Plastic Surgery 101

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