Thursday, August 31, 2006

Tattoos have officially jumped the shark & the "tramp stamp" video

New York Times columnist, David Brooks, published a column this weekend commenting on how have "jumped the shark" in pop culture. There's already some grumbling in the blogosphere here & here (among other places) painting Brooks as both 1) an old fuddy-dutty & 2) a little late to the party with his column.

Tattoo removal is a small part of a lot of
and practices that do a lot of laser surgery. Different color inks are best treated with different types of (eg. CO2, Erbium, Argon, etc..) which react with characteristics of the different pigments. By and large, a lot of the treatments are unsatisfactory to me. They're both painful & often incomplete. In addition, many of the colors being added to modern tattoos are poorly treated with current laser & intense pulsed light technologies.

The popularity of tattoos in recent years has bothered me a little as most people who've ever worked in a Veteran's Administration (VA) hospital can tell you the fate of many of these after several decades from treating WWII & Korean war vets, peer groups in whom tattoos seem to have been popular.

What exactly are people expecting to look like with barbed-wire or large tribal designs 20-30 years from now? They're going to look ridiculous. An amusing associated issue are a large number of Asian alphabet tattoos with gibberish or mistranslations coming in for removal. Story on this here.

Perhaps the one I think most will regret are the lower back tattoos on many young ladies. Alternately known as the "tramp stamp", ass antlers, California/Santa Cruz/Tijuana license tags, the "Hag Tag", or the "Panama City bumper sticker" this kind of 'ink has already been the butt (I could not resist that one) of a lot of jokes.

New Rule from Real Time with Bill Maher:
Just because your tattoo has Chinese characters in it doesn't make you spiritual. It's right above the crack of your ass. And it translates to "beef with broccoli." The last time you did anything spiritual, you were praying to God you weren't pregnant. You're not spiritual. You're just high.
In the film, Wedding Crashers, the character Jeremy Grey (Vince Vaughn), upon seeing a lower back tattoo, exclaims, "Tattoo on the lower back... might as well be a bullseye."

There's a hilarious commercial skit from a few years ago about a home treatment product, Turlington's Lower Back Tattoo Remover, for suburban moms with racy tattoos back tatoos. A product that promised "when applied once, every hour, for 72 straight hours," slowly burns away unwanted lower back tattoos. "That tingling means it's working!Turlington's Lower Back Tattoo Remover - Because it won't be cool forever..."

Here's a link for your viewing pleasure


Monday, August 28, 2006

Christopher Hitchens - American Hero (via the U.K.)

Now for something completely removed from Plastic Surgery........

An amazing ten minutes of television was on Real Time with Bill Maher on HBO over the weekend. Vanity Fair columnist, Christopher Hitchens, was a panelist on the show in an incendiary and brilliant segment. For those of you not familiar with the 'Hitch, he is a witty & sardonic British ex-pat who is the ultimate contrarian. He's also my hero and someone you never want to miss when he's on TV.

In the span of ten minutes he silences both Bill Maher & the left-leaning audience with a searing dismissal of pavlovian responses to our President and the fight against the rise of Islamic fascism. He was truly a shark among minnows in the intellectual firepower department as well as also managing to give them the finger (see picture above) in a devastatingly effective way.

The video can be downloaded here.

I'd like to thank The Malcontent blog for the video capture.

Now back to our regularly scheduled programming!



Sunday, August 27, 2006

Heavy handed comments by Aussie politician on teen Plastic Surgery procedures

New South Wales, state Premier Morris Iemma is quoted in today's Sunday Telegraph newspaper that he feels the number of people under 18 seeking enhancements has gotten out of hand.

What set this off? One, ,(pictured above). The article reports that Premier Iemma became "disturbed" when he learned that the teenaged Forscutt, a contestant on the program Big Brother, had had breast implants. Now Iemama has been inspired to introduce new laws requiring teenagers to get a referral from their doctor, have a "cooling off" period prior to surgery, and undergo counseling before receiving . Iemma's full editorial can be read here..
"It used to be the case that the biggest question parents faced was whether to give their children permission to have their ears pierced," Iemma told the paper.

"Then it was tattoos. But, increasingly, parents are being asked to fund breast implants or a nose job as birthday or graduation gifts," he added.

Ms Forscutt, who was 19 when she appeared on Big Brother, said she supported Mr Iemma's proposal for counseling under-18s. "It is a minute part of who I am. I'm more than just a pair of fake tits,'' the now 20-year-old said.

This is a pretty reactionary step without much data behind it that there indeed exists a problem to address in the first place. While some reasonable parental requirements for surgery consent in minors (much like American laws) exist, mandating a primary care doctor's "referral" for psychiatric counseling strikes me as both paternalistic and offensive.

Former Australian Society of Plastic Surgeons president Norm Olbourne said teen surgery is rare (at least in re. to breast augmentation) and that "there are the groups of girls wanting breast enlargements, although I've never seen a girl under 18 wanting one who didn't come in holding her mother's hand". Blanket responses like Iemma's give short shrift to many of the psychological consequences adolescents face when they possess particularly large, small, or deformed breasts, noses, and ears.

Saturday, August 26, 2006

UK feature misses the point re. breast implant sizes

This article in the London Daily Mail describes a scenario that is a failure of both doctor & patient education.

In a breezy feauture on sisters with "identical boob jobs" a 39 year old, 'Louise' is described as gleefully going from a 36B to a 36DD after augmentation. Louise describes her sensitivity over years of teasing by her friends and after deciding on surgery says "I decided to go for a 36DD - perfect for my frame - with silicone implants. I'm 5ft 6in and a size 12". It sounds like Louise has internalized an image common among breast augmentation candidates that the "average" womens breasts are larger then they are.

Bad idea. You can not achieve that increase from a B cup to a DD cup without aggresively violating her native breast boundry and placing 500-600cc implants. There is NO way that her tissue is going to support that for long. She's going to end up with knockers to her to her knees in 3-5 years with a difficult reoperative surgery required if she wishes something to resemble an aesthetic breast shape.


Wednesday, August 23, 2006

Bariatric surgery in the adolescent population

Very poignant article at Slate Magazine about one of the new frontiers in bariatric (weight loss) surgeries which pose the question, how young is too young to consider or for treating obesity?

This comes on the heels of the studies in the Annals of Medicine & the Journal of the American Medical Association which showed significantly shortened lifespan related to complications of obesity when it develops in teenagers. This difference appears to be far more significant the the already formidable problems we see in obesity with later onset.

The exploration of indications for operating on teens is one we've had publicly in for many years. Most often this has to do with the question of when is an appropriate age to consider , but increasingly there has been reports on a trend where teens are receiving rhinoplasties or as "graduation gifts".

I won't dwell on the specific of the story but some of the risk/benefit analysis is a very good read. As someone who did a lot of bariatric surgery during my general surgery training & has an active practice in post massive weight loss Plastic Surgery, I feel the benefits strongly exceed the risks. There is a real opportunity to nip life-threatening obesity in the bud in selected children who statistically have little real hope of controlling their weight on their own once they reach that age.

Also, I'd like to point people with an interest in weight loss surgery to a neat little community, Renewed Reflections, which is a forum for information & support for those considering or those who've had bariatric surgery.

Tuesday, August 22, 2006

ENT (ear,nose, & thighlifts?) nailed by California for playing Plastic Surgeon

As if some people really doubted my earlier blog entry on ENT doctors and others who were performing procedures arguably well outside the scope of their training.

An Irvin,California ENT (head & neck trained)surgeon was sanctioned by the California Medical Board in July for not telling a patient before performing a thigh-lift procedure that he was trained in ear, nose and throat surgery. The doctor was also cited for allegedly failing to appropriately treat the post-surgical wound complications and for not keeping accurate medical records. This episode is noted in the July report by the California Medical Association.

Performing complex body contouring procedures without the proper training documented is going to be hard to defend in court, even if the Physician in question has performed them before. Plastic Surgeons do not delight in these kind of public displays of bad judgement by other providers, as it's clear that the the public unfortunately does not largely understand the distinction between us and other medical specialties when it comes cosmetic surgery.


Thursday, August 17, 2006

Some bad news about cellulite and weight loss

A study published in August's Plastic & Reconstructive Surgery seems to put to bed one of the myths about cellulite and it's relationship to your weight. In summary, as you gain weight the appearance of cellulite will worsen but losing weight will not necessarily improve the appearance.

John Kitzmiller, a plastic surgeon and co-author on the study, said: "Cellulite is not specific to overweight people but excess weight may worsen the condition. Although the appearance of cellulite diminished for the majority of patients, weight loss did not totally eradicate the condition. The dimples appear to be permanent features that lessen in depth as the pounds come off."

This is really old news to some extent and highlights the two mechanisms we usually have to explain cellulite.

1. Cellulite is produced as cells of fat get bigger & stretch against and distort some of the connective tissue boundaries if adjacent tissue. This is why we think you get cellulite from weight gain (ie. the distortion causes the surface irregularities).

2. Cellulite is produced from relaxation and descent with resulting traction of connective tissue fibers that normally run perpendicular to the skin. This is the cellulite that you see on some very thin women and those who've lost large amounts of weight. You can witness this phenomena by watching the cellulite disappear or exaggerate depending upon one's position. In the massive weight loss group after gastric bypass or banding, the connective tissue is severely attenuated and ripples despite the fat collections often being deflated.


Wednesday, August 16, 2006

Breast Implant deflects Hizbollah rocket shrapnel

Quick hitter for today:

From the Reuters news wire today: An Israeli woman's breast implants saved her life when she was wounded in a Hizbollah rocket attack during Israel's war with the Lebanese group, a hospital spokesman said Tuesday.

Doctors found shrapnel embedded in the silicone implants, just inches from the 24-year-old's heart.

"She was saved from death," said a spokesman for Nahariya Hospital in northern Israel. The woman has been released from hospital.

Tuesday, August 15, 2006

Asian Plastic Surgey patients adopting western tastes for breast implants

There are international stereotypes relating to breast augmentation.
Americans like the breast big and the butt small.

Brazilians like the breast small and the butt big

Europeans like somewhere in between.

What about Asia? Well traditionally they weren't even part of the discussion as breast augmenatation was fairly limited outside of Japan. As the economies of Asia & Southeast Asia have grown, the #'s of elective cosmetic surgery procedures has been growing at a staggering rate.

For decades, the Chinese government forbade cosmetic surgery, seeing it as a reflection of despised western values. Only 20 years ago, plastic surgery expertise was restricted to a small number of doctors specializing in traumatic and cancer reconstructive surgeries. According to figures from the PRC government, at present the Chinese now spend 2.4 billion USD a year(!) on cosmetic surgery, with an estimated 1 million operations performed a year. The Japanese spend over 2 trillion yen (18.7 billion USD) on cosmetic surgery each year. South Korea's Seoul is now home to over 2,000 private clinics, with surveys suggesting that at least 50 percent of Korean women in their twenties have experienced some form of plastic surgery -- an estimate some call conservative. (The bulk of the proceding paragraph came from this article in Zee News)

As the average Asian woman is smaller in frame then those of western Euorpean, African, or Latin descent the sizes of implants were naturally somewhat smaller. However, as the tastes & expectations of the west are permeating the east via media and pop culture, trends in cosmetic surgery are also reflecting the American ideal.

At the plastic surgery clinic BARAM in South Korea surgeons say the size of breast implants has doubled from 135 cc on average in 1994 to 265 cc in 2003. BARAM clinic chief Sim Hyung-bo points out the obvious that “One way to tell augmented breasts with the naked eye is that it is safe to say that skinny women with very large breasts probably had them enlarged. It is true that Koreans’ physique has changed remarkably over the years, but their breasts are still smaller than those of Westerners.”

135 cc implants! Those aren't even commercially available in the United States & Europe except by special order. A survey a few years back in one of the Plastic Surgery trades had the average size of implant somewhere around 350cc. Discussions between Plastic Surgeons would seem to indicate that the "average" augmentation in some peoples practices has crept up over the 400-425cc range.

For a related post on implant sizes & the consequences thereof see"How big is too big?"


Friday, August 11, 2006

People who've made a difference part I - Dr. G. Patrick Maxwell

I'd like to start occassionally write some public thank you notes to people (outside my family)who helped me become the doctor (and person) I've become.

I'm going to start with Dr. G. Patrick Maxwell of Nashville,Tennessee. Among Plastic Surgeons there are a few whose skills and educational endeavors set them apart from the rest of us. Pat Maxwell is one of those surgeons. For over a quarter century his contributions to breast reconstruction and cosmetic surgery have made him a sought out visiting professor at meetings and training programs around the world.

I had the pleasure of serving as Dr. Maxwell's fellow in 2005 and I still look back and marvel at some of the technical and artistic refinments on some of the most complex cases you will ever see. To many Plastic Surgeons, Pat is arguably the best in the world at reoperative breast surgeries, one of the areas that most Plastic Surgeons find to be very difficult to get predictable results. Patients come from all over the country to be evaluated and operated in Nashville, TN of all places.

In 2005, Dr. Maxwell helped establish the excellent Inamed Academy series of educational symposiums that are held preceding many of our major meetings. With the pending reintroduction of silicone implants for primary cosmetic indications, expect to see Pat as the frontman in many of the educational programs that will be required for surgeons to be educated in prior to using these devices. We can also (hopefully) expect the availability of the revolutionary Inamed 410high-cohesive gel implant (the "Gummy Bear" implant) next year, a device that was in part developed by Dr. Maxwell.

Thank you Pat!

patrick maxwell.

Thursday, August 10, 2006

I've now seen it all - pubic trimming templates

I don't know why this surprises me, but Sazzi Designs (U.K.) now offers pubic hair "training wheels" for those not simply satisfied with "mainstream" pubic hair grooming styles.

Just in time for a Christmas stocking stuffer :)

For an in depth discussion on some of the particulars of lawn maintainence, I'd direct you to the delightful The Beauty Brains blog which highlights all kinds of interesting products like the "famous" Coochy After Shave Protection. Who can resist finding out what that's about? Not me!

Tuesday, August 08, 2006

A monster in Munster... (a very painful Plastic Surgery pun indeed)

I bet most of you did not now that the moniker for Otolayngolgy (Head & Neck Surgery), "ENT" no longer stood for Ear, Nose, and Throat. Somehow along the way it's turned into "ear, nose, and tummy-tucks" as otolaryngologists have sometimes ventured into cosmetic surgery below the neckline.

As insurance reimbursement for their traditional procedures have diminished, they (like a number of other physicians) have decided to reinvent themselves as Plastic Surgeons. A number of years ago the discipline of "Facial Plastic Surgery" was created. The title was chosen somewhat deliberately to confuse patients & restricting the use of this was unsuccessfully litigated at the time by the Plastic Surgery societies (the courts in that decision would not grant a copyright for the term plastic surgeon).

Sometimes the grass isn't always greener as in this story here, from Muncie, Indiana. In this episode an ENT and the medical center which gave him operating privledges are being sued for over $1 million after complications from a breast surgery. The suit says Dr. Jung-Il Park posed as a certified cosmetic and reconstructive surgeon at St. Margaret Mercy Healthcare Systems, but instead is a certified ENT. I don't know the specifics of this case, but it sure sounds like they better get their checkbooks out, as this is going to be extremely hard to explain to a jury.

Most Plastic Surgeons do not begrudge our ENT colleagues who practice plastic surgery-type procedures of the head & neck. Raised eyebrows, groans, and criticism do however follow when ENT's, Dentists/Oral Surgeons, and others start performing procedures many would argue they are undertrained to perform.


Saturday, August 05, 2006

Back alley liposuction death

In a story from near Boston that echoes a number of cases from immigrant communities, Fabiola DePaula, 24, died after respiratory arrest on July 30 after a Brazilian couple, unlicensed to practice medicine, gave her liposuction on a massage table in their basement. The Brazilian couple who performed the fatal liposuction on DePaula ran an underground ring, charging people around $3,000 relying on word-of-mouth referrals among Latino immigrants. The "surgeon", Luiz Carlos
Ribeiro, claims to be a licensed doctor in Brazil, and that he and his wife had come up to Framingham on a 30-day work visa just to perform the surgeries in the basement of the Framingham apartment complex.

In a sick display of hypocrisy,in a yet-to-be-broadcast interview recorded the week prior with Brazilian community leader Ilma Paixao, she said Ribeiro spoke of the risks, the procedures and the precautions people needed to follow before undergoing cosmetic surgeries. I guess the topic of operating in a basement under non-sterile conditions never came up!

I have to assume this was a scenario where the patient was over-sedated during conscious sedation anesthesia with a benzodiazepene-class drug (like Valium or Versed) and lost their airway (as there likely was no emergency airway equipment present. Other issues that can happen in the peri-operative period are fluid overload, toxicity from the local anesthetic (usually Lidocaine), and perforation of the abdominal wall with underlying bowel injury. Unlike respiratory failure, these other things present hours or even days later (in the case of bowel perforation).

This highlights several issues.

1. Black-market Plastic Surgery continues to flourish in immigrant communities. There have been a lot of issues in Florida, Texas, and California with major complications.

2. Liposuction IS real surgery and should be treated as such and should ideally be performed by surgical specialists.

3. The safety of surgery done outside the hospital or ambulatory surgery center is an issue that will continued to be debated. In 2000, an anonymous survey of Plastic Surgeons reported that for every 5,000 liposuction procedures from 1994 to 1998, one patient died - 95 in all. Among the causes were blood clots, anesthesia problems and internal injuries after the liposuction procedure. These are only the ones we know about. Throw in thousands of practicioners doing office based surgery who are under no obligation to report any complications and you can assume the true number was much higher for that period.

The American Society of Plastic Surgery has been the clear leader in responding to this data. Some practice guidelines were issued in 2004 and can be found here. There has been a tremendous amount of time and money spent educating surgeons about how to perform this procedure more safely for the patient. Many thanks go out to some of our leadership on this by Drs. Rod Rohrich and Jeff Kenkel (from the University of Texas-Southwestern), Dr. Peter Fodor, Drs. Patrick Maxwell & Mary Gingrass (from Nashville), and many others.

I think in some future post I'll wax poetic on some of these safety issues and the politics of office-based surgery.


Plastic Surgery