Save the cheerleader. Save the world. - Cheerleading Injuries

Fan's of NBC's show "Heroes" will appreciate the title for this post.

Cast-member, Hayden Panettiere, who plays a high-school cheerleader who has the ability to heal any injury, is pictured to the right.

Out of all athletic events, probably the riskiest one for serious injuries to participants is now cheer leading believe it or not. The nearly 25,000 injuries annually treated in ER's has doubled over the last 15 years as increasingly risky tumbling maneuvers have become routine. There's a great story on this in the New York Times "As Cheerleaders Soar Higher, So Does the Danger" (click to read). From the article:

In 2005, the National Collegiate Athletic Association’s Catastrophic Injury Insurance Program found that 25 percent of the money spent on claims for student-athletes since 1998 resulted from cheerleading. That made it second only to football.

For "not so great moments in cheerleading" click the YouTube window below.



During my Plastic Surgery residency,I did my training in hand surgery at the Kleinert Institute in Louisville (KY), which is kind of like the Mayo Clinic for hand surgery. People come from all over the world for evaluation and treatment of complex upper extremity injuries and problems. Kentucky is also home to the two most decorated collegiate cheer leading squads in the country at the University of Louisville and the University of Kentucky (which is an hour east in Lexington,KY). Competitive cheer leading is also a very big sport among high school girls in the area.

At least 2-3 times a week at the Kleinert clinics I can remember seeing broken hands and awful traumatic wrist injuries from tumbling exercises or falls in teens. The xrays of the hands/wrists of some of these girls with repative injuries had degenerative changes resembling of 50 or 60 year olds with arthritis.

In particular, tears of the distal radio-ulnar joint (DRUJ) was a particularly nasty injury ensuring a lifetime of future wrist pain. Pain secondary to DRUJ instability is located on the ulnar side of the wrist and is intensified by pronation or supination. DRUJ pain & injuries are also increasingly common in high-level tennis players who use two-handed backhands (usually in the non-dominant wrist) This tear of the cartilage and ligaments at the wrist progressive makes rotation and stability of the hand/wrist compromised and has historically had only partial relief with surgery. Not only do you suffer a loss of mobility of the wrist, you can get intense pain while trying to perform simple tasks, like turning a door knob or lifting a light object, or even while sleeping. It's a really bad condition to develop.


Pictured below is an xray of the wrist with dye injected demonstrating free leakage outside of the joint from a tear.


The most common surgical solution was to cut off part of the distal ulna to prevent the two forearm bones from painfully grinding on one another. And while this helps pain sometimes, patients still had little functionality left in the wrist. A revolutionary device, an artificial DRUJ replacement device called the APTIS was developed in 2005 by one of my mentors from the Kleinert Institute, Dr. Luis Scheker and is being increasingly used to treat the intractable wrist problems associated with this.

MRIs suggested for breast imaging

The American Cancer Society (ACS)came out with a fairly bold recommendation yesterday for dramatically expanding the use of MRI for screening breast cancer patients. A summary of this by WebMD can be read here.

The proposed groups which fall under these new guidelines are:

1. They carry mutations in the BRCA1 or BRCA2 breast cancer genes.

2. They have a parent, sibling, or child with a BRCA1 or BRCA2 mutation, even if they have yet to be tested themselves.

3. Their lifetime risk of breast cancer has been scored at 20%-25% or greater, based on one of several accepted risk-assessment tools that look at family history and other factors.

4. They had radiation to the chest between the ages of 10 and 30.

5. They have a rare medical condition linked to breast cancer -- Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome -- or have a parent, sibling, or child with one of these syndromes.

When you calculate the groups who fall into the nominally "high risk" group, it's somewhere between 1.6 to 2 million women annually who would be suggested to have MRI's. Right now it costs somewhere between $800-2000 per study so this is well over a billion dollars of potential new imaging study costs for our health care system (which is not pocket change for even federal programs like Medicare).

This will be interesting on how this plays out. The growth in imaging studies (mostly CT/MRI)are already one of the budget busters when you consider health care on a systems basis. Do not expect health insurers to quickly accept this recommendation by the ACS until they are forced kicking & screaming with long-term outcome data. Counter intuitively, we learned (read here)not to long ago that aggressively screening patients presumed to be at risk for lung cancer had ZERO effect on cancer-specific mortality and caused a great deal of morbidity from the work up of masses that may never have caused a problem.

Most angioplasties are unnecessary

An aside from Plastic Surgery 101 for today:

Major, major historic moment in the history of modern medicine was announced in a presentation today at the American College of Cardiology meeting in New Orleans IMO.

More than half a million people a year with chest pain are likely getting an unnecessary or premature procedure to unclog their arteries because drugs are just as effective and cardiac bypass (CABG) is superior on symptom relief and mortality data. You can read the AP wire summary here.

This single paper may dramatically change the way we treat coronary artery disease overnight around the world and potentially save billions of wasted dollars in procedural and device-related costs. It will be interesting to see how warmly this is received by interventional cardiologists who've commanded top salaries treating many non-emergent angina cases (which were reviewed in the study) in the cath lab :)

Is bigger better? Breast augmentation surgery linked to boost in self-esteem and sexuality

There's a study in this month's journal Plastic Surgery Nursing from the University of Florida reporting on several indices of patients' self-image improvements after breast augmentation surgery. A WebMD description of it can be read here.

The study included 84 women who were 21 to 57 years old, assessing their perceptions of self-esteem and sexuality before and several months after cosmetic breast augmentation. Responses were recorded with two widely accepted scientific scales to measure self-esteem and sexuality, which assess domains of sexual function, such as sexual arousal, satisfaction, experience and attitudes.

The average self-esteem score increased from 20.7 to 24.9 on a 30-point scale, and their average female sexual function score increased from 27.2 to 31.4 on a 36-point index. Of note, after the procedure, there were substantial increases in ratings of sexual desire (a 78.6 percent increase from initial scores), arousal (81 percent increase) and satisfaction (57 percent increase).

The study's author, Dr. Cynthia Figueroa-Haas CRNP, a clinical assistant professor at the University of Florida's College of Nursing had this to say:

"So much attention is directed to men's sexuality issues; we have all seen countless commercials on drugs and therapy devoted to improving men's sexuality. Unfortunately, very little is discussed regarding women's sexuality issues," Figueroa-Haas said. "I strongly believe that my research shows that interventions such as cosmetic plastic surgery can address these sorts of issues for some women. For example, those women who may have breast changes due to nursing or from the inevitable natural aging process. These women may not feel as attractive, which could ultimately negatively impact their levels of self-esteem and sexuality."

These kind of results really are not anything new though. Similar series of varying quality have been reported in the Plastic Surgery literature for almost 50 years. However, I think it's somewhat redundant to publish such data so early in follow-up which adds nothing much new to what's been published previously. The more important longitudinal findings in these patients need to be followed up years out, not months, to add something to our understanding of psyhcological outcome endpoints. Keep in mind that data presented to the FDA from the clinical trials required on silicone gel implants at 3-4 years out suggested much more conservative attribution of long-term self-esteem or self-identity benefits.

As I do a lot of breast surgery (ranging from mastectomies and reconstruction for cancer, breast reductions for overly-large breasts, breast lifts, and cosmetic surgery involving implants) it's pretty obvious from both my practice and the literature on these diverse patient groups that there is a great deal of psychological benefit from these procedures. I do feel however, that such short-term studies as this one are overstating or over-simplifying things too much.

Second Thoughts on Breasts (implants)

Found a thought-provoking editorial in The American magazine, titled "Second Thoughts on Breasts." which summarizes some of the history of regulatory issues with silicone implants. The effects of this on the corporation and employees of Dow Corning(which was sued out of existence)are touched upon nicely. It's ironic that if Dow had waited about 15 months (when the first of the large studies not finding links between silicone and disease was published by the Mayo Clinic) they would have not had to pay a dime of the multi-multi billion dollar settlement.

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Mouse Virus Linked to Breast Cancer

Some really interesting developments into our understanding of breast cancer biology are coming from the work of Dr. James Holland, distinguished professor of neoplastic diseases at Mt. Sinai School of Medicine in New York.

In a nutshell, they've been presenting fairly compelling evidence that a virus, the human mammary tumor virus (HMTV), a virus 95%+ similar to a virus commonly carried by the common house mouse (Mus domesticus),
may in fact be the trigger for a great number of human breast cancer cases, maybe up to 1/3. Copies of the gene affected by HMTV appear to be present in high numbers in tissue of women with aggressive forms of breast cancer or those developing during pregnancy or lactation periods.



Fascinating circumstancial evidence supporting this cause-effect relationshiop is the fact that you can draw a map of the planet where these mice flourish and it correlates very closely to areas where breast CA rates are higher. We've traditionally attributed geographic differences in breast cancer to genetics, diet, and the environment but maybe it's something as simple as "where the mice live". The obvious sociological observation that in many instances the poor and underclasses often live in closer proximity to rodents may explain why breast cancer rates are higher in poor neighborhoods (both in America and elsewhere).


The signifigance of this is profound in that we could potentially vaccinate for this much like we can do for the human papilloma virus (HPV) for women's cervical cancer.

News of the wierd! Blue Marlin Impales Woman's Breast Implant

Neat video clip story about a women who suffered a penetrating chest wound while sport fishing for marlin. Her treating physician speculates that her indwelling silicone implants (which were ruptured from the marlin bill) may have saved her life by blunting the force as she was stabbed. Apparently, serious penetrating injuries are not that rare from marlins as I found several recent reports (see here)

Another life saved by breast implants! :) As someone joked in re. to these stories last year about an Israeli woman saved from shrapnel and a car crash survival attributed to implants "Go big or die."

Plastic Surgery 101 mentioned in Plastic Surgery News article

Plastic Surgery 101 made into an article in this month's Plastic Surgery News, a monthly periodical published by the American Society of Plastic Surgeons.

The article deals with the issue of cyber-harassment by disgruntled patients, and features the real life experiences of some Doctor's who've had truly horrifying experiences of dealing with the new realities of the Internet as a medium. I was the "blogging expert" who talked with the author about the phenomena of "poison" blogging, which has been a vehicle in some instances to attack Plastic Surgeons' reputations as well as the potential for rapidly causing widespread serious mischief and disinformation on sources like blogs, usenet groups, wikipedia, chat rooms, and the like.

The camera doesn't lie - funny celeb clip on YouTube

I owe Plasticized for pointing me to this hilarious clip of tricked out celebrity pictures juxtaposed with candid shots sans makeup.

It makes me appreciate how beautiful my wife is first thing in the morning.

Click on the video below to play.

Plastic Surgery as a treatment for migraine headaches

A Cleavland Plastic Surgeon, Bahman Guyuron, made an interesting observation a few years ago when he was told by several of his brow lift patients that their migraine headaches went away after surgery. Working from that feedback he hypothesized that surgical release of several muscles that are divided to improve forehead wrinkle line act as trigger points for migraines. Eventually this led to the therapeutic use of BOTOX cosmetic for treating migraines, which has become quite a big business for neurologists.



Ironically, there were a number of Neurologists who initially aggressively protested that it was impossible for BOTOX to have an affect because Neurology dogma had migraines originating from central brain triggers rather then peripheral ones. However, the studies that have been published since have been overwhelmingly compelling for how effective this type of therapy can be in selected patients.

The graphic below demonstrates the classic central forehead/nasal injection pattern for paralyzing the procerus and corregator muscle groups which are the muscles divided in some brow lift procedures.



For several years in the Plastic Surgery literature we've been trying to better quantify who would be candidates for planned surgical division of 3 or 4 muscles for treating migraines with surgery for a permanent cure. The anatomy and refinements of surgical techniques for this are being developed by an acquaintance of mine, Dr. Jeff Janis (seen in picture at right), at the University of Texas-Southwestern in Dallas,TX. Jeff's been featured in a bunch of stories on this recently (see here)which is great for such a bright guy.

I ran into Dr. Janis at the Dallas Rhinoplasty meeting last week where he was about to commence a marathon cadaver dissection to study the anatomy in dozens of fresh human cadaver heads that had been used as part of the rhinoplasty course. The work he's doing is really developing an area that has tremendous potential to help some patients suffering from this terrible condition.

Note our new plastic surgery 101 friends links

Just wanted to quickly point out the recent additions to the "friends of Plastic Surgery 101"

Dr. DiSaia's "Truth in Cosmetic Surgery" blog - the original inspiration for Plastic Surgery 101


the lovely Beth Shea's "Ageless in Los Angeles" on some of the trends in Tineltown

The Beauty Brain's blog of all things cosmetic has a brand new home

Fat grafting for breast augmentation

Out of all the fillers (collagen, hyaluronic acid, & other) we use in Plastic Surgery, perhaps nothing is as good as your own fat for augmenting soft tissue. It's used in nasolabial fold (the creases alongside your nose which deepen with age), around the eye, in the lips, for buttock augmentation, and to correct "dents" from liposuction. The problem has to do with success rates running below 50% by most estimates.

Manhattan Plastic Surgeon, Dr. Syd Coleman, is the undisputed "king of fat grafting" and uses it above and beyond the indications most of the rest of us will do. He has described very refined techniques and presents results that are not reproducible for mere mortals. An article in the recent Plastic & Reconstructive Surgery journal described a series of fat graft breast augmentation cases of Dr. Coleman's, an area that has been taboo for years over concerns of issues of mammography artifacts.

Back in 1987 the American Society of Plastic Surgery (ASPS)issued a stong position against this procedure. The ASPS has wisely issued a new strong caution with this. From the lovely, Roxanne Guy, MD, current President of ASPS:

“Patients considering breast augmentation need to know that fat grafting for this indication is not recommended at this time, unless one is part of an ongoing clinical research study. Even though fat grafting techniques have become more refined and breast cancer detection methods have become more sophisticated with time, creating a great deal of excitement about the potential of fat grafting, we simply need more data before we can recommend that this procedure be generally used to augment breasts.”

At a panel at one of our meetings on controversies in Plastic Surgery last week, fat grafting outside Internal Review Board oversite was described as "human experimentation". Despite a number of small series describing this in reconstructive surgery, I'd tend to agree that this kind of fat grafting is something a little ahead of the issues that need to be studied.

Certain cities known for specific Plastic Surgery

This weekend is time of year for the Dallas Rhinoplasty Symposium, one of the bigger meetings in the Plastic Surgery calendar. Dallas has been one of the more influential cities for many years in Plastic Surgery due to some of the contributions of local Plastic Surgeons and it's become one of those places we (surgeons)immediately associate in our heads with nasal surgery. The work, teachings, and prolific writings from Dallas doctors Jack Gunter, Rod Rohrich, and others has really defined what rhinoplasty surgery is in 2007.

Besides Dallas with noses, there are a few other American cities that have such strong association with certain procedures which have to do with historical contributions to Plastic Surgery.

Manhattan - the spiritual home of the facelift and decades of influential craniofacial surgeons like Marquis Converse (former head of NYU Plastic Surgery division)

Atlanta - where breast surgery will always be synonymous due to the developments in breast reconstruction techniques (TRAM flaps, latissimus flaps) and the teachings and textbooks of the late John Bostwick MD (former chief of Plastic Surgery at Emory University)

Louisville (KY) - the Kleinert Clinic is the world's largest hand and microsurgery practice and has trained hundreds of American and international surgeons. Dr. Harold Kleinert, was a pioneer in the field and developed a super-tertiary group practice around his expertise that attracts patients from all over the world. When you think of hand surgery, you think of Louisville. Which is ironic as I trained there at the University and over at the Kleinert Institute and I don't do any hand or microsurgery to speak of - Rob

There are a lot of famous surgeons scattered in locations across the US, but I don't think any of those cities have such singular connotations with specific procedures. Please feel free to leave suggestions in the comments!

Breast Implants and suicide redux

The correlation between patients with breast implants and slightly higher suicide rates is something I touched on previously (see here).

To most observers this is a fairly easy phenomena to explain: higher rates of psychiatric issues and depression among cosmetic surgery patients would expect to result in a corresponding suicide rate increase. An excellent review of this literature was published in the February issue of Plastic & Reconstructive Surgery, the world's flagship scholarly journal for Plastic Surgery.

Still, among the cadre of anti-implant activists , there lingers the suggestion that these observed suicide rates are from either psychic or physical pain from their implants. This was voiced recently by the actress/ant-implant crusader, Sally Kirkland (see photo), who speculated that Anna Nicole Smith's death by drug overdose was from her breast implants. (As opposed to her reported history of depression, psychiatric problems, alcoholism, and drug abuse/dependency.)

"Dr." Kirkland's observations aside, an interesting addition to the literature popped up this week which asked the logical question of whether the increase in suicide rates was also seen in breast cancer patients. Surprising no one, the answer is no in a National Cancer Institute funded review of cancer registries. The skeleton of this study can be read here.

Hopefully this puts the stake in the flawed assertion that breast implants causes suicide, and redirects the attention towards more effective screening out of potential patients who would benefit from psychiatry rather then surgery.