Renaissance Plastic Surgery

National news agencies have reported the tragic death of an 18 year-old girl in Boca Raton, Florida, after plastic surgery to correct asymmetric breasts. The reported cause of death was Malignant Hyperthermia.

An event such as this one is a tragedy of proportions that are unimaginable outside the family of this girl and our heart and prayers go out to them. Beyond the immediate event, it once again raises the question of the safety of cosmetic surgery and the role of Malignant Hyperthermia, a rare anesthetic complication.

While I would not present myself as an anesthesiologist or an expert on this disorder, I would like to share some information. Malignant Hyperthermia is a rare defect of specific receptors of muscle cells which manifest when exposed to a variety of anesthetic agents. The result is a massive release of calcium which puts the cells into overdrive, using up all of the oxygen and producing large amounts of carbon dioxide. Heart rate and body temperature rise rapidly and unless treated promptly, it is fatal.

Many cases have been successfully treated and the key is early diagnosis.The drug Dantrolene can stop this reaction and is the mainstay of treatment along with treatment of secondary problems, such as excess carbon dioxide, calcium and potassium in the bloodstream.

Malignant Hyperthermia is rare and I have come across statistics ranging from 1 in 5,000 to 1 in 60,000. It does tend to run in families and if suspected the diagnosis can often be made ahead of time with a muscle biopsy. Unfortunately, up to half of the cases reported describe a prior anesthetic with no problems at all and many do not have a family history of this disease

Sadly, it is very unlikely that this patient and her family could have done anything to anticipate this tragedy. However, it does reaffirm the importance of doing your homework. In addition to finding a board certified plastic surgeon, be sure that you will have a board certified anesthesiologist and that your surgery will be performed in either a hospital or a fully accredited outpatient surgery center. None of these precautions will completely immunize you from risk, but it only makes sense to do everything you can to make your surgery as safe as possible.

I was recently interviewed by a local news network on the topic of teens and plastic surgery, and and I would like to share my thought on this topic with you. Today's teen has unprecedented exposure to the media and one of the hot topics has been celebrity plastic surgery. Although the percentage of plastic surgery performed on teenagers has remained steady at 3% over the past 15 years, the overall number of cosmetic plastic surgery procedures has increased dramatically and so the increase in teens having plastic surgery has followed this trend. The question that begs to be answered is if this is a bad thing.

Unfortunately, the answer is not a simple yes or no because it depends entirely on the circumstances. Plastic surgery can be a very positive experience that can build confidence and restore a fragile psyche. Procedures to correct protruding ears, large humps on the nose and boys who have developed breast tissue can be rewarding to both the surgeon and the patient. However, plastic surgery that is not well planned and thought out can have unintended consequences that may damage both appearance and self-esteem.

As parents or teens approaching this topic, there are some guidelines that should be followed to help insure that having plastic surgery is a the right decision. First, the idea of a cosmetic procedure should originate with the teen, not the parent. It is almost never a good idea for a parent to suggest cosmetic surgery to a teen unless it is in response to a problem that has become a struggle for them. If a teen is satisfied with his or her appearance, leave it alone.

A second principle is to avoid surgery on any part of the body that has not completed its' growth, unless of course it is a significant birth deformity. This means that breast and body contouring surgery (liposuction, tummy tuck) should be delayed in most cases until a teen in out of high school and has reached adulthood. It is reasonable to correct protruding ears anytime after the age of five or six because this is often a source of cruel teasing and growth of the ear is almost complete. Surgery to correct a large nasal hump is also reasonable but it is best to wait until the age of 16 to not disturb growth.

A third guideline is to remember that plastic surgery is real surgery, not a trip to the spa or health club. It has real risks that need to be considered regardless of the fact that they occur very infrequently. Teens are not known for giving thoughtful consideration to potential risks and consequences. They will need their parents' help understanding risk. Along the same lines, plastic surgery should be part of a discussion between parents and their children as a solution to a problem. It should not be packaged as a graduation present or a reward for good grades. These practices are well-intentioned but often trivialize a surgical procedure.

The last point is that teens are in constant change, both mentally and physically. A problem of crisis proportions today may be a small blip on the radar a few months later. If an issue of appearance comes up, consider it seriously but give it some time. If it doesn't go away, explore it more deeply, gather all of the information you need, and talk to a plastic surgeon, preferably two. At that point, if you have followed all of these guidelines and it still seems right, you will in all likely hood make the right decision.

#1 Wrinkles are mostly caused by aging.

False. While aging is a factor in the formation of wrinkles, it is the least important one up until about the age of 60. In younger patients, the main causes of wrinkles and other signs of aging are smoking, excess sun exposure and excess muscle activity around the eyes and forehead. Prevention, a prescription-based skin care regimen and selective use of Botox are all effective tools to delay this process.

#2 A sunscreen with a high SPF gives complete protection.

False. Sunscreens protect only against UVB (Ultraviolet B) rays but do not block UVA (Ultraviolet A) rays. Also, most sunscreens block less than 90% of the UVB light so limiting excessive sun exposure through avoidance or protective clothing is still beneficial.

#3 Over-the-counter skin care products are as effective as prescription-based products.

False. Over-the-counter skin care products sold at hair salons and high-end department stores contain most of the same ingredients but at a much lower strength. One example is hydroquinone, a bleaching agent used for sun and age spots. The concentration of hydroquinne in over-the-counter products is 2% but the concentration in our private label Lightener is 4%. The same is true for glycolic acids and alpha-hydroxy acids.

#4 Acne treatment can accelerate aging.

True. Cleansing agents that contain benzoyl peroxide or hydrogen peroxide can produce free radicals, which break down collagen and speed up aging. Sun exposure also increases the presence of free radicals and so an anti-oxident, such as Vitamin -C, should be part of a balanced skin care treatment regimen.

#5 Skin damage and aging cannot be reversed.

False. The typical signs of aging skin are a rough texture, enlarged pores, brown spots and wrinkles. A new laser technology, known as fractionated treatment (Fraxel is one trade name), can stimulate the deeper layers of the skin to remove the pigment in brown spots and create new collagen to tighten pores and fill out fine wrinkles. It also stimulates the outer layer of skin to shed so it is replaced with a new and fresh layer of cells.

Although it has been over two months since the tragic death of Donde West, mother of hip-hop star Kanye West, it remains fresh in the minds of the public and has raised many questions about the safety of plastic surgery. My own read on the media coverage thus far is that there has been as much rumor as fact, and I would like to set the story straight as best I can.

The facts we know are that Donde West underwent the procedures of breast reduction and abdominoplasty, also known as a tummy tuck, possibly with liposuction on a Friday by Dr. Jan Adams, a plastic surgeon. The following evening, a little over 24 hours after her surgery, she was at home and found unresponsive. Paramedics were called, she was brought to a nearby hospital and she died later that night. An autopsy was performed but the results were inclusive.

We also know that Dr. Jan Adams was a high profile Beverly Hills plastic surgeon who has appeared on Oprah and hosted a show on the Discovery Channel. According to the American Society of Plastic Surgeons, he is not listed as a board certified plastic surgeon. It has also been reported that he was being investigated by the California Medical Board for multiple DUI convictions.

What we don't know is even more important. We don't know if Ms. West had a general medical evaluation prior to surgery by a doctor specializing in Internal Medicine, a routine practice for a 58 year old woman, although reports have surface that this did not occur. We don't know if the surgery was performed in a hospital, a licensed outpatient surgery, or the the surgeon's office operating room. We also don't know whether Ms. West had her surgery as an outpatient or if she was kept overnight for observation, and if so, where this post-operative observation occurred. The issue of post-operative observation is especially important because patients who undergo this combination of procedures are at some risk for post-operative bleeding and dehydration, which is easily treated but if left untreated could lead to cardiac arrest.

This tragedy is a cautionary tale and although all of the facts are not yet available, there is a great deal to be learned from it. First, being a celebrity plastic surgeon has no correlation to either one's skills or credentials. One could easily be a good celebrity plastic surgeon or a bad celebrity plastic surgeon. It has only to do with how well someone plays to the camera.

Board certification does not guarentee that someone is a good plastic surgeon either, but it does provide an independent and fair assessment of a surgeon's knowledge and competence. Why, one might ask, would anyone choose a plastic surgeon who wasn't board certified? Statistics from the American Society of Plastic Surgeons state that there are over 6,000 board certified plastic surgeons in the United States. The problem isn't supply and demand; it's the education of the public about the importance of board certification.

Perhaps the most important point is that while plastic surgery is extremely safe, it is not completely risk-free. There is not enough information to know if the loss of Ms. West could have been prevented. However, a thorough pre-operative medical evaluation by an internal medicine or family practice doctor, and having both the surgery and at least 24 hours of post-operative observation completed in either a hospital or licensed, accredited surgery center, are all steps that normally would have been taken in this case. If all of these precautions are taken in similar situations, then patients and their families can have the peace of mind of knowing that they have taken all of the necessary steps to ensure that their surgery will be as safe as possible.

An injectable filler is defined as any substance that can be injected into or under the skin to fill out a wrinkle or depression. These products are considered off-the-shelf in that they are commercially prepared and ready to use.

The original injectable filler was collagen and for many years was the only product in this category, which makes it the standard against which all other products are compared. Collagen has largely been supplanted by other longer lasting products, but it still has its proponents. In a recent review, the advantages listed were ease of use, versatility and long safety record. These claims are true but all of the injectable fillers have excellent safety profiles when properly used. It is therefore hard to justify in my mind the use of collagen because it is only marginally less expensive but lasts about half as long as most other products.

The most popular fillers today are those that contain hyaluronic acid, a substance which can be found in the cell matrix of the skin. Hyaluronic acid (HA) is identical across all species, whether it is found in a human or animal, so allergic reactions are not a concern. HA can be injected into superficial wrinkles or deep folds on the face or to enhance lip size, and it is most often used for wrinkles that will not respond to Botox injections, although it can also be used after Botox. The most popular products are Restylane and Juvederm. Restylane typically lasts 4-6 months and tends to last longer in areas of less muscle activity. Juvederm may last up to 9 months but it is more expensive.

An alternative longer-lasting product is Radiesse, which contains calcium hydroxyappetite in a suspension gel. The components of calcium hydroxyappetite occur naturally in the body so once again allergic reactions are rare. It is not as soft as HA and therefore must be injected at a deeper level, which makes it unsuitable for more superficial wrinkles. It is approved for use in the deep folds around the mouth but it has been used in other areas as well. It may last up to one year.

The potentially longest-lasting substance is Artefill, which only recently became available in the US. Artefill contains microspheres of non-absorbable methylmethacrylate in a suspension of collagen. The expectation is that as the collagen is absorbed by your body, it is replaced by your body's own collagen. A second booster dose will be needed in some patients who do not form enough collagen. It has been available in Europe and has been reported to last for years and it can be permanent. The permanence can be a disadvantage, however, if it is improperly injected and creates a visible nodule. Assuming it lives up to its published reports, it will be a very popular choice because it will eliminate the need for repeated injections.

The segment of cosmetic surgery that has shown explosive growth is not really surgery at all. It is the field of Non-invasive Procedures; that is, techniques that do not require the use of a scalpel. The most popular procedures in this category are Botox Injections and Injectable Fillers.

Let's begin with Botox Injections, a technique that everyone has at least heard about. Botox is made by the company Allergan and is the trade name for botulinim toxin, a purified, medical grade chemical that inhibits nerve endings at the point where they stimulate the muscle.

Botox was initially used to treat a condition of uncontrolled blinking, known as blepharospasm, by injecting it into the muscles responsible for blinking. As an unexpected side effect, the wrinkles around the eyes (the dreaded "crow's feet") softened and in some cases went away completely. It didn't take long for someone to realize that certain wrinkles were the result of repetitive muscle contraction and blocking the contraction would improve the wrinkles. And it took even less time for the same people to realize that there was a cosmetic application for Botox and a lot of money to be made.

The wrinkles on our faces that are primarily the result of repetitive muscle activity are the horizontal forehead lines, the "squint or frown" line between the eyebrows, the "crow's feet" around the eyes, and the vertical lip lines. By injecting low doses of Botox, a portion of the muscle is blocked and the lines will improve and in some cases disappear without affecting function. The earlier treatment is begun, the better the results. Wrinkles that have been present for many years will not disappear but will still improve. This improvement can be enhanced by also injecting filler material to fill out the creases, which will be covered in depth in the next blog.

Botox lasts about three months and so must be considered as a maintenance tool, albeit a very effective one. The reason Botox has become popular is an obvious one: it works! If used carefully and selectively it will not wipe out your facial expressions and make you look like one of the "Stepford Wives". Side effects, other than the occasional minor bruise, have been reported but are extremely rare, .

In a world that is increasingly demanding results with low risk and no down-time, Botox is a treatment that has delivered on its' expectations. In the next installment, I will review the available options under Injectable Fillers.

If you are a movie fan, you will probably remember Jack Nicholson's famous line in "A Few Good Men" when he told Tom Cruise, "You can't handle the truth!" Apparently he was not alone in that thought.This has also been the attitude of many non-plastic surgeons who advertise their services under the moniker of "cosmetic surgery."

Lawmakers in Florida decided that this practice has gone too far and have structured a remedy in the Truth in Medical Education (TIME) law. Under this law, health care practitioners must identify the license under which they practice. Any misrepresentation of medical qualifications is a violation of the "federal unfair trade and practices statutes" and would result in a $10,000 fine.

What this law means, in Florida at least, is if you go to a "medi-spa" for a Botox injection, the person doing the injection has to display or identify his or her credentials. If the practitioner does not demonstrate some sort of a license, such as MD or RN or Medical Assistant, then said license probably doesn't exist.

Another important aspect of this statute is that a physician cannot claim board certification unless he identifies the specialty in which he is certified. In other words, a physician cannot advertise himself as "board certified, specializing in plastic surgery" if he is certified by the American Board of Obstetrics and Gynecology. This is not meant to single out gynecologists, the majority of whom would never consider such a practice, but this type of misrepresentation is practiced by several specialties with alarming regularity. This law also restricts use of the term board certification to those specialties recognized by the American Board of Medical Specialties, which hopefully will limit the practice of forming new, unsupervised organizations containing "cosmetic surgery" in their name whose main purpose is to certify their members.

The American Society of Plastic Surgeons (ASPS) has publicly supported the Florida TIME law, praising it for raising public awareness of these questionable practices and increasing the transparency of qualifications for those who want to practice plastic surgery, which can only lead to more protection for patients. The ASPS is currently working to support a federal law that would provide similar protections to plastic surgery patients on a national level, but at this time it is currently residing in a subcommittee of the House Energy and Commerce Committee. If you believe in the importance of this issue as I do, contact your representatives in Congress and ask them to support this bill. Until we have this type of protection on a federal level, the catch phrase for prospective plastic surgery patients must unfortunately be: "Let the buyer beware."