Renaissance Plastic Surgery | Dr. Joseph Fata

My last blog was a call to action for the proposed 5% tax on cosmetic surgery. In addition to my blog, I asked all of my existing patients to write to their US senators and object to this tax. Thanks to all who did so and anyone and all who made an effort to have their voices heard. Although you probably already know, I am happy to report that this tax was removed from the final senate version of the health care bill.

What is news is that the entire health care reform is now in jeopardy. Senate democrats lost their crucial 60th vote when Republican Scott Brown won Ted Kennedy's Senate seat in a special election, and he used his opposition to the current health care bill as a central theme to his campaign. The irony that a Republican could win a Senate in a liberal state that has been represented by a Democrat since 1952 and at the same time replace an icon whose biggest interest was health care reform has not been lost on our political leaders.

Democrats, including President Obama, recognize that the people of Masachusetts have sent a message on behalf of the American people that our leaders have lost touch with our interests and needs. The cosmetic surgery tax was just one example of the arrogance that has been at play as they set about to "solve our problems."

Everyone agrees we need health care reform. However, there are two crucial components that have been ignored. The first is some type of reform to reign in the costs of defensive medicine (tests, referrals, and procedures done to avoid being sued). These costs are extraordinary because they happen in every office and hospital in the country every day. Physicians need to be able to practice without looking over their shoulders.

The second is the existence of hospitals and insurance companies publicly traded on the stock exchange. As long as they exist, they have one primary responsibility: to increase profits. As anyone who has taken Accounting 101 knows, there are only two ways to increase profits. The first is to increase revenue (increase premiums); the second is to decrease costs. Yes, you can decrease costs by decreasing payments to caregivers, but this path can only continue so far and then there is nothing left to hold back and no one left willing to deliver health care. In the end, the only way to continually decrease costs is to withhold care, which is what is happening right now, and this is the number one frustration of the 85% of American who have insurance.

It is mind boggling that our leaders could pretend to have solved the health care mess without any meaningful attempt to address these two issues. Since that is not going to happen, we are better off if the changes made are small so they are easier to fix when they fall under the law of unintended consequences.

An unexpected controversy recently developed in the U. S. Senate when one of the provisions included in the Senate version of the health care reform bill was a 5% tax on all cosmetic surgery procedures. This tax does not reflect any of President Obama's goals in health care reform of providing affordable insurance or lowering the cost of health care. Instead it provides a back door maneuver to subsidize a plan that our country cannot afford on the backs of a targeted group: middle class women.

The American Society of Plastic Surgeons estimates that 60% of cosmetic surgery patients earn between $30,000 and $90,000 a year, clearly placing them in the middle class. Therefore, the idea that this is a luxury tax being imposed upon the rich is incorrect. The Senate is trying to push cosmetic surgery into the same "sin tax" category occupied by cigarettes and alcohol. They are punishing hard working people who are considering cosmetic surgery to improve their self-image and self-esteem.

Any tax on cosmetic plastic surgery would be discriminatory. An estimated 90% of cosmetic plastic surgery patients are women, most of whom are trying to improve their appearance and self-image through procedures like breast augmentation, liposuction and tummy tuck. This statistic could not have gone unnoticed by our lawmakers. It would be hard to find another piece of legislation that so clearly targets and discriminates against women. We can only hope that the organized groups who claim to represent the rights of women will not let this go unchallenged.

Several years a cosmetic plastic surgery tax became law in New Jersey. The actual revenue collected fell 60% short of the original estimates, and the enforcement was expensive and problematic. The original sponsor of the bill publicly admitted that it was a mistake and asked that it be repealed. Haven't we learned anything form our past mistakes?

The only way to stop this unfair tax proposal is to let your Senator and Congressman know how you feel. I strongly encourage you to visit the webiste www.stopcosmetictax.org where your can write to your local lawmakers and let them know you are against this type of discrimination.

It has been 3 years since the FDA approved the use of silicone breast implants for cosmetic breast augmentation, and so it seems like a good time to look back on our experience thus far. Silicone breast implants were initially viewed with understandably great caution by women and plastic surgeons, and it took some time for them to eventually embrace silicone breast implants as a viable, and in some cases, better option for cosmetic breast augmentation. Some of the reasons for this gradual thaw include the word-of-mouth positive experiences of patients and plastic surgeons with this new alternative of silicone breast implants for breast enhancement.

However, it takes time to accumulate solid statistical information to support these anecdotal experiences, and at this time up-to -date data is hard to come by. Fortunately, we can access the research done in Europe on silicone breast implants where they have been available for a much longer time. One of the best studies came out of Denmark where they studied 1472 women from 1999 to 2001, 85% of whom had cosmetic breast augmentation (88% were silicone breast implants and 12% were saline breast implants).

They found that the most common problem was change in sensation to the breast skin and nipple, although in the majority of cases such changes are temporary. They also found that hardening of the scar tissue (capsular contraction) occurred in just 4% of patients and most of these were minor. Most importantly, only 1% of women required additional surgery for complications related to breast augmentation.

As we await further studies in the U. S. on the use of silicone breast implants for cosmetic breast augmentation, the experience in Denmark and other European countries should allow women to confidently consider silicone breast implants as a safe option for cosmetic breast enhancement although breast augmentation with saline breast implants still remains a safe option as well.

Breast augmentation has a secure position as on of the most frequently requested cosmetic procedures, and demand for breast enlargement continues to grow. One of the most frequently asked questions I hear in my practice is 'what are the risks?'

The risks of breast augmentation are well documented but fresh information and new insights are always helpful, which makes the recent publication of "Local Complications after Cosmetic Breast Augmentation..." a timely addition. This study is special because it comes from Denmark from the Institute of Cancer Epidemiology and so would have no vested interest in promoting breast augmentation. Also, 97% of women had silicone gel breast implants while the remainder had saline breast implants.

The most common early complications of breast augmentation were hematoma (blood collecting around the implant) in 1.1% of patients and infection in 1.2% of patients. Looking at long-term complications, they found breast implant malposition (5.2%) and change in sensation (8.7%). The change in sensation is curious because in the first 30 days it occurred in less than 1% of patients but increased over time. One possible explanation is that not all of the women returned for follow up visits and perhaps those with changes in sensation or other concerns about their breast augmentation were more likely to return, which would artificially inflate the percentage frequency.

Another encouraging statistic was the frequency of severe capsular contracture (hardening/tightening of the implant capsule), which was reported to be 1.7%. Overall, the frequency of hematoma, infection, and capsular contracture was lower than in previously reported studies. Oddly they did not have any statistics regarding implant leaks or deflations.

The researchers found that less than 5% of women required re-operation for complications over a 9 year span. The general conclusion was that the overall frequency of complications was low and should be reassuring to women considering breast augmentation. Although no single study is the final word, the general consistency with prior results supports the general experience of most plastic surgeons that breast augmentation is one of the safest cosmetic procedures.

Branding is a term that is more commonly associated with marketing, not plastic surgery. However, the explosive growth of non-plastic surgery practitioners anxious and willing to provide plastic surgery services has increased the demand for cosmetic surgery patients. Whereas plastic surgeons were once found by word of mouth, marketing is now an important component of success, whether we like it or not.

Branding in plastic surgery takes traditional advertising one step further. A surgical procedure, which may be the same as or slightly different from a known, established procedure, is given a catchy name. That name is then heavily marketed.If enough marketing power (read money) is put behind it, this "new" technique may even find its' way to a television talk show like Oprah. At this point, it becomes a "must have" procedure, performed by only the best plastic surgeons.

Traditionally, new innovations in plastic surgery were presented at meetings or in journals and shared freely. When a procedure is branded, the rights to using it (or at least using the name) are licensed, and the entry fee for plastic surgeons is substantial. To protect against plastic surgeons who may want to borrow these techniques, the technical details are closely guarded and as such are never subjected to any scientific scrutiny or peer review.

The most outrageous example of how low branding can go was recently provided by the company 'Lifestyle Lift', who promotes their version of a facelift. This company has multiple locations across the U.S. and has branded what it claims to be a new procedure with better results and less down time than a traditional facelift when by all accounts it appears to be a minor variation on known techniques.

Lifestyle Lift was accused by the New York Attorney General's office of the fraudulent activity of "astroturfing", in which its' employees went to internet message boards and posed as satisfied customers with rave reviews for Lifestyle Lift. They also developed separate websites, such as myfaceliftstory.com, under the deception that they were independent websites created by satisfied customers. Lifestyle Lift settled the case for $300,000 in fines and agreed to refrain from such practices.

Other companies have branded technology, such as laser liposuction under the brand "Smart Lipo", suggesting that this was a new and improved version of liposuction, although there is no clear evidence that it is any better than existing techniques. At least they resisted partaking in any fraudulent internet activity.

If there is a lesson in all of this activity it is the old saw "Let the buyer beware." Potential patients should understand that branding in plastic surgery is a marketing ploy just as it is in any other business. They would be better served by choosing a plastic surgeon based on his or her credentials, reputation, and previous results, and then trust that they would be given a recommendation based on what would best suit their individual needs.

Patients who suffer from migraine headaches often find a migraine event incapacitating, totally disrupting their lives until it passes. A cure has been elusive and sometimes it seems as if there have been as many treatments as patients.

What does this have to do with plastic surgery? It begins with a shift in the thinking of the cause of migraines from vascular (blood vessel) changes to muscle tension surrounding the skull. Also, since we began using Botox for the cosmetic treatment of wrinkles between the eyebrows, almost every plastic surgeon has had patients who have found relief from their migraine headaches after injection of the muscles between the eyebrows. Since Botox relaxes the muscle fibers that are injected, this pain relief is consistent with the theory that migraines are triggered by muscle tension.

These findings among others have resulted in a shift in treatment models, and now one of the approved uses of Botox is the treatment of migraines. In fact, many large migraine treatment centers, including the Mayo Clinic, use Botox injections as part of their treatment protocol.

Another link between plastic surgery and migraines is the procedure Endoscopic Brow Lift. In this cosmetic procedure, surgical endoscopes are used to elevate and reposition a sagging brow through small incisions behind the hairline. During a Brow Lift, which may be done with or without a Facelift, many plastic surgeons also perform various techniques to weaken or remove the small muscles responsible for the "squint line", the same muscle targeted in Botox injections. They have found that some patients have gotten relief from their migraines. The effectiveness of this procedure for migraine relief is currently being investigated.

Throughout its' history, the field of plastic surgery has been deeply involved in reconstructive procedures that improve function as well as form, and the treatment of migraines is just the latest example of this rich history of innovation.

For the past few years, I have been using a rapid recovery program, or "24 hour Recovery Program", for breast augmentation. This program has stimulated a great deal of interest because patients looking for breast augmentation are in a very active stage of their lives and no one wants the down time anymore. But the most common question is: How is it possible?

The answer is that Yes, it is possible, and it's really just a situation in which a lot of small changes can add up to one big change. The big change is the recovery time, and it is based on a time-motion study of breast augmentation by a plastic surgery group in Texas. Since that study, plastic surgeons have added their own modifications, and I have personalized my approach as well, although the principles remain the same.

The main sources of pain after breast augmentation are trauma to the ribs and muscles, bleeding, and external pressure. In my current protocol, I use muscle relaxants during surgery to reduce the strain on the chest muscles and I protect the ribs from any trauma. I also take extra time to minimize bleeding and I have eliminated restrictive bandages in favor of a comfortable bra to avoid pressure on the breast implant. By introducing these changes, all of the main sources of pain have all been addressed.

After surgery, this attention to detail is continued. Much of the post-operative pain is inflammatory, and so anti-inflammatory medications (ibuprofen) are used as the first line of pain control, ahead of narcotics. The other source of post-operative pain is muscle spasm, and so muscle relaxants (I think Valium is the best) are continued.

This approach has eliminated the need for narcotics in over 90% of patients. No narcotics means no drowsy, "doped-up" feeling and no nausea, which are the two most common side effects. In other words, you get to feel like yourself again very quickly. The only restrictions are no heavy lifting or strenuous exercise for two weeks. Other than that you can do anything you feel up to. This includes going out to dinner or shopping the night after you surgery. The same guidelines are used for silicone gel breast implants and saline breast implants.

Does everyone get back to work and play in 24 hours? Not everyone, but the majority of patients do, and the rest just take another day or two. Once in a while someone might take a little longer to bounce back, but that has been the exception, not the rule. No one approach works for everyone, but my "24 Hour Recovery Program" has reduced the average recovery time after breast augmentation in my practice from 7-10 days to 24-48 hours. Now that's progress.