants. As the mystical snake-oil aspects of osteopathic medicine, like manipulation, have largely been shed from their curriculum, a DO and MD education is now practically similar. As there are only a handful of DO plastic surgery programs, I'm assuming this guy would have been an intelligent guy and good resident to get a position. End of editorial!

The writer's first consult was with the Plastic Surgeon, who came off really, really, really cheesy.

"Now the doctor and I stand in front of the floor-length mirror while he deconstructs the “before” me. “As a Caucasian woman, you probably—if you were doing lipo—would want this brought down,” he says, pointing to my “banana rolls”—his clever name for the part of my rear end that peeks from beneath my underwear lining. “And again, you know, in jeans, to most people … on white women, you guys like to get this down. And we like to see it down.” I gulp, realizing that I’ll never be able to eat my favorite fruit again without thinking of my own ass....

Back in the Upper East Side exam room, Dr. R******* pinches me from shoulders to knees before concluding: “You look absolutely nice, but, even if I were a blind guy and put my hands here”—he seizes my sides—“there are little lumps. This could be brought down just to give you a little bit better of a curve.” These lumps, I learn, are my “waist wads.” To his credit, Dr. R******* does note that my “waist wads” are “borderline.” But, he says, “I’ve done supermodels with much less than this. To them it was important. To each his own.”

He prefaces his conclusion with a hypothetical scenario: “I think if I were a single plastic surgeon, which I’m not, riding around in my Corvette, which I don’t, my license plate would read full c. O.K.? That would be my license plate. So that’s what I would think, in general, is the Promised Land of Breasts for most people.”

OMFG. Is this guy for real? I'll give him the benefit of the doubt that some of his comments were selectively edited, but I cannot imagine most of his peers would consider that language and tone very professional. Pushing services, as opposed to passive advice, is not how most experienced surgeons would teach their residents to act. I know we weren't. There was a well known surgeon in Louisville who was notorious for telling women at social events that that they needed a face lift. The funny thing was that on a number of occasions this surgeon had actually already done a face lift on that patient and just failed to recognize both the patient and his work. Open mouth, insert foot!

The other two consults described were actually much tamer and more professional IMO except for the part where the ENT's office manager offers to show off her implants to the prospective client. Chez tacky! Props to young Dr. Joseph A. Racanelli D.O., who despite being the least experienced, gave the most appropriate response to the honey trap offered by Vanity Fair.

Rob

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There's an interesting series of aging studies on twins in the literature recently.

The first (see here) was a series of observations made on the contributions of different factors on aging. These factors included

• smoking
• both obesity and being thin at different ages
• sun damage
• depression (?)
• divorce

The relationship of body weight is interesting, but kind of intuitive. A heavier body weight before the age of 40 was associated with an older appearance. However, in the women over 40, a heavier body mass index (BMI) was associated with a more youthful look. In plastic surgery, we've known for awhile that the aging face is not just loosening of the skin, but is driven by a progressive "deflation" of the fatty tissue, recession of the bony prominences of the cheek/midface, and thinning of parts of the skin
with simultaneous thickening of other parts from sun damage. Fat grafting and the use of off the shelf dermal fillers are now routinely used to complement face lifts.

I think this picture from the series is most illustrative of that principle.



Notice the deeper lines by the cheek (nasolabial folds) in the gaunt twin.

The other study is published in this weeks' Plastic Surgery journal and is titles "Identical Twin Face Lifts with differing techniques: A 10 year follow up". It was basically a bet among some of the heavy hitter face lift surgeons about which techniques would hold up best, with the gimmick being it would be performed on identical twin volunteers.

When the procedures were done in 1995, the debate was really about whether newer more invasive techniques being written about like the "deep plane facelift" would hold up better then older,simpler techniques ("SMAS flap" and "SMAS plication" procedures).

What's interesting is that all the twins looked better and the results were fairly well maintained, even 10 years out from surgery. The following editorial was very diplomatic (excellent results can be obtained from different techniques...yada, yada, yada)and not very conclusive, but seemed to talk past the elephant in the room.

Sometimes you have to call a spade a spade:
Looking at a study like this how could you plausibly still assert that the added risk of facial paralysis from the more complex surgery type is justifiable when it's not clear there is any maintained advantage in results. None. Zero. Zilch.

Dr. Dan Baker of Manhattan, face lift god, has been evangelical about this safety issue going back 15 years. He should know. As a young surgeon in the 1970's, he developed a reputation for fixing severed facial nerves from face lifts referred to NYU. Dr. Baker has a wonderful talk about his personal evolution on face lift surgery that I saw as a medical student 13 years ago that was seared in my brain. His simple theorem on risk/reward with complex face lifts has now clearly been validated in print. All the pictures are good results, but I'll be damned if Dr. Baker's patient in this twin series (the one on the far left)doesn't look the best and most natural 10 years out.



Rob

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There are several distinct types of ways we classify breast implants.

• silicone or saline filled


• round or anatomic shaped


• smooth surfaced or textured

For the material and shape issues, there clearly are performance characteristics that differ. As to the issue of the implant shell surface, it gets a little more confusing.

The routine use of rough or textured surfaces on breast implants in the prevention of capsular contracture has been debated for nearly 20 years.
In the early 1980's we first read in the literature that the surface texture of an implant is an important variable in determining the soft-tissue response to an implant's capsule surface and experiments suggested that texturing resulted in tissue ingrowth and adherence to the implant surface.

These observations were first made with polyurethane-coated breast implants which had rough surfaces and almost no observed capsular contractures in patients with breast implants. Texturing was then quickly translated to contemporary silastic (silicone rubber) covered implants, but whether or not the same effect was maintained has been a little murky.

If (a big if) there's a protective effect from texturing, the best data I've seen suggests that it's gone as you get closer to a decade out during surgery. If I had to guess why that's so, I'd say that reflects the ruptures starting to show up in those 4th generation implants at a decade out.

It's kind of interesting to see the split between the United States and the rest of the world on this issue. Our singular experience with saline implants from 1990-2006 led many surgeons to abandon textured implants for smooth round devices as they're less likely to show visible wrinkles or ripples thru the skin. The "velcro-like" effect of the implant on it's surrounding tissue causes these ripples when the implant shifts. The rest of the world has a strong preference for textured devices as they never went through dealing with the limitations of saline implants. Philosophically, those doctors made the decision that they're willing to accept more rippling as a trade off for (possibly) less capsular contracture (implant hardening).

I personally am kind of ambivalent on this. Being an American-trained surgeon, I saw mostly round smooth implants placed partially under the pectoralis muscle during my residency. Over time, I've come to believe there's a role for "subfascial" implant techniques(over the muscle, but under the muscle fascia) with smooth implants. Looking ahead, I think we're poised to see a lot of plastic surgeons getting reacquainted with textured implants with the new shaped "gummy bear" implants which are all textured to help prevent rotation of the implant in the body.

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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Sorry for the extended break!

Lots going on with the practice and the increasingly complex undertaking of building out a new office and surgery center while the country is treading water with the financial markets. There's lots of anxiety in Plastic Surgery these days as people's disposable income is drying up for cosmetic surgery, injectables (like BOTOX & Juvederm), and noninvasive laser treatments (IPL, hair removal etc..).

A number of medispa outfits have gone bankrupt, stock prices for major players in cosmetic medicine like Allergan & Mentor have fallen faster then other stocks of similar market cap size, and practices across the country are reporting flat or negative growth for 2008. Just today I heard that Rhytec, maker of the innovative Portrait Plasma laser resurfacing system is shutting down, potentially leaving owners SOL for replacing the disposable treatment tips on their expensive laser machines.

I've been obsessed reading a number of books about financial history, market theory, and asset allocation. I can't recommend enough the classic book by Dr. William Bernstein (who is a practicing Neurologist of all things BTW), "The Four Pillars of Investing" which lays out a very compelling lens thru which to view the ebb & flow of investment going back hundreds of years. Everything we're enduring now has happened in some form or another somewhere in history, and about once a generation we should expect the world markets to go crazy. It's ironic that if you're early in your adult life, the current events may make the best time to invest heavily in equities that you will ever see during your lifetime (in the "buy low, sell high" sense).

I'm thinking of this as I'm reading an article by Michael Lewis in today's Portfolio magazine "The End of Wall Street's Boom". Lewis is the author of the classic baseball book "Moneyball" and the 1980's wall street classic expose "Liar's Poker". This article revists the same territory of "Liar's Poker" and is a fascinating look at the insanity/stupidity of the Wall Street culture in priming the pump for our current problems. It really dovetails nicely with Bernstein's book at exposing what fools we mortals be!

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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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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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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Tragic events have a way of stimulating bad legislation.

Co-conspirator in Plastic Surgery blogging, "Dr. 48307", Tony Youn had a very insightful retort a few weeks backto a bill ("the Donde West law") introduced in the California legislature (read here) to mandate medical clearance on all patients undergoing cosmetic surgery. Something similar is now being mentioned in Illinois. Dr Youn writes:

This is a very interesting bill, considering less than a year ago the California legislature passed a law permitting oral surgeons (DDS dentists) to perform all forms of facial plastic surgery. Instead of forcing surgeons to make their patients undergo preoperative testing (some young, healthy patients may not need it), maybe they should instead make sure that anyone performing plastic surgery is a real, board-certified plastic surgeon?

Keep in mind that California is also the state where a judge ruled in 2006 that a certificate from a non-recognized cosmetic surgery "board" organization was equivalent (or better!) to the American Board of Plastic Surgery for accreditation proposes over the objections of the state medical board for California, the American Medical Association (AMA), the American Society of Plastic Surgeons (ASPS), the American Board of Facial Plastic Surgery, the American Board of Medical Specialties (ABMS), and others. This ruling ignored the existing state law that allowed physicians to advertise board certification only if the certifying board or association is recognized by ABMS or deemed equivalent by the state medical board.

BACK TO THE "DONDE WEST" LAW

Broad non-directed medical screening by 3rd parties would be an extremely inefficient and unnecessarily expensive way to clear patients for surgery. Besides, this process already takes part as part of a patients' surgery evaluation. Now your doctor can be a tool, and adopt the blanket position that "I send all my patients for medical clearance before surgery", but that's just punting the ball and practicing defensive medicine to the extreme.

The scale we commonly use to characterize surgery patients' anesthesia risk, called the ASA system, is a pretty good screening tool. The overwhelming amount of patients undergoing cosmetic surgery are low risk, and ASA class I or II patients should not need "medical clearance". In addition, many primary care doctors have absolutely no idea what "medical clearance" means anyway, and get a little peeved when patients show up for non-reimbursable office visits.

When we talk about medical clearance, it's usually in the context of chronic medical issues or asking whether the patient needs provocative testing for coronary artery disease. Patients who may need to be "tuned up" prior to surgery are those with:

• diabetes - Are there blood sugars under control?


• significant hypertension


• morbid obesity


• sleep apnea


• symptoms of (or strong risk factors for) coronary disease

Many of those conditions might be exclusionary for elective cosmetic surgery in the first place, particularly when combined. Keep in mind that the patient involved in the event triggering this reactionary bill, Donde West's, had undergone coronary testing earlier in the year (which was reportedly normal) and died over 24 hours postop from what sounds like a probable aspiration event. No amount of screening would prevent something like that.

"Smart Laws" relating to cosmetic surgery seem to be a little more difficult to implement. A more practical way to address the whole issue of office based surgery procedures would be to standardize the accreditation of facilities and remove the loopholes in some states that still exist. My state, Alabama, for instance has set a timetable for requiring accreditation for office an ambulatory surgery centers (ASC) over the next 18 months. The ASPS already makes it a requirement for membership that you will pledge to only operate in accredited (or planned accredited) office facilities. A common sense regulatory step would be to require hospital privileges for any surgery you'd propose to do in your office requiring sedation or general anesthesia, which would have the de facto effect of an additional level of credentialing applied by hospital medical staff offices. It's so common sense that it will be violently opposed by many "cosmetic surgeons" who would see their ability to practice cut off at the knees. Something to think about!

Thanks again Tony for your wonderfully entertaining blog!

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 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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The November issue of the journal, Annals of Plastic Surgery, features an up to date comprehensive review article on the state of research involving issues of safety surrounding silicone gel breast implants. Researchers from the Vanderbilt University Medical School-Ingram Cancer Center review several hundred related studies to produce this magnum opus. A story interview the lead researchers can be read on the Vandy News Service here.

This "snapshot" is the most thorough review of this topic since the landmark 1999 Institute of Medicine report and addresses the ongoing epidemiology studies thru the Fall of 2007. The body of literature continues to be remarkably consistent in that the weight of the epidemiological evidence does not support a causal association between breast implants and breast or any other type of cancer, definite or atypical connective tissue disease, adverse offspring effects, or neurological diseases.

From lead author, Dr. Joseph McLaughlin,

“Few implantable medical devices have been investigated for safety hazards more extensively than silicone gel-filled breast implants,” said McLaughlin. “For almost three decades researchers around the world have been conducting in-depth studies on the health of women with implants to determine if there are significant health risks. The evidence is clear that implants are not linked to serious disease.”

An increased suicide rate from patients implanted 20-30 years ago has been the only consistent finding across several large follow-up studies. I've touched on that issue before on Plastic Surgery 101 (read here) on how inferring causation is likely incorrect as epidemiology suggested significantly higher psychiatric co-morbidity among women in those studies from the 1960's to early 1990's (so you'd expect higher suicide rates/attempts). I cannot imagine how you could ever effectively study this subject prospectively, particularly in the United States where medical records aren't centralized. Confusing things even more I'd submit is the recent rise in the United States of pharmacological treatment with mood-altering drugs (Prozac, Daypro, Xanax, anti-depressants, ADHD drugs, weight-loss medicines, etc...) for people who don't have classic or formally diagnosed depressive disorders. I see women (and men) all the time on such medicines prescribed by their family doctor or internist who would not meet strict medical criteria for what they're medicated for.

It would seem to me at this point that the most important issues left to characterize about existing silicone implants would be:

1. Late rupture rates - what can we expect durability-wise at 12-15+ years out?
2. Suicide rates - how to most effectively screen out unstable patients?
   
   

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From my favorite New York Times columnist, Natasha Singer, comes the story "Botox Appointments Faster Than for Moles, Study Finds". This is similar to a story from MSNBC last year "The Dermatologist won't see you now."

Basically it highlights the September Journal of the American Academy of Dermatology article which published an "expose" on how it is easier to get a Dermatologist to return your call if they think you're going to schedule a BOTOX injection versus getting an appointment to have an irregular mole evaluated for skin cancer.

What was the difference?

More the three weeks delay on average (8 days versus 26 days).

Is this surprising?

Only in the sense that it only took 3 weeks to get in to a dermatologist for a mole to get looked at. Keep in mind that some other similar surveys have found much longer waits. For example almost 47 days in Syracuse, N.Y., 48 days in Phoenix and a whopping 73 days in Boston.

The amount of dermatologists being trained in the US has been artificially suppressed for many years. I saw reference somewhere to the fact that the number of dermatology residency training programs has remained stable for almost three decades with about 300 training positions. It's led to a significant backlog of people being able to be evaluated for cancers as the baby boom approaches AARP status, this volume of patients is expected to explode.

What's more, many of the medical students going into dermatology have no interest in general dermatology or treating skin cancers at all. It's been estimated that there's been almost a 50 percent shift in effort away from medical and pediatric dermatology. If you browse chat-rooms of medical students interested in derm, it's clear that many would like to set up clinics doing nothing but lasers, injectable skin fillers, and BOTOX. In a practice survey of dermatologists I found, younger women going into dermatology spent almost 20% less time seeing patient then male counterparts per week. As women make up increasing numbers of both medical students and dermatologists, this "contraction" of productivity is another factor likely affecting future access.

If you extrapolate that many (most) of these boomer patients will be Medicare beneficiaries, and that Medicare reimbursement could fall as much as 40% over the next few years, it seems likely that this bias towards BOTOX could become significantly larger. Expect to see some lobbying from Nurse Practitioners and Physician Assistant's for greater independent roles in the evaluation and management of skin lesions. For some related Medscape articles click here.

Rob

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I've featured a couple of unusual things over the last year which have reportedly caused implants to rupture. Who can forget the the implant that deflected rocket shrapnel , the implant's acting as an airbag, or the images of the Marlin harpooning the fisher-woman on video last year?

I'm not sure I believe this at face value, but there's a story in China that reports a woman's saline breast implant was punctured by a Hornet sting.

From the China Post

Dr. Tseng Ting-chang said a 31-year-old woman who received breast implants three years ago visited his clinic early this week complaining that one of her breasts had deflated after a hornet sting a couple of days before. The woman said the incident took place while she was riding a scooter in the countryside,whilst wearing a low-cut dress.

She took the sting in stride at first, but later was astonished to find that one of her breasts had shrunk a couple of days later. Dr. Tseng said he found saline from the woman's breast implant had leaked, apparently due to the hornet's sting. He said the woman had to undergo surgery to reconstruct her breast. Noting that the woman is quite thin and has little fat tissue under her skin, the doctor said it is possible the hornet's sting could have pierced the saline-filled sack, which is touted as being able to withstand pressure of up to 200 kilograms per square centimeter.

Must have been one of these Japanese "Yak Killer" hornets (native to Japan & Asia)which can be over 2 inches long and possess acidic venom which can dissolve human tissue ,and is strong enough to "kill a Yak" according to local folk-lore. See "Hornet's From Hell" at National Geographic. The venom is notably painful and was described by one entomologist who been stung as being akin to "a hot nail through my leg". An estimated 40 deaths annually come from these stings in Asia.


Below is a 9600x magnifiction of a hornet stinger on Electron microscopy.


For an interesting blog featuring unusual bugs check out this. It's cooler then it sounds!



Now a woman's skin flaps after mastectomy and implant reconstruction can be thinned out from tissue expansion, particularly in thin women who have little residual subcutaneous fat. Most implant reconstructions have the implant placed beneath the pectoralis major muscle, which can add up to 1 cm thick padding. Assuming the average male hornet (unlike the average male human) doesn't exaggerate the size of his stinger, they tend to run about 6-8 mm long according to my homework. It would take a forceful sting to reach a submuscular implant, and even then I'm not sure it would be able to actually pierce it.



Rob

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I saw a local Dallas new station segment on Plastic Surgery that was unintentionally ironic.

It is introduce with the statement that

"It's a nightmare situation. You've had Plastic Surgery and you don't like the results.....With rapidly rising number of physicians starting to call themselves Plastic Surgeons, (patient)complaints are starting to jump."

The segment features a Dallas doctor doing re-operative surgery on on a woman who 6 years prior, had cheek implants, eyelid surgery, and a brow lift performed and was unhappy. The doctor, takes a not too subtle swipe at how "other Dallas surgeons" don't understand facial aging and aesthetics and have been doing surgery wrong for years.



For some context, you have to understand that Dallas, Texas has some of the heaviest hitters among Plastic Surgeons in the world for facelifts and related procedures. (see my post "Cities known for certain Plastic Surgery procedures" from last spring) Dallas surgeons like Fritz Barton, Steve Byrd, Sam Hamra, Jack Gunter, Rod Rohrich, and others have literally rewritten parts of the vocabulary for understanding the aging face and how to address these changes surgically. Now there's a lot of ways to skin a cat (or rejuvenate a face in this instance), but you dismiss your forebears collective experience at your own peril in Plastic Surgery.

Back to my point! What's the irony of the story about consumer confusion on Plastic Surgery?

The doctor featured isn't even a Plastic Surgeon!

He's an ENT (ear, nose, & throat) surgeon who did not train in Plastic Surgery, but did a loosely regulated apprenticeship with other ENT's in "Facial Plastic Surgery". This type of ENT practice is not equivalent in either training or scope of practice, and most of these fellowships have evolved into tagging along with a cosmetic surgeon rather then actually something resembling training in the full scope of head & neck plastic surgery which is implied by the title.

There is no real standardized curriculum for facial plastic surgery training (as there is for Plastic Surgery) and you can still actually become certified in "facial plastic surgery" without any formal post-graduate training by just submitting a case-log and taking a test if you trained in ENT. I believe that most Plastic Surgeons feel it is a degree not worth the paper it's printed on, but that there's not much that can be done about it (it was actually challenged in court many years ago, but the decisions established that the term "plastic surgeon" could not be trademarked by the American Board of Plastic Surgery).

This in no way means such guys can't do cosmetic surgery well in many instances, but it is just another example of how such titles can confuse and blur distinctions that most patients (and apparently news media) are taking for granted.

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