E! talk show host Giuliana Rancic chooses double mastectomy for breast cancer treatment. Why this is the right choice

E! talk show host Giuliana Rancic, recently diagnosed with breast cancer (and having failed an attempt to remove the cancer with a lumpectomy) has decided to proceed with bilateral mastectomies and reconstruction for her treatment. Her decision is similar to those made by actress Christina Applegate and comedian Wanda Sykes in recent years. This choice is likely the right one for a number of reasons IMO.

• at 37 years old and without children (she was actually undergoing fertility treatments when diagnosed with cancer), she possesses two significant independent risk factors for future breast cancer 1) personal history of cancer and 2) delay or absence of childbirth.
• She has had prior attempt at lumpectomy, which almost guarantees significant cavitary breast deformity, particularly on a thinner woman such as Mrs. Rancic with additional attempts
• She (being an American adult female in good health) has an estimated life expectancy of almost 95 years, and 6+ decades of future surveillance on a high risk individual treated with breast conservation strategies has not been studied. Mastectomy does seem to have an advantage of lower recurrence rates verus lumpectomy with radiation, particularly as you get decades out from the initial treatment.
• A breast treated with lumpectomy and radiation will progressively look worse and worse over time as it relates to bot appearance and asymmetry with the other breast.

Selecting or suggesting a treatment for a younger patient like Mrs. Rancic becomes as much a question of psychology as it is about treatment of the cancer. While it's likely that a more aggressive surgical treatment of localized cancer will pay dividends as you get farther out from the mastectomy, many women will never be comfortable with the breast cancer surveillance requirements going forward and select a mastectomy to simplify their care. It's telling that when women plastic surgeons have been surveyed on whether they'd undergo mastectomy or breast conservation with radiation, that almost all of them would choose mastectomy (and prophylactic mastectomy of the other breast).

Rob

NJOM shows sick patients cost more to treat...... Who knew?

In the least surprising conclusion of recent articles in the New England Journal of Medicine (N. Engl. J. Med. 2011;365:1704-12,) it was proven that older, sicker patients cost more money to take care of!

from the summary in Internal Medicine News, 

"Eight commercial disease-management companies using nurse-based telephone care programs failed to improve quality of care, reduce hospital admissions, decrease emergency department visits, or cut health care costs in a pilot project of fee-for-service Medicare patients.

 Companies were required to meet preset targets for clinical quality and patient satisfaction, and to hold health care costs under a preset limit. An independent group, RTI International, won a competitive bid to evaluate the programs.

However, before the evaluation could be completed, five of the eight companies incurred such "substantial financial liability" that they terminated their programs, according to Nancy McCall, Sc.D., and Jerry Cromwell, Ph.D., of RTI International in Washington.

  

These findings show "it is unlikely that simply managing the care of elderly patients through telephone contact or an occasional visit will achieve the level of savings Congress had hoped for when it mandated the Medicare Health Support Pilot Program," Dr. McCall and Dr. Cromwell said."

So a majority of participating companies with extremely sophisticated resources to manage these patients could not make the numbers work, and Medicare is trying to capitate costs and financial risk of these patients onto providers in the future via "Accountable care Organizations" (ACO)?

This is the same thinking that led the geniuses who run Wall Street to put together a bunch of high risk,crappy mortgages together into a new vehicle, the synthetic  Collateralized Debt Obligation (CDO), and expect it to perform better then the underlying parts.  These products later nuked our economy by hyper accelerating speculative housing market bets.


Just as it took a physician running a hedge fund, Dr. Michael Burry (hero of the excellent book by Michael Lewis "The Big Short"), to point out that the emperor had no clothes in the housing bubble, major medical centers like the Mayo Clinic and Cleavland Clinic  have already told the government "no thanks!" on assuming open-ended risk on capitated care contracts for medicare patients.


Rob

Where are they now? Even supermodels get old like the rest of us

There's a really interesting demonstration of facial aging you can see in a "Where are they now?" slideshow in former supermodels of the 1970's, 1980's and 1990's you can see here. Here's a representative sample of a few different "vintages" which I think show some of the signs of aging that creep onto all of us as we age. The lifestyle of many models in terms of diet, sun-exposure, smoking, drug use, and depression clearly play a role in some of the exaggerated changes you might see in some of these beautiful people.

Christy Turlington, (age 43) multiple Vogue cover model of the early 1990's.You see the early loss of midface volume of the cheek and hollowed areas around the lower eyelid.

Janice Dickinson, (age 56) one of the 1st supermodels of the late 1970's early 1980's. You see a striking loss of volume of the face with sun-damage related changes to the skin. She's also had a number of well-publicized issues with substance abuse and depression which are known factors in early facial aging. Animation lines and fine wrinkles around the eyelid and mouth become more prominent.

Twiggy (age 62) the waif-like icon of mid 1960's swinging London fashion scene. Twiggy demonstrates the fact that it's hard to grow old when you're frozen in time in pop culture as the "It" girl of 1966. Her interval photos demonstrate all the changes you see from volume loss, sun damage with discoloration, and a gradual change of the heart-shaped "Ogee" curve of the youthful face and cheek to a flattened and round shape.

The women in the story are still striking, but do show some exaggerated changes of the aging face that we see in consultation in the office frequently. The single biggest things you can do to slow down facial aging are common sense steps like to avoid sun, not smoke, and maintain a steady weight and diet.

Rob

Victory for Common Sense: FDA drops MRI suggestion for patients with silicone implants

BREAKING NEWS: A fairly significant announcement by the USFDA was in the paper today re. silicone gel breast implants (see NYT summary here). Based on testimony and evidence presented, the FDA has finally agreed that the suggestion that patients need routine MRI screening of their implants is no longer one they support. This is bringing the United States into line with the rest of the world on being more pragmatic on the issue and reserving workup for symptomatic patients only.  Recent papers in the surgery literature have been reporting that MRI has been associated with overestimation of rupture rates, particularly when applied to asymptomatic patients. The panel also concluded that no new evidence has been presented to change prior determinations that silicone implants are not causally linked to any known systemic illness.

Rob

Groupon's model may be both bad business and illegle for cosmetic medical services

The use of social media services like Facebook and Twitter to promote your medical practice on the web has become common in recent years. For today's potential patients, if you don't have a web footprint then you might as well be invisible. A new wrinkle on this has been causing some concern that it might be both illegal and unethical when applied to medical services like laser hair removal, BOTOX injections, and other goods and services.

Services like Groupon offer heavily discounted goods and services to people who buy the "deal of the day" through Groupon. They then collect the money and keep a large percentage of the fee, passing the rest to the merchant. Groupon’s first daily deal in October 2008 was famously a half-price deal for a pizza restaurant located in its office building in Chicago. From that event, the service has exploded. This is now a big business, with such "deal of the day" businesses projected to exceed $6 billion in sales by 2015.

Is this good for anyone other then the principals of Groupon and the like? I don't think so. Like many of the so called "innovators" of silicone valley and the web (ie. Facebook), most ideas you see bubbling up merely seek to skim money off the top of transactions rather then creating a product of any kind of value. It's a giant long con that would seem to be creating another internet bubble for shareholders and investors in these companies.

Expect to see more signs like this from small businesses:

A blog post I found from earlier this year (see here) crystalizes the problem for Groupon noting,

"many businesses will still make the mistake of overestimating the value of the customers they are likely to get from them. The proportion of customers procured from Groupon who are likely to make a return visit/repeat purchase may be dramatically lower than average meaning that, especially when you also factor in the significant cut of the revenue that the retailers have to pay to Groupon, they could actually make a significant loss on the deal. It’s the same logic which has led many online retailers to shun voucher code sites which they see as catering only to bargain hunters as opposed to potentially loyal customers."

You're hearing more and more horror stories from merchants who are not realizing how insane participating with such budiness models is, particularly at the levels of revenue Groupon is skimming from them. In aesthetic medicine, we see more and more of such deals from Botox and laser treatments for hair removal, skin tightening, and body contouring. I see these offers and am boggled at what these clinics and spas are thinking. You cannot stay in business offering services for less then cost, and it is clear that patients who shop through Groupon will always be price shoppers rather then repeat clients. I recently saw a dermatologist lose almost $5000 on a special they did on one of these services not realizing how much they were actually promising to deliver after their cost of the Botox (which is almost $600/bottle).

A new wrinkle (no pun intended) has been the examination of such a relationship in the context of restrictions of what's known as "fee splitting". These types oflaws prohibit the offer, solicitation, payment or receipt of anything of value, direct or indirect, overt or covert, in cash or in kind, intended to induce referral of patient for items or services reimbursed. The language of such laws vary by state, but the spirit of most of them would seem to be at odds with the Groupon model. A number of experts are concluding that such programs, by virtue of their "per unit" fee model, violates such federal rules and many states medical board rules (see here and here) and are advising providers to tread carefully.

So, in summary we have an illogical business model that may or may not be legal for medical goods and services. What's not to like?

Rob

A teachable plastic surgery moment from Wimbledon 2011: Treating the "gummy smile"

I was checking Sports Illustrated's web page to get the updates from Wimbledon and they showed a smiling picture of German, Sabine Lisicki, who'd just won her quarterfinal match.

MS. Lisicki demonstrates a phenomena known as a "gummy smile" which is produced most often by an overly tight band of tissue under the upper lip called the frenulum.

Release and lengthening of this band is commonly performed during rhinoplasty procedure (at least in my hands) and produces an instance and sometimes dramatic correction of the smile with much less show of the gums and upper teeth. This surgery takes about 1 minute to do and can be performed under local anesthesia BTW.

Rob

SAFE: FDA re-confirms safety of silicone gel breast implants

In a not unexpected conclusion, yesterday the United States Food & Drug Administration re-affirmed their 2006 decision to reintroduce silicone gel breast implants into the United States market for cosmetic indications. In statements from the FDA, they explained that no new information has arisen to question the safety or efficacy of the devices for intended use. As has been discussed on Plastic Surgery 101 a number of times, this is not really news and has been accepted world-wide for a number of years now. Hopefully this statement from FDA heralds the availability of the new form stable "gummy bear" silicone implants here in the United States which have been available everywhere else for almost 15+ years.
Breast augmentation remains the most popular cosmetic surgery in the U.S., with nearly 300,000 women undergoing it last year. According to the American Society of Plastic Surgeons (ASPS), more than 70,000 others received implants for breast reconstruction.

The most disappointing finding was that only ~60% percent of women enrolled in a 1,000-patient study of one manufacturers implants are still accounted for after eight years. A larger study of 40,000 women conducted has lost nearly 80 percent of its patients after just three years. Diana Zuckerman of the National Research Center for Women and Families, one of the most prominent (and persistent) anti-implant activists, cried foul and suggested that most medical journals would not publish the studies cited by the FDA because of the missing data. I'd agree with her, but for different reasons. She's implying safety issues exist (which they don't by and large), while I'm more interested in outcome data to understand how to reduce re-operations.

Why the relatively poor follow up in the FDA trials?

Dr. Phillip Haeck, president of the American Society of Plastic Surgeons (ASPS)sums it up saying that, "When women are happy with their implants they tend to feel that a regular follow-up is pointless - it becomes a nuisance and an unnecessary expense". I'd agree 100% with that.

It also begs the question of what exactly are we trying to demonstrate with the FDA follow up studies. There is overwhelming world-wide information that suggests safety at this point. It would be nice to have a little more data on longevity so as to better counsel patients on when to consider routine exchange with prior devices, but as we're on the cusp of a major design change in the polymers that make the implant almost impossible to rupture (the "gummy bear" form stable devices) we're going to quickly lose interest in exhaustively studying older devices. This kind of technology advance has always created problems about making conclusions with medical devices, as you end up comparing apples to implants :) (bad pun alert).

Rob

In office breast cancer surgery, just a matter of time?

This is kind of a post I've been sitting on for about 7-8 months that I though would be kind of interesting. Last Fall there was an article in a New York business magazine about a small trend in some breast cancer surgeries being performed in plastic surgeon's offices in Manhattan. The article, "Mastectomies check out of the hospital" describes this phenomena and I found this quote interesting,

"Dr. Evan Garfein of Montefiore Medical Center was the driving force behind the new state law requiring that patients be informed of their surgical options. The breast surgeon says his effort was meant to correct a disparity: Poor minority women are less likely to get reconstructions because they often aren't told that federal law requires their insurers to cover the procedure.


But Dr. Garfein says he never thought the law's passage might drive a boom in office-based breast cancer surgery.“With the right doctor and the right patient, reconstruction can be safely done in an office,” he says. But not a mastectomy. “To me, that's the type of operation that should happen in a hospital.”

Dr. Garfein questions the motivation of plastic surgeons offering such procedures. The specialty has been hit hard by a drop in business during the recession. “When you look at the economics, you know that if a plastic surgeon owns his own operating room, it's [financially] better for him to do the surgery there,” Dr. Garfein says. “You have to ask, 'Why is this being done?' If there's a trend like this, it should be because patients are demanding it. Plastic surgeons shouldn't be driving a trend to get patients out of hospitals.” "

As someone with an interest in office based surgery, I found Dr. Garfein's comments kind of puzzling. Our office is equipped with a large hospital-grade operating room and is accredited for surgery by one of the same groups that reviews hospital and free-standing ambulatory surgery centers (ASC). We routinely do operations significantly longer and more difficult then breast cancer surgery (which is neither particularly long or difficult in most instances) at 1/2 the cost of the hospital with an infection rate close to 0% (our's is actually zero for over the 2 1/2 years we've been up and running). While there's a selection bias in outpatient surgery candidates towards younger, healthier patients there are many,many breast cancer procedures (both tumor removal and reconstruction procedures) we could absolutely do safely if we choose to.


The big hold up here in Alabama is the dysfunctional Certificate of Need (CON) process and the reluctance of insurance carriers to upset the hospitals (who would lose some cases).  State's with CON's are essentially franchise cartels that try and protect their exclusivity of where surgery can be performed. Predictably, CON  states become a political quagmire of competing hospital systems suing each other to prevent the other from outmaneuvering their business model. In Birmingham we currently have 4 hospital systems in court trying to prevent the state CON board from either allowing a hospital to move from one area to another in town (see here) or building new hospitals in attractive demographic areas where none exists nearby. As a direct result of the CON fights here, we actually have a former Democratic golden boy and governor, Don Sielgelman,  sitting in federal prison for taking bribes to appoint a requested person to the CON board (that's a post for another day).

In an era where we're pinching pennies to come up with cheaper ways to deliver care, it's mind boggling to dismiss a simple (and safe) way to do many procedures. I take issue with Dr. Garfein's suggestion that it's a financial incentive on the surgeon's part as if you actually expense running an office OR like an accountant would, it's likely a break even proposition (at best) with better paying insurance companies and likely in the red for Medicare and other low-paying insurers. While it's certainly helpful to 1) my efficiency and 2) the patient's experience (as they much prefer the office to the hospital), the main beneficiary in all that is the system which is likely to see equal or better outcomes at reduced cost. What's not to like?

Rob

Addition by subtraction - Pro tennis player's Simona Halep's breast reduction

Back in 2009 I wrote a post titled "Pro tennis player Simona Halep's cups no longer runneth over." (yes I was making bad puns then too) which highlighted WTA tennis player, Simona Halep, a promising Romanian junior tennis champion who's progress was being hampered by her very large breasts. Later that year she underwent a breast reduction surgery from a DD to a C cup bra size and has made steady progress with her career and is currently ranked #65 on the world tour. Today, Ms. Halep reached the final of a WTA event in Morocco and will play for her 1st WTA tour level title tomorrow.

 BRAVO! As shown below, it's easy to see how Ms. Halep's mobility should have been greatly improved by her surgery. It's hard to argue with results.

PREOPERATIVE in 2009











                                      
                                                  POST OPERATIVE in  April 2011

Rob

Putting a stake thru the routine MRI screening of silicone gel breast implants

When the USFDA lifted a nearly 2 decade moratorium on the use of silicone gel breast implants for cosmetic surgery indications in 2006, there were two puzzling things added to the product labeling.

1. The use of silicone gel implants should be limited to women >22 years olds.
2. That women should undergo routine MRI screening of their implants for rupture every 2-3 years.

The first instruction re. an age restriction on women 18-22 is patently absurd and is a nod to the "unique" political history of silicone breast implants in the USA. One more thing we thank lawyers for!


The second suggestion re. MRI was always puzzling, particularly as the rupture rate is so low for modern implants through the first decade where the FDA would otherwise be having patients undergo 5 screening MRI's (at year 3,5,7, & 9). This intuitively is throwing money down the drain as the yield is low and violates what most people consider appropriate in a screening test.

New data and review of the literature from the University of Michagan suggest that while MRI is fairly accurate in detecting implant-related problems, it is 14 times more likely to detect them in women with implant-related symptoms than in women without symptoms.It has been concluded that because most women in the studies had symptoms, the true accuracy of MRI for detecting implant-related problems in asymptomatic women is probably much,much lower and calls into question the whole idea about routine screening for rupture. Beyond the issue of accuracy, the authors comment that screening tests are generally performed to detect diseases with serious consequences-whereas the health risks associated with ruptured silicone implants, if any, are still unknown. To date, there is no single systemic disease or illness clearly attributable silicone gel implants despite them being the most studied medical device in the history of medicine.

Hopefully this will lead to the updating of the current FDA labeling for these devices that causes some confusion for patients and adds significant extra expense for no benefit.

Rob

Tickle Lipo is now here at Plastic Surgery Sepcialists

Rob

I am typically one of the biggest buzzkills for technology in plastic surgery and aesthetic medicine, particularly when it involves body contouring. As I've written about before, the whole laser liposuction (SmartLipo, et al.)thing has been very underwhelming on the results side (compared to traditional liposuction)for most practitioners willing to speak candidly on this. Recently, I decided to purchase a machine which is a little different kind of liposuction strategy. The technology, technically called Nutational Infrasonic Liposculpture (N.I.L), involves a novel hand piece with a tip that rotates in multiple dimensions while emitting low frequency vibrations.

In the Unites States, the technology is being marketed with the label "Tickle Lipo".

What's impressed me about the Tickle Lipo is the efficiency of the device for fat removal and the decrease in pain as compared to the gold-standard of traditional lipo. The decrease in pain is presumably from the fact that you can be much more gentle with the manual movement of the cannula while the vibratory effect is supposed to down regulate local pain receptors. When done awake or under light sedation, patient's describe the vibration as a "tickling" sensation, hence the name. SmartLipo and related devices hurt just as much as traditional liposuction (despite what's being marketed) because you still have to go back and remove the fatty tissue with a traditional suction devices, so you're really not doing anything different on that end. To my mind, Tickle Lipo is kind of a hybrid between power-assisted devices (PAL) and ultrasonic (UAL)without the heat generated by higher frequency ultrasound. The heat from UAL and SmartLipo can have severe complications with external or internal burns created.

At the recent meeting of the American Society of Aesthetic Plastic Surgery (ASAPS), (the premier cosmetic surgery meeting annually in the United States), members were surveyed on their feelings and practices re. liposuction. This survey group would be a representative of the most experienced and accomplished body contouring surgeons in the world. Standard liposuction was the preferred method of fat removal for 51% of them. Power-assisted liposuction (PAL) was second, preferred by 23% of respondents. Only 10% of ASAPS members surveyed employ laser-assisted liposuction (SmartLipo and others) in their practice. When these ASAPS members were asked why they used a laser liposuction platform, the main answer was that it gave them a marketing advantage (68%) rather then any clinical result. Ultrasonic liposuction (UAL) was the most likely method to have been abandoned by the respondents.

With regard to complications after liposuction, ASAPS members felt that ultrasonic and laser liposuction were the techniques most commonly associated with complications (35% and 23%, respectively).Of the respondents, almost 40% have taken care of a patient with significant complications secondary to laser liposuction. Contour deformity was the most common complication reported by respondents (71%), followed by unsatisfactory results (59%), burns (44%), and scarring (38%).

This has been my experience as well. We're seeing more issues from these laser devices, most of which are being performed by non plastic surgeons. I think that has to do with the fact that it's more frequently non plastic surgeons buying these platforms rather then the fact that we'd produce less complications with them (although I think we would). After trialing a number of these technologies, we were just impressed with both the effectiveness and safety of Tickle Lipo.


Rob

Laugh of the day: Your typical plastic surgery ER consult during residency

One of the most grueling things during surgical training is emergency room call, where you have to make yourself available for services 24/7. In plastic surgery there are 2 things that torture you
1) hand injuries - which inevitably happen late at night and can require urgent multi-hour surgery

2) calls to the children's hospital for lacerations.

Dealing with pediatric patients can be very tricky as they are difficult to anesthetize to repair even simple lacerations. What in an adult can take several minutes, can take an hour+ by the time everything is set up. Part of the frustration involves the sometimes "under informed" phone calls that usually come from a desk clerk or nurse who has little to no idea why they're calling you. Someone took the time to make a classic parody of this below. Too true & too funny!





Rob