You may not remember it much, but most of those of us who were forced to endure studying the epic poem, Beowulf were introduced to the concept of the weregild. In the 2007 CGI adaptation of Beowulf, apparently the side plot discussing the weregild was cut to make more time for Angelina Jolie's CGI-enhanced, naked, high heel wearing turn as Grendel's mom. Probably a smart decision by the producers in terms of the box office :)





The weregild was literally a "man price" you paid as compensation for killing someone, and there was a price on everyone from the dregs of society all the way for one prescribed for regicide (killing the king). It's a fascinating social compact that was used to try and temper blood feuds with their cycles of repeat violence and revenge. The Roman Catholic church eventually enacted their own version of "tort reform" on the weregild, condemning it and forcing elimination of the practice near the end of the 1st millennium AD.

From Wikipedia's entry,

The standard weregeld for a freeman appears to have been 200 solidi (shillings) in the Migration period, an amount reflected as the basic amount due for the death of a ceorl both in Anglo-Saxon and continental law codes. This fee could however be multiplied according to the social rank of the victim and the circumstances of the crime. For example, the 8th century Lex Alamannorum sets the weregeld for a duke or archbishop at three times the basic value (600 shillings), while the killing of a low ranking cleric was fined with 300, raised to 400 if the cleric was attacked while he was reading mass.

The size of the weregild was largely conditional upon the social rank of the victim. A regular enslaved man (ceorl) was worth 200 shillings in 9th century Mercian law (twyhyndeman), a nobleman was worth 1200 (twelfhyndeman). The law code even mentions the weregeld for a king, at 30000, composed of 15000 for the man, paid to the royal family, and 15000 for the kingship, paid to the people. An archbishop is likewise valued at 15000. The weregild for a Welshman was 110 if he owned at least one hide of land, and 80 if he was landless.

NOTE: For those interested, there's a fascinating catalog of such fines from the Salian Franks (a German dynasty)here, which covers the price of various offences, ranging from stealing your cow to gang raping your wife


Ok Rob, why are you talking about weregilds on Plastic Surgery 101 anyway?

There were several articles about healthcare I read this week that all kind of intersect at the fringe of the debate on healthcare and got me thinking about the equivalent of the modern weregild.

"A Place Where Cancer is the Norm", which describes Houston's MD Anderson cancer center.

"Cancer Society, in Shift, Has Concerns on Screenings" which describes a pullback from the American Cancer Society on just how effective mammograms and prostate cancer screening (via PSA tests) on affecting death from cancer.











"Can 'bundled' payments help slash health costs?" in USA Today

Sunday Night's 60 Minute's piece (click here to view)on more then $60 billion annual loss to Medicare fraud and how the Feds have been inept at policing it.

An article in Oregon's Statesman Journal, "Government Audits Are Hurting Small Business Owners" describing the federal government's Recovery Audit Contractor(RAC) program for Medicare fraud.

The articles on cancer screening and exotic treatments at MD Anderson hospital to me point towards a more strict cost-benefit analysis coming on cancer treatments. The tertiary chemotherapy drugs and adjuvant radiation treatments described are budget busters with very marginal utility in terms of outcomes. The care described in the article, where chemotherapy treatments were literally thrown against the wall to see what sticks, is not a sustainable model. We're going to asking more and more, "How much are 'x' additional months of this cancer patient's life worth?" in order to balance our health care budget. It is unavoidable that we don't end up with some federal utilization committee who's job it will be to tell us what we cannot do in terms of palliative care for cancer or other chronic diseases. Other countries already do this without much controversy, but President Obama won't touch this with a 10 foot pole.

The USA Today article on bundling payments seems unworkable in situations where physicians are not employees of the hospital or system involved. I would not trust a hospital corporation to distribute that money equitably to independent providers once they have it in their coffer. Would I have access to audit a hospital's books to make sure their accounting is accurate? What's the resolution process for disagreements on the balance sheet? Much like insurers, the temptation for them to slow-pedal payments to collect the interest would be impossible for them to resist. Except in certain "closed system" situations (where all MD's are employees)like the Mayo Clinic, the Cleavland Clinic, or the Kaiser network in California, this bundling would be a unacceptable working situation to most physicians.

The 60 Minutes piece on Medicare shows why no one who is familiar with healthcare believes that the federal government can run a single-payer system. They are unable to investigate or follow up on even the most blatant examples of fraud costing hundreds of billions over dollars a decade.


So what do they do instead? They reauthorize the "RAC" program to aim at providers and hospitals for fraud that may be pennies on the dollar compared to the fraud described in the 60 minutes piece. The feds have outsourced the Recovery Audit Contractor (RAC)program to incentivized companies to autopsy medicare billing going back over 3 years by hospitals and providers where any inaccurate billing (using our byzantine CPT system) is assumed fraudulent and due back with interest and penalties. Analysts expect that inaccurate coding underbills at least as often as it overbills, but do you know what these auditors have produced. What do you get however when you incentivize these companies to claim 8-12% of any recovery (but don't reward refunds)? You get 96%+ of these RAC audits finding overbilling only.

Rob

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President Obama has spent the week furiously trying to put lipstick on the pig that is his healthcare reform bill. He gave a fine speech last week which was noticeably short (by design) on specifics, and one which left out any plausible way to pay for the program. Trying to defang critics, he generalized a number of areas where centrist Democrats and Republican ideas would be incorporated. One of these was a brief mention of tort reform.

Color me uinmpressed.

As with his summer speech at the American Medical Society (AMA) meeting that was met with boos, the president has over and over made it clear he is not interested in addressing real medical tort reform. If you took the most disingenuous elements of lawyer-speak mixed equal parts with the opacity of politican-speak you end up with the President's message to his Democratic trial bar donors (alongside organized labor, the most influential group in Democratic politics). ie "Relax boys, THERE WILL BE NO REAL RESTRICTIONS ON YOUR ABILITY TO SUE DOCTORS, Amen!"

Anyway.....

From the 60 Minutes interview tonight(click here for video)

KROFT: If it came down to getting this plan passed would you be willing to do more in the area of tort reform and malpractice insurance? Would you be willing to agree to caps, for example, on malpractice judgments?

OBAMA: You know what I would be willing to do is to consider any ideas out there that would actually work in terms of reducing costs, improving the quality of patient care. So far the evidence I've seen is that caps will not do that. But there are a range of ideas that are out there, offered by doctors' organizations like the AMA, that I think we can explore.....

KROFT: And the conventional wisdom has been that the reason that the House has always voted against any kind of malpractice reform or tort reform was because of the heavy contributions from the trial lawyers.

OBAMA: That is the conventional wisdom. And I think there's also been philosophical issues and differences about whether or not patients who really have been subject to negligence, whether it's fair to just say to them, "You know what? You can only get a certain amount, no matter how egregious it is."

That is nothing but double-speak goblety-gook which avoid any commitment to do anything. At least Democratic leader Howard Dean had the balls to recently come out and say that tort reform is not going to be in the bill because of the relationship of the party to the trial bar.



Rob

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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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Choosing your business logo is important, and that holds true for plastic surgery practices as well. When we worked on ours, it took literally dozens of ideas and revisions to get where we wanted. It turned out pretty well if you consider the fact that our trademarked logo for Plastic Surgery Specialists has been "borrowed" by at least half a dozen web sites I've found.

Quick plagiarism trivia: If you'll remember, Richard Ashcroft, lead singer of British pop band The Verve was found guilty of plagiarizing the melody from the Andrew Oldham Orchestra recording of The Rolling Stones' 1965 song "The Last Time" for their 1997 #1 hit "Bittersweet Symphony". Ashcroft was forced to relinquish millions of dollars in songwriting royalties to Mick Jagger & Keith Richards.



Anyway, in doing research for our logo last year, Dr. Jason Jack and myself looked at hundreds of other practices logo choices. There were a few that stood out as really bad.

1. We thought this looked like the "Mud Flap trucker girl".



Versus



2. This one reminded me of all those bad 1970's brown color schemes


Compare it to this 1970's fabric courtesy of the "Tune Up" blog devoted to vintage fabric (talk about your narrow reader demographic!)


It also kind of reminds me of the 1970's San Diego Padres Uniforms.




3. This logo has four different type fonts fighting for supremacy




4. This logo was just too "subtle" :)




Did someone really think a Pitcher Plant emerging from some one's vagina was the right way to go with this ad? Obviously this campaign did not get wife approval factor (WAF) before going to print.

5. I call this ugly logo of various body parts the "Homunculus". A homunculus is any representation of a human being, and is often used to illustrate the functioning of a system.



In medical school neuroanatomy, the concept of this is used to show what areas of the brain control the body.




Not related to plastic surgery per se, but this pediatric clinic logo really could use a redesign :)


FYI, there's a great blog post on the world's worst logo here.
Rob

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Good story on some of what you have to give up to expand healthcare coverage. It's not all win-win when you disincentive 20% of the economy.

Hat tip to my partner, Dr. Jason Jack BTW!


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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There's a collision course of sorts that's been playing out in medicine for the last 25 years. As the costs of health care have consumed more and more of GDP, the system has become unsustainable. Physician salaries bore the brunt of early cost containment with effective pay cuts of 50-60% in real income since the mid 1980's. More recently it's been the patients on the receiving end, with more employers dropping coverage and more people enrolled in high deductible/high copay plans.

An article in the New Yorker Magazine, "The Cost Conundrum - What a Texas town can teach us about health care" profiles McAllen, Texas. McAllen is the most expensive place in the country in terms of annual expenditures on medicare beneficiaries. It illustrates the law of unintended consequences and reinforces the notion that anyone who thinks health care costs will come down with universal coverage is foolish. More coverage = more utilization, particularly when patients do not bare much of the costs themselves out of pocket.

The article also features the behavioral changes of physicians as they've become more entrepreneurial. It's profiled as a negative in the article, but it really should be encouraged. In modern medicine, if you do not run your practice like a business, then your practice will fail. Physicians should be encouraged (when able) to align their entrepreneurial interests with their patients. In many instances this will run you head first into government bureaucracy and established interests as in the case of my office surgery suite. Don't even get me started on the fact that I'd be able to do some procedures in my soon to be accredited office O.R. at 40%+ discounts to Medicare and Blue Cross for what it costs to do in a hospital. You'd think this would be of interest to Medicare and the state of Alabama as it would likely save several hundred thousand dollars annually, but instead it's like talking to a brick wall.

Cosmetic Plastic Surgery practices has been the attentive to economics for a long time, and you're forced to be cost-conscious to maintain that kind of practice. The revenue from the cosmetic procedures I do affords me the opportunity to maintain a busy reconstructive practice on cancer patients.

Rob

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Sudden shifts in medical advice can cause both patients and doctors confusion. In recent years the benefits of breast self exam for cancer, checking PSA (prostate specific antigen) levels for prostate cancer screening, vitamin supplements of any sort, and chest x-rays for lung cancer screening have all been reported to be ineffective and sometimes harmful to patients.

Add one more to the list - the routine use of low dose 81mg aspirin in the general population to decrease heart attack and stroke risk. This had been pushed such that most adults should consider taking a "baby" (81mg dose) aspirin a day. This seemingly harmless recommendation actually seems to be causing more problems then it's worth according to a new review of the literature.

Analysis of data from over 100,000 clinical trial participants found the risk of harm largely cancelled out the benefits of taking the drug. Use of aspirin in the lower-risk group was found to reduce non-fatal heart attacks by about 20%, with no difference in the risk of stroke or deaths from vascular causes. But it also increased the risk of internal bleeding by around 30%, a potentially life threatening complication. This is summarized here.


Only those who have already had a heart attack or stroke should be advised to take a daily aspirin is the new suggestion, at least for this week.

Click below to hear an audio summary:



Rob

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As the plastic surgeons of the United States await approval of Allergan's style 410 breast implant (aka "the gummy bear" implant), I frequently get questions from patients about when this device will be approved.

The short answer is "I don't know!"

The approval of medical devices of all sorts has been heavily politicized. After a number of recent high profile issues with prescription drugs, cardiac pacemakers, and vascular stents (devices used to prop open clogged blood vessels or fix aneurysms), the FDA is under the microscope. Caught up in all this is the fate of the next generation of breast implant devices, for which the FDA has been sitting on the manufacturers approval applications for nearly 3 years.

For some context, "form stable" implants like Allergan's 410 have been used clinically around the world for over 15 years. In clinical trials (like this)they have an unparalleled safety record for this kind of medical device, and offer both superior durability and a reduction in every single kind of indexed complication (pain, capsular contracture, rippling, rupture, etc...) after cosmetic and reconstructive breast surgery that we observe and track.

Allergan's Style 410 implant:


The NY Times reported earlier in April (here)on the ongoing reexamination of "legacy" devices that were exempted prior to the late 1970's from review as they were already being used. Silicone and saline breast implants actually already went through this review by the FDA in the early 1990's and eventually emerged with a clean bill of health. The only reason the newer implants have to go thru this process at all is the higher cohesiveness of the silicone polymer exceeds some artificial cut-off that would make them fall under the existing approval. This illogical rationale has cost tens of millions of dollars to companies and delayed patients access to improved devices.

As to the fate of the 410 implant, my understanding is that the FDA is satisfied with the safety and clinical efficacy of the implants and is negotiating on the final labeling to be included with the product. Apparently, surgeons will be required to attend an instructional course prior to being given access to the device (even someone like me who actually used these devices as a resident and fellow during clinical trials). We are hopeful that the ongoing activity signals approval is immanent this quarter!


Rob

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Someone wrote me the other day asking if I'd do another post on music after stumbling across my last group of recs in May (see here). I've gotten interested in how some artists are incorporating sampled guitar/rhythm loops into their acts, especially in live performances, so I think I'll point to some of my favorites!

Master of the sampled loop, Imogene Heap in "Just for Now". How the heck she can keep track of all these samples during this performance I have no idea. Absolutely jaw dropping! I also suggest the beautiful "Hide and Seek" which is introduced by NBC's "Scrubs" star, actor Zach Braff BTW.


KT Tunstall's "Black Horse and the Cherry Tree" live on the Today Show in 2006. This performance single handedly launched her career in the United States.


Yoav's creepy acoustic "Club Thing". His song "Beautiful Lie" is also really neat with the samples


The Kills industrial-tinged "Getting Down". There's a great feature on them on the Sundance channels' Live from Abbey Road series. Must see TV!


The Yeah Yeah Yeah's "Maps". This is an a great acoustic version. For the an extreme electrified live version go here


Please feel free to leave any suggestions in the comments for interesting music! I'm always looking for new stuff.

Rob

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I've pointed out here on Plastic Surgery 101 that despite the dysfunction of the American health care system, the alternatives in other western nations have their own problems. In 2007 I posed the question "So You Think You Want Universal Health care?" and featured Dr. Val's review of "Sicko" which glowingly featured other countries' systems.

It was particularly interesting to me to see the "religious conversion" of one Claude Castonguay on this topic. Who is Claude Castonguay? He's the father of Canada's socialized medicine program. After four decades, he finally admitting that the system he laid out for Canada is failing to meet both the medical needs of beneficiaries as well as the budget needs of the individual Canadian provinces. Castonguay now advocates contracting out services to the private sector and American-style co-pays for patients who want to see physicians.

For an interesting overview on this, read the Investor's Business Daily editorial page article "Canadian Health Care We So Envy Lies In Ruins, Its Architect Admits". The Canadian author, David Gratzer, has written extensively on Canada's uneasy relationship with their countries health program.


Rob

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I've got about a dozen half-finished blog-post drafts laying around. I;ve decided to take the easy way out today and do a quick hitter.

If you've never heard of the British band, Travis, you're missing out. It's ironic that prior to hitting the big time, Coldplay was considered too derivative of Travis to make it. The video for their single "Closer" is absolutely sublime and features a cameo appearance by actor, Ben Stiller.


Click on the image below to watch Travis' "Closer" via the magic of You-Tube.




This should have been a big hit stateside for Travis IMO. It really reminds of the wonderful Spike Jonze-directed video for Weezer's "Buddy Holly" from the mid-90's. To sample the body of work of Spike Jonez see Wax's "Southern California", Levi's jeans "Tainted Love" commercial, Fatboy Slim's "Weapon of Choice" (featuring a tap-dancing Christopher Walken)

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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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The syndicated New York Times piece out this last week on Plastic Surgery/aesthetic medicine blogs is the second story I've been interviewed for about about blogging.

The other, a cover story in Plastic Surgery News (a publication of the Amer. Society of Plastic Surgery) titled "Battle of the blogs Negative web logs targeting surgeons increasing – but tools to fight them are available." can be read full-text here.

While it's nice to be noticed, I think I'm characterized in the NYT as a little more Ralph Nader-ish then with the voice/tone that I actually write with. Over the next week or two, I think I'd like to touch on a few things that patients have misconceptions about when they come see a Plastic Surgeon.

Cheers!
Rob

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I'd like to put in a quick plug for an incredible free streaming Internet radio station, the wonderful RadioParadise. This station is kind of like the old AOR format stations which feature a little something for everyone. I find new and interesting artists every time I listen. At some hospitals with PC's in the O.R., I've even set it up to stream for background music when I've forgotten my beloved Ipod.

Audio streams from Radioparadise are available at bitrates up to 256k MP3 signals which approach CD quality (if you buy songs from iTunes or other major sources you get songs at about 1/2 the quality). If you're really industrious, you can download software which can "capture" these streams and save them onto your computer for playback.

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Got $500,000 USD laying around? You too could enter the plastic surgery business as the proud owner of a fully stocked clinic in Prague, Czech Republic.

This is actually listed on Ebay of all places here and comes advertised as a turn-key business.

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An aside from Plastic Surgery 101 for today:

Major, major historic moment in the history of modern medicine was announced in a presentation today at the American College of Cardiology meeting in New Orleans IMO.

More than half a million people a year with chest pain are likely getting an unnecessary or premature procedure to unclog their arteries because drugs are just as effective and cardiac bypass (CABG) is superior on symptom relief and mortality data. You can read the AP wire summary here.

This single paper may dramatically change the way we treat coronary artery disease overnight around the world and potentially save billions of wasted dollars in procedural and device-related costs. It will be interesting to see how warmly this is received by interventional cardiologists who've commanded top salaries treating many non-emergent angina cases (which were reviewed in the study) in the cath lab :)

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Plastic Surgery 101 made into an article in this month's Plastic Surgery News, a monthly periodical published by the American Society of Plastic Surgeons.

The article deals with the issue of cyber-harassment by disgruntled patients, and features the real life experiences of some Doctor's who've had truly horrifying experiences of dealing with the new realities of the Internet as a medium. I was the "blogging expert" who talked with the author about the phenomena of "poison" blogging, which has been a vehicle in some instances to attack Plastic Surgeons' reputations as well as the potential for rapidly causing widespread serious mischief and disinformation on sources like blogs, usenet groups, wikipedia, chat rooms, and the like.

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Just wanted to quickly point out the recent additions to the "friends of Plastic Surgery 101"

Dr. DiSaia's "Truth in Cosmetic Surgery" blog - the original inspiration for Plastic Surgery 101


the lovely Beth Shea's "Ageless in Los Angeles" on some of the trends in Tineltown

The Beauty Brain's blog of all things cosmetic has a brand new home

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