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

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.

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

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

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

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

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

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 :)

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!

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.

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

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?

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

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

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

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.

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!

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!

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

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

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

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

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!

A break from heavy things today.

This collection of game show bloopers is really funny!






Rob

Usher's wife update on anesthesia complication

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

A couple of things on my radar today



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

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


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


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


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

Rob

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

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

For directions click here.

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

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

Rob

How to make breast augmentation less painful - Depobupivicaine

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

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

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

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

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

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

Anyway......

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

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

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



Study Recruitment for Depo-bupivicaine FDA clinical trial:

Rob

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

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

From USA-Today:

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

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

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

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

Rob

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

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

• silicone or saline filled


• round or anatomic shaped


• smooth surfaced or textured

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

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

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

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

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

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

Rob

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

Being someone who did advanced fellowship training in breast reconstruction, I was interested in the article in today's New York Times, "Some Hidden Choices in Breast Reconstruction".

I came away somewhat disappointed. The article tangentially discusses the issue of some advanced breast reconstruction techniques and how they aren't always offered or discussed by surgeons. It mostly centers around some of the more advanced microsurgical breast reconstructions using what are called "perforator flaps", which are much more laborious then traditional muscle flap surgeries or implant based reconstruction techniques. Those operations are very elegant, lengthy, and complex cases whose "true value" is hard to demonstrate either in outcome data or to bean counters (who just pay attention to how much things cost). The editorial tone is basically suggesting that there's some conspiracy to not talk about these procedures to patients and that these advanced procedures are the most ideal reconstruction.

I have a few thoughts on this

1. I touched upon the resources and cost to the system of demanding the most exotic types of surgeries for all comers last October 2007 entitled "A Breast Reconstruction Lawsuit - Can We afford Cadillacs for all?" which involved a patient suing her insurer for NOT covering a redo operation with one of the perforator microsurgical flaps discussed in the article.

I asked the question then:

In a scenario like the one involved here (lawsuit over non-coverage), should someone have the right to demand complex and expensive surgery when less expensive options are available?

I'm conflicted here. It does not seem completely outrageous to me for this company to deny this request or at least ask the patient to pay part of the balance difference given the particulars as I understand them. She had an acceptable reconstruction with implants, and needs a quick & relatively inexpensive surgery to maintain her result. In other countries with state-funded ("universal") health care programs, I suspect there's no way in hell this would be approved. In an era of cost-containment, all health care costs are going to be scrutinized and there will be hard choices to make. Luxuries like exotic breast reconstruction almost two decades after the initial surgery seem hard to justify in that context

We just cannot afford the most exotic procedures and technologies for every indication in every patient. Complicating this issue with breast surgery is that these types of procedures are arguably cosmetic procedures rather then functional surgeries (ie. a reconstructed breast reproduces a secondary sex characteristic but does not lactate). As a society in the US, we've come treat this topic differently through legislation guaranteeing breast reconstruction after mastectomy. This did not however, promise funding however, and the savaging of reimbursement for the long procedures and large amount of aftercare have functionally served to ration patients access to breast reconstruction.

2. Surgeries involving your own tissue have significantly more morbidity up front then tissue expander/implant procedures. They are not appropriate for everyone, particularly the very fit, smokers, obese patients, or the elderly. The complications from these operations can be MUCH more spectacular then expander procedures.

In general, I think TRAM, DIEP, and other described flaps are best reserved for young patients with small-medium breasts who are only having one sided mastectomies. The benefit in them is the natural "aging" of the flap more like the remaining breast. For bilateral mastectomies I (and most surgeons) think it is an absolute no-brainer to use tissue expanders in most patients in terms of recovery, cost, and symmetric result of the reconstruction. The improvements in implant designs that we should have available this winter make this an even stronger recommendation for most patients. Surgeon's who

I'm trained in just about everything, but I do implant based reconstruction on probably 7 or 8 out of ten patients as it's the best choice for most people. Keep in mind, that's coming from someone (me) who's favorite operations are TRAM's and Latissimus breast reconstruction. IF you look at the rest of the world, similar % of patients are reconstructed in this fashion which I think represents a collective pragmatic balancing of costs and benefits.

Rob

Where are the chips? Nando's "double breasted" laugher

Love it!

Rob

The economic meltdown for dummies (via Rick Ferri)

No Plastic Surgery today!

If you've watched the chaos in the financial markets and wondered how in the heck this happened, I'd like to point you a conference call by the investment management company, Portfolio Solutions. I have no money invested with this company per se, but I do admire one of the principals there, one Rick Ferri. Mr. Ferri is an accomplished author of financial books like the super, "All About Asset Allocation" and a regular contributor on the Boglehead Forum (a site concerning index investing as advocated by Vanguard Investments founder, John Bogle).

Mr. Ferri's discussion of the mechanics of how we got to where we are is really interesting and Ferri is an excellent communicator, even for "dumb skin doctors" like me.

Click here to go to the archived speech.

Rob

Another one (....er, two) bite the dust! The body count rises in aesthetic medicine.

Artes Medical and Rhytec Inc. are the latest notable cosmetic medical companies to fold.

From the OC Register

Artes medical made a permanent dermal filler called Artefill which never gained much of a following. It was a gel based formulation of plastic "microspheres" made for injecting in deep layers of the skin. Most doctors have been reluctant to use these types of permanent fillers (like micro-droplet injectable silicone) as they are ruthlessly unforgiving for imprecise injections. If they're permanent and you have issues, then you have a permanent issue versus one that will regress as it's reabsorbed.

As hyaluronic acid fillers like Jevederm or Restylane are more user friendly and they go away after awhile, they are more of an attractive material. For a little longer lasting material for similar indications as Artefill, I think most people would use Radiess, which lasts closer to two years or so in duration. It's an extremely underated product IMO.

Rhytec's plasma based system was fairly novel and appeared at one time to have a lot of advantages. Compared to traditional laser resurfacing of the face with carbon dioxide or erbium lasers, it carried much less risk of pigmentation changes. I loved the candor of the Dermatologist quoted in the article who took some shots at other technologies that have been popular but have been panned off the record by many doctors.

Before Rhytec’s bankruptcy filing, Dr. Christopher Zachary, chairman of the UCI Department of Dermatologist, bemoaned the loss of a company with an innovative and effective therapy. He said, "Unlike companies that market laserlipo devices that are selling like hot cakes and are universally gimmicks and which have made companies like Syneron and Cynosure very healthy bottom lines, Rhytec, which makes a device that actually works, looks like it is in a major tailspin. Such is the cynical life of an aesthetic device manufacturing company."

Rob

Allergan "eyeing" FDA approval of new eyelash stimulating medicine Latisse

Allergan, maker of the popular Natrelle breast implants and BOTOX cosmetic is apparently poised to receive FDA approval of their next potential blockbuster. The new product, Latisse, is a topically applied drug which is effective for growing and thickening eyelashes. While that sounds like a superficial indication, there is expected to be a huge pent up demand for such a product.

From Seeking-Alpha

Allergan received an approval recommendation today from a FDA advisory panel for Latisse (bimatoprost solution 0.03%) as a cosmetic medicine treatment which would represent the first and only FDA-approved product to enhance eyelashes (making them darker, longer, and thicker). Latisse would be packaged with a special applicator to apply the drops on the edge of the eyelid as compared to the current use of bimatoprost as Lumigan, which is already on the market as a treatment for glaucoma to lower eye pressure.

Allergan estimates peak sales for Latisse of $500M, compared to trailing 12-month sales of $4.4B, with an expected FDA action date by mid-2009 on the pending NDA. Allergan is also a component in the ETFI Cosmetic & Reconstructive Medicine Index and could be a takeover target for big pharma after Johnson & Johnson (JNJ) agreed to pay $1.1B for breast implant maker Mentor (MNT) – although the market cap of Allergan is much larger at $11.7B with a wider range of businesses such as specialty pharma, medical devices, and cosmetic medicine.

Last Winter, cosmetic manufacturer, Jan Marini, was forced to pull a similar product off the market by the FDA because (as I understand it) they 1) didn't have FDA labeling approval to promote themselves for that indication, 2) didn't have any clearance to sell a prescription glaucoma drug (which was the active ingredient) over the counter, and 3) Allergan had patent rights on the substance that was the active ingredient. Talk about ballsy! A blurb last winter from the "Truth in Aging" blog about this can be read here.

I guess I must just have the "vision" thing for this sort of product as I kind of shrugged my shoulders when I heard about it before. However, pre-market surveys indicate there is a BIG market for it, and the price of this product is going to be fairly low. Expect every Tom, Dick, & Harry fringe aesthetic medical provider to be pushing it I predict.

Rob

Breast Implant designer commits suicide from Yew seeds(!)

A South African man died who'd designed a novel type of silicone breast implant recently committed suicide by eating poisonous yew berries from a nearby graveyard of all things.

From Wikipedia on the Yew tree toxicity:

The major toxin is the alkaloid taxane. The foliage remains toxic even when wilted or dried. Horses have the lowest tolerance, with a lethal dose of 200–400 mg/kg body weight, but cattle, pigs, and other livestock are only slightly less vulnerable.[7] Symptoms include staggering gait, muscle tremors, convulsions, collapse, difficulty breathing, and eventually heart failure. However, death occurs so rapidly that many times the symptoms are missed.

Jonathon Hamilton a talented design engineer who had recently lost majority control of his an implant business he'd founded when he was forced to sell stock to cover his debts. His company "Smart Implant" has a proprietary design where the filler of an implant is composed of hundreds of solid silicone beads instead of a viscous silicone gel.

Having never seen one of these implants in person, I'm not sure there's much to this departure from conventional design that is much of an advantage but it's an interesting idea. These type of implants are not available in the United States and I'm not aware that they've even applied to the FDA to conduct clinical trials here.

Rob

Kayne West's nurse cousin now being investigated in Donda West case

The death of Donda West, mother of hip-hop star Kanye West, the day after undergoing plastic surgery last year was big news. The surgeon involved in the case received a great deal of criticism and the implication was that he'd commit ed some horrible malpractice on Mrs. West.

I talked about this last Spring (see here), going over the autopsy report that was released online. The report vindicated Dr. Adams of some technical mishap, but was inconclusive on what actually caused her death. I speculated she vomited and aspirated with subsequent respiratory arrest, a not uncommon scenario we see in hospitals and nursing homes in elderly or infirmed patients.

A new wrinkle is being looked out apparently. Could Donda West's death be from an overdose of her pain medicine given by her cousin? I still think my aspiration idea is more plausible, but the role of pain killers could be a component in that mechanism (ie. narcotics can cause post-operative nausea/vomiting and a stuporous patient is more like to aspirate). I'm not sure that's a fair suspicion to throw on someone unless her toxicology had abnormally high serum levels of her pain medicine.

From the UK's Daily Mail

Police have now launched a probe into the possible role of her nephew, Stephan Scoggins, 46, a registered nurse who was allegedly supervising her post-surgery care.

A source tells American magazine People that investigators are looking into the alleged possibility that Scoggins administered too much of the painkiller Vicodin in a short period of time.

The insider also alleges that Scoggins left West in the care of a friend and Kanye's assistant to attend a baby shower prior to her death.

Last January, a Los Angeles coroner ruled that West died of 'multiple post-operative factors,' clearing West's embattled surgeon Dr. Adams of responsibility.

An investigator for the California Department of Consumer Affairs has issued subpoenas asking individuals 'to testify in the matter of the investigation of Stephan Scoggins,' a source tells the publication.

Rob

Breast implant maker Mentor Corp. now "augmenting" Johnson & Johnson's portfolio

Santa Barbara-based Mentor Corp., one of the the largest manufacturers of silicone breast implants, is in the news today with word of a takeover bid by Johnson & Johnson. If you're a shareholder in Mentor, you're going to be making some serious coin today. J&J is paying $31 for each Mentor share, a big 92% premium to Friday's closing price but well off its 52-week high of $40.82 about 11 months ago.

Mentor, and rival Allergan, have been locked in a real dogfight for market share of the American (and world) market in breast implants. Mentor today gets almost 90% of its revenue from breast implants, most of which are sold for cosmetic proposes. To survive, Mentor had been desperately broadening their portfolios to include dermal fillers, a BOTOX alternative ("PurTox") , an Alloderm alternative (NeoForm), and medical grade skin care lines. Their expansion to this point has run right into the teeth of the financial market downturns, and their earnings and stock price had been pummeled to this point. A real interesting transcript of the company's on the record discussions with institutional investors last week seemed kind of defensive. You can read it over at the excellent Seeking Alpha website of financial stories. They sure kept this deal under wraps!

This seems like an excellent opportunity to achieve synergy with some of J&J's research and development capability and distribution networks. It puts them on more equal footing with the large corporate entity Allergan.

Rob

A must see video guide for "Lost" fans

I was talking to someone the other day who had just discovered ABC's TV series "Lost". The storyline and mythology of that great show is formidable and can be overwhelming to most casual fans as it is extremely self referential to earlier episodes and full of allegory and oblique symbols. There is NO way for most people to decipher this show and catch all that the creators are "burying" on screen.

To the rescue come's "Seanie B" on Youtube. This guy takes each episode and breaks them down in detail, pointing out things you'd never have picked up. It really takes watching the show to a new level. Sean's "channel" on Youtube can be found here.

Below is a clip from Season 1


Rob

Quick thought for the day! Maybe we've already reached bottom on the stock market.

I just noticed, but last week was the best week in 34 years for the S&P US stock index, up 19%!

I've written before how much of a believe I am in all things Bogle (see last July's "Bogleheads of the World Unite!" (John Bogle being the father of passive index investing). Bogle's advice on staying the course and relying on age appropriate asset allocation offer some comfort at times like these.

In the words of investment guru Larry Swedroe "while it is almost 100% certain that the economic news will get worse (with unemployment certainly headed much higher) stock markets are FORWARD looking, leading indicators, something most investors either don't know or forget.". While we're still in choppy waters and lower earnings in early 2009 can erase this progress, history suggests we may be nearing the bottom of a 40% decline in the market's value.

If you don't stay invested and contribute during this period, you're going to miss out on historically low equity prices. When you look at a decade or more's worth of behavior of the market, there are only a few trading days where the growth of the market index value for an entire bull market is largely established. Last week was likely a clump of these days. Stay the course!

Rob

Happy Turkey Day 2008

Happy Thanksgiving from Plastic Surgery 101!

I've got lots of posts kind of half-finished so expect fairly regular output here in the next few weeks.

Rob

Plastic Surgery 101's winter music recs - Samples, Samples Everywhere!

Someone wrote me the other day asking if I'd do another post on music after stumbling across my last group of recs in May (see here). I've gotten interested in how some artists are incorporating sampled guitar/rhythm loops into their acts, especially in live performances, so I think I'll point to some of my favorites!

Master of the sampled loop, Imogene Heap in "Just for Now". How the heck she can keep track of all these samples during this performance I have no idea. Absolutely jaw dropping! I also suggest the beautiful "Hide and Seek" which is introduced by NBC's "Scrubs" star, actor Zach Braff BTW.


KT Tunstall's "Black Horse and the Cherry Tree" live on the Today Show in 2006. This performance single handedly launched her career in the United States.


Yoav's creepy acoustic "Club Thing". His song "Beautiful Lie" is also really neat with the samples


The Kills industrial-tinged "Getting Down". There's a great feature on them on the Sundance channels' Live from Abbey Road series. Must see TV!


The Yeah Yeah Yeah's "Maps". This is an a great acoustic version. For the an extreme electrified live version go here


Please feel free to leave any suggestions in the comments for interesting music! I'm always looking for new stuff.

Rob

Can some breast cancers just "go away"? Data mining says maybe, but it's complicated.

There's a paper this week in the Archives of Internal Medicine discussing the phenomena of some breast cancers possibly going away without treatment. As I do a lot of breast cancer related surgery, I know I'm going to get asked about this by a patient one of these days.

The paper is titled "The Natural History of Invasive Breast Cancers Detected by Screening Mammography" and can be read online here.

It opens with the observation that

...screening mammography has been associated with increased breast cancer incidence among women of screening age. If all of these newly detected cancers were destined to progress and become clinically evident as women age, a fall in incidence among older women should soon follow. The fact that this decrease is not evident raises the question: What is the natural history of these additional screen-detected cancers?

From autopsy studies of the elderly, we know we find many breast and prostate tumors which are clinically silent and that the patients died with rather then from. In an idealized world we could understand tumor biology enough that we could safely say some breast cancers could be watched, just as we already do with some prostate cancer.

This idea of "benign neglect" (no pun intended) for malignancies in regards to current standard treatments of surgery, chemotherapy, and radiation could potentially spare people significant morbidity and save the health system a great deal of money. One example of this would be the emerging idea that the drugs that block estrogen hormone metabolism (Arimidex) or estrogen receptors (Tamoxifen) may be just as effective as chemotherapy in post-menopausal women with estrogen receptor positive (ER+) tumors.

Now the study in question is taking some BIG leaps in logic making their conclusion. Much like financial analysts use "back casting" to test stock/bond buying strategies in the rear view mirror, these type of retrospective ideas can suffer from the fallacy of taking a result and looking back to make the data fit. This idea of watching these tumors would need to be done prospectively with very close followup. It would never be possible to do this trial in the United States due to internal review boards (IRB) and medical malpractice issues, but such an experiment might be possible in other countries (In the New York Times write up, Mexico is suggested for instance as a candidate. Gracias muchacho!)

Something to think about!

Rob

The FDA's got dermal fillers "under their skin"

This past week the FDA had some hearings to discuss the issues of dermal fillers (like the popular Juvederm, Restylane, Sculptura, & Radiess) and BOTOX. The use of such products has exploded in recent years and we've seen some real complications reported. The majority of such problems are usually minor and transient as most of these products degrade or wear off. However, there are some products whose effects are permanent (like some of the micro-silicone injectables which aren't used in the US) or last up to several years (like Radiess or Sculptura).

The FDA presented data on over 800 patients who suffered reactions after injection with dermal fillers between 2003-2008. There have been no deaths reported to the FDA, but almost 80% of the patients required follow-up treatment of some sort. Most of these were minor swelling and redness (which isn't really a complication, but expected IMO). However, the FDA also received reports of "serious and unexpected" problems, including facial, lip and eye paralysis, disfigurement, vision complications and some severe allergic reactions.

Most troublesome complications of these fillers are those injected around the eye to fill the hollow "tear trough" that develops under the lower lid with aging. Injections in that area offer a solution that cannot be reliably fixed surgically as the changes are produced from a combination of atrophy of the cheek bone (malar complex), deflation of the fatty tissue of the orbit/cheek, and thinning of the skin rather then something descending and producing loose skin. The thin skin of the lower lid is unforgiving for imprecise injection of dermal fillers as it shows each and every irregularity. In addition, inadvertent injection into a blood vessel in this area has been associated with embolic phenomena to the eye which can produce blindness. Natasha Singer, the NY Times go to girl for cosmetic surgery articles wrote a nice summary up last week (see here).

Not directly addressed at this hearing was the hornet's nest of exactly who is actually doing these procedures, particularly those indications that are still "off label" for the injectable. (Natasha, if you're reading this BTW that subject is screaming for an feature by you....Rob) To this point, states have been reluctant to engage the issues about qualifications and credentialing for doctors performing aesthetic medicine or surgeries. It strains common sense to allow people who are un or undertrained to perform these types of procedures. IMO, if you're not trained in lower eyelid surgery (a la an opthomologist, plastic surgeon, or ENT surgeon) you don't have much business pushing injectables or fat grafting that area - it's that finicky! In many other states, physicians are not even required to do these procedures themselves but are free to delegate them to low level providers or nurses.

Rob

The death of the bull market in cosmetic medicine (?)

Sorry for the extended break!

Lots going on with the practice and the increasingly complex undertaking of building out a new office and surgery center while the country is treading water with the financial markets. There's lots of anxiety in Plastic Surgery these days as people's disposable income is drying up for cosmetic surgery, injectables (like BOTOX & Juvederm), and noninvasive laser treatments (IPL, hair removal etc..).

A number of medispa outfits have gone bankrupt, stock prices for major players in cosmetic medicine like Allergan & Mentor have fallen faster then other stocks of similar market cap size, and practices across the country are reporting flat or negative growth for 2008. Just today I heard that Rhytec, maker of the innovative Portrait Plasma laser resurfacing system is shutting down, potentially leaving owners SOL for replacing the disposable treatment tips on their expensive laser machines.

I've been obsessed reading a number of books about financial history, market theory, and asset allocation. I can't recommend enough the classic book by Dr. William Bernstein (who is a practicing Neurologist of all things BTW), "The Four Pillars of Investing" which lays out a very compelling lens thru which to view the ebb & flow of investment going back hundreds of years. Everything we're enduring now has happened in some form or another somewhere in history, and about once a generation we should expect the world markets to go crazy. It's ironic that if you're early in your adult life, the current events may make the best time to invest heavily in equities that you will ever see during your lifetime (in the "buy low, sell high" sense).

I'm thinking of this as I'm reading an article by Michael Lewis in today's Portfolio magazine "The End of Wall Street's Boom". Lewis is the author of the classic baseball book "Moneyball" and the 1980's wall street classic expose "Liar's Poker". This article revists the same territory of "Liar's Poker" and is a fascinating look at the insanity/stupidity of the Wall Street culture in priming the pump for our current problems. It really dovetails nicely with Bernstein's book at exposing what fools we mortals be!

Rob

The Daily Mail's "keyhole" breast cancer surgery technique not so new (or useful?)

Ok, I bit on the headline of some new "revolutionary" (their words) breast cancer technique written up on the UK's Daily Mail..... the "keyhole technique"

The article describes an endoscopic (lighted camera) assisted mastectomy done to preserve the nipple during surgery in breast cancer cases. As nipple sparing mastectomies have been done by plastic surgeons (and more recently breast oncologists) for about 50 years, officially color me skeptical that this technique adds anything other then complexity and or time.

For instance, in the last 2 weeks I did 2 nipple sparing mastectomies thru 3 cm incisions (one for male breast enlargement - gynecomastia, and one prophylactic for a woman with a history of breast cancer) sans endoscope in well under 45 minutes

Rob

Plastic Surgery 101 takes on the big apple + Alloderm and breast surgery

Sorry for the gap in posts! It's been almost 2 weeks and I just haven't been "feeling it" for updating the blog.

Presently I'm in lower Manhattan at a symposium on the use of Alloderm in breast reconstruction surgery. Alloderm is produced from human skin where the proteins which would ordinarily cause you to reject the tissue graft have been removed. What's left is a "living prosthetic" that can be used to reinforce the body's tissues.

Alloderm has gained popularity in breast reconstruction as it allows us to bridge the concepts of traditional reconstruction with techniques we use in breast augmentation. I was kind of an early adopter of using Alloderm over 3 years ago in response to some of the limitations of the techniques I was taught during my training. At this point, Alloderm (or related products) are used not infrequently by many surgeons.

I'd like to briefly mention two restaurants here in NYC that my wife and I had wonderful dinners at

Bouley - where I'd strongly recommend the 5 course Chef's tasting menu. Magnifique!

The Tribeca Grill - Great steak! Very affordable for a nice restaurant in NYC.

Rob

Doctor Shopping - Finding the doctor you need

So I'm sitting in Starbucks near my house with my kids when this group of joggers comes in for a post-run sit around. They immediately get off into some discussion about orthopedic sports medicine and their various injuries, complete with editorials about how their doctor is wonderful, how they were "misdiagnosed", and wondering how different specialists gave them contradictory advice or opinions.

I kind of felt sorry for them. Picking a doctor is tricky, even for doctors. As I work doing surgery at half a dozen hospitals, I have a general idea of the reputation of different surgeons' abilities and personalities in several parts of town.

When I was a resident working with dozens of different attending surgeons, I definitely felt like I could get a feel for who was outstanding or poor. However, when my wife had musculoskeletal back pain, I was left to kind of "guess" at the competence of a neurologist (whom I really respect BTW) who was treating my wife. Some of their field is just too removed from my scope of practice to be fluent in.

Eavesdropping on the joggers reminded me of a letter in the New York Times health section on an article about picking doctors, "You Can Find Dr. Right, With Some Effort". There was a really insightful letter from an ER doctor that stood out to me which I think is worth republishing:

As an emergency physician for 32 years, here is how I would and would not go about finding a personal physician:

1. Chronic medical care: choose primarily based on personality, secondarily on skills. All doctors are smart, in the top 1% of the population, which makes them abnormal to start with. For ongoing care, you need the minority with great personalities. For skills, just make sure they are ABMS (www.abms.org) board-certified.

2. Surgical care: Choose primarily based on skills. Ignore their personality. Here you want the best technician with the best judgment, not Marcus Welby. It will usually be a short-term relationship for a problem that requires invading your body and significant medical judgment issues. It’s not worth trying to find someone who combines both skill and personality; if you get both, it’s a bonus.

3. Acute care: You’re at your most vulnerable and have no time to research. Your regular doctor rarely can see you for acute care: you end up in an urgent care center or ER. Choose based on skill and judgment only, which must necessarily be based on quickly accessible reputation and qualifications.

OK, how do you find someone based on skill/judgment, or based on personality?

1. Personality: Here’s the only place to use friends, neighbors, and trusted acquaintances. These people are qualified to judge this aspect of a physician. This is totally unrelated to a physician’s skill or competence, but this is important for chronic medical care.

2. Skills/judgment: Never use the recommendations of non-medical personnel. They have no basis on which to judge. Avoid online evaluations: they are statistically prejudiced and don’t account for individual practice variances. Instead, use trusted medical acquaintances such as physicians or nurses to make recommendations. They have both the personal experience and medical sophistication to make such recommendations.

I'd agree in general with the insights of this doctor, especially with surgeons. For instance, there were some grade-A sociopaths I knew/know in various specialties whom are outrageously gifted surgeons. I'd be happy to let them do my liver resection, organ transplant, aneurysm clipping, etc... as long as I did not have to speak to them ever again.

Rob

BOTOX on the brain - You know you're a plastic surgeon when....

You know you're a plastic surgeon when you watching the press conference tonite by the US Senate leadership about passing the $700 billion USD bailout bill and not being able to take your eye's off of Sen Mitch McConnell's BOTOX'd brow!




Sen. Mitch McConnell (R-KY)



Other pols who stand out for BOTOX

Hillary Clinton (D-NY)



Nancy Pelosi (D-CA)



Nancy Pelosi's Cat :)



Rob

Oliver Plastic Surgery's new home (and name) - coming January 2009!

Sneak peak for today! 

My good friend and colleague, Dr. Jason Jack, and I are busy working on moving our practice to our new home in suburban Birmingham. Hopefully we're set to open in January 2009. What's exciting has been the chance to design from scratch, an office to accommodate a 21st century Plastic Surgery practice.

I've learned more about fire codes, environmental issues, work flow theory, electrical engineering, and architectural design ten I've ever wanted to know about.

One thing I'm particularly excited about is the ability to offer a state of the art office surgery suite which will offer us tremendous flexibility and convenience for our patients for cosmetic procedures. It also makes us less vulnerable to the random and often pernicious pricing patterns that hospitals and anesthesia groups have for cosmetic surgery in a hospital setting.

Rob

Britain's Plastic Surgeons ask for truth in advertising

A big Cheers(!) to our colleagues 'across the pond' who are encouraging more professionalism in the business of cosmetic Plastic Surgery.

The British Association of Aesthetic Plastic Surgeons (BAAPS) has made a position statement that digitally enhanced pictures of bikini-clad women in writhing poses should be banned in advertisements as they mislead patients about expected results. BAAPS has singled out one chain of cosmetic clinics for particularly egregious promotion, pointing to an ad by the West One Clinic franchise which used models in advertisements that are "anatomically impossible".

Below is the wasp-waisted model with gi-normous breasts that apparently started this discussion. It clearly looks to me like she's been "morphed" with Photoshop to narrow her waist in relation to her trunk.


A second promotion offers a £250 ($462.55 USD by today's exchange rate) discount to customers as an incentive to have the surgery quickly, while a third offers a "lunchtime facelift", which arguably plays a little fast and loose by with downtown and recovery for short-scar facelift procedures.

This education that BAAPS is not a call per se for limiting all cosmetic surgery procedures, but rather it is a desire to see a more safe, thoughtful, and informed process take place when someone is considering surgery. It is impossible to remove unrealistic body images from pop culture, as both men and women strive for whatever form is popular in their era. What we do owe patients are frank discussions about the limits and morbidity of surgery minus the "magic brush" function of computer photo editing.



Rob

Another attempt by lawyers to get around tort limits on medical malpractice cases

This is getting real old, but the American trial bar is once again attempting to establish a game plan for circumventing liability protection that the FDA grants drug and device manufacturers after going thru the FDA approval process. An important legal precedent was upheld last winter which I wrote about in a post "Trial lawyers' ability to second guess the FDA on medical devices neutered" which refused a plaintiff's motion to allow layperson juries to essentially second guess the proceedings of expert FDA panels on medical devices. Medicines curently do not have that same level of insulation, and trial lawyers are contributing in record numbers to the Democrats for the fall election expecting favorable amendments to the law allowing expanded liability.

In a New York Times story this week, "Drug Label, Maimed Patient and Crucial Test for Justices" the case of a patient who had an inadvertent injection by a allied health provider (not a doctor)of a widely used anti-nausea medication (phenergan) into an artery in her hand and eventually suffered an amputation as a result of complications. This drug has been used for decades, and is both safe and cheap. The manufacturer of the drug is essentially being sued for a labeling issue where they claim that warnings about her particular complication were not prominent enough.

This type of action is embarrassing for our legal system, and demonstrates the great American legal tradition of finding the deepest pocket and suing the hell out of it. In this instance, the medical center already settled with this patient, but they're going for the big $$$$. While this individual had a terrible thing happen, it's not even clear that true malpractice even happened. Fines and putative damages on industry in these cases should be paid to the feds rather then individuals so as to remove the financial incentive for these ridiculous cases beyond economic damages.


rob

Does it make sense to screen asymptomatic breast implants with MRI?

One of the peculiarities of the USFDA process during silicone implant reintroduction in 2006 was the labeling on the devices recommending routine MRI surveillance of implants for rupture. When you step back and look at the proceedings and "unique" American history with breast implants, you can see that this was more a political concession to the anti-implant activist lobby then evidence-based medicine.

The FDA labeling currently suggests MRI's at 3 years post op and then every 2 years subsequently. It will be interesting with the coming form stable "gummy bear" implants whether or not this recomendation is still maintained.



Why 3 years for the first MRI?

That was the first data point with any ruptures reported in the FDA data during clinical trials. While there will be a certain failure rate associated with any manufactured device, it's likely that early failures of silicone devices were from missed trauma to the implant during insertion. Education courses on proper techniques for implant handling and insertion in recent years have emphasized ways to minimize this risk by suggesting larger incisions for gentler introduction and better visualization during closure.


But does it make sense to do this?

Clearly it does not. On this point, there's pretty much international agreement (USFDA excepted).

We've actually got a pretty good handle on rupture rates of 4th generation implants (conventional devices used for the last 15 years or so) up thru a decade, where it's pegged around 6-8% at 10 years based in two pretty solid studies on single devices by the two major implant makers Mentor & Allergan. If you take that and work backwards from the FDA recommendation, you're doing up to 4 MRI's during the first decade where the rupture rate is either almost nonexistent (years 3-7) or in the low single digits (year 9).



Whether you're screening an asymptomatic population for ruptured implants, colon cancer, breast cancer, or aortic aneurysms there's trade offs between costs and risk reduction. For tests to be effective for screening, they must satisfy both criteria. For a number of cancers, screening tests often fail this goal.

Take screening mammograms or breast self-exams for instance to detect breast cancer. In non-selected groups of women, both cancer detection modalities increase both cost and morbidity from unnecessary procedures without materially affecting death rates from breast cancer (arguably the whole point of screening). It's been persuasively argued when reviewing the data, that screening mammograms can be deferred to age 50 for low risk women (as opposed to the current recommendation for age 40) and perhaps discontinued altogether for women in their 70's with no affect whatsoever on breast cancer death rates. BTW, this same pattern of "dodgy logic" of routine screening also exists in regards to male prostate cancer and lung cancer screening in smokers.

Anyway, back to implants......

At the end of the day it's just hard to support screening implants for rupture in asymptomatic patients on either a cost basis or benefit basis. As it's been established that ruptured silicone implants (silent or otherwise) do not appear to correlate with systemic illness, the clear benefit of screening asymptomatic women is hard to establish. A team of doctor's from the world famous Sloan-Kettering Memorial Cancer Center agreed with this sentiment in a recent paper, Silicone Breast Implants and Magnetic Resonance Imaging Screening for Rupture: Do U.S. Food and Drug Administration Recommendations Reflect an Evidence-Based Practice Approach to Patient Care?


Rob

What Christina Applegate's looking at with her breast cancer reconstruction

Earlier this month, actress, Christina Applegate announced she'd undergone bilateral mastectomies for breast cancer. She reportedly possess one of the better characterized "breast cancer genes", BRCA1, which puts her at extraordinary high lifetime risks for developing breast or ovarian cancers. From the wire reports, she deferred reconstruction and plans on becoming pregnant after planned chemotherapy.

It sounds like she's received very mainstream advice for treating a younger breast cancer patient, particularly for a BRCA1 carrier. IMO these patients are excluded from consideration for lumpectomy procedures for treatment and should be strongly advised to consider prophylactic surgery on the other breast to maximally reduce lifetime risk of subsequent breast cancers. It's important to make sure patients understand that the highest risk factor for breast cancer is a personal history of breast cancer in the contra lateral breast. In young patients like Ms. Applegate, the math is even more persuasive for aggressive surgery as they have longer life expectancies during which breast cancers can develop. These patients are also frequently recommended to have the ovaries removed, both to suppress native estrogen production (which can stimulate some breast cancers) and to decrease the 40%+ increase in risk of ovarian cancer that brca1 confers.

I'm a little confused why they would not have proceeded with any part of her reconstruction at this point. She's trim enough that I do not believe she has enough bulk to do her reconstruction using her own tissues alone (probably using some microsurgical technique). I'd have strongly advised placing tissue expanders at the time of mastectomy to maintain the skin elasticity and you could later decide if you needed silicone gel implants or you could find an acceptable donor site for some autologous tissue to use. In a low risk patient, you really don't lose much by expander placement, while you realize an easier expansion process.




Rob

actor Gabriel Olds on women who've had plastic surgery -Put your asshat on, Gabe!

So B-list actor Gabriel Olds pens this piece for the August 2008 Glamour magazine titled, "Why men crave real (not perfect) bodies". It's funny when Jerry Seinfeld breaks up with a woman for having "man hands" in a classic Seinfeld episode, but you it's tacky when you're that frank in a print column.





Fine. You certainly can make thoughtful and plausible arguments why we all should ignore contemporary ideals of female beauty (real and imagined) and realize inner beauty for what it is. You do NOT have to do it in a dickhead tone of voice which alienates said women. Monsieur Olds quickly falls off the cliff quickly in that regard with his narcissistic article.

The women commenting to the article certainly had their fangs out over this:

I have breasts implants, and before I got them I spent my entire life being ridiculed by both men and women. I had absolutely no breasts. I was nothing but a nipple and I always felt like less of a woman. I couldn't find clothes that fit well, bathing suits were a nightmare, and shopping for bras was nearly impossible. I made the decision to undergo breast augmentation not because I wanted to be "perfect," it was because I wanted to be "normal".

I would like to say first, how presumptuous of Mr. Oldnutsack to assume that we should reveal our own medical history before we have even had the opportunity to see the size of his dick.(OUCH!)

I mean really, to dump someone/doubt their honesty because they didn't immediately tell you about a surgery?! I highly doubt you would go around telling first dates or third dates even, "I have ED. I have a dangling penis, so I take Viagra to make it perkier."

this author is SHALLOW. He had one superficial date with a women he is PHYSICALLY attracted to and he is writing her off! He is obviously not interested in getting to know her on the inside. I am a psychotherapist. People like him need to take a good LONG look at them selves and be honest about why they are afraid of intimacy. It is clear to any one reading this article that his motive was purely sexual. If the author wants perfection then he will need to accept that perfection is achieved by alteration and that anything natural has flaws. A word of advice: Try to shake your narcissism, mister. It's unattractive to women. Hey, are you sure she didn't dump you after she felt YOU up!

Rob

Good Doctor of the Day Award - Dr. Paul Offit on autism and vaccines

I've mentioned in a 2007 post, "Mad Science", about the political issue of autism's and their alleged link to childhood vaccinations in the past as a metaphor for what we went thru with the debunked tort driven silicone breast implant (SBI) scare in the late 1980's. Unlike SBI's which are a cosmetic product, vaccines save lives. Lots of them!

A wrong headed attempt to blame first a preservative in some vaccines (thimerosol) and later the vaccines themselves for new diagnosis of autism has led to a dangerous public health situation. Pockets of non-immunized children can clearly serve the role of "typhoid mary" for pandemics of illness if history is any guide.

The number of new measles cases in the U.S. is at its highest level since 1997, and nearly half of those involve children whose parents rejected vaccination. According to the Las Vegas Sun,

It is no longer endemic to the United States, but every year some Americans pick it up while traveling abroad and bring it home. Measles epidemics have exploded in Israel, Switzerland and some other countries. But high U.S. childhood vaccination rates have prevented major outbreaks here.

In a typical year, only one outbreak occurs in the United States, infecting perhaps 10 to 20 people. So far this year through July 30 the country has seen seven outbreaks, including one in Illinois with 30 cases, said Seward, deputy director of the CDC's Division of Viral Diseases.

....The nation once routinely saw hundreds of thousands of measles cases each year, and hundreds of deaths. But immunization campaigns were credited with dramatically reducing the numbers. The last time health officials saw this many cases was 1997, when 138 were reported. Last year, there were only 42 U.S. cases."

Leading the voices of reason and evidence-based medicine is Dr. Paul Offit, who has a great new book coming out this whole controversy and breaks it down for a lay audience as to what the issues are and what the evidence shows. Linked below is a nice clip of Dr. Offit summarizing this.




Rob

Plastic Surgery 101's Olympic Update - It's sunny side up on the beach volleyball coverage!

If you've ever watched professional sports events, you'll notice the cameramen have this habit of doing random crowd shots where they zoom in on pretty women pretty shamelessly. Women's beach volleyball coverage takes this to a whole new level.

Under the guise of "explaining the importance hand signals" during the match, NBC has about the most gratuitous photo gallery of women's backsides in teeny-weenie bikinis this side of Sports Illustrated's swimsuit issue. The whole idea of buttock aesthetics has received some attention in plastic surgery literature, and one of these days I'll write about it.

If you think I'm exaggerating about how blatant a T&A show the coverage is, please check NBC's gallery on the web which as far as I can tell was likely compliled by a 12 year old male NBC staffer!

Usually, in doubles competition, you have a server and you have his/her partner near the net. Crucial to a successful game play is a good line of communication between the players on a team as the court is a wide area for two players to cover. A lack of coordination between players will likely result in wide open spaces and a disjoint defense. It is up to the person nearest the net to call the shots and signal clandestinely to his/her partner what the intended game play is. In essence, the person nearest the net is the quarterback of the team.

There are 4 basic "modes" for each hand which is held behind the back to signal the other player. 'One finger' signals that the net player will block the opponent's spike down the line on the corresponding side of the hand. 'Two fingers' signals that the net player will block the opponent's spike at an angle cross-court on the corresponding side of the hand. A 'closed fist' signals that the net player will not block on the corresponding side of the hand. And finally an 'open hand' signals that the net player will block "ball," i.e. block according to how and where the opponent sets and swings.

I think this athlete's signaling she's wedging! :)




Rob

Plastic Surgery 101 suggests look before you leap (in logic) on hospital infections

There's an op-ed piece in today's Wall Street Journal by one Betsy McCaughey which has my blood pressure up. The article titled, "Hospital Infections: Preventable and Unacceptable" implies that any hospital acquired infection was preventable and should be remedied with class action lawsuits.

For someone who's bright like Ms. McCaughey, she shows little insight and understanding apparently into what drives and perpetuates many different types of infections. Nobody disagrees that common sense steps like hand washing and protocols for invasive intravenous (IV) access maintenance are important in limiting infections, it is both a dangerous and disingenuous idea to suggest that a goal of ZERO is attainable. It is impossible to achieve a failure rate of 0% for system or process, particularly one with infinite numbers of variables (as with a human population of patients). Unlike a Toyota, no two models of the human assembly line are exactly alike (even identical twins gradual accumulate differences due to environmental exposure).

Patients with more comorbities are going to have higher infection rates PERIOD. An overweight, diabetic, smoker (a frequent demographic for vascular disease patients in my neck of the woods) who has open heart surgery has more problems then others and an increased infection rate is more attributable to the patient's behavior rather then the hospital. Obese patients and smokers have higher rates of problems after elective plastic surgery (like breast reconstruction or reduction for instance)as well for that matter. You can be sure at some point, hospitals (and doctors) will be looking at patient demographic data to exclude higher risk patients from treatment at their facility whatsoever.

In referring to a list of "never events" recently laid out by Medicare for which they will not cover the cost of complications she blithely writes

"No wonder Medicare calls these infections "never events" Why should jurors reach a different conclusion in a lawsuit."

This coming from a bureaucrat and politician is hard to take. While we should always strive to be perfect, it's important to realize that there are processes which we can all agree on to attain low and reproducible rates of infection.

For a related writing here on Plastic Surgery 101 see the post "Medicare announces they won't pay for complications - How the F*** is this going to work?" that I wrote last year.


Cheers!
Rob

Beware! Entering a no spin zone: Predictable pullback on Smart-Lipo and other laser assisted liposuction systems

It was so predictable as to be boring!

So I'm reading a particularly shameless trade journal this week who's cover story promised updates on laser liposuction. This monthly glossy magazine is essentially a series of (not so) stealth ads with physicians shilling for lasers and other products for which they're paid spokesmen. As the topic turned to laser liposuction systems (like Cynosure's SmartLipo) you saw a lot of pullback on exactly how enthusiastic a number of surgeons are.

"In reality, the degree of fat melting attained with laser lipolysis has not met the high expectations of some practitioners"

When you see comments like that in a fluff trade journal which routinely celebrates every device/technology (whether it deserves it or not) you know this issue is understated significantly. When you take mostly non plastic surgeons and hand them a "magic wand" like SmartLipo while promising great body contouring results, it's a set up for under delivering. There still is no shortcut on mechanically removing tissue for most patients. An exception might be some one's neck which has almost no fat to speak of.

This is kind of like the thread lift fiasco all over again. It's become clear that these laser platforms are much less revolutionary, but are more likely modestly complementary (if that) to the 30 year old tumescent liposuction techniques introduced to the west by a French surgeon named Illouz.

The general "off the record" feelings of most experienced plastic surgeons experimenting with this is that these types of devices are safe but offer no clear advantage. Repeatedly it's described more as a succesful marketing phenomena rather than a real improvement. It's still not established that delivering thermal energy below the skin affects "tightening" whatsoever, which is the whole gimmick of the laser. If it does, it doesn't appear to do it without still having to do most of the heavy lifting with traditional lipo.

In contrast to this unnamed aforementioned trade journal which is lame, I'd like to give a nod to editor Jeff Frentzen and Plastic Surgery Products magazine which frequently has good articles - like mine for instance


Cheers,
Rob

Note to self - Never tell a woman she has a witch's chin deformity

Doh!

Sometimes our terminology and analysis comes out of our mouth without thinking about how people may internalize it. So I'm at this event the other night celebrating my new partner's addition to the practice, and I made the innocent mistake of telling someone I thought they had a little bit of a "witch's chin" when they were asking me about what they didn't like about their own chin.




Big mistake!I think I've now scarred that girl for life as she's now fixated on it! While I was implying a subtle chin feature that only someone like me is going to pick up on, she's imagining I've called her the wicked witch of the west. That awkward moment has inspired today's sermon on chins.

Cartoons characters such as Andy Gump and Broom Hilda the Witch are best known for their exaggerated facial features. In Plastic Surgery we have borrowed these characterization helping us to describe features with the “Andy Gump Syndrome” or the “Witches Chin Deformity.”




An Andy Gump deformity is produced from not reconstructing the jaw bone (mandible), most commonly when cancer surgeries in that area require removal. In 2008, such mandible problems are treated by taking a piece of your fibula (a lower leg bone) and doing microsurgical reconstruction to transplant it to the jaw. I did about a dozen of those in my training and it's an elegant surgery. As I don't do microsurgery in practice or work at a hospital where such large ENT cancer surgeries are performed, I hopefully will never be asked to do something like that again!

A "witch's chin" deformity describes either an excess of fat and/or drooping of said fat on the projecting part of you chin. The surgical correction involves removing the bulk and suspending it to the bony part of your chin. Seen below is a representative picture of the condition and a graphic of one of the operations to fix it.















For all you ever wanted to know about witch's appearences in pop culture throught history, check out the neat "Sexy Witch Blog" from Australia.

G'day mates!
Rob

Will the last medical dermatologist please turn off the lights? Access issues for dermatology patients

The trend of Dermatologists becoming more and more unavailable for actually treating dermatological conditions is in the news again in the front page of the New York Times. The article, "As Doctors Cater to Looks, Skin Patients Wait" discusses the discrepancy in how patients are catered to for cosmetic versus medical dermatologic conditions. I blogged about this same issue last September in "How Botox affects your access to a Dermatologist"

There's a few dermatologists quoted who really come off poorly in the language they use justifying their practice choices. You can bet they'd like a mulligan about now in their 'on the record' interview.

Peppered in the comments section to the article are the predictable griping like,

• "Doctors should not get rich off their patients. Period. End of story. Society has greatly subsidized every doctor's education. If a doctor wants to supplement his or her income with cosmetic procedures, this should be strictly evenings and weekends."



• "Why on earth should a 10-minute botox injection be worth $500?"



• "...clinics will not take patients without referrals, and unless a matter is urgent, it can take 4 - 5 months to get an appointment (which they keep as short as possible). However, if a patient wants a cosmetic procedure, it takes only 1 - 2 weeks for an appointment. The dermatology profession needs to examine its ethics, or the lack thereof."



• "The rest of the medical system will follow. Once health care becomes a one-payer system, there will be a second tier for the moneyed. This is how medicine works in Europe."



• "This is a perfect example of market forces at work, and proof the market works perfectly. Money talks. In this case, however, market forces pervert the delivery of good health care. The solution is to reimburse doctors for actually taking care of patients, not doing procedures or ordering expensive tests. With a regime change in Washington on the horizon, we will hopefully have a complete overhaul of our decrepit and wasteful health care-industrial complex."



• "Disgusting example of the growing scummy side of medicine. A terrific example of how the wrong people gain admission to medical school, sociopath sales persons, "I've always wanted to help people, blah, blah blah..." while only interested in the cash. We need a new health care system with salaried physicians"



• "These comments are scary. Most are uniformed, ignorant and miss the point. Physicans can't meet their overhead and are responding to "managed care" in the only way they can. It is the root cause of most of the ills we see today. We will never able to administer quality healthcare in this type of system. How is it possible for a small practice to negotiate equitable reimbursements from a market giant such as Cigna?"



• "The idea that patients with potential skin cancer have to literally beg to be seen by a doctor is absolutely horrifying. This is one area where civil suits can be an effective weapon. Drs. who refuse to deal with a skin cancer should be sued out of practice. And/or heavily regulated by the government or their own "Professional" organization (the AMA). Does this behavior actually conform to the AMA's code of conduct?"



• "Any doctor who will not see a patient who suspects a mole cancerous, or has a chronic skin disease, for longer than 72 hours, should be sued and forced to explain his negligence in a court of law. "


Reading the comment sections of articles in "the nation's newspaper" is always really illustrative to me. There's alot of frustration and hostility about healthcare in the public which gets (mis)directed at physicians. (Don't forget poor Dr. Zenn who was sniped by the breast implant nutters in June.) It's really a systemic issue, but it's easier to blame "greedy" doctors then actually recognize the costs of administering and delivering healthcare is affecting this. Commenter's also usually fail to understand that this issue with dermatologists is actually going to get worse rather then better with whatever "universal healthcare" system we end up with. Unless you pay physicians market wages for their services, they're going to look for opportunities to realize it elsewhere.

Reading this article I also kept thinking, why the hell would you feel like you absolutely have to go to a dermatologist (or Plastic Surgeon) to have a skin lesion or rash looked at? While I appreciate patient's opinion of our skills, evaluation and biopsy of lesions/rashes is simple enough that it logically should be largely the province of primary care providers or the nurse practitioners and physician assistants that affiliate with them in practice IMO. A lot of wound care clinics have such a set up, and I think wound care is much trickier then skin lesions!



Rob

Plastic Surgery 101 officially endorses Index Funds. Bogleheads of the world unite!

There's been kind of a truism in contemporary Plastic Surgery practice that our business is kind of like "stocks and bonds". Cosmetic surgery has been more and more like "stocks" - high growth with lots of dividends, while reconstructive surgery has been more like a "bond" - steady, boring, and losing ground to inflation. Cosmetic surgery tends to have it's own cycle in that it's busy 3-4 months of the year (late winter - early spring), slows during the summer, and grinds to a halt in August/September when school is back in and women in school or with children can't take the time off to recover.

As we're teetering in the brink of a recession from the real-estate and credit bubbles, there's a lot of stories about how many predominately cosmetic surgery practices are feeling the pinch. A cosmetic practice is usually higher overhead and when things slow, they can get hit hard. Much like the DOW Jones index, these "stocks" are stagnant.

Common sense says, "it must be a good time to be a bond holder (or reconstructive surgeon in this instance)" which usually zig when stocks zag in terms of value.
Unfortunately this isn't true either. We've just narrowly avoided a showdown in Washington over an immediate 10% cut (and planned additional 5% next quarter) in Medicare reimbursement to physicians, which has the effect of actually reducing inflation adjusted compensation up to 30%(!). Private insurers, never one to leave money on the table, will quickly index their rates to the new Medicare scale and there will be significant disruptions potentially in access to care.

As I've been poised to assume custodianship of our office's 401K plan, I've tried to take it upon myself to learn more about investments. Since last October, the American stock exchange value is down something like 20% and has been hammered by fuel costs, the subprime mortgage meltdown, soaring costs of commodities, and a general lack of consumer confidence.

Recently I've been reading two books which have really been transformative in how I think about the stock market. William Bernstein's "The Four Pillars of Investing" & John Bogle's "The Little Book of Common Sense Investing". Both books advocate a strategy called Index Investing which is an extraordinarily boring but productive way to conduct your finances.

A few common concepts to this school of thought:

Trying to accurately time peaks and valleys of the market is impossible

Routinely beating the market return after expenses is (nearly) impossible

"Cost is King"- low overhead funds (like Index Funds) offer extraordinary advantage over time due to compounding interest versus actively managed mutual funds or hedge funds

Index funds and the related Exchange Traded Funds (ETF's) are increasingly the investment vehicle of choice for the multi billion dollar pension plans, large endowment vehicles, and investment industry professionals personal portfolios. (If their unlimited access to the best minds and research teams has driven them to indexing, don't you think you should consider it too?)

Whatever insight you may think you have into a mutual fund or stock's prospects, you're going to get crushed competing and trading against the resources and insight of large investment organizations. They already know and have responded to any information you have before you even have that information.

Consider carefully the added costs of advice (in fees) and beware of stars (as in, star mutual fund managers)

Do not overrate past fund performance. Bull markets mask underperformance of funds compared to benchmarks

Don’t own too many funds. Buy your fund portfolio – and hold it!

What's a "Boglehead"?

"They are a bunch of diehard fans of John C Bogle, the founder of Vanguard, one of the most successful and largest mutual funds in the US. Started in 1975, the company is the pioneer of index funds. Its value proposition of low fees is well known to mutual fund investors all over.

The low fees give Vanguard an edge when it comes to returns. According to a recent article in smartmoney.com, Vanguard’s equity funds have returned 14.48% annualized over the last three years, compared to the company’s two closest rivals, American Funds (14.02%) and Fidelity (13.87%). The average equity fund in America returned 12.43%.

Vanguard’s largest fund, the S&P 500 Index fund has an expense ratio of below 0.20% per annum. "

Rob

Copping a feel - now a civic virtue in Russian town of Bataisk

The tiny town of Bataisk in southern Russia has established a hands on tradition on a new shrine to the female form.

There is a new bas-relief silhouette of a woman's chest in the town square, on whose breasts a man’s hand is lying. It is being touted by locals that if a man touches this bust he is going to attain "family happiness".

tacky de chez tacky!

Rob

Plastic Surgery 101 welcomes Dr. Jason Jack to our sandbox. Roll Tide!

I like to take this opportunity to welcome Dr. Jason Jack to my clinical practice and to Plastic Surgery 101. Jason is both a peer and friend of mine who was starting a new practice, and I was tickled to death to offer him a place in my office while he gets settled. Dr. Jack was a scholarship quarterback at the University of Alabama during their 1993 NCAA football championship before being an honors medical student and outstanding plastic surgery resident at the University of Kentucky.

Rob

Breast implants and observed breast cancer rates. Could they actually be protective? Let's ask the rats.

* Image at right spoofed from The Onion

One of the most serious claims in the class action lawsuits against Dow Corning Corp. during the "silicone crisis" involving breast implants in the late 1980's was that silicone breast implants caused breast cancer and/or delays in diagnosis of breast cancer. Despite there being no evidence for it actually happening, these were reasonable questions to ask. Over the last 20 years, we've been flooded with data that has been reassuring on these issues.

Implants do make conventional mammograms harder to interpret by their "shadow", but the increased ease of doing manual exams by having the implant to push against to feel lesions compensates a great degree. An MRI mammogram can be used to supplement mammograms when needed for better imaging for screening.

One of the more interesting findings in several of the large series of women with implants was the observation of significantly lower (almost 40%) rates of breast cancer in the implant group versus a control population of women without implants. The intuitive reason for this has been that these women with implants were a self-selected (rather then "randomly selected") group who were likely to be healthier and have less breast tissue, which both should lowered their expected rates.

To really sort out a true "expected rate" for breast cancer, you'd have to do some herculean effort of better characterizing the individual risks with a tool like one of the "Gail Model's" of the study participants, which is almost impossible in such large trials. The suggestion that the presence of implants themselves was protective wasn't really taken seriously. There could however, be something that makes us look at this issue a little closer.

I came across a pre-publication in the journal Aesthetic Plastic Surgery entitled, "Breast Implants as a Preventive Factor" describing the differential temperature seen on thermography (a imaging technique that shows temperature) from experimental rats with silicone implants placed and the resultant affect that had on local circulating hormone levels and cellular abnormalities (both of which were decreased in the implant group). Now this was only an animal model mind you, but it immediately occurred to me that maybe part of that effect we were seeing was from this phenomena. Interesting stuff!

rob

What's oncoplastic surgery?

The Wall Street Journal profiled the concept of "Oncoplastic Breast Surgery". This is conceptually just lumpectomy or mastectomy done better. The concept uses rotating breast tissue to fill defects at the time of lumpectomy or larger "quadrantectomy" procedures. These are maneuvers we use with breast reduction and mastopexy procedures adapted to some of the cancer surgery procedures.



It's a nice concept, but the rate-limiting step here is getting general surgeons to change how they think about breast surgery. Trying to coordinate someone else during the resection with a reconstruction is difficult, as they don't "think" like plastic surgeons do. I'm skeptical that short courses to surgeons can teach much beyond the most simple techniques. It's like putting someone in front of Guitar Hero on the Wii or Playstation and expecting them to play guitar professionally afterwards.

I'm constantly evaluating blood supply, tension, and tissue quality in a way that you just don't get taught in other specialties. Weekend courses in this discipline just aren't the same as having doing hundreds of different possible reconstructive techniques all over the body and bringing that to bear on a given case. I had the pleasure of working with two of the leaders in this field during my breast surgery fellowship, in Plastic Surgeon Dr. Pat Maxwell and (an occasional basis) Breast Cancer Surgeon, Dr. Pat Whitworth in Nashville. I though I knew how to do mastectomies and whatnot before I saw these guys do their thing. They're incredible! Both do such anatomically sound breast procedures with no superfluous steps that it's really beautiful (for lack of a better word) to watch. Dr. Whitworth is quoted in the article BTW.

Rob

Is Canada's health system overdue for an "Extreme Makeover"?

I've pointed out here on Plastic Surgery 101 that despite the dysfunction of the American health care system, the alternatives in other western nations have their own problems. In 2007 I posed the question "So You Think You Want Universal Health care?" and featured Dr. Val's review of "Sicko" which glowingly featured other countries' systems.

It was particularly interesting to me to see the "religious conversion" of one Claude Castonguay on this topic. Who is Claude Castonguay? He's the father of Canada's socialized medicine program. After four decades, he finally admitting that the system he laid out for Canada is failing to meet both the medical needs of beneficiaries as well as the budget needs of the individual Canadian provinces. Castonguay now advocates contracting out services to the private sector and American-style co-pays for patients who want to see physicians.

For an interesting overview on this, read the Investor's Business Daily editorial page article "Canadian Health Care We So Envy Lies In Ruins, Its Architect Admits". The Canadian author, David Gratzer, has written extensively on Canada's uneasy relationship with their countries health program.


Rob

Dr. Zenn flamed in Freakonomics plastic surgery Q & A session

Little did Duke University plastic surgeon, Dr. Michael Zenn, know what he was in for in a recent Q&A guest appearance in the Freakonomics Blog column in the New York Times. Out of about 20 questions on a range of subjects he responded to, he made the "mistake" of accurately discussing a single innocuous question about breast implants.

Q: Would you endorse cohesive gel instead of silicone due to the concern over safety issues of silicone? Or do you believe that was all just hoopla? Is it true that breast implants should be redone every 5 to 10 years?

A: Today’s breast implant options are saline or silicone. Saline implants are a silicone shell filled with salt water, silicone implants are a silicone shell filled with cohesive gel. Both implants are equally safe, both have the same safety profile.
The Institute of Medicine found that much of the concerns were hoopla — except for the problems that they both have: rupture, scarring, and infection. Most plastic surgeons and patients will tell you silicone just feels better. Implants are replaced when one of the above problems occurs

Skip down to the comments section and you'd think he was advocating beating your wife as nearly 5 out of every 6 comments are by breast implant "survivors" wailing alternately on his intelligence, character, and ethics. Ah, the wonders of the Internet to organize like-minded partisans into rapid response teams!

Much like the autism vaccine conspiracy theorists, the breast implant siliconistas come off looking out of touch with such reflexive outrage on command, particularly when you recognize the kind of heavy duty microsurgical and reconstructive surgery practice that Dr. Zenn is known for at Duke. He's one of the good guys for Pete's sake!

There's intelligent reasons to object to breast augmentation surgery, but claiming it caused symptom or disease "X,Y,Z...." is a dead horse that's been buried several times over! For a refresher see here and here to recap the comprehensive 2007 landmark review.

Rob

Follow up to a question on breast cancer

I got a question about some of the ideas I was talking about in my last post on how I think about breast cancer. A breast cancer patient wrote me and asked about the difference in how her oncologist explains things

"They quote an 80% recurrence free 10 year survival rate for stage IIA and 75% for stage IIB. I'm stage IIA and my onc says I am probably cured (after surgery, chemo, etc.).

Do you really think all node positive younger women are destined to recur?

Another question: how do you compare positive nodes with lympho vascular invasion? My onc says that there is no data that LVI is as negative an indicator as nodes."

I think it's important to understand that not all breast cancers of stage "x" are created equal, and the biologic "aggressiveness" of a tumor can really skew your personal risks. I talked about 3 of the more important factors (node status, estrogen receptor status, and tumor size), but you've also got histologic characteristics (like tumor grade) and other genetic markers (like HER2/neu) in the mix. Some % of these patients also identified or unidentified inherited genes or mutations which increase their risk substantially for breast and other cancers.

There were two competing worldviews of breast cancer in the classic "Halsted Model" (breast cancer progresses from local->regional->systemic disease) and the "Systemic Model" (breast cancer is already systemic at the time of most diagnosis). I found a nice summary of these ideas on this old newsgroup post for those interested. Personally, I split the difference in my head in that I think that if you're node negative with favorable histology the Halsted model is still true, and that a true absence of residual cancer is possible. If you have nodes involved I'm inclined to believe the Systemic Model in that you have already likely have had some cancer burden establish elsewhere. This is supported by the fact that metastatic breast cancers still show up decades after mastectomy on occasion with no local or regional recurrence of the original cancer preceding it.

Younger breast cancer patients are particularly worrisome in that you have some many decades left of potential exposure for recurrence or new primary breast cancers. It makes absolutely no sense to me to push breast conservation (lumpectomy and radiation) for all but the most favorable invasive cancers in women in their 20's or early 30's. I think maximum risk reduction should be advised for many of these women with bilateral prophylactic mastectomy.

For stage II/III breast cancers (those without systemic mets) the data's a pretty slippery slope where 10 year survival curves run from 70-78% in the more favorable patients to 20-40% depending on grade, size, and # of nodes. This data is laid out nicely at this British Cancer site. Keep in mind that all 3 of those factors are subject to sampling error, and that some of the stage II patients are actually stage III.


There's a great article in the Atlantic magazine "Good News and Bad News About Breast Cancer" from a decade ago which is much more eloquent then I am trying to be reluctant about telling people they're "cured" from breast cancer. It features some of the work by one of my professors, the late Dr. John Spratt from the University of Louisville, who was really visionary in describing tumor's behavior and growth clinically

Breast cancer, unfortunately, is not among this select group (of tumors we can eradicate). As far as we know, a woman found to have invasive breast cancer is always at higher risk of dying prematurely than women without breast cancer. Even thirty years after her diagnosis she is up to sixteen times as likely to die of the disease as a woman in the general population. That is why responsible researchers in this field avoid the word "cure." Even as they report advances, they must acknowledge the reality: Postsurgical chemotherapy and antihormonal therapy do buy time—an important advance. The slowed progress of the disease can give a woman additional years of life and even allow her to die of other, less traumatic, causes. But breast cancer is every bit as incurable as it was in Halsted's day.

Rob

Breast Cancer primer and a new wrinkle in breast cancer treatment

There was a good article for the lay public a week ago in the New York Times "With a Tiny Bit of Cancer, Debate on How to Proceed" about the phenomena and controversy over breast cancer "micrometastasis" to lymph nodes. I do a lot of breast cancer related surgery and have this kind of discussion frequently with patients. I've tried over the years to come up with simple concepts for these women who often feel overwhelmed with ideas and terms that have been poorly explained to them.

If you're trying to keep things simple for patients with invasive breast cancer (meaning it has acquired characteristics on microscopic exam suggesting it has the potential to spread elsewhere), it's important to come up with a simple way to explain what their diagnosis really means. There's 3 things that really affect whether or not you're likely to do well when you're diagnosed with invasive breast cancer.

1. the size of your tumor


2. the presence or absence of cancer in your lymph nodes


3. the presence of Estrogen hormone receptors on the cancer cells

Tumor size and nodal status are proxies for metastatic potential. A larger tumor is more likely to have spread to the lymph nodes at the time of diagnosis. A tumor present in the lymph nodes is in turn more likely to have spread elsewhere and show up again down the road as systemic terminal disease. Breast cancer, like most solid tumors that spread via lymphatic tissue, is conceptually really only "cured" if you remove it surgically before it gets to lymph nodes. This basic fact is essentially unchanged despite steady refinement in radiation (XRT) and chemotherapy (CRT) treatments for 60 years. XRT or CRT do not cure anything, but rather decrease/delay recurrence or palliate symptoms. (I'm simplifying this greatly, but that's the skinny in a nutshell).

Estrogen receptors (ER) are conceptually an "on/off" switch for normal breast tissue cells. A breast cancer cell that still maintains this normal regulatory switch offers a target for hormone manipulation. This "killswitch" provides the basis for medicines like Tamoxifen or Arimidex to show improvements in local recurrence after surgery by blocking these receptors or interrupting estrogen metabolism by essentially "starving" the tumor. We're increasingly seeing how important having this receptor is, particularly in post-menopausal women. It's looking more and more from tumor databases that many older women with ER+ tumors may be able to avoid chemotherapy altogether after surgery, and this observation is currently being tested in prospective trials. A breast cancer that's ER- (missing the receptor) suggests a more "primitive" tumor that's lost some of it's normal regulatory mechanisms and implies a worse prognosis. I found a really nice primer on this for people over at "Cancer Geeks"


BACK TO THE TIMES ON "MICROMETS"
Complicating treatment options now is our increasing ability to detect infinitesimal amounts of cancer cells (micrometastasis) in some lymph nodes that would have been labeled normal just a few years ago. Do we treat this the way we traditionally did positive nodes or are we over treating? We just don't know. It has played a little havoc with interpreting some breast cancer data that was suggesting we were doing better with our treatment.

Why? Well if you suddenly take these micromet positive patients and up the stage of their diagnosis like you would normally with positive nodes, you make both the node - and node + groups look like things are getting better. Nothings really changed except you're removing people who do worse from one group and putting them into a group of node + cancer patients where they will do better then their peers. (I cannot for the life of me think of the name for this statistical phenomena....)

Anyway, read the article (click here) as it's interesting.

Rob

Rob

Conan the Barbarian's wants his breasts back.

Computer game publisher Funcom had to do some fixing of their popular online mulitplayer game when apparently a recent update of the game's software code left the female characters suddenly "breast deficient".

The MMORPG Age of Conan: Hyborian Adventures features partially nude female character models. Based on the original stories by Robert E. Howard and brought to the big screen in 1982 by Gov. Arnold Schwarzenegger, the game takes place in the fantasy world of Hyboria, which combines fantasy elements with strong sexuality.

This issue has caused controversy all over nerd-dom with hundreds of messages left by players demanding Funcom bring their boobs back. Seen below is a pair of images whose player felt like they'd had a mastectomy.

"Funcom can confirm that some of the female models in the game have had the size of their breasts changed. This is due to an unintended change in data that was introduced in an earlier patch, data which controls the so-called morph values associated with character models and the size of their respective body parts. We are working on a fix for this and your breasts should be back to normal soon. The plastic surgeons of Hyboria apologize for the inconvenience."

Well at least they have a sense of humor about it!

Rob

Beverly Hills Rhinoplasty Blog

I'd like to direct some traffic to the really good Beverly Hills Rhinoplasty Blog. Excellent original and insightful articles without the up front promotion that plagues many Plastic Surgery/Cosmetic Surgery blogs run by surgeons.
I've enjoyed their particular focused writing on rhinoplasty and facial aging!

Rob

Something else that belongs on bull#%@*.com

I was pleased (snark!) to find out via the mail today that I am now officially one of "America's Top Surgeons" as recognized by the "Consumers' Research Council of America" (CRCA). Ever heard of it? Me neither.

What do you have to do to be recognized? Have a medical licence and a credit card to buy their over-priced cheezy swag plaques and knick-knacks to impress patients with as far as I can tell.

The sad thing is that some meaningless promotional thing like this is just as likely to get someone's attention for my skill as any of my academic awards, real diplomas, or multiple board-certification certificates.

Rob

www.bull#%@*.com - the wild,wild world of hospital rankings

US News and World Reports' (USNWR) annual hospital ranking, akin to their notorious college rankings, is kind of the king of the block for these types of rankings. Keep in mind though, there are hospitals on some of those lists that patients in some of those cities (and even some doctors who work in those hospitals) won't take their dog to, particularly in some urban teaching hospitals. (And No, I'm not naming names!)

The "leapfrog study" indexed by USNWR for rankings reviewed available data from nearly 1300 hospitals and ranked hospitals largely (as I understand it)on 4 endpoints

1. Having intensive care units staffed by specially trained doctors

2. Having computerized order-entry systems for medications and other orders with error-prevention measures

3. Performing procedures such as cardiac catheterization and caring for certain high-risk neonatal conditions

4. Having practices such as those designed to control hospital-related infections and cut down on medication and treatment errors.

It's hard to argue in theory that these are bad goals, but are these the things that patients need/want and is the information we're using to assess it accurate. A number of high profile institutions are typically included on these list which can make some doctors chuckle.


I saw an interesting editorial in the journal, Contemporary Surgery,a commentary on how confusing or misleading it is to try and figure out which hospitals, programs, or physicians are "the best". A quick review of a number of consumer oriented web sites provide significant inconsistencies -- for example, with colon resections for cancer, one hospital was ranked best by two sites but worst by the other site, and the hospital ranked best on that site was ranked worst on another, in a study reported in the journal, Archives of Surgery. Why is this so? There is no standard way of calculating quality differences, thus different sources (despite good intentions)come up with different results for the same hospitals

"What makes the 2007 Toyota Camry Motor Trend’s Car of the Year? Who decides who should be ranked number 1 in college football? Which tastes better: Coke or Pepsi? More importantly, is your hospital any good, and are you any good?...Ask patients to weigh in on their surgical experience or hospital care and you might be surprised to find out what they want (free parking). Or, what they don’t care about (board certification)."

Sites like Healthgrade, purport to offer patients some objective criteria for making comparisons between hospitals. This site ranks hospitals, surgery centers, and nursing homes based on data generated from Medicare records. Hospital rankings are based on 13 AHRQ (Agency for Healthcare Research and Quality) categories that include: decubitus ulcers, death in low mortality DRGs, postoperative hip fracture, and postoperative PE or DVT among others. The rankings are “calculated” by 100 employees in Golden, CO, using Medicare data that hospitals supply. Repeat: your very own hospital supplies the data!

If you want to get an even more confusing way to look at healthcare, you can also check out a site like Vimo.com which purports to give consumers (err......) patients comparisons for the cost of surgical procedures. As most of those numbers represent "funny money" (ie. neither the feds, hospitals, nor insurers expect to pay these imaginary numbers).

Rob

Malignant Hyperthermia confirmed in Florida Plastic Surgery death

An autopsy has confirmed that the South Florida teenager, Stephanie Kuleba, who died this Spring after corrective breast surgery (reportedly for significant asymmetry and inverted nipples) suffered from a rare genetic disease that had been speculated to have causes her death. Genetic testing at the University of Pittsburgh shows she possessed the genetic mutation RYR-1 which is responsible for most cases of the malignant hyperthermia (MH) response to certain inhaled anesthetics. However, over 80 genetic defects have now been potentially associated with MH. As these mutations are inheritable, they will vary in rates among the population and some increased clusters of MH mutation carriers have been suggested in states like Wisconsin, Nebraska, West Virginia and Michigan.

The exact incidence of Malignant hyperthermia is unknown, but the rate of occurrence has been estimated to be as frequent as one in 10,000 or as rare as one in 100,000 patients who undergo general anesthesia. (A range that big suggests they have no idea to me) There is no practical screening test to determine if a patient has the rare condition so you rely on family history or consultation questions to identify high risk patients. Again, the incidence is so rare there is no way to prevent these MH events from happening. The signs that develop are usually suble (ie. a tense jaw) before they're not (ie. 104 degree temp and cadiovasular collapse).


Despite her doctors efforts to treat the Ms. Kuleba during the event with the medication Dantrolene, her parents claim her Plastic Surgeon's office was not prepared to care for their daughter once they had figured out that she was suffering from the hidden hereditary condition and have (in the great American tradition) announced their intention to file a lawsuit.

When MH is identified or suspected, time becomes valuable for salvage treatment. As soon as the malignant hyperthermia reaction is recognized, all anesthetic agents are discontinued and the administration of 100% oxygen is recommended. Dantrolene should be administered by continuous rapid IV "push" beginning at a minimum dose of 1 mg/kg, and continuing until symptoms resolve or the maximum cumulative dose of 10 mg/kg has been reached.

Kulebas' family attorney Roberto Stanziale, has said the teenager should have received as many as seven vials of the drug as an initial dose. On medical records Stanziale obtained following her death, one doctor noted she received one vial of the antidote. The other doctor wrote she received two. It's not known at what time the drug was administered or whether there was enough Dantrolene available at Dr. Schuster's Boca Raton clinic, Schuster Plastic Surgery. Both doctors have defended their actions, saying the situation was handled appropriately and that Kuleba received the Dantrolene dose needed once they consulted with the Malignant Hyperthermia Association (MHA) hotline and called an expert at the Mayo Clinic in Minnesota.

This dosing issue and it's timing is going to be a big issue in the lawsuit. You can't really give informed consent for MH as it's so rare so that shouldn't be an issue (although that will likely be claimed by a plaintiff's attorney). According to the brochure for Dantrolene, each vial contains 20 mg of the drug. As it's suggested in her anesthesiologists notes, she received 2 vials initially (40mg) while they called the MHA hotline to confirm treatment (as again it's so rare no one really has a lot of experience with treating it). That 40mg dose is in the ballpark for the recommended range (by weight) for initial treatment for most thin teenagers.

At the end of the day, I'm not sure what's going to be achieved with this lawsuit. It sure seems like reasonable steps were initiated by her doctors after the event to try and save this girls life. There is only so much you can do when unforeseen or extremely rare complications arise and no amount of preparation can prevent some bad outcomes. Contrast the hostile posture of the Kuleba family attorney with this MH tragic event during orthopedic surgery on a 20 year old described by Dr. Henry Rosenberg, President of the Malignant Hyperthermia Association of the United States. The pain of the medical staff and their communion with the deceased's family is moving.

I hope that this event will continue to foster more discussion on oversight for office-based surgery and anesthesia. It's ironic that it's actually been Plastic Surgery that been the most progressive in regulatory oversite in ambulatory surgery. While this case was an anesthesia complication rather then a surgical one, the who's, where's , and how's of who can (or should) be doing surgery is overdue for more scrutiny.


Rob

Plastic Surgery 101's music endorsements

One of the nurses in the O.R. asked me what I was listening to on my IPOD. Today's detour from medical humdrum features the official Plastic Surgery 101 music endorsement post. I'm always into new music so if you have anything you'd like to suggest, drop it in the comments!

New England hipsters,Vampire Weekend's caribe flavored "A Punk"


The Duke Spirit - "The Step and The Walk"


Weezer's mind-blowingly clever "Pork and Beans" video.


Super songwriter, Steve Earle's definative song about hitting bottom in rehab "Goodbye"


Heavy-metal flamenco duo, Rodrigo y Gabriela tearing up "Diablo Rojo" on Letterman


British "new soul" prodigy, Adele's "Hometown Glory"


Bat For Lashes' trippy retro, "Whats a Girl To Do?". My kids love this BIZARRE video.


The Cardigans , best known for breezy 90's hit "Lovefool" from the movie Romeo & Juliet, bare their teeth on the "I need some fine wine and you, you need to be nicer!"


New Orlean's funk-rockers, Galactic with guest Lyrics Born "What You Need"

Rob

Sign of the Times - a short tort report!

Sorry for the "radio silence" over the past week! I've a couple posts in half finished drafts lying around which I plan to finish soon.

Meanwhile, for today's sign of the times:

According to US NEWS & World Report magazine, at the recent Mass Torts Made Perfect meeting, a who's who of class action lawsuit ambulance chasers, more then 1/3 of the audience excused themselves during a session title "Ethical & Liability Issues in Group Litigation"

Questions about breast reconstruction

I got a late question in the "mailbag" from a Plastic Surgery resident asking

"When I was applying to programs last year and traversing the country visiting programs, there were a few trends which enticed applicants, probably none more that microvascular breast reconstruction. I was curious whether you think this trend will persist, or do you think increased insurance skepticism and comparability of implant based reconstruction and rotational flap reconstruction will leave this procedure for the uber rich willing to pay the difference?"

One thing to understand with questions like this is that while quality in healthcare is applauded, it is not paid for in a vacuum. With rare exception, reimbursement for insurance will continue to be depressed as we creak towards some kind of "federal medicare for all". As the feds and 3rd party payers look at things, quality is measured in things like length of stay and total cost rather then measuring quality in terms of "Does this type of reconstruction look more like a breast?".

Microsurgical expertise is gradually being concentrated in fewer and fewer hands as it has become a financially unsustainable procedure for most surgeons. (you can witness the same phenomena in pediatric plastic surgery & increasingly, hand surgery btw) I don't think there exists a large population of "uber rich" to sustain the field in a robust fashion, and there really is no plausible stimulus pending (50% increase in RVU's for instance) for rekindling interest in free flap surgery when other options exist.

Rob

What do cosmetic surgery and Lesbians have in common?

Now that you've been roped in with a salacious post title, the answer is kind of boring and mundane.

So what do they have in common? Trademark issues.

This type of Lesbian on lesbian action involves the tiny Aegean Sea island of Lesbos, home to the ancient Greek poet, Sappho, who famously praised romantic love between women 2700 years ago and gave us the origin of the term lesbian, has been threatening to sue to protect it's name from being used by Gay rights groups.

Similar to other old world cities, and most often involving foodstuff or liquors, these areas do have some legal claims on words derived from the area if they've trademarked them in a concept known as "protected designation of origin".


Image Source: Slap Upside the Head Blog.

Think of things like

• champagne - which can only come from certain areas of France


• Bourbon whiskey - which has to come from Kentucky and be distilled a certain way


• Roquefort cheese - cheese must be made from milk of a certain breed of sheep, and matured in the natural caves near the town of Roquefort in France, where it is infected with the spores of a certain fungus that grows in local caves (Ick!)


• Budějovický Budvar beer from the Czech Republic city of Budweis which had brewed a budweiser (literally a "beer from Budweis") style of beer since the 13th century, had a 20 year lawsuit settled with American corporation, Anheuser-Busch Co. over their popular Budweiser brand. This Czech beer, praised by beer aficionados, is now available in the USA as the brand, Czechvar. (Good stuff!)

The concept of trademarking surgical procedures has caused a little controversy in recent years. In particular, a number of facelift variations have been given catchy monikers like QuickLift, ThreadLift, S-lift, MACS lifts, E-Z lift, Lifestyle lift, etc.... Some surgeons have even had enough gumption to send cease & desist letters claiming intellectual property violations for surgeons performing these procedures. They were actually asking for royalties to do these operations.

The "Lifestyle Lift", a minor variation of the "short scar" facelift procedures has been commercialized by a chain of clinics and is advertised heavily in print and media. There have been an inordinate number of complaints (see here) among patients with these clincs which may represent who is doing the surgery (often not plastic surgeons at these clinics) rather then some inherant flaw in the technique. You can get OK results in very modestly aged faces with these procedures, but I get the impression it's being used on people that need "real" facelifts. A popular variation (and one I like), the MACS lifts, is a little more powerful tool for trying to get by with shorter scars on some of these patients.

This practice goes against a long history of our profession disseminating ideas & innovations around the world. Cosmetic surgery is probably one of the only industries where businesses publish and lecture on their trade craft for free! In addition, many of these "new" surgeries have been described many times before if you know where to look. John McGraw, the father of modern reconstructive surgery, has quipped "If you think you've invented some new operation in Plastic Surgery, you probably haven't looked in German surgery journals from the 1920's!"

Rob

Revisional cosmetic breast surgery - Dr O in print this month

I like to say that unlike most blogs by plastic surgeons, Plastic Surgery 101 really isn't about me, but today's post is actually about me.

I was asked by the editor of Plastic Surgery Products (PSP) magazine, an industry trade journal, to come up with something interesting to write about for his magazine. One of the questions that I'm always thinking about is "What are the things we do that really cause long term problems and how can I avoid that?".

Spending time as a fellow working with the world's best re-operative breast surgeon (for my money), Nashville's Dr. Pat Maxwell, really gave me a different kind of respect for some of the long term sequalla we can produce with cosmetic and reconstructive breast surgeries. There's a famous quote (attributed to former Houston Oilers coach Bum Phillips) about Alabama football coach Paul "Bear" Bryant, that he could "Take his'n and beat your'n, and then take your'n and beat his'n.". Well Pat could do the same with some of the most unfavorable or difficult to treat scenarios in breast surgery that you can imagine.

Anyway, I've kind of gotten an interest in this kind of patient and put some of my understanding and thinking on these issues down for PSP in an article entitled "Solid Strategies in Revisional Breast Surgery" which you can read here.

Thanks to editor Jeff Frentzen for the opportunity to contribute, however Jeff, I'm going to demand the cover story next time :)

Ok now back to posts definately "not about me".

Rob

Hospitals poised to embrace "pay as you go" for patient care

There's a front page story in today's Wall Street Journal, "Hospitals Demand Cash Upfront From Patients" (login required) outlining the increasingly common practice of hospitals demanding pre-payment for services to be rendered.

I've been noticing this locally for awhile as well. As the amount of "bad debt" has been soaring from patients defaulting on their obligations which are the co-pays, deductibles, & any other part of the cost they're responsible for on their insurance. The really disturbing anecdote in the story surrounding a leukemia patient being treated at MD-Anderson Cancer Center in Houston is a painful reminder of the schizophrenic nature of American healthcare where we try to balance patient care and healthcare economics. It's stories like this that just convince me more then ever that we're hearing the death rattle of our traditional system as we move to some universal healthcare system.

Sympathy aside however, patients do need to understand their financial obligations under their insurance plans. One of the least fun things to do in medicine is to start sending collection notices to patients for unpaid charges from office visits or surgery. As you'd predict, it's much harder to get patients to pay after services are rendered then it is prior. There are very common misperceptions among many patients about how, when, and how much we're reimbursed for services.

I can still remember a massive weight loss patient after gastric bypass refusing to pay her co-payment of $1000 to our office for removing her excess abdominal skin (a panniculectomy or tummy tuck) because she felt like the $700 her insurer paid for 4 hours work and half a dozen post-op visits was enough. I'm a softie on many of these cases and we waive charges frequently (particularly on breast cancer reconstruction, which is a passion of mine) but we've had to become much more attentive to this issue as we see more kinds of cases creeping up.

Rob

Sour NOTES - a really, really stupid idea in surgery

At right, a picture of NOTES done "olde school" for a tooth extraction.

I'm not so far out of doing a few thousand abdominal procedures during my general surgery training that I don't still feel fluent in GI surgery. As I'm still boarded in General Surgery in addition to Plastic Surgery, I get a lot of trade journals sent to me on endoscopy, laparoscopy, etc... Occasionally, something I'll read about makes my eyebrow raise as I don't BOTOX yet :) The concept of NOTES surgery is one of those things.

Take an operation that is typically performed safely in less then 30 minutes with minimal pain or morbidity and turn it into one that last 3 hours, introduces unnecessary risk, and has no conceivable advantage. What do they call that at the University of California San Diego (UCSD)? They call it progress (!!!!!)

Welcome to the concept of NOTES "Natural Orifices" surgery (see here for a primer) where intrabdominal surgeries are performed by making a hole thru the stomach, anus, or vagina to work thru versus making several 3-5mm perforations in the abdominal wall with laparoscopic techniques. While ingenuity & creativity is always to be applauded in surgery, at some point you have to do an honest assessment of the risks, benefits, & outcome.

The surgeon in this WebMD article celebrating the first NOTES appendectomy in the United States at UCSD seems to have his intellectual blinders on when discussing this procedure.

Dr. Santiago Horgan, chief of minimally invasive surgery at UCSD, says “We’ve proven this approach works. We’ve seen the impact on patient care and on outcome: less pain, quicker recovery, improved cosmetics.”

So let me get this straight: The absence of three nearly invisible 3-5mm scars, with no advantage in length of stay, with the addition of a hole in your rectum, vagina, or stomach (which all can leak), with significantly prolonged surgery adding cost, increased nausea, and increased risks of deep vein thrombosis (DVT) is somehow supposed to be an improvement? This is a technique that needs to be put back in a holding pattern indefinitely where safe procedures exist until you can come up with some compelling rationale for doing them. If I was sitting on a hospital's Internal Review Board (IRB) looking at this I'm not sure I could give an endorsement for this.

In fairness, some of these same arguments were made when laparoscopic surgery first appeared in the late 1980's and it's now the preferred technique for many procedures. You have my permission to throw this post in my face in 2015 if everything is NOTES and laparoscopic equipment is gathering dust somewhere. I like my odds however!

Rob

Looking back to 1983 in Plastic Surgery and Pop Music

As I was leafing thru a recent Rolling Stone magazine, I noticed the list of top ten pop singles from February 1983. It's a diverse collection of songs that I actually know from being a 12 year old then who listened to the radio and watched MTV (when they actually played music). The singles in order were:

Patti Austin "Baby, come to me"
Men at Work "Down Under"
Bob Segar "Shame on the Moon"
Stray Cats "Stray Cat Strut"
Toto "Africa"
Michael Jackson "Billie Jean"
Eddie Rabbit "You and I"
Culture Club "Do You Really Want to Hurt Me?"
Duran Duran "Hungry Like the Wolf"
Phil Collins "You Can't Hurry Love"

Fast forward to Feb 2008 and I haven't heard of a single one of the top ten songs or most of the artists singing them. In fairness, the hipster in me is familiar with most of the music in the Americana Radio top ten, the "retirement home" for alternative music fans in the 1980's and early 1990's. I'll take this opportunity to plug Radio Paradise, the internet's best free streaming radio station.

My nostalgia for 1983 pop music got me to thinking
"What was going on in Plastic Surgery back then?".

Thru the archive online for our major journal, Plastic & Reconstructive Surgery, I was able to scan the "state of the state" of our field 25 years ago.

- One of the first articles on tummy tucks after gastric bypass (GBP) appeared. This was a little surprising to me as that GBP operation was fairly rare and people with experience in the plastic surgery after was uncommon. Interestingly many of the problems and concepts we act like we've just discovered were well described in that 25 year old article.

- A bunch of articles related to refinements in the traditional "open" (coronal) brow lift. The endoscopic brow lift wouldn't show up for almost another decade, whereupon the traditional operation was deemed obsolete, only to make a comeback in recent years as many have decided that "endo brows" do not last and when they do last it's in the least desirable place (the middle brow versus the lateral brow where people are complaining about). Modified open brows, incorporating lessons from the endo-brow experience, have made an impressive come back in recent years.

- The debate about whether immediate breast reconstruction after was either safe or feasible was being written about. At the time it was favorable to say that patients should "appreciate" their mastectomy defect as a rationale to do delayed reconstruction. Ugggggh! Talk about a paternalistic idea that hasn't aged well. We're actually having a related debate on more serious issues. A recent paper suggested that immediate reconstruction with either your own tissue or implants may decrease the beneficial effects of radiation (in patients requiring it) much more then previously suggested. If this hold up under scrutiny (and it may reflect how radiation therapists are failing proper technique more then the reconstruction) it could really decrease the number of women offered immediate reconstruction.

- A number of reconstructive pediatric urologic surgery procedures were still being talked about. This was a field that was really pioneered by early plastic surgeons generations ago. Since 1983 this whole area has really been abandoned by Plastic Surgery and is really almost now exclusively a Urology discipline. The last requirements for familiarity with these operation on our board certification exams were formally removed 2-3 years ago reflecting this

- Most humorously, an editorial by the chairman of an academic program frets about the ability of Plastic Surgery to attract qualified applicants compared to other surgical disciplines like cardiothoracic. That was a real swing and a miss 25 years later! Plastic Surgery is now indisputably the most competitive training pathway in all of medicine in the US while Cardiac Surgery struggles to fill 1/3 of it's training positions with US graduates.

Most striking to me of all changes is the change in editorial tone and professionalism of our flagship journal now versus then. Dr. Rod Rohrich from Dallas has been a tremendous leader in the upgrade in overall quality of articles included. With rare exception, you just don't see really dumb or inane topics thrown in in 2008.

I kid you not, in a Spring 1983 article there's a serious article "Decreased swimming speed following augmentation mammaplasty" and discussion of how breast augmentation theoretically affects the top end speed of a competitive swimmer complete with in depth mathematical hydrodynamic models.

Rob

Silicone-istas going batty over Newsweek breast implant story

If it wasn't so predictable it would be funny.

Newsweek magazine ran a vanilla story about breast implants called "Chest Right" which was an overview safety/educational guide for laypeople on some issues re. breast augmentation surgery. It's a very conservative piece and touches on a few important factors like choosing a qualified surgeon, complications, follow up, silicone vs. saline devices, etc.... It quotes the presidents of the two major Plastic Surgery organizations and one of the more well-known female Plastic Surgeons, all of whom are reputable and all of whom have extensive track records of championing patient safety issues. In summary, a very mainstream and respectful treatment of the issue.

Skip to the reader comments however, and you see breathless condemnation of the story by a number of the crusaders that populate the handful of web bulletin boards promoting the idea that a giant medical-industrial conspiracy exists to hide the truth from unsuspecting women about links of implants to every known medical condition and psychiatric disorder known to man. Readers of Plastic Surgery 101 know that there is pretty overwhelming international consensus that breast implants have been vindicated over and over in this regard in the medical literature (read here).

Now implants have their own issues, namely capsular contracture and surveillance for rupture, but we appear poised to make signifigant progress on these issues with the 5th generation form stable silicone implants seemingly poised for approval. Both the major manufacturers, Allergan & Mentor, have arranged for inservices this spring for their product reps on these devices. To me this suggests they've already heard thru the back channels that FDA approval is imminent and are getting ready for a new marketing push. You'd think with the improved performance data on these devices, the people upset over existing implants would be encouraging the FDA to act. On the contrary they're determined to push the FDA to rescind access to all breast implant devices (silicone and saline).

Rob

Does an Accolate a day keep the capsular contracture away?

Capsular contracture, an exaggerated hardening of the tissue around a foreign body, continues to be one of the most stubborn issues to stomp out with breast augmentation and reconstruction surgery. It's also been one of the most difficult things to study in a way that's useful because of a relative lack of a clear understanding of why it happens.

Forming a capsule is a normal physiologic process. It happens around everything your body doesn't recognize as "self" when it's implanted and is mediated by a well established interaction among signaling proteins on cell surfaces and your bodies immune system cells. When this process goes haywire, you get thickening and shortening of the capsule which can become painful and distort the shape of the breast.

There's a couple things we know clearly cause high rates of hard capsules with breast implants:

• post-operative hematoma


• infection around an implant


• a history of breast irradiation


• older silicone devices (1970's-19080's) with high rates of "gel bleed"


• rupture of silicone implants

What's more complex is trying to "reverse engineer" how to prevent capsules. Suggestions to reduce high grade capsule rates have included:

• textured implant surfaces


• placement of the implant underneath the pectoralis muscle


• polyurethane-coated implants


• antibiotic irrigation of the implants during insertion


• the use of contemporary "4th generation" implants with thicker "low bleed" shells and more cohesive fillers


• saline implants

The data on textured implants and position of the implant relative to the muscle have been somewhat mixed. At this point it's hard to definitively say that either make much difference long-term. Polyurethane foam works very well, but it's use in the US is likely DOA in the long-term due to liability issues over a (now debunked)risk of breast cancer. Antibiotic irrigation works well in the short-term, but it's not clear that it could affect capsular contracture years out from surgery.

It's been very interesting to see the performance of the "5th generation" silicone devices in published studies. These are the "gummy bear" implants which are semi-rigid and textured. Whether it's a synergistic effect or what is not clear, but these implants have dramatically lower rates of capsular issues almost a decade out. These devices appear to offer an improved solution to capsular (and rupture) issues and hopefully the FDA will give the green light sometime in 2008 for their US debut.

So what else do we have to offer?

There's a class of drugs used to treat asthma called leukotriene inhibitors (LTI) that has shown some promise in prevention or treatment. The two most common LTI's are Accolate and Singulair. Accolate has a small potential for liver problems and has mostly been avoided in favor of Singulair. Singulair was in the news as it's been alleged to cause suicidal ideation by people suing Merck. (How you prove a negative here is anyone's guess, but call me the skeptic.)

Anyway the genesis of this post was a study I saw in a European journal showing dramatic inhibition of capsule thickening in an animal model using zafirlukast (aka Accolate) which you can see view here). This is the first basic science model I've seen actually showing this idea of LTI's can work. This information gives us another option to discuss in the high risk capsule former which is good!

Rob

VA Voodoo Economics - Krugman wrong on John McCain

A few months ago I introduced some of the audience to the idea of "VA (Veteran's Administration System)logic". VA logic is the bizarre culture that has crept into the bureaucracy of the VA system that lead doctors who have trained or work in the VAMC system to shake their head when the system is held up as some paragon of universal health care.

While the VA system has America's only comprehensive electronic medical record system (which is a great thing), it has the world's most effective system of "nurses with clipboards" (NWC), non-clinical personal who walk around nagging everyone and serving little utility. Ironically, it's many VA employee's goal to be promoted to NWC/supervisor status because they get pay raises for doing less work then actually taking care of patients.

The VA system is much better benefits then no insurance at all or medicaid, but offers much less choice of providers or locations then a federal program like medicare. Veterans' reactions to the VA are very polarized in my experience. Some are very emotionally attached to the system, while others are resentful of the inconvenience of having to travel great distances and then having to suffer thru puzzling bureaucracy for appointments, consults, and surgery. My grandfather-in-law, a multiple purple heart & bronze star veteran from Iwo Jima & Guadalcanal in WW II, refuses to set foot in the VA even for free prescription benefits he'd be eligible for.

It is puzzling to imagine how building some parallel healthcare universe like the VA system is either cost-effective or sustainable. There already exists enough capacity in the "civilian" system to accommodate veterans without having to federally subsidize each and every VA hospital, clinic, & pharmacy. The federal benefits we're also covering for VA employees are also often much more generous then regular health systems.

I got thinking about this after reading the world's worst syndicated columnist, New York Times liberal Paul Krugman's column on "Voodoo Health Economics". Reading Paul Krugman columns regularly is like subjecting yourself to the cesspool of the Daily Kos (which I used to like BTW). Both have become so hyper-polarized with ideology they've ceased to be relevant.

He writes

As I’ve mentioned in past columns, the Veterans Health Administration is one of the few clear American success stories in the struggle to contain health care costs. Since it was reformed during the Clinton years, the V.A. has used the fact that it’s an integrated system — a system that takes long-term responsibility for its clients’ health — to deliver an impressive combination of high-quality care and low costs. It has also taken the lead in the use of information technology, which has both saved money and reduced medical errors.

Sure enough, Mr. McCain wants to privatize and, in effect, dismantle the V.A. Naturally, this destructive agenda comes wrapped in the flag: “America’s veterans have fought for our freedom,” says the McCain Web site. “We should give them freedom to choose to carry their V.A. dollars to a provider that gives them the timely care at high quality and in the best location.”

That’s a recipe for having healthy veterans drop out of the system, undermining its integrated nature and draining away resources.

I'd first like to offer a squid like Mr. Krugman the middle finger for disrespecting a man like John McCain.

On substance I could not agree more with Sen. McCain. We should be offering vets more flexibility rather then herding them into the VA system. How do you do that? You simply make them preferred Medicare enrollees which instantly give them access to any hospital (and potentially 90-95% of providers) they want. How do you guarantee the vets access? You sweeten the payment for this class of beneficiaries 3-5% above medicare rates or offer tax rebates for their care. Even that slim margin would start tremendous competition to serve that group. If vets are as happy with the VA as Krugman suggests, he should have to little to fear from offering them choice in the private sector, he's supposed to be an economist for chrizsake!

If Mr. Krugman was as savvy as he thought, he'd be encouraging something like this because Medicare is the front & back door towards the Universal Health Care system he's always ranting about. The more people enrolled, the greater the momentum it gets.

Rob

A big (non) decision by the Supreme Court with huge universal health care implications

A nerdy public policy-wonk post today!

Despite a surprisingly brief blurb on the AP wire & broadcast news media, there was a very important move last week by the Supreme Court of the United States (SCOTUS) about the future of health care in this country. The court refused to hear an appeal by the American Association of Retired Peoples (AARP) about a companies ability to terminate health care benefits when a retired former employee becomes eligible for Medicare at 65. The AARP is one of the most powerful political lobbies in the United States, and this is a pretty big defeat for them.
The court's action upholdsa a rule adopted last year by regulators that says the "coordination of retiree health benefits with Medicare" is exempt from the anti-age-bias law.


This case has pitted the interests of younger employees and unions against retirees over the dwindling budget for job-related benefits. In recent years, many employers have pulled back from providing these kind of benefits to their retirees because of the soaring cost obligations. But until Monday it had been unclear whether it was illegal to use a worker's age -- in this instance, 65 -- to trigger a reduction in benefits.

"In some cases, it's become a millstone around their necks," said Jack Kyser, chief economist of the Los Angeles County Economic Development Corp. "Corporations aren't all heartless, but in many cases, you're competing with multinational corporations that don't have quite the obligations that domestic firms have."

This decision not to hear the appeal is interesting because it's going to grease the skids for a large shift of healthcare obligations from the private sector to the feds. As I remained convinced that we're quickly moving towards "Medicare for all" as the eventual American adoption of universal health coverage, the incorporation of more people under it's existing umbrella seems another move in that direction.


Rob

Anesthesia related death during plastic surgery

From the Palm Beach Post comes the tragic death of Florida teen, Stephanie Kuleba, from a rare allergic reaction to inhalation anesthetics called malignant hyperthermia (MH). Wikipedia describes it succinctly as a idiosyncratic reaction that "induces a drastic and uncontrolled increase in skeletal muscle oxidative metabolism which overwhelms the body's capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if untreated."

There's really no way to screen for this process and a patient can die quickly. Most surgeons and anesthesiologists may go their entire career and never see a true case of it. I was talking to one of my colleagues the other day about office based surgery and he said he was unlikely to return to doing that after seen a near fatal MH on a cosmetic surgery case he was doing in an ambulatory surgery center adjacent to a hospital.

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

Rob

'Tis the season for - Chocolate Bunny Melting

Happy Easter from Plastic Surgery 101!

Courtesy of YouTube, some stylish chocolate bunny immolation. You know, artsy types are just different then the rest of us!





Cheers!
Rob

Do Americans want fee for service medicine?

There's an article on Salon.com about health kiosks in places like Walgreen's and Wal-Mart called "Wal-Mart can be good for your health!".

This is a hot topic in medicine as it gets into a number of hot topics

• Who will own these clinics? (doctors or industry)




• Who will staff & oversee these?




• What affect will this have on continuity of care?




• What affect will this have on the financial sustainability of medical practices when routine patient visits are siphoned off to these clinics?

One theme that jumps out at me, particularly when you read the reader comments section to the article, is that people are schizophrenic when they think about this (ie. Is medicine a business or nonprofit public utility?) and look at this from a completely different perspective than health care providers.

A number of complaints arise which basically boil down to that "the competition these clinics provide against doctor's office visits will be good and result in better service". This pretends that medicine is some true market economy rather then a corporate & federally-rigged game of Jenga. The winner of this "competition" gets the privledge of working much harder for much less money for much more aggrevation.

If you want to send a primary care doctor thru the roof, complain about having to pay a co-pay for and office visit and about not being able to be seen at a moment's notice. There's little understanding (or sympathy) for exactly how much our system is squeezing physicians to achieve savings in our health care system.

Particularly offensive to me is a Minnesota internet start up company I read about called CAROL, whose business model is essentially to try and turn medicine into Priceline.com

“We want to let consumers define value,” said Tony Miller, Carol’s founder and chief executive. “We don’t have care competition in the marketplace today.”The free site, which went live in January, generates revenue from health-care providers who become “tenants” on the site. When a consumer sets up an appointment with a clinic or doctor on Carol.com, the provider pays the site a fee.

Great! We were missing one more layer of capitalists strip mining the health care system.

Rob

Dumb laws and smart laws re. plastic surgery

Tragic events have a way of stimulating bad legislation.

Co-conspirator in Plastic Surgery blogging, "Dr. 48307", Tony Youn had a very insightful retort a few weeks backto a bill ("the Donde West law") introduced in the California legislature (read here) to mandate medical clearance on all patients undergoing cosmetic surgery. Something similar is now being mentioned in Illinois. Dr Youn writes:

This is a very interesting bill, considering less than a year ago the California legislature passed a law permitting oral surgeons (DDS dentists) to perform all forms of facial plastic surgery. Instead of forcing surgeons to make their patients undergo preoperative testing (some young, healthy patients may not need it), maybe they should instead make sure that anyone performing plastic surgery is a real, board-certified plastic surgeon?

Keep in mind that California is also the state where a judge ruled in 2006 that a certificate from a non-recognized cosmetic surgery "board" organization was equivalent (or better!) to the American Board of Plastic Surgery for accreditation proposes over the objections of the state medical board for California, the American Medical Association (AMA), the American Society of Plastic Surgeons (ASPS), the American Board of Facial Plastic Surgery, the American Board of Medical Specialties (ABMS), and others. This ruling ignored the existing state law that allowed physicians to advertise board certification only if the certifying board or association is recognized by ABMS or deemed equivalent by the state medical board.

BACK TO THE "DONDE WEST" LAW

Broad non-directed medical screening by 3rd parties would be an extremely inefficient and unnecessarily expensive way to clear patients for surgery. Besides, this process already takes part as part of a patients' surgery evaluation. Now your doctor can be a tool, and adopt the blanket position that "I send all my patients for medical clearance before surgery", but that's just punting the ball and practicing defensive medicine to the extreme.

The scale we commonly use to characterize surgery patients' anesthesia risk, called the ASA system, is a pretty good screening tool. The overwhelming amount of patients undergoing cosmetic surgery are low risk, and ASA class I or II patients should not need "medical clearance". In addition, many primary care doctors have absolutely no idea what "medical clearance" means anyway, and get a little peeved when patients show up for non-reimbursable office visits.

When we talk about medical clearance, it's usually in the context of chronic medical issues or asking whether the patient needs provocative testing for coronary artery disease. Patients who may need to be "tuned up" prior to surgery are those with:

• diabetes - Are there blood sugars under control?


• significant hypertension


• morbid obesity


• sleep apnea


• symptoms of (or strong risk factors for) coronary disease

Many of those conditions might be exclusionary for elective cosmetic surgery in the first place, particularly when combined. Keep in mind that the patient involved in the event triggering this reactionary bill, Donde West's, had undergone coronary testing earlier in the year (which was reportedly normal) and died over 24 hours postop from what sounds like a probable aspiration event. No amount of screening would prevent something like that.

"Smart Laws" relating to cosmetic surgery seem to be a little more difficult to implement. A more practical way to address the whole issue of office based surgery procedures would be to standardize the accreditation of facilities and remove the loopholes in some states that still exist. My state, Alabama, for instance has set a timetable for requiring accreditation for office an ambulatory surgery centers (ASC) over the next 18 months. The ASPS already makes it a requirement for membership that you will pledge to only operate in accredited (or planned accredited) office facilities. A common sense regulatory step would be to require hospital privileges for any surgery you'd propose to do in your office requiring sedation or general anesthesia, which would have the de facto effect of an additional level of credentialing applied by hospital medical staff offices. It's so common sense that it will be violently opposed by many "cosmetic surgeons" who would see their ability to practice cut off at the knees. Something to think about!

Thanks again Tony for your wonderfully entertaining blog!

Rob

The charity business as (un)usual - Operation Smile

There's a nice story on featuring Operation Smile in the New York Time's magazine. Operation Smile is an organization that organizes and performs cleft lip and palate surgery in developing countries. The story is not really about the altruism of Operation Smile, but rather it focuses on how it became an effective organization only after operating more like a business and less like a traditional charity.


3rd world missions by plastic surgeons, where a team flys in for a few days, does a lot of pediatric plastic surgery (cleft lip/palate) and leaves would seem like a hard thing to be criticized, but it has been increasingly done. The appropriateness of these kinds of surgeries performed by surgeons who didn't do them in their state side practice and by loosely-supervised residents (as was often the case on these trips) has been questioned for years. Groups like operation smile have addressed this, and require active practices in pediatric plastic surgery among volunteers. More importantly IMO has been the change in philosophy to where we're now increasingly training local physicians in these countries to do simple and reproducible operations to correct these defects recognizing the limitations of resources they may face in terms of speech therapy and orthodontics post operatively.


Rob

Wall Street Journal on SmartLipo - I scooped 'em!