Breast Reconstruction article in the NYT - there's really nothing "hidden" about it

Being someone who did advanced fellowship training in breast reconstruction, I was interested in the article in today's New York Times, "Some Hidden Choices in Breast Reconstruction".

I came away somewhat disappointed. The article tangentially discusses the issue of some advanced breast reconstruction techniques and how they aren't always offered or discussed by surgeons. It mostly centers around some of the more advanced microsurgical breast reconstructions using what are called "perforator flaps", which are much more laborious then traditional muscle flap surgeries or implant based reconstruction techniques. Those operations are very elegant, lengthy, and complex cases whose "true value" is hard to demonstrate either in outcome data or to bean counters (who just pay attention to how much things cost). The editorial tone is basically suggesting that there's some conspiracy to not talk about these procedures to patients and that these advanced procedures are the most ideal reconstruction.

I have a few thoughts on this

1. I touched upon the resources and cost to the system of demanding the most exotic types of surgeries for all comers last October 2007 entitled "A Breast Reconstruction Lawsuit - Can We afford Cadillacs for all?" which involved a patient suing her insurer for NOT covering a redo operation with one of the perforator microsurgical flaps discussed in the article.

I asked the question then:

In a scenario like the one involved here (lawsuit over non-coverage), should someone have the right to demand complex and expensive surgery when less expensive options are available?

I'm conflicted here. It does not seem completely outrageous to me for this company to deny this request or at least ask the patient to pay part of the balance difference given the particulars as I understand them. She had an acceptable reconstruction with implants, and needs a quick & relatively inexpensive surgery to maintain her result. In other countries with state-funded ("universal") health care programs, I suspect there's no way in hell this would be approved. In an era of cost-containment, all health care costs are going to be scrutinized and there will be hard choices to make. Luxuries like exotic breast reconstruction almost two decades after the initial surgery seem hard to justify in that context

We just cannot afford the most exotic procedures and technologies for every indication in every patient. Complicating this issue with breast surgery is that these types of procedures are arguably cosmetic procedures rather then functional surgeries (ie. a reconstructed breast reproduces a secondary sex characteristic but does not lactate). As a society in the US, we've come treat this topic differently through legislation guaranteeing breast reconstruction after mastectomy. This did not however, promise funding however, and the savaging of reimbursement for the long procedures and large amount of aftercare have functionally served to ration patients access to breast reconstruction.

2. Surgeries involving your own tissue have significantly more morbidity up front then tissue expander/implant procedures. They are not appropriate for everyone, particularly the very fit, smokers, obese patients, or the elderly. The complications from these operations can be MUCH more spectacular then expander procedures.

In general, I think TRAM, DIEP, and other described flaps are best reserved for young patients with small-medium breasts who are only having one sided mastectomies. The benefit in them is the natural "aging" of the flap more like the remaining breast. For bilateral mastectomies I (and most surgeons) think it is an absolute no-brainer to use tissue expanders in most patients in terms of recovery, cost, and symmetric result of the reconstruction. The improvements in implant designs that we should have available this winter make this an even stronger recommendation for most patients. Surgeon's who

I'm trained in just about everything, but I do implant based reconstruction on probably 7 or 8 out of ten patients as it's the best choice for most people. Keep in mind, that's coming from someone (me) who's favorite operations are TRAM's and Latissimus breast reconstruction. IF you look at the rest of the world, similar % of patients are reconstructed in this fashion which I think represents a collective pragmatic balancing of costs and benefits.

Rob

Where are the chips? Nando's "double breasted" laugher

Love it!

Rob

The economic meltdown for dummies (via Rick Ferri)

No Plastic Surgery today!

If you've watched the chaos in the financial markets and wondered how in the heck this happened, I'd like to point you a conference call by the investment management company, Portfolio Solutions. I have no money invested with this company per se, but I do admire one of the principals there, one Rick Ferri. Mr. Ferri is an accomplished author of financial books like the super, "All About Asset Allocation" and a regular contributor on the Boglehead Forum (a site concerning index investing as advocated by Vanguard Investments founder, John Bogle).

Mr. Ferri's discussion of the mechanics of how we got to where we are is really interesting and Ferri is an excellent communicator, even for "dumb skin doctors" like me.

Click here to go to the archived speech.

Rob

Another one (....er, two) bite the dust! The body count rises in aesthetic medicine.

Artes Medical and Rhytec Inc. are the latest notable cosmetic medical companies to fold.

From the OC Register

Artes medical made a permanent dermal filler called Artefill which never gained much of a following. It was a gel based formulation of plastic "microspheres" made for injecting in deep layers of the skin. Most doctors have been reluctant to use these types of permanent fillers (like micro-droplet injectable silicone) as they are ruthlessly unforgiving for imprecise injections. If they're permanent and you have issues, then you have a permanent issue versus one that will regress as it's reabsorbed.

As hyaluronic acid fillers like Jevederm or Restylane are more user friendly and they go away after awhile, they are more of an attractive material. For a little longer lasting material for similar indications as Artefill, I think most people would use Radiess, which lasts closer to two years or so in duration. It's an extremely underated product IMO.

Rhytec's plasma based system was fairly novel and appeared at one time to have a lot of advantages. Compared to traditional laser resurfacing of the face with carbon dioxide or erbium lasers, it carried much less risk of pigmentation changes. I loved the candor of the Dermatologist quoted in the article who took some shots at other technologies that have been popular but have been panned off the record by many doctors.

Before Rhytec’s bankruptcy filing, Dr. Christopher Zachary, chairman of the UCI Department of Dermatologist, bemoaned the loss of a company with an innovative and effective therapy. He said, "Unlike companies that market laserlipo devices that are selling like hot cakes and are universally gimmicks and which have made companies like Syneron and Cynosure very healthy bottom lines, Rhytec, which makes a device that actually works, looks like it is in a major tailspin. Such is the cynical life of an aesthetic device manufacturing company."

Rob

Allergan "eyeing" FDA approval of new eyelash stimulating medicine Latisse

Allergan, maker of the popular Natrelle breast implants and BOTOX cosmetic is apparently poised to receive FDA approval of their next potential blockbuster. The new product, Latisse, is a topically applied drug which is effective for growing and thickening eyelashes. While that sounds like a superficial indication, there is expected to be a huge pent up demand for such a product.

From Seeking-Alpha

Allergan received an approval recommendation today from a FDA advisory panel for Latisse (bimatoprost solution 0.03%) as a cosmetic medicine treatment which would represent the first and only FDA-approved product to enhance eyelashes (making them darker, longer, and thicker). Latisse would be packaged with a special applicator to apply the drops on the edge of the eyelid as compared to the current use of bimatoprost as Lumigan, which is already on the market as a treatment for glaucoma to lower eye pressure.

Allergan estimates peak sales for Latisse of $500M, compared to trailing 12-month sales of $4.4B, with an expected FDA action date by mid-2009 on the pending NDA. Allergan is also a component in the ETFI Cosmetic & Reconstructive Medicine Index and could be a takeover target for big pharma after Johnson & Johnson (JNJ) agreed to pay $1.1B for breast implant maker Mentor (MNT) – although the market cap of Allergan is much larger at $11.7B with a wider range of businesses such as specialty pharma, medical devices, and cosmetic medicine.

Last Winter, cosmetic manufacturer, Jan Marini, was forced to pull a similar product off the market by the FDA because (as I understand it) they 1) didn't have FDA labeling approval to promote themselves for that indication, 2) didn't have any clearance to sell a prescription glaucoma drug (which was the active ingredient) over the counter, and 3) Allergan had patent rights on the substance that was the active ingredient. Talk about ballsy! A blurb last winter from the "Truth in Aging" blog about this can be read here.

I guess I must just have the "vision" thing for this sort of product as I kind of shrugged my shoulders when I heard about it before. However, pre-market surveys indicate there is a BIG market for it, and the price of this product is going to be fairly low. Expect every Tom, Dick, & Harry fringe aesthetic medical provider to be pushing it I predict.

Rob

Breast Implant designer commits suicide from Yew seeds(!)

A South African man died who'd designed a novel type of silicone breast implant recently committed suicide by eating poisonous yew berries from a nearby graveyard of all things.

From Wikipedia on the Yew tree toxicity:

The major toxin is the alkaloid taxane. The foliage remains toxic even when wilted or dried. Horses have the lowest tolerance, with a lethal dose of 200–400 mg/kg body weight, but cattle, pigs, and other livestock are only slightly less vulnerable.[7] Symptoms include staggering gait, muscle tremors, convulsions, collapse, difficulty breathing, and eventually heart failure. However, death occurs so rapidly that many times the symptoms are missed.

Jonathon Hamilton a talented design engineer who had recently lost majority control of his an implant business he'd founded when he was forced to sell stock to cover his debts. His company "Smart Implant" has a proprietary design where the filler of an implant is composed of hundreds of solid silicone beads instead of a viscous silicone gel.

Having never seen one of these implants in person, I'm not sure there's much to this departure from conventional design that is much of an advantage but it's an interesting idea. These type of implants are not available in the United States and I'm not aware that they've even applied to the FDA to conduct clinical trials here.

Rob

Kayne West's nurse cousin now being investigated in Donda West case

The death of Donda West, mother of hip-hop star Kanye West, the day after undergoing plastic surgery last year was big news. The surgeon involved in the case received a great deal of criticism and the implication was that he'd commit ed some horrible malpractice on Mrs. West.

I talked about this last Spring (see here), going over the autopsy report that was released online. The report vindicated Dr. Adams of some technical mishap, but was inconclusive on what actually caused her death. I speculated she vomited and aspirated with subsequent respiratory arrest, a not uncommon scenario we see in hospitals and nursing homes in elderly or infirmed patients.

A new wrinkle is being looked out apparently. Could Donda West's death be from an overdose of her pain medicine given by her cousin? I still think my aspiration idea is more plausible, but the role of pain killers could be a component in that mechanism (ie. narcotics can cause post-operative nausea/vomiting and a stuporous patient is more like to aspirate). I'm not sure that's a fair suspicion to throw on someone unless her toxicology had abnormally high serum levels of her pain medicine.

From the UK's Daily Mail

Police have now launched a probe into the possible role of her nephew, Stephan Scoggins, 46, a registered nurse who was allegedly supervising her post-surgery care.

A source tells American magazine People that investigators are looking into the alleged possibility that Scoggins administered too much of the painkiller Vicodin in a short period of time.

The insider also alleges that Scoggins left West in the care of a friend and Kanye's assistant to attend a baby shower prior to her death.

Last January, a Los Angeles coroner ruled that West died of 'multiple post-operative factors,' clearing West's embattled surgeon Dr. Adams of responsibility.

An investigator for the California Department of Consumer Affairs has issued subpoenas asking individuals 'to testify in the matter of the investigation of Stephan Scoggins,' a source tells the publication.

Rob

Breast implant maker Mentor Corp. now "augmenting" Johnson & Johnson's portfolio

Santa Barbara-based Mentor Corp., one of the the largest manufacturers of silicone breast implants, is in the news today with word of a takeover bid by Johnson & Johnson. If you're a shareholder in Mentor, you're going to be making some serious coin today. J&J is paying $31 for each Mentor share, a big 92% premium to Friday's closing price but well off its 52-week high of $40.82 about 11 months ago.

Mentor, and rival Allergan, have been locked in a real dogfight for market share of the American (and world) market in breast implants. Mentor today gets almost 90% of its revenue from breast implants, most of which are sold for cosmetic proposes. To survive, Mentor had been desperately broadening their portfolios to include dermal fillers, a BOTOX alternative ("PurTox") , an Alloderm alternative (NeoForm), and medical grade skin care lines. Their expansion to this point has run right into the teeth of the financial market downturns, and their earnings and stock price had been pummeled to this point. A real interesting transcript of the company's on the record discussions with institutional investors last week seemed kind of defensive. You can read it over at the excellent Seeking Alpha website of financial stories. They sure kept this deal under wraps!

This seems like an excellent opportunity to achieve synergy with some of J&J's research and development capability and distribution networks. It puts them on more equal footing with the large corporate entity Allergan.

Rob

A must see video guide for "Lost" fans

I was talking to someone the other day who had just discovered ABC's TV series "Lost". The storyline and mythology of that great show is formidable and can be overwhelming to most casual fans as it is extremely self referential to earlier episodes and full of allegory and oblique symbols. There is NO way for most people to decipher this show and catch all that the creators are "burying" on screen.

To the rescue come's "Seanie B" on Youtube. This guy takes each episode and breaks them down in detail, pointing out things you'd never have picked up. It really takes watching the show to a new level. Sean's "channel" on Youtube can be found here.

Below is a clip from Season 1


Rob

Quick thought for the day! Maybe we've already reached bottom on the stock market.

I just noticed, but last week was the best week in 34 years for the S&P US stock index, up 19%!

I've written before how much of a believe I am in all things Bogle (see last July's "Bogleheads of the World Unite!" (John Bogle being the father of passive index investing). Bogle's advice on staying the course and relying on age appropriate asset allocation offer some comfort at times like these.

In the words of investment guru Larry Swedroe "while it is almost 100% certain that the economic news will get worse (with unemployment certainly headed much higher) stock markets are FORWARD looking, leading indicators, something most investors either don't know or forget.". While we're still in choppy waters and lower earnings in early 2009 can erase this progress, history suggests we may be nearing the bottom of a 40% decline in the market's value.

If you don't stay invested and contribute during this period, you're going to miss out on historically low equity prices. When you look at a decade or more's worth of behavior of the market, there are only a few trading days where the growth of the market index value for an entire bull market is largely established. Last week was likely a clump of these days. Stay the course!

Rob

Happy Turkey Day 2008

Happy Thanksgiving from Plastic Surgery 101!

I've got lots of posts kind of half-finished so expect fairly regular output here in the next few weeks.

Rob

Plastic Surgery 101's winter music recs - Samples, Samples Everywhere!

Someone wrote me the other day asking if I'd do another post on music after stumbling across my last group of recs in May (see here). I've gotten interested in how some artists are incorporating sampled guitar/rhythm loops into their acts, especially in live performances, so I think I'll point to some of my favorites!

Master of the sampled loop, Imogene Heap in "Just for Now". How the heck she can keep track of all these samples during this performance I have no idea. Absolutely jaw dropping! I also suggest the beautiful "Hide and Seek" which is introduced by NBC's "Scrubs" star, actor Zach Braff BTW.


KT Tunstall's "Black Horse and the Cherry Tree" live on the Today Show in 2006. This performance single handedly launched her career in the United States.


Yoav's creepy acoustic "Club Thing". His song "Beautiful Lie" is also really neat with the samples


The Kills industrial-tinged "Getting Down". There's a great feature on them on the Sundance channels' Live from Abbey Road series. Must see TV!


The Yeah Yeah Yeah's "Maps". This is an a great acoustic version. For the an extreme electrified live version go here


Please feel free to leave any suggestions in the comments for interesting music! I'm always looking for new stuff.

Rob

Can some breast cancers just "go away"? Data mining says maybe, but it's complicated.

There's a paper this week in the Archives of Internal Medicine discussing the phenomena of some breast cancers possibly going away without treatment. As I do a lot of breast cancer related surgery, I know I'm going to get asked about this by a patient one of these days.

The paper is titled "The Natural History of Invasive Breast Cancers Detected by Screening Mammography" and can be read online here.

It opens with the observation that

...screening mammography has been associated with increased breast cancer incidence among women of screening age. If all of these newly detected cancers were destined to progress and become clinically evident as women age, a fall in incidence among older women should soon follow. The fact that this decrease is not evident raises the question: What is the natural history of these additional screen-detected cancers?

From autopsy studies of the elderly, we know we find many breast and prostate tumors which are clinically silent and that the patients died with rather then from. In an idealized world we could understand tumor biology enough that we could safely say some breast cancers could be watched, just as we already do with some prostate cancer.

This idea of "benign neglect" (no pun intended) for malignancies in regards to current standard treatments of surgery, chemotherapy, and radiation could potentially spare people significant morbidity and save the health system a great deal of money. One example of this would be the emerging idea that the drugs that block estrogen hormone metabolism (Arimidex) or estrogen receptors (Tamoxifen) may be just as effective as chemotherapy in post-menopausal women with estrogen receptor positive (ER+) tumors.

Now the study in question is taking some BIG leaps in logic making their conclusion. Much like financial analysts use "back casting" to test stock/bond buying strategies in the rear view mirror, these type of retrospective ideas can suffer from the fallacy of taking a result and looking back to make the data fit. This idea of watching these tumors would need to be done prospectively with very close followup. It would never be possible to do this trial in the United States due to internal review boards (IRB) and medical malpractice issues, but such an experiment might be possible in other countries (In the New York Times write up, Mexico is suggested for instance as a candidate. Gracias muchacho!)

Something to think about!

Rob

The FDA's got dermal fillers "under their skin"

This past week the FDA had some hearings to discuss the issues of dermal fillers (like the popular Juvederm, Restylane, Sculptura, & Radiess) and BOTOX. The use of such products has exploded in recent years and we've seen some real complications reported. The majority of such problems are usually minor and transient as most of these products degrade or wear off. However, there are some products whose effects are permanent (like some of the micro-silicone injectables which aren't used in the US) or last up to several years (like Radiess or Sculptura).

The FDA presented data on over 800 patients who suffered reactions after injection with dermal fillers between 2003-2008. There have been no deaths reported to the FDA, but almost 80% of the patients required follow-up treatment of some sort. Most of these were minor swelling and redness (which isn't really a complication, but expected IMO). However, the FDA also received reports of "serious and unexpected" problems, including facial, lip and eye paralysis, disfigurement, vision complications and some severe allergic reactions.

Most troublesome complications of these fillers are those injected around the eye to fill the hollow "tear trough" that develops under the lower lid with aging. Injections in that area offer a solution that cannot be reliably fixed surgically as the changes are produced from a combination of atrophy of the cheek bone (malar complex), deflation of the fatty tissue of the orbit/cheek, and thinning of the skin rather then something descending and producing loose skin. The thin skin of the lower lid is unforgiving for imprecise injection of dermal fillers as it shows each and every irregularity. In addition, inadvertent injection into a blood vessel in this area has been associated with embolic phenomena to the eye which can produce blindness. Natasha Singer, the NY Times go to girl for cosmetic surgery articles wrote a nice summary up last week (see here).

Not directly addressed at this hearing was the hornet's nest of exactly who is actually doing these procedures, particularly those indications that are still "off label" for the injectable. (Natasha, if you're reading this BTW that subject is screaming for an feature by you....Rob) To this point, states have been reluctant to engage the issues about qualifications and credentialing for doctors performing aesthetic medicine or surgeries. It strains common sense to allow people who are un or undertrained to perform these types of procedures. IMO, if you're not trained in lower eyelid surgery (a la an opthomologist, plastic surgeon, or ENT surgeon) you don't have much business pushing injectables or fat grafting that area - it's that finicky! In many other states, physicians are not even required to do these procedures themselves but are free to delegate them to low level providers or nurses.

Rob

The death of the bull market in cosmetic medicine (?)

Sorry for the extended break!

Lots going on with the practice and the increasingly complex undertaking of building out a new office and surgery center while the country is treading water with the financial markets. There's lots of anxiety in Plastic Surgery these days as people's disposable income is drying up for cosmetic surgery, injectables (like BOTOX & Juvederm), and noninvasive laser treatments (IPL, hair removal etc..).

A number of medispa outfits have gone bankrupt, stock prices for major players in cosmetic medicine like Allergan & Mentor have fallen faster then other stocks of similar market cap size, and practices across the country are reporting flat or negative growth for 2008. Just today I heard that Rhytec, maker of the innovative Portrait Plasma laser resurfacing system is shutting down, potentially leaving owners SOL for replacing the disposable treatment tips on their expensive laser machines.

I've been obsessed reading a number of books about financial history, market theory, and asset allocation. I can't recommend enough the classic book by Dr. William Bernstein (who is a practicing Neurologist of all things BTW), "The Four Pillars of Investing" which lays out a very compelling lens thru which to view the ebb & flow of investment going back hundreds of years. Everything we're enduring now has happened in some form or another somewhere in history, and about once a generation we should expect the world markets to go crazy. It's ironic that if you're early in your adult life, the current events may make the best time to invest heavily in equities that you will ever see during your lifetime (in the "buy low, sell high" sense).

I'm thinking of this as I'm reading an article by Michael Lewis in today's Portfolio magazine "The End of Wall Street's Boom". Lewis is the author of the classic baseball book "Moneyball" and the 1980's wall street classic expose "Liar's Poker". This article revists the same territory of "Liar's Poker" and is a fascinating look at the insanity/stupidity of the Wall Street culture in priming the pump for our current problems. It really dovetails nicely with Bernstein's book at exposing what fools we mortals be!

Rob

The Daily Mail's "keyhole" breast cancer surgery technique not so new (or useful?)

Ok, I bit on the headline of some new "revolutionary" (their words) breast cancer technique written up on the UK's Daily Mail..... the "keyhole technique"

The article describes an endoscopic (lighted camera) assisted mastectomy done to preserve the nipple during surgery in breast cancer cases. As nipple sparing mastectomies have been done by plastic surgeons (and more recently breast oncologists) for about 50 years, officially color me skeptical that this technique adds anything other then complexity and or time.

For instance, in the last 2 weeks I did 2 nipple sparing mastectomies thru 3 cm incisions (one for male breast enlargement - gynecomastia, and one prophylactic for a woman with a history of breast cancer) sans endoscope in well under 45 minutes

Rob

Plastic Surgery 101 takes on the big apple + Alloderm and breast surgery

Sorry for the gap in posts! It's been almost 2 weeks and I just haven't been "feeling it" for updating the blog.

Presently I'm in lower Manhattan at a symposium on the use of Alloderm in breast reconstruction surgery. Alloderm is produced from human skin where the proteins which would ordinarily cause you to reject the tissue graft have been removed. What's left is a "living prosthetic" that can be used to reinforce the body's tissues.

Alloderm has gained popularity in breast reconstruction as it allows us to bridge the concepts of traditional reconstruction with techniques we use in breast augmentation. I was kind of an early adopter of using Alloderm over 3 years ago in response to some of the limitations of the techniques I was taught during my training. At this point, Alloderm (or related products) are used not infrequently by many surgeons.

I'd like to briefly mention two restaurants here in NYC that my wife and I had wonderful dinners at

Bouley - where I'd strongly recommend the 5 course Chef's tasting menu. Magnifique!

The Tribeca Grill - Great steak! Very affordable for a nice restaurant in NYC.

Rob

Doctor Shopping - Finding the doctor you need

So I'm sitting in Starbucks near my house with my kids when this group of joggers comes in for a post-run sit around. They immediately get off into some discussion about orthopedic sports medicine and their various injuries, complete with editorials about how their doctor is wonderful, how they were "misdiagnosed", and wondering how different specialists gave them contradictory advice or opinions.

I kind of felt sorry for them. Picking a doctor is tricky, even for doctors. As I work doing surgery at half a dozen hospitals, I have a general idea of the reputation of different surgeons' abilities and personalities in several parts of town.

When I was a resident working with dozens of different attending surgeons, I definitely felt like I could get a feel for who was outstanding or poor. However, when my wife had musculoskeletal back pain, I was left to kind of "guess" at the competence of a neurologist (whom I really respect BTW) who was treating my wife. Some of their field is just too removed from my scope of practice to be fluent in.

Eavesdropping on the joggers reminded me of a letter in the New York Times health section on an article about picking doctors, "You Can Find Dr. Right, With Some Effort". There was a really insightful letter from an ER doctor that stood out to me which I think is worth republishing:

As an emergency physician for 32 years, here is how I would and would not go about finding a personal physician:

1. Chronic medical care: choose primarily based on personality, secondarily on skills. All doctors are smart, in the top 1% of the population, which makes them abnormal to start with. For ongoing care, you need the minority with great personalities. For skills, just make sure they are ABMS (www.abms.org) board-certified.

2. Surgical care: Choose primarily based on skills. Ignore their personality. Here you want the best technician with the best judgment, not Marcus Welby. It will usually be a short-term relationship for a problem that requires invading your body and significant medical judgment issues. It’s not worth trying to find someone who combines both skill and personality; if you get both, it’s a bonus.

3. Acute care: You’re at your most vulnerable and have no time to research. Your regular doctor rarely can see you for acute care: you end up in an urgent care center or ER. Choose based on skill and judgment only, which must necessarily be based on quickly accessible reputation and qualifications.

OK, how do you find someone based on skill/judgment, or based on personality?

1. Personality: Here’s the only place to use friends, neighbors, and trusted acquaintances. These people are qualified to judge this aspect of a physician. This is totally unrelated to a physician’s skill or competence, but this is important for chronic medical care.

2. Skills/judgment: Never use the recommendations of non-medical personnel. They have no basis on which to judge. Avoid online evaluations: they are statistically prejudiced and don’t account for individual practice variances. Instead, use trusted medical acquaintances such as physicians or nurses to make recommendations. They have both the personal experience and medical sophistication to make such recommendations.

I'd agree in general with the insights of this doctor, especially with surgeons. For instance, there were some grade-A sociopaths I knew/know in various specialties whom are outrageously gifted surgeons. I'd be happy to let them do my liver resection, organ transplant, aneurysm clipping, etc... as long as I did not have to speak to them ever again.

Rob

BOTOX on the brain - You know you're a plastic surgeon when....

You know you're a plastic surgeon when you watching the press conference tonite by the US Senate leadership about passing the $700 billion USD bailout bill and not being able to take your eye's off of Sen Mitch McConnell's BOTOX'd brow!




Sen. Mitch McConnell (R-KY)



Other pols who stand out for BOTOX

Hillary Clinton (D-NY)



Nancy Pelosi (D-CA)



Nancy Pelosi's Cat :)



Rob

Oliver Plastic Surgery's new home (and name) - coming January 2009!

Sneak peak for today! 

My good friend and colleague, Dr. Jason Jack, and I are busy working on moving our practice to our new home in suburban Birmingham. Hopefully we're set to open in January 2009. What's exciting has been the chance to design from scratch, an office to accommodate a 21st century Plastic Surgery practice.

I've learned more about fire codes, environmental issues, work flow theory, electrical engineering, and architectural design ten I've ever wanted to know about.

One thing I'm particularly excited about is the ability to offer a state of the art office surgery suite which will offer us tremendous flexibility and convenience for our patients for cosmetic procedures. It also makes us less vulnerable to the random and often pernicious pricing patterns that hospitals and anesthesia groups have for cosmetic surgery in a hospital setting.

Rob

Britain's Plastic Surgeons ask for truth in advertising

A big Cheers(!) to our colleagues 'across the pond' who are encouraging more professionalism in the business of cosmetic Plastic Surgery.

The British Association of Aesthetic Plastic Surgeons (BAAPS) has made a position statement that digitally enhanced pictures of bikini-clad women in writhing poses should be banned in advertisements as they mislead patients about expected results. BAAPS has singled out one chain of cosmetic clinics for particularly egregious promotion, pointing to an ad by the West One Clinic franchise which used models in advertisements that are "anatomically impossible".

Below is the wasp-waisted model with gi-normous breasts that apparently started this discussion. It clearly looks to me like she's been "morphed" with Photoshop to narrow her waist in relation to her trunk.


A second promotion offers a £250 ($462.55 USD by today's exchange rate) discount to customers as an incentive to have the surgery quickly, while a third offers a "lunchtime facelift", which arguably plays a little fast and loose by with downtown and recovery for short-scar facelift procedures.

This education that BAAPS is not a call per se for limiting all cosmetic surgery procedures, but rather it is a desire to see a more safe, thoughtful, and informed process take place when someone is considering surgery. It is impossible to remove unrealistic body images from pop culture, as both men and women strive for whatever form is popular in their era. What we do owe patients are frank discussions about the limits and morbidity of surgery minus the "magic brush" function of computer photo editing.



Rob

Another attempt by lawyers to get around tort limits on medical malpractice cases

This is getting real old, but the American trial bar is once again attempting to establish a game plan for circumventing liability protection that the FDA grants drug and device manufacturers after going thru the FDA approval process. An important legal precedent was upheld last winter which I wrote about in a post "Trial lawyers' ability to second guess the FDA on medical devices neutered" which refused a plaintiff's motion to allow layperson juries to essentially second guess the proceedings of expert FDA panels on medical devices. Medicines curently do not have that same level of insulation, and trial lawyers are contributing in record numbers to the Democrats for the fall election expecting favorable amendments to the law allowing expanded liability.

In a New York Times story this week, "Drug Label, Maimed Patient and Crucial Test for Justices" the case of a patient who had an inadvertent injection by a allied health provider (not a doctor)of a widely used anti-nausea medication (phenergan) into an artery in her hand and eventually suffered an amputation as a result of complications. This drug has been used for decades, and is both safe and cheap. The manufacturer of the drug is essentially being sued for a labeling issue where they claim that warnings about her particular complication were not prominent enough.

This type of action is embarrassing for our legal system, and demonstrates the great American legal tradition of finding the deepest pocket and suing the hell out of it. In this instance, the medical center already settled with this patient, but they're going for the big $$$$. While this individual had a terrible thing happen, it's not even clear that true malpractice even happened. Fines and putative damages on industry in these cases should be paid to the feds rather then individuals so as to remove the financial incentive for these ridiculous cases beyond economic damages.


rob

Does it make sense to screen asymptomatic breast implants with MRI?

One of the peculiarities of the USFDA process during silicone implant reintroduction in 2006 was the labeling on the devices recommending routine MRI surveillance of implants for rupture. When you step back and look at the proceedings and "unique" American history with breast implants, you can see that this was more a political concession to the anti-implant activist lobby then evidence-based medicine.

The FDA labeling currently suggests MRI's at 3 years post op and then every 2 years subsequently. It will be interesting with the coming form stable "gummy bear" implants whether or not this recomendation is still maintained.



Why 3 years for the first MRI?

That was the first data point with any ruptures reported in the FDA data during clinical trials. While there will be a certain failure rate associated with any manufactured device, it's likely that early failures of silicone devices were from missed trauma to the implant during insertion. Education courses on proper techniques for implant handling and insertion in recent years have emphasized ways to minimize this risk by suggesting larger incisions for gentler introduction and better visualization during closure.


But does it make sense to do this?

Clearly it does not. On this point, there's pretty much international agreement (USFDA excepted).

We've actually got a pretty good handle on rupture rates of 4th generation implants (conventional devices used for the last 15 years or so) up thru a decade, where it's pegged around 6-8% at 10 years based in two pretty solid studies on single devices by the two major implant makers Mentor & Allergan. If you take that and work backwards from the FDA recommendation, you're doing up to 4 MRI's during the first decade where the rupture rate is either almost nonexistent (years 3-7) or in the low single digits (year 9).



Whether you're screening an asymptomatic population for ruptured implants, colon cancer, breast cancer, or aortic aneurysms there's trade offs between costs and risk reduction. For tests to be effective for screening, they must satisfy both criteria. For a number of cancers, screening tests often fail this goal.

Take screening mammograms or breast self-exams for instance to detect breast cancer. In non-selected groups of women, both cancer detection modalities increase both cost and morbidity from unnecessary procedures without materially affecting death rates from breast cancer (arguably the whole point of screening). It's been persuasively argued when reviewing the data, that screening mammograms can be deferred to age 50 for low risk women (as opposed to the current recommendation for age 40) and perhaps discontinued altogether for women in their 70's with no affect whatsoever on breast cancer death rates. BTW, this same pattern of "dodgy logic" of routine screening also exists in regards to male prostate cancer and lung cancer screening in smokers.

Anyway, back to implants......

At the end of the day it's just hard to support screening implants for rupture in asymptomatic patients on either a cost basis or benefit basis. As it's been established that ruptured silicone implants (silent or otherwise) do not appear to correlate with systemic illness, the clear benefit of screening asymptomatic women is hard to establish. A team of doctor's from the world famous Sloan-Kettering Memorial Cancer Center agreed with this sentiment in a recent paper, Silicone Breast Implants and Magnetic Resonance Imaging Screening for Rupture: Do U.S. Food and Drug Administration Recommendations Reflect an Evidence-Based Practice Approach to Patient Care?


Rob

What Christina Applegate's looking at with her breast cancer reconstruction

Earlier this month, actress, Christina Applegate announced she'd undergone bilateral mastectomies for breast cancer. She reportedly possess one of the better characterized "breast cancer genes", BRCA1, which puts her at extraordinary high lifetime risks for developing breast or ovarian cancers. From the wire reports, she deferred reconstruction and plans on becoming pregnant after planned chemotherapy.

It sounds like she's received very mainstream advice for treating a younger breast cancer patient, particularly for a BRCA1 carrier. IMO these patients are excluded from consideration for lumpectomy procedures for treatment and should be strongly advised to consider prophylactic surgery on the other breast to maximally reduce lifetime risk of subsequent breast cancers. It's important to make sure patients understand that the highest risk factor for breast cancer is a personal history of breast cancer in the contra lateral breast. In young patients like Ms. Applegate, the math is even more persuasive for aggressive surgery as they have longer life expectancies during which breast cancers can develop. These patients are also frequently recommended to have the ovaries removed, both to suppress native estrogen production (which can stimulate some breast cancers) and to decrease the 40%+ increase in risk of ovarian cancer that brca1 confers.

I'm a little confused why they would not have proceeded with any part of her reconstruction at this point. She's trim enough that I do not believe she has enough bulk to do her reconstruction using her own tissues alone (probably using some microsurgical technique). I'd have strongly advised placing tissue expanders at the time of mastectomy to maintain the skin elasticity and you could later decide if you needed silicone gel implants or you could find an acceptable donor site for some autologous tissue to use. In a low risk patient, you really don't lose much by expander placement, while you realize an easier expansion process.




Rob

actor Gabriel Olds on women who've had plastic surgery -Put your asshat on, Gabe!

So B-list actor Gabriel Olds pens this piece for the August 2008 Glamour magazine titled, "Why men crave real (not perfect) bodies". It's funny when Jerry Seinfeld breaks up with a woman for having "man hands" in a classic Seinfeld episode, but you it's tacky when you're that frank in a print column.





Fine. You certainly can make thoughtful and plausible arguments why we all should ignore contemporary ideals of female beauty (real and imagined) and realize inner beauty for what it is. You do NOT have to do it in a dickhead tone of voice which alienates said women. Monsieur Olds quickly falls off the cliff quickly in that regard with his narcissistic article.

The women commenting to the article certainly had their fangs out over this:

I have breasts implants, and before I got them I spent my entire life being ridiculed by both men and women. I had absolutely no breasts. I was nothing but a nipple and I always felt like less of a woman. I couldn't find clothes that fit well, bathing suits were a nightmare, and shopping for bras was nearly impossible. I made the decision to undergo breast augmentation not because I wanted to be "perfect," it was because I wanted to be "normal".

I would like to say first, how presumptuous of Mr. Oldnutsack to assume that we should reveal our own medical history before we have even had the opportunity to see the size of his dick.(OUCH!)

I mean really, to dump someone/doubt their honesty because they didn't immediately tell you about a surgery?! I highly doubt you would go around telling first dates or third dates even, "I have ED. I have a dangling penis, so I take Viagra to make it perkier."

this author is SHALLOW. He had one superficial date with a women he is PHYSICALLY attracted to and he is writing her off! He is obviously not interested in getting to know her on the inside. I am a psychotherapist. People like him need to take a good LONG look at them selves and be honest about why they are afraid of intimacy. It is clear to any one reading this article that his motive was purely sexual. If the author wants perfection then he will need to accept that perfection is achieved by alteration and that anything natural has flaws. A word of advice: Try to shake your narcissism, mister. It's unattractive to women. Hey, are you sure she didn't dump you after she felt YOU up!

Rob

Good Doctor of the Day Award - Dr. Paul Offit on autism and vaccines

I've mentioned in a 2007 post, "Mad Science", about the political issue of autism's and their alleged link to childhood vaccinations in the past as a metaphor for what we went thru with the debunked tort driven silicone breast implant (SBI) scare in the late 1980's. Unlike SBI's which are a cosmetic product, vaccines save lives. Lots of them!

A wrong headed attempt to blame first a preservative in some vaccines (thimerosol) and later the vaccines themselves for new diagnosis of autism has led to a dangerous public health situation. Pockets of non-immunized children can clearly serve the role of "typhoid mary" for pandemics of illness if history is any guide.

The number of new measles cases in the U.S. is at its highest level since 1997, and nearly half of those involve children whose parents rejected vaccination. According to the Las Vegas Sun,

It is no longer endemic to the United States, but every year some Americans pick it up while traveling abroad and bring it home. Measles epidemics have exploded in Israel, Switzerland and some other countries. But high U.S. childhood vaccination rates have prevented major outbreaks here.

In a typical year, only one outbreak occurs in the United States, infecting perhaps 10 to 20 people. So far this year through July 30 the country has seen seven outbreaks, including one in Illinois with 30 cases, said Seward, deputy director of the CDC's Division of Viral Diseases.

....The nation once routinely saw hundreds of thousands of measles cases each year, and hundreds of deaths. But immunization campaigns were credited with dramatically reducing the numbers. The last time health officials saw this many cases was 1997, when 138 were reported. Last year, there were only 42 U.S. cases."

Leading the voices of reason and evidence-based medicine is Dr. Paul Offit, who has a great new book coming out this whole controversy and breaks it down for a lay audience as to what the issues are and what the evidence shows. Linked below is a nice clip of Dr. Offit summarizing this.




Rob

Plastic Surgery 101's Olympic Update - It's sunny side up on the beach volleyball coverage!

If you've ever watched professional sports events, you'll notice the cameramen have this habit of doing random crowd shots where they zoom in on pretty women pretty shamelessly. Women's beach volleyball coverage takes this to a whole new level.

Under the guise of "explaining the importance hand signals" during the match, NBC has about the most gratuitous photo gallery of women's backsides in teeny-weenie bikinis this side of Sports Illustrated's swimsuit issue. The whole idea of buttock aesthetics has received some attention in plastic surgery literature, and one of these days I'll write about it.

If you think I'm exaggerating about how blatant a T&A show the coverage is, please check NBC's gallery on the web which as far as I can tell was likely compliled by a 12 year old male NBC staffer!

Usually, in doubles competition, you have a server and you have his/her partner near the net. Crucial to a successful game play is a good line of communication between the players on a team as the court is a wide area for two players to cover. A lack of coordination between players will likely result in wide open spaces and a disjoint defense. It is up to the person nearest the net to call the shots and signal clandestinely to his/her partner what the intended game play is. In essence, the person nearest the net is the quarterback of the team.

There are 4 basic "modes" for each hand which is held behind the back to signal the other player. 'One finger' signals that the net player will block the opponent's spike down the line on the corresponding side of the hand. 'Two fingers' signals that the net player will block the opponent's spike at an angle cross-court on the corresponding side of the hand. A 'closed fist' signals that the net player will not block on the corresponding side of the hand. And finally an 'open hand' signals that the net player will block "ball," i.e. block according to how and where the opponent sets and swings.

I think this athlete's signaling she's wedging! :)




Rob

Plastic Surgery 101 suggests look before you leap (in logic) on hospital infections

There's an op-ed piece in today's Wall Street Journal by one Betsy McCaughey which has my blood pressure up. The article titled, "Hospital Infections: Preventable and Unacceptable" implies that any hospital acquired infection was preventable and should be remedied with class action lawsuits.

For someone who's bright like Ms. McCaughey, she shows little insight and understanding apparently into what drives and perpetuates many different types of infections. Nobody disagrees that common sense steps like hand washing and protocols for invasive intravenous (IV) access maintenance are important in limiting infections, it is both a dangerous and disingenuous idea to suggest that a goal of ZERO is attainable. It is impossible to achieve a failure rate of 0% for system or process, particularly one with infinite numbers of variables (as with a human population of patients). Unlike a Toyota, no two models of the human assembly line are exactly alike (even identical twins gradual accumulate differences due to environmental exposure).

Patients with more comorbities are going to have higher infection rates PERIOD. An overweight, diabetic, smoker (a frequent demographic for vascular disease patients in my neck of the woods) who has open heart surgery has more problems then others and an increased infection rate is more attributable to the patient's behavior rather then the hospital. Obese patients and smokers have higher rates of problems after elective plastic surgery (like breast reconstruction or reduction for instance)as well for that matter. You can be sure at some point, hospitals (and doctors) will be looking at patient demographic data to exclude higher risk patients from treatment at their facility whatsoever.

In referring to a list of "never events" recently laid out by Medicare for which they will not cover the cost of complications she blithely writes

"No wonder Medicare calls these infections "never events" Why should jurors reach a different conclusion in a lawsuit."

This coming from a bureaucrat and politician is hard to take. While we should always strive to be perfect, it's important to realize that there are processes which we can all agree on to attain low and reproducible rates of infection.

For a related writing here on Plastic Surgery 101 see the post "Medicare announces they won't pay for complications - How the F*** is this going to work?" that I wrote last year.


Cheers!
Rob

Beware! Entering a no spin zone: Predictable pullback on Smart-Lipo and other laser assisted liposuction systems

It was so predictable as to be boring!

So I'm reading a particularly shameless trade journal this week who's cover story promised updates on laser liposuction. This monthly glossy magazine is essentially a series of (not so) stealth ads with physicians shilling for lasers and other products for which they're paid spokesmen. As the topic turned to laser liposuction systems (like Cynosure's SmartLipo) you saw a lot of pullback on exactly how enthusiastic a number of surgeons are.

"In reality, the degree of fat melting attained with laser lipolysis has not met the high expectations of some practitioners"

When you see comments like that in a fluff trade journal which routinely celebrates every device/technology (whether it deserves it or not) you know this issue is understated significantly. When you take mostly non plastic surgeons and hand them a "magic wand" like SmartLipo while promising great body contouring results, it's a set up for under delivering. There still is no shortcut on mechanically removing tissue for most patients. An exception might be some one's neck which has almost no fat to speak of.

This is kind of like the thread lift fiasco all over again. It's become clear that these laser platforms are much less revolutionary, but are more likely modestly complementary (if that) to the 30 year old tumescent liposuction techniques introduced to the west by a French surgeon named Illouz.

The general "off the record" feelings of most experienced plastic surgeons experimenting with this is that these types of devices are safe but offer no clear advantage. Repeatedly it's described more as a succesful marketing phenomena rather than a real improvement. It's still not established that delivering thermal energy below the skin affects "tightening" whatsoever, which is the whole gimmick of the laser. If it does, it doesn't appear to do it without still having to do most of the heavy lifting with traditional lipo.

In contrast to this unnamed aforementioned trade journal which is lame, I'd like to give a nod to editor Jeff Frentzen and Plastic Surgery Products magazine which frequently has good articles - like mine for instance


Cheers,
Rob

Note to self - Never tell a woman she has a witch's chin deformity

Doh!

Sometimes our terminology and analysis comes out of our mouth without thinking about how people may internalize it. So I'm at this event the other night celebrating my new partner's addition to the practice, and I made the innocent mistake of telling someone I thought they had a little bit of a "witch's chin" when they were asking me about what they didn't like about their own chin.




Big mistake!I think I've now scarred that girl for life as she's now fixated on it! While I was implying a subtle chin feature that only someone like me is going to pick up on, she's imagining I've called her the wicked witch of the west. That awkward moment has inspired today's sermon on chins.

Cartoons characters such as Andy Gump and Broom Hilda the Witch are best known for their exaggerated facial features. In Plastic Surgery we have borrowed these characterization helping us to describe features with the “Andy Gump Syndrome” or the “Witches Chin Deformity.”




An Andy Gump deformity is produced from not reconstructing the jaw bone (mandible), most commonly when cancer surgeries in that area require removal. In 2008, such mandible problems are treated by taking a piece of your fibula (a lower leg bone) and doing microsurgical reconstruction to transplant it to the jaw. I did about a dozen of those in my training and it's an elegant surgery. As I don't do microsurgery in practice or work at a hospital where such large ENT cancer surgeries are performed, I hopefully will never be asked to do something like that again!

A "witch's chin" deformity describes either an excess of fat and/or drooping of said fat on the projecting part of you chin. The surgical correction involves removing the bulk and suspending it to the bony part of your chin. Seen below is a representative picture of the condition and a graphic of one of the operations to fix it.















For all you ever wanted to know about witch's appearences in pop culture throught history, check out the neat "Sexy Witch Blog" from Australia.

G'day mates!
Rob

Will the last medical dermatologist please turn off the lights? Access issues for dermatology patients

The trend of Dermatologists becoming more and more unavailable for actually treating dermatological conditions is in the news again in the front page of the New York Times. The article, "As Doctors Cater to Looks, Skin Patients Wait" discusses the discrepancy in how patients are catered to for cosmetic versus medical dermatologic conditions. I blogged about this same issue last September in "How Botox affects your access to a Dermatologist"

There's a few dermatologists quoted who really come off poorly in the language they use justifying their practice choices. You can bet they'd like a mulligan about now in their 'on the record' interview.

Peppered in the comments section to the article are the predictable griping like,

• "Doctors should not get rich off their patients. Period. End of story. Society has greatly subsidized every doctor's education. If a doctor wants to supplement his or her income with cosmetic procedures, this should be strictly evenings and weekends."



• "Why on earth should a 10-minute botox injection be worth $500?"



• "...clinics will not take patients without referrals, and unless a matter is urgent, it can take 4 - 5 months to get an appointment (which they keep as short as possible). However, if a patient wants a cosmetic procedure, it takes only 1 - 2 weeks for an appointment. The dermatology profession needs to examine its ethics, or the lack thereof."



• "The rest of the medical system will follow. Once health care becomes a one-payer system, there will be a second tier for the moneyed. This is how medicine works in Europe."



• "This is a perfect example of market forces at work, and proof the market works perfectly. Money talks. In this case, however, market forces pervert the delivery of good health care. The solution is to reimburse doctors for actually taking care of patients, not doing procedures or ordering expensive tests. With a regime change in Washington on the horizon, we will hopefully have a complete overhaul of our decrepit and wasteful health care-industrial complex."



• "Disgusting example of the growing scummy side of medicine. A terrific example of how the wrong people gain admission to medical school, sociopath sales persons, "I've always wanted to help people, blah, blah blah..." while only interested in the cash. We need a new health care system with salaried physicians"



• "These comments are scary. Most are uniformed, ignorant and miss the point. Physicans can't meet their overhead and are responding to "managed care" in the only way they can. It is the root cause of most of the ills we see today. We will never able to administer quality healthcare in this type of system. How is it possible for a small practice to negotiate equitable reimbursements from a market giant such as Cigna?"



• "The idea that patients with potential skin cancer have to literally beg to be seen by a doctor is absolutely horrifying. This is one area where civil suits can be an effective weapon. Drs. who refuse to deal with a skin cancer should be sued out of practice. And/or heavily regulated by the government or their own "Professional" organization (the AMA). Does this behavior actually conform to the AMA's code of conduct?"



• "Any doctor who will not see a patient who suspects a mole cancerous, or has a chronic skin disease, for longer than 72 hours, should be sued and forced to explain his negligence in a court of law. "


Reading the comment sections of articles in "the nation's newspaper" is always really illustrative to me. There's alot of frustration and hostility about healthcare in the public which gets (mis)directed at physicians. (Don't forget poor Dr. Zenn who was sniped by the breast implant nutters in June.) It's really a systemic issue, but it's easier to blame "greedy" doctors then actually recognize the costs of administering and delivering healthcare is affecting this. Commenter's also usually fail to understand that this issue with dermatologists is actually going to get worse rather then better with whatever "universal healthcare" system we end up with. Unless you pay physicians market wages for their services, they're going to look for opportunities to realize it elsewhere.

Reading this article I also kept thinking, why the hell would you feel like you absolutely have to go to a dermatologist (or Plastic Surgeon) to have a skin lesion or rash looked at? While I appreciate patient's opinion of our skills, evaluation and biopsy of lesions/rashes is simple enough that it logically should be largely the province of primary care providers or the nurse practitioners and physician assistants that affiliate with them in practice IMO. A lot of wound care clinics have such a set up, and I think wound care is much trickier then skin lesions!



Rob