Rob

I am typically one of the biggest buzzkills for technology in plastic surgery and aesthetic medicine, particularly when it involves body contouring. As I've written about before, the whole laser liposuction (SmartLipo, et al.)thing has been very underwhelming on the results side (compared to traditional liposuction)for most practitioners willing to speak candidly on this. Recently, I decided to purchase a machine which is a little different kind of liposuction strategy. The technology, technically called Nutational Infrasonic Liposculpture (N.I.L), involves a novel hand piece with a tip that rotates in multiple dimensions while emitting low frequency vibrations.

In the Unites States, the technology is being marketed with the label "Tickle Lipo".

What's impressed me about the Tickle Lipo is the efficiency of the device for fat removal and the decrease in pain as compared to the gold-standard of traditional lipo. The decrease in pain is presumably from the fact that you can be much more gentle with the manual movement of the cannula while the vibratory effect is supposed to down regulate local pain receptors. When done awake or under light sedation, patient's describe the vibration as a "tickling" sensation, hence the name. SmartLipo and related devices hurt just as much as traditional liposuction (despite what's being marketed) because you still have to go back and remove the fatty tissue with a traditional suction devices, so you're really not doing anything different on that end. To my mind, Tickle Lipo is kind of a hybrid between power-assisted devices (PAL) and ultrasonic (UAL)without the heat generated by higher frequency ultrasound. The heat from UAL and SmartLipo can have severe complications with external or internal burns created.

At the recent meeting of the American Society of Aesthetic Plastic Surgery (ASAPS), (the premier cosmetic surgery meeting annually in the United States), members were surveyed on their feelings and practices re. liposuction. This survey group would be a representative of the most experienced and accomplished body contouring surgeons in the world. Standard liposuction was the preferred method of fat removal for 51% of them. Power-assisted liposuction (PAL) was second, preferred by 23% of respondents. Only 10% of ASAPS members surveyed employ laser-assisted liposuction (SmartLipo and others) in their practice. When these ASAPS members were asked why they used a laser liposuction platform, the main answer was that it gave them a marketing advantage (68%) rather then any clinical result. Ultrasonic liposuction (UAL) was the most likely method to have been abandoned by the respondents.

With regard to complications after liposuction, ASAPS members felt that ultrasonic and laser liposuction were the techniques most commonly associated with complications (35% and 23%, respectively).Of the respondents, almost 40% have taken care of a patient with significant complications secondary to laser liposuction. Contour deformity was the most common complication reported by respondents (71%), followed by unsatisfactory results (59%), burns (44%), and scarring (38%).

This has been my experience as well. We're seeing more issues from these laser devices, most of which are being performed by non plastic surgeons. I think that has to do with the fact that it's more frequently non plastic surgeons buying these platforms rather then the fact that we'd produce less complications with them (although I think we would). After trialing a number of these technologies, we were just impressed with both the effectiveness and safety of Tickle Lipo.


Rob

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Nod to LL Cool J in the post title :)

California is an iconic part of the United States that sets many trends. Unfortunately one of these trends is the growth of under or untrained physicians performing cosmetic surgery procedures.

A snapshot of who is performing cosmetic procedures in California, published this month in the journal, Plastic and Reconstructive Surgery, examined 1,876 cosmetic practitioners from San Diego to Los Angeles. Only 495 of them were actually trained in plastic surgery. Primary care physicians with no surgical training to speak of made up the 4th group of liposuction providers following plastic surgeons, dermatologists and otolaryngologists.

Scary, Scary stuff! It seems obvious, but always look for a board certified Plastic Surgeon if you're considering plastic surgery.

Rob

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It was so predictable as to be boring!

So I'm reading a particularly shameless trade journal this week who's cover story promised updates on laser liposuction. This monthly glossy magazine is essentially a series of (not so) stealth ads with physicians shilling for lasers and other products for which they're paid spokesmen. As the topic turned to laser liposuction systems (like Cynosure's SmartLipo) you saw a lot of pullback on exactly how enthusiastic a number of surgeons are.

"In reality, the degree of fat melting attained with laser lipolysis has not met the high expectations of some practitioners"

When you see comments like that in a fluff trade journal which routinely celebrates every device/technology (whether it deserves it or not) you know this issue is understated significantly. When you take mostly non plastic surgeons and hand them a "magic wand" like SmartLipo while promising great body contouring results, it's a set up for under delivering. There still is no shortcut on mechanically removing tissue for most patients. An exception might be some one's neck which has almost no fat to speak of.

This is kind of like the thread lift fiasco all over again. It's become clear that these laser platforms are much less revolutionary, but are more likely modestly complementary (if that) to the 30 year old tumescent liposuction techniques introduced to the west by a French surgeon named Illouz.

The general "off the record" feelings of most experienced plastic surgeons experimenting with this is that these types of devices are safe but offer no clear advantage. Repeatedly it's described more as a succesful marketing phenomena rather than a real improvement. It's still not established that delivering thermal energy below the skin affects "tightening" whatsoever, which is the whole gimmick of the laser. If it does, it doesn't appear to do it without still having to do most of the heavy lifting with traditional lipo.

In contrast to this unnamed aforementioned trade journal which is lame, I'd like to give a nod to editor Jeff Frentzen and Plastic Surgery Products magazine which frequently has good articles - like mine for instance


Cheers,
Rob

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A real gauntlet was thrown down this past week with the publication reviewing the effects of excess weight and morbid obesity on our health. Dr. Walter J. Willett, a professor of epidemiology and nutrition at the Harvard School of Public Health, and 20 co-authors, compiled the 500+ page report, entitled "Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective".

Their meta-analysis of several thousand existing studies found that "excess body fat influences the body's hormones, and these changes can make it more likely for cells to undergo the kind of abnormal growth that leads to cancer." In short, "[t]he risk from excess weight begins at birth." Therefore, obese girls who begin menstruation earlier in life "will have more menstrual cycles. This extended exposure to estrogen is associated with increased risk for premenopausal breast cancer."

This staggering review, which took over five years to develop, indicates that "excess body fat increases the risk of cancer of the colon, kidney, pancreas, esophagus, and uterus as well as postmenopausal breast cancer."Obesity seems poised to become the number one risk factor for cancer in America, as obesity increases and the number of smokers decreases.

What can we do surgically about this?

Well, it appears the weight loss procedures, gastric bypass & gastric banding, can significantly reduce or eliminate many associated comorbidities including diabetes, hypertension, obstructive sleep apnea, and progressive osteoarthritis from excess weight load. In 2006, almost 180,000 patients underwent bariatric surgery of some type.

Last year researchers found that gastric bypass surgery patients were 40% less likely to die from any cause during a mean 7 years of follow-up, compared with the obese controls. It's kind of intuitive that there should be some risk reduction for some of these cancer risks associated with obesity, but I don't believe we have evidence to leap to that conclusion. It might be a very small effect statistically unless it was done on an obese adolescent in whom you'd have decades to track this.

I found a nice collection of review studies re. to Gastric Bypass here at Thinner Times if you're interested.

What about plastic surgery?

Unfortunately there is fairly poor evidence that plastic surgical treatment of weight, whether by resecting excess skin/fat or by liposuction, has an effect on any of these benchmarks. What we can do is cosmetic changes only. A paper from Washington University (St. Louis) published in the New England Journal of Medicine in 2004 found no benefit from high volume liposuction (as you''d expect from weight loss via other methods or diet), where as much as 20% of patients subcutaneous fat stores were removed via liposuction. There have been a small handful of lesser quality papers (like this) suggesting that large volume liposuction may improve glucose control in some type-2 obese diabetics, but the evidence is weak and the studies not really well done (it's a hard subject to study with any uniformity).

However, there is some rationale for a mechanism of how it could work. Large areas of lipodystrophy (fat deposits) are essentially your bodies "batteries" for energy storage. Obese people have a resistance to the effect of insulin mediated in part by their excess fat. In more than 80% of patients who are severely obese and have diabetes and then have gastric bypass surgery, the diabetes is cured. So remove the fat, remove the diabetes, right? Well it turns out it's not quite that simple. It appears the visceral fat (fat inside your abdomen and liver) may be the bigger culprit then the fat outside that you remove with excision or liposuction.

Below is a photo of a visceral fatty deposits in a mouse liver in two different species of mice involved in obesity research. The upper photo shows an "obese mouse", while the lower photo shows the "fit mouse" liver. You can clearly see the "marbling" of the fatty liver.

Rob

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I'm really not trying to beat a dead horse on this theme, but there is an absolute stunning case developing in Arizona re. the actions of an Internist who reinvented himself as a cosmetic surgeon.

From the Arizona Republic:

A massage therapist performed a liposuction procedure in which a woman died. A homeopathic physician who was denied a medical doctor's license by the state board did another procedure in which a patient died.Others who performed cosmetic surgery did not have formal medical training,including a bookkeeper and a former restaurant owner. The procedures were all conducted in one Anthem doctor's office, according to a report by the Arizona Medical Board on a case that has left three people dead since December.

After two patients suffered cardiac arrest and died during liposuction procedures in December and April, Dr. Peter James Normann was ordered by the state in May to stop performing surgeries and administering sedation drugs.Less than two months after the order was issued, Gary Page, a homeopathic doctor whom Normann had contracted with to perform medical procedures, did a liposuction on a 53-year-old woman in Normann's office (who later died from either oversedation or lidocaine toxicity I suspect)

Dr. Normann's Web site indicates he is an experienced cosmetic surgeon. But his medical certification was in internal medicine, and his specialty was listed as emergency medicine, according to state medical board records.

This case is absolutely nauseating to me to imagine someone like that is practicing medicine. Three deaths from liposuction in 6 months is staggering. Dr. Normann is certainly not representative of all wanna-be Plastic Surgeons, but he does highlight the seriousness of traditional plastic surgery procedures perceived to be "simple" like liposuction or breast augmentation. I cannot believe that there isn't going to be some real backlash in Arizona over this, and maybe there should be.

This case represents the second well-publicized episode within a year of office-based surgery deaths in AZ (see this post "Office based surgery, is this going o be legislated away?" from last February) the last involving the death of a prominent attorney in an accredited office surgery suite from anesthesia complications. It only takes the energy of a single state representative to put signifigant restrictions on office surgery into play in the legislature.

Rob

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Mesotherapy, off-label injections of soy lecithin & bile salts which are promoted to melt fat, is the focus of a story in this weeks US News & World Report entitled "A Shot to Melt the Fat?" which is a nice & sensible overview urging caution.

Several patients with disappointing results are quoted which is what I expect to see more of when this is more widespread. If you have big areas of fatty collection (lipodystrophy in doctor-speak) you likely won't do well with this. On the other hand, my curiosity is peaked with the effectiveness on smaller areas like under the chin and arm.

In other news re. to mesotherapy, the state of Kansas has apparently banned it for unrestricted use (story here from New Beauty magazine)requiring it be part of institutional studies. You may see that type of regulation spreading IMO.




Rob

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New technologies have been flooding the Plastic Surgery market for the last 20 years at an impressive clip. During that period of time there have been a few revolutionary device, a lot of evolutionary changes in those devices, and some real clunkers that have faded (or are fading) into obscurity. Some of these technologies start as revolutions before fading to clunker-status.

The term "$100,000 coat-rack" refers to the significant cost of many of the devices pushed by industry to doctors and patients. Many of these after an initial rush of enthusiasm had a tendency to gather dust in the corner with their owner reminded painfully of how much capital they had invested in it.

One of the best surgeons and businessmen I know, Dr. Marc Salzman, (a Plastic Surgeon from Louisville), preached to me the risk/reward profiles of these devices. Basically, on the rat-race for latest & greatest, if you can't recoup your investment in the short-term, it will be obsolete as patients come in asking for the next device featured on Oprah or Cosmopolitan magazine.

A canny observation from Marc was that a reliable way to figure out the trends in what was out of favor with lasers was to look on Ebay (search terms like syneron, fraxel, thermage, lumenis, candella, or other vendors) and see what was getting dumped at large discounts by laser resellers or doctor's offices. One caveat I'd make for "Dr. Salzman's Ebay Rule" circa 2007 would be that as some medi-spas close or doctors dive into cosmetic laser-like devices, lose money, & liquidate is that you will find some. good technology available

REVOLUTIONS
1. the wound V.A.C. (vacuum assisted closure) device which has a monopoly in the multi-billion dollar vacuum wound care market.

2. laser skin resurfacing - originally with CO2 (and then erbium lasers)jump started the "minimally invasive" trend in the 1980's. Enthusiasm has waned significant however (see below) as downtime has become more of an issue to patients. Intense pulsed light (IPL) and "gentler" laser-like devices (fraxelated CO2, plasma, Radiofrequence, diode/pulsed dye lasers) are the flavor of the month, but are nowhere near as effective for deep wrinkles in a single treatment as CO2 lasers are.

3. BOTOX for animation wrinkles
4. Off the shelf injectables. Collagen was the initial clumsy product to be replaced by safer & longer acting hyaluronic acid products (Resetelene, Juvederm, & others)

5. Titanium plates and screws for rigid fixation of facial fractures. This was a quantum leap in precision and stable repair from previously used steel wires which were essentially "twist ties" hogging bone near the other fracture edge.


6. Tumescent liposuction - introduced from a French Plastic Surgeon over 25 years ago, this technique is continuing to find new applications and refinements. Adding fluid (tumescence) allowed safer, more predictable surgery then preceding attempts at liposuction. It's interesting that a famous liposuction case in the early 20th century where a French ballerina required bilateral leg amputations from complications stymied interest in this area for nearly 50 years. It's now routinely combined with surgical procedures like tummy tucks to enhance results.

OUT TO PASTURE TECHNOLOGY (or heading that way)

1. Endoscopic procedures - a few years ago you might have lumped this in the revolutionary category, but it is fairly rapidly being abandoned in most instances. Endo-brow lifts (the most common application) are felt by many surgeons (but not all) to be less effective, less precise, more expensive, & much less durable then open brow-lifts. FYI, the endo-brow was invented by some of my neighbors here in Birmingham Drs. Core & Vasconez, both of whom are real gentlemen and recognized experts in endoscopic techniques.

Endoscopy has stimulated a bunch of novel "mini" brow lifts, which incorporated some of the anatomic lessons we learned from endoscopic appproaches. As these techniques can be done under local without $20,000+ of endoscopic equipment, I think these hybrid procedures will become the norm as the pendulum swings towards more office-based surgery.

Endo-breast augmentation (which isn't that popular to begin with anymore) will fade into obscurity quickly I predict, as saline implants are used much less often. The recommended access incisions (~5 cm) for silicone gel implants are large enough that the resulting visible scarring (even of good quality) in the armpit won't be acceptable to patients. The soon coming form-stable ("gummy bear") gel implants from Allergan & Mentor require even bigger incisions and more precision in pocket disection to imagine many will push the envelope with endoscopic approaches.

2. traditional (ablative) laser resurfacing - as I mentioned above, CO2 lasers (along with liposuction & collagen) were the catalyst for minimally invasive procedures. However, patients in 2007 will no longer accept looking like a burn-victim for 3-4 weeks during the healing process. In addition, there have been a tremendous number of patients with uncorrectable hypo/hyperpigmentation reactions from resurfacing lasers and the skin also can take this odd-looking smooth,waxy look.

Plastic Surgeons got tired of being told that their revolutionary laser from 3 years ago is no good anymore by the same people that sold them their previous one. This happened frequently during the late 1980's thru late 1990's as the glow was off the original CO2 lasers. Older surgeons pointed to the fact that they can achieve similar (or better) skin resurfacing as CO2/erbium lasers using concentrated TCA or deep Phenol peels for about $5 worth of supplies (you've still got to deal with the "burn victim" look for a few weeks however with those kind of peels).

3. Ultrasonic liposuction (UAL) - heavily touted in the late 1990's, UAL had a spectacular fall from grace as it had higher complication rates, saved no time, and required expensive equipment as compared to traditional tumescent liposuction. Other then that, what's not to like? UAL is useful for dense fatty areas (upper back fat & male gynecomastia), but has been abandoned en masse by most surgeons. The $15,000 UAL machine at my hospital is gathering cobwebs and no one currently working there even remembers how to assemble or operate it at this point (I'm not kidding!).

4. Thread-lifts. One of the first posts in late 2005 on Plastic Surgery 101 was on thread lifts entitled, "The Jury is still out (on thread-lifts)". Well the jury is back and the fact that Quill medical has recently withdrawn the Countour Thread barbed suture from the market speaks volumes. It just didn't work, and when it did work, it didn't last was the consensus. For money approaching the cost of real-face/brow lifts the techniques for this currently are lemons. Newer suspension suture styles and materials may make us reevaluate this down the road.

5. Thermage - for a device costing nearly $100,000 plus expensive disposable parts, most doctors and patients expect results that don't require 75x magnification with Photoshop to demonstrate. I feel sorry for people who get up at meetings and show pictures of their results with Thermage only to have the audience of their peers squint at the picture trying to imagine something has happened.

In addition, it is notoriously painful during treatments and can have a tendency to cause facial fat to atrophy (as written up by blogging amigo Dr. Tony Youn). This (or thread lifts) has to be the most maligned and polarizing device I've ever heard of at Plastic Surgery meetings, leading the President of the Aesthetic Surgery Society (at the time) to mentioned at one of our meetings that he'd been trying to figure out ways to throw the device out his office window onto I-20 in Atlanta it was causing he, his partners, and his patients so much grief. Newer device settings have been proposed by the complany and some doctors who favor this device, which they claim will improve things. I'll believe it when I see it.

6. Trans-umbilical breast augmentation (TUBA) - most Plastic Surgeons think this is a flawed approach to begin with. The move towards silicone implants (which can't be placed this way without damaging them) will make this technique fade from knowledge in short order as no one learns it.

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