Panniculectomy Prior to Renal Transplantation -- an Article Review

Updated 3/2017 -- all links removed (except to my own posts) as many no longer active.


There is an interesting article in the current edition of the Plastic & Reconstructive Surgery Journal (December 2011). The focus of the article is a small subset of renal patients who need kidney transplants but whose abdominal panniculus excludes them due. A significant panniculus creates an infrapannicular area prone to increased moisture, skin maceration, and elevated bacterial counts, predisposing the patient to postoperative wound infections, necrosis, and dehiscence. Not good for anyone, but really not for someone on immunosuppression.

The article discusses the use of abdominal panniculectomy in these patients in preparation for the transplant. Nine patients , 3 men and 6 women, with a mean age of 54.5 years and a mean BMI 28.3 are the focus of the article. The focus is not a cosmetic abdominoplasty but a functional panniculectomy, most often of just the lower abdominal excess skin and not addressing the area above the umbilicus.

It must be remembered that this is a high-risk group by definition: ESRD, requiring a kidney transplant. Mean length of hospital stay of 1.75 days. No one required blood transfusions. All patients were followed postoperatively for 3 months. Complications included an abscess and a skin dehiscence treated with local wound care.




REFERENCE
Panniculectomy in Preparation for Renal Transplantation: A New Indication for an Old Procedure to Reduce Renal Transplantation–Associated Wound Complications; Kuo, Jennifer H.; Troppmann, Christoph; Perez, Richard V.; Wong, Michael S.; Plastic & Reconstructive Surgery. 128(6):1236-1240, December 2011; doi: 10.1097/PRS.0b013e318230c7b8Abstract

Shout Outs

Updated 3/2017 -- all links removed (except to my own posts) as many no longer active.


My thanks to @jordangrumet for this tweet.  It gave me the motivation I needed to sit down and write.  I have lacked it lately, unsure where my blog is headed with the job transition, not wanting to lose contact with my fellow bloggers.  So thanks, Jordan. 

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Glass Hospital is the host for this week’s Grand Rounds.  You can read this week’s edition here.

Welcome to Grand Rounds, where writers, readers, and bloggers send in their best stuff on a weekly basis to share, cross-pollinate, and build new audiences.

Tip of the hat to Grand Rounds co-creator Nick Genes, MD, PhD, an ER doc in NYC who knows a thing or two about blogging, tweeting and now Tumblr.

a timeless and inspiring read...

The theme of this week’s Grand Rounds is “Finding Meaning in Medicine,” with full attribution to Dr. Rachel Naomi Remen, author of the masterful book Kitchen Table Wisdom: Stories that Heal.  …………..

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H/T to @medicallessons who tweeted about this very unusual medical case in the NEJM:  Disappearance of a Breast Prosthesis during Pilates (includes images)

A 59-year-old woman with a history of breast cancer who underwent bilateral mastectomy and placement of breast prostheses presented for evaluation, reporting that her “body swallowed one of the implants” during a Pilates stretching exercise ….

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Another plastic procedure gone awry documented in a NEJM case report (h/t to @Neil_Mehta):  Blindness after Fat Injections

A 32-year-old man presented with vision loss in the left eye. one week earlier, while under local anesthesia, he had had an autologous fat injection into his forehead for correction of glabellar frown lines. The patient reported that while he was receiving the injection, he felt a sudden, severe periocular pain and had complete vision loss in his left eye. …..

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I found out via a Christmas card I received last week that a classmate from medical school was diagnosed with early mild cognitive impairment(mci) amnestic type last December.  He began writing a blog to chronicle his journey as he progresses towards Alzheimer's disease:  organicgreendoctor. 

He was a Family Practice doc before he retired.  He was/is a super nice guy.

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TBTAM has finally (smile) gotten around to giving us a list recommended NYC Restaurants

Home cooking is what I do best. And yet, the most frequent e-mail request I get from readers, friends and family is – “Where should we eat when we come to New York?”  And so, after years of wracking my brain for recommendations, I decided to create a list here of the places I go to and like. Some I’ve reviewed here on the blog – Most I have not (even though I have dozens of pics  and the best of intentions). But let me be clear – I am not a restaurant connoisseur. I’m just an ordinary New Yorker who knows what she likes. …..

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I never get around to reading all the books recommended to me, but still…  Here’s a list from Seattle Times reviewers:  32 of the year's best books

………Here are the results — 32 books, 21 fiction (who says the novel is dead!?), 11 nonfiction. Top vote getters were three novels, "The Sense of an Ending" by Julian Barnes, "The Marriage Plot" by Jeffrey Eugenides and "Ed King" by David Guterson, and Erik Larson's work of nonfiction, "In the Garden of Beasts." ……..

DVT Prophylaxis – Two Articles

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


There were two articles regarding deep venous thrombosis prevention in the November 2011 issue of the Plastic and Reconstructive Surgery Journal.  Both are worth reading.  I have supplied the full references below with links.

From the second article:

Between 1 and 7 percent of surgeons have personally experienced a venous thromboembolism–related patient death after high-risk plastic surgery.  Plastic surgeons' self-reported practice patterns indicate a disparity between clinical understanding and clinical practice. The majority of surgeons can identify patients at high risk for postoperative venous thromboembolism. However, examination of their self-reported practice patterns indicates that a substantial proportion of surgeons (>50 percent) provide inadequate levels of venous thromboembolism prophylaxis for high-risk patients.  In addition, surgeons recognize modifiable venous thromboembolism risk factors (such as oral contraceptive use) but may fail to modify those factors before surgery. 

“Never event” is a poor descriptor for venous thromboembolism, as it implies that all events are potentially preventable. Breakthrough venous thromboembolism events routinely occur in the face of rigorous protocols and criterion-standard prophylaxis, as has been reported in the plastic surgery, orthopedic surgery, and general surgery literature. We observed multiple breakthrough events in the Venous Thromboembolism Prevention Study enoxaparin group, although the distinct causes of these events remain unclear. Unrecognized hypercoagulability has been identified as a major contributor to venous thromboembolism risk.  Venous Thromboembolism Prevention Study data support the belief that a prior personal history of venous thromboembolism is an important risk factor as well (Table 3).

Venous thromboembolism represents a financial burden for patients and payers. The mean cost of hospitalization for an index deep venous thrombosis event is over $20,000.   Previous work has shown that enoxaparin is a cost-effective method of venous thromboembolism prevention.  In July of 2010, the U.S. Food and Drug Administration approved production of enoxaparin in generic form, which should result in substantially decreased costs to patients.

For a complete overview of venous thromboembolism in plastic surgery, we refer readers to two excellent reviews that have recently been published by Miszkiewicz and colleagues and Venturi and colleagues. These reviews built on the foundation of several outstanding reviews and consensus statements published previously.

I added the references mentioned in the last paragraph to the section below.  DVT prevention is important.  It can be done safely.  It needs to be done.


Related Posts:
Deep Venous Thrombosis Prevention  (June 19, 2007)
DVT Prevention (June 4, 2008)
Prevent Pulmonary Thromboembolism – an Article Review (February 23, 2009)
DVT Screening and Prevention (February 3, 2010)

REFERENCES

1.  Changing Practice: Implementation of a Venous Thromboembolism Prophylaxis Protocol at an Academic Medical Center; Pannucci, Christopher J.; Jaber, Reda M.; Zumsteg, Justin M.; Golgotiu, Vlad; Spratke, Lisa M.; Wilkins, Edwin G.; Plastic & Reconstructive Surgery. 128(5):1085-1092, November 2011; doi: 10.1097/PRS.0b013e31822b67ff

2.  Postoperative Enoxaparin Prevents Symptomatic Venous Thromboembolism in High-Risk Plastic Surgery Patients; Pannucci, Christopher J.; Dreszer, George; Wachtman, Christine Fisher; Bailey, Steven H.; Portschy, Pamela R.; Hamill, Jennifer B.; Hume, Keith M.; Hoxworth, Ronald E.; Rubin, J. Peter; Kalliainen, Loree K.; Pusic, Andrea L.; Wilkins, Edwin G.; Plastic & Reconstructive Surgery. 128(5):1093-1103, November 2011; doi: 10.1097/PRS.0b013e31822b6817

3.  Miszkiewicz K, Perreault I, Landes G, et al.. Venous thromboembolism in plastic surgery: Incidence, current practice and recommendations. J Plast Reconstr Aesthet Surg. 2009;62:580–588.

4.  Venturi ML, Davison SP, Caprini JA. Prevention of venous thromboembolism in the plastic surgery patient: Current guidelines and recommendations. Aesthet Surg J. 2009;29:421–428.

5.  McDevitt NB. Deep vein thrombosis prophylaxis. American Society of Plastic and Reconstructive Surgeons. Plast Reconstr Surg. 1999;104:1923–1928.

6. Davison SP, Venturi ML, Attinger CE, Baker SB, Spear SL. Prevention of venous thromboembolism in the plastic surgery patient. Plast Reconstr Surg. 2004;114:43E–51E.

7. Young VL, Watson ME. The need for venous thromboembolism (VTE) prophylaxis in plastic surgery. Aesthet Surg J. 2006;26:157–175.

Shout Outs

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

David, Health Business Blog, is the host for this week’s Grand Rounds. You can read this week’s edition here.

Welcome to the latest edition of the Grand Rounds blog carnival, the weekly roundup of medical blog posts!

The Blog That Ate Manhattan kicks us off with the Meaningful Use Song, surely the most antic entry I’ve ever hosted. Can’t beat the zippy refrain “I am the model user of an EMR that’s meaningful.” ………….

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Have you discovered Joanna Cannon’s blog yet? Here’s a nice post: Abor Vitae

The oak tree was worn and tired and sat in a field, where it waited to die.

“I have lived my life,” said the oak tree, “I have felt the seasons turn beneath my roots and I have watched the years unfold and spill themselves through my branches. Now it is time for me to move on.”

The other trees were distressed and pleaded with the oak tree to stay. ……

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bongi, other things amanzi, has a new post after a hiatus: physician, heal thyself

even doctors get sick, but there is often a difference.

i was rotating through orthopaedics and was on call that night. …... once i had finished operating i rushed through the change rooms to get back to casualties. while i was changing i heard the unmistakable sounds of someone throwing up in the toilet cubicle. quite soon the door opened and out came the orthopaedic registrar who was on call that night with me. he did not look good……….

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My friend Elizabeth, Methodical Madness, has a nice post: Fan Mail

I've had a handful of readers over the past couple of years e-mail me to ask me questions about pathology and advice about medicine but no one, until last Thursday, has ever prefaced their question as "Fan Mail." I was tickled pink. A first year medical student from a far away institution asked this, and kindly allowed me to answer in a post:

"My question for you is, are there times when you wished non-pathologist physicians remembered more about histology? What would you like them to know?"

The short answer is this: NOTHING. ……….

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H/T to @hrana for the link to the Wall Street Journal article by Robert Johnson: Plastic surgery is on the rise among older Americans

Mary Lou Ray decided at age 65 that she had seen enough of the person in her mirror.

"My life led up to this. I had been divorced for 13 years, my children were grown, and with the death of my mother—not to be unkind—I was finally free of criticism about things like dyeing my hair," she says.

So last year she spent $13,000 on a face lift and other cosmetic procedures that proved rejuvenating.

"I'm absolutely thrilled," says Ms. Ray, a real-estate agent in Roanoke, Va. "I think a lot of friends in my age bracket would like to try this, but they're afraid of getting that unnatural, yanked-up look. I don't have that; I still look like me." ……..

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H/T to @DrVes for the link to the Lancet article: Haemorrhagic herpes zoster 

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Check out this NPR article by Adam Cole: Visualizing How A Population Grows To 7 Billion   

Body Contouring Not Common After Bariatric Surgery

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

A study on this topic was presented at the recent American Society of Plastic Surgeons (ASPS) annual conference in Denver.   The article is also in the October issue of the Plastic and Reconstructive Surgery journal (reference #2 below).

The article notes that more than 220,000 bariatric procedures are done annually in the United States.  This number (IMHO) is likely to increase as these procedures have become an major tool in the treatment of obesity which now affects a third of adults in this country.

Massive weight loss, regardless of whether by bariatric procedure or by diet/exercise, will often leave the individual with excess skin.  This excess skin can be both a cosmetic and functional issue for the individual.

Jason Spector, MD and colleagues designed their study to “explore demographic features and patient education regarding body contouring procedures in the bariatric surgery population.”

Their study consisted of a survey mailed to 1,158 patients who underwent bariatric surgery between 2003 and 2011. Two hundred eighty-four patients responded (24.5%). 

Of the responders, 97.2% had their bariatric procedure covered by insurance.  Only 72 of the responders (25.4%) reported having discussed body contouring surgery with their bariatric surgeon.  Only 40 (14.1%) were referred for a plastic surgery consultation.

Only 33 (11.6%) actually had body contouring procedures done at the time of the survey.  The article does not mention what percentage of these procedures were covered by insurance verse considered self-pay.  I have found it infrequent that insurance will actually pay for removal of excess skin resulting from massive weight loss after a bariatric procedure.  It is a battle to prove the health issues (rashes, skin infections, mobility/comfort issues depending on where the excess skin is located, etc).

The article does note that the most frequent reasons cited for not undergoing body contouring surgery were expense (29.2%) and lack of awareness (23.6%). 

Body contouring after massive weight loss is a mixture of cosmetic and non-cosmetic.  Sometimes it is clearly one or the other, more often it is a combination. 

Spector states (in the press release), "Many massive weight loss patients suffer large amounts of loose, sagging skin as a result of their rapid weight loss that, if not removed, can cause rashes, wounds, infection, and limit comfortable mobility.  It is apparent that insufficient counseling at the time of bariatric surgery is obscuring viable body contouring options for these patients."

Yes, counseling is important, but if the individual can not afford it and insurance doesn’t cover it then the percentage of patients having the body contouring procedures isn’t likely to change.

REFERENCES

Many Would Remove Loose Skin if Informed of Options, Insurance Covered Procedures, Study Reveals; ASPRS press release, 09/21/2011

Body-Contouring Following Bariatric Surgery: How Much Is Being Done?; Reiffel, Alyssa J.; Jimenez, Natalia; Millet, Yoann H.; Dent, Briar L.; Lekic, Nikola; Burrell, Whitney A.; Pomp, Alfons L.; Dakin, Gregory F.; Spector, Jason A.; Plastic & Reconstructive Surgery. 128():12-13, October 2011; doi: 10.1097/01.prs.0000406221.46933.5a

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. ………….

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)

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

Dr. Ralph Millard,

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

Dr. D. Ralph Millard (1919-2011) is known in the plastic surgery community for his contribution to improved surgical techniques for the correction of cleft palates.  He died Sunday, June 19, 2011. (photo credit)

PSNews tribute:  Plastic surgery pioneer D. Ralph Millard Jr., MD, dies at age 92
NBC Miami tribute:  Cleft Palate Pioneer Ralph Millard Laid to Rest

……He trained more than 180 young, and not so young, men and women in whom his legacy is entrusted.  The “Chief,” as he was known to his residents at the University of Miami, was an exacting task master, an elegant surgeon and a consummate teacher.  His surgical greatness cannot be denied, but his most profound legacy may be as a teacher of Plastic Surgery.  Through the gift of his text books and manuscripts he tried to pass on to all Plastic Surgeons his vision of our specialty.  ……

The Millard technique or the rotation-advancement cleft lip technique (photo credit)

Dr. Millard was a “giant” in plastic surgery who will be missed.  My condolences to his family.

REFERENCES to just a few of Millard’s articles (full bibliography)
1.  Millard DR Jr. Rotation-advancement versus Giraldes’ cleft lip technique. Plast Reconstr Surg Transplant Bull. 1961;28:595-7.
2.  Millard DR Jr. Refinements in rotation-advancement cleft lip technique. Plast Reconstr Surg. 1964;33:26-38.  (pdf file)
3.  Millard DR Jr. Rotation-advancement principle in cleft lip closure. Cleft Palate J. 1964;12:246-52.
4.  Millard DR Jr. The unilateral cleft lip nose. Plast Reconstr Surg. 1964;34:169-75.
5.  Millard DR Jr. Closure of bilateral cleft lip and elongation of columella by two operations. Plast Reconstr Surg. 1971;47(4):324-31

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

Update: Stem Cells and Fat Grafting

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

Here are a few new items on stem cells and fat grafting I’ve come across recently. 

First are a couple of nice posts by fellow plastic surgeon/blogger Dr. Thomas Fiala, the Orlando plastic surgery blog who is attending The Aesthetic Meeting 2011 in Boston this week.

Live from Boston: Fat grafting controversies !!  (May 6, 2011)

……It's pretty clear that fat grafting works, and can be done safely. There seem to be two major methods that work……

One bit of consensus: if the breast was not pre-expanded, you can't expect to get more than 100 cc of fat to survive.

ASAPS 2011: Best of Hot Topics (May 9, 2011)

Here are my choices for the "Hot Topics" presented at the Boston ASAPS meeting:

1. "Stem Cell Facelift" - Dr. Peter Rubin reviewed the literature on the so-called Stem Cell facelift. It turns out that there really is no consistent technique for this method. Many advertised "stem cell facelifts" are simply regular facelifts with regular fat grafting and don't involve any extra stem-cell work at all. Furthermore, to date, there is NO DATA that this technique is superior to facelift with standard fat grafting. Summary: as of today, the stem cell facelift can either be considered unproven and under development, or if you are a little more cynical, it might just be "marketing hype".

The review by Rubin was highlighted in a press release:   ASAPS and ASPS Issue Joint Position Statement on Stem Cells and Fat Grafting on Monday, May 9, 2011.

….. Based on the current state of knowledge, the task force made the following recommendations to ASAPS/ASPS members and their patients:

•     Terms such as "stem cell therapy" or “stem cell procedure” should be reserved to describe those treatments or techniques where the collection, concentration, manipulation, and therapeutic action of the stem cells is the primary goal, rather than a passive result, of the treatment. For example, standard fat grafting procedures that do transfer some stem cells naturally present within the tissue should be described as fat grafting procedures, not stem cell procedures.
•     The marketing and promotion of stem cell procedures in aesthetic surgery is not adequately supported by clinical evidence at this time.
•     While stem cell therapies have the potential to be beneficial for a variety of medical applications, a substantial body of clinical data to assess plastic surgery applications still needs to be collected. Until further evidence is available, stem cell therapies in aesthetic and reconstructive surgery should be conducted within clinical studies under Institutional Review Board approval, including compliance with all guidelines for human medical studies.  ………….

And the last item comes from the PRSonally Speaking Blog:  Articles of Interest Sneak Peak: Breast fat grafting with platelet-rich plasma: a comparative clinical study and current state of art.  It highlights the abstract of an article which will be published in the PRS journal in June 2011.

The role of Platelet-Rich Plasma (PRP) in enhancing fat grafts take is attracting the scientific community. However, there is a lack of clinical series on the matter.

The aim of this paper is to report Authors' experience in breast fat graft with and without PRP and to investigate the state-of-art on adipose tissue PRP enrichment……

Conclusion: In Authors' retrospective analysis no effect of PRP was seen in enhancing fat graft take when compared to Coleman fat graft. Further research and prospective clinical studies are strongly needed to understand the role of PRP, if any, in fat grafting.

Screening Prior to Cosmetic Breast Surgery – an article review

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

How are we plastic surgeons with screening prior to cosmetic breast surgery?  This article from November 2009 (full reference below)  reviews this topic.  Note this survey was done prior to the release of the new USPSTF guideline recommendations for screening mammograms the same month.   I wonder if a new survey would have different outcomes.

The article reports on a study which looked at breast cancer screening practices of American plastic surgeons (self-reported) and the degree to which those practices adhere to the American Cancer Society guidelines.

The study was conducted using an online survey of the members of the American Society of Plastic Surgeons over a 5 month period (January 2008 to May 2008). The 20 multiple-choice questions were designed to assess physician practice composition and familiarity with American Cancer Society guidelines, and to ascertain specific practices for preoperative evaluation and breast cancer screening in patients seeking aesthetic breast surgery. The survey comprised four components: general practice information, breast cancer screening practice, criteria for obtaining breast cancer screening, and criteria for further evaluation of breast cancer risk.

There were 1094 respondents (out of 4520 society members), so only a 24% response rate.   Twenty-eight responses were excluded because these surgeons responded that they do not do breast surgery, do not operate, are pediatric surgeons, are retired, or work with cancer patients only on an initial screening question.

Of the 1066 included respondents, 82% were male and 73% were in private practice.  The participants were roughly evenly distributed with respect to total years in practice, and a majority of surgeons performed augmentation mammoplasty, reduction mammoplasty, and mastopexy (96%).

In total, only 47% appeared to follow the American Cancer Society guidelines.  Only 64% claimed familiarity.

Not all responders always reviewed risk factors preoperatively in their aesthetic breast surgery patients (only 89%), nor did all responders always perform a clinical breast examination preoperatively (86%).

• 89% of respondents claimed that they obtain mammographic screening based on age
• 57% claimed to do so based on positive family history, regardless of age
• 61% stated they followed the ACS screening guidelines, 61 percent stated that they did follow the guidelines
• 24% stated that they did not know the guidelines

Seventy-five percent (n = 799) of plastic surgeons considered a mammogram within 1 year to be valid, whereas 15% (n = 166) stated that this was age dependent.

The authors concluded:

Breast cancer is a major public health problem, for which screening is at least part of the solution. Plastic surgeons are in a unique position to screen women who may not otherwise receive screening. Knowledge of the American Cancer Society guidelines is an essential component of effective cancer screening, but unfortunately only somewhat more than half of plastic surgeon respondents who perform breast surgery have knowledge of these guidelines. Being male predicted more accurate knowledge of the guidelines, but being female resulted in more aggressive screening, and possibly more diagnoses. Familiarity with the American Cancer Society screening guidelines also resulted in a greater number of perioperative diagnoses. As plastic surgeons, we have an obligation to actively participate in the health and well-being of our patients, and this involves understanding and applying good breast cancer screening practices.

Related posts:
New Breast Cancer Screening Guidelines  (November 17, 2009)
The New Mammogram Guidelines - What You Need to Know (December 27, 2009; TBTAM)
Screening Mammogram Recommendations (January 7, 2010)
USPSTF Breast Screening Guidelines Pushback  (January 26, 2011)



REFERENCE

Breast Cancer Screening Prior to Cosmetic Breast Surgery: ASPS Members' Adherence to American Cancer Society Guidelines; Selber, Jesse C.; Nelson, Jonas A.; Ashana, Adedayo O.; Bergey, Meredith R.; Bristol, Mirar N.; Sonnad, Seema S.; Serletti, Joseph M.; Wu, Liza C.; Plastic & Reconstructive Surgery. 124(5):1375-1385, November 2009; doi: 10.1097/PRS.0b013e3181b988c4

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

Are Patients Making Good Decisions About Breast Reconstruction?

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

An outcomes article in the January 2011 issue of the Journal of Plastic and Reconstructive Surgery asks the question:  Are Patients Making High-Quality Decisions about Breast Reconstruction after Mastectomy?

The objective of the study was to “measure women's knowledge about reconstruction and to evaluate the degree to which treatments reflected patients' goals and preferences.”

Their conclusion (bold emphasis is mine):

Women treated with mastectomy in this study were not well-informed about breast reconstruction. Treatments were associated with patients' goals and concerns, however, and patients were highly involved in their decisions. Knowledge deficits suggest that breast cancer patients would benefit from interventions to support their decision making.

Granted the study was small, but it left me wondering if we the medical community fails to educate these women.  

The study involved a cross-sectional survey of early-stage breast cancer survivors from four university medical centers.  The survey included measures of knowledge about specific reconstruction facts, personal goals and concerns, and involvement in decision making.   Only 84 patients participated (59% response rate).

Participants answered only 37.9% of knowledge questions correctly.

 

Here are the general information questions asked in the survey with the correct answers: 

1.  In general, which women are more satisfied with their breast
reconstruction --those who have reconstruction at the time of the mastectomy or who have delayed reconstruction?

They are both equally satisfied (only 33.3% of the women surveyed knew this)

2.  After which type of breast reconstruction are women more satisfied with the look and feel of the reconstructed breast—implants or flaps?

Flaps (only 15% knew this)

3.  Mark whether or not it is true for breast reconstruction with an implant -- uses fat and tissue from other parts of the body to make a breast.

Answer is false. (only 13.1% knew)

4.  Mark whether or not it is true for breast reconstruction with a flap -- usually requires more than one surgery.

Answer is true. (only 28.6% knew)

5.  Which breast reconstruction surgery is easier on the body, that is, heals faster? 

Implants are easier (only 57.1% knew this)

6.  Of every 100 women who have breast reconstruction, about how many will have a major complication, such as needing hospitalization or an unplanned procedure, within 2 years?

The answer is 25–50.  (only 3.6% knew the correct answer)

7.  How does breast reconstruction affect future screening for breast cancer?  

It has little or no effect on finding cancer  (only 35.7% knew this)

 

 

Which is right for you depends on many things. 

Are you a candidate for flap surgery and if so which is best for you – TRAM, Latissimus Dorsi, etc. 

What kind of recovery time are you willing to put up with?  Recovery from flap surgery is longer than for implant surgery

Does the thought of having a foreign body (implant) in your body bother you?  If so, then put up with the longer flap recovery time and forgo the implants.

Ask to talk with other patients who have been through the surgery, preferably with your surgeon.  They can tell you better than we can about recovery (ie the little things that can make life miserable or better).

 

 

REFERENCES

1.  Are Patients Making High-Quality Decisions about Breast Reconstruction after Mastectomy? [Outcomes Article]; Lee, Clara N.; Belkora, Jeff; Chang, Yuchiao; Moy, Beverly; Partridge, Ann; Sepucha, Karen; Plastic & Reconstructive Surgery. 127(1):18-26, January 2011.doi: 10.1097/PRS.0b013e3181f958de

2.  Determinants of Patient Satisfaction in Postmastectomy Breast Reconstruction; Alderman, Amy K.; Wilkins, Edwin G.; Lowery, Julie C.; Kim, Myra; Davis, Jennifer A.; Plastic & Reconstructive Surgery. 106(4):769-776, September 2000.

3.  Sacramento Area Breast Cancer Epidemiology Study: Use of Postmastectomy Breast Reconstruction along the Rural-to-Urban Continuum; Tseng, Warren H.; Stevenson, Thomas R.; Canter, Robert J.; Chen, Steven L.; Khatri, Vijay P.; Bold, Richard J.; Martinez, Steve R.; Plastic & Reconstructive Surgery. 126(6):1815-1824, December 2010.; doi: 10.1097/PRS.0b013e3181f444bc

4.  Patient Satisfaction in Postmastectomy Breast Reconstruction: A Comparative Evaluation of DIEP, TRAM, Latissimus Flap, and Implant Techniques; Yueh, Janet H.; Slavin, Sumner A.; Adesiyun, Tolulope; Nyame, Theodore T.; Gautam, Shiva; Morris, Donald J.; Tobias, Adam M.; Lee, Bernard T.; Plastic & Reconstructive Surgery. 125(6):1585-1595, June 2010.; doi: 10.1097/PRS.0b013e3181cb6351

VIPS Guidelines for Providing Surgical Care

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

No this VIPS doesn’t stand for “very important person” or the famous (local or national) person you might care for in your practice.   I think it is best to try to treat everyone with the same standards of care.  Similar to the checklist that Atul Gawande has brought to the public eye, this keeps you from “missing” something or not providing some important aspect of care.  The Cleveland Clinic Journal of Medicine had a nice article by Dr. Jorge Guzman recently on this topic:   Caring for VIPs: Nine principles

…….

In this case, VIPS stands for “volunteers in plastic surgery.”  

The online site of the Journal of Plastic and Reconstructive surgery has an article discussing the guidelines for VIPS who provide surgical care for children in the less developed world.

The guidelines were developed by the Volunteers in Plastic Surgery (VIPS) Committee of the ASPS/PSEF  in conjunction with the Society for Pediatric Anesthesia (SPA).

This document is not intended to represent a standard that must be followed by everyone performing this work in developing countries.  Locations, circumstances, and needs may vary greatly depending on the site.  Rather it is intended to provide a framework for providers involved in the care of children in the less developed world.

The guidelines can also be found here as a pdf file:  Guidelines for the Care of Children in the Less Developed World. 

The VIPS program stresses working in conjunction with the local plastic surgeons by invitation and proper planning with a mission/purpose for the trip.  Adhere to high standards of quality of surgery, care, and teaching.  Be sensitive to host needs and customs.  Be a Good Guest!

 

 

 

 

REFERENCE

Volunteers in Plastic Surgery (VIPS) Guidelines for Providing Surgical Care for Children in the Less Developed World; Schneider, William J.; Politis, George D.; Gosain, Arun K.; Migliori, Mark R.; Cullington, James R.; Peterson, Elizabeth L.; Corlew, D. Scott; Wexler, Andrew M.; Flick, Randall; Van Beek, Allen L.; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 8 February 2011; doi: 10.1097/PRS.0b013e3182131d2a

The Role of Humanitarian Missions in Modern Surgical Training; Campbell, Alex; Sherman, Randy; Magee, William P.; Plastic & Reconstructive Surgery. 126(1):295-302, July 2010; doi: 10.1097/PRS.0b013e3181dab618

Photography in Medicine

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

Fellow blogger Sterile Eye recently did a post on the historical use of mirrors in photos of wounded soldiers.  At the time I was reading an article in the journal Advances in Skin & Wound Care (full reference below) on wound photography.

Photography, not only in wound care, but in many areas of medicine/surgery (before and after photos, changes in hemangiomas, etc) is important.  As the article points out, if more than one person is to be responsible for taking these photos it is equally important that practice standards be implemented and adhered to.

The authors created a wound photography performance checklist to ensure consistency.   In addition to the patient’s name, wound evaluator’s name, and date, here are a few (not all) of the critical items on the checklist:

• Confirm patient has written consent for wound photographs on approved hospital consent form.  [This could apply to any medical photograph and any location, ie office.]
• Explain procedure to the patient and/or caregiver.
• Place camera case on hard, clean surface, avoiding floor or patient care items.
• Record patient information on customized photo label to include patient initials, medical record number, date, wound number, and location.  [Body part or hemangioma or nevus could substitute for wound.]
• Place the patient in a comfortable position to expose the wound for picture.  [Use consistency of position as suggested in pdf from ASPRS for photography in plastic surgery.]
• Apply customized photo label to the border of the wound for photograph.  [Could do this for nevi or skin lesion photos, but not for breast/abdomen photos.]
• Wash hand and remove camera from carrying case while maintaining appropriate infection control practices.  Avoid using gloves when handling camera.

The American Society of Plastic and Reconstructive Surgeons (ASPRS), along with the Plastic Surgery Educational Foundation(PSEF) and Canfield Imaging Systems have put together a really nice brochure (pdf file) as a reference.  Once again, consistency is key to having photos that can be used to assess change from growth,  healing, or surgery, etc.

The brochure show standard position when taking photos of the face, the ear, the breasts, the abdomen, the hip/thigh, the leg/foot, the hand, the forearm, and the finger.

Consistency in key.  Changes can be more reliably measured when consistency in position, distance (camera to patient), lighting, makeup (same or none when photographing the face) is maintained.

The ASPRS brochure offers these additional tips which are nice.  Sometimes photos will be taken in different locations (an ER documenting the initial injury, the office for followup) so lighting and background may be different.  Optimally:

• Use an appropriate backdrop.  Photograph patients against a solid-colored background. Light to medium blue is a good choice because it contrasts well with skin tones.  Medium gray
  may also work well.  Use a fabric drape or other non-reflective material.
• Remove distractions.  Jewelry and clothing create an unnecessary distraction in patient photos.  They should be removed from the area of interest prior to photography.For
  body photos, it is advisable to use special modesty garments (available from medical supply dealers) instead of the patient’s underwear.
• Use controlled lighting.  Patients should be photographed using a flash system or studio strobes (available room lighting is not appropriate).  Balanced cross-lighting (i.e., two strobes positioned symmetrically on either side of the camera) brings out surface texture without creating shadows that are overly harsh.
• Reduce cast shadows.  The use of balanced lighting with diffusers can soften the shadows cast by the patient.To completely eliminate cast shadows, one or two additional lights may be aimed directly at the backdrop.
• Record settings.  As much as possible, the same camera settings should be used for every patient. For settings that must be adjusted from patient to patient (such as exposure compensation), all values should be recorded, stored with the photos and referenced during post-op photography.

 

 

REFERENCES

Collaboration in Wound Photography Competency Development: A Unique Approach; Bradshaw, Leah Marie; Gergar, Margaret E.; Holko, Ginger A.; Advances in Skin & Wound Care. 24(2):85-92, February 2011; doi: 10.1097/01.ASW.0000393762.24398.e3

Photographic Standards in Plastic Surgery; ASPRS, PSEF, 2006 (pdf file)

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

BDD Patients Can Get Better

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

The Science Daily article, Body dysmorphic disorder patients who loathe appearance often get better, but it could take years, discusses the The Journal of Nervous and Mental Disease (JNMD) article (full reference below, abstract available for free).  

The JNMD article reports the results of the longest-term study so far to track people with body dysmorphic disorder.  The study was conducted by researchers at Brown University and Rhode Island Hospital.

The good news:  the researcher “found high rates of recovery, although recovery can take more than five years.”

This is a small study with only 15 BDD patients who were followed over an eight-year span.

After statistical adjustments, the recovery rate for sufferers in the study over eight years was 76 percent and the recurrence rate was 14 percent. While a few sufferers recovered within two years, only about half had recovered after five years.

The subjects were a small group diagnosed with the disorder out of hundreds of people participating in the Harvard/Brown Anxiety Research Project (HARP). Study co-author Martin Keller, professor of psychiatry and human behavior and principal investigator of the HARP research program which has been ongoing for more than 20 years, said that because the BDD sufferers were identified through this broader anxiety study, rather than being recruited specifically because they had been diagnosed with BDD, they generally had more subtle cases of the disorder than people in other BDD studies. In comparing the HARP study with the prior longitudinal study of BDD, it is possible that the high recovery rate in the HARP study is due to participants having less severe BDD on average.

Body Dysmorphic Disorder

• In its simplest definition, it is an obsessive preoccupation with a slight, imperceptible, or actually nonexistent anatomic irregularity to the degree that it interferes with normal adjustment within society.
  
• This disorder may be present in varying degrees. It is the most common aberrant personality characteristic seen by the plastic surgeon.
  
• When postoperative dissatisfaction occurs (and in most cases, it will), it almost always is based on what the patient understood rather than what was actually said.
  

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The Barbie Syndrome  (March 25, 2010)
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REFERENCE

The Clinical Course of Body Dysmorphic Disorder in the Harvard/Brown Anxiety Research Project (HARP); Andri S. Bjornsson, Ingrid Dyck, Ethan Moitra, Robert L. Stout, Risa B. Weisberg, Martin B. Keller, Katharine A. Phillips;  The Journal of Nervous and Mental Disease, 2011; 199 (1): 55 DOI: 10.1097/NMD.0b013e31820448f7

Body Dysmorphic Disorder; eMedicine Article, September 3, 2010; Iqbal Ahmed, MBBS and Lawrence Genen, MD, MBA