Make Sure Your Surgeon is Trained for Your Procedure

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active. 

Don’t simply look for a surgeon who is board certified.  Make sure they are trained to do the procedure you are having.  Yes, board certification is important, but the training is more so (in my humble opinion).

If you are having a breast augmentation, you don’t want a board certified maxillofacial surgeon or Ob-Gyn or neurosurgeon.  You want someone trained in plastic surgery.  It is a bonus if they are board certified.  By the same token, if you need brain surgery you don’t want a board certified plastic surgeon you want someone trained in neurosurgery. 

This rant was prompted by the USA Today article written by Jayne O’Donnell:  Lack of training can be deadly in cosmetic surgery

……….Sant Antonio is one of a soaring number of doctors who trained in other medical specialties, such as vision or obstetrics, but have branched into the more lucrative field of cosmetic surgery. Because state laws governing office-based surgeries often are lax, levels of training vary so widely that some doctors are performing cosmetic procedures after only a weekend observing other doctors. Sant Antonio himself has offered three-day liposuction training at his office for the last few years, according to interviews with doctors who have trained under him.

Some dentists trained in oral surgery now do breast implants; OB/GYNs perform tummy tucks, and radiologists are doing liposuction. The results can be disastrous, according to interviews with scores of victims, plaintiffs' lawyers and plastic surgeons, and a review of lawsuits. ………….

Modification of Square Face

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

Recently an article in the Archives of Facial Plastic Surgery (full reference below) led to a Reuters news by Genevra Pittman:  Face too square? There's a surgery for that

The journal article is from China where the surgical procedure to modify a square face to a more oval face is done much more commonly than in the United States.  The Reuters article includes quotes from two U.S. surgeons:  Dr. Jeffrey Spiegel, chief of facial plastic and reconstructive surgery at the Boston University School of Medicine, and Dr. Ross Clevens, a cosmetic surgeon in Melbourne, Florida.

Spiegel states he does the procedure described in the Archives article two to four times each week.  Clevens states “he doesn't treat many male patients who want a more "feminine" face shape.”

Xiaoping Chen, MD, International Plastic and Cosmetic Center, China, and colleagues reviewed the procedure done for nineteen men with a square face (aged 22-30 years).  The time span of the cases was not given (ie 2001 to 2010) in the article.

The procedure involves an ostectomy with resection of the mandibular angle, splitting of the lateral cortex around the mandibular angle, and reduction of the width of the chin by an intraoral approach. (photo credit)

It sometimes was necessary to resect part of a hypertrophic masseter muscle. In addition, partial buccal fat pad removal was performed in patients with prominent cheeks. When the operation was completed, the wound was irrigated; a suction tube to allow drainage was then placed and maintained for 48 to 72 hours. The patient's lower face was lightly compressed with a dressing. Antibiotics were administered for 3 to 5 days, and the sutures were removed 7 days postoperatively.

In this series of 19 patients, there were no complications.  Complications that can occur include:  microgenia, facial asymmetry, hematoma, infection, or permanent mental nerve injury.

All patients developed edema in their lower face  (tx’d with corticosteroid therapy, 10 mg/d for 3 days) and varied amounts of difficulty in opening their mouth for 1 to 2 weeks.

Results can be as dramatic as the procedure needed to achieve them  (photo credit)


The Reuters news article states, “The procedure typically takes an hour or two, and costs up to $10,000, surgeons said.”



REFERENCE

Modification of Square Face in Men; Xiaoping Chen, Jinde Lin, Jie Lin, Jian Shen, Yudan Zhou, Xuan Wu, Yanwu Xu; Arch Facial Plast Surg. 2011;13(4):244-246.doi:10.1001/archfacial.2011.47

Plastic Surgery in Ethnic Groups

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Earlier this week @hrana twitted this:

News: Plastic surgery boom as Asians seek 'western' look http://bit.ly/ifQFBs - Don't get me started on this topic. #health

The link is to the CNN article by Kyung Lah:  Plastic surgery boom as Asians seek 'western' look

The article is an interview of a 12 yo Korean girl, her mother, and Dr Kim Byung-gun (head of Seoul, South Korea's biggest plastic surgery clinic, BK DongYang).

The young girl doesn’t like her eyes and wants to have a double fold created in her eyelids to give her a more western look.

Is it wrong to want to look like another ethnic group rather than your own?  Are you slighting your heritage or family if you chose to change your eyes, your nose, etc?

I was taught, as a surgeon, the neoclassical canons of facial attractiveness (1st reference below).  These don’t necessarily translate well into all ethnic groups (ie Asians, African-American).  Neither does the Marquardt facial mask. 

Media and the cross-culture of our society affects the idea of beauty.  M. Jain in her college paper (3rd reference below) notes “that women of different generations and locations have felt the globalization of a Western ideal- skinny, "white" features, tall, and non-curvaceous body.”

Is it a form of self-hatred to want to change the identifying ethnic trait -- Asian eyelids, Mediterranean nose (ie Roman), African-American nose?  Is this somehow different than someone who wants more hair, wants bigger/smaller breasts, fuller buttocks, anti-aging cosmetic surgery?

REFERENCES

1.  History and Current Concepts in the Analysis of Facial Attractiveness; Bashour, Mounir; Plastic & Reconstructive Surgery. 118(3):741-756, September 1, 2006.

2.  Ethnic trends in facial plastic surgery; Sturm-O'Brien AK, Brissett AE, Brissett AE; Facial Plast Surg. 2010 May;26(2):69-74. Epub 2010 May 4.

3.  The Cultural Implications of Beauty; Meera Jain; course paper at Bryn Mawr College, Spring 2005

4.  Differences in perceptions of beauty and cosmetic procedures performed in ethnic patients; Talakoub L, Wesley NO; Semin Cutan Med Surg. 2009 Jun;28(2):115-29. (pdf file)

5.  The Legacy of Narcissus; Scott Isenberg, J.; Plastic & Reconstructive Surgery. 110(7):1815, December 2002

6.  Putting Beauty Back in the Eye of the Beholder; Little, Anthony; Perrett, David; The Psychologist Vol 15 No 1, January 2002 (pdf file)

7.  Physical appearance and cosmetic medical treatments: physiological and socio-cultural influences; Sarwer DB, Magee L, Clark V; J Cosmet Dermatol. 2003 Jan;2(1):29-39.

8.  Motivating factors for seeking cosmetic surgery: a synthesis of the literature; Haas CF, Champion A, Secor D; Plast Surg Nurs. 2008 Oct-Dec;28(4):177-82.

9.  Correlates of Young Women’s Interest in Obtaining Cosmetic Surgery; Charlotte N. Markey & Patrick M. Markey; Sex Roles (2009) 61:158–166; DOI 10.1007/s11199-009-9625-5 (pdf file)

10. Orthodox Jewish Law (Halachah) and Plastic Surgery; Westreich, Melvyn; Plastic & Reconstructive Surgery. 102(3):908-913, September 1998

FDA Update: Restylane

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

The FDA General and Plastic Surgery Devices Panel of the Medical Devices Advisory Committee met on April 27, 2011 to review the request for expanding the use of Restylane for augmentation of the lips.  The panel voted 6 to 0 (1 abstaining) that Restylane for lip augmentation is generally safe and effective for this purpose and that the benefits outweigh the risks.

The FDA still has to make a final decision on Restylane injectable gel for lip augmentation, but the agency usually follows the advice of its advisory panels, which consist of outside experts.

Restylane was approved by the FDA in 2003. It is a non-animal stabilized hyaluronic acid gel. Restylane is free from animal proteins. This limits any risk of animal-based disease transmissions or development of allergic reactions to animal proteins. Allergy pretesting is not necessary.

Perlane is a more robust form of Restylane intended for use in the deep dermis and at the dermal-fat junction. Restylane is indicated for the correction of moderate to severe facial wrinkles and folds.

The most commonly observed side effects are temporary redness and swelling at the injection site, which typically resolve in less than seven days. Both are made by Medicis.  Both are available with lidocaine (Restylane-L, Perlane-L).  Patients should be limited to 6.0 mL per treatment.

According to Medicis, Restylane is the most-studied aesthetic dermal filler in the world, and has been used in over 10 million treatments worldwide.

From Medscape news article:

During the public comment portion of the meeting, Gloria Duda, MD, board-certified plastic surgeon from McLean, Virginia, who was representing the American Society for Aesthetic Plastic Surgery, noted that Restylane is commonly used off-label to augment and contour the lips, and she encouraged the panel to support its use for this indication.

Lip augmentation is a "very frequently" requested procedure, Dr. Duda said, and, in her experience, the results are "immediate and reproducible and the risks with hyaluronic acid are minimal."

"I perform over 120 lip augmentations per year with no complications and 95% retention with return visits at 8 to 12 months for repeat procedures," Dr. Duda said.

General and Plastic Surgery Devices Panel of the Medical Devices Advisory Committee. Meeting held April 27, 2011, in Gaithersburg, Maryland.

Related posts:
Dermal Fillers (August 30, 2007)
Lip Augmentation (January 25, 2008)
Guest Post by Dr Val--Lip Plumping With Restylane: What Your Doctor Might Not Tell You (September 25, 2008)
Injectables Roundup (November 11, 2010)


REFERENCES
Medicis Press Release, April 27, 2011
FDA:
Restylane™ Injectable Gel  (approval date December 2003)
April 27, 2011: General and Plastic Surgery Devices Panel of the Medical Devices Advisory Committee Meeting Announcement
2011 Meeting Materials of the General and Plastic Surgery Advisory Panel (April 27, 2011)

Longevity or Perfect Figure?

Updated 3/2017--  all links (except to my own posts) removed as many no longer active. 

I’ve spent some time thinking about this survey.   I couldn’t find any better information on the survey than the press release from the University of the West of England (UWE).  Perhaps in the future it will be published in a journal for better review.

The  survey was apparently done by the  new eating disorder charity The Succeed Foundation in partnership with the University of the West of England (UWE).  The editor’s notes indicate 320 women (ages 18 – 65 years, average age 24.49)  studying at 20 British universities completed The Succeed Foundation Body Image Survey in March 2011.  

Notably, the survey found that 30% of women would trade at least one year of their life to achieve their ideal body weight and shape.

The research has also found that in order to achieve their ideal body weight and shape:

•        16% would trade 1 year of their life
•        10% would trade 2-5 years of their life
•        2% would trade 6-10 years of their life
•        1% would trade 21 years or more of their life

I would love to see an age breakdown of the respondents here.  Do we women become more comfortable with our bodies as we age?  Or did as many of the over 50 year olds want to trade longevity for “the perfect body” as the 20 year olds?

In addition to longevity, the survey also notes that in order to achieve their ideal body weight and shape, 26% of the women surveyed were willing to sacrifice at least one of the following:

•         £5000 from their annual salary (13%)
•         A promotion at work (8%)
•         Achieving a first class honors degree (6%)
•         Spending time with their partner (9%)
•         Spending time with their family (7%)
•         Spending time with their friends (9%)
•         Their health (7%)

Again, I would love to see an age breakdown.  It would be interesting to see how this might differ between the younger respondents vs the older (over 50 year olds) ones.

The survey results suggest that body dissatisfaction was common among the women surveyed, with 1 in 2 women saying that more needs to be done on their university campus to promote healthy body image.

•         46% of the women surveyed have been ridiculed or bullied because of their appearance.
•         39% of the women surveyed reported that if money wasn’t a concern they would have cosmetic surgery to alter their appearance. Of the 39% who said they would have cosmetic surgery, 76% desired multiple surgical procedures. 5% of the women surveyed have already had cosmetic surgery to alter their appearance.
•         79% of the women surveyed reported that they would like to lose weight, despite the fact that the majority of the women sampled (78.37%) were actually within the underweight or ‘normal’ weight ranges. Only 3% said that they would like to gain weight.
•         93% of the women surveyed reported that they had had negative thoughts about their appearance during the past week. 31% had negative thoughts several times a day 

Yes, I know as a plastic surgeon I make a living (in part) from cosmetic procedures, but I feel strongly that my nieces and other young women should be grow up to love themselves and their bodies.  

Related posts:
Steriod Use in Girls  (February 21, 2008)
Get Girls to Focus on Skin’s Appearance  (May 19, 2010)
Maternal Influence  (January 3, 2011)


REFERENCE

30% of women would trade at least one year of their life to achieve their ideal body weight and shape; UWE press release, March 31, 2011

CO2 Laser Use

 Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Over the past couple of months there have been a few good commentary articles on the use of CO2 laser us. 

The first one referenced below is a commentary by Dr. Scott J. Trimas on the treatment of facial acne scarring using CO2 laser abrasion.  He references his article from 10 years ago (2nd reference).  Full references are given to both articles below.

Over a 10 year period, Dr. Trimas, did 54 additional patients not included in his first article (the 2nd reference below) using full-face CO2 laser treatment for facial acne scarring. Their ages ranged from 16 to 74 years. Of those patients reviewed, 8 were male and 46 were female. He notes this population was similar to that of the original study. Most patients were followed for up to 2 years.

Dr. Trimas writes “notable improvement can be achieved with the use of the carbon dioxide laser, especially in the areas of the forehead, medial cheeks, and perioral region. Lesser improvement is noted in the areas of the lateral cheeks and temples. Nevertheless, substantial improvement is achieved in all areas.”

He also adds that one of the most substantial changes he has made is the addition of surgical excision of ice-pick scars prior to the laser resurfacing procedure. He performs the excision of the ice-pick scars at least 6 weeks prior to carbon dioxide laser abrasion.

The rationale for this excision technique was that some of the areas of the face did not seem to improve enough with just resurfacing, and I felt that ice-pick scars may have been the contributing factor. In fact, most ice-pick scars that were punch excised were in the lateral cheek regions.

That makes sense to me, as ice-picks scars are often too deep to be adequately treated by resurfacing procedures (laser or chemical peel) alone.

…..

The other recent article (third reference below) covers the use of CO2 laser for more than simply acne scarring.  It was published in the February 2011 issue of the Plastic Surgery Practice.  In the article, Dr. Joseph Niamtu III, discusses his use of the CO2 laser, giving practical tips – both the traditional ablative and the newer fractional lasers.

Take for example his notes on “Postlaser Wound Care—Past and Present”

If there is one drawback in employing traditional CO₂ ablative laser resurfacing, it is the area of postlaser wound care. It adds extra layers of work (and sometimes frustration) for the patient, surgeon, and staff. If the process and experience of postlaser wound care could be ultimately simplified, the promoting of traditional CO₂ treatments would be much easier.

I know several experienced laser surgeons who have abandoned the procedure because of the intensity of the wound care and the hand-holding required to get the patient through it successfully.

Inducing an intentional and controlled second-degree facial burn removes the entire epithelium and part of the dermis. This is obviously a giant insult to the normally intact integument. Patients who undergo fully ablative, high-fluence, high-density, multipass CO₂ laser resurfacing have to understand in the preop period that this treatment will be their hobby for 4 to 6 weeks. I am very blunt with my patients who are considering this type of laser treatment, and I do not sugarcoat the recovery.

Incidentally, for new practitioners, understating a recovery from laser treatment—or any procedure, for that matter—can really come back and bite you in the foot. In an era of new "miracle" treatments and surgeries emerging daily, some surgeons feel compelled to downplay the patient-recovery phase of treatment in hopes of "selling" a procedure. There is no better way to infuriate a patient then to tell them that a 2-week recovery is 1 week, etc. Not only does it upset them, it can cost them in other ways, such as missed work and other scheduled events, and disrupt family life in general.

I tell my patients that they won't like me for a week, that they will need about 2 weeks before they can get back in makeup, and that they will be pink for several more weeks. If I tell them the recovery is 14 days and it takes only 10 days, I am a hero. If I tell the inverse, I am a zero.

Understating a recovery is unethical and promotes negative marketing. I have seen too many instances in which a physician says 1 week for a 2-week recovery, then tries to squirm out of it by blaming the patient for "not healing well."

I really appreciate how he is blunt with his patients regarding the recovery.  Patients need to hear this along with the expected results and risks.

REFERENCES 

1.  Facial Acne Scarring:  Ten Years of Treatment With the Carbon Dioxide Laser (Commentary); Trimas SJ; Arch Facial Plast Surg Jan/Feb 2011 2011;13(1):62-64.

2.  Carbon Dioxide Laser Abrasion: Is It Appropriate for All Regions of the Face?; Trimas SJ, Boudreaux CE, Metz RD;  Arch Facial Plast Surg. 2000;2(2):137–140, pmid:10925440

3.  Confessions of a Master Blaster:  How to use CO2 laster in a cosmetic facial surgery practice; Niamtu III, Joseph; Plastic Surgery Practice, February 2011

Advertising

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

I am old school and find it difficult to advertise. I don’t begrudge others who do so ethically and in good taste.

There is a local cosmetic surgeon who is running a special via TV ads and on his website (the photo is a screensaver shot of the website cropped to remove his name) that for me is unethical.

For me the ad “entices” potential patients into surgery without giving them information about potential risk.   Hopefully that information is given in detail when the patient is seen in the office consultation.

……

This was not an issue when I was in medical school (graduated in 1982).  I trained under surgeons who had never been allowed to advertised and frankly did not think doctors should. 

Deborah Sullivan, PhD has written a nice piece on the history of advertising in medicine, specifically cosmetic surgery:

Cosmetic surgery was re-commercialized in 1982. Before then, physicians, like other members of learned professions, were exempt from the 1890 Sherman Antitrust Act. The AMA could enforce bans on advertising because the fiduciary services physicians offered were not considered a commercial trade. Opinion changed in the deregulatory climate of the Reagan years. Hoping to bring down health care costs, the Federal Trade Commission sued the AMA for restraint of trade over their prohibition of advertising. Over the strenuous objections of the AMA and the plastic surgery specialty associations, a split Supreme Court decision let a lower court ruling in favor of the Federal Trade Commission stand [8, 9]. Advertising in medicine returned, with its ethical dilemmas, and cosmetic surgery was once again on the cutting edge.

As Dr. Sullivan notes (bold emphasis is mine)

The purpose of advertising is to persuade people to do something. The most effective ads appeal to emotions—fears and desires—and associate the subject of the advertisement with highly valued attributes. It is not difficult to persuade people to do something that will give them a more youthful, sexually attractive appearance in a culture that bestows real social and economic rewards on those who possess these traits. The lure of such rewards can make us gullible and impulsive when it comes to buying the promise of beauty.

………

There are a number of physician advertising practices that are deemed inappropriate (reference 2, 3, 5).  These include

• Payment in exchange for referral of patients or media coverage
• Exaggerated claims intended to create false expectations of favorable surgical results
• Promotional inclusion of preoperative and postoperative photographs intended to misrepresent results through different lighting, expressions, or manipulated poses

I think Robert Aicher, Esq comments (reference 4)  regarding a surgeon’s web site could be extended to TV and print ads:

In this commentator’s view, ethical inferences from Web site to practitioner should be suspect. For instance, a former AMA member and Beverly Hills cosmetic surgeon, Dr. Jan Adams, surrendered his license to practice medicine on April 1, 2009, after it was suspended in 2008 for failure to pay child support, with prior alcohol-related convictions in 2003 and 2006. The November 10, 2007, death of his patient, Donda West, and his malpractice judgments of $217,337 and $250,000 in 2001 were not factors in his license surrender. Dr. Adams currently has an excellent Web site that makes no reference to any of these public records.  Accordingly, “quality” Internet advertising does not guarantee a quality practitioner, and conversely, patients routinely obtain quality results from cosmetic surgeons who do not have “quality” Web sites.

………

I’m all for educating the public.  I love the segments Dr. Anonymous does with his local TV stations for just that reason. 

REFERENCES

1.  Advertising Cosmetic Surgery: The use of advertisements for cosmetic surgery has fluctuated throughout the twentieth century; Deborah A. Sullivan, PhD; Virtual Mentor. May 2010, Volume 12, Number 5: 407-411.

2.  Are Plastic Surgery Advertisements Conforming to the Ethical Codes of the American Society of Plastic Surgeons?; Spilson, Sandra V.; Chung, Kevin C.; Greenfield, Mary Lou V. H.; Walters, Madonna; Plastic & Reconstructive Surgery. 109(3):1181-1186, March 2002.

3.  The quality of Internet advertising in aesthetic surgery: an in-depth analysis; Wong WW, Camp MC, Camp JS, Gupta SC.; Aesthet Surg J. 2010 Sep 1;30(5):735-43.

4.  Commentary on "The quality of Internet advertising in aesthetic surgery: an in-depth analysis"; Aicher RH; Aesthet Surg J. 2010 Sep 1;30(5):744.
5.  ASPS Advertising Code of Ethics and Advertising 101 (in pdf form)
6.  Advertising cosmetic surgery: are doctors complying with ethical standards?; Australian Medical Association, June 2002

Determining Implant Size Preop

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

There is an interesting debate going on regarding bra stuffing for implant size at PRSonally Speaking.  In the interest of full disclosure, I use normal saline implant sizers which I place inside a thin sleep bra.  I then inflate with sizer (usually use two different sizes for comparison) with air.  I then have the woman place her shirt on and stand in front of the full length mirror.  It has worked well for me over the years.  And, yes, I know it is not perfect, but it allows the two (or three if a friend or spouse has come with her) to assess how she looks AND presents herself. (photo credit)

It has amazed me over the years how some women will decide on larger implants when I show them what a “C” cup for their body really is [the volume for a 34C is not the same as for a 38C] but also how some will decide they can’t go as large as they intended.  It has worked both ways.  Most of the time the decision is made in one office visit, occasionally two.  Rarely, do they come back wishing we’d made a different choice on size.

Back to the discussion at the PRSonally Speaking:  Letters to the Editor in Advance: Bra Stuffing for Implant Sizing? Satisfaction? Who, When, and Compared to What?

The discussion is in regards to an article in the PRS Journal’s June 2010 edition (full reference below)
A portion of Dr. John Tebbett’s comment

The authors characterize their bra stuffing implant sizing methodologies as “simple” and “accurate”. Simple? Up to three visits to the surgeon’s office to ruminate over shades of gray using a totally subjectively derived decision processes based on indefinable cup size parameters and patient’s visual perceptions? Accurate? 30% of sized respondents reported that the sizing methods were inaccurate.

Choosing breast implant size by bra stuffing has a repetitive, three decade track record of 15-25% reoperation rates (and a major percentage of reoperations for size change) …...

The authors’ implication that objective, scientifically validated, defined process implant selection methods preclude or minimize patient involvement in the decision making processes is misguided and incorrect…

A portion of Dr. David Hidalgo replies

……..What is truly outdated is the model of the surgeon as an autocratic figure that dictates what is best while ignoring patient input beyond presenting anatomy. The trend today instead is towards personalized medicine. ……….

While FDA PMA studies may show a 15-25% reoperation rate preoperative sizing techniques are not specifically implicated as the source of the problem, as implied. In fact the vast majority of reoperations today are for capsular contracture, implant malposition, and saline implant deflations. ……

To be clear, preoperative sizing is not a precise method and is of course subjective. Improvements in the technique would be helpful and hopefully forthcoming. We do not believe that the ongoing advances in three dimensional patient photography with implant size simulation is the answer. There is no substitute for the patient trying on different sizes and visualizing the effect in clothing as well as experiencing the implant weight. The method is very instructive in revealing the patient’s aesthetic vision in a way that dictating a size based on tissue characteristics alone can never do. …….

Thoughts?  Add them here or over at PRSonally Speaking


REFERENCE

Preoperative Sizing in Breast Augmentation; Hidalgo, David A.; Spector, Jason A.; Plastic & Reconstructive Surgery. 125(6):1781-1787, June 2010; doi: 10.1097/PRS.0b013e3181cb6530

Five Critical Decisions in Breast Augmentation Using Five Measurements in 5 Minutes: The High Five Decision Support Process; Tebbetts, John B.; Adams, William P.; Plastic & Reconstructive Surgery. 118(7S):35S-45S, December 2006; doi: 10.1097/01.prs.0000191163.19379.63

Prophylactic Antibiotics in Aesthetic Surgery

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

There is a very nice review of this topic in the Nov/Dec 2010 issue of the Aesthetic Surgery Journal (full reference below).

While we want to prevent surgical site infections (SSIs), we don’t want to over utilize antibiotics.   Consequences of which include:   Clostridium difficile infections [CDI] and development of resistant organisms.

The authors note that currently no national guidelines for antibiotic prophylaxis in aesthetic surgery although they do for cardiac, colorectal, neurosurgical, and orthopedic procedures.  “In fact, studies examining the impact of prophylactic antibiotics have produced contradictory results.”

So what should we do:

Until randomized controlled trials examining the efficacy of prophylactic antibiotics in aesthetic surgery are performed, we recommend giving prophylactic antibiotics in accordance with SIP project guidelines.

The ideal antibiotic for surgical prophylaxis should (1) cause minimal toxicity or side effects, (2) be effective against the most likely organisms that will cause an SSI but have a narrow spectrum, (3) achieve adequate tissue concentrations at the surgical site for the duration of the procedure, and (4) be administered for the shortest effective period.

For most patients undergoing aesthetic procedures, the preferred antimicrobial agent is a first-generation cephalosporin such as cefazolin (1 gm IV).  Increase the dose if the patient weighs more than 160 pounds (approximately 80 kg) --  the dose of cefazolin may be increased to 2 g IV.

A second dose of antibiotics should be given IF the surgical procedure lasts more than three to five hours or if the patient has lost a significant amount of blood (greater than or equal to 1500 mL).

Patients with a beta-lactam allergy may receive clindamycin or vancomycin.  If used, remember their longer half-lives if redosing is necessary (clindamycin every four to six hours; vancomycin every six to 12 hours).

Vancomycin may be given for surgical prophylaxis in facilities with a high incidence of methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-resistant coagulase-negative staphylococci. Guidelines recommend against the routine administration of vancomycin for antibiotic prophylaxis.

……

The authors not strategies to prevent MRSA SSI are controversial, but current guidelines from the CDC and the Society for Healthcare Epidemiology of America recommend against routine universal screening for MRSA.

The authors suggest that until more data are available to support routine active surveillance and decolonization among patients undergoing plastic and reconstructive surgery, these interventions should be reserved for patients who are colonized with MRSA or are known to have had an MRSA infection in the past.

As I posted last week, when decolonization is deemed appropriate:

• Nasal decolonization with mupirocin twice daily for 5–10 days.
• Nasal decolonization with mupirocin twice daily for 5–10 days and topical body decolonization regimens with a skin antiseptic solution (eg, chlorhexidine) for 5–14 days or dilute bleach baths. (For dilute bleach baths, 1 teaspoon per gallon of water [or ¼ cup per ¼ tub or 13 gallons of water] given for 15 min twice weekly for 3 months can be considered.)

 

Antibiotic prophylaxis should be given prior to surgery to achieve tissue and serum concentrations that will produce bactericidal levels at the time surgical incision is made.  Most antibiotics should be administered within 60 minutes before incision. If fluoroquinolones or vancomycin is indicated, the infusion should begin 120 minutes before incision. If a proximal tourniquet is required for the surgery, the entire antibiotic dose should be administered before the tourniquet is inflated.

The authors point out that prolonged courses of antibiotics given for prophylaxis have not shown benefit as compared to a single dose of prophylactic antibiotics.  The SIP project endorses cessation of antibiotics within 24 hours of the end of surgery.

What about if a drain(s) is placed?  I, like many surgeons were trained to continue antibiotics for as long as the surgical drains are in place.  The authors point out:  “there is a lack of evidence to support this practice in aesthetic surgery.” 

The SIP project guidelines recommend against continuing antibiotic prophylaxis for the duration of surgical drain placement for orthopedic and cardiothoracic procedures.   It should be noted that antibiotic therapy is appropriate when the surgical drain is placed for therapeutic drainage of an infected space or abscess.

REFERENCE

Prophylactic Antibiotics in Aesthetic Surgery; Lane, Michael A., Young, V.Leroy, Camins, Bernard C.; Aesthetic Surgery Journal November/December 2010 30: 859-871

Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project; Bratzler DW, Houck PM; Clin Infect Dis 2004;38:1706-1715.

Management of multidrug-resistant organisms in health care settings, 2006; Siegel JD, Rhinehart E, Jackson M, Chiarello L;  Am J Infect Control 2007;35(suppl 2):S165-S193.

L-Brachioplasty – an Article Review

 Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

With the increase number of patients receiving weight-loss surgery, there is has been an increase in those asking for procedures to remove the remaining excess skin such as panniculectomy, abdominoplasty, lower body lift, brachioplasty (arm lifts), and thigh lifts.

The scars involved in brachioplasty surgery are not a good trade-off if there is minimal skin excess or looseness.  These individuals are better served by upper arm exercises to increase the muscle mass.

Brachioplasty (arm lift) is defined as the removal of excess skin and subcutaneous tissue to reshape the upper arm (axilla to elbow). (photo credit)

The L-brachioplasty described in the Hurwitz article from the July/August 2010 issue of the Aesthetic Surgery Journal addresses significant excess upper arm skin and the excess which often extends to the chest wall lateral to the breasts (photo credit).

The article very clearly described the procedure from the beginning to middle to end to postoperatively.  If you do brachioplasty surgeries, it is an article worth reading.

The operative time for each arm is approximately 40 minutes. The incisions are covered with sponge dressing and then wrapped in ACE bandages (BD, Franklin Lakes, New Jersey) with the hands elevated. The sponges and bandages are removed and replaced with tightly fitting elastic sleeves five days postoperatively.

Hurwitz mentions 13 women and two men were treated over the past four years using this procedure.  Complications included one seroma (treated by aspirated on one occasion) and incision dehiscence limited to less than 1 cm in five patients.  No patients had contractures across the axilla. 

Most insurance companies (as with Aetna and Cigna) consider brachioplasty surgery a cosmetic procedure.


REFERENCES

L-Brachioplasty: An Adaptable Technique for Moderate to Severe Excess Skin and Fat of the Arms; Hurwitz, Dennis J., Jerrod, Keith; Aesthetic Surgery Journal, July/August 2010 30: 620-629;  doi:10.1177/1090820X10380857

Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. Sep 1995;96(4):912-20.

Arm Lift Photo Gallery from Sean Younai, MD, FACS

Families and Plastic Surgery

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I read this article by Colin Stewart , Spouses often are jerks about plastic surgery (link removed 3/2017), a few weeks ago.  Since then I have been thinking about not just the husbands but families in general I see in my practice.  Remember I practice in Little Rock, Arkansas not Hollywood but I still find this to be true and not just of husbands.

Husbands of plastic surgery fans have a sensitive role to play.

It’s a challenge that most of them fail. Instead of communicating effectively and caringly with their wives about plastic surgery, husbands tend to act like jerks or wimps.

I think often the patient may also fail in communicating effectively to her spouse, significant other, family, and friends why she feels the need to have cosmetic/plastic surgery.  In defense of the spouse and others, it can be a mind-field.  After all, you don’t want to suggest your loved one is less than perfect with her small breasts or her saddle bags or the bat wings or her father’s nose or …..

It is easier for me to ask the question “why do you want to have ____?” in my office.  There’s less judging, not the same emotional baggage.  The individual is less likely to feel rejection from me if I suggest she re-examine her reasons or discuss them more fully with me.

I want the individual to be the one who initiated the visit to my office.  I certainly don’t want a pageant mom to bring in her daughter for liposuction or breast augmentation anymore than I want a husband to push his wife into having larger breasts.

The article mentions

The wimpy approach.

“You look wonderful, dear,” they say. “You don’t need any work done, but if it makes you happy, go ahead.”

The in-control approach.

Many other husbands go to the other extreme and become dictators. They demand their own way, whether it’s pro- or anti-plastic surgery.

It’s much nicer for all involve when the patient and her/his family discuss the options with respect for each other.  Some family members are anti-surgery because of fear of losing the person when they change themselves.  Some are anti-surgery because of the fear of losing the loved one to a complication of anesthesia or the surgery itself.

When those fears are voiced, the individuals can address the emotions.  Marriage counseling is often a better solution than surgery.  Bigger breasts won’t necessarily keep the husband from leaving for the younger woman.  And, yes, some women pre-plan their cosmetic surgery before the divorce.

Certainly a family member’s fear of losing the loved one to a death related to potential risks of surgery/anesthesia need to be addressed.  Complications happen.  Deaths happen, fortunately rarely, but they do happen.

The desired improvements must be weighed against those risks.  The patient (and her family) must be realistic regarding expectations. 

The article describes a successful discussion between a patient and husband.  She gave voice to specific reasons for desiring the surgery.  He voiced his concern.  They both listened to each other.  She won him over.

When Rinna began considering lip-reduction surgery to remove the scar tissue, she expected Hamlin to object, and she was right.

Plastic surgery is “never a good thing, in my opinion,” he told People magazine. “Plastic surgery is just an extension of that whole ‘let’s stay fresh and young’ vibe.”

She said, “I knew Harry would say, ‘Don’t touch it, don’t mess with it.’ He was like, ‘Maybe you should just leave it alone.’ He loves me the way I am.”

But she told him how important the operation was to her and what it was like to be the butt of never-ending snarky comments about her lips.

Family discussions can help the patient to be honest with herself regarding her reasons and expectations.

Injectables Roundup

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I have come across some interesting articles recently regarding injectables.  Let’s begin the non-controversial one: Behind the Lines by Linda W. Lewis, Nov/Dec 2010 MedEsthetics (pp 32-.  This one notes several filler discontinuations:

Johnson & Johnson (jnj.com) withdrew porcine collagen-based Evolence in November 2009; Allergan (allergan.com) discontinued its human and bovine collagen fillers, CosmoDerm, CosmoPlast, Zyderm and Zyplast, late last year and will stop distribution by the end of 2010.

The article mentions the latest filler introductions:

Juvederm XC from Allergan and Restylane-L and Perlane-L from Medicis (medicis.com).  These products differ from their predecessors only in the addition of lidocaine to the formulations.

Much greater changes are on the horizon, however, as manufacturers seek approval for exciting new products like Novabel (Merz Aesthetic, merzaesthetics.com) and Aquamid (Contura, aquamid.com).

The article also mentions that some physicians are using Restylane SubQ in buttock and breast enlargements.  This leads me to the next article (full reference below):   Macrolane(TM) for breast enhancement: 12-month follow-up.  The Swedish study used a new formulation of a stabilized hyaluronic acid-based gel of non-animal origin (NASHA(TM)-based gel) called Macrolane(TM) VRF30) in their open-label, multicentre, non-comparative study.

The aim of this study was to develop a reproducible technique for injecting NASHA-based gel posterior to the mammary gland (subglandular injection), and to assess treatment safety and efficacy. The feasibility of dual-plane submuscular injection was also explored.

Twenty-four non-pregnant, non-breastfeeding women (mean age 37 years) with small breasts were recruited, 20 of whom underwent subglandular injection.   Patients were treated in groups of four to enable step-wise revision of the injection technique. Safety and efficacy assessments (12-month follow-up) included adverse event (AE) reporting and the Global Esthetic Improvement Scale, respectively.

It’s a small study with the authors reporting 83% satisfaction in the post-procedure breast appearance at 6 months, 69% at 12 months.  I find it interesting that the most commonly reported adverse event was capsular contracture.   Obviously,  larger studies are needed before this can be routinely recommended to patients.

……………………….

Dentist are “pushing” their scope of practice beyond the teeth/dentition to include Botox and fillers.   While dentists may know how to do injections well and should know facial nerve/muscle anatomy well, I personally feel this is beyond the definition of dental practice.  I suppose it will be up to state dental and medical boards to work this out.

 The Evolving Role of Dentist in the Injectables Business by Jeff Frentzen, PSP Blog  leads you to the full article: The next revolution in dentistry: facial injectables by Bruce G. Freund, DDS, Oct 25, 2010.

REFERENCE

Macrolane(TM) for breast enhancement: 12-month follow-up; Per Hedén; Plastic & Reconstructive Surgery: POST ACCEPTANCE, 14 October 2010; doi: 10.1097/PRS.0b013e318200ae57; Original Article: PDF Only

ISAPS Plastic Surgery Survey

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active.

The International Society of Aesthetic Plastic Surgery (ISAPS) is celebrating it’s 40th anniversary.  To commemorate the event ISAPS commissioned a global survey of plastic surgeon and procedure in the top 25 countries and regions. 

The ISAPS Biennial Global Survey involved survey participants completing a two‐page, English‐based questionnaire that focused on the number of surgical and non‐surgical procedures they performed in 2009.  Approximately 20,000 plastic surgeons were sent the survey and then reminders.  Unsure what percentage responded.

Breast augmentation has been the most popular plastic surgery procedure for the last ten years in the United State.  This study found that liposuction has gained that spot.  The study found that the top five procedures in the U.S are liposuction (18.8%), breast augmentation (17%), eyelid lifts (13.5%),  rhinoplasty (9.4%),  and abdominoplasty  ( 7.3%).

The popularity of surgical procedures varied by country.

The top 25 countries and their top two surgical procedures:
1. United States (1st -- liposuction, 2nd -- breast augmentation)
2. Brazil (liposuction, breast augmentation)
3. China (breast augmentation, liposuction)
4. India (liposuction, breast augmentation)
5. Mexico (breast augmentation, blepharoplasty)
6. Japan (liposuction, breast augmentation)
7. South Korea (breast augmentation, liposuction)
8. Germany (liposuction, blepharoplasty)
9. Italy (liposuction, breast augmentation)
10. Russia (liposuction, breast augmentation)
11. Turkey (breast augmentation, liposuction)
12. Spain (liposuction, breast augmentation)
13. Argentina (breast augmentation, liposuction)
14. France (liposuction, breast augmentation)
15. Hungary (liposuction, blepharoplasty)
16. Canada (breast augmentation, liposuction)
17.  Colombia  (liposuction, breast augmentation)
18. United Kingdom (liposuction, breast augmentation)
19. Taiwan  (breast augmentation, liposuction)
20. Venezuela (liposuction, blepharoplasty)
21. Thailand (breast augmentation, liposuction)
22. Australia (blepharoplasty, rhinoplasty)
23.  Portugal (liposuction, breast augmentation)
24.  Belgium  (liposuction, breast augmentation)
25.  Saudi Arabia (breast augmentation, liposuction)

The study found the number of non-surgical procedures topped the surgical procedures.  The top five non surgical procedures were found to be Botox injections (32.7%), hyaluronic acid injections (20.1%), laser hair removal (13.1%), autologous fat injections (taking a patient's fat from one location and transferring it in the same patient in another location) (5.9%) and IP Laser treatment (4.4%).

Cosmetic Surgery -- Not Always Pretty

Updated 3/2017 -- photo and all links removed as many no longer active.

 

H/T to Berci who shared this article from Power of Data Visualization: Crazy Facts About Plastic Surgery


[Via: Medical Coding]

Neurotoxins: Dysport and Botox

 Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Medscape has a nice CME article on neurotoxins (activity expired, link removed 3/2017), Dysport^® and Botox^® Cosmetic. Dysport is abobotulinumtoxinA. Botox Cosmetic is onabotulinumtoxinA. Dr Monheit begins with the interesting history of botulinum toxin.

1895: Clostridium bacterium identified

1940s: BoNT-A purified (Schantz and colleagues)

1950s: BoNT-A mechanism of action elucidated

1970s: BoNT-A investigated as a treatment for strabismus (Dr. Alan B. Scott)

1979 Botulinum neurotoxin type A was approved by the FDA [US Food and Drug Administration] and became a registered mechanism for use in ophthalmology. It was called Oculinum at first.

1987: Dr. Jean Carruthers notices effect on the glabella when treating patients with BoNT-A for blepharospasm.

1989: Botox approved by FDA for the treatment fo strabismus and blepharospasm (originally approved under the brand name Oculinum)

1992: Dr. Jean Carruthers and Dr. Alastair Carruthers publish seminal paper on the use of BoNT-A for the aesthetic treatment of glabellar rhytides.

2002: Botox Cosmetic approved by FDA for the treatment of glabellar rhytides.

2009: Dysport approved by FDA for the treatment of glabellar rhytides.

Dr. Monheit then procedes to describe the science beginning with the molecule itself and the subtypes. He points out that the active neurotoxin protein at 150 kD is the same for both Botox and Dysport. It is the surround complex that is different.

We have in the botulinum toxin molecule a heavy chain (100 kD) and a light chain (50 kD). It's actually the light chain that is responsible for the nicking and the final cleavage that occurs.

Upon absorption into the body, the complex disassociates, and we're left with the bare neurotoxin molecule.

As we understand the science and the technical variables, such as the neurotoxin protein at 150 kD, the hemagglutinin and nonhemagglutinin proteins, the difference in the complex sizes -- 300 kD and 900 kD (depending on whether we're talking about the Botox^® molecule or the Dysport^® molecule)..

Dr. Monheit proceeds to go through the clinical trials and tips/cautions for proper use of the neurotoxins. You can either listen to his lecture or read the transcript. I found it to be an enjoyable lecture.

The central difference between Dysport^® and Botox^® Cosmetic is the dosage units. The units of measurement for the 2 botulinum neurotoxin A products are proprietary measures that are different for each product. The injection points for the 2 products do not differ significantly, and the toxin molecules have the same molecular weight. Differences in onset of action have not been demonstrated in clinical trials.

One of the important things for you to feel comfortable with is the dilution [you] can [or] should use. As you know, as you add more saline, or dilute it more, you do get more spread. You also have more volume that you're putting in. The dilution used for all of the clinical studies was 1.5 mL. Many people are comfortable with 2.5 mL. In Europe, they're using either 2.5 or 1.5 mL, giving the number of units you see in both Botox^® and Dysport^® [units]. But rather than try to translate these units back and forth, you should learn to live in the units you're working with and learn the language of the units you're treating.

REFERENCE

Neurotoxins: Now and in the Future; Medscape article, Sept 9, 2009; written by Gary D. Monheit, MD (free registration required)

(Bo)Tax on Elective Surgery

Updated 3/2017--  all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

I agree with all who feel there needs to be healthcare reform (or more honestly health insurance reform), but I don’t agree with Senator Harry Reid who feels one way to pay for it is by taxing elective surgery. 

This proposed tax has been dubbed the Bo-Tax and was first mentioned back in the summer.  Then it was proposed as a 10% tax on elective and cosmetic procedures.  Now it is proposed as a 5% tax on those procedures.

As defined by the Internal Revenue Code of 1986, "Any procedure which is directed at improving the patient's appearance and does not meaningfully promote the proper function of the body or prevent or treat illness or disease."  These procedures would be the target of the proposed tax.

The price tag for the proposed bill (here in pdf ) is reported to be $849 billion over 10 years, according to the nonpartisan Congressional Budget Office.   The costs are reported be offset by reductions in the growth of Medicare and new taxes (including the bo-tax).

Mr. Reid’s bill (text available here) is expected to extend health insurance coverage to 31 million people who currently do not have any and add new benefits to Medicare.  So why should anyone who can pay for elective or cosmetic procedures care?  They are all wealthy, right?

Wrong.

Even though Americans may spend more than $10 billion each year on cosmetic surgery, most of these patients are female (86%) and most of them are middle income not the wealthy.  At least a third of them have incomes less than $30,000 per year.  Many of them have borrowed money to pay for the tummy tuck or breast augmentation or excision of excess skin (after lap band).  Many in this last group (the massive weight loss group) have to pay for the excision of the skin which hampers than hygiene or ambulation because their insurance won’t cover it (usually a rider or the way the policy is written).  Refer back to the definition of cosmetic surgery—surgery for this last group often does improve function of the body by making ambulation easier or hygiene better.

So now instead of borrowing $5000 or $10,000, the patient will need to borrow an added 5% to pay the federal tax.  This then will be subject to the interest on the loan.  It is a tremendous burden added to the wrong population.

I would agree with Malcolm Roth of the American Society of Plastic Surgeons, and a plastic surgeon at Maimonides Medical Center in Brooklyn, N.Y., who feels that such a a tax "would be a discriminatory tax against women."

I also object to the fact this tax would turn me into a tax collector.  If I don’t collect the tax from the patient, then I become liable for it.

COLLECTION.-Every person receiving a payment for procedures on which a tax is imposed under subsection (a) shall collect the amount of the tax from the individual on whom the procedure is performed and remit such tax quarterly to the Secretary at such time and in such manner as provided by the Secretary. "(3) SECONDARY LIABILITY.-Where any tax imposed by subsection (a) is not paid at the time payments for cosmetic surgery and medical procedures are made, then to the extent that such tax is not collected, such tax shall be paid by the person who performs the procedure.". (this section shall apply to procedures performed on or after January 1, 2010.)

If you would like to add you name to a petition apposing the botax, go here.

ASPRS Press Release:  Plastic Surgeons Respond To Proposed Cosmetic Surgery Tax

Internal US Technique Treats Hyperhidrosis—an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

This was suppose to simply be an article review. I was intrigued by the potential of using ultrasound (US) to damage the sweat glands when I read this article in the August issue of Cosmetic Surgery Times. I even went back and read the Aesthetic Plastic Surgery Journal article referenced, but I have gotten sidetracked by this photo. It troubles me.

See how it is labeled an intra-operative photo? Notice the surgeon is wearing what appears to be a large jeweled ring under her sterile glove. Who wears jewelry in the OR??? That’s not proper sterile technique!

Intra-operative photo shows application of internal ultrasound therapy to damage the sweat glands. (Photo credit: Sharon Giese, M.D., F.A.C.S.)

In the article Dr. Giese states the procedure uses the heat energy of the ultrasound liposuction to “presumably kills the sebaceous glands. Permanently." No biopsies done to know for sure. No starch– iodine testing to quantify the decrease in sweat.

Dr Giese reports good results with her patients, but doesn’t quantify the number of patients. She reports that all the women no longer need deodorant. She reports that one male has had 65% reduction in sweating which can now be controlled by deodorant.

In looking further into the technique I found two more recent articles (the 3rd and 4th below).

In the 4th article, the researchers had 13 patients (3 males, 10 females) with significant axillary hyperhidrosis which they treated with the VASER ultrasound and followed for 6 months. Eleven of 13 patients had significant reduction in sweat/odor with no recurrence of significant symptoms at 6 months. Two patients had a reduction in sweat/odor but not to the degree they desired. No significant complications were noted. They report the complete procedure takes less than 1 h to treat two axillae using local anesthetic.   Once again, no objective measures of sweating.

I remain intrigued with this procedure, but would love more scientific measures and studies.  Still, I suppose the patients only care about the subjective measures when it comes to sweating.

REFERENCES
Internal ultrasound technique treats hyperhidrosis; Cosmetic Surgery Times, Aug 1, 2009; Donley-Hayes, Karen

Very Superficial Ultrasound-assisted Lipoplasty for the Treatment of Axillary Osmidrosis; Aesthetic Plast Surg. 2000 Jul-Aug;24:275-279; Park S

Characteristics of Refractory Sweating Areas Following Minimally Invasive Surgery for Axillary Hyperhidrosis; Aesthetic Plast Surg, Volume 33, Number 3 / May, 2009; Falk Georges Bechara, Michael Sand and Peter Altmeyer

Treatment of Axillary Hyperhidrosis/Bromidrosis Using VASER Ultrasound; Aesthetic Plast Surg, Volume 33, Number 3 / May, 2009; George W. Commons and Angeline F. Lim

Use of Zafirlukast for Capsular Contracture

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I first read of the off-labeled use of zafirlukast back in 2002.  I had one patient with a unilateral Baker’s Grade IV capsular contracture who wanted to avoid surgery (open capsulectomy).  I told her it wasn’t proven (only 30 patients) but that half experienced softening of their capsules.  I went over the possible side-effects of the drug with her.  She wanted to give it a try.  So I prescribed  zafirlukast 20 mg twice daily for 3 months.  She responded with softening of her capsule.  After 3 months she asked for a refill to try to achieve more softening.  She now had a Grade II-III capsular contracture.  I agreed.  It softened to a Grade II and she was happy.  

I now have another patient who is in the same state.  I have decided to try to review the literature and see if the early study has been confirmed.  The first six articles referenced below are the ones I found.  All were small in number, ranging from 20-120 human patients or 40 rats. 

The last article cautions us to remember the adverse side effects which can sometimes be worse than the problem being treated.  In this case – liver injury with zafirlukast.  Dr James L. Baker, Jr in a commentary (7th article referenced below -- 3/2017 link removed as no longer active) gives this caution:

The effectiveness of Accolate and Singulair in treating
capsular contracture remains anecdotal. It is quite  possible that while acting as an antagonist against the
leukotriene receptor, Accolate and Singulair may in reality work as a histamine receptor site antagonist and cause the relaxation of the myofibroblast, with improvement in capsular contracture in some patients. However, the increasing evidence of an association between treatment with Accolate and liver dysfunction in patients with asthma, as reported by Dr. Gryskiewicz, is a powerful argument against widespread off-label use of asthma medications to treat capsular contracture without further investigation. In addition to liver toxicity, Churg-Strauss syndrome (systemic eosinophilic vasculitis) has been reported with both drugs, more frequently with Singulair. This syndrome can have permanent ramifications, including limitation of lifestyle.

Surgeons treating patients for benign conditions with
medications carrying potentially lethal side effects should thoroughly advise patients of the off-label status and the serious risks. I discourage the use of Accolate and Singulair in the treatment of capsular contracture until such time as we can prove through laboratory research exactly how these drugs work on the myofibroblast and capsular tissue and better determine the risk-reward ratio of the therapy.

The six articles which looked at the effectiveness of zafirlukast for treating capsular contracture while noting the positive response in many of their patients also note that further studies need to be done.

Conclusions

Zafirlukast appears effective in treating early capsular contracture after primary submuscular breast augmentation using saline-filled, smooth-walled implants. Further prospective studies with control groups and long-term follow-up will be needed to address many unanswered questions, including whether leukotriene inhibitors have long-term effects on capsular contracture following breast augmentation.

If this patient and I decide to proceed with zafirlukast treatment, I will be sure she is aware of the potential side effects (minor and major) of the drug.


REFERENCES

1.  A new treatment for capsular contracture. (Letter to the editor);  Aesthetic Surg. J. 2002; 21: 164-165; Schlesinger SL and Heck RT.

2.  Zafirlukast (Accolate): A new  treatment for capsular contracture;  Aesthetic Surg. J. 2002; 22: 329-336; Sclesinger SL, Ellenbogen R, Desvigne MN, Svehlak S, and Heck R. 

3. The effect of zafirlukast (Accolate) on early capsular contracture in the primary augmentation patient: A pilot study; Aesthetic Surgery Journal, Volume 25, Issue 1, Pages 26-30 (January 2005); R.Reid, S.Greve, L.Casas

4.  The Effects of Zafirlukast on Capsular Contracture: Preliminary Report;  Aesthetic Plastic Surgery, Volume 30, Number 5, October 2006 , pp. 513-520(8); Scuderi, Nicolò; Mazzocchi, Marco; Fioramonti, Paolo; Bistoni, Giovanni

5.  Effects of zafirlukast on capsular contracture: controlled study measuring the mammary compliance; Int J Immunopathol Pharmacol 2007 Jul-Sep; 20(3):577-85; Scuderi N, Mazzocchi M, Rubino C

6.  Reduction of Capsular Thickness around Silicone Breast Implants by Zafirlukast in Rats; Eur Surg Res 2008;41:8-14 (DOI: 10.1159/000121501); A. Spano, B. Palmieri, T. Palmizi Taidelli, M.B. Nava

7.  Investigation of accolate and singulair for treatment of capsular contracture yields safety concerns;  Aesthet Surg J. 2003 Mar;23(2):98-101; Gryskiewicz JM

Recent NPR Stories on Plastic Surgery

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I want to say these two stories were well done (both aired on June 1, 2009).  I was actually interviewed, but not quoted, for the story on fat-grafting.  I pointed Allison Aubry to Dr Scott Spear as her expert.  He is involved in one of the U.S. studies on breast augmentation using fat grafting. 

Sculpting the Body with Recycled Fat by Allison Aubry.

Doctors Still Unsure Of Long-Term Risks

Surgeons like Dr. Scott Spear of Georgetown University Hospital want to know more about the techniques used to transfer fat for breast augmentation.

"We're at the beginning of the learning curve," he says. He has initiated a clinical trial to answer some questions about the best way to perform the procedure and whether there are any measurable risks. To date, there are no published studies in the United States, so doctors are relying on their own clinical experience.

Silicone Injections May Harm Some Patients by Patti Neighmond

When people get injected with silicone at pumping parties, Gorton says "there is no way to verify if they're using medical-grade silicone. You can go to hardware stores and buy a big tub of it," he says. "The element is the same, but it's just not the same safety or purity or quality."

My past related posts:
How Not to Do Buttocks Enhancement
Short Cuts to Beauty?
Fat Injections for Breast Augmentation
Complications After Autologous Fat Injections to the Breast – an Article Review

Short Cuts to Beauty?

 Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Interesting article recently in the New York Times written by Anemona Hartocollis and Christina Davidson, A Cheap, Fast and Possibly Deadly Route to Beauty  (April 16, 2009).  The article reports on how an increasing number of people are participating in “pumping parties” which use illegal silicone injections for cosmetic purposes.

The injections are administered at home, in motel rooms, in makeshift offices or at “pumping parties,” where the guests take turns injecting one another, officials said.

Silicone injections are not legal in the United States.  It’s use is considered by the FDA as a violation of Federal law as the use of liquid silicone injections “does not have an approved application for marketing or currently approved investigational exemption to permit scientific study. Liquid injectable silicone has been regulated as a device by FDA since 1976. It was previously regulated as a drug.”

There are many side effects that can occur which are being overlooked by the participants in the parties or maybe not even discussed with them.  These side effects include:

• uneven distribution of the silicone resulting in a lumpy or nodular appearance
• development of localized infections
• formation of granulomas
• silicone pneumonitis (rare, when large quantities are used)
• silicone embolism  (rare)

Many who perform this injections at the “pumping” parties are not physicians or even medically trained individuals.  And  medical grade silicone is not used in all cases.

Industrial-grade silicone can be bought at a hardware store. But Dr. Graber said there have been reports of the use of substitutes like castor oil, mineral oil, petroleum jelly and even automobile transmission fluid.

I would encourage anyone looking to have liquid silicone injections to NOT do so.  If you ignore that advise, then perhaps look for a well trained physician who used medical grade liquid silicone.  You at least will have less likelihood of complications that way.

Related Posts
How Not to Do Buttocks Enhancement
Medical Lasers and the Law
Medical Spa Regulations


Sources
List of Legal Injectable Fillers (FDA)
Lip Augmentation; eMedicine article, November 12, 2008; Jorge I de la Torre, MD, FACS
Face: Liquid Silicone Injections ASAPS — Position Paper
A History of Silicone Infections (pdf) by Dr Robert Yoho