A nerdy public policy-wonk post today!

Despite a surprisingly brief blurb on the AP wire & broadcast news media, there was a very important move last week by the Supreme Court of the United States (SCOTUS) about the future of health care in this country. The court refused to hear an appeal by the American Association of Retired Peoples (AARP) about a companies ability to terminate health care benefits when a retired former employee becomes eligible for Medicare at 65. The AARP is one of the most powerful political lobbies in the United States, and this is a pretty big defeat for them.
The court's action upholdsa a rule adopted last year by regulators that says the "coordination of retiree health benefits with Medicare" is exempt from the anti-age-bias law.


This case has pitted the interests of younger employees and unions against retirees over the dwindling budget for job-related benefits. In recent years, many employers have pulled back from providing these kind of benefits to their retirees because of the soaring cost obligations. But until Monday it had been unclear whether it was illegal to use a worker's age -- in this instance, 65 -- to trigger a reduction in benefits.

"In some cases, it's become a millstone around their necks," said Jack Kyser, chief economist of the Los Angeles County Economic Development Corp. "Corporations aren't all heartless, but in many cases, you're competing with multinational corporations that don't have quite the obligations that domestic firms have."
This decision not to hear the appeal is interesting because it's going to grease the skids for a large shift of healthcare obligations from the private sector to the feds. As I remained convinced that we're quickly moving towards "Medicare for all" as the eventual American adoption of universal health coverage, the incorporation of more people under it's existing umbrella seems another move in that direction.


Rob

Anesthesia related death during plastic surgery


From the Palm Beach Post comes the tragic death of Florida teen, Stephanie Kuleba, from a rare allergic reaction to inhalation anesthetics called malignant hyperthermia (MH). Wikipedia describes it succinctly as a idiosyncratic reaction that "induces a drastic and uncontrolled increase in skeletal muscle oxidative metabolism which overwhelms the body's capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if untreated."

There's really no way to screen for this process and a patient can die quickly. Most surgeons and anesthesiologists may go their entire career and never see a true case of it. I was talking to one of my colleagues the other day about office based surgery and he said he was unlikely to return to doing that after seen a near fatal MH on a cosmetic surgery case he was doing in an ambulatory surgery center adjacent to a hospital.


I'm not sure what the take home message from this is. It's such a rare event that it's hard to justify having exotic protocols at all times in low risk procedures. Most office surgery suites maintain a supply of Dantrolene, a medicine to treat MH which is almost $2500 per dose and must be restocked often to stay current. There's plenty of adverse events more common then MH, but we don't have aortic balloon pumps or cardiac bypass machines routinely laying around for that. It already sounds like that the family has hired an attorney who is already assuming an aggressive posture in his comments to the media so I'm sure we'll see some legal proceedings even if perfect care for MH was instituted.


Do Female Hormones in the Water Cause More “Man Boobs?”

Will the U.S. see more cases of gynecomastia, the much-despised condition resulting in “Man boobs” or “Moobs,” as they are also known?

It may be due to the many pharmaceuticals found in U.S. drinking water.



Some plastic surgeons in England have already noticed that their rate of performing gynecomastia surgery is going up. In 2007, according to the British Association of Plastic Surgeons, 4,000 “blokes” had cosmetic plastic surgery to create flatter, more masculine chests. In contrast, 2005 saw only 2,100 such operations.

During 2007, the U.S. recorded 20,289 such cases, according to the American Society of Aesthetic Plastic Surgery (ASAPS).

Here’s a typical story (“How I got Rid of My ‘Moobs’”) about what a guy with large breasts must put up with from his “mates.” Read more.

Doctors and other scientists say no single drink of tap water is like getting a dose of medicine. It’s just that the trace elements in water build up over time to create the effect.

Gynecomastia Causes

However, drinking water is not the only culprit. If a “bloke” drinks too much booze, uses street drugs, has hormone therapy for cancer of the prostate, eats foods containing the female hormone estrogen, his breasts often enlarge -- even in thin guys -- to the average size of teen girl.

(I know what you’re thinking! Should you wear a bra if you have gynecomastia? Or a training bra, at least? Actually, Seinfeld once called bras for men “bros.” Anyhow, this is not the way these guys wanted to get in touch with their feminine sides!)


A then 14-year-old patient is pictured on the left before his gynecomastia was corrected through surgery. (Photo courtesy of Elliott Jacobs, M.D.)

There appears to be no way to work off or exercise away gynecomastia. Alan Kingdon, M.D., a London cosmetic surgeon, noticed the increase in male breast reduction surgery and conducted a study on the tissues removed. He found that bone fide mammary gland tissue, which normally grows only in women. More.

Given the nature of male humor, it’s only a matter of time until some U.S. fraternity writes a new song for their parties and names it, “Drink and be Mary.”

But wait, there’s more! A popular shampoo may also cause gynecomastia. More.

And: read about an MTV contest winner who wanted to have a surgically created chest like that of Arnold Schwarzenegger, the “Governator.”

Guys: Tell Us about Your Life with “Man Boobs.”

Gals: How do You React to Guys with Fleshy Chests?

'Tis the season for - Chocolate Bunny Melting


Happy Easter from Plastic Surgery 101!

Courtesy of YouTube, some stylish chocolate bunny immolation. You know, artsy types are just different then the rest of us!





Cheers!
Rob

Do Americans want fee for service medicine?


There's an article on Salon.com about health kiosks in places like Walgreen's and Wal-Mart called "Wal-Mart can be good for your health!".

This is a hot topic in medicine as it gets into a number of hot topics





  • Who will own these clinics? (doctors or industry)



  • Who will staff & oversee these?



  • What affect will this have on continuity of care?



  • What affect will this have on the financial sustainability of medical practices when routine patient visits are siphoned off to these clinics?

One theme that jumps out at me, particularly when you read the reader comments section to the article, is that people are schizophrenic when they think about this (ie. Is medicine a business or nonprofit public utility?) and look at this from a completely different perspective than health care providers.
A number of complaints arise which basically boil down to that "the competition these clinics provide against doctor's office visits will be good and result in better service". This pretends that medicine is some true market economy rather then a corporate & federally-rigged game of Jenga. The winner of this "competition" gets the privledge of working much harder for much less money for much more aggrevation.

If you want to send a primary care doctor thru the roof, complain about having to pay a co-pay for and office visit and about not being able to be seen at a moment's notice. There's little understanding (or sympathy) for exactly how much our system is squeezing physicians to achieve savings in our health care system.


Particularly offensive to me is a Minnesota internet start up company I read about called CAROL, whose business model is essentially to try and turn medicine into Priceline.com



We want to let consumers define value,” said Tony Miller, Carol’s founder and chief executive. “We don’t have care competition in the marketplace today.”The free site, which went live in January, generates revenue from health-care providers who become “tenants” on the site. When a consumer sets up an appointment with a clinic or doctor on Carol.com, the provider pays the site a fee.

Great! We were missing one more layer of capitalists strip mining the health care system.




Dumb laws and smart laws re. plastic surgery

Tragic events have a way of stimulating bad legislation.
Co-conspirator in Plastic Surgery blogging, "Dr. 48307", Tony Youn had a very insightful retort a few weeks backto a bill ("the Donde West law") introduced in the California legislature (read here) to mandate medical clearance on all patients undergoing cosmetic surgery. Something similar is now being mentioned in Illinois. Dr Youn writes:


This is a very interesting bill, considering less than a year ago the California legislature passed a law permitting oral surgeons (DDS dentists) to perform all forms of facial plastic surgery. Instead of forcing surgeons to make their patients undergo preoperative testing (some young, healthy patients may not need it), maybe they should instead make sure that anyone performing plastic surgery is a real, board-certified plastic surgeon?

Keep in mind that California is also the state where a judge ruled in 2006 that a certificate from a non-recognized cosmetic surgery "board" organization was equivalent (or better!) to the American Board of Plastic Surgery for accreditation proposes over the objections of the state medical board for California, the American Medical Association (AMA), the American Society of Plastic Surgeons (ASPS), the American Board of Facial Plastic Surgery, the American Board of Medical Specialties (ABMS), and others. This ruling ignored the existing state law that allowed physicians to advertise board certification only if the certifying board or association is recognized by ABMS or deemed equivalent by the state medical board.


BACK TO THE "DONDE WEST" LAW

Broad non-directed medical screening by 3rd parties would be an extremely inefficient and unnecessarily expensive way to clear patients for surgery. Besides, this process already takes part as part of a patients' surgery evaluation. Now your doctor can be a tool, and adopt the blanket position that "I send all my patients for medical clearance before surgery", but that's just punting the ball and practicing defensive medicine to the extreme.


The scale we commonly use to characterize surgery patients' anesthesia risk, called the ASA system, is a pretty good screening tool. The overwhelming amount of patients undergoing cosmetic surgery are low risk, and ASA class I or II patients should not need "medical clearance". In addition, many primary care doctors have absolutely no idea what "medical clearance" means anyway, and get a little peeved when patients show up for non-reimbursable office visits.


When we talk about medical clearance, it's usually in the context of chronic medical issues or asking whether the patient needs provocative testing for coronary artery disease. Patients who may need to be "tuned up" prior to surgery are those with:



  • diabetes - Are there blood sugars under control?

  • significant hypertension

  • morbid obesity

  • sleep apnea

  • symptoms of (or strong risk factors for) coronary disease

Many of those conditions might be exclusionary for elective cosmetic surgery in the first place, particularly when combined. Keep in mind that the patient involved in the event triggering this reactionary bill, Donde West's, had undergone coronary testing earlier in the year (which was reportedly normal) and died over 24 hours postop from what sounds like a probable aspiration event. No amount of screening would prevent something like that.


"Smart Laws" relating to cosmetic surgery seem to be a little more difficult to implement. A more practical way to address the whole issue of office based surgery procedures would be to standardize the accreditation of facilities and remove the loopholes in some states that still exist. My state, Alabama, for instance has set a timetable for requiring accreditation for office an ambulatory surgery centers (ASC) over the next 18 months. The ASPS already makes it a requirement for membership that you will pledge to only operate in accredited (or planned accredited) office facilities. A common sense regulatory step would be to require hospital privileges for any surgery you'd propose to do in your office requiring sedation or general anesthesia, which would have the de facto effect of an additional level of credentialing applied by hospital medical staff offices. It's so common sense that it will be violently opposed by many "cosmetic surgeons" who would see their ability to practice cut off at the knees. Something to think about!

Thanks again Tony for your wonderfully entertaining blog!


Rob

Top 7 Plastic Surgery Foods

1. Beer for Breast Growth

Okay, so it’s not food! And it won’t replace professional breast augmentation any time soon. But beer has massive amounts of nutrients, as any dedicated beer drinker will attest after he (or sometimes, she) has gained a huge stomach. (They don’t call it a beer belly for nothing!)


Boza Beer -- brewed in Bulgaria
(TheMightyQuill photo)


But this beer promises to enlarge breasts and not stomachs! Boza Beer in Bulgaria is now big business because European Union members are traveling there to bring Boza back to their significant others….by the case. Will the suds be a cohort to the King of Beers, join royalty and become known as the Queen of Beers? And why not? We’ve got Queens of various nations, such as England and Denmark, as well as the Queen of Country Music, the Queen of the Hop, the Queen of Mean, the Queen of Soul and the royalty who rule the Isle of Dogs and the Kingdom of Yap. More.

2. The F-Cup Cookie


(Nippon photo)

You must travel to Japan to munch this product, but the buzz is that a couple of “special” cookies a day will eventually create an F-sized bustline, thereby replacing the need for surgical breast augmentation. Supposedly, the eats contain a “secret” Asian ingredient that mimics estrogen, the female hormone. Read more. A plastic surgeon’s take? Not likely!

3. Lollipop Weight Loss

Have you ever wondered what’s up with Hollywood celebrities being seen with a lollipop jammed into their mouths? At first, I personally thought it was a refreshing new wave of juvenile regression, with pseudo-adults making the quarter leap necessary to get back to full childhood.


Britney Spears with a lollipop.
(TMZ Photo)


But, no, it could be more unbelievable than that. There is actually such a thing as a weight loss lollipop. The magic ingredient this time? An African herb known as hoodia gordoni. And why a lollipop? It’s the delivery method.
You’re supposed to consume hoodia slo-o-o-o-wly for it to knock off the pounds. More.

(If you’re interested, read about body contouring, the plastic surgery procedure for people who have lost massive amounts of weight -- without any lollipops.)

4. Chocolate Facial

This is a fantastic development! Talk about a total regression to childhood! You get to wear chocolate all over your face like you did when you were a kid; licking the bowl when mom baked a cake. What’s more, this facial supposedly replaces the need for not-so-tasty, facial skin rejuvenations such as dermabrasion or facial peels.

If you’re on the more mature side, you don’t have to ask for a so-called “chocolate facial.” It’s also known as a CoCo2 facial. More.

5. Botox Cookie

Ever notice how wrinkled your tongue is? Lots of grooves and wrinkly tissues in there? Well, a picture is worth one thousand words, right?


In the U.K., a U.S. cookie is known as a “biscuit.”
(Photo: Botox biscuit by su-lin via Flickr)


Well, it appears a couple of pranksters at Flickr.com put a cookie (hey, not the F-cup kind! Wrong procedure!) in a Botox container and took a picture. You can’t really buy a Botox cookie, but the concept is more interesting than a weight loss lollipop, don’t you think?

6. Cosmetics for Meat and Fish

While we’re on the topic of plastic surgery and food, there is one type of food that may be getting its own type of cosmetic makeover.

The U.S. meat industry wants to pass H.R. 3115, a bill which would allow the industry to treat meat, fowl, and fish with carbon monoxide, (or CO, if your favorite reading is the periodic chart of the elements.) Why? Makes meat look fresher.

However, one lawmaker, Congressman Bart Stupak, brought some two-year-old ground beef that had been treated with CO to a Congressional meeting. According to Stupak, it was as red as the day it was purchased. Read more. (But hold your nose!)

7. Pigs’ Feet (Really!)


(Vixs photo)

We are not making any of this up! A scientist somewhere has found that pigs’ feet, the time-honored delicacy way down South, contains huge amounts of collagen, the protein responsible for smooth skin and taunt muscle tone. After that discovery, the inevitable happened: a classy Japanese restaurant in New York starting serving 33 dishes that feature some form of pigs’ feet. Some doctors claim a tasty dish of pigs’ feet is as good for your complexion as a collagen shot.

I would like to say yummy to all this…..but I just can’t bring myself to utter the words.

Hey, let’s be realistic, here. I always thought the true purpose of raising pigs was for the creation of footballs.
More.

Do you have a favorite plastic surgery food?


NEXT: Does our drinking water cause guys to grow breasts?

The charity business as (un)usual - Operation Smile


There's a nice story on featuring Operation Smile in the New York Time's magazine. Operation Smile is an organization that organizes and performs cleft lip and palate surgery in developing countries. The story is not really about the altruism of Operation Smile, but rather it focuses on how it became an effective organization only after operating more like a business and less like a traditional charity.


3rd world missions by plastic surgeons, where a team flys in for a few days, does a lot of pediatric plastic surgery (cleft lip/palate) and leaves would seem like a hard thing to be criticized, but it has been increasingly done. The appropriateness of these kinds of surgeries performed by surgeons who didn't do them in their state side practice and by loosely-supervised residents (as was often the case on these trips) has been questioned for years. Groups like operation smile have addressed this, and require active practices in pediatric plastic surgery among volunteers. More importantly IMO has been the change in philosophy to where we're now increasingly training local physicians in these countries to do simple and reproducible operations to correct these defects recognizing the limitations of resources they may face in terms of speech therapy and orthodontics post operatively.


Rob

Wall Street Journal on SmartLipo - I scooped 'em!


A visitor to the site pointed out to me that today's Wall Street Journal also featured a profile of Cynosure's SmartLipo platform highlighting some of the same thoughts I had in my post yesterday.

If you're interested, you can read it here.

I'm constantly amazed at the ability of the internet to put like minded people in touch from around the world. I can still remember the thrill I got from Napster's heyday where I was able to communicate in real time with fans of artists I liked (Richard Thompson, Bruce Cockburn, Chris Whitley, among others) around the world.

While I may only be the 281st most popular health care blog this week according to Healthcare100.com (I demand a recount!) , like many under appreciated rock bands I'm now "big in Europe". I'd like to give a shout out to American ex-pat, Ms. Erika Wolfe, who took the time to send some beautiful postcards from her adopted home in Kopavogur, Iceland telling me how much she enjoys Plastic Surgery 101. I wish I had some "PS 101 brand" swag I could mail you back! My Icelandic is kind of "rusty" but via the magic of web-translator programs - Ericka, þakka þú fyrir the póstkort

Ericka sent me stunning images from:

Waterfall Dettifoss, north Iceland




Iceland's famous "Blue Lagoon"



Rob

I had the chance to go to an educational event last month put on by Cynosure, manufacturers of the "SmartLipo" platform for body-contouring. Cynosure is a well respected company and has manufactured generally well designed laser platforms. SmartLipo's gimmick is to place a pulsed laser (a 1064nm Nd:YAG for tech geeks in the audience) on a fiber optic cable which is used like a liposuction cannula. The theory is that the laser's energy disrupts and emulsifies fat cells, thereby eliminating or reducing the need for conventional suction assisted lipectomy (SAL). Also promoted is enhanced skin contracture from the thermal energy adjacent to the skin.

I've got to say I was a little unimpressed with the results shown from this device with body contouring procedures. It just didn't produce dramatic results. The presenting doctor in this instance was an ENT surgeon, which I think may have something to do with this. Much like many pictures shown by Dermatologists who do liposuction, there sometimes seem to be an ignorance or indifference to the skin quality and underlying anatomy of patients. (in fairness, many plastic surgeons are guilty of this too.) So picture after picture gets shown of people with undercorrection of significantly fatty areas and lots of residual loose skin in patients who were poor candidates for SAL, SmartLipo, Ultrasonic Liposuction, VASER, etc.... in the first place.

When you read industry publications quoting paid investigators & consultants who are "hanging crepe" about patient selection and expectations, that's usually a code word to me it works best on people who arguably need surgery the least. That's what the expectations had been dumbed down to with the "thread lift" fiasco in 2005-2007 (see here for one of my first blog entries on it).

To get results with SmartLipo, you're still going to have to do traditional liposuction afterwards, begging the question of whether a $100K-120K laser platform that can't be used for other indications makes any sense. It may also be effective for small touch up liposuction cases, but that's an awfully flawed business plan for a doctor assuming that much overhead.

I did see some nice results with SmartLipo when used in the neck/face, and it makes sense that it would work better in those area. If you've got thin fatty layers (like in the neck/face), you may indeed be able to treat that and get skin improvement. Complicating my assessment was the fact that many of those patients had face or neck life surgery simultaneous, which makes it hard to sort the skill of the surgeon's techniques from any effect of the laser. Facial and neck procedures might be the better group for this, but blindly applying high thermal energy to tissue adjacent to nerves and the carotid artery could potentially result in catastrophic complications.

In a nutshell, there may be some applications for this technology but presently I still feel it's more of a marketing tool then revolutionary device.



Rob
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