Friday, March 20, 2009

Vanity Fair's "Undercover Plastic Surgery" expose

Just like when your wife or girlfriend asks "Do I look fat in this?", it is surely the deadliest of traps when a cosmetic surgery patient asks you the open-ended "What do YOU think I need done?". Most Plastic Surgeons know not to take the bait with this question, but rather tease more out of the patient about what is concerning them.

A careless phrase or suggestion can produce both anger and anguish to a patient. I still think I'm getting pain from a voodoo doll for my inadvertent pointing out a "witch's chin" deformity to a patient (Long story, read here to get up to speed).

Vanity Fair magazine put this to the test when they had a writer go "undercover" on three consults for cosmetic surgery. (The article can be viewed here). One with a Manhattan Plastic Surgeon (whom I've actually heard of), one with an ENT trained "cosmetic surgeon" (who notably was sanctioned for defrauding Medicare in 2003 - Don't these people use Google?), and one osteopathic (a DO as opposed to an MD degree) surgeon who'd trained in an osteopathic plastic surgery residency.

Note: There is really nothing about Plastic Surgery as a discipline that is related to osteopathic tenants. As the mystical snake-oil aspects of osteopathic medicine, like manipulation, have largely been shed from their curriculum, a DO and MD education is now practically similar. As there are only a handful of DO plastic surgery programs, I'm assuming this guy would have been an intelligent guy and good resident to get a position. End of editorial!

The writer's first consult was with the Plastic Surgeon, who came off really, really, really cheesy.

"Now the doctor and I stand in front of the floor-length mirror while he deconstructs the “before” me. “As a Caucasian woman, you probably—if you were doing lipo—would want this brought down,” he says, pointing to my “banana rolls”—his clever name for the part of my rear end that peeks from beneath my underwear lining. “And again, you know, in jeans, to most people … on white women, you guys like to get this down. And we like to see it down.” I gulp, realizing that I’ll never be able to eat my favorite fruit again without thinking of my own ass....

Back in the Upper East Side exam room, Dr. R******* pinches me from shoulders to knees before concluding: “You look absolutely nice, but, even if I were a blind guy and put my hands here”—he seizes my sides—“there are little lumps. This could be brought down just to give you a little bit better of a curve.” These lumps, I learn, are my “waist wads.” To his credit, Dr. R******* does note that my “waist wads” are “borderline.” But, he says, “I’ve done supermodels with much less than this. To them it was important. To each his own.”

He prefaces his conclusion with a hypothetical scenario: “I think if I were a single plastic surgeon, which I’m not, riding around in my Corvette, which I don’t, my license plate would read full c. O.K.? That would be my license plate. So that’s what I would think, in general, is the Promised Land of Breasts for most people.”

OMFG. Is this guy for real? I'll give him the benefit of the doubt that some of his comments were selectively edited, but I cannot imagine most of his peers would consider that language and tone very professional. Pushing services, as opposed to passive advice, is not how most experienced surgeons would teach their residents to act. I know we weren't. There was a well known surgeon in Louisville who was notorious for telling women at social events that that they needed a face lift. The funny thing was that on a number of occasions this surgeon had actually already done a face lift on that patient and just failed to recognize both the patient and his work. Open mouth, insert foot!

The other two consults described were actually much tamer and more professional IMO except for the part where the ENT's office manager offers to show off her implants to the prospective client. Chez tacky! Props to young Dr. Joseph A. Racanelli D.O., who despite being the least experienced, gave the most appropriate response to the honey trap offered by Vanity Fair.


Monday, March 16, 2009

The Boston Massacre - The Blueblood hospitals assault the suburbs in Boston

It's getting ugly up in Massachusetts. While the state was initially celebrating it's plan to offer near universal health coverage, it's now bankrupting the state. They're now looking for "creative" solutions to paying for this. Today's New York Times (click here) writes

"They want a new payment method that rewards prevention and the effective control of chronic disease, instead of the current system, which pays according to the quantity of care provided. By late spring, the commission is expected to recommend such a system to the legislature......Some health policy experts argue that changes in payment practices will not be enough to slow the growth in spending, even when combined with other cost-cutting strategies. To truly change course, they say, the state and federal governments may need to place actual limits on health spending, which could lead to rationing of care."

Complicating the landscape is the leverage that Boston Children's Hospital, Massachusetts General Hospital (MGH) and Brigham & Women's (B&W) Hospital have used in negotiating their fees from insurers (see here). Each of these providers (MGH & B&W merged under a relationship called Partners) has such market clout that they've been able to dictate terms to insurance companies that capture 15-20% premiums compared to their competitors in Massachusetts. While their fees are not way out of line compared to national figures, they're much higher then Massachusetts' peers. Partners has also ruffled feathers of it's competitors by buying up hospitals and opening satellite clinics in the suburbs of Boston and greater Massachusetts. This begs the question of whether it's fair to penalize Partners for leveraging the bargaining power of their brand names to cut better deals. I say hell no!

This "premium" for Partners hospitals and providers is now a tantalizing target for Massachusetts to attack in their cost containment plans I figure. The low lying fruit for these measures is always the doctors reimbursements. Expect this to get real ugly in the next few years there.


Thursday, March 12, 2009

Aging studies on identical twins

There's an interesting series of aging studies on twins in the literature recently.

The first (see here) was a series of observations made on the contributions of different factors on aging. These factors included
  • smoking
  • both obesity and being thin at different ages
  • sun damage
  • depression (?)
  • divorce

The relationship of body weight is interesting, but kind of intuitive. A heavier body weight before the age of 40 was associated with an older appearance. However, in the women over 40, a heavier body mass index (BMI) was associated with a more youthful look. In plastic surgery, we've known for awhile that the aging face is not just loosening of the skin, but is driven by a progressive "deflation" of the fatty tissue, recession of the bony prominences of the cheek/midface, and thinning of parts of the skin
with simultaneous thickening of other parts from sun damage. Fat grafting and the use of off the shelf dermal fillers are now routinely used to complement face lifts.

I think this picture from the series is most illustrative of that principle.

Notice the deeper lines by the cheek (nasolabial folds) in the gaunt twin.

The other study is published in this weeks' Plastic Surgery journal and is titles "Identical Twin Face Lifts with differing techniques: A 10 year follow up". It was basically a bet among some of the heavy hitter face lift surgeons about which techniques would hold up best, with the gimmick being it would be performed on identical twin volunteers.

When the procedures were done in 1995, the debate was really about whether newer more invasive techniques being written about like the "deep plane facelift" would hold up better then older,simpler techniques ("SMAS flap" and "SMAS plication" procedures).

What's interesting is that all the twins looked better and the results were fairly well maintained, even 10 years out from surgery. The following editorial was very diplomatic (excellent results can be obtained from different techniques...yada, yada, yada)and not very conclusive, but seemed to talk past the elephant in the room.

Sometimes you have to call a spade a spade:
Looking at a study like this how could you plausibly still assert that the added risk of facial paralysis from the more complex surgery type is justifiable when it's not clear there is any maintained advantage in results. None. Zero. Zilch.

Dr. Dan Baker of Manhattan, face lift god, has been evangelical about this safety issue going back 15 years. He should know. As a young surgeon in the 1970's, he developed a reputation for fixing severed facial nerves from face lifts referred to NYU. Dr. Baker has a wonderful talk about his personal evolution on face lift surgery that I saw as a medical student 13 years ago that was seared in my brain. His simple theorem on risk/reward with complex face lifts has now clearly been validated in print. All the pictures are good results, but I'll be damned if Dr. Baker's patient in this twin series (the one on the far left)doesn't look the best and most natural 10 years out.