Saturday, September 30, 2006

Iran - nose job capital of the world?

Who would believe it, but according to the BBC one thing we share we apparently share with Iran is a growing appetite for cosmetic surgery. In Tehran alone, there are a reported 3000 Physicians practicing plastic surgery procedures.

An interesting cultural angle on this is the large #'s of women undergoing rhinoplasty. As the nose and the eyes are the only facial features displayed in traditional women's Islamic garb, these women are determined to make sure what show looks good. The traditional Iranian ethnic nose has fallen out of favor it seems as the influence of Western pop culture has invaded Iran via satellite TV.

Here a link to a CBS news story on this rhinoplasty phenomena

Sunday, September 24, 2006

Desperate measures by anti-implant lobby

Predictably as we prepare for the long overdue reintroducing of silicone breast implants, there's a final desperate attempt to do an end run around overwhelming scientific and medical evidence.

In the irony of ironies, a bill was introduced by Connecticut Democrat, Rosa DeLauro which ties claims of political interference delaying release OTC emergency contraception pills with a call for political interference to delay the reclassification of silicone implants from investigational status. For a summary of the major studies on silicone breast implants read this.

First the widely discredited issue re. platinum in implants was dug up from the grave (see here) in their press release:
"FDA decisions surrounding silicone breast implants have also been subject to industry pressures, according to the National Organization for Women (NOW). Women with breast implants have higher rates of hazardous levels of an oxidized form of platinum in hair, urine, blood, and breast milk samples. Some women were unaware of these risks, and made their children sick after breast feeding."

Even more ridiculous and echoing the bizarre testimony at several FDA hearings was the presence of someone at the press conference who claimed silicone implants both caused his wife to commit suicide & blamed breast-feeding for his daughters health problems(!).
"My wife, P.J., breast-fed two of our daughters after getting implants. Both are seriously ill," said Ed Brent during the press briefing. "My daughter Catherine is now in a wheelchair. In addition, five major studies, including one by National Cancer Institute, found that women with implants are more likely to commit suicide than other women. After my wife killed herself, the autopsy showed that she had platinum in her brain tissue, which a CDC scientist said could have influenced her decision. That's why the FDA needs to make sure that the implants being sold now are safe for long-term use, meaning ten years or more."

The findings that breast augmentation patients in some European studies have had slightly higher suicide rates is long been known (This has not been reproduced in North American series which have compared implant patients to all cosmetic surgery patients BTW). No one plausibly argues that implants cause suicidal ideations, but rather it correlates to a higher incidence of psychiatric disorders and depression among the self-selected group seeking cosmetic surgery. The issue re. to breast feeding has also long been settled to the medical community at large.


Wednesday, September 20, 2006

World's 1st penis transplant - "On again, off again!"

I missed the announcement of this tabloid-esq Plastic Surgery first, but some Plastic Surgeons performed the world's first penis transplant in China recently. The man had the surgery in Guangzhou, China after his own penis was damaged beyond repair in an accident this year, leaving him with a 1cm stump with which he was unable to urinate or have sexual intercourse. Surgeons at Guangzhou General Hospital said it took 15 hours of microsurgery on the unidentified 44-year-old man to attach the 4-inch organ donated by the family of a younger brain-dead patient.

The surgery itself went without problems which is not surprising. The techniques of microsurgical & urologic surgery used are well-established & have been used to reattach a number of traumatic amputations (eg. John Wayne Bobbit from a few years back). After 10 days, tests revealed the organ had a rich blood supply and the man could urinate normally. This is a truly remarkable achievement to get such brisk return of function IMO.

Much like the face and hand transplants done prior, the real problems with these procedures are

1. How can the morbidity of the immunosuppressive be reduced to justify more widespread use? Our current immunosuppresive therapy has advanced tremendously, but we still require patients to take expensive drugs indefinitely which predispose them to opportunistic infections and cancers.

2. Are we as a society prepared to pay for these VERY expensive transplant scenarios when the healthcare system is going bankrupt?

3. How well are these transplanted organs going to function & what are we going to consider a success?

4. Who is a qualified candiate psychologically to receive part of another human?

It's this last point that has reared it's head again with this patient. Surgeons had to remove the penis after just two weeks. "Because of a severe psychological problem of the recipient and his wife, the transplanted penis regretfully had to be cut off," Dr Hu (the surgeon who performed the procedure) said.


This once again show a breakdown in patient screening that plagued the first hand & partial face transplant patients performed by Dr. Jean-Michel Dubernard in France. The desire for publicity runs ahead of measures to allow true "informed consent" to patients.


Sunday, September 17, 2006

Tracking outbreaks of unusual breast augmentation infections

An interesting study of microbial forensics was published about surgical wound infections caused by an unusual and rapidly growing mycobacterium (seen at right) developed in 15 women after breast augmentation. Using sophisticated DNA sequencing, the outbreak was traced back to a single surgeon operating at an outpatient surgery center.

Identical strains of mycobacterium were grown from the infected wounds of the patients; from the eyebrows, hair, face, nose, ears, and groin of this particular surgeon. What's also interesting was the infection was also thriving in the surgeon's outdoor whirlpool. As this strain of mycobacterium was somewhat distinct from common strains, the authors have proposed "Mycobacterium jacuzzii", which I think that's some kind of inside nerd joke :)

When "Typhoid Hairy" discontinued his use of the whirlpool and began cleaning the hairy areas of his body with a shampoo containing triclosan, the outbreak ended.

Clinical infections with breast implant surgery are very low, usually cited as <1%. Routine procedure would include an antimicrobial skin prep as well as a dose of antibiotics prior to surgery. Subclinical bacterial contamination has been suspected (though not proved) to be the cause of many cases of capsular contracture (hardening of the breast)as it seems that irrigation of the pocket around the implant with triple antibiotic solutions seem to be effective in reducing (but not eliminating) capsular contracture.

Physician to patient infections can occur in many scenarios. Hand washing and gowns in particular have received a lot of attention in recent years. A number of outbreaks have been traced to one person. Often this has been MRSA which can asymptomatically colonize people, most commonly harboring quietly in their nasal passage. Just this week I diagnosed and started treatment on a nurse who was having outbreaks of MRSA boils break out on her frequently. One of the most heart-breaking stories has been the outbreak of infections in neonatal ICU's & nurseries attributed to infections harbored under nurses fingernails.

From an article on Sign on San Diego discussing this:
Studies offer mounting evidence that long nails or those that are bonded with cosmetic acrylic or plastic material can shelter bacteria, viruses or fungi such as yeast and pose a special danger to those with weakened immune systems. According to a growing number of studies, nails longer than a quarter of an inch offer a good environment for infections to grow. Newborns, patients with cancer and other diseases, and those in high-risk settings such as intensive-care units or operating rooms are especially vulnerable.


Thursday, September 14, 2006

The utility of Botox cosmetic for improving scar quality

I saw this blurb somewhere else but it's somewhat interesting.

There's a study showing some short term (6 month) follow-up of using
as an aid to improving facial scar quality. This may sound strange, but it actually makes a lot of sense. Botox is a product sourced from the toxin produced by the bacteria that causes botulism. It has the effect of muscle paralysis. The first indications for it's use were in opthamology for problems with eyelid muscles, when one of the physicians noticed an improvement in brow/forehead wrinkles which are produced or exagerated by the muscles of facial expression. This observation birthed a multi-billion dollar industry.

Since it's original indications, we've seen series of patients being treated for migraine headaches, incontinence, prostate enlargement, hidradenitis (infected sweat glands in the armpits & groin), excess sweating of the palms/armpit, etc....

How does this improve scar quality? Well in areas of facial expression the movement of the underlying muscles causes shear & tension on the wound. Selectively paralyzing these mimetic muscles presumably would decrease that & improve scar quality.

Is BOTOX practical for this use? Not currently. The true cost (sans mark-up) is nearly $500 USD per vial of 100 units of the product. It would take ~15-20 units in many areas to paralyze selective areas for this & he patient would likely be charged several hundred dollars for this out of pocket. This makes it cost-prohibitive for most patients & would make this a real niche market. It is also not clear whether this suggested effect of BOTOX is going to be real & reproducible or superior to many other product used topically for improving scar quality (eg. Scar-Gard, Mederma, etc.)


Saturday, September 09, 2006

Woman awarded $8.25M after breast augmentation & mastopexy complication

In a full display of "jackpot justice" American-style, a Florida jury awarded a women over $ 8 million (USD) to compensate for pain and suffering for complications resulting from an augmentation mastopexy surgery. This episode highlights both a tort system out of control as well as the risk associated many breast operations (reductions, lifts, augmentations).

Simultaneous augmentation-mastopexy are tricky operations with known higher complication rates. If you think about it conceptually, you're doing a procedure with two competing forces - tightening the skin + "stuffing" the inside. When these the tension from the surgery exceeds the remaining blood supply to the breast tissue & nipple complex, you get tissue loss. Sometimes this is confined to just "fat necrosis" where some small areas of the fatty breast tissue harden & cause little problem other then being able to be felt. Large areas of fat necrosis can require surgery to remove as it can be both painful and hard.

Despite risks much higher then either procedure alone, we do these fairly frequently. Why? Patient demand and convenience. Staging these procedures requires 2 facility, anesthesia, and surgeons' fees which raise the cost a great deal. Also factor in recovery time from an additional procedure and it's easy to see why patients demand theses & surgeons' offer them.

What can be done to minimize the risks?
Don't operate on smokers or diabetics
Don't stuff oversized implants in
Don't go to "the edge of the ledge" while tucking the skin
Consider an adjustable device like the Mentor Spectrum implant (see here)


Tuesday, September 05, 2006

Get well cards for Plastic Surgery

Tapping into the pop culture emergence (and acceptance of cosmetic surgery), a company has now designed a line of get well cards for Plastic Surgery patients. Lift Me Up Cards, whose a privately held company based out of Dallas, TX who says they developed these cards "because as they say...everything is bigger in Texas".

A feature in the Florida Sun-Sentinal writes:

"The idea came in 2005 when four of creator Camie Dunbar's family and friends had work done. Dunbar couldn't find suitable cards, so she jotted messages and sketched stick figures. One card for her breast-enhanced friends said, "Congratulations on the Twins!" A liposuction card read, "I thought we could just sit around and chew the fat …"

Enlisting the help of South Florida graphic designer Matt Santamarina, the cards tread where major card companies fear is taboo, Dunbar said."

The line of cards (seen here) includes ones for breast augmentation, breast lifts, liposuction, vein removal, and BOTOX cosmetic.

Saturday, September 02, 2006

Ick! Breast discovered buried at Pa. church

In Meadville,PA workers renovating a church unearthed a package of m ,(edical waste that contained a woman's , and police believe it was buried there by someone who had . Officials at the Unitarian Universalist Church of Meadville told police it may have been put there by a woman 10 to 15 years ago who had requested prayers for healing of breast cancer.

story link here