The trend of Dermatologists becoming more and more unavailable for actually treating dermatological conditions is in the news again in the front page of the New York Times. The article, "As Doctors Cater to Looks, Skin Patients Wait" discusses the discrepancy in how patients are catered to for cosmetic versus medical dermatologic conditions. I blogged about this same issue last September in "How Botox affects your access to a Dermatologist"

There's a few dermatologists quoted who really come off poorly in the language they use justifying their practice choices. You can bet they'd like a mulligan about now in their 'on the record' interview.

Peppered in the comments section to the article are the predictable griping like,




  • "Doctors should not get rich off their patients. Period. End of story. Society has greatly subsidized every doctor's education. If a doctor wants to supplement his or her income with cosmetic procedures, this should be strictly evenings and weekends."


  • "Why on earth should a 10-minute botox injection be worth $500?"


  • "...clinics will not take patients without referrals, and unless a matter is urgent, it can take 4 - 5 months to get an appointment (which they keep as short as possible). However, if a patient wants a cosmetic procedure, it takes only 1 - 2 weeks for an appointment. The dermatology profession needs to examine its ethics, or the lack thereof."


  • "The rest of the medical system will follow. Once health care becomes a one-payer system, there will be a second tier for the moneyed. This is how medicine works in Europe."


  • "This is a perfect example of market forces at work, and proof the market works perfectly. Money talks. In this case, however, market forces pervert the delivery of good health care. The solution is to reimburse doctors for actually taking care of patients, not doing procedures or ordering expensive tests. With a regime change in Washington on the horizon, we will hopefully have a complete overhaul of our decrepit and wasteful health care-industrial complex."


  • "Disgusting example of the growing scummy side of medicine. A terrific example of how the wrong people gain admission to medical school, sociopath sales persons, "I've always wanted to help people, blah, blah blah..." while only interested in the cash. We need a new health care system with salaried physicians"


  • "These comments are scary. Most are uniformed, ignorant and miss the point. Physicans can't meet their overhead and are responding to "managed care" in the only way they can. It is the root cause of most of the ills we see today. We will never able to administer quality healthcare in this type of system. How is it possible for a small practice to negotiate equitable reimbursements from a market giant such as Cigna?"


  • "The idea that patients with potential skin cancer have to literally beg to be seen by a doctor is absolutely horrifying. This is one area where civil suits can be an effective weapon. Drs. who refuse to deal with a skin cancer should be sued out of practice. And/or heavily regulated by the government or their own "Professional" organization (the AMA). Does this behavior actually conform to the AMA's code of conduct?"


  • "Any doctor who will not see a patient who suspects a mole cancerous, or has a chronic skin disease, for longer than 72 hours, should be sued and forced to explain his negligence in a court of law. "


  • Reading the comment sections of articles in "the nation's newspaper" is always really illustrative to me. There's alot of frustration and hostility about healthcare in the public which gets (mis)directed at physicians. (Don't forget poor Dr. Zenn who was sniped by the breast implant nutters in June.) It's really a systemic issue, but it's easier to blame "greedy" doctors then actually recognize the costs of administering and delivering healthcare is affecting this. Commenter's also usually fail to understand that this issue with dermatologists is actually going to get worse rather then better with whatever "universal healthcare" system we end up with. Unless you pay physicians market wages for their services, they're going to look for opportunities to realize it elsewhere.

    Reading this article I also kept thinking, why the hell would you feel like you absolutely have to go to a dermatologist (or Plastic Surgeon) to have a skin lesion or rash looked at? While I appreciate patient's opinion of our skills, evaluation and biopsy of lesions/rashes is simple enough that it logically should be largely the province of primary care providers or the nurse practitioners and physician assistants that affiliate with them in practice IMO. A lot of wound care clinics have such a set up, and I think wound care is much trickier then skin lesions!



    Rob


All the world loves Botox, the ubiquitous wrinkle remover. But like the discovery of electricity or the Internet, people keep finding unusual -- and sometimes, off-the-wall -- uses for it.

Here’s our take on the top 10:

1. Writer’s Cramp


(nazerth photo)

Given the Internet, I don’t know who uses a pen, pencil, or clay tablet and stylus. Anyhow, the researchers managed to find 40 people suffering writer’s cramp (or maybe holding their forks too tightly) and test Botox.

And, yes, Botox can relieve the painful muscle contractions of the fingers, hand, or arm brought on by arduously applied graphomotor representation. (That’s science-speak for handwriting.) Read more.

2. Bladder Control

No, it’s not about drinking all the coffee you want on a long road trip. Some people have injuries that make it hard to recognize a full bladder. Here’s why:

Damaged muscles can send signals to the bladder at the worst of times -- like when you’re in a job interview, giving your Nobel Prize acceptance speech, during a courtroom trial, or whatever. Those errant messages cause the muscles to squeeze without warning. And although you really don’t have to go, the next thing you know, you’ve already gone.

Solution: shots of Botox to the bladder. More. (I’ve got a question for the doctors already: How long is the needle that places the Botox into the bladder muscles? And how does it get there?)

3. Sweaty Armpits


(LilGoldWmn photo)

Now here’s a no-brainer: The surgical procedure to cure overly sweaty armpits -- or, axillary hyperhidrosis, as your doctor might call it -- is no fun. Basically, the doc liposuctions some, or all, of the underarm sweat glands.

Or, you can just opt for some Botox injections every few months to paralyze the same muscles. Although nobody will see you literally sweat, the normal fear factors remain active so your heart races, you’ll have butterflies in your stomach, your eyes dart around and your brain probably goes blank at exactly the wrong time, too. But at least you will not drip with perspiration. Read more about Botox in the armpits.

4. Sweaty Palms



What could be worse than shaking hands with somebody and sensing you are gripping a clammy, warm washcloth? While there are no surgical options for removing sweat glands in the palms, Botox again works nicely to dry things out here as well. (Remember, we make up nothing, here.) More.

5. Sagging Breasts

Being a connoisseur of all things plastic surgery, you have already read everything known to humankind about breast augmentation. But if you or your partner do not want any sharp instruments near milady’s bosom, haul out the Botox.

The technique may not be ready for prime time, but several doctors are offering breast enhancement via Botox. Unfortunately, it wears off after a couple of months, returning those, ah, augmented areas to their pre-Botox state. Read more.


6. Facial Scars


Six-year-old child with four-year-old
dog bite scar on right cheek after three
scar reduction procedures.
(Ben Lee, M.D., photo)


Been to war or in a lot of fist fights? Divorced, maybe? If so, you may be interested in knowing how Botox can lessen facial scars.

Researchers at the Mayo (no, it does not refer to mayonnaise!) Clinic in Cleveland, Ohio, tested Botox on 31 patients with facial scars.

Half received the real deal while the other half received injections of salt water as a placebo. Plastic surgeons then rated the wounds’ appearance on a one to 10 scale, where a one would equal Frankenstein and Christian Bale would get a 10. Read more.

Results? The Botox group scored 8.9 compared to the saline group which only scored 7.1. I would personally go with salt water -- it’s almost as effective and a heck of a lot cheaper. But that’s just me.

The researchers actually want the more expensive brand, the Botox, applied to scars when they are first created. Now, that’s okay for surgery but if you go to war, get in fights or slug it out in divorce court, what are you supposed to do? Carry emergency vials of Botox?

7. Lifting Aging Eyebrows


(brbankston photo)

When eyebrows have been around awhile and start to droop, they can make their owner look older and angrier, although the person may be thinking the most gentle of thoughts. Normally, fallen eyebrows require the skills of a cosmetic surgery procedure to look vigorous again.

But Corey Maas, M.D., an associate professor and chief of the division of facial plastic surgery at the University of California, San Francisco, lead a study that revealed drooping eyebrows can be treated with Botox.

Of course, there’s never a free lunch.

“With surgery, eyebrows can be lifted for 10 to 20 years,” says Dr. Maas. “But Botox results in sagging eyebrows that can last three to six months.” Read more.

8. Voice Tremors

Imagine this: you are trying to explain to a judge why you sped through a stop sign. Or your boss wants to know why you took the day off because you thought Halloween was a holiday. Maybe your wife wants an explanation about how your secretary’s lipstick and perfume got on your white shirt.

In all those stressed situations, your voice tends to shake and quiver. And rightfully so! You’ve been busted! How do you talk your way clear of these messes? Well, it helps a lot if whatever you say is in a voice that is clear, steady and without shaking.

You better really need the help because it requires an injection of Botox into the vocal cords. Read more about the testing.

9. Rejuvenate Sagging Necks


Surgical correction of a sagging neck.
(Robert Kotler, M.D. photo)


Usually, a sagging neck needs surgical attention. (Read more about the surgical fix for necks.) But some surgeons are using Botox to reduce the lines, rings and turkey gobbler necks. Read more.


10. Removing Wrinkles from Shar-pei Dogs


A Shar-pei puppy. Massive wrinkles at only 8 weeks! Is life unfair or what?
(beverlytaz photo)



Of course, it’s only done in the most posh regions of the nation, like Beverly Hills, Manhattan, and Miami Beach.

But many owners of Chinese Shar-pei dogs, like the one shown above, take their purebred canines to special Botox canine clinics where the dogs receive sufficient amounts of the wrinkle removers to get a completely smooth, unfurrowed coat.

I mean, it makes sense! Why would a wealthy 70-year-old who looks 40 want a dog with massive wrinkles? And is it fair that a creature under one year of age should suffer severe wrinkling long before his or her time?

(Okay, you’re not buying this; well, we did wing that last one, but the other nine are 100 percent true. Honest!)

NEXT: Plastic Surgery Games You Can Play Online.

There's been kind of a truism in contemporary Plastic Surgery practice that our business is kind of like "stocks and bonds". Cosmetic surgery has been more and more like "stocks" - high growth with lots of dividends, while reconstructive surgery has been more like a "bond" - steady, boring, and losing ground to inflation. Cosmetic surgery tends to have it's own cycle in that it's busy 3-4 months of the year (late winter - early spring), slows during the summer, and grinds to a halt in August/September when school is back in and women in school or with children can't take the time off to recover.

As we're teetering in the brink of a recession from the real-estate and credit bubbles, there's a lot of stories about how many predominately cosmetic surgery practices are feeling the pinch. A cosmetic practice is usually higher overhead and when things slow, they can get hit hard. Much like the DOW Jones index, these "stocks" are stagnant.

Common sense says, "it must be a good time to be a bond holder (or reconstructive surgeon in this instance)" which usually zig when stocks zag in terms of value.
Unfortunately this isn't true either. We've just narrowly avoided a showdown in Washington over an immediate 10% cut (and planned additional 5% next quarter) in Medicare reimbursement to physicians, which has the effect of actually reducing inflation adjusted compensation up to 30%(!). Private insurers, never one to leave money on the table, will quickly index their rates to the new Medicare scale and there will be significant disruptions potentially in access to care.

As I've been poised to assume custodianship of our office's 401K plan, I've tried to take it upon myself to learn more about investments. Since last October, the American stock exchange value is down something like 20% and has been hammered by fuel costs, the subprime mortgage meltdown, soaring costs of commodities, and a general lack of consumer confidence.

Recently I've been reading two books which have really been transformative in how I think about the stock market. William Bernstein's "The Four Pillars of Investing" & John Bogle's "The Little Book of Common Sense Investing". Both books advocate a strategy called Index Investing which is an extraordinarily boring but productive way to conduct your finances.

A few common concepts to this school of thought:

  • Trying to accurately time peaks and valleys of the market is impossible

  • Routinely beating the market return after expenses is (nearly) impossible

  • "Cost is King"- low overhead funds (like Index Funds) offer extraordinary advantage over time due to compounding interest versus actively managed mutual funds or hedge funds


  • Index funds and the related Exchange Traded Funds (ETF's) are increasingly the investment vehicle of choice for the multi billion dollar pension plans, large endowment vehicles, and investment industry professionals personal portfolios. (If their unlimited access to the best minds and research teams has driven them to indexing, don't you think you should consider it too?)

  • Whatever insight you may think you have into a mutual fund or stock's prospects, you're going to get crushed competing and trading against the resources and insight of large investment organizations. They already know and have responded to any information you have before you even have that information.

  • Consider carefully the added costs of advice (in fees) and beware of stars (as in, star mutual fund managers)

  • Do not overrate past fund performance. Bull markets mask underperformance of funds compared to benchmarks

  • Don’t own too many funds. Buy your fund portfolio – and hold it!

    • What's a "Boglehead"?
      "They are a bunch of diehard fans of John C Bogle, the founder of Vanguard, one of the most successful and largest mutual funds in the US. Started in 1975, the company is the pioneer of index funds. Its value proposition of low fees is well known to mutual fund investors all over.

      The low fees give Vanguard an edge when it comes to returns. According to a recent article in smartmoney.com, Vanguard’s equity funds have returned 14.48% annualized over the last three years, compared to the company’s two closest rivals, American Funds (14.02%) and Fidelity (13.87%). The average equity fund in America returned 12.43%.

      Vanguard’s largest fund, the S&P 500 Index fund has an expense ratio of below 0.20% per annum
      . "




      Rob

      Plastic Surgery Poll

      Which is NOT the Real Plastic Surgery Procedure?

      Of the procedures listed below, five are real and one is bogus. Leave your answers in the comment box below. Test Your Plastic Surgery Knowledge!

      (1) “Bird Poop” Facial

      A high-end New York City spa has come up with a way to rejuvenate delicate facial skin -- and without painful surgery. You’ve probably heard that sales pitch before, but master aesthetician Shizuka Bernstein is offering the Geisha Facial.

      The concoction is made from several Japanese ingredients, held together with heavy doses of Nightingale droppings. (In Japan, it’s an ancient, time-honored ingredient known as “Uguisu no Fun.”) The treatment is being referred to as the “Bird Poop” Facial by the few who have actually had it smeared, er, that is, I mean applied and the thousands who stand by -- at a distance -- and watch in amazement.

      (2) Breast Implants for the Lips

      For years, surgeons have implanted empty breast implants in the chests of bosom-challenged women and then filled them with saline after the devices were securely nested inside the patient’s chest. Then, the implants were filled to a size that fits the patient’s frame, bone structure and wishes.

      So why not do the same thing to make lips larger and more luscious?

      Surgeons can now implant a tiny little saline bag in the lips and, then working through equally tiny filler tubes, fill the implants with just enough saline to make those smackers truly kissable.

      (3) Water Jet Liposuction

      You would have to travel to Thailand, but a new way to remove fat from those stubborn pockets of flab is blasting it away with powerful jets of water. One of the chief benefits is that no heat is produced inside the body, according to the owners of the SP Clinic in Bangkok, Thailand. Just think of the device as an internal Water Pik for liposuction.

      (4) ScarArt Hides Surgical Scars

      Have a tummy tuck scar that runs across your lower stomach or perhaps a scar left from a C-Section, but still want to look sharp in a bikini? A new temporary tattoo, designed by a woman for other women, allows you to slap on a waterproof, smear-proof, and extremely colorful tat to hide that pesky scar. It lasts three days.

      (5) Robotic Breast Augmentation

      It doesn’t have anything to do with a clanking, whirring automaton doing surgery on its own. But, it’s possible for a surgeon sitting at a console to perform breast enhancement by giving instructions to extremely slim robotic hands.

      The chief benefit is that the robot has the steadiest “hands” known and works through extremely tiny openings in the patient’s skin.

      (6) The “Earlobe Job”

      While almost every other part of the human body can have its drooping, sagging or shriveling parts rejuvenated, medical science has somehow missed the earlobes.

      The problem? After decades of supporting dangling, swaying earrings that usually weigh a little less than a VW, aging earlobes become stretched and can sway and flop around like the ears on a blood hound. What woman wants earlobes sitting on her shoulders? Totally ruins the effect of a spaghetti strap dress!

      Solution? Lobe Pumping. Just a syringe full of a facial filler like Restylane does the job for the short haul.

      Of course, Restylane wears off in about nine months. For really severe cases, patients should see their plastic surgeon about surgical earlobe reduction.

      Which is NOT the Real Plastic Surgery Procedure?

      …Check back soon to see if you know which plastic surgery procedure is false!

      Docs Study Tattoos - And Who Hates 'em

      A Texas researcher surveyed 196 people who went to dermatologic clinics for tattoo removal. Results? People who want their tats removed are more likely to be women than men. They want the skin markings removed because others make nasty cracks about the tattoos, which were jeered in some (READ: high paying) work locations.

      The 66 men and 130 women from the survey first got the tattoos at age 20 because:
      • 44 percent wanted to feel unique
      • 33 percent wanted to show independence
      • 28 percent wanted some life experience to stand out
      • 21 percent wanted to mark a special occasion like a birthday, marriage or their newly found independence.

      A tattoo with a breast implant. It was later removed.
      (photo by Lane Jensen)


      The researchers next asked the subjects why they wanted the tattoos taken off between ages 24 and 39.

      Here’s what they said:
      • 57 percent were embarrassed
      • 38 percent said it lowered their body image
      • 37 percent cited problems with clothes revealing the tattoo
      • 25 percent felt singled out
      (Note: totals do not equal 100 because some study respondents marked multiple reasons.)

      Read more about the study.

      Top 10 Plastic Surgery Discounts

      If you are interested in the costs of plastic surgery but concerned about spending too much, check out an article that has plastic surgeons telling how to wheedle a discount from your plastic surgeon.

      Discounts are available on the family and group plan, during slow seasons, if one patient has multiple procedures, if you pay by check or in cash and if you are willing to wait to have surgery on a stand-by basis. More.
      It’s not as exciting, say, as the “Did Hillary Clinton may have plastic surgery?” debate, but mole removal is a huge topic among devotees of plastic surgery. The Internet is searched thousands of times daily for practitioners who know their way around laser mole removal, along with the other removal techniques.

      So when Sarah Jessica Parker, star of “Sex and the City,” had that BB-size mole taken off her chin. The only real question is: why now?

      New York Observer writer Rex Reed once observed: “That growth on her face just gets bigger with every close-up, and in the full-length movie version of ‘Sex and the City,’ it’s so distracting you can’t concentrate on anything else. It’s not a beauty mark.” More.


      Sarah Jessica Parker’s mole, left, and after its removal.
      (Zuma Press.com/AP photo)

      Copping a feel - now a civic virtue in Russian town of Bataisk


      The tiny town of Bataisk in southern Russia has established a hands on tradition on a new shrine to the female form.

      There is a new bas-relief silhouette of a woman's chest in the town square, on whose breasts a man’s hand is lying. It is being touted by locals that if a man touches this bust he is going to attain "family happiness".


      tacky de chez tacky!

      Rob
      I like to take this opportunity to welcome Dr. Jason Jack to my clinical practice and to Plastic Surgery 101. Jason is both a peer and friend of mine who was starting a new practice, and I was tickled to death to offer him a place in my office while he gets settled. Dr. Jack was a scholarship quarterback at the University of Alabama during their 1993 NCAA football championship before being an honors medical student and outstanding plastic surgery resident at the University of Kentucky.

      Rob
      * Image at right spoofed from The Onion

      One of the most serious claims in the class action lawsuits against Dow Corning Corp. during the "silicone crisis" involving breast implants in the late 1980's was that silicone breast implants caused breast cancer and/or delays in diagnosis of breast cancer. Despite there being no evidence for it actually happening, these were reasonable questions to ask. Over the last 20 years, we've been flooded with data that has been reassuring on these issues.


      Implants do make conventional mammograms harder to interpret by their "shadow", but the increased ease of doing manual exams by having the implant to push against to feel lesions compensates a great degree. An MRI mammogram can be used to supplement mammograms when needed for better imaging for screening.


      One of the more interesting findings in several of the large series of women with implants was the observation of significantly lower (almost 40%) rates of breast cancer in the implant group versus a control population of women without implants. The intuitive reason for this has been that these women with implants were a self-selected (rather then "randomly selected") group who were likely to be healthier and have less breast tissue, which both should lowered their expected rates.


      To really sort out a true "expected rate" for breast cancer, you'd have to do some herculean effort of better characterizing the individual risks with a tool like one of the "Gail Model's" of the study participants, which is almost impossible in such large trials. The suggestion that the presence of implants themselves was protective wasn't really taken seriously. There could however, be something that makes us look at this issue a little closer.


      I came across a pre-publication in the journal Aesthetic Plastic Surgery entitled, "Breast Implants as a Preventive Factor" describing the differential temperature seen on thermography (a imaging technique that shows temperature) from experimental rats with silicone implants placed and the resultant affect that had on local circulating hormone levels and cellular abnormalities (both of which were decreased in the implant group). Now this was only an animal model mind you, but it immediately occurred to me that maybe part of that effect we were seeing was from this phenomena. Interesting stuff!




      What's oncoplastic surgery?

      The Wall Street Journal profiled the concept of "Oncoplastic Breast Surgery". This is conceptually just lumpectomy or mastectomy done better. The concept uses rotating breast tissue to fill defects at the time of lumpectomy or larger "quadrantectomy" procedures. These are maneuvers we use with breast reduction and mastopexy procedures adapted to some of the cancer surgery procedures.



      It's a nice concept, but the rate-limiting step here is getting general surgeons to change how they think about breast surgery. Trying to coordinate someone else during the resection with a reconstruction is difficult, as they don't "think" like plastic surgeons do. I'm skeptical that short courses to surgeons can teach much beyond the most simple techniques. It's like putting someone in front of Guitar Hero on the Wii or Playstation and expecting them to play guitar professionally afterwards.

      I'm constantly evaluating blood supply, tension, and tissue quality in a way that you just don't get taught in other specialties. Weekend courses in this discipline just aren't the same as having doing hundreds of different possible reconstructive techniques all over the body and bringing that to bear on a given case. I had the pleasure of working with two of the leaders in this field during my breast surgery fellowship, in Plastic Surgeon Dr. Pat Maxwell and (an occasional basis) Breast Cancer Surgeon, Dr. Pat Whitworth in Nashville. I though I knew how to do mastectomies and whatnot before I saw these guys do their thing. They're incredible! Both do such anatomically sound breast procedures with no superfluous steps that it's really beautiful (for lack of a better word) to watch. Dr. Whitworth is quoted in the article BTW.

      Rob

      Surgery In Egypt




      I recently returned from Egypt, where my father and I performed a specialized surgery we developed to help quadriplegic patients breathe without the aid of a ventilator. (My dad is a neurosurgeon. Neurosurgery has elements of nerve surgery and plastic surgery, so the procedure is perfect for us to do together.)

      Our procedure uses a nerve graft to take a functioning nerve and attach it to the nerve that controls breathing via the diaphragm, and which does not work in patients with quadiplegia. A phrenic nerve pacemaker is then used on this new hybrid nerve to stimulate and control breathing. Once this system is in place, patients can breathe without the constraints created by being dependent on a ventilator.

      We have performed this surgery in Chile, Brazil, Israel, England, Switzerland, Turkey, and now Egypt. More information can be found on our web site dedicated to this procedure with the phrenic nerve pacemaker.
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