A little depressing medical economics for today.
A story in Tuesday's USA-Today hints at the looming financial catastrophe largely driven by federal Medicare & state Medicaid programs. As usual, politicians and bureaucracy are jockeying over the "lipstick on this pig" (ie. how it's hidden on the accounting sheet) rather then the problems and painful solutions itself by arguing for less transparent and accurate accounting practices to keep the books looking prettier. In fairness (I guess) the true numbers would affect interest rates for the worse for the US debt burden.



Bottom line: Taxpayers are now on the hook for a record $59.1 trillion in liabilities, a 2.3% increase from 2006. That amount is equal to $516,348 for every U.S. household. By comparison, U.S. households owe an average of $112,043 for mortgages, car loans, credit cards and all other debt combined. Unfunded promises made for Medicare, Social Security and federal retirement programs account for 85% of taxpayer liabilities.


The Financial Accounting Standards Advisory Board, which sets federal accounting standards, is considering requiring the government to adopt accounting rules similar to those for corporations. The change would move Social Security and Medicare onto the government's income statement and balance sheet, instead of keeping them separate. The White House and the Congressional Budget Office oppose the change, arguing that the programs are not true liabilities because government can cancel or cut them. Chad Stone, chief economist at the liberal Center on Budget and Policy Priorities, says it can be misleading to focus on the government's unfunded liabilities because Medicare's financial problems overwhelm the analysis. "There is a shortfall in Medicare and Medicaid that is potentially explosive, but that is related to overall trends in health care spending," he says.




Rob

New Beauty magazine's TestTube program



There's a novel subscription-based way to try out many of the newer over the counter and private line cosmetic skin treatments via a program from New Beauty magazine.

For about $30 a quarter, you get the TESTTUBE™ delivered to your door which contains about half a dozen products from major cosmetic companies and smaller boutique brands.

While there is good reason to be skeptical of the claims made by many (most) cosmaceutical products (read here), a program with such a modest outlay gives you a great way to test some of these products yourself. I actually just bought a subscription for my wife this morning!

BTW, I have no conflicts of interest to declare with New Beauty :)

Rob


New York Times columnist, Natasha Singer, features an overview of the issue of MRI surveillance of silicone breast implants in her style/health column on Friday. I read Natasha's columns frequently, especially when they mention me :)

I think the title "Implants Are Back, and So Is Debate." is a little misleading to someone who didn't read the story. The debate, in this case, is not in re. to safety but rather about how, when, & why we should be doing serial MRI's after implantation.

It's pretty clear that no one is embracing the non-binding FDA recommendations about MRI's after implantation, and if you know anything about the data on this topic and observe practice patterns/standards of care world-wide, you can see that the FDA position is more political CYA then evidence based medicine. Health Canada (the Canadian FDA equivalent) so much as said so when they released the last of their token restrictions one months prior to the United States.

One thing mentioned in the story which I've never heard of was the investigation of radio frequency (RFID) tags made by Novalert to be embedded in implants to warn of potential rupture. Unless these add only pennies to the cost of the device or obviate the need for MRI's, I see a lot of potential barriers to it being used (especially outside the USA).

An interesting way to finance your breast implants



Where a need in the market exists, someone will fill it. In an era where there are literally hundreds of ways to finance Plastic Surgery, I give you My free breast implants.com is a website that purports to be a "matchmaking" service between women who want breast implants and people who wish to "help them out" to pay for it. More than 1,000 women and more than 5,000 men donors are currently on the site, and an estimated 20 women have gotten free breast implants in the year that the MyFreeImplants has been up and running. The money goes directly from the Web site to the surgeons apparently with the webmaster taking a 10% commission.
"It works similar to any other social networking Web site like Facebook or Myspace. A guy signs up and a girl signs up they each create their own profile. They got their own bio. They got photos and basically you start trying to meet people on the Web site," founder Jason Grunstra said.

I guess it shouldn't be surprising when tens of millions will pay $1 per vote by phone to participate in the electoral college of American Idol that you'd get people contributing for people's cosmetic surgery they'd never met. Strange but (apparently) true.

Many of the major banks have watched the growth in cosmetic surgery, cosmetic dentistry, fertility medicine, and laser eye surgery with interest as well. Most of the big boys have divisions of their bank devoted specifically to this market. Oliver Plastic Surgery, for instance, uses Capital One Bank's program. These various programs give fairly favorable interest rates based on some calculus of your credit score.

Rob

I've seen the future.... and it's Richard Ellenbogen

There's a great,great interview with him about "volumetric facelifts" and fatty stem-cell injections on Make Me Heal that got me thinking. A reprint of a 2004 article on this concept from the Aesthetic Surgery Journal can be read on his website here.

Dr. Ellenbogen, who was famous within Plastic Surgery circles prior to his Dr. 90210 gig, has been an innovative visionary in my field since I was just out of diapers. I've never had the pleasure of meeting Dr. E, but the more I observe in practice, the more of his ideas about facial aging I find myself coming to independently. Dr. Tony Youn featured his mentor on his blog in April which can be read here.

Concepts of how facial volume loss (both fatty tissue and bony wasting) contribute to the aging face are becoming increasingly in vogue now in the Plastic Surgery literature. Dr. Ellenbogen has been preaching this for nearly two decades against a tide of "wind swept" facelifts as mocked in director Terry Gilliam's 1985 opus "Brazil" on actress Katherine Helmond.

Smart Money's "10 Things Your Plastic Surgeon Won't Tell You"


Props to Dr. DiSaia for pointing out out an article on Smart Money.com called "10 Things Your Plastic Surgeon Won't Tell You".

  1. "I trained a whole weekend to learn this procedure."
  2. "I make a mint off other surgeons' mistakes."
  3. "Sure, I can turn back the clock, but it just starts ticking again."
  4. "You'd be better off spending this money on a good therapist."
  5. "Of course I'm board certified — for what that's worth."
  6. "You can get this done for a fraction of the price overseas."
  7. "I make my living off the fat of the land — literally."
  8. "Long-term effects? Beats me."
  9. "Silicone's back — and putting my kids through college!"
  10. "Those who need surgery the most will benefit from it the least."

You can click the link above (or here) to read this in context. I've actually touched on many of these "dirty secrets" here on Plastic Surgery 101, most of which are neither dirty nor secret. They touch on the issue of who/what can call themselves a Plastic or Cosmetic Surgeon (which is pretty much anybody), prevalence of psychiatric disease among patients, & patient selection among other things.

I'd strongly disagree with their point #6, the breezy attitude towards having cosmetic surgery in 3rd world countries (aka "scalpel tourism"). Just briefly scan Google's newswire to find dozens or reports highlighting peril with this. There are just too many potential variables to endorse that. You want to be in a place where you have access to your doctor or an associate for complications. These can be devastating, especially with some of the body contouring and facial procedures.

Fair or not, a true "dirty secret" is that you're going to get a big red flag attached to you for having surgery in remote locations as a likely problem patient for showing such poor judgement in the first place. Good luck trying to find a doctor on short notice in the USA who is going to be rushing to take care of someone else's complication, particularly when it occurred overseas.

Plastic Surgery revolutions and the dreaded $100,000 coat-rack


New technologies have been flooding the Plastic Surgery market for the last 20 years at an impressive clip. During that period of time there have been a few revolutionary device, a lot of evolutionary changes in those devices, and some real clunkers that have faded (or are fading) into obscurity. Some of these technologies start as revolutions before fading to clunker-status.

The term "$100,000 coat-rack" refers to the significant cost of many of the devices pushed by industry to doctors and patients. Many of these after an initial rush of enthusiasm had a tendency to gather dust in the corner with their owner reminded painfully of how much capital they had invested in it.

One of the best surgeons and businessmen I know, Dr. Marc Salzman, (a Plastic Surgeon from Louisville), preached to me the risk/reward profiles of these devices. Basically, on the rat-race for latest & greatest, if you can't recoup your investment in the short-term, it will be obsolete as patients come in asking for the next device featured on Oprah or Cosmopolitan magazine.

A canny observation from Marc was that a reliable way to figure out the trends in what was out of favor with lasers was to look on Ebay (search terms like syneron, fraxel, thermage, lumenis, candella, or other vendors) and see what was getting dumped at large discounts by laser resellers or doctor's offices. One caveat I'd make for "Dr. Salzman's Ebay Rule" circa 2007 would be that as some medi-spas close or doctors dive into cosmetic laser-like devices, lose money, & liquidate is that you will find some. good technology available

REVOLUTIONS
1. the wound V.A.C. (vacuum assisted closure) device which has a monopoly in the multi-billion dollar vacuum wound care market.



2. laser skin resurfacing - originally with CO2 (and then erbium lasers)jump started the "minimally invasive" trend in the 1980's. Enthusiasm has waned significant however (see below) as downtime has become more of an issue to patients. Intense pulsed light (IPL) and "gentler" laser-like devices (fraxelated CO2, plasma, Radiofrequence, diode/pulsed dye lasers) are the flavor of the month, but are nowhere near as effective for deep wrinkles in a single treatment as CO2 lasers are.

3. BOTOX for animation wrinkles
4. Off the shelf injectables. Collagen was the initial clumsy product to be replaced by safer & longer acting hyaluronic acid products (Resetelene, Juvederm, & others)

5. Titanium plates and screws for rigid fixation of facial fractures. This was a quantum leap in precision and stable repair from previously used steel wires which were essentially "twist ties" hogging bone near the other fracture edge.


6. Tumescent liposuction - introduced from a French Plastic Surgeon over 25 years ago, this technique is continuing to find new applications and refinements. Adding fluid (tumescence) allowed safer, more predictable surgery then preceding attempts at liposuction. It's interesting that a famous liposuction case in the early 20th century where a French ballerina required bilateral leg amputations from complications stymied interest in this area for nearly 50 years. It's now routinely combined with surgical procedures like tummy tucks to enhance results.

OUT TO PASTURE TECHNOLOGY (or heading that way)


1. Endoscopic procedures - a few years ago you might have lumped this in the revolutionary category, but it is fairly rapidly being abandoned in most instances. Endo-brow lifts (the most common application) are felt by many surgeons (but not all) to be less effective, less precise, more expensive, & much less durable then open brow-lifts. FYI, the endo-brow was invented by some of my neighbors here in Birmingham Drs. Core & Vasconez, both of whom are real gentlemen and recognized experts in endoscopic techniques.

Endoscopy has stimulated a bunch of novel "mini" brow lifts, which incorporated some of the anatomic lessons we learned from endoscopic appproaches. As these techniques can be done under local without $20,000+ of endoscopic equipment, I think these hybrid procedures will become the norm as the pendulum swings towards more office-based surgery.

Endo-breast augmentation (which isn't that popular to begin with anymore) will fade into obscurity quickly I predict, as saline implants are used much less often. The recommended access incisions (~5 cm) for silicone gel implants are large enough that the resulting visible scarring (even of good quality) in the armpit won't be acceptable to patients. The soon coming form-stable ("gummy bear") gel implants from Allergan & Mentor require even bigger incisions and more precision in pocket disection to imagine many will push the envelope with endoscopic approaches.

2. traditional (ablative) laser resurfacing - as I mentioned above, CO2 lasers (along with liposuction & collagen) were the catalyst for minimally invasive procedures. However, patients in 2007 will no longer accept looking like a burn-victim for 3-4 weeks during the healing process. In addition, there have been a tremendous number of patients with uncorrectable hypo/hyperpigmentation reactions from resurfacing lasers and the skin also can take this odd-looking smooth,waxy look.

Plastic Surgeons got tired of being told that their revolutionary laser from 3 years ago is no good anymore by the same people that sold them their previous one. This happened frequently during the late 1980's thru late 1990's as the glow was off the original CO2 lasers. Older surgeons pointed to the fact that they can achieve similar (or better) skin resurfacing as CO2/erbium lasers using concentrated TCA or deep Phenol peels for about $5 worth of supplies (you've still got to deal with the "burn victim" look for a few weeks however with those kind of peels).


3. Ultrasonic liposuction (UAL) - heavily touted in the late 1990's, UAL had a spectacular fall from grace as it had higher complication rates, saved no time, and required expensive equipment as compared to traditional tumescent liposuction. Other then that, what's not to like? UAL is useful for dense fatty areas (upper back fat & male gynecomastia), but has been abandoned en masse by most surgeons. The $15,000 UAL machine at my hospital is gathering cobwebs and no one currently working there even remembers how to assemble or operate it at this point (I'm not kidding!).

4. Thread-lifts. One of the first posts in late 2005 on Plastic Surgery 101 was on thread lifts entitled, "The Jury is still out (on thread-lifts)". Well the jury is back and the fact that Quill medical has recently withdrawn the Countour Thread barbed suture from the market speaks volumes. It just didn't work, and when it did work, it didn't last was the consensus. For money approaching the cost of real-face/brow lifts the techniques for this currently are lemons. Newer suspension suture styles and materials may make us reevaluate this down the road.

5. Thermage - for a device costing nearly $100,000 plus expensive disposable parts, most doctors and patients expect results that don't require 75x magnification with Photoshop to demonstrate. I feel sorry for people who get up at meetings and show pictures of their results with Thermage only to have the audience of their peers squint at the picture trying to imagine something has happened.

In addition, it is notoriously painful during treatments and can have a tendency to cause facial fat to atrophy (as written up by blogging amigo Dr. Tony Youn). This (or thread lifts) has to be the most maligned and polarizing device I've ever heard of at Plastic Surgery meetings, leading the President of the Aesthetic Surgery Society (at the time) to mentioned at one of our meetings that he'd been trying to figure out ways to throw the device out his office window onto I-20 in Atlanta it was causing he, his partners, and his patients so much grief. Newer device settings have been proposed by the complany and some doctors who favor this device, which they claim will improve things. I'll believe it when I see it.

6. Trans-umbilical breast augmentation (TUBA) - most Plastic Surgeons think this is a flawed approach to begin with. The move towards silicone implants (which can't be placed this way without damaging them) will make this technique fade from knowledge in short order as no one learns it.


Israel has a substantial population of Russian Jews who emigrated over the last two decades. The Plastic Surgery division at Rebecca Seiff Government Hospital in Safed, has recently reported a series of patients with some unknown substance ulcerating thru their breast/chestwall skin. These women were injected years prior in Russia with some as yet unidentified substance

Dr. Kasis Shukri, an attending Plastic Surgeon said
"All we know about the material is from the women themselves, who say they were told at the time it is called 'Bio-Gel.' It is unknown to us, unknown, unidentified and unrecognized by modern medicine. It is completely undocumented in medical literature.... Yellow material with the texture of banana puree came out. The material had been injected directly into the tissues"


If I had to guess what this mystery substance is I would guess it might be hydrophilic polyacrylamide gel (PAAG), an injectable alloplastic biomaterial, imported from the Ukraine has been used for augmentation mammaplasty in China (click to read)& Southeast Asia. This material is profoundly inflammatory when injected and has been reported in a number of case reports of complications from "injectable breast augmentation" in some of the Asian medical literature.

Another more disturbing possibility was discussed in a quote in Israeli newspaper Haaretz

"Bio-Gel is a commercial product with no scientific significance," deputy chief of plastic surgery at Tel Hashomer Dr. Eyal Winkler told Haaretz yesterday. In the past, the Soviet medical establishment made various attempts to overcome a shortage of silicone implants, Winkler explained. "Due to the high price of the implants, there were various efforts to develop alternative methods, one of which was the injection of fats from cadavers into women's breasts. Nonetheless, this was on the margins of the margins, and the number of cases is extremely limited."

Winkler recommended that women who underwent such surgeries, and are concerned or feel unwell, be examined by an expert. "If they feel well, there is no reason to panic." Winkler said he has encountered just five cases of cadaver-fat injections causing infection and requiring surgical intervention in the past decade.

Plastic Surgery blogs


The syndicated New York Times piece out this last week on Plastic Surgery/aesthetic medicine blogs is the second story I've been interviewed for about about blogging.

The other, a cover story in Plastic Surgery News (a publication of the Amer. Society of Plastic Surgery) titled "Battle of the blogs Negative web logs targeting surgeons increasing – but tools to fight them are available." can be read full-text here.

While it's nice to be noticed, I think I'm characterized in the NYT as a little more Ralph Nader-ish then with the voice/tone that I actually write with. Over the next week or two, I think I'd like to touch on a few things that patients have misconceptions about when they come see a Plastic Surgeon.

Cheers!
Rob

Welcome New York Times readers


Plastic Surgery 101 merited mention in the New York Times Fashion & Style section of all places today. Click here to read.

Welcome all new visitors!
Rob Oliver Jr. MD

Plastic Surgery as a graduation gift



There's an article on MSN.com today "Way to go, grad! Here's a check for a new nose - Is cosmetic surgery an appropriate commencement gift for teens?" that's kind of interesting. It's a brief synopsis over the increasing trickle-down of Plastic Surgery procedures to teens which ballooned to 244,000+ procedures in 2006 (data form the Amer. Society of Plastic Surgeons (ASPS)), including about 47,000 nose jobs and 9,000 breast augmentations. The discussion mostly centers around teenage girls and breast surgery. The few teenage boys you see in a Plastic Surgeon's office usually have gynecomastia (excess male breast tissue).

The story of one of the the teens featured caught my eye,
When Courtney Powers graduated from high school last year, she didn’t receive a new computer or a trip to Europe. The North Carolina teen got a pair of D-cup breast implants.

“My breasts hadn’t grown since I was 16,” says Powers, who underwent cosmetic surgery two days after her 18th birthday. “I was a 36AA and my mom and dad knew I was very self-conscious
.”


Not to beat a dead horse, but in general, I'd consider the implant size (425-500+ cc) required to go from an A-cup to a D-cup to be a very,very poor choice for long term results in most women. Larger implants are both heavier and wider which dramatically accelerate "aging" of the breast tissue and skin. Ms. Powers' native horizontal and vertical boundaries and tissue attachments likely had to be violated to accommodate her implants, which is something best avoided when you can help it. Avoiding over-sized implants (particularly saline, as they're heavier) is the single most-effective thing you can do in breast surgery to minimize reoperation rates. Last year the perceived problem breast augmentation in teens by a prudish politician caused a mild political controversy in Australia, which I touched upon here.

Issues about the propriety of doing surgery on adolescents or young adults come up a good deal in our field as almost all these procedures are elective rather then absolutely necessary. It's a little patronizing to make blanket statements about older teens like Ms. Powers, as many of them are old enough to vote, marry, or serve in the military. With younger teens it becomes something to consider on an individual basis and becomes invested with a lot of gray area.

Is it appropriate to do teen surgery for breast reductions or reconstruction of congenital breast deformities (which often require implants)? Many feminists who decry cosmetic surgery in teens (or adults) would probably make exceptions for those patients despite the fact that those operations are often cosmetic (rather then functional). The ASPS position paper on elective breast surgery and other procedures recommends using 18 years old as a relative (but not absolute) guide for practice guidelines.

There's a little of the PC sentiment about inner beauty proffered in the article on MSN by Courtney Macavinta, author of “Respect: A Girl’s Guide to Getting Respect and Dealing When Your Line Is Crossed.”

"By giving teen girls, in particular, surgery we’re just sending this message to them that they can be anything they want to be — they can go to any school or do anything in life — as long as they look a certain way on the outside.

I’m all for taking a shower, combing your hair and getting a cute outfit, but there is only a tiny percentage of people whose profession and success rely on appearance,” says Macavinta. “The girls who thrive and prosper in life very quickly invest their energy other places — like their brains, compassion and humor
."


This is quickly squashed with a cold,hard dose of reality by Dr. David Sarwer, Associate Professor of Psychiatry at the Hospital of the University of Pennsylvania, and probably the world's authority on issues of body image and psychological outcomes in Plastic Surgery
From a societal perspective, the reality is that whether we like it or not, our appearance does seem to matter.Studies show that attractive people are treated more favorably and that a positive body image can account for up to one-third of self-esteem....Body image improves after surgery. Self-esteem and quality of life can improve as well. However, more studies are needed before we can say that kids benefit the same way adults do.” "


Rob Oliver Jr. MD

A brief history of advertising by physicians


Believe it or not, advertising of services by Doctors was not only frowned upon, but considered illegal in many instances. What changed that? A case brought by a lawyer (Bates v. State Bar of Arizona) who sued the state bar which was at that time prohibiting all advertising. It worked it's way up to the US Supreme Court (SCOTUS) who sided with the plaintiff and ruled that while states may regulate some aspects of advertising, "...a blanket prohibition against advertising by attorneys was unconstitutional as a violation of the first amendment."

(If your a political junkie like me)It's interesting that the SCOTUS is currently poised to strike down the Bipartisan Campaign Reform Act of 2002 (aka the "McCain-Feingold act") legislation restricting corporate-funded campaign advertising in print and television on similar first amendment grounds after a challenge was heard last week in Washington.




After Bates v. State Bar of Arizona, the American Medical Association adjusted their Code of Medical Ethics position suggesting that there be no restrictions except those "justified to protect the public from deceptive practices....(and that) communications shall not be misleading because of the omission of necessary material information, shall not contain any false or misleading statement, or shall not otherwise operate to deceive" (the current statement can be read here)

Advertising has exploded in Plastic Surgery and related fields in cosmetic medicine. At this point there is little regulation about how your advertise your expertise and skills. Like we've seen over and over in the media, there are case where complications after cosmetic surgery occur and the patient contends that they were led to believe their doctor was a Plastic Surgeon. I highlighted a few cases last year involving scope of practice issues involving Ear, Nose, & Throat (ENT) surgeons doing breast & body surgery called "ENT (ear,nose, & thighlifts?)" and "A monster in Munster...". At least those instances involved surgeons of some kind as opposed to the radio-station contest featuring an ER doctor on probation doing breast I talked about in April. click here.

This argument of misrepresenting one's training frequently becomes an element of claims in malpractice cases under fraud or failure to accurately give informed consent.
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