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

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

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

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

Rob

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

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

from the summary in Internal Medicine News, 

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

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

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

  

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

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

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


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


Rob

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

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

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

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

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

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

Rob

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

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

Rob

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

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

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

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

Expect to see more signs like this from small businesses:

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

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

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

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

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

Rob

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

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

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

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

Rob

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

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

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

Why the relatively poor follow up in the FDA trials?

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

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

Rob

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

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

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


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

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

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


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

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

Rob

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

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

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

PREOPERATIVE in 2009











                                      
                                                  POST OPERATIVE in  April 2011

Rob

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

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

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

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


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

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

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

Rob

Tickle Lipo is now here at Plastic Surgery Sepcialists

Rob

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

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

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

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

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

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


Rob

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

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

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

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





Rob

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

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!

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

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"

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

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

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

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

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

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

1. the patient's likelihood of getting a second breast cancer in the non-removed breast increases with time
2. 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

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

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)

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

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

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?

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

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

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

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.

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

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