Earlier this month, actress, Christina Applegate announced she'd undergone bilateral mastectomies for breast cancer. She reportedly possess one of the better characterized "breast cancer genes", BRCA1, which puts her at extraordinary high lifetime risks for developing breast or ovarian cancers. From the wire reports, she deferred reconstruction and plans on becoming pregnant after planned chemotherapy.

It sounds like she's received very mainstream advice for treating a younger breast cancer patient, particularly for a BRCA1 carrier. IMO these patients are excluded from consideration for lumpectomy procedures for treatment and should be strongly advised to consider prophylactic surgery on the other breast to maximally reduce lifetime risk of subsequent breast cancers. It's important to make sure patients understand that the highest risk factor for breast cancer is a personal history of breast cancer in the contra lateral breast. In young patients like Ms. Applegate, the math is even more persuasive for aggressive surgery as they have longer life expectancies during which breast cancers can develop. These patients are also frequently recommended to have the ovaries removed, both to suppress native estrogen production (which can stimulate some breast cancers) and to decrease the 40%+ increase in risk of ovarian cancer that brca1 confers.

I'm a little confused why they would not have proceeded with any part of her reconstruction at this point. She's trim enough that I do not believe she has enough bulk to do her reconstruction using her own tissues alone (probably using some microsurgical technique). I'd have strongly advised placing tissue expanders at the time of mastectomy to maintain the skin elasticity and you could later decide if you needed silicone gel implants or you could find an acceptable donor site for some autologous tissue to use. In a low risk patient, you really don't lose much by expander placement, while you realize an easier expansion process.




Rob

So B-list actor Gabriel Olds pens this piece for the August 2008 Glamour magazine titled, "Why men crave real (not perfect) bodies". It's funny when Jerry Seinfeld breaks up with a woman for having "man hands" in a classic Seinfeld episode, but you it's tacky when you're that frank in a print column.





Fine. You certainly can make thoughtful and plausible arguments why we all should ignore contemporary ideals of female beauty (real and imagined) and realize inner beauty for what it is. You do NOT have to do it in a dickhead tone of voice which alienates said women. Monsieur Olds quickly falls off the cliff quickly in that regard with his narcissistic article.

The women commenting to the article certainly had their fangs out over this:

I have breasts implants, and before I got them I spent my entire life being ridiculed by both men and women. I had absolutely no breasts. I was nothing but a nipple and I always felt like less of a woman. I couldn't find clothes that fit well, bathing suits were a nightmare, and shopping for bras was nearly impossible. I made the decision to undergo breast augmentation not because I wanted to be "perfect," it was because I wanted to be "normal".


I would like to say first, how presumptuous of Mr. Oldnutsack to assume that we should reveal our own medical history before we have even had the opportunity to see the size of his dick.(OUCH!)


I mean really, to dump someone/doubt their honesty because they didn't immediately tell you about a surgery?! I highly doubt you would go around telling first dates or third dates even, "I have ED. I have a dangling penis, so I take Viagra to make it perkier."


this author is SHALLOW. He had one superficial date with a women he is PHYSICALLY attracted to and he is writing her off! He is obviously not interested in getting to know her on the inside. I am a psychotherapist. People like him need to take a good LONG look at them selves and be honest about why they are afraid of intimacy. It is clear to any one reading this article that his motive was purely sexual. If the author wants perfection then he will need to accept that perfection is achieved by alteration and that anything natural has flaws. A word of advice: Try to shake your narcissism, mister. It's unattractive to women. Hey, are you sure she didn't dump you after she felt YOU up!



Rob
You read it here first!

Last April, we told you about a study of 33 doctors that showed video gamers make good surgeons, plastic surgeons included. It’s because of all the hand-eye coordination that develops.

On the heels of that study comes yet another, this time of 303 laparoscopic surgeons. The testers (doctors, not gamers) recommend that patients ask an important question before any operation:

“Doc, are you a gamer?”


This is not a shooting or driving game but a laparoscopic surgeon
hard at work operating on the patient across the room. The doc tells
where his surgical tools are -- and what they are doing -- by watching
the screen in front of him.
(Archives of Surgery photo)


Here’s how it all came about: Douglas Gentile, Ph.D., a psychologist at Iowa State University, and Dr. James Rosser, chief of minimally invasive surgery at Beth Israel Deaconess Medical Center in Boston, compared surgeons who play video games to those who do not. Results? Gaming docs rule!

“The most important predictor of surgical skills is how often surgeons played video games in the past and how much they currently play,” says Dr. Gentile. “So the first query you should make to your surgeon is how many times he or she has done the operation you are going to have. The next question should be ‘Are you a gamer?’” Read more.

Good Doctor of the Day Award - Dr. Paul Offit on autism and vaccines


I've mentioned in a 2007 post, "Mad Science", about the political issue of autism's and their alleged link to childhood vaccinations in the past as a metaphor for what we went thru with the debunked tort driven silicone breast implant (SBI) scare in the late 1980's. Unlike SBI's which are a cosmetic product, vaccines save lives. Lots of them!

A wrong headed attempt to blame first a preservative in some vaccines (thimerosol) and later the vaccines themselves for new diagnosis of autism has led to a dangerous public health situation. Pockets of non-immunized children can clearly serve the role of "typhoid mary" for pandemics of illness if history is any guide.

The number of new measles cases in the U.S. is at its highest level since 1997, and nearly half of those involve children whose parents rejected vaccination. According to the Las Vegas Sun,

It is no longer endemic to the United States, but every year some Americans pick it up while traveling abroad and bring it home. Measles epidemics have exploded in Israel, Switzerland and some other countries. But high U.S. childhood vaccination rates have prevented major outbreaks here.

In a typical year, only one outbreak occurs in the United States, infecting perhaps 10 to 20 people. So far this year through July 30 the country has seen seven outbreaks, including one in Illinois with 30 cases, said Seward, deputy director of the CDC's Division of Viral Diseases.

....The nation once routinely saw hundreds of thousands of measles cases each year, and hundreds of deaths. But immunization campaigns were credited with dramatically reducing the numbers. The last time health officials saw this many cases was 1997, when 138 were reported. Last year, there were only 42 U.S. cases."


Leading the voices of reason and evidence-based medicine is Dr. Paul Offit, who has a great new book coming out this whole controversy and breaks it down for a lay audience as to what the issues are and what the evidence shows. Linked below is a nice clip of Dr. Offit summarizing this.




Rob

Tattoos on Face = “I Really Like it Here!”

You’ve heard the expression about wearing your feelings on your sleeve, right?

Sam Bloomfield, 58, who was born on the island nation of Tonga, takes the old saying to the next level. He wears his feelings about his adopted country on his face…..in bold tattoos, below.


Sam Bloomfield
(Seattle Post-Intelligencer photo)


But it wasn’t always that way.

After Sam arrived in the U.S. in 1976, he found things in the U.S. so much to his liking, he painted his house red, white, and blue. Next, came a blue shingled roof. Then, flags and patriotic streamers seemed to sprout everywhere from his house.

After all that, where else but body art could a guy go, billboards notwithstanding? So Sam found a tattoo artist and told him to get busy. The artist did just that, amassing a bill of $1,500 for patriotic tats.

Currently, Sam’s skin includes somewhere around 100 pieces of skin markings, including the banners of 20 nations. He even bears on his back a yellow “Support Our Troops” tag.

Laser Surgery

But the day may come when Sam returns to Tonga or one of those 20 other nations and wants to be a bit more demur about his love for any one particular nation. If it does come to tattoo removal, Sam will spend a lot more than $1,500 removing the tats. Considering that one average tattoo requires two to five visits to remove, it would appear Sam would be in for somewhere between 200 to 500 visits to a dermatologist or plastic surgeon. The gross national product of Tonga would about cover the charges.

If you ever want to remove some of your own tattoos, here are three questions to ask a dermatologist or laser surgeon.
If you've ever watched professional sports events, you'll notice the cameramen have this habit of doing random crowd shots where they zoom in on pretty women pretty shamelessly. Women's beach volleyball coverage takes this to a whole new level.

Under the guise of "explaining the importance hand signals" during the match, NBC has about the most gratuitous photo gallery of women's backsides in teeny-weenie bikinis this side of Sports Illustrated's swimsuit issue. The whole idea of buttock aesthetics has received some attention in plastic surgery literature, and one of these days I'll write about it.

If you think I'm exaggerating about how blatant a T&A show the coverage is, please check NBC's gallery on the web which as far as I can tell was likely compliled by a 12 year old male NBC staffer!
Usually, in doubles competition, you have a server and you have his/her partner near the net. Crucial to a successful game play is a good line of communication between the players on a team as the court is a wide area for two players to cover. A lack of coordination between players will likely result in wide open spaces and a disjoint defense. It is up to the person nearest the net to call the shots and signal clandestinely to his/her partner what the intended game play is. In essence, the person nearest the net is the quarterback of the team.

There are 4 basic "modes" for each hand which is held behind the back to signal the other player. 'One finger' signals that the net player will block the opponent's spike down the line on the corresponding side of the hand. 'Two fingers' signals that the net player will block the opponent's spike at an angle cross-court on the corresponding side of the hand. A 'closed fist' signals that the net player will not block on the corresponding side of the hand. And finally an 'open hand' signals that the net player will block "ball," i.e. block according to how and where the opponent sets and swings.


I think this athlete's signaling she's wedging! :)




Rob

There's an op-ed piece in today's Wall Street Journal by one Betsy McCaughey which has my blood pressure up. The article titled, "Hospital Infections: Preventable and Unacceptable" implies that any hospital acquired infection was preventable and should be remedied with class action lawsuits.

For someone who's bright like Ms. McCaughey, she shows little insight and understanding apparently into what drives and perpetuates many different types of infections. Nobody disagrees that common sense steps like hand washing and protocols for invasive intravenous (IV) access maintenance are important in limiting infections, it is both a dangerous and disingenuous idea to suggest that a goal of ZERO is attainable. It is impossible to achieve a failure rate of 0% for system or process, particularly one with infinite numbers of variables (as with a human population of patients). Unlike a Toyota, no two models of the human assembly line are exactly alike (even identical twins gradual accumulate differences due to environmental exposure).

Patients with more comorbities are going to have higher infection rates PERIOD. An overweight, diabetic, smoker (a frequent demographic for vascular disease patients in my neck of the woods) who has open heart surgery has more problems then others and an increased infection rate is more attributable to the patient's behavior rather then the hospital. Obese patients and smokers have higher rates of problems after elective plastic surgery (like breast reconstruction or reduction for instance)as well for that matter. You can be sure at some point, hospitals (and doctors) will be looking at patient demographic data to exclude higher risk patients from treatment at their facility whatsoever.

In referring to a list of "never events" recently laid out by Medicare for which they will not cover the cost of complications she blithely writes
"No wonder Medicare calls these infections "never events" Why should jurors reach a different conclusion in a lawsuit."

This coming from a bureaucrat and politician is hard to take. While we should always strive to be perfect, it's important to realize that there are processes which we can all agree on to attain low and reproducible rates of infection.

For a related writing here on Plastic Surgery 101 see the post "Medicare announces they won't pay for complications - How the F*** is this going to work?" that I wrote last year.


Cheers!
Rob

It was so predictable as to be boring!

So I'm reading a particularly shameless trade journal this week who's cover story promised updates on laser liposuction. This monthly glossy magazine is essentially a series of (not so) stealth ads with physicians shilling for lasers and other products for which they're paid spokesmen. As the topic turned to laser liposuction systems (like Cynosure's SmartLipo) you saw a lot of pullback on exactly how enthusiastic a number of surgeons are.

"In reality, the degree of fat melting attained with laser lipolysis has not met the high expectations of some practitioners"
When you see comments like that in a fluff trade journal which routinely celebrates every device/technology (whether it deserves it or not) you know this issue is understated significantly. When you take mostly non plastic surgeons and hand them a "magic wand" like SmartLipo while promising great body contouring results, it's a set up for under delivering. There still is no shortcut on mechanically removing tissue for most patients. An exception might be some one's neck which has almost no fat to speak of.

This is kind of like the thread lift fiasco all over again. It's become clear that these laser platforms are much less revolutionary, but are more likely modestly complementary (if that) to the 30 year old tumescent liposuction techniques introduced to the west by a French surgeon named Illouz.

The general "off the record" feelings of most experienced plastic surgeons experimenting with this is that these types of devices are safe but offer no clear advantage. Repeatedly it's described more as a succesful marketing phenomena rather than a real improvement. It's still not established that delivering thermal energy below the skin affects "tightening" whatsoever, which is the whole gimmick of the laser. If it does, it doesn't appear to do it without still having to do most of the heavy lifting with traditional lipo.

In contrast to this unnamed aforementioned trade journal which is lame, I'd like to give a nod to editor Jeff Frentzen and Plastic Surgery Products magazine which frequently has good articles - like mine for instance


Cheers,
Rob

Note to self - Never tell a woman she has a witch's chin deformity


Doh!

Sometimes our terminology and analysis comes out of our mouth without thinking about how people may internalize it. So I'm at this event the other night celebrating my new partner's addition to the practice, and I made the innocent mistake of telling someone I thought they had a little bit of a "witch's chin" when they were asking me about what they didn't like about their own chin.




Big mistake!I think I've now scarred that girl for life as she's now fixated on it! While I was implying a subtle chin feature that only someone like me is going to pick up on, she's imagining I've called her the wicked witch of the west. That awkward moment has inspired today's sermon on chins.

Cartoons characters such as Andy Gump and Broom Hilda the Witch are best known for their exaggerated facial features. In Plastic Surgery we have borrowed these characterization helping us to describe features with the “Andy Gump Syndrome” or the “Witches Chin Deformity.”




An Andy Gump deformity is produced from not reconstructing the jaw bone (mandible), most commonly when cancer surgeries in that area require removal. In 2008, such mandible problems are treated by taking a piece of your fibula (a lower leg bone) and doing microsurgical reconstruction to transplant it to the jaw. I did about a dozen of those in my training and it's an elegant surgery. As I don't do microsurgery in practice or work at a hospital where such large ENT cancer surgeries are performed, I hopefully will never be asked to do something like that again!

A "witch's chin" deformity describes either an excess of fat and/or drooping of said fat on the projecting part of you chin. The surgical correction involves removing the bulk and suspending it to the bony part of your chin. Seen below is a representative picture of the condition and a graphic of one of the operations to fix it.















For all you ever wanted to know about witch's appearences in pop culture throught history, check out the neat "Sexy Witch Blog" from Australia.

G'day mates!
Rob
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