Sunday, February 25, 2007

So you think you want Universal Healthcare?

While the United States lurches towards some kind of Universal Healthcare plan, the alternative is not always palatable.

From Britain's Telegraph Daily
A NHS surgeon today exposed how cash-strapped hospitals were being barred from operating on cancer patients who had not waited long enough.

Wayne Jaffe laid the blame for the appalling state of affairs at the feet of Tony Blair, with his vision of reduced waiting times and 24-hour surgery. In a withering assessment of the financial management of the health service, Mr Jaffe said that doctors were being restricted in getting waiting lists down by financial limitations and ever-changing targets.

The consultant plastic and reconstructive surgeon, who specialises in skin cancer and breast reconstruction, said he and his colleagues are being prohibited from operating in non-urgent cases
unless the patient has been waiting for a minimum of 20 weeks.

Tuesday, February 20, 2007

Office-based Plastic Surgery: Is this going to be legislated away?

Some times you can survey events in our field and get an idea about the way things are likely to change in the future. Office-based plastic surgery is one of those things which I think is destined to become an endangered species.

A story like this in the Arizona Daily Star is one of those things that gets my wheels spinning. Last year a healthy well-known Tuscon, AZ lawyer died during an office based surgery from respiratory arrest. There was no salacious back story about either the Doctor or his clinic, it just happened. The office O.R. was accredited and a nurse anesthetist was present which both meet standards of care.

It only takes a few publicized instances of these case to really cause dramatic changes in the law. This already happened in Florida a few years ago and is likely to spread.

Why are so many cases done in the office? It's more convenient for patients and doctors and dramatically cheaper. Using a hospital or surgery center will nearly double the cost of many procedures. A less admirable reason for many providers who do office-based procedures is that they cannot get hospital privileges to do surgery. This is where Dermatologists, OBGYN's, and ENT/Facial Plastic Surgeons do liposuction, breast surgery, & other things they are arguably under trained to perform.

Again surveying the news I have no doubt that IV conscious sedation & general anesthesia will eventually become so heavily regulated that it makes it impractical to be done in the office and the pendulum swings back to doing all these procedures in the hospital again. I do a great deal of minor office surgery under local (biopsies, skin cancers, some skin grafts), but do major procedures in the hospital. It has less to do with feeling uncomfortable about office-surgery, but reflects my hesitancy to make a large capital investment for an accredited office OR when with the stoke of a pen I can no longer use it.

Saturday, February 17, 2007

Beauty ideals over time - Antony & Cleopatra

Who says ideas of beauty don't change over time?

Discovery of several ancient Roman coins which depict legendary temptress Cleopatra & Roman general Marc Antony were announced recently. Contemporary portrayals of the pair on the currency is much different then the idealized versions of modern pop culture, particularly of Cleopatra.

Neither individual displays features suggesting physical attractiveness by our standards with Cleopatra sporting a pointed chin, thin lips and sharp nose. Mark Antony, fares little better with a hook nose, bulging eyes and a thick neck. Hopefully this puts the notion to bed about Cleopatra being either an idealized western European like Elizabeth Taylor or some politically correct black African beauty as was popular to do in Afro-American studies classes in years past.

Lindsay Allason-Jones, a director of archaeological museums, said that the image of her as a great beauty is comparatively modern.

"Roman writers tell us that Cleopatra was intelligent and charismatic and that she had a seductive voice, but, tellingly, they do not mention her beauty. It's one of those perpetual myths that has been perpetuated by having people like Elizabeth Taylor playing her and it's very difficult to get that out of peoples' psyches".

"She does look as if she's forgotten to put her teeth in", she says

HBO's incredible series Rome has a very interesting portrayal of the pair to compare to.

Antony is played by classically trained British actor, James Purefoy while Cleopatra is portrayed by fellow-Brit, Lyndsey Marshal. While Purfoy is a pretty good-looking guy (he was screen tested to be James Bond around the time Pierce Brosnan got the role), his Antony is a grubby,vile character in the series. Marshal, is a rather dramatic juxtaposition from immortal Elizabeth Taylor's presence on screen. Her character was introduced last-year as a short-haired opium junkie who oozed reptile-like sexuality from body language. I'm not sure what ethnicity Marshal comes from, but she definitely resembles someone of Egyptian descent more then other portrayals prior.

If you haven't treated your self to "Rome" yet on HBO, rent the first season box-set. It is a real treat!

Monday, February 12, 2007

Stem cell technology potential for breast augmentation or reconstruction

I'm a big Drudge Report fan and I check it once or twice a day to survey the wonderful mix of important or interesting things on the newswire. One of the stories featured today was this from the UK Daily Mail about how fat stem cells have potential to graft or grow new breast and could be used for implants to replace current saline or silicone versions.

This is really an idea not ready for prime-time in the near future. We don't have the technology to grow or implant these cells predictably. Still to be answered are what (if any) effect on the development of breast cancer these cells could have or whether their presence would affect screening mammograms. Fat grafting of the breast, a once seriously taboo topic in Plastic Surgery, has been readdressed in a number of journal articles as a way to fill in some contour irregularities in breast reconstruction.

The problem with fat is that the take of it as a graft material is historically cited as only ~50%, so getting predictable results when large volumes are required cannot be achieved. This has limited interest for it as an augmentation material. The amount of size added from these stem cell was very modest and could not achieve a useful size for most cosmetic cases where we would currently use an implant.

Despite the sexy headline, don't expect anything like this to be widely used in the near future. If you looking for the next big advance for breast surgery in the United States, look forward to the approval of the real high-cohesive form stable implants like the Inamed 410 & Mentor CPG devices.

Saturday, February 10, 2007

Adventures in lip augmentation

Children of the 80's may remember the British Disco synth-pop group "Dead or Alive" who had a couple minor hits which live on indefinitely on classic rock stations featuring the 80's new-wave music. The lead singer of that group, Pete Burns, has been a walking billboard for what resembles body dysmorphic pathology (a psychiatric condition re. body image) for years having had dozens of procedures which have left him progressively less humanoid looking.

Mr. Burns is now in the news after horrible complications from lip augmentation, a picture of which is shown below. (from This is London):

In 2000 Burns went to Dr Maurizio Viel at the London Centre for Aesthetic Surgery to have a lip implant removed.

But instead of having the original implant taken out, he was injected with a filler called Evolution and then later with another called Outline.

Despite complications, Dr Viel persisted and injected more of the substance - only for the problems to escalate, causing swelling, blisters, discharge and lumps.

Eventually the singer was left so disfigured he could not eat normally, could only drink through a straw and did not leave his house for months. He said his career would have been at its peak if it were not for the botched surgery, as he was about to record with the Pet Shop Boys and pursue a number of solo projects as well as launch a greatest hits album.

Lip augmentation is tricky business. There are hundreds of celebrity pictures with the infamous "trout pout" from aggressive collagen injections in years gone by. Hyaluronic acid fillers like Restylene or Juvederm have largely replaced collagen and tend to last longer with fewer potential allergic reactions. Many patients continue to ask for longer term options and that means lip implants (silicone, Gore-tex), fat grafting, long-acting temporary fillers, or permanent fillers.

As Mr. Burns case points out, permanent fillers can go real bad, real quick and has tempered the enthusiasm of many of us for such products. The perfect filler hasn't been developed yet but we know what we want. Ideally we have a very long lived or permanent product with some way to dissolve it if we needed to. Unfortunately, the only fillers we can dissolve easily are the hyaluronic acid ones which only last a few months anyways.

You also have to question the judgment of any physician willing to continue to perform elective surgery or cosmetic treatments to someone like Mr. Burn who is clearly body dysmorphic. In the insane (no pun intended) legal environment of the United States there have even been doctors sued with failure to diagnose body dysmorphia as a cause of action by patients during malpractice suits.