Plastic Surgery 101

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

2011-12-06T13:39:00.000-05:00

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?

2011-12-05T11:09:00.000-05:00

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

2011-09-23T13:06:00.000-04:00

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

2011-09-01T12:56:00.000-04:00

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

2011-08-28T12:30:00.001-04:00

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"

2011-06-28T14:12:00.000-04:00

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

2011-06-23T10:44:00.000-04:00

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?

2011-05-06T08:27:00.000-04:00

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

2011-04-23T13:57:00.000-04:00

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

2011-04-22T10:13:00.000-04:00

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

2011-03-18T11:23:00.000-05:00

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

2011-02-07T14:14:00.000-05:00

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

Crazy Eyes: Adventures in Eye doctors doing breast surgery part deux

2010-10-16T07:06:00.001-04:00

While it's hard to top the debacle I wrote about in Atlanta where an eye surgeon nearly boxed someone trying to do a breast augmentation surgery in his office, I came across this other article by another opthomolgist turned "breast expert". I don't know whether he's trying to be clever marketing a procedure or is just ignorant about breast surgery in general, but I came away from this article shaking my head.

The doctor is proposing a breast lift (mastopexy) surgery performed thru the armpit by suturing the breast to the pectoralis muscle and then placing an implant. He describes the surgery appropriate for women with little ptosis. Looking at his picture, you can see that whatever effect he's proposing is nonexistent as the patient doesn't even have ptosis (droop) of the breast. Any illusion of a "lift" is by placing an overly large implant for her frame and actually lowering her breast position to centralize the implant. There is clearly no "lift" going on whatsoever, but rather he's stretched out her lower breast.

I do not predict a good long-term result from this as that skin will frequently continue to stretch unless she develops hardening of her implant. I also would be reluctant to have suggested such a large implant for this patient as you had to violate her native breast boundaries to place it, again a poor strategy for long term results. These are elementary principles of modern breast augmentation.

It's been pretty well established thru collective world-wide experience among plastic surgeons that the maneuver of trying to sew the breast to a higher position to exaggerate the upper pole does not work, which has been demonstrated on a number of follow up studies when this has been attempted.

Rob

Plastic Surgery Specialists of Birmingham's new website is Live!

2010-08-23T14:03:00.000-04:00

Our practice's totally redesigned website has gone live today! Check us out on the web at Plastic Surgery Specialists. We hope to more fully realize the technology available to communicate our practice to potential patients.

I'd like to thank the guys at Plastic Surgery Studios for working with this over the last few months on this project. It was a lot of sweat equity to get to the finished product and we're very happy.

Rob

Ways to (nearly) ruin your life 101 - Choosing an Atlanta eye doctor to do your breast augmentation surgery

2010-08-15T13:30:00.000-04:00

This summer there was an awful instance of medical negligence in Georgia involving an eye-doctor (opthamologist) who had major complications while attempting to perform breast augmentation surgery in his office. You can hear a frantic 911 call from the doctor explaining that he has encountered uncontrollable bleeding he created while during her breast implant surgery and has no idea how to fix it. Since the patient was under only local anesthetic (with presumably mild oral or IV sedation) during the operation, she told reporters that she heard the call go out to 911 for help and then her doctor saying that he couldn’t stop her bleeding. Can you imagine how horrifying that must have been listening to that conversation?

You can view 2 video news clips on the story here & here.

This is a really frightening story as it highlights the proliferation of unqualified and untrained physicians attempting to practice cosmetic plastic surgery procedures. If you are not trained in plastic surgery you should not be performing these procedures PERIOD. The inability of this eye surgeon to handle routine issues during breast implant surgery and the patient safety issues it raises should cause state medical boards to get involved with scope of practice issues and office based surgery regulations.

Rob

Why is breast cancer reconstruction surgery with implants done in multiple stages? "Baby Steps"

2010-07-27T09:58:00.000-04:00

From time to time you will get asked by breast cancer patients whether their reconstruction surgery can be done all in one stage at the time of mastectomy. The answer is you can, but there are a number of factors working against you for the best result, such that "baby steps" (planned sequential small procedures)

Typically, most implant reconstruction surgery involves placing a temporary implant called a "tissue expander" at the time of mastectomy that is later replaced by a permanent implant. As compared to a regular implant, a tissue expander is shaped different to maximize shape of the lower breast. It is decidedly more rigid and firm and then permanent devices, particular when silicone implants are later used. The advantage of such specialized devices is that they allow either 1) expansion of the skin by periodically adding fluid to them and 2) better resisting shrinkage of the skin following mastectomy.

Planned 2 stage surgery was popularized by Dr. Pat Maxwell (my mentor) and Dr. Scott Spears, and is well established as the most popular way to do breast reconstruction world wide. There has always been some interest in trying to skip the intermediate step, but doing it predictably is elusive. The big problem is tissue shrinkage of the skin, which as I mentioned is better resisted by the more rigid expander implant versus the softer permanent ones. The best candidates are those with smaller breasts who are having nipple-sparing procedures so that the native skin is 100% conserved. Even in that group, I find I'd be increasingly likely to go back and fat graft to camouflage the implant in a 2nd stage surgery. To my way of thinking, the benefit of single stage surgery just work enough to give up the benefit of the expander structural advantages.

Rob

Latisse (the eyelash drug) has been a raging clinical success

2010-07-24T12:29:00.000-04:00

Quick thought of the day:

After dispensing Allergan's Latisse medication for enhancing eyelash growth for over a year now, I'm officially impressed. It is hand's down the single most reliable treatment we offer to patients, and I have not seen anyone who does not respond well with it. Part of it's popularity is also the relatively low price tag (~ $120-$130 for a 2 month supply).

The "off the record" advice I have for Latisse users is that I think you can actually use it less frequently then daily and maintain results. I advise patients that once they get to a good clinical result that they try every other or every third day for application. Rationing the medication like that can make a single box extend for 3-4 months instead of 2 without much diminishing results. A good cosmetic budgeting strategy in these times!

Rob

When is a medical record not a medical record? When the Obama adminstration get's PC with it

2010-07-22T13:48:00.000-04:00

If the roll out of 21st century health care could have been more poorly handled, I'm not sure how. From a slow bleed over the spring involving an ill-conceived re-imagination of American health care delivery by the Democrats we are now presented with statements from President Obama's electronic medical record (EMR) czar that a medical record does not have to actually reflect what your medical history is.

Dr. David Blumenthal, the National Coordinator for Health Information Technology, said in an interview with CNS news (see here) that patients can choose to omit procedures such as abortions, positive HIV tests, or other perceived embarrassing information from their electronic health records (EHR).This is concerning in that a purported health record reporting a patient's comprehensive history could be edited so as to be politically correct. As a provider it would be important (for instance) to know that a patient had hepatitis or HIV before scheduling major elective procedures so as to protect oneself and operating room staff from unnecessary exposure or even advise patients to avoid some procedures altogether. Much as a physician has an informed consent with a patient, a provider must be aware of any and all material issues when delivering care.

Rob

What to look for for well done breast augmentation surgery -The inframammary fold

2010-07-11T15:54:00.000-04:00

Sorry for the long break! We've been busy designing our practice's new web site. It's gonna POP! Stay Tuned.

This post is kind of an "inside baseball" topic about what surgeons look at when we judge our own or others work. One thing I fixate on more and more with cosmetic breast surgery is the position of the inframammary fold (IMF). The IMF (in layman's terms) is an anatomic landmark created by adherence of connective tissue to the chest wall. It defines the inferior border of the anatomic breast, and it's location makes it the most popular place for an incision to place breast implants via the "inframammary" approach.

One of the things I look for in someone I've operated on or whom comes in for revision surgery by another provider is where a prior inframammary scar is. If the scar is stable and in the position it was originally made in then I'm satisfied the surgical dissection was performed well. If the scar is now residing up on the skin of the lower breast, that suggests over release of the native IMF during prior surgery. Once violated, that anatomic border is hard to reliably recreate. Just a little extra attention during surgery can prevent a lot of issues down the road as it relates to this.

Rob

Use it or lose it: study shows consistant BOTOX use can allow longer results

2010-05-08T18:54:00.000-04:00

Confirming what many Plastic Surgeons have noticed, a study just published suggests that patients who maintain their treatments with BOTOX for several years need fewer treatments to maintain their results.

On average, someone receiving treatment of their forehead or glabella (area between the eyebrow) requires retreatment every 3-4 months. The new study from the OHSU School of Medicine in Portland,OR shows that after 2 years of consistent treatments, the interval between treatment could be extended to 6 months with no difference in results.

Rob

Prophylactic Mastectomy - an ounce of prevention is worth 5% of cure

2010-04-29T21:13:00.000-04:00

Sometimes things that are so obviously intuitive still have to be validated. After a number of years of controversy, an increasing utilized surgery to prevent breast cancer is now being shown to be quite effective in both risk reduction and cancer-related mortality. The study "A Population-Based Study of Contralateral Prophylactic Mastectomy and Survival Outcomes of Breast Cancer Patients" is published in the Journal of the National Cancer Institute and can be seen here.

Contralateral prophylactic mastectomy, (CPM), a preventive procedure to remove the unaffected breast in patients with disease in one breast, clearly appears to offer a survival benefit to breast cancer patients age 50 and younger, who have early-stage disease and are estrogen receptor (ER) negative. We've known for several decades that CPM reduced the risk of developing breast cancer, but it was always more elusive to show that it actually saved lives at the end of the day. The practice of CPM has expanded significantly, with >150% growth in the number of such surgeries since the late 1990's.

How effective is CPM? Those younger than age 50 with early stage cancer with ER negative disease had a survival benefit of almost 5% at five years. For a therapeutic intervention for cancer, 5% is really substantial. You can take it to the bank that following these patients out even farther that we will show increased survival benefit with longer follow-up in the population. This is due to the fact that

the patient's likelihood of getting a second breast cancer in the non-removed breast increases with time
patients with prior breast cancer are among the highest risk group for developing breast cancer

Women older then 50 have a little more complicated decision. In cold, hard actuarial terms you are more likely to die from something else before a new breast cancer would kill you. On the other hand, steadily increasing lifespans of adult Americans has made some of these kind of statistical bets have to be reexamined. I would guess that the reported benefit of CPM gradually increases towards 60 years in future clinical guidelines.

Rob

Study confirms that breast implants do not affect breast cancer survival

2010-04-27T09:34:00.000-04:00

A recent Canadian study long term follow-up (see here) confirms prior observations that women with breast implants who go on to develop breast cancer have similar outcomes as women without implants who develop cancer. This is more reassurance to our patients about this theoretical concern with implants (ie. that potential difficulty with mammograms would lead to delayed breast cancer diagnosis and worse outcomes). Along a similar vein, women with implants actually have a much lower (~ 40% lower I think) rate of breast cancer as compared to peer groups in the population.

Rob

Slick Deals from Allergan for Botox or Juvederm rebate

2010-04-16T12:47:00.000-04:00

One of my favorite shopping websites is Slickdeals (www.slickdeals.net) which is a user driven collection of random shopping deals around the internet. You can find some fantastic bargains on all kinds of things, and the site is updated throughout the day by users reporting sales and promotional items.

In honor of this, I'd like to point out the "slick deal" Allergan is offering on it's products thru July. Allergan is the world's largest breast implant manufacturer, but they also make BOTOX, the dermal filler Juvederm, and the eyelash growing solution Lastisse. Thru July they are offering a $50 rebate coupon on either BOTOX or Juvederm purchases when you try Latisse. Details are available here.

Rob

FDA to mesotherapy - Put up or shut up! (but shut up first)

2010-04-15T09:01:00.002-04:00

The FDA last week issued cease and desist orders for a number of clinics offering fat melting "mesotherapy" injections. The drugs most regularly used in this process are phosphatidylcholine and deoxycholate. Other drugs or products such as vitamins, minerals, and herbal extracts are often mixed into the "gumbo", complicating any assessment of safety or efficacy. Phosphatidylcholine is not approved for injection into your body and has never been evaluated for that use in controlled settings. The new warning shot over the bow went out to six U.S clinics:

Monarch Medspa in King of Prussia, Pa.
Spa 35 in Boise, Idaho
Medical Cosmetic Enhancements in Chevy Chase, Md.
Innovative Directions in Health in Edina, Minn.
PURE Med Spa in Boca Raton, Fla.
All About You Med Spa in Madison, Ind

I would strongly advise people considering using these facilities to think again, as their disregard for patient safety with off label experimentation of these injectable concoctions should signal a general disregard for their patients. As alerts to this FDA warning went out on the ambulance chaser network of websites, expect to see ads shortly recruiting clients for lawsuits.

FYI If you are interested in reading about mesotherapy, I've written several entries about it since 2007 which can be seen here.

Rob

There's no escape from Magical Thinking on health care apparently

2010-04-11T11:11:00.000-04:00

There's a good bit of magical thinking around the idea of preventive care. One of the most disingenuous aspects of this is the push for these measures as "free" as part of the health care reform debate. Nothing of value is free, and in health care the overhead propping up the system makes that even more true.

Now there are both cheap and expensive measures that included in what we call preventive care or cancer screening, but at the end of the day they do not save money (even if they may make us healthier). It's actually counterintuitive that some bad habits or diseases from them (smoking or diabetes) may actually save money as they die younger and end up costing less over a lifetime. That's not a reason to not support early intervention, but it is something that has to be considered when making your countries health care budget.

The truth that the health care costs as a % of GDP are ignored by the bill passed is really scandalous. Facing those true costs was not something the left was going to let get in the way of entrenching their goal of federal health care. A story about the effects of the health care reform bill I read (see here) seemed to forget that all costs matter until pointed out over and over by readers in the comments section. I thought this one was spot on,

Colonoscopies and mammograms are absolutely not “preventive” care, they are early detection. Having a mammography will not prevent breast cancer any more than owning an umbrella will prevent rain. It may stave off the full and most dire effects of a diagnosis of cancer by allowing early intervention, but that is far from prevention. You will have to pay for the surgery, the radiation, the medication, all the same. Talk about “magical thinking”.

The politics of telling people NO is complicated and gets caught up in issue driven advocacy groups. A large study from Denmark touched on this obliquely by studying an area of screening efficacy (or lack thereof) when they found no evidence that screening women for breast cancer has any effect on death rates when applied to their countries women in well organized screening programs. For context, breast cancer is the most common cancer in women worldwide, accounting for around 16 percent of all female cancers and is attributed to almost 519,000 people globally each year.

How do other western countries with modern health care systems screen for breast cancer? In Denmark, women are screened every two years from age 50, while in Britain the policy is for women over 50 to be screened about every 3 years. Evidence now suggests that for every 2,000 women who are screened over 10 years, only one stands to have her life saved by the mammogram program, whereas the chance of getting an unnecessary breast cancer diagnosis is 10 times that.

If you'll remember in 2009, we had a hailstorm of controversy here in America when it was suggested that our current guidelines of starting screening mammograms at 40 was neither cost-effective nor evidence-based for affecting breast cancer mortality. There was a lot of ignorant political grandstanding on this as a woman's issue (step forward congresswoman Debbie Wasserman-Schultz D-FL) and Democrat's were furious that this kind of recommendation was coming out during their poorly-conceived sales job on health care reform. God forbid there be any notion that evidence based medicine might infringe upon you right to insist on your ______ (Mammogram, CT Scan, MRI, back surgery, etc....) without considering considering the cost or efficacy. It was a lie then and it's a lie now.

Rob

Growing Hacks in Cali...Cali - Underqualified cosmetic surgeons plague the Golden State

2010-04-09T13:52:00.001-04:00

Nod to LL Cool J in the post title :)

California is an iconic part of the United States that sets many trends. Unfortunately one of these trends is the growth of under or untrained physicians performing cosmetic surgery procedures.

A snapshot of who is performing cosmetic procedures in California, published this month in the journal, Plastic and Reconstructive Surgery, examined 1,876 cosmetic practitioners from San Diego to Los Angeles. Only 495 of them were actually trained in plastic surgery. Primary care physicians with no surgical training to speak of made up the 4th group of liposuction providers following plastic surgeons, dermatologists and otolaryngologists.

Scary, Scary stuff! It seems obvious, but always look for a board certified Plastic Surgeon if you're considering plastic surgery.

Rob

Are your breast implants under warranty?

2010-04-05T09:49:00.000-04:00

The New York Times had a story last week (see here) on how expensive orthopedic implants for knees and hips were to replace when they failed. As the cost of the devices themselves (without hospital or physician charges) can run north of $15,000, it can be more then $50K on the price tag when these patients require re-operation for premature failure. Highlighted in the story was the fact that the manufacturers did not expressly provide a warranty for replacement costs of their implants.

Much like these orthopedic devices, patients with breast implants can expect their devices to have to be replaced at some point in their life, either thru device failure or for aesthetic revision issues as their body changes. In contradistinction to the orthopedic companies, both Allergan and Mentor Corp. (whom combined sell 99% of all breast implants in the United States) have offered lifetime replacements on their failed devices for several years now. Allergan in particular has been admirable, as the parent company that makes the implants has been sold twice from it's roots as McGhan medical (later Inamed Corp.). As both Allergan and Johnson & Johnson (owner of Mentor Corp. since 2009) are huge multinationals, it would seem patients with these implants should have a good deal of security of their devices fail for replacement of their implants.

These implant companies do not however cover all other costs associated with the replacement of the devices, but have come up with a fairly generous standard program matched by both Mentor & Allergan

10 years of guaranteed financial assistance
Up to $1200 in out-of-pocket expenses for surgical fees, operating room and anesthesia expenses not covered by insurance
Silicone filled and saline filled breast implants are both covered
Lifetime product replacement
Automatic enrollment at the time of your original surgery

Now as a breast implant is relative expensive to design and test clinically, but inexpensive to manufacture by the unit, it's easy to see how these companies can absorb the cost. I don't know exactly their margin per device, but I think it's $600-700+ per silicone implant they sell.

Rob

Go Gators! An interesting use of "sovereign immunity" in Florida's medical malpractice reform

2010-03-25T09:46:00.001-04:00

It's been an awful week or two for medical malpractice reform with state supreme courts in Georgia and Illinois striking down award caps on the vague category of "pain and suffering". (Missouri's supreme court reaffirmed that state's caps this same week ~ Rob)Such caps have been one of the most effective ways of discouraging frivolous or borderline lawsuits as it disincentives such proceedings unless the cases are truly egregious.

Florida has a bill being considered in it's legislature that would extend the concept of "sovereign immunity" to providers in the Emergency Room. Such status makes providers de facto ``agents of the state'', and consequently immune from medical malpractice lawsuits. In that setting the state would administer any successful claim, which would be subject to the sovereign immunity cap of $200,000. To recover more, victims would need to file a claims bill in the Florida Legislature. This turns the malpractice system into more of a no-fault worker's comp type of arrangement.

You can't help but think that would be a more efficient and fair way to administer such claims. Of course, trial lawyers are screaming bloody murder, but keeping them happy is low on society's to-do list (unless you are a Democrat politician accepting their ~~bribes~~ err... campaign contributions). If physicians are going to be involuntarily obligated by hospital credential committees or federal and state licensing issues to provide emergency services, they should at least enjoy some protection from these high risk (for malpractice exposure) duties. Kudos to Florida for experimenting with some real world solutions to tort reform!

Read more at the Miami Herald about this interesting idea.

Rob

New conflict of interest (COI) rules could decimate academic plastic surgery

2010-03-23T09:43:00.000-04:00

The potential of conflicts (COI) for physicians who accept stipends or consulting fees has led some medical schools to formally prohibit their clinical faculty from accepting such compensation. This movement led to the resignation of a number of distinguished doctors who participate in industry sponsored research, consulting arrangements, and educational events. While not universal among medical schools at this point, this trend is likely to keep some of the best and brightest out of academics. Some consultants and speaks make tens or hundreds of thousands of dollars annually to supplement their clinical practice. As academic overhead tends to run high, this opportunity to make alternative income allowed some people to stay in academic surgery who might otherwise leave for pure private practice setups.

Stanford University has now (read here) taken the dramatic step of restricting even volunteer clinical or "adjunct" faculty from this as well. This type of restriction could have a potentially devastating effect on Plastic Surgery training as a number of the most prominent programs in plastic surgery (NYU, University of Texas-Southwestern, Emory, Johns Hopkins, Georgetown, Michigan, etc...) feature many active and adjunct surgeons whom recieve industry support or give educational seminars. The loss of access to these surgeons for training for real (or imagined) COI would be a big blow to the field. In January, the issue was highlighted in a when Boston doctor and well known Allergist-Immunologist, Dr. Lawrence DuBuske, resigned his Harvard medical school position rather than give up his speaking engagements. DuBuske got almost $99,000 from pharmaceutical giant GlaxoSmithKline in three months last year, more than any other doctor in the country.

While most speakers don't score that much in fees, it can add up to a substantial supplement to someone's clinical practice. COI have been managed in recent years by more stringent required disclosures by speakers at meetings and in our medical journals. The FDA has made efforts to remove panel members from hearings with any potential COI from drug and medical device hearings, including the hearings over silicone gel breast implants earlier this decade. The loggerheads with that idea is that many of the experts in these specialized fields inevitably have some COI from funding, speaking fees, stock holdings, or even intellectual property (shared or owned patents). Scott Spears (chief of plastic surgery at Georgetown University) is one of the world's experts on breast implants, but his testimony before the FDA during the hearings on silicone breast implants was attacked by activists trying to prevent the reintroduction of those devices by any means necessary because he is involved with dozens of companies in R&D, educational endeavours, and speaking sessions.

IMO, as long as clear disclosure by physicians is made these COI issues are manageable as long we always maintain some skepticism about what we are told and review data critically.

Rob

Plastic Surgery 101's "Mythbusters" on the health care debate

2010-03-21T20:07:00.001-04:00

As a physician, I have a vested interest in following the debate on reinventing the American health care system. Listening to these discussions, I find there is a distinct lack of candor about where the costs are in the system and little insight into where true potential savings are.

MYTH: Electronic medical records (EMR) will save money

FACT: No one can plausibly explain how any money will be saved. EMR does offer portablility of records, but does nothing to control cost in and of itself. The costs for physicans and hospitals to purchase equipment and pay ongoing subscription and IT costs will be a HUGE burden.
WINNERS: EMR vendors, IT companies, database miners and researchers
LOSERS: productivity of an office
OFF THE RECORD: Why should I be expected to subsidize a national EMR system through my office overhead when it's uncompensated and will surely be used down the road to squeeze providers?

MYTH: Primary Care Providers (PCP) are the sacred cow in reform and hold the key to holding costs down

FACT: The PCP workforce is under and ill-equiped to treat a mass influx of patients into the system. It will take years to retool the training infrastructure to handle the volume of patients. Massachusetts experiment in universal care for it's citizens has been crippled by an insufficent number of participating PCP MD's.
WINNERS: PCP will be getting a small increase in fees for routine office visits per the federal government at the expense of some specialists (Cardiologists, Radioloists, & GI docs mostly)
LOSERS: specialists physicians
OFF THE RECORD: Medical students will continue to avoid primary care because they percieve it tedious and they realize that nurse practictioners can do 85%+ of what they do for 50 cents on the dollar. It's also intuitive that specialists who work more and have trained 2-3x as long would be expected to earn a good deal more then PCP's.

MYTH: It's hard to find savings in healthcare!

FACT: There are some big savings in proceduras that could clearly be achieved with little affect on quality of care. Rigidly restricting (thru evidence based indications) the use of knee/shoulder arthroscopy and joint replacement surgery by orthopedists, upper/lower endoscopy by Gastroentreologists, coronary catheterization and stents by Cardiologists, lumbar spine surgery by Neurosurgeons, and the overuse of CT/MRI scans by all of us are the low hanging fruit in cost containment.
WINNERS: whoever's paying the bill (the feds or insurers)
LOSERS: whichever doctor's procedures are restricted and the idea (endorsed by my mother, wife, and many non-thoughtful doctors) that procedure or study "x" should be done "Just to be safe."
OFF THE RECORD: There's no way to make the numbers work without doing these kinds of restrictions. BTW I would not want to be a radiologist who expects to make big bucks in the next few years as they're about to get scalped.

One thing that makes me shake my head is the disconnect in the popular press when they talk about how individual doctor's practices are coping or planning to cope with whatever's coming. My favorite is the young PCP who is featured just out of residency boldly proclaiming things about how they're going to reinvent the doctor patient relationship by their use of technology.

http://www.businessweek.com/magazine/content/09_27/b4138034173005.htm

rob

Breast Implant bombs - Can you weaponize an implant? Unfortunately yes.

2010-03-01T11:05:00.000-05:00

I saw a story today which touched on something I'd been thinking about for years. Apparently Islamic terrorists have been working on a way of turning a breast implant into a way to smuggle explosive liquids onto airliners. While that may sound like a joke headline from The Onion, it's really a scarry idea.

From relatively simple and innocuous ingredients, a highly explosive liquid can be produced.

This link to a BBC story demonstrates the devastating effect on a plane fuselage that such a liquid explosive could have:
http://news.bbc.co.uk/2/hi/uk_news/7536167.stm

I'm not exactly sure how you would trigger it, but presumable you could stab into the implant with a wire or pin and wire it to a celphone or battery (this type of liquid material can be ingnited with an electic charge)

Denied insurance claims- the bane of patients AND doctors

2010-02-26T08:23:00.000-05:00

I started this post 2 weeks ago and got inspired by yesterday's goofy "health summit" between President Obama and Congress. Excuse the juxtaposition of the two subjects, but I think in the end they are related.

The issue of health insurance denying authorization for surgery or denying claims for procedures already performed is one of the most frustrating parts of being in practice. The New York Times featured a story on this entitiled , "Fighting Denied Claims Requires Perseverance" as it related to a patient fighting her insurer for coverage of an arthroscopic hip surgery.

To me the article is less about a hip operation, but rather represents the collisions of four forces

1. Insurers trying to control their cost and make money by limiting care
2. The people who pay for employee's health care trying to control their expenses by restricting unlimited utilization
3. Patients who want what they want, when they want it (but are removed from the actual costs of these procedures)
4. Physicians who are interested in advanced techniques and technology for procedures (who are slightly less, but still somewhat removed from the costs of these procedures)

As a society, America has not learned to reconcile our desire for expensive (and often futile) treatments with the fact that someone has to pay for all this. The congressional healthcare "summit" yesterday was a grotesque kabuki theater filled with political spin and lip service to the tough choices that have to be made to make the health care system sustainable. In summary: Democrats reflexively refuse to offend unions and ambulance chasers while afraid to limit or trim entitlement growth, while Republicans offer tepid (but useful) reform at the margins and refuse to budge on likely required tax increases.

The article about some advanced new orthopedic technique parallels the series the Times ran this week on an advanced melanoma treatment which described (what I presume) what was a very expensive palliative treatment which offered no cure and "worked" such that lifespan was extended for short periods of time. This kind of treatment is not sustainable for our health system, and focusing on it adds little value for considering "bending the curve" of costs. Ultimately, we'll have to decide whether we want society to pay for such exotic medical care, or expect patients to finance their own surgeries and treatments that go above and beyond approved evidence-based medicine (EBM) treatments.

Rob

Related letter to the editor on Mayo Clinic model and Medicare

2010-02-14T11:25:00.000-05:00

In January, I wrote about the Mayo Clinic's satellite in Arizona dropping Medicare patients claiming it was financially unsustainable. (see "The Mayo Clinic decision signals the health care bill is "One Big Ass Mistake, America"). Besides being embarrassing for the Obama administration as he'd held it up as his model health delivery vehicle, it produced a lot of teeth gnashing. For many people, they always assumed nearly all doctors accepted Medicare, and certainly an institution like the Mayo Clinic would accept Medicare rates (no questions asked).

Mayo exists as a really weird historical quick of American Medicine. It established a reputation for excellence generations ago and managed to make that name a "franchise" for medical care. While Mayo has some fine clinicians, it's kind of well known among most surgeons that a place like Mayo has had a hard time keeping the talent happy in terms of compensation and selling rural Minnesota as a destination to live. It takes a certain kind of personality to accept the trade-offs of that clinic system, but security of such a protected & salaried position is certainly going to become more common.

Exactly how Mayo operates as to your insurance has always been confusing to many people, and the Medicare announcement had a lot of people looking for answers. I found a great letter to the Editor in a Boston Globe article that is the most succinct summary to date

I am a surgeon practicing in Phoenix, Arizona. I also grew up in Rochester, MN where my father was a physician at Mayo for 35+ years. It's time to set the record straight on the misconceptions of the Mayo Clinic as a model for efficiency.

1)Mayo does not take Medicare, as outlined in the article.
2)Mayo does not take Medicare supplements for new patients.
3)Mayo has never emphasized primary care and in fact closed their family practice program here in Phoenix at a time of acute shortage in our state, citing costs. Primary care is labor intensive
4)Mayo refuses to provide care to citizens of Phoenix, the city in which they reside, in need of specialty care in situations where their specialists have availability and where there are acute shortages in the community. Their decisions for taking patients is made by administrators, not doctors, based solely on insurance. Doctor to doctor requests are frequently denied.

5)The Dartmouth Study, touted by many as the proof of efficiency of the Model compared Medicare expenditures county by county, throughout the country. Mayo Rochester resides in a rural farming community, where Medicare usage would be expected to be low. But since Mayo does cares for virtually none of these Medicare patients, extrapolating the cost efficiency of Mayo is simply wrong.
6) Mayo's model is very much a boutique model, catering to the wealthy, those willing to pay extra or out of pocket for their care or those with very good indemnity insurance coverage. Mayo is not in network for virtually every HMO and PPO plan, based simply on the high reimbursements demanded by Mayo. Mayo quotes 2-4 times the cost for surgical procedures that those in the community at large get paid.
7)Mayo relies heavily on the$ 200-300M/year in endowment money each year, to supplement their payrolls, build their buildings, fund research, and fund their pension plan. The cost structure of the Mayo Clinic is prohibitive without this additional funding. In this recession, Mayo is having considerable difficulty because it has been having appealing to those who used to come out of pocket for perceived more individualized care.
7) Community physicians in Jacksonville and Phoenix/Scottsdale assume virtually all the care for those in need, regardless of ability to pay.

I have always been of the belief that Mayo has the perfect right to practice Medicine the way in which they believe. Their doctors are dedicated to their mission and contribute each and everyday to the growth of medical knowledge.

Please, however be honest about what the Mayo model is: exclusive medical care for those with means and those willing to pay considerably more for their services.

Cheers!

Rob

Horrible radiation injuries in NYC - One more reason Plastic Surgeons do not like radiation therapy

2010-01-24T13:30:00.000-05:00

The bane of existence for plastic surgeons who treat breast cancer is the deliverence of external beam radiation (XRT) after surgery. It creates a hostile environment in the tissue exacerbating stiffening of the skin and scar formation. Above all else, it is the most disruptive factor for getting good results from breast reconstruction surgery.

The negative experiences of plastic surgeons with XRT in this setting has produced the interesting survey results among us, that we would overwhelmingly suggest our spouse (or self in the case of women plastic surgeons) get a mastectomy instead of lumpectomy and XRT. Most women recieving mastectomy would not be suggested XRT except in rare instance involving more aggressive tumors, innvolvement of the chest wall, or extensive spread to the armpit (axillary) lymph nodes. In contrast, European physicians are much more likely to perscribe XRT to the chest and axillae. The practice patterns have to do with how the different countries interpret the same literature regarding this practice. IMO, the rationale Europeans emply to justify XRT is pretty sketchy and is hard to show much difference in outcomes.

On the front page of the New York Times today (click here) is an absolutely horrifying story on the frequent misdosing of patients recieving XRT in the NYC metro area entitled, "Radiation Offers New Cures, and Ways to Do Harm ". Some of the stories are jaw-dropping in how the series of events led to serious adverse events. It is absolutely incovievable that the delivery of XRT, a largely computer driven process, should be doing this. The number of radiation therapists, nurses, and techs who had to drop the ball or ignore clear warnings for these events to happen is staggering. Heads will roll in the Big Apple hospitals for this!

Rob

The Mayo Clinic decision signals the health care bill is "One Big Ass Mistake, America"

2010-01-04T20:39:00.000-05:00

I've been on a little hiatus but hope to get back to semi regular output here on PS 101.

Since I last wrote, the Senate voted their version of the health care reform bill to consensus conference with the house. Even for Washington, the "sausage making" of this bill was pretty ugly. The naked bribes required to get Sen. Ben Nelson (D-NE) & Mary Landrieu's (D-LA) votes were particularly offensive, and quite possibly illegal (see here).

One story that is very symbolic but did not get much play in the media was the announcement that one of the Mayo Clinic satellites in Arizona would no longer see Medicare patients. Mayo is doing this because it lost $840 million last year on Medicare patients, and specifically it's Arizona hospital and four primary-care clinics lost over $120 million. No matter how efficient you are, that is unsustainable. It must be particularly embarrassing to Pres. Obama to see his "model" franchise for health care telling him to his face that he does not understand the effects of the legislation both he and his party are foisting on America.

To doctors in practice, it was always amusing to see the Mayo clinic proposed as a replicable model for our health care system. For starters they operate in a coccon on a largely wealthy, educated, and homogenous patient group. Even more ironic is the fact that the Mayo clinic doesn't even really take Medicare, but exists as a "non participant (non-par)" where they reserve the right to balance bill the patient for what they think their services are worth. From the Mayo website

"Mayo Clinic is a non-participating provider in the Medicare Program. We do not accept assignment on claims submitted to Part B Medicare except:

•where the law requires us to;
•in the case of documented financial hardship;
•when the supplemental insurance is a contract payer;
•when the patient resides in the state of Minnesota.
When claims are sent to Medicare on a non-assigned basis, the benefits for the services are sent directly to the patient. Mayo Clinic is entitled to bill the patient for the difference between our billed amount and Medicare's approved amount. We do not have to accept Medicare's approved amount as payment in full. Mayo Clinic limits its charges according to the limits set forth by HCFA for the Medicare program. Mayo hospital claims are sent assigned."

Expect to see real push back from providers at other places who treat these patients.

Rob

Oy vey! Laser suturing techniques from Israel

2009-12-10T12:09:00.000-05:00

An Isralei group is working on a novel technique for laser welding skin incisions. Dr. Abraham Katzir from Tel Aviv is promoting his prototype which advertises itself as the first tissue friendly device for such anapplication. From the description of the technology it sounds like they use some protein-like gel in the wound as "cement" and then use the laser to heat it, essentially spot welding the area. From Technology Review magazine:

Katzir and his colleagues developed a laser-based system with a feedback loop that prevents overheating. First, they had to determine the optimal temperature at which flesh melts but can still heal (about 65 degrees Celsius). Then the group created a pen-sized tool that incorporates optic fibers: one that channels a carbon dioxide-powered infrared laser to the wound with pinpoint precision, and another that leads from the pen to an infrared sensor, which measures the temperature and ensures that the heat remains within the ideal range, between 60 and 70 degrees. All a surgeon has to do is move the pen's tip along the cut, strengthening and sealing the weld with a solder of water-soluble protein.

Below is a picture of two laparoscopic surgery access sites with the top closed with sutures and the lower picture using the laser technique.

Give me a break!
This is a technology that seems a little dodgy on exactly what advantage it offers, which is the lens thru which all medical devices must be examined going forward. In an era where healthcare dollars are rationed, you better show more then bells and whistles. This way of closing a wound is many, many more times expensive then sutures, glue, or staples and will require high maintainence durable medical goods (the laser). I'm not exactly sure what their market is going to be

The world's worst timing in magazine covers - 10 things Obama can learn from Tiger Woods

2009-12-04T09:15:00.000-05:00

Fate has a sense of humor apparently. Could you have imagined more ironic timing then the cover of last weeks Golf Digest touting the "10 tips Obama can take from Tiger".

I'm sure Mrs. Obama will be very interested in this article! :)

Rob

"When someone is doing sex to me..." SNL nails Obama on China. Must see TV!

2009-11-23T22:43:00.000-05:00

In one of the most brutal political comedy skits ever, Saturday Night Live has found it's voice on President Obama. After bending over backwards to avoid criticism of the President due to their political leanings, SNL is back with it's fangs out. Obama is now forever going to be rightfully caricatured as the milqetoast technocrat rather then some trans formative figure. You wonder if there's any buyer's remorse they cast Hilary Clinton aside?

The new mammogram and self exam guidelines set off a hornet's nest of controversy

2009-11-19T10:17:00.000-05:00

The suggestions of the United States Preventive Services Task Force (USPSTF) regarding mammograms and breast self-exam have touched off a hornet's nest (to say the least). The new guidelines recommend that women in their 40s no longer have annual mammograms and that women ages 50 to 74 have them only every other year instead of annually. After having the message drummed into American women that they HAVE to have a mammogram annually starting at age 40, why the change in advice?

The task force report explains that for every 1,000 women in their 40s who receive routine mammograms, only two cases of cancer are detected. Alongside this is the fact that 98 women will also have "false positives" mammograms which will detect something that possibly looks like cancer, but that further testing shows actually is not. The cost and morbidity of routine mammography of the population (and the subsequent workup of such lesions) therefore brings the issue of cost-effectiveness of the program into question.

Last month I wrote a post "The Return of the weregild" discussing how the cost of healthcare gets into the accounting practices of establishing how much a life is worth to society and how much we can afford in support of such a life. Although downplayed by the USPFTF, this actuarial view played some role in the decision. It is my opinion that this is actual the thoughtful way we'll have to address health care spending. Although no one wants the heath care curve "bent" at their expense, you have to look at cost/benefit of practices to the system to control spending and give yourself the biggest bang for the buck for your tax dollars.

If you step back from the hysteria, I don't particularly find the recommendations controversial. It actually reflects the world consensus re. mammograms that mammograms in younger women (<50) are a poor way to affect how many women actually die from breast cancer (the whole point of screening). No other western nation practices routine mammograms under 40 that I'm aware of (and hasn't for some time) looking at this same data. If you're going to screen younger women it needs to be done more selectively to those with strong family history or palpable abnormalities that require further workup. This is exactly what's endorsed by USPFTP and should be a model of thoughtful care for patients going forward.

My first though re. this report was actually that "I wonder how long it's going to be before insurers adopt this" and require certain guidelines be met for women less then 50 perscribed a mammogram. It didn't take long as some HMO's have said they're reviewing their policies in light of this. If you're interested there's a short article on that issue in today's New York Times.

Rob Oliver Jr.

Oh Canada! - excellent NY Times letter response on health reform

2009-11-09T18:37:00.000-05:00

I read an extroidinarilary good comment on this article in the "Prescriptions Blog" NY Times today that I thought was worth reprinting. It was a response to another comment from a Canadian chastising the United States and pointing out what an absurd and misleading benchmark it is to compare the systems and problems of Canada to the United States in many respects:

“Let me tell you about my life. We (Canadians) have health care that is equal to that which an insured American gets for about 1/3 the cost. ”

Let me tell you about Canada. It is 1/10 the size of the US. There is this thing called scaling. Take any program and scale it up 10x and see what happens.

First off it is about 1/2 the cost, not 1/3. US is 2.2x more expensive per capita.

Healthcare is not equal. The infamous study that ranked the US so low overall grugding concluded it was tops in choice and quality. Per capita spending is about double for Canada.
But guess what, the US is top in a number of things that add to that cost. Some examples:
#1 in teen pregnancy (20 times more than Canada)
#1 in obesity (more than twice that of Canada)
#2 in abortions (about 15 times more than Canada)

“We pay about 1/2 the cost for prescription drugs.”
Because the US is in effect subsidizing the Canadian government’s negotiated prices.

“We have about 1/10 the level of gun violence in our country”
Which means healthcare in the US has to be higher to cover those violence related injuries. Which are treated in emergency rooms so they are very expensive.

The US has about, at low estimate, 12M illegals. Canada, by high estimate, has 120K. That is 100x more in the US.

So, once you tried to scale the Canadian system into the US with its differing problems, but trying to keep the same high choice and high quality levels, I would not be surprised to see that medical costs per capita would be very similar to what they are today. Single payer being cheaper per capita in the US than what we have now has NEVER been substantiated. What single payer in the US would do is make it APPEAR cheaper (how many post here have talked about FREE Canadian or English healthcare) to many by placing a higher burnen on higher income earners. The Dems don’t want single payer because it will reduce overall costs, they want it because it can easily be turned into the most progressive payments system around.

Announcing the birth of the Birmingham Breast Blog

2009-11-08T19:48:00.000-05:00

Just a note to frequent readers. Due to requests by some of the audience to address some specific topics about breast cancer and cosmetic breast surgery, I started a "companion" blog to Plastic Surgery 101 titled the "Birmingham Breast Blog". Put it on you check in list for some content that will be a little more focused then the stream of consciousness topics I get around to here.

http://birminghambreast.blogspot.com/

FYI, At right is a photo of the statue of Vulcan, symbolizing my hometown.

Lady GaGa - as performed by Christopher Walken

2009-11-02T15:06:00.000-05:00

Whimsy post today! No groaning over politics and mediceine (I promise).

Actor, Christopher Walken has such a terrific deadpan that I could listen to him read the phonebook and laugh. He made a classic star turn on the BBC's 'Friday Night with Jonathan Ross' this past weekend, where he killed the audience with a dramatic reading of Lady GaGa's disco ditty, 'Poker Face'

Swimming with the sharks - Democrats once again sell out on malpractice reform

2009-10-31T17:21:00.000-05:00

IF anyone doubted the how much the trial lawyers own the Democratic party, please check out this little present to the ambulance chasers tucked away in the 1900+ page healthcare reform bill

In Section 2531, entitled “Medical Liability Alternatives,” establishes an incentive program for states to adopt and implement alternatives to medical liability litigation. [But]…… a state is not eligible for the incentive payments if that state puts a law on the books that limits attorneys’ fees or imposes caps on damages.

So basically it says states are free to experiment with alternative settlement systems, but keep your hands off the big contingency fees of our donor base or we'll withhold federal money. Ironically, this bill would also incentivize states to encourage more frivolous suits by removing existing caps on non-economic damages.

This is absolutely disgusting!

Rob

Welcome to the return of the weregild - your life on the healthcare balance sheet

2009-10-28T08:06:00.000-05:00

You may not remember it much, but most of those of us who were forced to endure studying the epic poem, Beowulf were introduced to the concept of the weregild. In the 2007 CGI adaptation of Beowulf, apparently the side plot discussing the weregild was cut to make more time for Angelina Jolie's CGI-enhanced, naked, high heel wearing turn as Grendel's mom. Probably a smart decision by the producers in terms of the box office :)

The weregild was literally a "man price" you paid as compensation for killing someone, and there was a price on everyone from the dregs of society all the way for one prescribed for regicide (killing the king). It's a fascinating social compact that was used to try and temper blood feuds with their cycles of repeat violence and revenge. The Roman Catholic church eventually enacted their own version of "tort reform" on the weregild, condemning it and forcing elimination of the practice near the end of the 1st millennium AD.

From Wikipedia's entry,

The standard weregeld for a freeman appears to have been 200 solidi (shillings) in the Migration period, an amount reflected as the basic amount due for the death of a ceorl both in Anglo-Saxon and continental law codes. This fee could however be multiplied according to the social rank of the victim and the circumstances of the crime. For example, the 8th century Lex Alamannorum sets the weregeld for a duke or archbishop at three times the basic value (600 shillings), while the killing of a low ranking cleric was fined with 300, raised to 400 if the cleric was attacked while he was reading mass.

The size of the weregild was largely conditional upon the social rank of the victim. A regular enslaved man (ceorl) was worth 200 shillings in 9th century Mercian law (twyhyndeman), a nobleman was worth 1200 (twelfhyndeman). The law code even mentions the weregeld for a king, at 30000, composed of 15000 for the man, paid to the royal family, and 15000 for the kingship, paid to the people. An archbishop is likewise valued at 15000. The weregild for a Welshman was 110 if he owned at least one hide of land, and 80 if he was landless.

NOTE: For those interested, there's a fascinating catalog of such fines from the Salian Franks (a German dynasty)here, which covers the price of various offences, ranging from stealing your cow to gang raping your wife

Ok Rob, why are you talking about weregilds on Plastic Surgery 101 anyway?

There were several articles about healthcare I read this week that all kind of intersect at the fringe of the debate on healthcare and got me thinking about the equivalent of the modern weregild.

"A Place Where Cancer is the Norm", which describes Houston's MD Anderson cancer center.

"Cancer Society, in Shift, Has Concerns on Screenings" which describes a pullback from the American Cancer Society on just how effective mammograms and prostate cancer screening (via PSA tests) on affecting death from cancer.

"Can 'bundled' payments help slash health costs?" in USA Today

Sunday Night's 60 Minute's piece (click here to view)on more then $60 billion annual loss to Medicare fraud and how the Feds have been inept at policing it.

An article in Oregon's Statesman Journal, "Government Audits Are Hurting Small Business Owners" describing the federal government's Recovery Audit Contractor(RAC) program for Medicare fraud.

The articles on cancer screening and exotic treatments at MD Anderson hospital to me point towards a more strict cost-benefit analysis coming on cancer treatments. The tertiary chemotherapy drugs and adjuvant radiation treatments described are budget busters with very marginal utility in terms of outcomes. The care described in the article, where chemotherapy treatments were literally thrown against the wall to see what sticks, is not a sustainable model. We're going to asking more and more, "How much are 'x' additional months of this cancer patient's life worth?" in order to balance our health care budget. It is unavoidable that we don't end up with some federal utilization committee who's job it will be to tell us what we cannot do in terms of palliative care for cancer or other chronic diseases. Other countries already do this without much controversy, but President Obama won't touch this with a 10 foot pole.

The USA Today article on bundling payments seems unworkable in situations where physicians are not employees of the hospital or system involved. I would not trust a hospital corporation to distribute that money equitably to independent providers once they have it in their coffer. Would I have access to audit a hospital's books to make sure their accounting is accurate? What's the resolution process for disagreements on the balance sheet? Much like insurers, the temptation for them to slow-pedal payments to collect the interest would be impossible for them to resist. Except in certain "closed system" situations (where all MD's are employees)like the Mayo Clinic, the Cleavland Clinic, or the Kaiser network in California, this bundling would be a unacceptable working situation to most physicians.

The 60 Minutes piece on Medicare shows why no one who is familiar with healthcare believes that the federal government can run a single-payer system. They are unable to investigate or follow up on even the most blatant examples of fraud costing hundreds of billions over dollars a decade.

So what do they do instead? They reauthorize the "RAC" program to aim at providers and hospitals for fraud that may be pennies on the dollar compared to the fraud described in the 60 minutes piece. The feds have outsourced the Recovery Audit Contractor (RAC)program to incentivized companies to autopsy medicare billing going back over 3 years by hospitals and providers where any inaccurate billing (using our byzantine CPT system) is assumed fraudulent and due back with interest and penalties. Analysts expect that inaccurate coding underbills at least as often as it overbills, but do you know what these auditors have produced. What do you get however when you incentivize these companies to claim 8-12% of any recovery (but don't reward refunds)? You get 96%+ of these RAC audits finding overbilling only.

Rob

Fallout from NJ Democrat meddling at the FDA will hold up medical device approval. Thank you very much New Jersey!

2009-10-07T17:12:00.004-04:00

Thanks to the intervention of 4 New Jersey Democrats in the FDA approval process for one of their constituents, all medical devices are on the sloooooow track for approval. An editorial in the New York Times summarizes this nicely here.

In short: A New Jersey orthopedic medical device firm, ReGen turned to four Democrats to lobby on their behalf for approval of an orthopedic knee device — Sen Robert Menendez and Sen. Frank Lautenberg, as well as Congressmen Frank Pallone and Steven Rothman. According to the Washington Post, Regen paid Sen Mendez's former chief of staff nearly $300,000 for lobbying services, and Hutton contributed nearly $40,000 to Menendez and the three other Democrats who wrote a letter to the FDA urging the agency to make a decision on the company’s application.

This kind of "pay for play" is par for the course for New Jersey Democrats, but not as appreciated by federal regulators. The blowback from the intervention of theses pols and former FDA head, Andrew von Eschenbach, has reignited scrutiny of the FDA's practices and procedures.

Caught up in this are hundreds of devices in final stages of approval, including the next generations of silicone (and saline) breast implants. I wrote about this last April in a post called "An Exercise in Clock Watching" talking about the bureaucracy of FDA device approval in re. to breast implants. It's amazing and frustrating to think that improved devices used world-wide (US excepted) for 15+ years are still clinically unavailable here.

Rob

Behind the (1 in ) eight ball: More breast cancer patients choosing prophylactic mastectomy

2009-09-28T08:14:00.004-04:00

The AP wire is reporting that the number of women opting for surgery to remove the healthy breast after a cancer diagnosis in one breast is rising, despite a lack of evidence that the surgery can improve survival. Sometimes this is presented as controversial, but I think this represents rationale behavior by many women choosing this.

There's the powerful slogan that's penetrated popular culture that women have a "1 in 8" risk of breast cancer. That's kind of correct but oversimplifies things. Biology is destiny with breast cancer and appears to overwhelm anything in your diet or the environment in terms of producing breast cancer. Like most cancers, risk of breast cancer increases as you get older. Taking all comers in the United States, a woman's chance of being diagnosed with breast cancer is about 1 in 233 when she's in her 30s which steadly rises to 1 in 8 by the time she's reached 85. However, there are women in that group who are at substancially more or substancially less risk.

Younger patients in particular would seem to benefit the most from prophylactic removal of the breast due to this increasing bias for later tumor development. The survival benefit for this surgery hasn't really been studied (as far as I can tell) in your breast cancer patients out for decades. It's assumed that you'd likely see a significant difference in that groups risk of breast cancer in the post menopausal group. Widely referenced studies (see here) suggest that after prophylactic mastectomy a woman's risk for later developing breast cancer is reduced by an average of 90% (some even suggest closer to 100%).

It's clear to me which way I'd suggest for all but the most favorable tumors in young women. Is it for you?

Rob

UPDATE on teen breast augmentation death: Florida state medical board finds no fault with doctors action

2009-09-26T08:49:00.003-04:00

I just saw an update in the Miami Herald (here) on the events surround the anesthesia related death during breast augmentation of Florida teen Stephanie Kuleba, who underwent a fatal malignant hyperthermia(MH)reaction. This is a case I wrote about in Spring 2008 here & here.

Office based anesthesia is common for many procedures including oral surgery, dentistry, colonoscopies, otolaryngology (ENT), and plastic surgery. There's lots of reviews on this demonstrating outcomes and safety data comparable to hospital operating suites. Most plastic surgery procedures in this setting are on healthier patients, which can make a death more shocking.

Writing back then I said,

"I'm not sure what the take home message from this is. It's such a rare event that it's hard to justify having exotic protocols at all times in low risk procedures. Most office surgery suites maintain a supply of Dantrolene, a medicine to treat MH which is almost $2500 per dose and must be restocked often to stay current. There's plenty of adverse events more common then MH, but we don't have aortic balloon pumps or cardiac bypass machines routinely laying around for that. It already sounds like that the family has hired an attorney who is already assuming an aggressive posture in his comments to the media so I'm sure we'll see some legal proceedings even if perfect care for MH was instituted."

Predictably, the teen's parents in this case are still wanting their pound of flesh and have recently decided to proceed with medical malpractice lawsuits against her surgeon and anesthesiologists despite the Florida Department of Health finding there was no evidence of deviation of standards of care in this tragic event. Does that make any sense to anyone?

Rob

On tort reform, President Obama DOES lie

2009-09-13T19:53:00.005-04:00

President Obama has spent the week furiously trying to put lipstick on the pig that is his healthcare reform bill. He gave a fine speech last week which was noticeably short (by design) on specifics, and one which left out any plausible way to pay for the program. Trying to defang critics, he generalized a number of areas where centrist Democrats and Republican ideas would be incorporated. One of these was a brief mention of tort reform.

Color me uinmpressed.

As with his summer speech at the American Medical Society (AMA) meeting that was met with boos, the president has over and over made it clear he is not interested in addressing real medical tort reform. If you took the most disingenuous elements of lawyer-speak mixed equal parts with the opacity of politican-speak you end up with the President's message to his Democratic trial bar donors (alongside organized labor, the most influential group in Democratic politics). ie "Relax boys, THERE WILL BE NO REAL RESTRICTIONS ON YOUR ABILITY TO SUE DOCTORS, Amen!"

Anyway.....

From the 60 Minutes interview tonight(click here for video)

KROFT: If it came down to getting this plan passed would you be willing to do more in the area of tort reform and malpractice insurance? Would you be willing to agree to caps, for example, on malpractice judgments?

OBAMA: You know what I would be willing to do is to consider any ideas out there that would actually work in terms of reducing costs, improving the quality of patient care. So far the evidence I've seen is that caps will not do that. But there are a range of ideas that are out there, offered by doctors' organizations like the AMA, that I think we can explore.....

KROFT: And the conventional wisdom has been that the reason that the House has always voted against any kind of malpractice reform or tort reform was because of the heavy contributions from the trial lawyers.

OBAMA: That is the conventional wisdom. And I think there's also been philosophical issues and differences about whether or not patients who really have been subject to negligence, whether it's fair to just say to them, "You know what? You can only get a certain amount, no matter how egregious it is."

That is nothing but double-speak goblety-gook which avoid any commitment to do anything. At least Democratic leader Howard Dean had the balls to recently come out and say that tort reform is not going to be in the bill because of the relationship of the party to the trial bar.

Rob

Buy one (implant), get one free - Stay classy Wisconsin!

2009-09-09T18:18:00.005-04:00

A really, really tacky billboard campaign in rural Wisconsin by a wannabe made me immediately think to quote the Will Ferrel character, Ron Burgundy, from the movie "Anchorman",

"Stay classy, Wisconsin!"

Tasteful advertising! Does it surprise anyone that this Doctor promoting plastic surgery is not actually a Plastic Surgeon? Well at least he's a surgeon which is not the case with all these cases. Of note, this yahoo was recently fined (see here) closed to $20,000 for Medicare billing fraud.

Remember to always look for a board-certified Plastic Surgeon when you're considering cosmetic surgery. You can inquire here on the American Board of Plastic Surgery website.

Rob

Breast Reduction Amazon style - the legend of Amazonian breast mutiliation

2009-09-05T16:15:00.000-04:00

According to Greek historian, Herodotus, the Amazons were a race of female warriors living on the Thermodon River in Scythia. There were no men in the community, and any boy born was killed or dispatched to his father beyond the river.

Hippocrates wrote that the girls had their right breast burnt off with hot irons such that they might better draw the bow. In the 3rd century AD, Roman historian Justin asserted that the mythological Amazon is derived from the Greek roots a (without) and mazos (breast). In Anabasis of Alexander, mention of the Amazons, said that their right breasts were smaller and were uncovered in battle. This observation could mean the legend of elective mastectomy was really right breast underdevelopment caused by deliberate binding or pinching.

Does it make sense that a mastectomy would make using a bow easier?

Actually it does. It's been observed that most competitive women archers are smaller breasted, and a chest guard is actually worn by many competitors to avoid inadvertent injury to their breast when shooting. The weight of the breast also changes the center of gravity and requires active extension of your lower back muscles to remain erect, a distinct liability for horseback based or hand to hand combat.

Among these legendary Amazonians were Queens Hippolyta, whose girdle Hercules was assigned to recover (sure sounds like a panty raid to me) as one of his 12 great tasks, Penthesilea for whose death Achilles mourned, and Thalestrias who had an affair with Alexander the Great.

In DC Comics, the famous Wonder Woman is supposed to be Diana, daughter of Hippolyta and Amazonian princess. For whatever reason she apparently did not get the memo about having small breast :)

Factoid to store away next time you're a contestant on Jeopardy: Spanish conqueror, Francisco de Orellana named the Amazon River as such after encountering women warriors among the Indian tribes of South America.

Rob

Pro tennis player Simona Halep's cups no longer runneth over.

2009-08-23T15:07:00.006-04:00

While we're on a run of breast reduction posts, I'd like to highlight the related story of Romanian tennis player, Simona Halep. Ms. Halep is a 17 year old tennis prospect who was good enough to win the French Open junior division in 2008 and is working her way up the WTA rankings (currently at #274). Unfortunately for her, she was attracting as much attention for her breast size (reportedly 34DD) as she was for her tennis talent.

Well word got out in the spring that she was considering a breast reduction (reduction mammaplasty), it took things to a whole other level. Photo spreads in British tabloids, fan sites, "Stop Simona from reducing her breasts" Facebook groups (I'm not kidding, click here), and even the infamous Opie & Andy show on satellite radio got in on the act.

Here's a video clip of her practicing where you can see the problems large breasts would cause with movement. WOW, Does she really hit the ball hard or what!

Well it would appear Simona quietly went ahead with the surgery this summer and is recovering to return to her high level athletic career. Resuming the training and competing after this operation could be tricky. There's real reason to be extremely conservative in clearing her to train. At 2 weeks after surgery the breaking strength of her scar would be about 50%, and by six weeks it would be approaching 90% tensile strength. With the kind of torque, tension, and range of motion she will be putting on her incisions there is real reason to believe she may have issues with poor scarring from her reduction.

Discussing her decision in interviews, Ms. Halep

But Simona's set proved too much to handle during matches and she feared they were stopping her from winning titles.

Last month she admitted: "It's the weight that troubles me - my ability to react quickly, my breasts make me uncomfortable when I play as well.

"I don't like them in my everyday life either. I would have gone for surgery too, even if I hadn't been a sportswoman," she added.

The photo below is purportedly after her surgery in late June or early July.

A breast reduction the size of hers is likely not going to be possible with many of the modern "short scar" techniques that I prefer. I would bet she had a traditional "Wise Pattern" or anchor shaped incision.

Rob

Breast reduction surgery and quality of life - Addition by Subtraction!

2009-08-17T13:57:00.000-04:00

Breast reduction surgery presents an interesting issue when we're getting into an era where every health care cost is going to be scrutinized. As a society, is this a procedure we're going to be willing to commit major funding to? Currently there is a patchwork of indications that vary between different insurance companies as to what meets medical necessity for this operation.

In general, most insurers make you do extensive documentation of "conservative therapy" before even considering approval. I'm not sure what conservative management of big breast is exactly anyway! There are differing weight requirements for the tissue to be removed as well. Blue Cross of Alabama for instance requires a minimum of 500 grams (~1.1 lbs) per breast to be removed. Others use a sliding scale called the "Schnur Scale" to correlate appropriate weight removal to a calculation of your total body surface area (TBSA). The Schnur scale came from a paper by a plastic surgeon who was trying to quantify symptoms in his breast reduction patients.

The recommendations from that study by Dr. Schnur were perverted by insurers, written into policy guidelines, and are now used to exclude many patients from having breast reduction surgery. There now exists a great deal of literature showing that reductions much less then prescribed by insurance companies is effective in patients suffering from neck, back, and shoulder pain. In fact, a Finnish study suggests breast reduction surgery seems to improve the health-related quality of life indicators as much or more then surgeries for hip or knee joint replacement.These studies are dismissed by insurers as observational,flawed, or biased by greedy doctors, but if they could speak honestly they would explain that they don't want to open eligibility for the procedure to a whole new class of patients and cost themselves a great deal of money.

Apparently we're not the only country that is having issues on whether to cover breast reduction surgery. Hat tip!

A court in the German state of Hessen has ruled that insurance companies do not need to cover the cost of breast reduction surgery as having a large bust is not a medical problem. The decision means that insurers will only have to pay to correct breasts which are deformed.

The case was brought by a 38-year-old woman who suffered orthopaedic and physical problems due to the weight of her boobs. She had been advised by doctors to have breast reduction surgery.

But her insurance company didn’t see it as a necessity and therefore refused to cover the costs of the operation. It claimed she was suffering from back problems because she was overweight and that her physical discomforts would be reduced if she trimmed down weight and built some muscle up.

The court agreed with the insurance company and the big-breasted woman lost her case.

Two and a half years ago, the court in Hessen rejected the case of a woman who thought her breasts were too small. She wanted her medical insurance to cover a breast enlargement operation and claimed that she was physically harassed for her small boobs. The court declared then that small breasts are not an illness

Rob

The World's Worst Plastic Surgery Logos

2009-08-11T21:56:00.015-04:00

Choosing your business logo is important, and that holds true for plastic surgery practices as well. When we worked on ours, it took literally dozens of ideas and revisions to get where we wanted. It turned out pretty well if you consider the fact that our trademarked logo for Plastic Surgery Specialists has been "borrowed" by at least half a dozen web sites I've found.

Quick plagiarism trivia: If you'll remember, Richard Ashcroft, lead singer of British pop band The Verve was found guilty of plagiarizing the melody from the Andrew Oldham Orchestra recording of The Rolling Stones' 1965 song "The Last Time" for their 1997 #1 hit "Bittersweet Symphony". Ashcroft was forced to relinquish millions of dollars in songwriting royalties to Mick Jagger & Keith Richards.

Anyway, in doing research for our logo last year, Dr. Jason Jack and myself looked at hundreds of other practices logo choices. There were a few that stood out as really bad.

1. We thought this looked like the "Mud Flap trucker girl".

Versus

2. This one reminded me of all those bad 1970's brown color schemes

Compare it to this 1970's fabric courtesy of the "Tune Up" blog devoted to vintage fabric (talk about your narrow reader demographic!)

It also kind of reminds me of the 1970's San Diego Padres Uniforms.

3. This logo has four different type fonts fighting for supremacy

4. This logo was just too "subtle" :)

Did someone really think a Pitcher Plant emerging from some one's vagina was the right way to go with this ad? Obviously this campaign did not get wife approval factor (WAF) before going to print.

5. I call this ugly logo of various body parts the "Homunculus". A homunculus is any representation of a human being, and is often used to illustrate the functioning of a system.

In medical school neuroanatomy, the concept of this is used to show what areas of the brain control the body.

Not related to plastic surgery per se, but this pediatric clinic logo really could use a redesign :)

FYI, there's a great blog post on the world's worst logo here.
Rob

20/20 segment on the tradeoff's in healthcare reform

2009-08-09T19:58:00.002-04:00

Good story on some of what you have to give up to expand healthcare coverage. It's not all win-win when you disincentive 20% of the economy.

Hat tip to my partner, Dr. Jason Jack BTW!

Rob

Democracts backpedal on federal "BOTAX" to plug budget holes

2009-07-28T09:17:00.004-04:00

Well, it appears that calmer heads (or at least calmer foreheads) are prevailing.

Yesterday it leaked that the Democratic caucus was considering taxing BOTOX & cosmetic surgery in their desperate search for revenue to provide a fig leaf of budget neutrality in the health care power grab. After much ridicule on the ludicrousness at the feasibility and effectiveness of it, they're backing off.

Presumably, house speaker Nancy Pelosi , she of frozen forehead, killed this :)

Rob

Nip/Tuck gets "nipped" by FX - thank you God!

2009-06-22T08:55:00.003-04:00

The insufferable (vaguely) plastic surgery -related drama, Nip/Tuck , has been terminated by the FX network. From the LA Times,

"When "Nip/Tuck" made its debut in 2003, it broke cable-viewing records and instantly distinguished itself with its stylized look, tongue-in-cheek tone, gorgeous stars and fresh take on America's obsession with beauty and youth. Those qualities earned it a Golden Globe for best drama, critical acclaim and water-cooler buzz that lasted for most of its first four seasons.

But when one of FX's signature series quietly wrapped last week on the Paramount lot, it did so without the usual fanfare associated with the end of a noteworthy show. In part, the silent send-off was because TV viewers won't see the "Nip/Tuck" finale, which finished shooting on June 12, for a long time, probably as late as 2011, making it tricky to publicize. Behind the scenes too, during the last week of production, there was an awkward sense that the end had already happened, since much of the crew had already moved to creator Ryan Murphy's new Fox musical, "Glee," last year, and Murphy himself was out of the country location-scouting for an upcoming movie.

....In the five seasons that have aired, the doctors, who are in their 40s, have almost died several times, slept with dozens of women, broken up their partnership a few times and dumped a dead body in the Florida Everglades. In the 19 new episodes, which will probably air over two seasons and may begin in January, the series will become even more operatic and dark, elements that, critics say, have diminished its pleasures over time.
"

Plastic Surgeons, will uniformly celebrate the demise of this tawdry show which did little to accurately portray or advance our field. While less offensive then Dr. 90210, The Swan, Miami Slice, and other "reality" shows, Nip/Tuck was painful to watch. Other then having supermodels throw themselves at me weekly, I just can't can't relate to this show ;)
(just kidding Honey!)

Rob

Doh! Obama's longtime personal physician says the President just doesn't get it on healthcare.

2009-06-20T10:16:00.000-04:00

Those pesky septuagenarians just say the darnest things!

It's ironic that President Obama's longtime personal physician in Chicago, 71 year old Dr. David Scheiner, is on the record (see here) saying that the president does not understand the healthcare system or the changes that will be required to fix it.

He spikes the president on a number of issues including

having close advisers who have no healthcare experience
getting in bed with the trial lawyer's on killing malpractice reform

failing to understand the economic concerns of physicians and fair reimbursement

Rob

Free Breast Implants - a Prague hospital's alternative to an employee's 401K

2009-06-19T08:37:00.001-04:00

Employee compensation is a tricky subject. During medical school and training you really don't get much background in running an office and you rely upon senior partners and "on the job" training to keep the office running. In this environment, many practices are tightening their belts and finding innovative ways to compensate employees. It's common at many hospitals to offer signing bonuses for new nurses, but in this economy they're exploring alternatives to.

Which brings us to a story about a clinic in Prague

AN understaffed Prague clinic has signed up nurses by offering boob jobs, liposuction and tummy tucks as a bonus.
Nurses, doctors and secretaries who sign up with the small private clinic for three years can choose their free plastic surgery.

"It has been a success," Jiri Schweitzer, a manager at the Iscare clinic, said, adding the establishment was now fully staffed and had to reject dozens of beauty-hunting job applicants.

Petra Kalivodova, a 31-year-old nurse who has been working at the clinic for four years, has had a breast implants - the most popular choice among nurses - so she underwent liposuction for her signing on perk.

"I have mentioned this to colleagues and friends, and the interest in working here is huge," she said.

The clinic charges up to 75,000 koruna ($5060) for a breast implant, almost three times the average nurse's monthly wage, and up to €1880 ($3380) for liposuction.

Many Czech nurses have been tempted out of the country by higher wages offered in western European nations and the Czech health system now needs about 6000 nurses in addition to the 90,000 it already employs, according to official data.

Rob

AMA comes out against single payor and NY Times audience erupts

2009-06-19T02:34:00.000-04:00

While the New York Times is rightfully known as the nations' newspaper (sorry USA Today), their articles bring out the worst in it's audience when healthcare articles are feature. Witness last weeks article "Doctors’ Group Opposes Public Insurance Plan" which describes the American Medical Association's (AMA) on the record objections to some of the single payor plans being floated by President Obama's administration and by Democrats in congress. As I write this, there are well over 600 comments to this article on the website, with 99%+ full of fury direct towards doctors.

I don't think most of these commentators actually read the AMA's position carefully to understand what they fear.

1. Crippling of the system by an influx of uninsured or newly covered participants

2. Forced participation by physicians in government plans at below market rates

3. Monopolistic pricing to exclude any competition from private plans

4. No attempts to address the malpractice climate

We've already seen what happens when you mandate universal coverage and then don't fund it adequately in Massachusetts. Similar problems exist in Canada and Great Britain where national health systems infrastructure teeters on the brink of collapse. There's a disconnect about how much money we're talking about to make something like this work and most of the New York Times' crowd thinks it's greedy doctors' fault.

No plan or option is going to actually save ANY money, it's actually going to cost a great deal in taxes to expand coverage. That's fine, but it's a decision you have to make in context of a budget. If you spend it on healthcare it's going to come from social security's money pot in all likelihood. Right now there is a distinct lack of discussing of the cost shifting that's going to occur and the consequences thereof.

Rob

Manhattan's new office surgery rules causing surgeons headaches

2009-06-17T07:30:00.000-04:00

New York doctor comrades, I feel your pain!

On July 14, all medical offices in New York performing surgery requiring anything other then local anesthesia will have to be accredited by one of the major ambulatory surgery regulatory boards. While this is imminently logical, it does create special problems in an older city like New York with mostly preexisting structures and high real estate costs. Many physicians are scrambling to find places that can be brought up to code when they get the sticker shock for potential remodeling costs, assuming their current space can meet code at all (which may not be possible in some buildings). Click here to read a feature on this in the NY Times.

Having just finished the build out of an office surgery suite in a blank shell, the easiest way to incorporate the special design needs of a modern O.R., I can attest to the fact of how complex it is. Out of the 4000+ sqf we have in our build out, almost 50% is just to accommodate the workings of a single O.R. Imagine trying to renovate a prewar building in Manhattan, many of which also have co-op boards to deal with as well.

Despite the headaches, it is a good move by New York to require this. Office O.R.'s and the doctor's who use them need closer scrutiny!

Rob

Barry's in the house - President Obama booed at American Medical Association speech

2009-06-16T01:07:00.005-04:00

I was inspired to choose a picture of the two-faced Roman god, Janus, to place next to this post. In ancient Rome, Janus was used to symbolize change and transitions, but also associated with the later metaphors of being two-faced or speaking out of both sides of your mouth. Our silver tongued commander in chief managed to do that very well in an anticipated speech before doctors today.

In thee speech before members of the American Medical Association (AMA) today, President Obama was booed. What set that off? His position that any element of true tort reform for medical malpractice was off the table. Up to that point he was being well received and was discussing some fuzzy notions of medical tort reform and the concepts of standardized practices which could offer some imaginary shield of immunity.

"Don't get too excited yet," he warned the cheering AMA members. "Just hold onto your horses here, guys. . . . I want to be honest with you. I'm not advocating caps on malpractice awards."

That last sentence shows his lack of backbone and highlights the way that trial lawyers are one of the tails that wag the dog of the Democratic party. (Screwing Chrysler bond holders last month by ignoring established bankruptcy law to favor labor unions showed us one of the other tails BTW). There has been feverish lobbying on this issue by lawyers to ensure that Democrats protect their interests in medical malpractice and medical product liability cases.

Hell even the logical idea that if a physician adheres to broad standards of care established by their peers they're by definition not committing malpractice is already being fought. The American Association for Justice, which represents trial lawyers and has met with Nancy-Ann DeParle, Mr. Obama’s liaison for health reform issues, to express its concerns. Linda Lipsen, the association’s chief lobbyist, said medical practice guidelines have been established by 'unregulated' medical societies and “should not be conclusive” in a court of law. GIVE ME A BREAK!

From today's Wall Street Journal editorial, "Obama's Malpractice Gesture",

The trial bar and its Democratic allies say that the threat of lawsuits promotes better care and assures accountability. But they've fought even modest changes that would offer liability protection if doctors adhere to evidence-based guidelines. Mr. Obama showed again with his AMA speech that he's willing to nod at the concerns of his political opponents and take media credit for brave truth-telling, only to dump his conciliation if it offends liberal interest groups.

In a nutshell, if you do not explicitly remove the jackpot justice aspects of medical malpractice thru strict caps on non-economic compensation then you've achieved nothing. There's a brand new review of torts by Lawrence McQuillan of the Pacific Research Institute and it discusses what specific maneuvers and reforms have achieved true reduction in frivolous lawsuits. Click to read "Tort Law Tally"

The cost of defensive medicine, unnecessary tests and procedures designed to mitigate malpractice claims, is elusive but has been estimated at over $125 billion per year. That's real money folks. If even 15-20% of that could be saved annually, it goes a long way towards making the math of financing Pres. Obama's plan more plausible. Right now we are being LIED to about the cost of any major healthcare shift and LIED to about what steps would be required to fund it. (Hello rationing and the VAT tax).

I ended my last post with the comment that, "It's this attitude and the distorted liability culture that Obama, et al. are going to be working against to make any gains in health care reform. We are our own worst enemy!". Once again I feel vindicated in that.

Rob

Exhibit A in why we won't be able control health care costs

2009-06-12T07:00:00.000-04:00

If you're looking for tangible evidence of

1. how some people feel unbelievably entitled
2. just how distorted people's views of what health insurance is for
3. how distorted our legal system is

Then look no farther then one Tess Sosa, one of the blessed to have ever survived a forced water landing by a commercial airliner. She and her family were passengers on the US Airways flight 1549 which crashed into the Hudson River outside New York City after striking a flock of birds this past winter.

You think Mrs. Sosa and other passengers would count their blessing to be alive and be thrilled with the $5000 check US Airways issued each passenger in compensation (which they didn't even an obligation to do). Apparently this was not acceptable to Mrs. Sosa who is demanding the airlines insurer, A.I.G., pay for all costs associated with her psychotherapy for post traumatic stress disorder, the unprovable sinkhole of psychiatric diagnoses.

From the New York Times,

Tess Sosa, who was aboard Flight 1549 with her husband, 4-year-old daughter and infant son, said she suffered a mild concussion during the landing, and her husband was treated for a leg injury and hypothermia. The family, from New York, continues to get hospital bills, she said. But her top priority was getting the insurer to pay for therapy to reduce the risk of post-traumatic stress disorder for her and her daughter.

Ms. Sosa said Sophia “remembers everything. I just want her to walk away from this knowing that we did everything we could to make it make sense.” A.I.G. agents have told her that for therapy she should use her own health insurance, but it has a $3,000 deductible for mental health care.

“Why should we be paying out of pocket?” she said. “That’s why they’re there. They’re the insurer.”

WTF! She's upset that she's being forced to apply this $5,000 windfall towards her copay and deuctible. Incredible! Also mentioned in the article are other passengers who are refusing to accept settlements in hopes they'll get larger offers. Why do these people feel they're entitled to anything? There was an "Act of God" event that people miraculously escaped alive from, end of story. It's this attitude and the distorted liability culture that Obama, et al. are going to be working against to make any gains in health care reform. We are our own worst enemy!

Rob

Plastic Surgery 101 is ranked #3 in Plastic Surgery blogs! I'd like to thank the academy :)

2009-06-11T22:22:00.002-04:00

According to iScrub, Plastic Surgery 101 is now the 3rd best plastic surgery blog on the web. I demand a recount :)

Writing a blog has been an interesting discipline. It can be real hard to come up with something that I think is worthwhile talking about. Unlike some medical related blogs which seem more like Twitter level entries, I try to put enough effort to make it worth coming back to. With the new office and little league consuming most of my free time, I haven't been able to be as consistent with output as compared to a few years ago. In the "draft bin" I've got nearly 50 blog posts or ideas that I've not gotten around to finishing.

For plastic surgery blogs, I'd really like to celebrate Dr. R.L. Bates' "Sutures for a Living". I have respect for the quality, consistency, and complete lack of self-promoting B.S. that Dr. Bates brings to her blogging. Toni Youn's "Celebrity Plastic Surgery" & Joe DiSala's "Truth in Cosmetic Surgery" blog are about the only other one's I check on from time to time. Joe's was the first blog out there, followed by myself and Toni a few years ago. Most of the other blogs by Plastic Surgeons are extensions of their marketing campaign with little interesting original writing.

Rob

Your healthcare tax dollars at work - a Trillion dollars just doesn't go as far as it used to!

2009-06-06T23:06:00.003-04:00

From the Dow Jones Newswire comes a thought provoking observation,

Ezekiel Emanuel, a bioethicist with the National Institutes of Health and brother of White House Chief of Staff Rahm Emanuel, put into perspective the more than $2 trillion spent on healthcare in the U.S. every year.

"People don't have any idea of what a trillion is," said Emanuel, pointing out that healthcare's steady increase will theoretically consume the entire economy one day.

He gave a shocking math lesson:

How long ago was a million seconds?

Less than two weeks ago.

How long ago was a billion seconds?

About the time when President Richard Nixon resigned from office in 1974.

How long ago was a trillion seconds?

30,000 B.C. - which was 15,000 years before the first human stepped on North America.

McAllen, Texas - America's failing experiment in health care cost control.

2009-06-01T12:00:00.000-04:00

There's a collision course of sorts that's been playing out in medicine for the last 25 years. As the costs of health care have consumed more and more of GDP, the system has become unsustainable. Physician salaries bore the brunt of early cost containment with effective pay cuts of 50-60% in real income since the mid 1980's. More recently it's been the patients on the receiving end, with more employers dropping coverage and more people enrolled in high deductible/high copay plans.

An article in the New Yorker Magazine, "The Cost Conundrum - What a Texas town can teach us about health care" profiles McAllen, Texas. McAllen is the most expensive place in the country in terms of annual expenditures on medicare beneficiaries. It illustrates the law of unintended consequences and reinforces the notion that anyone who thinks health care costs will come down with universal coverage is foolish. More coverage = more utilization, particularly when patients do not bare much of the costs themselves out of pocket.

The article also features the behavioral changes of physicians as they've become more entrepreneurial. It's profiled as a negative in the article, but it really should be encouraged. In modern medicine, if you do not run your practice like a business, then your practice will fail. Physicians should be encouraged (when able) to align their entrepreneurial interests with their patients. In many instances this will run you head first into government bureaucracy and established interests as in the case of my office surgery suite. Don't even get me started on the fact that I'd be able to do some procedures in my soon to be accredited office O.R. at 40%+ discounts to Medicare and Blue Cross for what it costs to do in a hospital. You'd think this would be of interest to Medicare and the state of Alabama as it would likely save several hundred thousand dollars annually, but instead it's like talking to a brick wall.

Cosmetic Plastic Surgery practices has been the attentive to economics for a long time, and you're forced to be cost-conscious to maintain that kind of practice. The revenue from the cosmetic procedures I do affords me the opportunity to maintain a busy reconstructive practice on cancer patients.

Rob

An aspirin a day may not keep the doctor away after all

2009-05-29T10:48:00.003-04:00

Sudden shifts in medical advice can cause both patients and doctors confusion. In recent years the benefits of breast self exam for cancer, checking PSA (prostate specific antigen) levels for prostate cancer screening, vitamin supplements of any sort, and chest x-rays for lung cancer screening have all been reported to be ineffective and sometimes harmful to patients.

Add one more to the list - the routine use of low dose 81mg aspirin in the general population to decrease heart attack and stroke risk. This had been pushed such that most adults should consider taking a "baby" (81mg dose) aspirin a day. This seemingly harmless recommendation actually seems to be causing more problems then it's worth according to a new review of the literature.

Analysis of data from over 100,000 clinical trial participants found the risk of harm largely cancelled out the benefits of taking the drug. Use of aspirin in the lower-risk group was found to reduce non-fatal heart attacks by about 20%, with no difference in the risk of stroke or deaths from vascular causes. But it also increased the risk of internal bleeding by around 30%, a potentially life threatening complication. This is summarized here.

Only those who have already had a heart attack or stroke should be advised to take a daily aspirin is the new suggestion, at least for this week.

Click below to hear an audio summary:

Rob

Ireland and others on board with regulating cosmetic surgery providers - The end for Tom's Rhinoplasty, et. al?

2009-05-13T11:00:00.000-04:00

The United States is not alone in trying to come up with a way to ensure quality and standards among providers of cosmetic surgery and related procedures. The Independent (UK) wrote about this problem in Ireland and the U.K. last fall (see here) saying,

"Once you have a basic medical degree you need no specialist qualification in order to perform plastic surgery. A GP could do a breast augmentation in the morning, even though he had never seen it done or performed one -- and that is perfectly legal. The International Association of Plastic Surgeons (IAPS) members are trained in plastic, reconstructive and aesthetic surgery. Other people carry out procedures despite having no formal qualifications." One major concern of the IAPS is that of surgeons being flown in from abroad by private clinics and simply flying home after performing a procedure. "You would expect any other surgeon to be resident in the country in which he is practising," says Mr David O'Donovan, Secretary of the IAPS.

"Yet private clinics are shipping in surgeons who are not around when the patient needs aftercare, or complications arise. Some say their doctors are specialists, but they don't say what they're specialists in. For instance, a doctor performing breast surgery could, in fact, be a bowel specialist."

Similar stories can can found around the world from the United States, Australia, and other western countries. It certainly seems likely to get worse here as reimbursements for physicians are poised to take a big hit with whatever happens with American health care reform. There will be even more pressure for many doctors to encroach outside of their areas of expertise and become self-styled "Cosmetic Surgeons" or "Aesthetic Medicine" specialists.

Catering to this trend is the ever proliferating alphabet of organizations seeking to give some fig leaf of authenticity for doctor's credentials who have little or no formal training in some of the services they're now offering. (WTF is laser "vaginal rejuvenation" by the way?). One of the "cosmetic surgery boards" here in the United States has even had the nerve to suggest that their members are more qualified then Plastic Surgeons to perform cosmetic procedures and has railed against hospital medical staffs who have (quite rightly) not granted their hodge podge of members surgical privileges outside the scope of their accredited training.

For a Gynecologist's take on some of his colleagues trying to peddle themselves off as reinvented cosmetic surgeons, read this great post at "David's waste of bandwidth".

"Cosmetic surgery can kill people. It can maim and disfigure people. Just as I think surgeons should respect the procedures we do as gynecologists, we should respect the things they do, and only do them when we really have the training and judgment to proceed. No weekend course on ”cosmetic gynecology“ (whatever the f that is) is going to provide skills and judgment comparable to someone who is boarded in cosmetic surgery and plastic/reconstructive surgery. As it is, the folks who are boarded in cosmetic surgery are rightfully pissed at those cosmetic surgeons who are doing this without board certification or a decent background in plastic and reconstructive surgery. Why are we adding to this nonsense?

As an example in terms of judgment, you're mentioning the possibility of doing ”gspot injections“ (sic). This is inappropriate and has no place in modern practice, cosmetic surgery, gynecology or otherwise.

To my point exactly. We have no business doing this crap. I sympathize with those who do, and understand their motivation in terms of a cash business. But we're surgeons and professionals, NOT car dealers trying to make a fast buck. Or are we?"

It's not so far fetched to imagine a proverbial "Tom's Rhinoplasty Clinic" (an olde school South Park season 1 reference) popping up every block stamped with the seal of approval by ____________. (fill in the blank with bogus board certification du jour)

Rob

(smart) Skin Care for Dummies..... keep it simple stupid

2009-05-07T08:05:00.000-04:00

There is an overwhelming amount of skin care products on the market, and it can get kind of confusing to patients and doctors about sorting out hype from substance. At the end of the day I think you've got to keep it simple and try to minimize the number of steps and products that people use.

At a basic level you need to consider 3 things to be essential

a gentle daily cleanser (which can be something cheap)
a restorative agent(s) to improve or maintain your skin
protection from the sun

There's a whole bunch of peripheral products addressing pigmentation (toners, hydroquinone products, etc...) that serve niche roles as well.

I've become a fan of the Neo Cutis line of products for two reasons
1. it's reasonably priced for medical grade skin products
2. you can do a lot with a very simplified regimen

The gimmick with NeoCutis is a substance called "PSP" which is a proprietary protein derivative of sorts derived from fetal skin cells. This PSP ingredient is common to their different product lines in different concentrations and with some other additives. For men, their gel-based, "Biogel"
is a very easy single product that men can use without overwhelming our simple brain or making us feel overly metrosexual. Highly recommended and one tube will last 3 months or so, pretty reasonable for $120-150 dollars. Neocutis makes a more concentrated PSP product eye cream which is also great. As I understand it, a lot of people just use it for their whole face. It seems to work well and be very tolerant to people even with sensitive skin.

I'm not here to pimp for that particular company, but I think they make a value-based product line that is very simple. If you combine one of their PSP products with an OTC gentle cleanser, Retin A (or another retinoid-like product), and some sunscreen you suddenly have a fairly formidable combination for less then $200-250.

rob

"Going Dutch" for ideas on healthcare reform

2009-05-03T10:18:00.006-04:00

There's a real lovely article in the NY Times Sunday magazine about the Netherlands. The ostensible focus is on the social welfare network of the state, and contrasting an American expat's experience there. One of the issues discussed is health care, a very timely topic as it relates to the United States.

Since I started writing Plastic Surgery 101 in December 2004, I've periodically touched on medical economics as it's something that's fascinating both personally and professionally. It's been clear for several decades that we're creeping towards some type of state funded system ("Universal healthcare"), and the time table has sped up due to a couple of factors

the coming retirement of the bulk of the baby boomers. A demographic who has always been described as somewhat self-entitled. Their clout and collective zeitgeist are proving a potent voice in this.

the economic incentives of employers and unions coming into alignment on this. Someone wrote a few years ago that when Wal Mart decided it was time for universal health care, then discussions would happen in earnest.

a liberal president has a aggressively liberal congress and slight liberal majority senate

the real estate and stock market crisis have made not having both a job and health insurance a reality for a lot of middle, upper-middle, and white-collar classes.

I've been convinced that we're going to end up with a public-private system where basic care is covered and people with more money will be able to purchase higher levels of care or convenience to care. It's what actually exists in most of the world. There will still be moaning and gnashing of teeth about unequal access, quality, etc... but we'll be better off then we are on the whole.

Anyway, there's a great descriptor of this in the article I was referring to, "Going Dutch"

"The Dutch health care system was drastically revamped in 2006, and its new incarnation has come in for a lot of international scrutiny. “The previous system was actually introduced in 1944 by the Germans, while they were paying our country a visit,” said Hans Hoogervorst, the former minister of public health who developed and implemented the new system three years ago. The old system involved a vast patchwork of insurers and depended on heavy government regulation to keep costs down. Hoogervorst — a conservative economist and devout believer in the powers of the free market — wanted to streamline and privatize the system, to offer consumers their choice of insurers and plans but also to ensure that certain conditions were maintained via regulation and oversight. It is illegal in the current system for an insurance company to refuse to accept a client, or to charge more for a client based on age or health. Where in the United States insurance companies try to wriggle out of covering chronically ill patients, in the Dutch system the government oversees a fund from which insurers that take on more high-cost clients can be compensated. It seems to work. A study by the Commonwealth Fund found that 54 percent of chronically ill patients in the United States avoided some form of medical attention in 2008 because of costs, while only 7 percent of chronically ill people in the Netherlands did so for financial reasons.

The Dutch are free-marketers, but they also have a keen sense of fairness. As Hoogervorst noted, “The average Dutch person finds it completely unacceptable that people with more money would get better health care.” The solution to balancing these opposing tendencies was to have one guaranteed base level of coverage in the new health scheme, to which people can add supplemental coverage that they pay extra for. Each insurance company offers its own packages of supplements.

Nobody thinks the Dutch health care system is perfect. Many people complain that the new insurance costs more than the old. “That’s true, but that’s because the old system just didn’t charge enough, so society ended up paying for it in other ways,” said Anais Rubingh, who works as a general practitioner in Amsterdam. The complaint I hear from some expat Americans is that while the Dutch system covers everyone, and does a good job with broken bones and ruptured appendixes, it falls behind American care when it comes to conditions that involve complicated procedures. Hoogervorst acknowledged this — to a point. “There is no doubt the U.S. has the best medical care in the world — for those who can pay the top prices,” he said. “I’m sure the top 5 percent of hospitals there are better than the top 5 percent here. But with that exception, I would say overall quality is the same in the two countries.”

While free associating on things Dutch, Sasha Cohen's Borat paid Amsterdam a visit a few years back. Good stuff!

Rob

An exercise in clock watching - the fda's review of Allergan's 410 "gummy bear" breast implants

2009-04-26T11:19:00.000-04:00

As the plastic surgeons of the United States await approval of Allergan's style 410 breast implant (aka "the gummy bear" implant), I frequently get questions from patients about when this device will be approved.

The short answer is "I don't know!"

The approval of medical devices of all sorts has been heavily politicized. After a number of recent high profile issues with prescription drugs, cardiac pacemakers, and vascular stents (devices used to prop open clogged blood vessels or fix aneurysms), the FDA is under the microscope. Caught up in all this is the fate of the next generation of breast implant devices, for which the FDA has been sitting on the manufacturers approval applications for nearly 3 years.

For some context, "form stable" implants like Allergan's 410 have been used clinically around the world for over 15 years. In clinical trials (like this)they have an unparalleled safety record for this kind of medical device, and offer both superior durability and a reduction in every single kind of indexed complication (pain, capsular contracture, rippling, rupture, etc...) after cosmetic and reconstructive breast surgery that we observe and track.

Allergan's Style 410 implant:

The NY Times reported earlier in April (here)on the ongoing reexamination of "legacy" devices that were exempted prior to the late 1970's from review as they were already being used. Silicone and saline breast implants actually already went through this review by the FDA in the early 1990's and eventually emerged with a clean bill of health. The only reason the newer implants have to go thru this process at all is the higher cohesiveness of the silicone polymer exceeds some artificial cut-off that would make them fall under the existing approval. This illogical rationale has cost tens of millions of dollars to companies and delayed patients access to improved devices.

As to the fate of the 410 implant, my understanding is that the FDA is satisfied with the safety and clinical efficacy of the implants and is negotiating on the final labeling to be included with the product. Apparently, surgeons will be required to attend an instructional course prior to being given access to the device (even someone like me who actually used these devices as a resident and fellow during clinical trials). We are hopeful that the ongoing activity signals approval is immanent this quarter!

Rob

A Partisan's political pandering poised to poison prevention - Why Rep. Waserman's breast cancer bill is wrong.

2009-04-19T18:21:00.001-04:00

That was a heck of the title, eh? My little pun on the "6 P's" ;)

Of all medical diseases, few are surrounded by as much politics as breast cancer. After all, who doesn't want to advance the treatment of breast cancer? The problems arise when feel good political ideas triumph over evidence based medicine and you end up with legislation which is almost sure to cause as many problems as it solves.

Enter the boldly titled "Breast Cancer Education and Awareness Requires Learning Young Act of 2009" (EARLY Act) introduced by Rep. Debbie Wasserman Schultz (D-Fl). For whatever reason, Rep Schultz is one one of the single most obnoxiously partisan members of congress and gets on my every last nerve when I come across her on television. Schultz's bill seeks to spend $45 million over five years to start educational campaigns that would include promoting regular breast self-exams to secondary school students, even though the this has been proven ineffective and quite possibly harmful in clinical trials.

Breast self-examination may seem an innocuous and intuitive way to assist the self-detection of breast cancer except for the fact that IT DOES NOT WORK when applied on large populations of non-selected women. All young women have dense lumps and bumps in their breasts tissue which represent fibrous breast tissue or benign cysts that become symptomatic with their menstrual cycles. Recommending breast self-exams to this group of women will cause fear, many expensive negative imaging studies, false-positive results of various screenings, and many unneeded biopsies.

There's some math you need to think about with these younger women. The probability that a woman who is age 15 years will develop invasive breast cancer by age 40 years is less than one-half of one percent (0.497%). This can be compared to a 5% probability that a 50 year old woman will develop breast cancer by age 70 years (5.62%). The American Cancer Society reports that during 2000-2004, only 5% of new cases and 3% of breast cancer deaths occurred in women under 40 years of age. For women aged 20-24, there were only 1.4 cases per 100,000 women. The goal of an effective screening program is to find disease and save lives. Unfortunately, at the end of the day there is no effective method of detecting breast cancer in a healthy population of women under 40.

Other then family history, we're currently left with little other then some of the expensive genetic tests (like BRCA1 & BRCA2)to try and select out people for closer surveillance. Despite the strong association between BRCA mutations and breast cancer (where as many as 85% would be expected to develop invasive breast cancer), only 5-10% of all breast cancer patients have BRCA1 or BRCA2 mutations. This again gets back to the difficulty in effective screening.

Leslie Bernstein PhD of the City of Hope Hospital in California published an open letter to legislators considering this bill to explain why this is a poorly aimed directive and likely to cause more problems then it solved. The letter can be read here. A better public policy goal in my opinion would be to mandate insurers and Medicare to cover breast MRI for screening in high risk women.

Rob

Will the last of the Dow Corning breast implant plaintiffs please turn out the light!

2009-04-08T22:37:00.000-04:00

The Star (UK) reports (here) on a plaintiff from the 1980's class action lawsuit against Dow-Corning involving silicone breast implants who finally received her share of the remaining settlement for a grand total of £207 ($304.50 USD at today's exchange rate).

It's hard to believe that elements of the 2nd or 3rd biggest "whale" of American class action lawsuits are still in existence. I call it 2nd or 3rd because asbestos and tobacco suits have dwarfed it now in overall compensation (Don't even get me started on the claims that smokers had no idea they could get addicted to cigarettes or get lung cancer!). The shenanigans of the trial bar in our country cultivating these proceedings does not reflect well on our legal system.

The person in the Star article had what sounds like subcutaneous mastectomies for painful breast cysts and reconstruction with silicone implants. She's attributed multiple and diffuse symptoms to the fact she had silicone breast implants in. (Keep in mind, large databases of women around the world with implants have failed to demonstrate an increase in any common rheumatologic symptom.)

She was among thousands of women from the USA and Europe who took action against the company claiming their health had been damaged after their silicone breast implants leaked or caused immune system reactions.

Now more than a decade of waiting the cases have finally been settled.

"It is an insult, they might as well have given us nothing at all," said Shirley. Women were originally expected to received thousands of pounds in compensation when the action was first launched. But Dow Corning, which did not admit liability in the legal case, went into bankruptcy and the amount of compensation available fell.

Well, if you believe the overwhelming world scientific consensus (see here) that has shown no linkage of any identifiable disease to breast implants , you might make the argument she received £207 too much. What's most striking is to consider how much the handful of class action plaintiff's lawyers literally stole from investors of Dow Corning (hundreds of millions of dollars) and how little claimants received some 20 years later.

Rob

Plastic Surgeon goes CSI to bust Booby bandit!

2009-04-05T11:32:00.001-04:00

From NBC comes this story:
"Yvonne Jean Pampellonne, 30, allegedly used a fraudulent identity to pay for liposuction and a breast implant exchange, according to the Huntington Beach Police Department. The total cost of the surgeries is valued at more than $12,000.

The Laguna Niguel woman is accused of opening a line of credit in someone else's name in September 2008, having the procedures and then never showing up for any follow-up appointments, police said."

The plastic surgeon who'd been defrauded for cost of the procedure apparently didn't take this lying down. They hadn't yet disposed of the patients old breast implants (which were exchanged during the procedure) when the fraud was discovered. They used the serial number imprinted on the old implants to track her down to her previous surgeon's office, and identified her via photos from the other office. I love it!

If you would like to "friend" Ms. Pampallone on MySpace, her profile can be found here. Apparently Ms. Pampallone was unfamiliar with myfreeimplants.com as she might have saved herself a multiple felony convictions.

Rob

Vanity Fair's "Undercover Plastic Surgery" expose

2009-03-20T18:31:00.000-04:00

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.

Rob

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

2009-03-16T20:25:00.000-04:00

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.

Rob

Aging studies on identical twins

2009-03-12T21:24:00.006-04:00

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.

Rob

The most underrated dermal filler - Radiesse

2009-02-27T19:58:00.005-05:00

Quick thought of the day on practical matters....

I continue to be impressed with the dermal filler, Radiesse. It's nowhere near as popular as the Hyaluronic Acid fillers (like Juvederm and Restylane), but it has some very useful properties.

Radiesse is made of calcium-based "microspheres" suspended in a water-based carrier gel. The gel degrades after injection, but the calcium spheres persist and cause an inflammation that stimulates collagen deposition.
Results like below (which I found on the net)are pretty striking when you direct this product into the cheek and deep nasolabial folds and "marionette lines" under the mouth.

Why do I like this so much? In two words, it's effective and efficient. One syringe of Radiesse is worth the effect of 2 of the hyaluronic acid fillers syringes and lasts up to two years to boot! In general, I think this is a much better deal for most patients even though it probably generates less revenue for me because patients don't need as many injections (due to the length of duration).

Rob

Game Show Bloopers!

2009-02-22T17:06:00.000-05:00

A break from heavy things today.

This collection of game show bloopers is really funny!

Rob

Usher's wife update on anesthesia complication

2009-02-18T11:37:00.000-05:00

Information about the emergency Usher's wife underwent in Brazil recently came to light. Two months after giving birth to the couple's second son, Raymond, 38, traveled to Brazil to have liposuction on her stomach by São Paulo plastic surgeon Dr. Silvio Sterman.According to the doctor involved, Tameka Raymond went into "cardiac arrest" while being anesthetized before a liposuction procedure. She was quickly revived and then placed in an induced coma(?) for 24 hours as a precaution and apparently remains in stable condition in a Sao Palo hospital. The news wire is reporting that she was discharged today and will be returning stateside shortly.

Ellen Dastry, spokeswoman for plastic surgeon Silvio Sterman, says Tameka Raymond checked into the Sao Rafael Hospital last Friday for a "simple liposuction." Dastry said that Raymond suffered a cardiac arrest while being anesthetized for the procedure "but was revived in less than a minute by heart massage." She was then placed in an induced coma before being taken to the intensive-care unit, a procedure Dastry said was "absolutely normal" and performed in order to "avoid unnecessary complications."

I'm a little confused about what may have happened here. It doesn't sound like she had a malignant hyperthermia (see related post here) reaction, but I can't figure out the rationale for the "induced coma". That would not be a normal treatment for a heart attack or lethal arrhythmia (irregular heartbeat), but could be present with malignant hyperthermia.

In a brief search for some consensus in the anesthesia literature on this I found some reference in a recent text which wrote

"Postpartum concerns include a decreased blood hemoglobin and the increased risk of pulmonary aspiration. Anemia is almost always present as a result of physiologic anemia of pregnancy combined with blood loss during and following delivery"

That's pretty tangential to this case, but it's all I can find with superficial snooping. Now liposuction after childbirth would not be expected to be a particularly bloody procedure, it is still something to consider.

More important would be questioning the logic of doing liposuction that early after pregnancy. I'd submit it would be someone with poor judgment who would proceed with that surgery on a practical basis. Good results with lipo rely upon contraction of the skin after it's debulked. There a are a number of circulating hormones associated with pregnancy that predispose tissue to expand to accommodate the developing embryo. Those mediators have clearly not normalized at only two months, and the patient has not reached a plateau in terms of her weight or abdominal wall tone at that point. Pro ceding with surgery is likely to not achieve the expected results in most instances. When would be a "normal" recommendation to proceed in the short term? Think closer to 9-12 months post delivery.

Of note, the NY Daily news is reporting that that the patient may have not been truthful with her surgeon about how far post partum she was. Evan a few months may have been the difference in her being deemed fit for surgery in this instance.

So what else could have happened?

Well, as the fluid used to perform liposuction has adrenaline and local anesthetic solution in it, a large intravascular bolus of this could precipitate a heart arrhythmia or event. Dilated veins in the postpartum abdominal wall may be more likely "targets" to be inadvertently speared by the infusion cannula used to put fluid in to tumesce the tissues for liposuction.

Just a thought!

Rob

News of the day - Fall in the house of Usher - Usher's wife's surgery complication, vitamins, and the failure of preventive care model

2009-02-11T20:16:00.000-05:00

A couple of things on my radar today

1) Hitting the news wire today is the report that R&B singer, Usher's wife has had serious complications from cosmetic surgery performed in Brazil. This procedure was also performed only two months after childbirth, something that raise eyebrows in re. to timing any major procedure on the breast or body. I guarantee the first thought that most Plastic Surgeons are going to have is that "Why would you fly to South America for surgery when you have the money to see anyone in the United States?".

It is absolutely a poor decision to do something like elective surgery half a world away from your doctor's and family. While there are truly some magnificent surgeons in Latin America, you introduce a lot of potential logistical issues when there are complications. In this instance, they've apparently flown a doctor down there to oversee treatment (as I'm presuming they were uncomfortable with the local care). That alone speaks volumes as to why this is a bad idea. The low cost cosmetic surgery "chop shops" that exists right over the border in Mexico are notorious for having complications and dumping patients stateside for treatment.

2) In the latest of a series of large studies (click here) assessing the effects of vitamin supplements, we once again see NO demonstrable benefit in a daily multivitamin. This follows on the heals of similar studies (with similar findings) on vitamins A, C, and E. It once again confirms "Rob's Rule" that you cannot outsmart mother nature.

3) The Chicago Tribune points out that an "ambitious effort to cut costs and keep aging, sick Medicare patients out of the hospital mostly didn't work," according to a study published in this week's Journal of the American Medical Association (JAMA). Any doctor, nurse, medical student, or even janitor who works in a hospital could have told you that minus the hundreds of man hours spent performing that study. In a corollary to "Rob's Rule" on mother nature, I might add that in general you don't save any money with preventive health care, you just redistribute it in other directions (and may in fact end up costing even more, it's counter intuituve, I Know!).

It would be nice if President Obama, et al. would be willing to admit that any steps they do that are "painless" to patient choice or patient care (ie. preventive care, the "medical home", or the electronic medical record (EMR)) will not save one dime on health care costs. Those choices that will affect cost have winners and (big) losers and will be extremely polarizing. Barack Obama does not want to be campaigning for reelection in Florida in 2012 explaining why 75 year old grandma can't get her hip replaced because his actuarial based plans for health care spending suggest her quality of life is less valuable then someone in their 50's needing a total knee replacement.

Rob

Plastic Surgery Specialists - Our new office's grand opening!

2009-02-06T21:18:00.003-05:00

Well we moved into our new office this week. Wow! What an incredible amount of logistics for a (relatively) small construction project. We're working on the office OR suite accreditation and hope to be doing cases by April on site.

For directions click here.

I continue to be incredulous over office surgery regulations (or thereof). It's amazing that a family practice doctor, OBGYN, or radiologist could go to a weekend course and start performing major cosmetic surgery in a un-inspected exam room without scrutiny or real oversight. My partner and I on the other hand, designed an OR suite that exceeds hospital standards and will require ongoing QA and inspections. To build, furnish, run, and accredit this is expensive (think hundreds of thousands of dollars) but worth it to provide a safe environment.

Once again, I call on states to address this area of office surgery more closely.

Rob

How to make breast augmentation less painful - Depobupivicaine

2009-01-26T12:08:00.009-05:00

One thing that patients frequently ask about when considering undergoing breast augmentation is how much pain and discomfort they'll experience. I think in general, the pain is directly correlated to the surgical technique.

If you could find a video of breast augmentation circa 1975, you'd see a set of instruments like this used:

Those hockey-stick shaped devices are called "Dingman breast dissectors" (after Dr. Reed Dingman, former chief of plastic surgery at Michigan in the 1960's-70's). Basically, they're a lever to mechanically dissect a pocket to place an breast implant into. Breast augmentation in that era consisted of making an incision, shoving one of these instruments in, tearing a pocket out bluntly, and holding pressure until the patient quit bleeding. Sounds great, huh?

Blood around an implant, as we know, is a potent stimulator of capsular contraction, and techniques like this combined with silicone implants of that era probably precipitated many (with a capital M) cases of hardening breast. There is no way to predictably minimize bleeding with blunt dissection, and it should be largely avoided in breast augmentation except when gently refining a previously dissected pocket.

Believe it or not, there are still some surgeons who use that kind of technique when they place implants thru the armpit (transaxillary approach) and belly button ("TUBA" technique). Evidence based medicine and the refinements in surgical techniques described by surgeons like John Tebbetts, Pat Maxwell, and others have clearly shown us ways to get better results, with less bleeding, less inflammation, and softer breasts over the long term.

The key to safe and excellent plastic surgery is precision and planning. As the apocryphal "7 P's" quote from the British military goes:
"Prior Planning and Preparation Prevents Piss Poor Performance". This is particularly true as it relates to long term outcomes from breast augmentation surgery.

Anyway......

The take home message is that more atraumatic technique produces less pain and controlled dissection of the space for the implant under direct vision increases precision and decreases bleeding. We're getting to the point where there are few technical steps to be discovered that will decrease pain much more. Most of available improvement involves intercostal nerve blocks with local anesthetics (which last 6-8 hours), disposable external pulsed electromagnetic field generators (PEMF) (like those made by Ivivi or ActiPatch), or indwelling pain pumps which trickle a local anesthetic in the breast pocket for 2-3 days. They all work, but have limitations due to duration (nerve blocks), external device requirements and costs(PEMF), or potential contamination of the implant from the skin (pain pumps).

I'm currently involved in some phase III FDA trials with breast augmentation on a long-acting local anesthetic that may solve all these problems. It involves bonding a local anesthetic to a fatty lipid molecule which serves to make a very effective sustained release drug. Where normally this drug (marcaine) might last 6-8 hours, when bound to this carrier molecule it lasts up to 3 days.

That is a game changer in post operative pain control IMO. It gives both proven efficacy with long action and no external devices/catheters to pay for. Our most recent patients we've done have have used nothing but tylenol for post-op for pain control, which is pretty amazing for sub-muscular implants.

Study Recruitment for Depo-bupivicaine FDA clinical trial:

Rob

It's BOTOX Obama-nation - the left will now have have fewest wrinkles of any administration

2009-01-18T18:36:00.004-05:00

Apparently, there is a rush on regional practices in the Washington D.C. area on politicians, celebs, high-society, and the media to get BOTOX done before next weeks inauguration.

From USA-Today:

Washington, D.C.-area cosmetic dermatologists, and skin experts in other major cities, say despite the sagging economy, requests for quickie cosmetic fixes, such as Botox and microdermabrasion, have picked up during the last few weeks as people pretty-up for inaugural fetes.

"We have been absolutely swamped since the election with people desiring rejuvenation procedures for the upcoming inauguration," says Washington, D.C., cosmetic dermatologist Tina Alster.

"My normal load for cosmetic procedures has doubled, except for hyaluronic acid fillers — Perlane and Restylane — which have almost tripled," reports cosmetic and laser surgeon Hema Sundaram, who runs two offices in the Washington, D.C., area.

I guess if you need you're skin cancer checked you're still SOL (see here for related post)in the beltway. So apparently, Democrats are not only more miserly in charitable contributions (see here), but they are more venal as well :)

Rob

Who's into the rough stuff? (textured breast implants that is)

2009-01-13T22:25:00.000-05:00

There are several distinct types of ways we classify breast implants.

silicone or saline filled

round or anatomic shaped

smooth surfaced or textured

For the material and shape issues, there clearly are performance characteristics that differ. As to the issue of the implant shell surface, it gets a little more confusing.

The routine use of rough or textured surfaces on breast implants in the prevention of capsular contracture has been debated for nearly 20 years.
In the early 1980's we first read in the literature that the surface texture of an implant is an important variable in determining the soft-tissue response to an implant's capsule surface and experiments suggested that texturing resulted in tissue ingrowth and adherence to the implant surface.

These observations were first made with polyurethane-coated breast implants which had rough surfaces and almost no observed capsular contractures in patients with breast implants. Texturing was then quickly translated to contemporary silastic (silicone rubber) covered implants, but whether or not the same effect was maintained has been a little murky.

If (a big if) there's a protective effect from texturing, the best data I've seen suggests that it's gone as you get closer to a decade out during surgery. If I had to guess why that's so, I'd say that reflects the ruptures starting to show up in those 4th generation implants at a decade out.

It's kind of interesting to see the split between the United States and the rest of the world on this issue. Our singular experience with saline implants from 1990-2006 led many surgeons to abandon textured implants for smooth round devices as they're less likely to show visible wrinkles or ripples thru the skin. The "velcro-like" effect of the implant on it's surrounding tissue causes these ripples when the implant shifts. The rest of the world has a strong preference for textured devices as they never went through dealing with the limitations of saline implants. Philosophically, those doctors made the decision that they're willing to accept more rippling as a trade off for (possibly) less capsular contracture (implant hardening).

I personally am kind of ambivalent on this. Being an American-trained surgeon, I saw mostly round smooth implants placed partially under the pectoralis muscle during my residency. Over time, I've come to believe there's a role for "subfascial" implant techniques(over the muscle, but under the muscle fascia) with smooth implants. Looking ahead, I think we're poised to see a lot of plastic surgeons getting reacquainted with textured implants with the new shaped "gummy bear" implants which are all textured to help prevent rotation of the implant in the body.

Rob

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

2008-12-28T10:43:00.000-05:00

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

2008-12-21T13:16:00.001-05:00

Love it!

Rob

The economic meltdown for dummies (via Rick Ferri)

2008-12-16T20:55:00.002-05:00

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.

2008-12-14T11:06:00.000-05:00

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

2008-12-09T06:51:00.000-05:00

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(!)

2008-12-07T15:55:00.000-05:00

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

2008-12-04T08:08:00.000-05:00

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

2008-12-01T15:13:00.000-05:00

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

2008-11-30T18:30:00.003-05:00

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.

2008-11-29T01:33:00.005-05:00

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

2008-11-27T10:59:00.001-05:00

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!

2008-11-26T07:59:00.000-05:00

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