Friday, September 28, 2007

Dr. O in American Sexuality Magazine........ Mom will be so proud!

I was interviewed awhile back for San Francisco's American Sexuality magazine which finally came to print. The article "Plastic Surgery and the New Standard, Unnatural Beauty" can be read by clicking here.

My contribution to this had to do with the question of:

  1. Whether we're becoming a society of have & have-not's for plastic surgery along class lines

  2. Whether we're in an era of unprecedented beauty standards

I made two observations.

One - that rather then becoming more exclusive, the access to cosmetic plastic surgery has never been more readily accessible to the masses. Decades ago, there were only a handful of providers who catered mostly to the very well-to-do. Now we have many different kinds of doctors doing "cosmetic medicine" of all types at historic discounts with low-interest financing available from multiple sources. The cost of theses procedures is historically low and are frequently offered in convenient retail-like environments.

Two - "unnatural" standards of beauty have always existed and I'm not so sure that what passes now (BOTOX'd foreheads, laser "Brazilian" hair removals, breast implants, etc...) are more radical things that have been done since time immemorial (infant head molding, feet binding, corsets ("wasp waists"), neck stretching, tattooing, ritual scarring/piercing). In fact, there's kind of been some pushback towards less radical surgical and non-surgical treatments towards less obvious and more natural results.


Tuesday, September 25, 2007

The best breasts (?)

In what I guess passes for peer-reviewed literature in the UK, a London surgeon has proclaimed to have identified the perfect breast. The model mammary has a nipple that points slightly up, and an upper breast pole just a bit smaller than the bottom half. Apparently UK surgeon, Dr. Patrick Mallucci, spent many hours "poring over photos of topless models in lads magazines and tabloid newspapers" to come up with this theory.

While observing the "ideal" (as defined by cultural norms) is an ok way to make some general observations about beauty, I'd take issue that "laddie mags" (STUFF, Maxim, etc....) and pornography are the best reference point. A disporportionate number of models in those mediums have had breast augmentations which changes your whole frame of reference for comparison. The ideal augmented breast should approach the ideal un-augmented breast, which most (don't flame me here) would point to as the symetric nulliparous (prior to childbearing) breast with little ptosis (droop) that possesses some degree of upper pole fullness. This is pretty much what Dr. Mallucci describes, but I take some contention to his methods and conclusions. Most women will never have this kind breast naturally, but "good" breast surgery can move someone closer to it. The ideal breast shouldn't be pointed to one that does not and cannot exist in nature, ie. Baywatch circa 1996.

Who has the "best breast" according to this doctor? The "why exactly am I famous again?" model/singer/personality, Caprice Bourret

And the worst? The world's most famous soccer mom, Victoria (Posh Spice) Beckham

I'd agree that Ms. Beckham's result isn't the best, but thin women have a hard time hiding all but the most modest implants. She would have done better with smaller and narrow implants, and would have been ideal for the anatomically-shaped gumy bear devices (form-stable high cohesive silicone gel devices like the Inamed 410 or Mentor CPG).

But picking 36 year-old Caprice Bourret as the best "natural" breast shape (as described by this doctor in the article)? She's got a classic over-sized, over-round result you get from big implants (again that Baywatch thing). She's claimed in the past not to have had extensive plastic surgery, but I find that implausible.

Do you?

While it may in fact be a result that both earns Ms. Bourret a great deal of attention and be one that many women think they want, it's a setup for multiple future complications. That tissue just won't maintain that result for any length of time.


Thursday, September 20, 2007

Urban legend debunked: Can you donate skin from your tummy tuck to the Shriner's burn center for skin grafting?

I do a good bit of surgery on people after the two most common weight loss operations, gastric bypass and gastric banding (the "lap-band"). Every few months I get an email from someone asking about a rumor they've heard that if they donate their excised skin from their tummy tuck (panniculectomy) surgery that they will get the cost of their surgery covered by the Shriner's, the charitable social organization whose endowment funds many of the largest burn units across the country.

The idea that that skin could be used easily always sounded fishy to me, as post weight loss skin is "damaged goods" and would seem like poor material to be considered for use as it tends to be very thin and attenuated tissue.

Cadaver skin has been harvested for a long time for use as temporary wound coverage. If you try grafting it on someone else, their body ultimately mounts an immune response and rejects it. Still, it can make an effective temporary closure for very large burns. A number of companies turn cadaver skin into commercial products like Alloderm by removing the proteins from it that trigger your immune system. Alloderm (usually processed from the very thick back skin) is a very strong material I increasingly use during breast reconstruction.

Anyway, back to busting the urban legend thing.............

From the Shriner's Hospital website:

Q: Can skin from gastric bypass surgery be donated to children for skin grafts?

A: No, the only donor skin that can be used at the burn center is cadaver skin processed through a skin bank. Only skin from cadavers is used for skin grafts, because cadavers give the greatest amount of surface area – up to 10 sq. feet of usable skin for a burn patient. Skin that could be taken from a person who had excessive weight loss would not generate the amount of skin or quality skin needed to treat burn patients.


Thursday, September 13, 2007

Redefining indications for breast reduction

In this month's Plastic & Reconstructive Surgery, our profession's flagship journal, there's a study about the symptomatic relief woman receive after breast reduction who fall below the minimum threshold insurers require for coverage. To no one's surprise, even reductions less then half of the average weight removed showed dramatic symptomatic improvement at over 1 year out from surgery.

Most health insurance plans require a minimum of 500 gm (~ 1.1 lbs) of tissue to be removed per side for coverage in addition to documentation of symptoms related to their breast size. Occasionally you get some asinine form letter asking for proof of "conservative" treatment of large breasts prior to surgery, whatever the hell that is!

The authors of this study call for review by insurers of their criteria for coverage. Good luck! Insurers haven't been recording record profits by dramatically expanding their potential exposure for surgical procedures. This study doesn't really offer much that hasn't been presented to these companies for years. They're not interested in the close to three dozen papers with similar findings in the published literature.

The catch-22 here is that when coverage is expanded usually the reimbursement for the surgeon is cut. Breast reductions are long and physically hard procedures which can take 3-4 hours when you do it by yourself on large reductions. What we get paid for these is about 20-30% of what is commanded for mastopexy (breast lift) surgery, a closely related procedure which often may involve a small reduction component. It's gotten to the point for many surgeons that they just won't do it anymore as (depending upon the insurer) these hover right at the break even point for their practice when all the costs and follow-up care are figured. If you don't believe me, try finding a list of providers who will accept Medicaid assignment for these.


Tuesday, September 11, 2007

Britney Spears' tummy troubles

Britney Spears recent appearance at the MTV video awards sporting a figure a notch down from a few years ago has generated a lot of publicity. When you make it as a Drudge Report headline entitled "LARD and CLEAR" you know you've had a bad week.

There have been some articles asking whether it's fair or not to criticize her for her figure and how that reflects pressure on actresses, models, or women in general to achieve unrealistic bodies. Well, my take is that when you've built up a music career centered around sexuality/physicality rather then music or voice talent, you reap what you sew.

Ms. Spears doesn't look in fact look "bad", she looks normal after having 2 children in rapid succession. Unfortunately, normal people aren't the benchmark for her field of work, and she did herself no favors wearing an outfit accentuating her body's changes.

She's got a modest "mommy tummy" which is relaxation of her muscles and fascia of the abdominal wall you get from pregnancy, weight gain/loss, and normal aging. The younger you are and the less weight you gain when you get pregnant, the less of this you tend to see.

She appears lucky enough to not have to deal with strech marks. Stretch marks represent tearing/shearing of the structural elements of you skin and are something you're individually predisposed to. Some people get them with modest weight gain or on their breast with breast feeding, but they're produced more often with significant weight gain. There is really no non-surgical treatment for strech marks and if you're lucky they confined in your lower abdomen and can be completely excised. Strech marks with redder colors may be improved by fading the color some with laser treatments, but DO NOT GET TALKED INTO BELIEVING LASER WILL MAKE THEM GO AWAY. Dermatologists are notorious for treating people this way, and I've seen a lot of unsatisfied patients out several thousand dollars.

What does someone like Ms. Spears need to do to improve this non-surgically? Strengthen her abs and watch her weight. That may not be enough however to return her to her previous figure. To do that she'd need some variation of a tummy tuck with some skin/fat excised, liposuction, and have her muscle and fascia physically tightened with sutures back to the midline.


Tuesday, September 04, 2007

Plastic Surgery research council get's OK to proceed with mesotherapy study

The Aesthetic Surgery Education and Research Foundation (ASERF) announced today that it has received approval from the U.S. Food and Drug Administration to initiate a clinical trial investigating the safety and efficacy of one type of mesotherapy (injection lipolysis) treatment. Mesotherapy is a technique of injecting various off-label medicines and god-knows-what concoctions into superficial fat to shrink it. How does it work? Not real sure, but it appears to be directly toxic to tissues. Is it safe? We hope so.

The number of these procedures were performed last year included at least 28,901 Americans -- six times the number of procedures performed the previous year. This is currently a real "wildcat" industry attracting people with no business doing things like it for the promise of quick, easy money. A number of dodgy "societies" and "boards" have sprung up offering weekend training.

This trial will follow patients for close to a year using standardized treatment protocols and index a number of safety and efficacy parameters. I'm proud of our professional society for their approach to studying this method of treating fat excess. The paucity of any coherent science or safety studies from anyone else at this point has been telling.

From Dr. Alan Gold, ASERF President,

"Although there are clinical reports of significant and positive results, they are all anecdotal, and unfortunately there is currently insufficient scientifically valid evidence to support the long term safety and efficacy of injection lipolysis. We hope that this study will provide the data needed to clarify some of the controversy and confusion surrounding this potentially beneficial treatment. The more we know, the better we will be able to educate and inform our patients, and recommend to them, with confidence, the safest and most effective treatments to provide them with the best results,"

Monday, September 03, 2007

How BOTOX affects your access to a Dermatologist. (Hint: it's not in a good way)

From my favorite New York Times columnist, Natasha Singer, comes the story "Botox Appointments Faster Than for Moles, Study Finds". This is similar to a story from MSNBC last year "The Dermatologist won't see you now."

Basically it highlights the September Journal of the American Academy of Dermatology article which published an "expose" on how it is easier to get a Dermatologist to return your call if they think you're going to schedule a BOTOX injection versus getting an appointment to have an irregular mole evaluated for skin cancer.

What was the difference?

More the three weeks delay on average (8 days versus 26 days).

Is this surprising?
Only in the sense that it only took 3 weeks to get in to a dermatologist for a mole to get looked at. Keep in mind that some other similar surveys have found much longer waits. For example almost 47 days in Syracuse, N.Y., 48 days in Phoenix and a whopping 73 days in Boston.

The amount of dermatologists being trained in the US has been artificially suppressed for many years. I saw reference somewhere to the fact that the number of dermatology residency training programs has remained stable for almost three decades with about 300 training positions. It's led to a significant backlog of people being able to be evaluated for cancers as the baby boom approaches AARP status, this volume of patients is expected to explode.

What's more, many of the medical students going into dermatology have no interest in general dermatology or treating skin cancers at all. It's been estimated that there's been almost a 50 percent shift in effort away from medical and pediatric dermatology. If you browse chat-rooms of medical students interested in derm, it's clear that many would like to set up clinics doing nothing but lasers, injectable skin fillers, and BOTOX. In a practice survey of dermatologists I found, younger women going into dermatology spent almost 20% less time seeing patient then male counterparts per week. As women make up increasing numbers of both medical students and dermatologists, this "contraction" of productivity is another factor likely affecting future access.

If you extrapolate that many (most) of these boomer patients will be Medicare beneficiaries, and that Medicare reimbursement could fall as much as 40% over the next few years, it seems likely that this bias towards BOTOX could become significantly larger. Expect to see some lobbying from Nurse Practitioners and Physician Assistant's for greater independent roles in the evaluation and management of skin lesions. For some related Medscape articles click here.