Sunday, May 20, 2007

Plastic Surgery revolutions and the dreaded $100,000 coat-rack

New technologies have been flooding the Plastic Surgery market for the last 20 years at an impressive clip. During that period of time there have been a few revolutionary device, a lot of evolutionary changes in those devices, and some real clunkers that have faded (or are fading) into obscurity. Some of these technologies start as revolutions before fading to clunker-status.

The term "$100,000 coat-rack" refers to the significant cost of many of the devices pushed by industry to doctors and patients. Many of these after an initial rush of enthusiasm had a tendency to gather dust in the corner with their owner reminded painfully of how much capital they had invested in it.

One of the best surgeons and businessmen I know, Dr. Marc Salzman, (a Plastic Surgeon from Louisville), preached to me the risk/reward profiles of these devices. Basically, on the rat-race for latest & greatest, if you can't recoup your investment in the short-term, it will be obsolete as patients come in asking for the next device featured on Oprah or Cosmopolitan magazine.

A canny observation from Marc was that a reliable way to figure out the trends in what was out of favor with lasers was to look on Ebay (search terms like syneron, fraxel, thermage, lumenis, candella, or other vendors) and see what was getting dumped at large discounts by laser resellers or doctor's offices. One caveat I'd make for "Dr. Salzman's Ebay Rule" circa 2007 would be that as some medi-spas close or doctors dive into cosmetic laser-like devices, lose money, & liquidate is that you will find some. good technology available

1. the wound V.A.C. (vacuum assisted closure) device which has a monopoly in the multi-billion dollar vacuum wound care market.

2. laser skin resurfacing - originally with CO2 (and then erbium lasers)jump started the "minimally invasive" trend in the 1980's. Enthusiasm has waned significant however (see below) as downtime has become more of an issue to patients. Intense pulsed light (IPL) and "gentler" laser-like devices (fraxelated CO2, plasma, Radiofrequence, diode/pulsed dye lasers) are the flavor of the month, but are nowhere near as effective for deep wrinkles in a single treatment as CO2 lasers are.

3. BOTOX for animation wrinkles
4. Off the shelf injectables. Collagen was the initial clumsy product to be replaced by safer & longer acting hyaluronic acid products (Resetelene, Juvederm, & others)

5. Titanium plates and screws for rigid fixation of facial fractures. This was a quantum leap in precision and stable repair from previously used steel wires which were essentially "twist ties" hogging bone near the other fracture edge.

6. Tumescent liposuction - introduced from a French Plastic Surgeon over 25 years ago, this technique is continuing to find new applications and refinements. Adding fluid (tumescence) allowed safer, more predictable surgery then preceding attempts at liposuction. It's interesting that a famous liposuction case in the early 20th century where a French ballerina required bilateral leg amputations from complications stymied interest in this area for nearly 50 years. It's now routinely combined with surgical procedures like tummy tucks to enhance results.

OUT TO PASTURE TECHNOLOGY (or heading that way)

1. Endoscopic procedures - a few years ago you might have lumped this in the revolutionary category, but it is fairly rapidly being abandoned in most instances. Endo-brow lifts (the most common application) are felt by many surgeons (but not all) to be less effective, less precise, more expensive, & much less durable then open brow-lifts. FYI, the endo-brow was invented by some of my neighbors here in Birmingham Drs. Core & Vasconez, both of whom are real gentlemen and recognized experts in endoscopic techniques.

Endoscopy has stimulated a bunch of novel "mini" brow lifts, which incorporated some of the anatomic lessons we learned from endoscopic appproaches. As these techniques can be done under local without $20,000+ of endoscopic equipment, I think these hybrid procedures will become the norm as the pendulum swings towards more office-based surgery.

Endo-breast augmentation (which isn't that popular to begin with anymore) will fade into obscurity quickly I predict, as saline implants are used much less often. The recommended access incisions (~5 cm) for silicone gel implants are large enough that the resulting visible scarring (even of good quality) in the armpit won't be acceptable to patients. The soon coming form-stable ("gummy bear") gel implants from Allergan & Mentor require even bigger incisions and more precision in pocket disection to imagine many will push the envelope with endoscopic approaches.

2. traditional (ablative) laser resurfacing - as I mentioned above, CO2 lasers (along with liposuction & collagen) were the catalyst for minimally invasive procedures. However, patients in 2007 will no longer accept looking like a burn-victim for 3-4 weeks during the healing process. In addition, there have been a tremendous number of patients with uncorrectable hypo/hyperpigmentation reactions from resurfacing lasers and the skin also can take this odd-looking smooth,waxy look.

Plastic Surgeons got tired of being told that their revolutionary laser from 3 years ago is no good anymore by the same people that sold them their previous one. This happened frequently during the late 1980's thru late 1990's as the glow was off the original CO2 lasers. Older surgeons pointed to the fact that they can achieve similar (or better) skin resurfacing as CO2/erbium lasers using concentrated TCA or deep Phenol peels for about $5 worth of supplies (you've still got to deal with the "burn victim" look for a few weeks however with those kind of peels).

3. Ultrasonic liposuction (UAL) - heavily touted in the late 1990's, UAL had a spectacular fall from grace as it had higher complication rates, saved no time, and required expensive equipment as compared to traditional tumescent liposuction. Other then that, what's not to like? UAL is useful for dense fatty areas (upper back fat & male gynecomastia), but has been abandoned en masse by most surgeons. The $15,000 UAL machine at my hospital is gathering cobwebs and no one currently working there even remembers how to assemble or operate it at this point (I'm not kidding!).

4. Thread-lifts. One of the first posts in late 2005 on Plastic Surgery 101 was on thread lifts entitled, "The Jury is still out (on thread-lifts)". Well the jury is back and the fact that Quill medical has recently withdrawn the Countour Thread barbed suture from the market speaks volumes. It just didn't work, and when it did work, it didn't last was the consensus. For money approaching the cost of real-face/brow lifts the techniques for this currently are lemons. Newer suspension suture styles and materials may make us reevaluate this down the road.

5. Thermage - for a device costing nearly $100,000 plus expensive disposable parts, most doctors and patients expect results that don't require 75x magnification with Photoshop to demonstrate. I feel sorry for people who get up at meetings and show pictures of their results with Thermage only to have the audience of their peers squint at the picture trying to imagine something has happened.

In addition, it is notoriously painful during treatments and can have a tendency to cause facial fat to atrophy (as written up by blogging amigo Dr. Tony Youn). This (or thread lifts) has to be the most maligned and polarizing device I've ever heard of at Plastic Surgery meetings, leading the President of the Aesthetic Surgery Society (at the time) to mentioned at one of our meetings that he'd been trying to figure out ways to throw the device out his office window onto I-20 in Atlanta it was causing he, his partners, and his patients so much grief. Newer device settings have been proposed by the complany and some doctors who favor this device, which they claim will improve things. I'll believe it when I see it.

6. Trans-umbilical breast augmentation (TUBA) - most Plastic Surgeons think this is a flawed approach to begin with. The move towards silicone implants (which can't be placed this way without damaging them) will make this technique fade from knowledge in short order as no one learns it.


Dr. Tony Youn said...

Great write-up Rob. I would have to agree with you on most of the issues you have brought up (Botox, injectables, use of peels instead of expensive lasers, etc.) but I would disagree on a couple things. I do believe that endoscopic surgery is going to continue to play a large role in our field, mainly with browlifts. No one wants the large coronal scar anymore. The "hybrid" lift is a thought however. Also, I've been using a VASER UAL for years now, with (no exaggeration and knock on wood) NO complications in hundreds of cases. I have not seen a single seroma in all of these cases. Finally, I do think the saline implants will continue to be used for that section of patients who demand smaller, more hidden (transaxillary) scars.
I can't agree with you more on the resurfacing lasers, Thermage, wound VAC, thread lifts, and tumescent lipo. Had the two of us invented the VAC (so simple, yet so effective) we'd be retired now and living on an island somewhere!

Dr. Rob Oliver said...


Aside from the issue of whether you think you get good & lasting results with endo-brows, I think as a practical matter with endoscopy, as more surgery is done in the office, fewer surgeons will invest $20K plus for endoscopic equipment that would be used infrequently in most practices. David Knize and others have shown work-arounds for minimal access brows without endoscopes which mimic the anatomic principles (subperiosteal release). I really think the "ancient" hairline incision is going to resurface in a big way with brow lifts because it works, there's no hardware, and it can be done under local in the office.

VASER's a neat idea, but I think it's something that will never take off until the price drops signifigantly for the generator. Is it really $70,000 USD better then a SAL pump/aspirator? I think the limited market penetration has answered that question. There's a lot more interest in power-assisted units (PAL) at 15% of the cost of owning a VASER.

As to saline implants, I think they'll be a rare bird in ten years here like they are world-wide. Scar issues haven't detered women elsewhere so I don't believe it will here. BTW an underappreciated issue with the salines is the greater weight per volume (as compared to silicone)over time, particularly it's effect on thinning out the lower-pole tissue.