Breast Reduction - Improving the Quality of Life

Breast reduction quality of life improvements have also been significant. The July 2008 issue of the Aesthetic Surgery Journal published study results that involved 100 breast reduction candidates for surgery. The individuals in the study were given The Rosenberg Self-Esteem Scale and Rolland-Morris test to identify positive outcomes for the enhancement of self-esteem. The benefits that can be achieved through breast reduction include:
· Improved emotional state.
· Greater self-esteem.
· Lack of pain in the back and shoulders.
· Ability to participate and function with greater daily skills, social and sexual situations.
· Resolution for skin conditions associated with oversized breasts.Breast surgery today offers leveraged beauty, balanced proportions and a change in life that can remain for many years to come.

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

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

I have a few thoughts on this

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

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

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

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

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

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

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


Combined plastic surgery - Advantages and downsizes

A combined plastic surgery is a procedure in which more then one type of cosmetic surgery is being performed. Dr. Balu, Westchester plastic surgery, has explained the advantages and downsizes in procedures such as this:
In many cases the patient might be interested in performing more then one cosmetic moderation. Not all type of plastic surgery can be performed at the same time but there are some that can. Also, not all people can go through a combined plastic surgery due to their physical condition.
The most obvious advantage in a combined plastic surgery is the times you go trough anesthesia. It is a well known fact that anastisia demands a lot from the human body and in some cases is even dangerous. In a combined plastic surgery you will have all operations under one anesthesia. Another advantage is the time saving. The surgery and recovery time is being shortened substantially.
The downsize of combined plastic surgery is the risk in a longer operating time. Also, the recovery can be harder to take when recovering from more then one procedure.

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

Love it!


Breast augmentation video

This video is about the breast augmentation procedure:

Plastic surgery has been around for a few decades now. There are documentations of constructive surgery performed in India on 800 BC.
As any other profitable field, plastic surgery has a substantial amount of research performed for improving and for learning how to achieve new goals. Every year there is a new procedure or a different way to do and improve an existing one.
For the patient, of course, this is good news, but for plastic surgeon this means having to keep them selves constantly up to date with currant methods and procedures in the world of Plastic surgery.

The economic meltdown for dummies (via Rick Ferri)

No Plastic Surgery today!

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

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

Click here to go to the archived speech.


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

From the OC Register

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

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

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

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


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

From Seeking-Alpha

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

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

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

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


Breast Implant designer commits suicide from Yew seeds(!)

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

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

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

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


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

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

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

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

From the UK's Daily Mail

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

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

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

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

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


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

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

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


A must see video guide for "Lost" fans

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

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

Below is a clip from Season 1


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

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

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

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


Happy Turkey Day 2008

Happy Thanksgiving from Plastic Surgery 101!

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


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

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

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

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

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

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

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

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


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

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

It opens with the observation that

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

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

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

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

Something to think about!


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

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

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

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

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


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

Sorry for the extended break!

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

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

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

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

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

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

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


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

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

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

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

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

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

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


Doctor Shopping - Finding the doctor you need

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

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

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

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

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

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

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

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

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

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

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

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


Breast Implants Help a Rare Heart Condition

What would you do -- total panic notwithstanding -- if doctors were to find your heart beating under your kidney?

In a case so rare it has no medical name -- but is being described only as “a floating heart,” -- a Florida woman’s heart was found to be shifting around in her body. Doctors found it stuck in her rib cage under her kidney.

According to news reports, the 35-year-old woman’s right lung had been removed long ago, leaving space for her heart in which to wander around.

Having never seen the condition before, physicians were at a loss to come up with a treatment. One doctor said the patient was the only person in the world with the disorder.

The treatment? Breast implants!

Robert Rey, M.D. of Dr. 90210 fame shows a breast
(Photo, courtesy of Dr. Rey.)

It required a four and one-half hour operation, but breast implants -- used in the standard breast augmentation procedure -- filled the space where the lung used to be and holds the heart in the correct position.

“Clever idea, actually,” says Robert Kotler, M.D., a board certified Beverly Hills cosmetic surgeon. “The chest surgeons used the breast implants as a large-space ‘filler’.”

Editor’s note: Dr. Kotler is one half of the Tuck ‘n’ Stitch bloggers.

Top 10 Cosmetic Surgery Lawsuits

Taking Botox to court is something akin to suing Santa Claus. Almost everybody likes Botox as much as Santa, so how would you get a jury to vote against either one? Only time will tell….about Botox, that is.

Three months before Christmas, Santa is certainly on safe ground.

So nobody is suing Santa. Yet, anyhow. But in January, all bets are off!

Given the number of lawyers looking for something to do, the Momma-put-a-lump-of-coal-in-my-Xmas-stocking class action lawsuit is just around the corner.

(Pamela Moore photo)

Patrick Hudson, M.D., a plastic surgeon in New Mexico, located some insider statistics that show which plastic surgery procedures are most likely to lead to the court house.

Here are the top ten litigated procedures, along with the percentages of actions the procedure draws. More.

1. Nose surgery……………………..22 %
2. Breast reduction………………….17 %
3. Eyelid surgery……………………16%
4. Breast enlargement……………….13%
5. Face lift…………………………… 9%
6. Various………………………… 7%
7. Breast reconstruction…………..… 6%
8. Tummy tuck……………………… 5%
9. Liposuction……………………….. 3%
10. Facial resurfacing………………. …2%

Nose surgery heads the list because it’s the most difficult plastic surgery procedure to learn and perform. More.

Breast reduction involves removing a lot of tissue; however, eyelid surgery is a surprise because it is supposed to be one of the easier procedures to perform. Breast enlargement made its way onto the list because it’s very popular, with 329,000 patients undergoing the procedure in 2007, the most recent year for which statistics exist. A tummy tuck involves a long incision across the abdomen so insurance companies should be thankful the percentage is relatively low. Ditto breast reconstruction.

Hint: If, for some reason, you aren’t satisfied with the outcome of your plastic surgery, two eminent Beverly Hills cosmetic plastic surgeons, Drs. Robert Kotler and Stuart Linder, tell the top five constructive things to do if your procedure does not go well.

Read their blog, Top 5 Remedies for Unsatisfying Plastic Surgery.

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

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

Sen. Mitch McConnell (R-KY)

Other pols who stand out for BOTOX

Hillary Clinton (D-NY)

Nancy Pelosi (D-CA)

Nancy Pelosi's Cat :)


Nose Job Complication? Use Honey!

One of the possible complications of a rhinoplasty is a case of sinusitis. But there’s a, uh, sweet cure for it -- honey. Now, plastic surgeons must figure out the best way to spread the stuff inside your schnoz. (Read more about nose job complications.)

(Photo credit:

What’s more, honey in medicine is nothing new -- it has been used since the time of the ancient Egyptians as a natural anti-microbial dressing. Read more.

Back in present time, Canadian researchers, lead by Dr. Joseph G. Marsan at the University of Ottawa, used honey in the lab on the bacteria that cause sinusitis. The problem has always been that super-powerful germs hide inside the nose under a thick covering known as biofilms, which can’t be penetrated by “even the most power anti-microbials,” according to Dr. Marsan.

Plastic Surgery Procedures

Two certain types of honey, Manuka honey from New Zealand and Sidr honey from Yemen, are powerful enough to zap through the biofilm and kill the bacteria. (Read the whole report.)

So will plastic surgery procedures have fewer complications?

The next step: do you sniff, spread, inject, swallow, or hold the honey under your tongue to get it inside your snout? Don’t know yet. Hey, no worries, they’re working on it!

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

Sneak peak for today! 

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

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

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


Britain's Plastic Surgeons ask for truth in advertising

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

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

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

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

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

There’s a standard list of questions a patient should ask when considering any type of breast surgery.

But, given that some places are now offering expensive dishes that contain mother’s milk, here are some more appropriate questions to ask plastic surgeons before a breast procedure:

1. If I have a breast lift, will my milk still mix well in a Crème Brule sauce for braised tenderloin tips and asparagus?

2. If I go ahead with a breast enhancement, will surgery do anything to the milk to spoil the appeal of curry in a nice breast milk creamy sauce with tender bits of Rock Island lobster tails?

3. Will a breast reduction affect the formulation and consistency of breast milk used in Bosomberry milk ice cream?

Here’s how it all came about:

Swiss Restaurateur Hans Locher, head honcho of the restaurant Storchen (Little Stork in German) intended to serve a special soup and a recipe calling for antelope steak with mother’s milk sauce. Another dish consists of small chunks of meat, also in a creamy milk sauce.

Hans Locher with his favorite recipes.
(Swiss Info photo)

For supply, Hans lined up some new moms who were willing to sell breast milk for $14.50 a quart.

Gastronomes were, ah, udderly delighted. But the authorities declared that mother’s milk for the public is verboten. Read more about Hans.

On the other side of the globe, the Chinese were not to be outdone in tapping a seemingly heretofore unknown market and started offering fresh poached abalone and perch in a human breast milk sauce. More.

Poached abalone and Perch in a creamy sauce.
(BBC News photo.)

Said the restaurant owner: “When customers are having the human milk banquet, they can experience maternal love at the same time.”

In the United States, a California entrepreneur first used his wife’s breast milk to create the following cheeses:

• Holy’s Original Blend

• Mothers’ Milk Maid Cheese

• Miss Cheese.

Care to guess what the not-so-shy guy named his business? Hooterville Farms!

You can even email them and inquire about other products like YoGoGirls yougurt or his Chunky Mammal and Bosomberry ice creams, also containing, well, hey, you’ve got the picture now.

Just go to and check it out.

Okay, you’re a wonderful sport for hanging in there, but you’ve been had! I went for it too and quickly saw that is actually a shameless link farm that has nothing at all to do with mother’s milk. (But an off-kilter article says it’s the real deal. Read it just for fun.)

Nonetheless, the rest of our report is true! Really!

It seems Hans started something. PETA read about his restaurant and is now asking Ben & Jerry’s to give up cow milk for human breast milk in their ice cream. (We’re NOT making this up….read more.)

Now, here’s the disclaimer part: kill joy health inspectors say you should not actually consume any real dishes containing human breast milk because nobody knows the health status of the donor.

Now that we took care of that chore, I would like to point out that a McGill University study of 14,000 children reveals that breastfeeding results in a higher I.Q.
Read more.

If it works for babies, won’t it also help adults?

Robot Surgery: Like Playing a Video Game!

Gamers, check it out!

You have the manual dexterity necessary to become a top surgeon! Using a robot, no less.

Says a top surgeon: “Using the da Vinci surgical robot is almost like paying a video game, like Play Station 3.” So declares Michael Hibner, M.D., director of gynecological surgery at St. Joseph’s Hospital and Medical Center in Phoenix. Read more.

A game hip surgeon working a surgical robot.
(Arizona Republic photo)

Breast Augmentation

So hey, why continue in your present job when you can game all day? And help people, too. (Of course, you have to graduate from medical school but, hey, that’s only eight years or so.)

One surgeon already tried using a robot for breast augmentation but she says she could not get the results she wanted. More.

Dr. 90210 Plastic Surgeon as Artist?

Q: What type of plastic surgery starts with reading all the art books any art student must know?

A: High-definition LipoSculpture.

John Millard, M.D., one of the doctors seen on Dr. 90210, learned to combine art with medicine and sculpts not stone, but people.

So who needs it?

Fitness and iron pumping buffs who strain, toil and sweat for endless hours in the gym to create bulging muscles….that are hidden by just a little fat.

Most of us would be thrilled to look like the people in the doc’s before pictures. But people who have undergone high-definition liposuction look like a living Venus de Milo (with arms, of course!) or an Arnold Schwarzenegger in his heyday.

What does Dr. Millard do differently? He learned where the most arty places are on the human body and now uses his plastic surgery skills to allow those pumped up muscles to shine through in all their glory. Not to get too high brow here, but it’s a concept known as negative space. Read more about High-Definition Liposculpture and art concepts.

Before and After Plastic Surgery Photos

The before and after pictures below show a 43-year-old woman who works out in the gym five days a week.

Her after picture shows what a high-def LipoSculpture looks like when just the right amount of fat is taken from just the right places…exactly like you might find in an book for art students.



It works for guys, too. Pictured below is a 34-year-old firefighter who has been a body builder for about 15 years.

Before Hi-def LipoSculpture


(Photos courtesy of John Millard, M.D.)

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

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

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


Plastic Surgery is a Star in Burn after Reading

Plastic surgery is often in the movies in Korea; in fact, rejuvenation surgery is a constant theme. (Read our blog about one Korean plastic surgery flick.)

Now, plastic surgery drives the wacky plot of the current highest grossing U.S. movie, Burn After Reading.

John Malkovich stars in Joel and Ethan Cohen’s dark spy comedy, BURN AFTER READING, a Focus Features release. (Photo credit: Focus Features)

The movie starts as Linda, an aging gym instructor (played by Frances McDormand) sees a plastic surgeon and finds her basic rejuvenation is going to require four, “major” procedures. (READ: equal to the annual gross national product of the Isle of Man, the Kingdom of Yap and the Isle of Dogs.)

She decides on a combined breast lift and breast augmentation; liposuction, and a face lift, including rhinoplasty.

Linda’s gym sidekick and fitness instructor, Chad, who is played by Brad Pitt, is a charming but totally self-possessed dolt and all-round airhead.

Because the movie is set in Washington, D.C., a former C.I.A. operative, Osborne, (played by John Malkovich,) has penned a tell-all book about the morons who run the nation’s spy agency. But Osborne loses the book -- written on a CD -- at the gym, aptly named Hardbodies.

Costs of Plastic Surgery

The action then gets a kick in the pants when Linda lays her hands on the tell-all book and assumes it’s real, classified intelligence worth the GNP of several large nations. She and Chad then concoct a dopey scheme to blackmail the author, collect a mountain of cash and pony up for the costs of plastic surgery.

The rest of the movie is a riot of confused identities, deadly pratfalls, mistaken shootings, bedroom intrigues and a handful of bodies that need hiding, along with some stark raving madness, aptly performed by George Clooney who plays Harry, a U.S. Marshal who repeats about 20 times daily that he never fired his gun in 20 years on the job.

Before and After Plastic Surgery Pictures

The movie ends with a C.I.A. big-wig trying to figure out how it all happened, where to hide the bodies, how much payoff cash to allow, and what, if anything, the agency is supposed to have learned from the zaniness.

You’re probably wondering how Linda looks in her before and after plastic surgery pictures. But we are sworn never to give away the endings!

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

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

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

Why 3 years for the first MRI?

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

But does it make sense to do this?

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

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

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

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

Anyway, back to implants......

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


Plastic Surgery Stops Bullies in their Tracks!

When I was in grade school, no self-respecting kid would tolerate a bully, the weakest, whiniest and most puny kids not withstanding.

We weren’t tough guys; it’s just that any boy over the age of oh, 18 months, would get far worse when his dad found out his kid had succumbed to bullies and forked over his lunch money, baseball cap, pocket knife, the family IRA or whatever.

The standing rule was: face up to bullies and fight back, even if there were dozens trying to shake you down.

I think the Father’s Instruction Book had a chapter about one punch on a bully’s nose stopping the lot of them. The one exception about fighting back: if you were in an iron lung, wheelchair or in traction, your punching ability was somewhat restricted, making it understood you might miss the bully’s nose. But you had to fight back. According to The Father’s Instruction Book, there was no shame in fighting back and losing.

But in reality, I never did come across a bully who was put off by one -- or even one dozen -- punches in the nose. I think they became bullies in the first place because they were born without pain receptors. So logic for nine-year-old bullies was simple: “Hey, we can’t feel pain. Let’s just pick on people! So what if they hit us back?”

Your lunch money or your life!
(iynmeyer photo)

However, all of that was before plastic surgery stopped the assaults. In England, a new way of dealing with the problem is by rejuvenating the body parts bullies like to taunt other youngsters about.

Some British surgeons are giving children and teens surgical rejuvenation so that bullies won’t be picking on odd-looking features or making punch-deserving jokes about large noses or ears or small breasts. (Read more.)

(Disclaimer: kids’ lunch money may still be up for grabs, even after plastic surgery!)


*Mr. Douglas McGeorge, head of the British Association of Aesthetic Plastic Surgeons (BAAPS,) recently revealed he had reshaped the nose of one youngster and supplied breast implants for others to stop teasing and bullying. For instance, one younger teen was picked on and bullied at three separate schools, because of an unattractive nose. Her parents were about ready to go “case-o” -- British slang for “going bonkers” -- before hitting on the idea of ponying up 3,500 Pounds (that’s $6121.50 U.S. dollars) for
rhinoplasty. Her parents say the problem was solved.

Breast Implants

Because some bullied teens are still growing, the thoughtful doc has put in expandable breast implants, which help to gradually expand the bosom. (Read about how expandable breast implants work.) Additionally, a nine-year-old in Scotland begged his parents for surgery to rid his face of a mole because school bullies called him “Moley” and beat him up after school because of his appearance. (More about mole removal.)

But the trend is not news. Back in 2006, it was reported that Britain’s National Health Service was springing for cosmetic plastic surgery for bullied youngsters in Scotland. (More.)

What do you think? Will plastic surgery stop U.S. bullies? Or, should we concentrate on pain receptor transplants for bullies?

*In the British Isles, M.D.’s are known as “Mr.”


Welcome to our plastic surgery blog. Plastic surgery generates a great deal of interest, but there is much misinformation floating around. This blog is designed to provide real-time information about this rapidly evolving field, and allow for the exchange of ideas through questions, answers, and comments.

Thanks for stopping by!

Please send questions by email to or find more information on

Artist Rakes in Money with Tattoos on Swine and People

A leading service among plastic surgeons is tattoo removal. It’s known as “labor intensive” because the patients must return to the plastic surgeon anywhere from two to six times and let the doc do erasing work with a laser.

Basically, the cosmetic surgeon zaps the ink in the tat with a laser. (Read more about cosmetic tattoo removal.)

But when a tattoo is considered art -- and fetches a king’s ransom -- you gotta think about leaving it on.

Wim Delvoye, a Belgian artist living in Beijing, China, started by tattooing eight pigs with designs reportedly similar to Louis Vuitton logos. (Animal lovers, chill! The porkers, shown below, were anesthetized!) A few swine were inked with Walt Disney characters.

Artist Wim Delvoye and his four-footed canvases
( photo)

After the oinkers have lived a long and productive life, the pig skins will be sold for $120,000 each. (Can you imagine -- a Louis Vuitton football? What a way to get more chicks into the NFL! Can’t you just hear the girl talk now? “They fumbled a Vuitton Beaubourg in the first quarter and then tried an on-side kick with a Mahina XXL clutch in the 4th!”)
(Read more about the tattooed pigs.)

Tattoo Removal

The following will make tattoo removal experts worldwide cringe, but Wim’s latest project was inking an elaborate tat of the Virgin Mary on the back of Tim Steiner, a 32-year-old Swiss man who is cashing in on his tattoo.

Here’s how: Wim did his usual masterful job and sold the artwork on Tim’s back to a German art collector for a cool $275,000. The cash is split among the art gallery that arranged the sale, Wim and Tim. More.

Tim Steiner, a two-legged canvas
(Paolo Foschini photo)

Then, not unlike the pigs, Tim hopefully goes on living a long and productive life. Now, I know what you’re thinking and that’s not it -- Tim does not -- repeat, NOT -- become a football!!

Plastic Surgeons Verboten

Instead, many decades from now, just before Tim is laid down for a dirt nap, the skin of his back is removed and the Virgin Mary tat becomes the sole property of the art dealer who can sell it if he wishes.

And that’s not all. Contractually, Tim must display his back in public three times yearly to art lovers worldwide.

However, plastic surgeons who know how to remove tattoos are verboten in the shows!

Plastic Surgery for Pooches

Yearly, some appearance-challenged canine is named top dog in the World’s Ugliest Dog Contest at the Sonoma-Marin Fair in Petaluma, California. (Read more.)

Gus, a Chinese Crested, won for 2008 even though he has had a rough row to hoe in life. He has lost one leg to disease, one eye in a cat fight, a handful of teeth due to chewing on countless bones, and a furry coat due to heredity; after all, he is a hairless Chinese crested dog. Gus was simply born to be as ugly as a mud fence.

Nonetheless, his owners think Gus, pictured below, is precious.

Gus relaxing at home
(iStock photo)

2007’s winner was even more revolting. Also a Chinese Crested, Elwood, pictured below, won that year, perhaps because he is even more crested and has even less hair than Gus. You have to admit that when it comes to looks, Elwood is also just a real dog.

Elwood, 2007’s Top Ugly Dog
(Canada News Photo)

A Plastic Surgeon for Dogs

Anyhow, there’s somebody we would like Gus and Elwood to meet -- Brazilian doctor Vet Elgado Brito, a big proponent of pet plastic surgery.

To the Brazilian way of thinking, if you make people beautiful, hey, why not make their “animal companions” beautiful, too? Works for me! (As long as the creature is house broken; there’s no way that beauty alone makes up for, well, you’ve got the picture by now.)

Botox and Breast Augmentations

Dr. Brito has used Botox to straighten inverted doggy eyelashes so that Fido’s eyeball is not irritated. Among other cosmetic surgery, the South America doc has even performed canine breast augmentation by tightening mammillae of female dogs before beauty contests so that the dogs could take part in the type of contests in which good looks -- and not vile features -- are judged. (Read more about Dr. Brito.)

The owners of this Sharpei wanted Botox
to remove the dog’s wrinkles
but could not afford 1,500 vials of Botox.
(iStock.xchng photo)

But if you look closely enough, others are making unsightly animals more attractive, too.

Rhinoplasty and Eyelid lifts

The Animal Medical Center of Southern California requires a medical reason for cosmetic treatments on animals; nonetheless, the work often results in an eyelift, facelift, rhinoplasty or abdominoplasty, a procedure we Homo Sapiens fondly call a “tummy tuck.” However, liposuction is out, partly because dogs don’t mind being fat.

If your “animal companion” is a Pug, Bulldog or a Boston terrier, breeds in which breathing problems are common, the mutt may be eligible for rhinoplasty. Sharpeis and Chows often have a congenital defect that make their eyelids roll inwards, causing the eye winkers to rub the eye, perhaps resulting in scratches. The solution? A canine style eyelid lift.

Lip Augmentation

And there is the heart-warming case of Feznick, a 75-pound gray kangaroo who lives at a farm for Hollywood animal actors. Feznick was bitten on the face by his neighbor, a wolf and fellow actor when he, Feznick, poked his snout into the next cage. That left the ‘Roo with a snarling lip and totally unsuitable for his close-ups. So, back in 2006, a vet named Dr. Wolff (really!) repaired Feznick’s lip with a little cosmetic surgery described much like the human procedure, “except with a lot more hair.” (Read more.)

This Kangaroo isn’t Feznick (we could not afford
his picture!) but another Kangaroo who is available
for movies and commercials. (His day job is being an
attraction at a petting zoo.)