Questions about breast reconstruction

I got a late question in the "mailbag" from a Plastic Surgery resident asking

"When I was applying to programs last year and traversing the country visiting programs, there were a few trends which enticed applicants, probably none more that microvascular breast reconstruction. I was curious whether you think this trend will persist, or do you think increased insurance skepticism and comparability of implant based reconstruction and rotational flap reconstruction will leave this procedure for the uber rich willing to pay the difference?"

One thing to understand with questions like this is that while quality in healthcare is applauded, it is not paid for in a vacuum. With rare exception, reimbursement for insurance will continue to be depressed as we creak towards some kind of "federal medicare for all". As the feds and 3rd party payers look at things, quality is measured in things like length of stay and total cost rather then measuring quality in terms of "Does this type of reconstruction look more like a breast?".

Microsurgical expertise is gradually being concentrated in fewer and fewer hands as it has become a financially unsustainable procedure for most surgeons. (you can witness the same phenomena in pediatric plastic surgery & increasingly, hand surgery btw) I don't think there exists a large population of "uber rich" to sustain the field in a robust fashion, and there really is no plausible stimulus pending (50% increase in RVU's for instance) for rekindling interest in free flap surgery when other options exist.

Rob

What do cosmetic surgery and Lesbians have in common?

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

Revisional cosmetic breast surgery - Dr O in print this month

I like to say that unlike most blogs by plastic surgeons, Plastic Surgery 101 really isn't about me, but today's post is actually about me.

I was asked by the editor of Plastic Surgery Products (PSP) magazine, an industry trade journal, to come up with something interesting to write about for his magazine. One of the questions that I'm always thinking about is "What are the things we do that really cause long term problems and how can I avoid that?".

Spending time as a fellow working with the world's best re-operative breast surgeon (for my money), Nashville's Dr. Pat Maxwell, really gave me a different kind of respect for some of the long term sequalla we can produce with cosmetic and reconstructive breast surgeries. There's a famous quote (attributed to former Houston Oilers coach Bum Phillips) about Alabama football coach Paul "Bear" Bryant, that he could "Take his'n and beat your'n, and then take your'n and beat his'n.". Well Pat could do the same with some of the most unfavorable or difficult to treat scenarios in breast surgery that you can imagine.

Anyway, I've kind of gotten an interest in this kind of patient and put some of my understanding and thinking on these issues down for PSP in an article entitled "Solid Strategies in Revisional Breast Surgery" which you can read here.

Thanks to editor Jeff Frentzen for the opportunity to contribute, however Jeff, I'm going to demand the cover story next time :)

Ok now back to posts definately "not about me".

Rob

Hospitals poised to embrace "pay as you go" for patient care

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

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

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

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

Rob

Sour NOTES - a really, really stupid idea in surgery

At right, a picture of NOTES done "olde school" for a tooth extraction.

I'm not so far out of doing a few thousand abdominal procedures during my general surgery training that I don't still feel fluent in GI surgery. As I'm still boarded in General Surgery in addition to Plastic Surgery, I get a lot of trade journals sent to me on endoscopy, laparoscopy, etc... Occasionally, something I'll read about makes my eyebrow raise as I don't BOTOX yet :) The concept of NOTES surgery is one of those things.

Take an operation that is typically performed safely in less then 30 minutes with minimal pain or morbidity and turn it into one that last 3 hours, introduces unnecessary risk, and has no conceivable advantage. What do they call that at the University of California San Diego (UCSD)? They call it progress (!!!!!)

Welcome to the concept of NOTES "Natural Orifices" surgery (see here for a primer) where intrabdominal surgeries are performed by making a hole thru the stomach, anus, or vagina to work thru versus making several 3-5mm perforations in the abdominal wall with laparoscopic techniques. While ingenuity & creativity is always to be applauded in surgery, at some point you have to do an honest assessment of the risks, benefits, & outcome.

The surgeon in this WebMD article celebrating the first NOTES appendectomy in the United States at UCSD seems to have his intellectual blinders on when discussing this procedure.

Dr. Santiago Horgan, chief of minimally invasive surgery at UCSD, says “We’ve proven this approach works. We’ve seen the impact on patient care and on outcome: less pain, quicker recovery, improved cosmetics.”

So let me get this straight: The absence of three nearly invisible 3-5mm scars, with no advantage in length of stay, with the addition of a hole in your rectum, vagina, or stomach (which all can leak), with significantly prolonged surgery adding cost, increased nausea, and increased risks of deep vein thrombosis (DVT) is somehow supposed to be an improvement? This is a technique that needs to be put back in a holding pattern indefinitely where safe procedures exist until you can come up with some compelling rationale for doing them. If I was sitting on a hospital's Internal Review Board (IRB) looking at this I'm not sure I could give an endorsement for this.

In fairness, some of these same arguments were made when laparoscopic surgery first appeared in the late 1980's and it's now the preferred technique for many procedures. You have my permission to throw this post in my face in 2015 if everything is NOTES and laparoscopic equipment is gathering dust somewhere. I like my odds however!

Rob

Looking back to 1983 in Plastic Surgery and Pop Music

As I was leafing thru a recent Rolling Stone magazine, I noticed the list of top ten pop singles from February 1983. It's a diverse collection of songs that I actually know from being a 12 year old then who listened to the radio and watched MTV (when they actually played music). The singles in order were:

Patti Austin "Baby, come to me"
Men at Work "Down Under"
Bob Segar "Shame on the Moon"
Stray Cats "Stray Cat Strut"
Toto "Africa"
Michael Jackson "Billie Jean"
Eddie Rabbit "You and I"
Culture Club "Do You Really Want to Hurt Me?"
Duran Duran "Hungry Like the Wolf"
Phil Collins "You Can't Hurry Love"

Fast forward to Feb 2008 and I haven't heard of a single one of the top ten songs or most of the artists singing them. In fairness, the hipster in me is familiar with most of the music in the Americana Radio top ten, the "retirement home" for alternative music fans in the 1980's and early 1990's. I'll take this opportunity to plug Radio Paradise, the internet's best free streaming radio station.

My nostalgia for 1983 pop music got me to thinking
"What was going on in Plastic Surgery back then?".

Thru the archive online for our major journal, Plastic & Reconstructive Surgery, I was able to scan the "state of the state" of our field 25 years ago.

- One of the first articles on tummy tucks after gastric bypass (GBP) appeared. This was a little surprising to me as that GBP operation was fairly rare and people with experience in the plastic surgery after was uncommon. Interestingly many of the problems and concepts we act like we've just discovered were well described in that 25 year old article.

- A bunch of articles related to refinements in the traditional "open" (coronal) brow lift. The endoscopic brow lift wouldn't show up for almost another decade, whereupon the traditional operation was deemed obsolete, only to make a comeback in recent years as many have decided that "endo brows" do not last and when they do last it's in the least desirable place (the middle brow versus the lateral brow where people are complaining about). Modified open brows, incorporating lessons from the endo-brow experience, have made an impressive come back in recent years.

- The debate about whether immediate breast reconstruction after was either safe or feasible was being written about. At the time it was favorable to say that patients should "appreciate" their mastectomy defect as a rationale to do delayed reconstruction. Ugggggh! Talk about a paternalistic idea that hasn't aged well. We're actually having a related debate on more serious issues. A recent paper suggested that immediate reconstruction with either your own tissue or implants may decrease the beneficial effects of radiation (in patients requiring it) much more then previously suggested. If this hold up under scrutiny (and it may reflect how radiation therapists are failing proper technique more then the reconstruction) it could really decrease the number of women offered immediate reconstruction.

- A number of reconstructive pediatric urologic surgery procedures were still being talked about. This was a field that was really pioneered by early plastic surgeons generations ago. Since 1983 this whole area has really been abandoned by Plastic Surgery and is really almost now exclusively a Urology discipline. The last requirements for familiarity with these operation on our board certification exams were formally removed 2-3 years ago reflecting this

- Most humorously, an editorial by the chairman of an academic program frets about the ability of Plastic Surgery to attract qualified applicants compared to other surgical disciplines like cardiothoracic. That was a real swing and a miss 25 years later! Plastic Surgery is now indisputably the most competitive training pathway in all of medicine in the US while Cardiac Surgery struggles to fill 1/3 of it's training positions with US graduates.

Most striking to me of all changes is the change in editorial tone and professionalism of our flagship journal now versus then. Dr. Rod Rohrich from Dallas has been a tremendous leader in the upgrade in overall quality of articles included. With rare exception, you just don't see really dumb or inane topics thrown in in 2008.

I kid you not, in a Spring 1983 article there's a serious article "Decreased swimming speed following augmentation mammaplasty" and discussion of how breast augmentation theoretically affects the top end speed of a competitive swimmer complete with in depth mathematical hydrodynamic models.

Rob

Silicone-istas going batty over Newsweek breast implant story

If it wasn't so predictable it would be funny.

Newsweek magazine ran a vanilla story about breast implants called "Chest Right" which was an overview safety/educational guide for laypeople on some issues re. breast augmentation surgery. It's a very conservative piece and touches on a few important factors like choosing a qualified surgeon, complications, follow up, silicone vs. saline devices, etc.... It quotes the presidents of the two major Plastic Surgery organizations and one of the more well-known female Plastic Surgeons, all of whom are reputable and all of whom have extensive track records of championing patient safety issues. In summary, a very mainstream and respectful treatment of the issue.

Skip to the reader comments however, and you see breathless condemnation of the story by a number of the crusaders that populate the handful of web bulletin boards promoting the idea that a giant medical-industrial conspiracy exists to hide the truth from unsuspecting women about links of implants to every known medical condition and psychiatric disorder known to man. Readers of Plastic Surgery 101 know that there is pretty overwhelming international consensus that breast implants have been vindicated over and over in this regard in the medical literature (read here).

Now implants have their own issues, namely capsular contracture and surveillance for rupture, but we appear poised to make signifigant progress on these issues with the 5th generation form stable silicone implants seemingly poised for approval. Both the major manufacturers, Allergan & Mentor, have arranged for inservices this spring for their product reps on these devices. To me this suggests they've already heard thru the back channels that FDA approval is imminent and are getting ready for a new marketing push. You'd think with the improved performance data on these devices, the people upset over existing implants would be encouraging the FDA to act. On the contrary they're determined to push the FDA to rescind access to all breast implant devices (silicone and saline).

Rob

Does an Accolate a day keep the capsular contracture away?

Capsular contracture, an exaggerated hardening of the tissue around a foreign body, continues to be one of the most stubborn issues to stomp out with breast augmentation and reconstruction surgery. It's also been one of the most difficult things to study in a way that's useful because of a relative lack of a clear understanding of why it happens.

Forming a capsule is a normal physiologic process. It happens around everything your body doesn't recognize as "self" when it's implanted and is mediated by a well established interaction among signaling proteins on cell surfaces and your bodies immune system cells. When this process goes haywire, you get thickening and shortening of the capsule which can become painful and distort the shape of the breast.

There's a couple things we know clearly cause high rates of hard capsules with breast implants:

• post-operative hematoma


• infection around an implant


• a history of breast irradiation


• older silicone devices (1970's-19080's) with high rates of "gel bleed"


• rupture of silicone implants

What's more complex is trying to "reverse engineer" how to prevent capsules. Suggestions to reduce high grade capsule rates have included:

• textured implant surfaces


• placement of the implant underneath the pectoralis muscle


• polyurethane-coated implants


• antibiotic irrigation of the implants during insertion


• the use of contemporary "4th generation" implants with thicker "low bleed" shells and more cohesive fillers


• saline implants

The data on textured implants and position of the implant relative to the muscle have been somewhat mixed. At this point it's hard to definitively say that either make much difference long-term. Polyurethane foam works very well, but it's use in the US is likely DOA in the long-term due to liability issues over a (now debunked)risk of breast cancer. Antibiotic irrigation works well in the short-term, but it's not clear that it could affect capsular contracture years out from surgery.

It's been very interesting to see the performance of the "5th generation" silicone devices in published studies. These are the "gummy bear" implants which are semi-rigid and textured. Whether it's a synergistic effect or what is not clear, but these implants have dramatically lower rates of capsular issues almost a decade out. These devices appear to offer an improved solution to capsular (and rupture) issues and hopefully the FDA will give the green light sometime in 2008 for their US debut.

So what else do we have to offer?

There's a class of drugs used to treat asthma called leukotriene inhibitors (LTI) that has shown some promise in prevention or treatment. The two most common LTI's are Accolate and Singulair. Accolate has a small potential for liver problems and has mostly been avoided in favor of Singulair. Singulair was in the news as it's been alleged to cause suicidal ideation by people suing Merck. (How you prove a negative here is anyone's guess, but call me the skeptic.)

Anyway the genesis of this post was a study I saw in a European journal showing dramatic inhibition of capsule thickening in an animal model using zafirlukast (aka Accolate) which you can see view here). This is the first basic science model I've seen actually showing this idea of LTI's can work. This information gives us another option to discuss in the high risk capsule former which is good!

Rob

VA Voodoo Economics - Krugman wrong on John McCain

A few months ago I introduced some of the audience to the idea of "VA (Veteran's Administration System)logic". VA logic is the bizarre culture that has crept into the bureaucracy of the VA system that lead doctors who have trained or work in the VAMC system to shake their head when the system is held up as some paragon of universal health care.

While the VA system has America's only comprehensive electronic medical record system (which is a great thing), it has the world's most effective system of "nurses with clipboards" (NWC), non-clinical personal who walk around nagging everyone and serving little utility. Ironically, it's many VA employee's goal to be promoted to NWC/supervisor status because they get pay raises for doing less work then actually taking care of patients.

The VA system is much better benefits then no insurance at all or medicaid, but offers much less choice of providers or locations then a federal program like medicare. Veterans' reactions to the VA are very polarized in my experience. Some are very emotionally attached to the system, while others are resentful of the inconvenience of having to travel great distances and then having to suffer thru puzzling bureaucracy for appointments, consults, and surgery. My grandfather-in-law, a multiple purple heart & bronze star veteran from Iwo Jima & Guadalcanal in WW II, refuses to set foot in the VA even for free prescription benefits he'd be eligible for.

It is puzzling to imagine how building some parallel healthcare universe like the VA system is either cost-effective or sustainable. There already exists enough capacity in the "civilian" system to accommodate veterans without having to federally subsidize each and every VA hospital, clinic, & pharmacy. The federal benefits we're also covering for VA employees are also often much more generous then regular health systems.

I got thinking about this after reading the world's worst syndicated columnist, New York Times liberal Paul Krugman's column on "Voodoo Health Economics". Reading Paul Krugman columns regularly is like subjecting yourself to the cesspool of the Daily Kos (which I used to like BTW). Both have become so hyper-polarized with ideology they've ceased to be relevant.

He writes

As I’ve mentioned in past columns, the Veterans Health Administration is one of the few clear American success stories in the struggle to contain health care costs. Since it was reformed during the Clinton years, the V.A. has used the fact that it’s an integrated system — a system that takes long-term responsibility for its clients’ health — to deliver an impressive combination of high-quality care and low costs. It has also taken the lead in the use of information technology, which has both saved money and reduced medical errors.

Sure enough, Mr. McCain wants to privatize and, in effect, dismantle the V.A. Naturally, this destructive agenda comes wrapped in the flag: “America’s veterans have fought for our freedom,” says the McCain Web site. “We should give them freedom to choose to carry their V.A. dollars to a provider that gives them the timely care at high quality and in the best location.”

That’s a recipe for having healthy veterans drop out of the system, undermining its integrated nature and draining away resources.

I'd first like to offer a squid like Mr. Krugman the middle finger for disrespecting a man like John McCain.

On substance I could not agree more with Sen. McCain. We should be offering vets more flexibility rather then herding them into the VA system. How do you do that? You simply make them preferred Medicare enrollees which instantly give them access to any hospital (and potentially 90-95% of providers) they want. How do you guarantee the vets access? You sweeten the payment for this class of beneficiaries 3-5% above medicare rates or offer tax rebates for their care. Even that slim margin would start tremendous competition to serve that group. If vets are as happy with the VA as Krugman suggests, he should have to little to fear from offering them choice in the private sector, he's supposed to be an economist for chrizsake!

If Mr. Krugman was as savvy as he thought, he'd be encouraging something like this because Medicare is the front & back door towards the Universal Health Care system he's always ranting about. The more people enrolled, the greater the momentum it gets.

Rob

A big (non) decision by the Supreme Court with huge universal health care implications

A nerdy public policy-wonk post today!

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


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

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

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


Rob

Anesthesia related death during plastic surgery

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

'Tis the season for - Chocolate Bunny Melting

Happy Easter from Plastic Surgery 101!

Courtesy of YouTube, some stylish chocolate bunny immolation. You know, artsy types are just different then the rest of us!





Cheers!
Rob

Do Americans want fee for service medicine?

There's an article on Salon.com about health kiosks in places like Walgreen's and Wal-Mart called "Wal-Mart can be good for your health!".

This is a hot topic in medicine as it gets into a number of hot topics

• Who will own these clinics? (doctors or industry)




• Who will staff & oversee these?




• What affect will this have on continuity of care?




• What affect will this have on the financial sustainability of medical practices when routine patient visits are siphoned off to these clinics?

One theme that jumps out at me, particularly when you read the reader comments section to the article, is that people are schizophrenic when they think about this (ie. Is medicine a business or nonprofit public utility?) and look at this from a completely different perspective than health care providers.

A number of complaints arise which basically boil down to that "the competition these clinics provide against doctor's office visits will be good and result in better service". This pretends that medicine is some true market economy rather then a corporate & federally-rigged game of Jenga. The winner of this "competition" gets the privledge of working much harder for much less money for much more aggrevation.

If you want to send a primary care doctor thru the roof, complain about having to pay a co-pay for and office visit and about not being able to be seen at a moment's notice. There's little understanding (or sympathy) for exactly how much our system is squeezing physicians to achieve savings in our health care system.

Particularly offensive to me is a Minnesota internet start up company I read about called CAROL, whose business model is essentially to try and turn medicine into Priceline.com

“We want to let consumers define value,” said Tony Miller, Carol’s founder and chief executive. “We don’t have care competition in the marketplace today.”The free site, which went live in January, generates revenue from health-care providers who become “tenants” on the site. When a consumer sets up an appointment with a clinic or doctor on Carol.com, the provider pays the site a fee.

Great! We were missing one more layer of capitalists strip mining the health care system.

Rob

Dumb laws and smart laws re. plastic surgery

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

The charity business as (un)usual - Operation Smile

There's a nice story on featuring Operation Smile in the New York Time's magazine. Operation Smile is an organization that organizes and performs cleft lip and palate surgery in developing countries. The story is not really about the altruism of Operation Smile, but rather it focuses on how it became an effective organization only after operating more like a business and less like a traditional charity.


3rd world missions by plastic surgeons, where a team flys in for a few days, does a lot of pediatric plastic surgery (cleft lip/palate) and leaves would seem like a hard thing to be criticized, but it has been increasingly done. The appropriateness of these kinds of surgeries performed by surgeons who didn't do them in their state side practice and by loosely-supervised residents (as was often the case on these trips) has been questioned for years. Groups like operation smile have addressed this, and require active practices in pediatric plastic surgery among volunteers. More importantly IMO has been the change in philosophy to where we're now increasingly training local physicians in these countries to do simple and reproducible operations to correct these defects recognizing the limitations of resources they may face in terms of speech therapy and orthodontics post operatively.


Rob

Wall Street Journal on SmartLipo - I scooped 'em!

A visitor to the site pointed out to me that today's Wall Street Journal also featured a profile of Cynosure's SmartLipo platform highlighting some of the same thoughts I had in my post yesterday.

If you're interested, you can read it here.

Plastic Surgery 101 - Iceland's most popular plastic surgery blog :)

I'm constantly amazed at the ability of the internet to put like minded people in touch from around the world. I can still remember the thrill I got from Napster's heyday where I was able to communicate in real time with fans of artists I liked (Richard Thompson, Bruce Cockburn, Chris Whitley, among others) around the world.

While I may only be the 281st most popular health care blog this week according to Healthcare100.com (I demand a recount!) , like many under appreciated rock bands I'm now "big in Europe". I'd like to give a shout out to American ex-pat, Ms. Erika Wolfe, who took the time to send some beautiful postcards from her adopted home in Kopavogur, Iceland telling me how much she enjoys Plastic Surgery 101. I wish I had some "PS 101 brand" swag I could mail you back! My Icelandic is kind of "rusty" but via the magic of web-translator programs - Ericka, þakka þú fyrir the póstkort

Ericka sent me stunning images from:

Waterfall Dettifoss, north Iceland

Iceland's famous "Blue Lagoon"

Rob

Is SmartLipo a smart choice for you liposuction? I'm sticking with "dumb lipo" (for now)

I had the chance to go to an educational event last month put on by Cynosure, manufacturers of the "SmartLipo" platform for body-contouring. Cynosure is a well respected company and has manufactured generally well designed laser platforms. SmartLipo's gimmick is to place a pulsed laser (a 1064nm Nd:YAG for tech geeks in the audience) on a fiber optic cable which is used like a liposuction cannula. The theory is that the laser's energy disrupts and emulsifies fat cells, thereby eliminating or reducing the need for conventional suction assisted lipectomy (SAL). Also promoted is enhanced skin contracture from the thermal energy adjacent to the skin.

I've got to say I was a little unimpressed with the results shown from this device with body contouring procedures. It just didn't produce dramatic results. The presenting doctor in this instance was an ENT surgeon, which I think may have something to do with this. Much like many pictures shown by Dermatologists who do liposuction, there sometimes seem to be an ignorance or indifference to the skin quality and underlying anatomy of patients. (in fairness, many plastic surgeons are guilty of this too.) So picture after picture gets shown of people with undercorrection of significantly fatty areas and lots of residual loose skin in patients who were poor candidates for SAL, SmartLipo, Ultrasonic Liposuction, VASER, etc.... in the first place.

When you read industry publications quoting paid investigators & consultants who are "hanging crepe" about patient selection and expectations, that's usually a code word to me it works best on people who arguably need surgery the least. That's what the expectations had been dumbed down to with the "thread lift" fiasco in 2005-2007 (see here for one of my first blog entries on it).

To get results with SmartLipo, you're still going to have to do traditional liposuction afterwards, begging the question of whether a $100K-120K laser platform that can't be used for other indications makes any sense. It may also be effective for small touch up liposuction cases, but that's an awfully flawed business plan for a doctor assuming that much overhead.

I did see some nice results with SmartLipo when used in the neck/face, and it makes sense that it would work better in those area. If you've got thin fatty layers (like in the neck/face), you may indeed be able to treat that and get skin improvement. Complicating my assessment was the fact that many of those patients had face or neck life surgery simultaneous, which makes it hard to sort the skill of the surgeon's techniques from any effect of the laser. Facial and neck procedures might be the better group for this, but blindly applying high thermal energy to tissue adjacent to nerves and the carotid artery could potentially result in catastrophic complications.

In a nutshell, there may be some applications for this technology but presently I still feel it's more of a marketing tool then revolutionary device.

Rob

Trial lawyers' ability to second guess the FDA on medical devices "neutered"

The US Supreme Court (SCOTUS) has dramatically shifted the balance of power in product liability lawsuits for makers of medical devices. By an 8-1 margin last week, the Justices decided that the tort system should not be a system that second guesses the scientific evaluations of the FDA on medical device designs. In the "Riegel Case", the Supreme Court concluded that the premarket approval process (PMA) would bar patients from later filing lawsuits.

This week they're hearing similar arguments over pharmaceuticals in Warner-Lambert v. Kent , a case from Michigan, click here to read about. The case was brought by plaintiffs who claim they were injured as a result of taking the diabetes pill, Rezulin, which has since been withdrawn from the US market. The plaintiffs claim the company withheld evidence from the F.D.A. of potential dangers to the liver that might have led the agency to deny an approval. They fighting against existing precedent from a 2001 case where the Supreme Court held that plaintiffs cannot sue based upon claims that a manufacturer defrauded the F.D.A.

While no one would reward fraud by industry, this claim has exploded by trial lawyers in all these cases and frequently comes down to statistical hair-splitting of published data rather then some "smoking gun" company memo. Even liberal jurist Steven Breyer has expressed frustration and skepticism of using state or federal courts to "retry" the FDA approval process before people unqualified to understand or interpret most of the studies and data that will be argued over. He posed the rhetorical question of who should be the arbiter of product safety during oral arguments yesterday,

An expert agency (the FDA) on the one hand or 12 people pulled randomly for a jury role who see before them only the people whom the drug hurt and don’t see those who need the drug to cure them?

This whole debate relates a little to the whole breast implant controversy from two decades ago where trial lawyers pulled off a multi-billion dollar shakedown of Dow Corning and others based on innuendo. We now have compelling safety studies from all over the world and universal treatment of these products by every western government health agency. It would appear these recent SCOTUS decisions would put the final stake in product liability cases relating to approved breast implant designs or materials. It's a little moot anyway, as trial lawyers largely haven't taken implant cases for years anyway as they're aware of the consensus body of of literature and know there's no money in it.

Rob

The ghost of "Bond Girls" past - What you can learn from Britt Eklund's aging face

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

Bedsores and surgery - an exercise in futility?

A little blurb in today's New York Times "Fighting Bedsores With a Team Approach" got me thinking about pressure sores

In the Plastic Surgery and wound care literature there are literally thousands of papers published re. to the surgical treatment of pressure sores ulcers. Many very elegant operations where soft tissue and muscle flaps are rotated to cover these wounds have been described.

These ulcers add an estimated burden nearly $10 Billion USD of expenditures and an additional 2.2 million Medicare hospital days to the United States healthcare system. The cost of treatment of large ulcers can approach nearly $50,000, depending on the stage of development. For reconstructive surgery candidates, costs might be an additional $25,000+ per patient in surgical charges. The actual costs of preventing and treating pressure ulcers in hospitals are not easy to figure as costs are distributed across many providers and settings for nursing and clinical care, but the likely overall costs are stunning, with perhaps 5% or more of our total healthcare costs attributable in some way to patient care involved with these wounds.



What's the dirty secret about these wounds?

Almost all approaches besides letting these wounds heal by scarring (secondary intention) have abysmal track records. Data from medicare patients and from the VAMC have suggested that in excess of 90% of these reoccur within a year. When you consider the tremendous expense of these surgeries and post-operative convalescence, you have to wonder why we've treated these the way we have. Increasingly, you're seeing more plastic surgeons no longer attempt such aggressive closures which is evidence-based medicine at work.

If you are going to try to close these wounds, you've got to pick your spots. The only people I consider good candidates for closure are high functioning young paraplegics and o