Ageism and Plastic Surgery

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

I admit that over the years my idea of “how old is too old” has changed.  Part of that is my increasing age, but a bigger part has come from the patients themselves – the 72 year old woman with a deflated NS implant who wanted it replaced rather than removed, etc.

Never Too Old for Plastic Surgery  (photo credit) By Tara Parker-Pope

If you think you’re too old for a few nips and tucks, consider the story of 83-year-old Marie Kolstad. ……….

To learn more, read Abby Ellin’s article “The Golden Years, Polished With a Nip and a Tuck,” …….

Don’t forget to read the comments of Parker-Pope’s article.

Still I have mixed feelings about what I see as not “aging gracefully” and tend to agree more with bioethicist Carl Elliott who is mentioned in Gary Schwitzer’s post:  Some reactions to NY Times' "Never Too Old for Plastic Surgery"

Minnesota bioethicist Carl Elliott wrote a book, "Better Than Well: American Medicine Meets the American Dream." In it, he wrote:

"We need to understand the complex relationship between enhancement technologies, the way we live now, and the kinds of people we have become."

I asked for his comment on the NY Times story, and he wrote:

"Everyone agrees that one root of the problem is toxic social pressures. The problem is that giving in to these pressures just reinforces them. The more cosmetic surgery older people get, the more social pressure that other older people feel to get the surgery themselves. (And articles like this just make the problem worse.)

Also, does anyone really think that cosmetic surgery actually makes these people look younger? What it really does is make them look as if they've had work done. And having work done is not so much a marker of youth as it is of money."

When is someone too old for plastic surgery?  There’s not an easy answer.  I think it comes down to an individual.  To their health.  To their reasons.  To their expectations. 

Related posts:
Suitability  (January 3, 2008)
“Suitable” for Plastic Surgery? (January 14, 2010)
Psychological Considerations of the Bariatric Surgery Patient Undergoing Body Contouring Surgery--An Article Review (September 22, 2008)

Rejection

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Doctor Richard Edwards, a chiropractor from Oklahoma and the nation's third double hand transplant, was recently in the news again.  This time it a report that he “may lose the fingertips on his right thumb and pinkie because his body started to reject the new limbs.”

Dr. Edwards’ surgery was live tweeted when it was done in August by Louisville surgeons at The Jewish Hospital Hand Care Center.

Jeff Kepner, the first patient in the United States to receive two hands simultaneously, experienced an episode of rejection which was dealt with successfully.

Rejection is never a good thing in a transplant patient not matter which organ or part transplant.  Even though I applaud the advances being made, we must always consider the cost of the proposed treatment and ask if there a better option for this individual?

Hand or arm transplantation is not possible for all.  A missing arm can bring (social) rejection to the individual as it did for this woman, Tammy Chinander (photo credit, shown with her daughter Krystal).  [H/T from @vpmedical]

The Rudd native lost her arm at the age of 2 when she caught it in a wringer washing machine. The arm was amputated above the elbow.

For years, she managed with an arm with a hook, but at the age of 31, she decided she was through with it.

"I got tired of it hanging there," she said. "It wasn't working. It looked bad. My son was scared of it."

 

The best choice for her turned out to be a German-manufactured Otto Bock DynamicArm, typically $75,000 to $100,000 in cost which will be paid by her insurance.

Chinander's goal is to get the new arm to work as well as her other arm. Right now, it takes serious concentration to use it.

"I'm going through the second part of my life learning to do everything two-handed," she joked.

…..Krystal could not hold back the tears as she described what it is like for them.

"Getting that first two-armed hug from your mom that you see all the other kids getting is really wonderful," she said.

 

 

REFERENCES

Hand Transplant Fact Sheet: History and Evolution of Hand Transplantation;  UPMC/University of Pittsburgh Schools of the Health Sciences 

Transplantation — A Medical Miracle of the 20th Century; Peter J. Morris, F.R.S.; N Engl J Med 2004; 351:2678-2680December 23, 2004

Immunosuppression and Rejection in Human Hand Transplantation; Schneeberger S, Gorantla VS, Hautz T, Pulikkottil B, Margreiter R, Lee WP;  Transplant Proc. 2009 Mar;41(2):472-5.

Longevity of SMAS Face Lift

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 think it is safe to say that all plastic surgeons have been asked, “How long will my face lift last?”  As pointed out, by Dr. Sundine and colleagues (first reference article) this question is difficult to answer using our current literature.  They tried to answer the question focusing specifically on the two-layer superficial musculoaponeurotic system (SMAS) face lift.

To do this, Sundine and colleagues conducted a retrospective chart review of 42 patients who underwent secondary face lifts performed by the senior author from January of 2001 to December of 2008. Patients who had their primary face lift performed by another surgeon were excluded.  The charts were reviewed for the dates of the initial surgery and subsequent operations, patient data, procedures performed, and complications. The patient photographs were also reviewed.

The average age at the time of the primary face lift was 50.7 years (range, 34.9 to 69.9 years), and the average age at the time of the secondary face lift was 61.9 years (range, 43.6 to 77.2 years).

The average length of time from the primary to secondary face lift was 11.9 years (range, 1.0 to 34.5 years). ….

One glaring shortcoming of the study is the failure of the authors to contact every patient the senior author performed a primary face lift (there were 299 during the time frame) to determine whether any patients received a secondary face lift with another surgeon.

So while the over-simplified answer may be “approximately 10 years,” there really is no simple answer.  Patients give many reasons for desiring a second facelift.  (second reference)

Readers of this article will already know that people have a universe of reasons for having a face lift. In practice, one commonly notes not only unhappiness with the mirror but also the loss of a spouse or the anticipation of finding one: the patient's social milieu and group dynamics (face lifts as a rite of passage). Some people perceive an advantage in finding or maintaining employment, all reasons that may have little to do with the face itself but with life conditions of the person requesting the procedure. In other words, subjectivity and life forces are major factors, and the decision to have such a procedure may have little relationship to how the patient actually appears.

Biological factors such as skin quality, facial weight, and the age at which the initial procedure is performed significantly affect both the quality of the initial result and its duration, and the same cultural and personal forces remain. There is no distinct tissue endpoint for undergoing a secondary lift, just as there is no distinct biological point at which a primary lift becomes “necessary.” With so many factors to be considered, the longevity of any type of face lift remains a difficult question to answer with any certainty.

In addition, to the above there are the constraints of life that may prevent a patient from returning for a desired facelift – poor health, financial concerns, family reasons, and perhaps even a poor experience the first time.

REFERENCE

Longevity of SMAS Facial Rejuvenation and Support; Sundine, Michael J.; Kretsis, Vasileios; Connell, Bruce F.; Plastic & Reconstructive Surgery. 126(1):229-237, July 2010.; doi: 10.1097/PRS.0b013e3181ce1806

Discussion: Longevity of SMAS Facial Rejuvenation and Support; Lambros, V.; Stuzin, J. M.; Plastic & Reconstructive Surgery. 126(1):238-239, July 2010; doi: 10.1097/PRS.0b013e3181dab6f3

The Measure of Face-Lift Patient Satisfaction: The Owsley Facelift Satisfaction Survey with a Long-Term Follow-Up Study [Outcomes Article]; Friel, M.T.; Shaw, R. E.; Trovato, M. J.; Owsley, J. Q.; Plastic & Reconstructive Surgery. 126(1):245-257, July 2010; doi: 10.1097/PRS.0b013e3181dbc2f0

Discussion: The Measure of Face-Lift Patient Satisfaction: The Owsley Facelift Satisfaction Survey with a Long-Term Follow-Up Study [Outcomes Article]; Pusic, A.L.; Klassen, A. F.; Scott, A. M.; Cano, Stefan J.; Plastic & Reconstructive Surgery. 126(1):258-260, July 2010; doi: 10.1097/PRS.0b013e3181dbba19

Patient Satisfaction Following Breast Reconstruction Using Implants

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

As more women turn to postmastectomy breast reconstruction, surgeons are beginning to look at outcomes.  Not simply safety and complications, but also patient satisfaction. 

A recent March 2010 article in the Journal of Plastic and Reconstructive Surgery (full reference below) looked patient satisfaction among women who had reconstruction using implants. 

The authors note that research in this field has been “hindered by the absence of an outcomes measure for use in evaluation of patient satisfaction and health-related quality of life (HRQoL).”

The BREAST-Q is a new questionnaire that specifically measures postsurgical body image and quality of life in the breast reconstruction patient.  The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (Br23) [EORTC QLQC30 (Br23)] is a cancer-specific questionnaire that incorporates a breast-specific module and measures overall functioning following breast cancer treatment. 

This study used these two questionnaires to evaluate patient satisfaction and health-related quality of life following alloplastic (implant) breast reconstruction and more specifically if the type of implant used (saline versus silicone) has an effect on health-related quality of life.

A chart review of University of British Columbia patients was performed, compiling data on the following demographic features: type of breast cancer, unilateral versus bilateral reconstruction, history of radiation or chemotherapy, complications, type of implant, follow-up time, age at second stage, timing of reconstruction, and comorbidities.

A total of 280 patients were identified. Sixteen patients were deceased and 17 patients had noncurrent addresses (neither responders nor nonresponders).  Out of the 247 “active” charts, there were 75 silicone implant recipients and 68 saline implant recipients who responded (an overall response rate of 58 %). Chart review was possible for 100 of the 104 nonresponders.

In this patient population, responses to the BREAST-Q indicated a statistically significant higher overall satisfaction with breast reconstruction, higher psychological well-being, higher sexual well-being, and higher satisfaction with surgeon for silicone implant recipients. This finding was maintained after adjusting for variables that differed between groups. In addition, radiation exposure and unilateral versus bilateral reconstruction were included in the regression analysis, as these variables were felt a priori to influence overall satisfaction with outcome.

…………….

Results using the EORTC QLQC30 showed no statistically significant difference on any subscale, with the exception of higher overall physical function in silicone patients and higher systemic therapy side effects in saline patients. This is a cancer-specific questionnaire that examines function and symptom severity in cancer patients. In general, condition-specific measures allow greater responsiveness to intervention-related change compared with generic outcomes measures.

The BREAST-Q was developed at the Memorial Sloan Kettering Cancer Center and the University of British Columbia.  This instrument measures health-related quality of life following breast surgery. The module used in this study was specific to breast reconstruction. This instrument encompasses six scales: (1) psychosocial well-being, (2) physical well-being, (3) sexual well-being, (4) satisfaction with breasts, (5) satisfaction with outcome, and (6) satisfaction with care.

The EORTC QLQC30 (Br23) was developed by the European Organization for Research and Treatment of Cancer at the Netherlands Cancer Institute.   This instrument evaluates health-related quality of life in cancer patients. The QLQC30 module incorporates nine scales (five functional, three symptom, and one global health-related quality of life).

The authors drew these conclusions:

Responses on a surgery-specific instrument show silicone recipients to have overall higher satisfaction with the reconstructed breast(s). After adjusting for age, follow-up time, radiation therapy, and unilateral versus bilateral surgery, silicone recipients scored an average of 64 points for overall satisfaction with breast while saline patients scored 57 points. Similar results were seen for sexual well-being, psychological well-being, and overall satisfaction with surgeon.

Findings using the EORTC-QLQC30 revealed no statistically significant difference in overall global health status. Thus, it may be concluded that increased satisfaction in silicone implant recipients found using the BREAST-Q is not equivalent to increased overall global health as measured by the EORTC-QLQC30. The findings of this study provide reliable data that will allow surgeons to adequately inform their patients preoperatively regarding the expected outcomes of breast reconstruction using silicone and saline implants.

REFERENCE

Patient Satisfaction and health-Related Quality of Life following Breast Reconstruction:  Patient-Reported Outcomes among Saline and Silicone Implant Recipients; Macadam, Sheina A.; Ho, Adelyn L.; Cook, E. F. Jr; Lennox, Peter A.; Pusic, Andrea L.; Plastic and Reconstructive Surgery. 125(3):761-771, March 2010; doi: 10.1097/PRS.0b013e3181cb5cf8