Wednesday, January 23, 2008

Questions from the mail bag

Today is the innagural session of attempting to answer questions from the audience. I'd like to make this a regular feature.

Gorgeous black woman (what a great ID!) asks me to discuss "relatively new procedures (SmartLipo, Liposelection, surgery-free nose job, transumbilical breast augmentation)"

Everyone's always looking for "something for nothing" which describes most of those things you're asking about. My thoughts in order.

1. "Smartlipo" - this is a kind of liposuction machine which has a weak laser at the tip of the liposuction instrument which ostensibly breaks up fat at the end. It's promoted as having less edema, pain, etc... which is a claim that Plastic Surgeons have learned to be skeptical about. I'm withholding judgement on this particular device, but the track record of this kind of "laser assisted" liposuction is poor there are very experienced liposuction surgeons panning this. The fact that you will still need to extract the emulsified fat with traditional liposuction instruments makes some skeptical that it makes sense to buy a $100K+ machine to pretreat an area prior to suction.

Another thing to note is who is promoting these devices. By and large it's dermatologists, gynecologists, and the nebulous "cosmetic surgeon" types rather then Plastic Surgeons who actually have a great deal of body contouring training and experience. If you go to the manufacturers website the 3 physicians spotlighted are a family practice doctor and 2 gynecologists, one of whom claims "board-certification" by the American Academy for Cosmetic Gynecology of all things (color me impressed!). The 3 doctors in my state promoting this are a dermatologist and two ENT doctors BTW.

That's a big red flag to me that this is more sizzle then steak, but I am interested in seeing this hands on. I reserve the right to reevaluate this technology as it's techniques matures.

2. Liposelection (aka. VASER) this is a refined version of ultrasonic liposuction (UAL) technology. Despite initial enthusiasm, UAL has stiffed as it has been associated with higher complication rates with no clear advantage in results. VASER is a "kinder, gentler" UAL which has actually gotten fairly good reviews. The cost of the device ($50K+ I think) has killed wider usage, as it's really not clear that it offers any advantage over traditional techniques. Much like SmartLipo, the economics of it make no sense for most surgeons. If the price comes down it's use may increase somewhat. Think of it as an alternative to Smartlipo with a little better track record at this point.

3. "surgery free" rhinoplasty is not something I think you want to jump on board with. A number of referral rhinoplasty experts report that they are seeing serious complication from injectables in the nose with dramatic amounts of scarring/inflammation which make surgery very difficult. The picture at right is from Dr. Dean Toriumi, a rhinoplasty super(duper)star from November's "Cosmetic Surgery Times" feature on this practice.

Nasal skin is fairly specialized and can be pretty finicky in how it reacts to either defatting (to thin it out) or to augmentation with soft tissue fillers. Some defects can be camouflaged by fillers or more traditionally cartilage grafts (which have their own set of complications long-term). If I was going to be attempting correction with a filler it would probably be with something like the small-particle size Juvederm which should cause the least problems and wear off at some point.

The article by Dr. Toriumi clearly shows why if you are considering doing this, you need to have someone who actually knows nasal anatomy and surgery discuss this with you. This is not something your dermatologist or other cosmetic medicine provider she be dabbling with.

Anon, a breast cancer survivor, asks "I take tamoxifen. I exercise an hour a day - tough things like spinning and hiking. I keep gaining weight. Yes, I eat. But do I really need to starve myself? Is it the meds? The surgery? The menopause?"

Tamoxifen and other related drugs (Arimadex, Femora) literally induces a "chemical menopause" as they block estrogen receptors. It can play havoc with some people's metabolisms. At the end of the day though, all weight gain comes from taking in more calories then you're expending. If you're having problems with your diet, consider sitting down with a dietitian and they may have some relatively painless ways to cut back on high-cal/high-carb intake.

Anon #2 asks me to comment on the rumor that various insurance companies are cancelling or refusing to grant medical policies to women with breast implants.

I've yet to see this in writing anywhere, but I've heard it anecdotally from a surgeon in California. This should become less of an issue as we continue to produce better data on outcomes after breast augmentation. The longitudinal data that keeps churning out from the U.S. FDA data and from Europe looks better and better, particularly with the devices we're about to get wider access to in the United States.

Keep your questions & comments coming. I love this stuff!




rlbates said...

Nice! Good questions and answers!

Anonymous said...

Do you think American women will make the switch to the Style 410 implants? Or does the required larger incision size, and un-naturally firm texture overwhelm the advantages of the non-collapsing shape? I read about lower capsule rates in the literature - but is that because they're so darned hard to start with? What was the consensus at the Atlanta meeting?

Keep up the good work on your blog!
Tom Fiala, MD

Gorgeous Black Women said...

Thanks for answering. I read an article about the surgery-free nose job which appeared to be for people with bumps. I know two people who got rhinoplasty when they graduated from high school. It seems like the only time one can really afford to do this. The recovery time is way too long.

I haven't actually seen any great results from SmartLipo and I joined a big forum where people post their pictures and give each other advice. The one thing I noticed though was far less bruising with both SmartLipo and Vaser. I only saw one picture with uneven results with the Vaser. One butt cheek was noticeably larger than the other.

Anonymous said...

Rob, In the past I have actually have had to fight for months against one of the largest
retail stores in the world over a patient where my plastic surgeon husband, Dr. Gene Moor, thought it necessary for her to have a mammogram. The company would NOT pay for the ordered mammogram and never gave in, quoting that it would not pay for anything in "relation to Breast Implants". They cited a contract clause for this refusal on the grounds of her "having breast implants". Maybe the patient would be well advised to read the contract at the time of employment?