A Trendy Topic: The Past Decade of Plastic Surgery

As we inch toward 2010, it seems appropriate to reflect on the past decade in plastic surgery. Ten years ago, we were still in the dot-com economic bubble and plastic surgery was increasing in popularity, after a recession earlier in the 1990’s. Breast implants were becoming more and more accepted, with doubts about their safety having been largely dispelled, though it would be several more years before the FDA would clear silicone implants for general use. Another bubble may have burst, but breast augmentation has now overtaken liposuction as the most popular plastic surgical procedure in America. Plastic surgery in general has become much more accepted and attitudes more positive.

But lost in the big picture is the procedure that has actually increased the most. (This doesn’t count nonsurgical procedures, or Botox would be the clear winner with millions of patients treated.) Although only the 5th most popular procedure, abdominoplasty (tummy tuck) has gone from about 43,000 cases annually a decade ago to nearly 150,000 according to the most recent statistics, a nearly 5-fold increase. We even have a new term for the tummy tuck/breast enhancement combo, the “mommy makeover.”

Why the big run on tummy tucks? There are a number of possible explanations, one of which is the improvements in safety and technique for abdominoplasty. One technique that I have been a fan of is called the Progressive Tension Suture technique. (See my website for details.) Mostly though I think it is just women who are done with childbearing and looking to improve their lives now that the children are grown.

Botax axed

It may seem self-serving to criticize the proposed tax on cosmetic surgery and medical procedures such as Botox injections (hence the too-clever term "Botax"), but there is a long list of reasons why it is unworkable. Fortunately it appears to have been dropped from the health care reform legislation at least for now, replaced by a proposal to tax tanning beds.

So what's the big deal? isn't a "vanity tax" justifiable, just like the "sin taxes" on alcohol and cigarettes? For one thing, it dismisses all cosmetic procedures as being motivated by superficiality and obsession with unrealistic notions of beauty, which anyone in this business can tell you is plain wrong. Cosmetic surgery patients are just moms who want their old bodies back, or those trying to re-enter the workforce and find themselves competing with younger workers. Cosmetic patients are middle income, heart of America folks, and plastic surgeons are employers and small businesspeople trying to do their part to reboot the economy.

Maybe you don't buy that, but there are practical issues too. Here in Washington State there was a proposal two years ago to do the very same thing, and it was dropped as being unworkable. One reason is that it is deceptively difficult to separate what is purely cosmetic, and what is reconstructive or therapeutic. Take the case of breast reconstruction: it is so important to a woman's recovery from cancer after mastectomy that it is a federally mandated insurance benefit. But it isn't a functional breast, just a cosmetic facsimile. Rhinoplasty may be done to correct a breathing problem but a little cosmetic alteration is done at the same time; how much of the expense (including anesthesia and operating room time) is to be allocated to each part?And half of all Botox is used for therapeutic uses. One example of this is patients who have to pay out-of-pocket for it but do it to prevent debilitating migraine headaches. There's an idea for you: tax migraine prevention treatment. Washington State ended up deciding it was just too complicated to sort out, and fortunately the other Washington seems to have done the same thing.

Tanning salons on the other hand, that's an interesting proposal. Earlier this year, the UV lamps used for tanning were officially declared to be a class 1 carcinogen. My guess is that the business is already declining and this will only hasten its demise, with the projected tax revenues evaporating along with it.

Does vitamin C cause cataracts?

Finding solutions to difficult problems sometimes requires tossing aside assumptions and looking at things from a new perspective. Plastic surgery, at is best, consists of this type of creative problem-solving. In fact, the word plastic implies flexibility and changeability. But sometimes our assumptions are so ingrained that challenging them risks being seen as imprudent, if not reckless. The wisdom of taking vitamin supplements is one such sacred cow, though evidence consistently leads us in the other direction.

Albert Szent-Györyi, who won a Nobel prize for his discovery of vitamin C in 1937, said “Discovery consists of seeing what everyone else has seen and thinking what no one else has thought.” He would have been surprised to see how much attention vitamin C would attain as an anti-oxidant supplement, a theory in its infancy during his time. It’s something we take as gospel. I was giving a lecture recently on wine and health, and as I sometimes do I noted that studies have consistently found no anti-aging benefit to use of vitamins. Afterward, one of the attendees said she appreciated the points about wine but disagreed with my statements about vitamins. I gently replied that I am only the reporter on this, is just what the science shows regardless of what we have been told.

What makes it particularly difficult to grasp is that not only do antioxidant vitamins fail to show any benefits in terms of age-related diseases, they actually appear to be harmful. For example, vitamin E users have a higher mortality than those who don’t take supplements. And now vitamin C is implicated in causing cataracts, according to a recently published study from Sweden. But try Googling “vitamin C +cataracts” and all you will find is sites touting the benefits of C in cataract prevention.

Ultimately, it isn’t really complicated. Those who enjoy the best health are those who eat a sensible diet where the vitamins come from natural sources, in their natural context. And wine is a part of this diet; wine drinkers live an average of 5 years longer than teetotalers, and have better health overall.

Lessons from the world's first plastic surgeon

Judging from some of the ads I see, you would have to conclude that plastic surgery was a recent invention, with any number of people taking full credit. But while it may be true that plastic surgery as we know it is less than a century old, its roots go back more than two millennia. While I was in India last week, I noticed that there was an exhibit at the National Science Center Museum highlighting an Indian physician and surgeon from the 5th century B.C. named Susruta, who preceded Hippocrates by hundreds of years. He was a teacher, healer, inventor of many surgical instruments, and developed a cheek flap procedure for nose reconstruction, without a doubt the world’s first plastic surgery. A variation of that is still used today.
So what does this mean for plastic surgeons today? For one, it is humbling to think of the long heritage of innovation and service that we inherit. It reminds us that we should try to create a lasting contribution to the specialty, and treasure the opportunity to make a lasting difference in our patients’ lives. Particularly during the holiday season, we need to remember that our talents are a gift. So while the poverty in India is indeed overwhelming, I am richer for the experience of having gone.

Bollywood Masala: My India Report

Inspired, perspired, impressed, depressed: like India itself, the operative word for my experience there this past week is “contrast.” No question India is worth seeing, not just because with 5 times the U.S. population it is by far the world’s largest democracy, but because despite all of its challenges it is doing a lot of good things. As it turns out, I was there on the one-year anniversary of 26/11 (November 26th), the terrorist attacks on Mumbai and other sites. India has comported itself well in the aftermath of that tragedy, and the commemorative observances were moving.
I was there to give a paper at the IPRAS meeting (International Confederation for Reconstructive, Plastic, and Aesthetic Surgery) in New Delhi. It was interesting to be on a panel with plastic surgeons from Brazil, Columbia, Iran, the U.K., and Portugal. The IPRAS meeting was more than just a meeting of the minds though, it was a source of inspiration in itself. Plastic surgeons around the world have long been able to put aside political differences between governments and work together in the interest of service. Through partnerships with organizations such as Doctors without Borders, and a new effort called Women to Women, IPRAS has fostered efforts to care for burn victims (mostly women) and children with birth defects, where access is limited either by cultural customs, lack of funding, or both. The challenge remains a large one, but encouraging progress is being made.
Of course there was some fun to be had, and seeing the Taj Majal is a worth the effort. We just missed seeing Ben Kingsley (Academy Award-winning actor who played Ghandi) there by a day. He is doing a movie based on the life of Mumtaz Mahal, the wife whose love inspired the Taj.

What's with the attitude? Views on plastic surgery around the world

With Botox annual sales approaching $1 billion, and breast augmentation and liposuction in the hundreds of thousands of cases each year in the U.S., it would seem that people who haven’t had “a little work” done would be the exception. There are still those who don’t “approve” of plastic surgery, but annual surveys by the American Society for Aesthetic Plastic Surgery show attitudes are steadily becoming more positive. It’s not a uniquely American thing though; when I was in Argentina and Brazil a couple of years ago for an international plastic surgery conference, it was hard to escape the impression that the South Americans thought they invented plastic surgery. They did have a head start on the cosmetic surgery side of the specialty, and attitudes have always been more favorable there.
It’s becoming a worldwide phenomenon. Korea, of all places, has the highest number of plastic surgeons per capita of any country, and a survey in Russia found that about half would “consider plastic surgery.” Rhinoplasty specialists are known to do a thriving business in Iran, and Turkey is becoming a destination for cosmetic surgery. I am off to India for a plastic surgery conference this month, and plastic surgery is becoming popular there among those who can afford it. Interestingly, the Dutch and Norwegians remain staunchly against it.
Whatever your view, there is a good side to all this. The more it is out in the open, the more scrutiny will be brought to bear which in turn will foster improved techniques and standards. One downside is that now everyone wants to be a plastic surgeon – often without the years of specialty training.

Enhanced results with lipo plus Thermage

As usual, the Hot Topics session at this week's meeting of the American Society of Plastic Surgeons served up a number of issues. I had the opportunity to present the data from our studies proving that Thermage given immediately after liposuction enhances skin tightening. The reason that this is important to prove in a scientific way is that skin shrinks all by itself after lipo, so additional shrinkage can only be claimed if it is demonstrated to be greater than what occurs normally. Patients who benefit from this are those who have some looseness to the skin, such that lipo alone would not give a good result, but not so much that they need something like a tummy tuck. This latter part is important because some plastic surgeons are pitching laser lipo as an alternative to tummy tucks. It's a risky proposition because I am already seeing patients who should have had a tummy tuck but chose laser lipo instead, and the results are not pretty.
To be fair, there was some data presented showing enhanced skin shrinkage with smart lipo (though not as much as with lipo-Thermage) and another suggesting that VASER ultrasound helps too. But each of these has its own risks and benefits, so for now my money is on the one designed to tighten skin in the first place.

Fat chance: Has the time for breast enlargement with fat injection arrived?

The annual meeting of the American Society of Plastic Surgeons (ASPS) is just about to wrap up here in Seattle. As a member of the Emerging Trends committee, I am involved in putting on the “hot topics” session, which always has a few zingers. I’ll be posting on some of those in the coming days, but the question of whether or not it is safe and effective to use one’s own fat for breast augmentation is front and center.
It’s a simple idea: why can’t we just take some fat out from the bottom, or the love handles, or some other area where it isn’t wanted, and use it to enlarge the breasts? Certainly, there can be no more natural means of breast enhancement. In recent years, techniques for fat grafting have improved a lot and they are being used to improve the results from breast reconstruction and some cases of implant augmentation, by smoothing out contours and irregularities. Why not just do it for the entire breast in the first place?
At the meeting there were a few reports of some success, but also a few cautionary notes. For one, the volumes used are low, with no more than a cup size or so of enlargement possible. Concerns about the grafts leaving lumps that interfere with mammograms seem to have been addressed, so that barrier is coming down. But a French surgeon reported some evidence from animal studies that it is theoretically possible that the grafted fat could stimulate breast cells, resulting in an unknown effect on the risk of breast cancer. There is no evidence of this in humans, but it is a sign that we should proceed cautiously. So stay tuned, but don’t expect every plastic surgeon to be offering the procedure in the immediate future.

Winterize your skin

The Seattle rain festival appears to be in full swing, but forecasters are predicting clearing by June or July. In all seriousness though, it’s time to think about winter skin care. We do love our sunshine, but given that skin cancer is the most common type of cancer, it’s not all bad to have a break. True, most skin cancers are of a non-aggressive type, but deaths from skin cancer are up 50% from the 1970’s, and melanoma-the deadliest type-has risen dramatically too. Even teenagers are now being diagnosed with skin cancer.
So the gray months of the year are a good time for what we might call “corrective” skin care. The basics are moisturizers, because of dry air, but more intense therapies are in order too. Skin peels leave the skin more sun-sensitive for a while so they tend to be less popular during the summer. Products such as tretinoin (Retin-A) are a mainstay of corrective skin care but again the issue of sun sensitivity limits their use for some during sunny times of year.
Just giving your skin a break from UV exposure is a good thing too, but don’t assume that there isn’t any just because the skies are overcast and the days are short. Sunscreen SPF only measures UVB protection from burning, but not UVA which is aging. The deal with UVA is that it penetrates window glass and clouds just as it does skin.
All of this has to be placed in perspective of course. Sun exposure converts cholesterol into vitamin D, and you should probably be taking a D supplement especially during the winter. But there is a growing movement of “sun haters” who take matters to the extreme. So while I do recommend “pleasantly pale” over “terminally tanned,” let’s not get carried away.

Anti-aging: a "Nobel" cause

Mark Twain famously said “Age is an issue of mind over matter. If you don’t mind, it doesn’t matter.” Great advice to be sure, and there is ample evidence to support the notion of a healthy attitude as an anti-aging strategy. But of course how the body ages is important too.
I spend much of my time practicing what is called anti-aging, but the term has lost some of its meaning in recent years. What we call anti-aging these days has more to do with restoring the appearance of youth more than with slowing the aging process itself, or at least steering it in a healthy direction. Recognition of that fact is one of the things that motivated my book Age Gets Better with Wine, out next week. But the science of anti-aging is regaining credibility, as evidenced by last week’s announcement of the Nobel Prize in physiology and medicine. Three Americans-Elizabeth Blackburn, Carol Greider and Jack Szostak-were named winners for their chromosome research that has profound implications for cancer and aging.
Here’s what they found: whenever a cell divides, which it must do in order to heal a wound, refresh the skin, and rebuild organs to maintain their function, it must replicate the chromosomes that hold the DNA programming code. This is accomplished by a sort of unzipping of the DNA strands, but at the end of each one is a sort of cap like on a shoelace called the telomere. These normally limit the number of times the DNA (and therefore the cell) can replicate, but an enzyme called telomerase rebuilds the telomere. In cancer cells, this goes on continuously and out of control, but for anti-aging it may hold the key to extending the cell’s replicative lifespan. This in turn translates to healthier organs, glowing skin, and a sharper mind.
A lot remains to be learned about this process, but the promise is more than enticing. In the meantime, focus on that positive attitude and healthy lifestyle.

Is beauty truly in the eye of the beholder?

I may not be a beautician with a scalpel but thre is no question that I am in the beauty business. As such, I spend a lot of time thinking about beauty. There are even academic books on the history of beauty, and when you put it all together it becomes obvious that superficial beauty is meaningless without inner beauty. When we think about beauty being in the eye of the beholder (an idea first put forth in classical Greece but written in its modern form in the 1878 book Molly Bawn by an author going by the pseudonym "The Dutchess"), it would seem that it is up to others to decide. Some find this a liberating idea, assuming that all that matters is how we feel about ourselves, but like so many aspects of human nature it is more complicated than that.
What it comes down to is that how others perceive us matters whether we like it or not. When we express a positive attitude, others will respond in kind, and that in itself is a beautiful thing. But that isn't to discount physical appearance completely. How we take care of ourselves, our own sense of confidence, is manifest in appearance, and that has tangible benefits too.

What is the best antioxidant?

Everywhere you turn these days you see advice about getting more antioxidants in your diet, in your skin care products, and your vitamins. The theory about oxidative damage as a major factor in aging has been around for several decades, and it’s a good one. It’s those products of metabolic combustion (we are essentially burning caloric fuel with oxygen) that cause so much damage to our DNA, which in turn means the proteins and other things that constitute the tissues of our bodies improperly manufactured. Eventually, things just break down. So if we can limit the oxidation, we can slow down aging.
That’s where antioxidants come in. For years, faith was placed in the antioxidant vitamins (A,C, and E) for salvation, but every major study has found no benefit to taking supplements above the recommended daily allowance. It’s not for lack of studies, there are actually dozens of them, there is just no benefit and it appears that it may actually be harmful. But don’t look to this lack of effect to question the antioxidant theory, it’s just that there are better antioxidants out there. These are a family of molecules called polyphenols, which include the pigments in berries and fruits, and the now famous extracts of wine such as resveratrol.
So which one is best? I’m banking on the wine polyphenols. A couple of years ago, I tested a skin care product containing resveratrol at the same concentration as another antioxidant called idebenone in the product Prevage. Previously, Prevage had tested their formula against all other antioxidants out there: alpha lipoic acid, vitamins, you name it. Prevage announced that it was the strongest antioxidant on the market. But using a standard antioxidant test called ORAC (there are different ways to measure antioxidant potency) we found that the resveratrol product was 17 times stronger.
So rather than pumping vitamins, it makes the most sense to just eat whole foods with antioxidants already in. These include pigmented berries, pomegranate juice, acai, and of course red wine.

Have the Amish taken over the FDA?

The Amish must have taken over the FDA. How else could their recent proclamations be explained? This week they sent a letter to Allergan, the makers of the eyelash-growth product Latisse, requiring them to suspend their marketing materials until they could be suitably revised. The concern is that they weren’t emphasizing the potential risks enough. I emphasize “potential” because the primary issue troubling the FDA seemed to be that Allergan was downplaying the possibility of a problem that could occur with a different product containing the same active ingredient, a condition of iris pigment change in a small number of patients. In that case, the product is an eyedrop formulation for glaucoma treatment; in other words, it is placed directly into the eye, unlike Latisse, which is placed onto the skin of the eyelid. So even though there is not a single reported case of Latisse causing iris pigment change, the FDA felt that mentioning the risk as relating only to a “similar” drug was not scary enough. Come to think of it, there are a lot of things that we put on our skin that could cause problems if you get some in your eye. Apparently the FDA just wants women to be plain.

But there’s more to my theory that the FDA is being run by a fundamentalist cult that scorns modern beauty technology. They have also recently updated their requirements for Botox labeling, requiring that practitioners hand patients a “Medication Guide” listing a range of effects than can occur from the toxin spreading beyond the injection site, causing things such as difficulty speaking, trouble breathing, even loss of bladder control. It’s a pretty frightening document until you come to the part about there not being any confirmed cases of any of this happening at the recommended doses. In fact, like Latisse, Botox is an extraordinarily safe and effective product when used properly. It is a bit like having a requirement reminding people every time they start their car that driving 80 miles an hour through a school zone is probably going to cause problems. Or perhaps we should all go back to the horse and buggy. But whether you are following the FDA’s guidance or walking behind a horse, either way you need to watch where you step.

How long do breast implants last?

One of the most frequent questions we get about breast implants is how long they are supposed to last. Our good friends at the FDA have added to the confusion by requiring disclosure that implants will probably need to be replaced every 10 years, so patients naturally assume that is the case when they read it. That would indeed be quite a commitment, but on the other hand the manufacturers of breast implants also have a lifetime replacement policy so that if the implant ever does develop a hole on the outer shell they will provide a new one free. Obviously they are not planning to do this every 10 years.

One reason the actual number is so hard to pin down is that implant designs and manufacturing standards continue to improve, so data from implants made 25 years ago isn't really applicable to implants made today. Another reason is that patients tend to drop out of studies over time, valuing their privacy over the need to contribute personal information to long-term clinical data. And of course people move, names change with divorces and marriages, and just keeping track of a large population of women with a specific type of implant is impossible over the long run. Adding to the problem is that most implant "ruptures" (really the wrong word) are silent and harmless events. So it isn't for lack of effort that the long-term data is hard to come by.

There are some numbers to go on though. Prior to FDA approval of silicone gel implants a couple of years ago, statistics from what is called the core study were submitted. In that group, the rate of "ruptures" was 2.7% at 4 years (for Allergan implants), implying that for the vast majority the implants will last a very long time. In my own experience, having used the implants for some 15 years (initially as part of what is called the adjunct study), I can't recall a single silicone implant rupture from one that I put in. About 80% of our patients are now going with silicone, for a more natural feel than saline.

The implant index: Is cup size the new economic indicator?

A retired colleague of mine came up with the idea that plastic surgery bookings are a marker of returning consumer confidence and predict a rebound from a faltering economy. If that is the case, then we are headed in the right direction. One sign is that women who have been postponing their facelifts are no longer waiting, and breast augmentation is more popular than ever.

But I have noticed another trend. It appears that no only do hemlines come down during a recession, but the choice of breast implant size drops too. Interestingly, while breast augmentation surged past liposuction to claim the number one spot in cosmetic surgery popularity despite economic woes last year, the implants seemed to be smaller after years of edging ever larger. The smallest category, 300 cc’s or less (a full “B” cup for the typical patient) increased from less than a third of all patients to about half, in tandem with more widely recognized economic indicators. Breasts were almost literally shrinking as our economic institutions collapsed.
There is of course no way of knowing why this should be the case but I have a few ideas. (It isn’t cost, all implants cost the same regardless of size.) Women in the Northwest have always favored a more natural look, whether it be with their facelift or their breast implants, but in some parts of the country it became almost a status symbol to display the results of the plastic surgeon’s touch. Fake became the new natural. But when so many started feeling the pinch of the recession, flaunting one’s assets became less fashionable.

According to a recent article in the Wall Street Journal, fashion trends are definitely moving in the direction of a less edgy look, and the models being featured most prominently during Fashion Week reflect this. Managers at Elite Model management are quoted as saying that models like Joan Smalls are more “commercially viable” because they fit the natural aesthetic. Models with the classic look are replacing the ones with more exaggerated features.

Whether or not this is useful will depend on how the Implant Index performs during the return to economic stability. If it holds true, the “C” cup economy is where we want to be. It certainly makes more sense to me that some other ideas that have been proposed, like the size of boxer shorts (true!), but in any case signs are positive. Meanwhile, I will continue to focus on the natural look regardless of size.

Calling all collagen

For all the talk about collagen, the primary structural protein of which we are made, there remains a fair amount of misinformation about it. Here’s a primer: The collagen molecule is composed of long coiled strands, or fibers, which interconnect and weave together to form the matrix of everything from skin to tendons. There are different types, such as elastin, which as the name implies contribute more to flexibility. And like all molecules in the body, collagen is continually broken down and replaced. However, with age and environmental damage, the new collagen has defects, which leads in turn to the visible signs of aging in the skin.

So the real question is how do we encourage new healthier collagen to form? There are several strategies, the primary one being prevention. This involves all the simple things like sunscreen. A healthy diet may be helpful, but only in a general sense. Consuming the tendons rather than the more tender portions of meat, a common practice in Japan, is unlikely to make a difference. Vitamin C is often touted, both in the diet and as an ingredient in skin creams. The logic is that since it is a co-factor for the enzyme that builds collagen (which is why the disease scurvy develops when it is absent from the diet), extra C builds better collagen. But while it is true that collagen can’t be adequately made if it is lacking, extra doesn’t drive the process any faster. The worst idea of all is collagen or elastin in skin creams; skin is a barrier to prevent large molecules like these from entering. So it’s like throwing bricks at a wall and expecting them to somehow be taken in and make the wall stronger.

There is hope though. One sure fire way to encourage new collagen is to recruit the body’s healing processes by essentially creating a controlled injury. This is how chemical peels and lasers work. Thermage functions this way too, and has the advantage of no downtime. And because it works by building new collagen, the results are long-lasting.

The cup size question

One of the most common questions we get is what breast implant size is needed to achieve a certain cup size. Real Self, the website where people can ask questions of plastic surgeons, has a question on that almost daily. The problem is, there is no simple answer because the cup size system of bra sizing is just not very scientific. It's an indirect measurement of the breasts, inherited from more modest times. The modern bra dates to about 1914, though the oroginal design was intended to flatten the breasts as the "flapper" style was in. The inventor of the bra, Mary Phelps Jacob, sold the idea to the Warner Bros. Corset Company for $1500. In the 1930's, when a more voluptuous figure was in fashion, Warner Brothers introduced the familiar A-D cup system. They reportedly made millions on their original investment.
Breast implants, now the most popular cosmetic surgical procedure, come in a variety of dimensions and sizes, but cup size is a combination of chest size, breast size, and shape. For that reason, there is no single implant size that correlates to a given cup size. I always recommend that the desired cup size should be a starting point, and so we have patients use a bra of that size and try samples tucked into the bra. In the end it's best to pick what just looks right.

skin tightening with liposuction

We all know that liposuction is for recontouring areas of localized fat that doesn't respond to diet and exercise, and tummy tucks and the like are needed where the skin is loose (among other things.) But a lot of people fall in between; there isn't enough loose skin to justify a procedure like a tummy tuck which leaves a scar and has a longer recovery, but it isn't elastic enough to snap back after fat removal with lipo either. Helping these patients achive a smoother contour and some skin tightening has been one of the biggest challenges in cosmetic surgery in recent years.
If you believe all the hype from the various marketing claims for laser-assisted lipo (all of those brand names that sound so slick) then you might assume the problem has been licked. I even had a pitch a couple of weeks ago that one of the laser lipo devices could replace tummy tucks! A good deal of skepticism is called for here, but progress is being made. There are some reports proving that using the laser will tighten skin more than happens with lipo alone.
About time I say, because two years ago I proved that you can do this with immediate post-lipo Thermage. I will have the opportunity to present it at the Hot Topics" session at the American Society of Plastic Surgeons meeting in October. But the bottom line here is that none of these technologies do enough to replace tummy tucks, though they do have a place. We can expect all of them to continue to improve. The important thing is to be able to prove the claims and not inflate expectations ahead of what the technology can deliver.

Where does innovation come from?

I just finished reading a book called Art and Physics (yes I am that nerdy) the premise of which is that major developments in modern art have anticipated breakthroughs in physics. It is a bit of a far-fetched idea, but the author (a surgeon) makes a good case. Ultimately it comes down to integration of right brain thinking (spatial, artistic, intuitive) with left brain thinking (logical, mathematical). Albert Einstein recognized that his breakthroughs arrived through the door on the right side of the brain when he said "Invention is not the product of logical thought, even though the product is tied to a logical structure."
I finished the book on a flight back from a meeting with the people at Lifecell, the company that makes a graft material called Alloderm (and a new one called Strattice.) I started using Alloderm about 10 years ago for certain problems that are associated with breast implants, such as rippling and malposition. It turned out to be very successful and so I published the techniques. A lot of very smart people started working with the idea, and now it is becoming a standard technique with breast reconstruction. It turns out that Alloderm is regenerative tissue, meaning that it actually replaces missing tissue. The field of regenerative medicine is in its infancy but the potential is extremely exciting.
The original idea was not a logical one, but one that arrived by seeing the problem globally. It was a right brain thing.

Julia Child's anti-aging strategy

The success of the new movie "Julia and Julia" has gotten me thinking about putting up my own certificate from the Cordon Bleu cooking school in Paris, where Julia Child trained. It's true! Even though it was only one day, they still give you a certificate. It would look good on the wall with all of my other certificates (I wonder if anyone would notice).
Seriously though, the good news about the movie is that it has rekindled an interest in cooking, and a healthy way of living that Julia Child personified. The trend in recent years has been more toward fast food, processed almost beyond recognition and certainly beyond any real nutritional value. It's hard to believe that only recently margarine loaded with trans-fats was offerred as a healthier alternative to butter. We need to get back to what author Michael Pollan calls "real food"--things your grandmother would recognize. Anti-aging is of course more than Botox, skin creams, and a few nips and tucks (though they have their place); it's about whole foods in the diet. This includes fruits and/or vegetables with every meal, whole grains, that sort of thing. It just isn't that complicated. The hard part is finding foods not laced with high-fructose corn syrup and the like. Here's a simple rule: if it has artificial coloring added, then that means the good nutrients were removed and so it's probably not something to waste calories on.

Shedding some light on tanning beds and skin cancer

Think it’s a good idea to hit the tanning salon for some color before your vacation? Think again. A new report from the World Health Organization found that the ultraviolet-A (UVA) light in tanning beds, initially thought to be safe as compared to UVB, increases the risk of skin cancer markedly. An analysis of 20 separate studies concluded that the use of tanning beds before the age of 30 was found to increase the risk of skin cancer by 75%. Tanning beds are now considered to be a class I carcinogen, meaning that they move up from a “likely cause” to a “definite cause” of skin cancer.
This shouldn’t have caught anyone by surprise, as it has been known for some time that UVA is associated with premature aging of the skin, and cancer is one of the manifestations of the damage that occurs to skin cells from ultraviolet radiation. My suggestion is to use the spray tans if you must have some color, and get your natural sunlight exposure in the morning or late afternoon.

Do that which cannot be done

It is often said that plastic surgery is art and science, and it is true. So I draw inspiration from artists who innovate as well as scientists with imagination. Picasso once said “I am always doing that which I cannot do, so that I may learn how to do it.” Much of what is now almost routine in plastic surgery must have seemed impossible only a few generations ago; in fact as a recognized specialty it is less than 100 years old. (The term comes from the Greek word plastikos, which means to change form or restore.) How does one rebuild an ear or a breast using only available “spare” parts? That kind of creative challenge is the real joy of plastic surgery.
But surprisingly there are old ideas that seem to reappear in new packaging from time to time. The heavily advertised “brand name” facelifts look a lot like the descriptions of the very first facelifts, yet are heralded as dramatic breakthroughs. And too many plastic surgeons fail to update their skill set or way of thinking, preferring the safe, tried and true methods. There’s nothing wrong with safe and predictable, but we are in a world of rapidly evolving technology, and consumers (our patients) are being bombarded with information overload. Only some of what’s new and innovative is truly worthwhile, but it takes the sort of mind that embraces what seems impossible to learn what is.

"Paint by Numbers" Plastic Surgery?

Lately I have been thinking more about the relationship of art and plastic surgery. What usually sets me off on this train of thought is an article or lecture by some expert who has developed an elaborate mathematical analysis of the approach to a particular operation. While there are circumstances where numbers are important (for example matching the base diameter of a breast implant to the dimensions of the patient) but they can be misleading just as often. Take the example of rhinoplasty (nose reshaping): there are standards that can be referenced for every angle of every part of the nose, so that an “ideal” result can be achieved. So what is wrong with this “cookie cutter” approach?

The answer is that there is no such thing as an ideal set of proportions that works on every face, or every body. Consider for example the actress Penelope Cruz: a mathematical analysis of her nose would likely show that it is too long, the angle from the nose to the lip is too acute, and so forth; but she is widely regarded (and I agree) to be one of the most beautiful women in Hollywood.

There have been some intriguing articles written where people are surveyed as to which celebrities have the best features; who has the nicest nose, the most luscious lips, etc. A computer program is then used to cut and paste all of these favorites into a composite face, which usually ends up looking fairly bizarre. This is why these canons of beautiful proportion have been routinely debunked, but they reappear on a regular basis nonetheless. I call it “paint by numbers” surgery, like the kits that help you reproduce a “masterpiece” by just painting in the designated color onto the numbered spaces. The thing is, they never quite look like the real deal either.

Good Sport: Botox Competitor Dysport Successful

A few basics: Dysport (pronounced to rhyme with “miss sport”) is a product newly approved by the FDA for marketing in the U.S. where it is positioned to challenge Botox, which celebrates 20 years of clinical use. Both products are similar and work the same way. Both are used to relax muscles, either for medical conditions or aesthetic purposes, specifically “dynamic” wrinkles such as the worry lines between the eyebrows.
The arrival of a lower-cost alternative to Botox has already had an effect. Allergan, the maker of Botox, has announced a $50 rebate on cosmetic Botox injections this summer. We just saw our first series of Dysport patients in follow-up this week and all have done well, with results in about 3 days. The above photos are with maximum frowning attempt before (bottom) and 5 days after (top).

More info here.
Oh and the name? Medicis, the manufacturer, had planned to call it “Reloxin” but for practical reasons went with Dysport as it is known in Europe. It comes from its original indication for use, a condition called cervical dystonia (cervix means “neck” if you didn’t know) and its site of manufacture in Portsmouth, England.

A is for Aging, B is for Burning: Summer Skin Care Tips

We are experiencing an event in Seattle as rare as an eclipse: a sunny forecast for the fourth of July. Local tradition has summer officially starting on the 5th, perhaps some sort of punishment from the weather gods for our usually mild climate. One thing for sure is that the sunshine, siren-like, draws us outdoors; like Odysseus tied to the mast, extreme measures would be required to keep us inside.
So some loss of compulsion about wearing sunscreen is understandable, and my point here is not to begrudge anyone their moment in the sun. In fact, if you get some sunshine in the morning or late afternoon, you are actually converting cholesterol into vitamin D, which in turn has some anti-cancer benefits. But if you are frying in the midday, your skin will pay the price.
Just keep one important thing in mind: Your sunscreen’s SPF rating doesn’t tell the whole story, because it only measures protection against burning, which is due to UVB rays. That’s a good thing of course, but it is the UVA rays-the same ones that you get in tanning beds-that actually cause the long-term aging changes in the skin. As yet, there is no universally recognized standard for UVA protection, so you need to look for it specifically. The easiest way is to look for the term “full spectrum” protection, or specific UVA blockers like Mexoryl.
Another simple thing you can do is make sure you include antioxidants in your diet. Since one of the best sources of these is berries and pigmented fruits, take advantage of blueberries and cherries in season. And stay well-hydrated, but please, don’t go for the sugary vitamin-enhanced drinks. Just do like Mom says: play outside for a while, get plenty of rest, and eat your vegetables.

Beyond the yellow brick road: More on Dr. Oz and resveratrol

A couple of weeks ago I posted a piece titled “A view from the emerald city” (meaning evergreen Seattle, of course) about Dr. Mehmet Oz’s endorsement of resveratrol supplements. During one of his appearances on Oprah, he spoke favorably about resveratrol, the substance from red wine that has such impressive anti-aging properties. Since reports about resveratrol’s ability to extend lifespan in certain organisms, and its possible anti-cancer, ant-diabetes, and anti-Alzheimer’s potential, it has been widely touted. In a couple of short years it went from a substance few had heard of (and couldn’t pronounce if they had) to the latest miracle cure available from literally hundreds of internet sites. Dr. Oz is featured as a prominent endorser for some, even giving the impression that the product is his own creation.
But there are a couple of problems. First, despite the promise of resveratrol as an anti-aging remedy, it has not been proven in people. More to the point here is that it turns out that Dr. Oz has nothing to do with any of these companies. He may wish he had if anything is eventually proven about their effectiveness, but my hunch is that it will be synthetically derived pharmaceuticals based on the molecular structure of resveratrol that will prove to be the real deal. There are some uses that make sense, such as in skin care, where it can be applied directly instead of depending on absorption through the digestive tract, but in general the resveratrol supplement market has all the trappings of the snake oil salesmen that used to roam the west preying on the naïve. So kudos to Oz for staying above the fray (or behind the curtain) and remember he doesn’t really offer anything that you don’t already have: common sense about diet and exercise for the heart, and the courage and wisdom to make the right choices.

Is the FDA’s oversight of tobacco a good idea?

The newly enacted law giving the Food and Drug Administration the authority to regulate tobacco has generated a lot of strong opinion. On the one hand, nicotine is a pharmacologically active substance and highly addictive, so it is hard to refute the logic that it should be regulated; and clearly there can be no dispute as to the enormous toll that tobacco use has taken in terms of life and health. Others see it as big government meddling in matters of personal choice, pointing out that our health and well-being is ultimately our own responsibility. I see it as naïve political posturing.
Here’s why: In the words of one of the senators who advocated for the law, the new authority will be used to immediately require larger warning labels, so that smokers will have to pause and reconsider before lighting up. The problem is that warning labels don’t work; it’s not like the ones that are there now are invisible. Smokers see them now just as they will when the warnings are larger. So what is really going on in the minds of people who consume a product labeled as likely to be deadly when used as intended? Understanding that is the key to understanding the decision to smoke, and to effective public health measures.
There is some information on this thanks to a technology called functional MRI (magnetic resonance imaging), or fMRI. This captures what is going on in the brain in real time. Martin Lindstrom, in his book Buyology: Truth and Lies About Why We Buy reports using fMRI to study the issue of warning labels and other factors related to decision-making. (The field of study is called “neuromarketing.”) Lindstrom was able to definitively show that warning labels have no effect on smoking cravings. This was true even if the subjects answered in an interview that the labels were a deterrent.
There are a number of potential reasons for this, but the point is that the science is way ahead of the policy-making process here, as with so many other topics. Requiring calories and fat content to be displayed on restaurant and fast-food menus seems equally unlikely to stem the tide of obesity, or admonishments on liquor bottles to prevent drunk driving.

Awake augmentation? Sleep on it before you decide.

Wouldn't it be great if, instead of having to decide before surgery what breast implant size you want, or having to leave it up to your surgeon, you could just be awake during surgery and have some input? That what some surgeons (notice I didn't say plastic surgeons) are doing. They use only local anesthesia so the patient is awake, and then a temporary expander is inserted which can be adjusted to preview what different sizes would look like. The patient gets to sit up and even have some friends or family weigh in. Sound like a good idea?
I can think of a lot of reasons why it isn't, and not very many why it is. Patients do like to have a say as to size, which is a good thing; in fact I insist that they make the final choice, with guidance as to what the limitations of their anatomy are. We have them try on implants at least two different times before deciding. But ultimately there is no way to make the process perfect, because what looks right at one point may not be later. There is a very typical sequence that goes something like this: Right after surgery, there is swelling and the implants haven't settled, so patients may feel they are too large; then after a few weeks, everything looks fantastic and they are proud of what a great decision they made about size; and after 6 months to a year, we might hear "I am happy with them, but if I had to do it all over again i would have gone a little larger." So a decision made during surgery really has no advantage in the long run.
But there are other problems. For one, doing an augmentation under local really won't work very well with implants under the muscle, which is how most of them are done and for good reason. so if the awake approach isn't limited to carefully selected patients, there will be a lot of fake looking results and unhappy patients. another is the question of sterile technique; having the patient sit up and look in a mirror may compromise the rules of sterility that are critically important whan placing an implant of any type. I could go on, but you get the idea.
Most telling is that the technique is being adopted by doctors with little training in plastic surgery. After nearly 20 years and thousands of breast implant patients, I can tell you that it is a lot more difficult to do consistently well than someone just embarking on breast augmentation can appreciate. So sleep in it, for a long time, before making a decision to do the wide awake augmentation.

O Suzanne

I almost hesitate to post this one, because I don't want anyone to think that I am down on Oprah, but the "crazy talk" cover story on Newsweek really hit the mark on some of the wacky things her misinformed guests have spouted over the years. Case in point is Suzanne Somers, who apparently has never seen a supplement pill she doesn't like. According to the article, whenever she drinks wine she detoxifies with high doses of vitamin C. This is exactly backwards! Wine polyphenols are much more potent antioxidants than vitamin C or any other vitamin, and vitamin megatherapy has been debunked in every major study that has looked at it. Typical of this way of thinking, the hard science is dismissed as a conspiracy between the pharmaceutical industry and miseducated doctors, as if she would be in a position to know. As a dedicated and honest physician, I can't begin to tell you how insulting and naive that is.
By the way, what ever happened to the thighmaster? One thing Suzanne Somers did get right was the importance of regular exercise. Time to start exercising some good judgment about supplements.

A view of Oz from the Emerald City

In case you didn’t know, we denizens of Seattle refer to our metropolis as the Emerald City, though mossy green would be a more apt label for the color chip. So picture my plastic surgery clinic here as a scene from The Wizard of Oz, when Dorothy and her companions first enter the wondrous city: snip snip here, snip snip there, and a couple of tra-la-la’s …
OK what this is really about is Dr. Oz, of Oprah fame, and his “real age” website that allows you to calculate your functional age based on your diet, exercise, and other lifestyle patterns. I have to admit that I have always been attracted to the idea, but their follow-up recommendations always seem to include vitamin supplements, which have been widely disproven to have any anti-aging benefit in the context of a normal diet. To their credit, they seem to have toned this down since I first checked them out a couple of years ago. Maybe they actually read some of the references I sent them, though they didn’t seem particularly eager to have their philosophy challenged, especially at the interface where vitamin sales produce revenue.
So now Dr.Oz is on the resveratrol bandwagon, selling his own brand of this compound from red wine that has gained so much attention as a potential anti-aging intervention. (CBS TV’s “60 minutes” reran their update on this on May 24th.) It is true that with more than 2400 scientific articles on resveratrol, a pretty strong case is made for its use; I have added an entire chapter on resveratrol to the second edition of my book “Age Gets Better with Wine: New Science for a Healthier, Better, and Longer Life” due out in July from the Wine Appreciation Guild press. Impressive results in lifespan extension and disease reduction in a variety of laboratory animals have been reported and resveratrol has practically become a household word. You can even find resveratrol pills at the vitamin section at most supermarkets now.
There is, however, one small problem: To date, no clinical trials of resveratrol supplementation in humans have been reported in peer-reviewed literature. In other words, the use of resveratrol supplements is as unproven as teleporation by clicking your heels together three times. A lot is still unknown about what actually happens to resveratrol after oral ingestion; what is known is that it is rapidly metabolized and altered. Clinical trials are underway, and there are reasons to be encouraged, but as of now that is all we have to go on.
It’s a gamble for Dr. Oz. If his support of resveratrol turns out to be a good idea, he will look like a wizard. (I do feel obligated to point out here that I was talking about this several years ago.) However, if it turns out to be less than miraculous in humans, he may well go the way of Linus Pauling, who staked his considerable reputation on vitamin C mega-dosing. In case you haven’t heard, it didn’t really work out.

It's a team effort

Plastic surgeons are generally not known for humility (or understatement I suppose). We are certainly fortunate to be in a unique position, one which is personally rewarding and when done for the right reasons, a benefit to our patients as well. While some dismiss our occupation as catering to the vain, we do help people to lead better lives. You get the point if you have been following my recent posts.
What I want to focus on in this post is the team of people who help it all to happen. To begin with, no matter how much talent a person has, they need teachers who have the interest and special capability to help others along. (When people note the expense of surgery, I explain that they aren’t paying for the couple of hours the operation takes, but the thousands of hours of training and education that precede the event.) It takes a generous spirit to mentor others.
Then of course there is the staff who assist me directly. If they don’t have a caring attitude and dedication, then the patient doesn’t have a good experience no matter how technically successful the surgery may be. I am fortunate to have long-term staff, a few of whom will have been with me for 10 years this summer. Our repeat patients, who may have gone several years between procedures, comment on how great it is to see the same faces when they come back.

Botox, Re-lox, black box; new toxins, new controversies

Pop quiz: What do Botox, Xerox, Kleenex, and Clorox have in common (besides alliteration)? The answer is they all are brand names that are interchangeable for the product itself. True, we most often say “photocopy” now instead of Xerox, but it is still common to ask for a Kleenex instead of a “facial tissue,” no? Similarly, Allergan’s Botox has become synonymous with Botulinum toxin type A, and the brand celebrates its 20th anniversary since FDA approval. But the FDA welcomed a new member to the family with yesterday’s approval of Dysport from competitor Medicis, best known for the popular wrinkle filler Restylane.

But as we have come to expect from our friends at the FDA, what the one hand gives the other takes away. Both products will come with what is called a boxed warning regarding potentially serious side effects. Given that there is a 20-year record of remarkable safety for Botulinum toxin, why the sudden concern? You can thank Ralph Nader’s misguided lobby, Public Citizen, which a year ago petitioned the FDA to look into reports of adverse reactions from Botox. These are of course the same people who stirred up all the trouble with silicone breast implants, which were completely vindicated in scientific studies.

Is there really a safety issue with Botulinum toxin? Most people know it only as a wrinkle reducer, which requires tiny doses and is harmless when properly used. But at least half of the market for this product is to treat spastic muscles associated with such conditions as cerebral palsy, which requires large doses, often in children, and a much greater potential for side effects. But the good that is done, improving quality of life for thousands to millions by increasing mobility for the disabled to preventing migraine headaches needs to be taken into consideration. The FDA’s acting deputy director of the Office of Drug Evaluation stated that “we don’t mean in any way to discourage” the use of these products, but given the way these things are misinterpreted by a public primed for panic, it rings hollow. I do take the FDA’s guidance seriously, I just want them to acknowledge and take seriously the political influences under which they operate.

Whether the new product will carve out a slice of the market remains to be seen. There are some subtle differences between the products from Allergan and Medicis, but clinical experience will tell if these are important.

Is plastic surgery an art form?

It’s no secret that I am into art; I collect art, I make art, and it colors my approach to plastic surgery. So in a sense I consider plastic surgery an art form as much as a technical tour de force, but a new exhibit at a gallery in New York makes the point literally. Apexart, in the TriBeCa district, has a new show curated by a plastic surgeon featuring “before and after” images and surgery videos. The patients are the medium, the operating room the studio. I haven’t seen the show, but I understand that it covers a range of procedures from pediatric reconstructive cases to facelifts.

The concept is interesting, but I suppose it was just a matter of time. Superficially, it seems perfectly legitimate to consider plastic surgery an art form, and I will be the first to defend the idea. But it also begs the question of what art really is. Plastic surgeons have long debated whether what we do is more science or craft; I am of the opinion that it is both. The downside to a show like this is not that it sensationalizes plastic surgery, but that it may oversimplify the question of art’s importance in a broader sense.

I am reminded of the recent case of a private college whose endowment fund evaporated with the economic collapse last year. They were forced to consider selling the one thing that had retained its value over the years: their art collection. Art isn’t merely a luxury, and its value isn’t arbitrary; according to Denis Dutton, author of The Art Instinct, making art is in our genes. And just take a look around to confirm that self-adornment and self-enhancement are impulses just as ingrained. It’s not a question of whether these are natural and normal pursuits but where to draw the line between good and bad taste.

I have a suggestion for the bad taste side: Another new art show, this one at the Weisman Art Museum in Minnesota, features a petunia plant. Named “Edunia,” the plant has a copy of one of the artist’s genes spliced in, making it technically part human (he calls it a “planimal”). In this case, using biomedical technology to create a living “work of art” just seems meaningless to me. Sure, the idea is provocative, which is the probably the whole point, but so what?

So I’ll stick with figure drawing and working toward bringing out people’s natural beauty with plastic surgery. Oh and I am definitely all about the new technology too, but I think of it as a tool and not the statement in and of itself.

Happy 50th Barbie

Much has been made of the symbolism of the iconic Barbie doll, who I’m told turned 50 last month. (No plastic surgery needed because she is plastic; her ludicrously long legs and other features setting an unrealistic standard of beauty; and even the jokes from her celebrated dumping of Ken because he was anatomically incomplete to “divorcee Barbie” costing more because she comes with most of Ken’s stuff.) But some take seriously the question of what Barbie says about a society that creates such a preposterously proportioned plaything. Do girls, and women, really aspire to be like Barbie?

At least one person has, a plastic surgery “addict” named Cindy Jackson who was born the same year as Barbie and who has made it her goal in life to become a sort of human Barbie doll. The reported cost of this plastic surgery transformation is in the range of six figures. Has this made her happy? You will have to ask her.

Plastic surgeons have become more attuned over the years to the problems that can go with this sort of plastic surgery compulsion. Patients who have serial plastic surgery without ever being truly pleased with their appearance often have a condition called Body Dysmorphic Disorder, or BDD. Fortunately this is not common, and most people who show up in a plastic surgeon’s office have healthy motives. They just want their old body back after having kids, or a less tired look to match their true energy level. Plastic surgery to please someone else or to try and live up to perceived societal expectations is always a bad idea.

But the truth is that Barbie really is more likely to end up with a fancy sports car and a swanky Malibu home. Looks do matter. And there is a place for plastic surgery, somewhere between the extremes of trying to be the human Barbie doll and acceptance of whatever our genetics have in store for us, no matter how unattractive. (We could continue that line of reasoning to birth defects, which few would argue should not be repaired, but these are at the end of a continuum of conditions that include merely disproportionate noses or crooked teeth.) The psychological effects of plastic surgery have been studied quite a bit, and they are uniformly positive when it is done for the right reasons. Self-esteem is improved, along with a generally more favorable outlook, leading to better measures of functioning in daily life.

Ultimately, it isn’t all that complicated. Plastic surgery isn’t a substitute for the things you can do for yourself with diet and exercise, nor is it a cure-all for every disappointment in life. As a rule, people really don’t want to be Barbie, they just want a restored version of themselves. Oh and Barbie?-Your AARP card is in the mail.

Hydration theory all washed up?

There was a feature on the local TV news recently about some new anti-aging product – I don’t recall what it was, but there was some controversy about its effectiveness – and the anchor wrapped up by summarizing what we all take for granted about anti-aging behaviors: get enough sleep, exercise, and drink lots of water. That last piece of advice seems to be widely applied, judging from the number of people lugging water bottles around as though they are concerned about suddenly wandering out of damp Seattle and finding themselves in the Sahara. Does drinking lots of water really make us healthier, or are we just wet behind the ears?

Intuitive reasoning bears on this behavior. By making an effort to drink more water, we are flushing out the “toxins” that are so harmful, right? And our skin needs lots of water so that it will stay well-hydrated and youthful, so it seems like a no-brainer. But there is a disconnect here between intuition and clinical science. What, if anything, can be proven about this theory?

Some have suggested that dehydration is an inflammatory state, and we do know that inflammation is an important underlying process in premature aging. But even that conclusion is based on pretty scant data. And to take it a step further by recommending extra hydration (as opposed to adequate hydration) is a wholly unproven proposition. There just isn’t any research data to back it up, and I have looked. Further, the notion that we can convince out bodies to bypass all of the normal mechanisms that determine how much water to hold on to and put some of the excess into our skin, or flush out more toxins, is a theory that just doesn’t hold water. Our kidneys are smarter than that.

You may be saying, “Well, it makes sense anyway, and what can it hurt?” Other than having to schedule your day around proximity to lavatories, there actually is a potential downside. Even water can be harmful in excess, as tragically demonstrated by a woman who died trying to win a water-drinking contest from a local radio show last year. That is admittedly an extreme case, but it illustrates how it is a possible to throw a lot of things out of balance by not simply listening to your body and drinking when you are thirsty. Our bodies are pretty well fine-tuned to inform us when we need a drink. So drink enough water, just don’t go overboard.

Plastic surgery down but not out

The 2008 statistics were released this week from the American Society for Aesthetic Plastic Surgery (ASAPS), which represents board-certified plastic surgeons who devote most of their practice to aesthetic (cosmetic) surgery. It’s an annual ritual and the numbers are dissected every which way to see what they imply about trends in plastic surgery and society as a whole. The statistics also measure nonsurgical cosmetic procedures.
So what’s the big news this year? Surgical procedures overall were down for the first time, by about 15% overall, which isn’t any great surprise given the economic climate. What few expected though was that breast augmentation is now the number one surgical procedure, overtaking liposuction, which has held the number one spot since ASAPS first started collecting the data 12 years ago. One likely explanation for the rise of breast augmentation (more than 350,000 cases last year) relates to the FDA clearance of silicone implants a little over 2 years ago. Since they give more natural results for many women, there may have been a sort of pent-up demand, and some women unhappy with their saline implants may have been changing to silicone. In a broader sense though, there is just more comfort now that silicone is in fact safe and people just tired of hearing otherwise when the science gave the implants a clean bill of health years ago.
There is a bigger message in the statistics if you look back over the past few years. Even though plastic surgery has more than doubled since the turn of the millennium, nonsurgical procedures such as Botox and dermal fillers have increased some 750%. The rise of cosmetic medicine, and the inevitable decline of more invasive procedures will be the theme in coming years. Of course there is a long way to go before nonsurgical procedures can truly compete in terms of results, but there are compelling benefits if they can. For now, it is one big happy family since the medical procedures for the most part do what surgery can’t and vice-versa, but watch for big changes down the road.

Botox and mood: It's a good thing

Billy Crystal had a character he played on Saturday Night Live back in the day who used to say "If you look good, you feel good darling" or something like that. Turns out, it's true, and even something like Botox can help according to a study just out in the Journal of Cosmetic Dermatology. Doctors at the University of Cardiff, in the U.K., evaluated mood in 25 subjects who received Botox to the worry lines between the eyebrows. The patients showed significantly less negative mood by standard measures, as compared to a control group. Specifically, subjects were less irritable, depressed, and anxious. This has actually been studied before and these results confirm those earlier findings.
There is more to this than might appear at first glance. The authors of this study point out that facial muscles are not just involved in expressing emotion, they are involved in the experience of emotion as well. The muscles between the eyebrows (called "corrugators") convey concern, anger, and worry. By relaxing them with Botox, the experience of these emotions seems to be lessened through a sort of biofeedback loop. An interesting question is whether this is also related to the effect of Botox in lessening the frequency and severity of migraine headaches for a large number of people. In any case, there is something to smile about.

patterns

It's funny how things seem to appear in groups. this week we had one day that had several mother-daughter consults together, the next was everyone from Alaska, and we seem to have gone through more Botox in the last week than the whole previous month. Surgery this week is mostly tummy tucks (abdominoplasty), while next week seems to be facelift week. We certainly don't plan things this way but that's the way it often works out.
The mother-daughter thing is not what many assume; it is simply a matter of mutual support. Mothers may feel that it is time to do something for themselves after raising a family, while daughters are often dealing with the more recent changes from childbearing. Sometimes there are issues that the daughter was born with such as asymmetrical breasts, and the young woman is now old enough to consider correction. Those who may criticise and say that we would all be better off learning to accept our flaws should walk a mile in their shoes first. We are not dealing with vanity here.
I am tempted to interpret the surge in Botox and fillers (Restylane, Juvederm, Evolence) as a sign that the economy is improving, though there are few other signs offering such encouragement. In at least one or two cases, it is people competing with younger professionals in a more tenuous employment market. Perhaps other people are just getting tired of hearing about all the gloom and doom and just wanting to get on with their lives.

The buzz on caffeine (It’s good for you)

It may come as no surprise to coffee-fueled Seattleites, but the latest research from the University of Washington here has caffeine addicts buzzing. Turns out that caffeine is not only a health food, but perhaps the next exciting skin care ingredient, according to UW skin cancer expert Dr. Paul Ngheim. I have been following the caffeine story for a while, even including some interesting data about caffeine’s healthful properties in the first edition of Age Gets Better with Wine.

This latest research is based upon findings from the UW and Dr. Allan Conney at Rutgers University, which found that caffeine protected mice from the effects of ultraviolet radiation, a known trigger for skin cancer. But as with many such findings, it wasn’t where they expected the research path would lead. They started with an evaluation of tea extracts, assuming that the polyphenols-antioxidant molecules similar to those found in red wine-were the active ingredients. Tea is known to have great antioxidant properties, and polyphenols have been shown in a number of studies to confer protection against UV radiation. But when the decaffeinated version failed to work as well as the full octane type, attention focused on the caffeine, which when tested independently turned out to be the key. Coffee, by the way also has good levels of antioxidants, and both coffee and tea drinkers enjoy lower rates of cancer overall.

But the news gets even better for latte lovers. Another large study out this month from Harvard found that caffeine consumption-whether from coffee or tea-was associated with a lower risk of stroke, particularly for women. There are actually several studies with similar results published in recent years. And does anyone remember the cellulite creams that were so popular a decade ago? They did work (although they had to be applied 5 times a day) and the active ingredients were caffeine and similar compounds. Caffeine seems to shrink fat cells too.

So if you will excuse me, I am going to make a run to Starbucks. Can I get you anything?

Wine, skin, and the spa experience

Many of you know about my ongoing interest in the use of wine polyphenols, especially resveratrol, for healthy skin. I had a chance to sound off on the subject in an article in the March/April issue of Spa magazine. They took notice of my published research in the Journal of Cosmetic Dermatology last year, in which I made the case that resveratrol and other botanical antioxidants are likely to be the next big thing in skin care.
Why all the fuss? To begin with, antioxidants are increasingly being recognized as important elements in anti-aging skin treatments, but the ones we have been relying upon for years--vitamins A, C, and E--just aren't potent enough. Even the active ingredient in Prevage, an enhanced derivative of coenzyme Q called idebenone, is 17 times weaker as an antioxidant than resveratrol. But it is the other capabilities of wine polyphenols that make it really interesting: anti-inflammatory, anti-cancer, and estrogen-like properties that may help the skin retain moisture. There are other ingredients contending for a role in the new science of skin care, such as acai, and a milk thistle extract called sylimarin, but the most extensively studied and head of the class is resveratrol.

Plastic Surgery at the Oscars

Normally I watch the Academy Awards for the same reasons many others do: to marvel at the fashions, dismay at the choices for the awards, and in my case critique the results of the stars' plastic surgery. This year was a pleasant surprise on many fronts though. Even though nominee Mickey Rourke has publicly bemoaned his plastic surgery experiences, he actually looked pretty good so maybe he has had some touch-up work done. In any case, my read overall is that the overdone look is out. We do know that both movie stars and ordinary people are still getting their maintenance work done, whether it is strategically placed Botox or a subtle enhancement with Restylane or Juvederm injections, but a more natural look is in fashion. That of course is what we have been doing here in the Northwest for quite a while.
A particular joy was seeing the short documentary "Smile Pinki" get recognized. This inspirational movie told the story of a girl with a cleft lip and palate from a poor section of rural India. Her cleft was repaired by a volunteer plastic surgery team working with the international organization Smile Train, one of many such groups. I can tell you from personal experience that there is no greater calling or reward than doing this type of work. It is a rare opportunity to make an intervention in a child's life that changes it permanently and dramatically for the better. Many plastic surgeons believe that for this reason, this is the "heart and soul" of plastic surgery.
Does that mean that cosmetic surgery is on the way out? Not by a long shot. Statistics do show that less invasive procedures are being done while some postpone their facelift or tummy tuck, but there are limits to how much can be accomplished without surgery. And surgical procedures are getting less invasive and producing more natural looking results anyway, so one way to view it is simply part of a long-term trend. Like the designers who displayed bright colors at Fashion week in New York last week, I am optimistic that good work will continue to be appreciated, whether it be fashion, plastic surgery, moviemaking, or any of the other endeavors that enrich our lives.

How does art inform plastic surgery?

I was at my regular life drawing group yesterday, and reflecting on how drawing relates to my "day job” of aesthetic plastic surgery. Plastic surgeons love to talk about artistry in their work, but it is actually a tricky thing to pull off. Surgery is partly a manual skill, but one that is fundamentally based on science. Art on the other hand is a "right brain” thing: more intuitive. At least that is according to Betty Edwards, author of the now classic work “Drawing on the Right Side of the Brain.” I had some interesting correspondence with her last year, as she had been invited to participate in a drawing course for plastic surgeons at our annual meeting and she was trying to figure out how plastic surgeons think. “Right brain” plastic surgeons tend to be less verbal during the surgery, as the verbal domain is on the left side.
In my view, the key is to be able to integrate both sides, truly blending the rational scientific side with the spatial, artistic side. It’s more difficult to do than it sounds, and it is something that I have consciously worked on over the years. But the artistic side needs to be freed up sometimes, just for its own sake. That is where the drawing groups come in. A little Mozart music, the model strikes the pose, and everyone just draws, saving the conversation for the breaks.
This right brain-left brain thing works both ways of course. Just as a surgeon needs to acquire a substantial base of knowledge in order to employ the best judgment about how to manage a case, artists need to study the techniques of the masters. And in both instances, the ability to envision the final result in the mind’s eye before starting is hugely beneficial. As my technical proficiency has increased with experience in performing surgery, my drawings have become more anatomically precise but perhaps less artistic. So it is a constant effort to keep the artistic side engaged in concert with the logical left brain. It helps me as a plastic surgeon and as an artist.
Check out a sample of my sketches here: http://www.baxterplasticsurgery.com/art_main.htm.

What is it about male facelifts?

I saw an interview with Sir Paul McCartney this week and couldn’t help noticing the work he has had done. (Perhaps I need to keep up more, apparently this was done last year.) I honestly don’t know the details, but in appearance at least he has now joined the unfortunate (in my opinion) ranks of other notable male facelift misadventures including the Olympic decathlete Bruce Jenner and country music legend Kenny Rogers. It’s sad in a way to see such accomplished people have such obvious work done. The best work always looks natural, and we wouldn’t all be talking about these cases if it did.
So what is it that went wrong? The common denominator is that they look feminized. This typically comes from applying the same strategies to men as with women. It isn’t so much the lower face-we all want a clean jawline and a smooth neck-but the upper face where it really makes a difference. Consider the upper eyelid/eyebrow: In a woman, the ideal brow shape is most often considered to be an arch, lower in the middle and with the highest point just lateral to the pupil. For men, we typically see a flatter eyebrow shape. So when the brow is lifted in order to “correct” a tired look, the brows often come up too much and arch more than they should in men. Related to this is displacement of the hairline; when the cheek and temple skin is pulled up and tightened, the hairline moves up and back, unless the procedure is modified to prevent this. That I think was part of Sir Paul’s problem.
The other treacherous area for men is the upper eyelid. A procedure called a blepharoplasty is usually done to remove excess skin that is hooding and contributing to the tired look. Often some of the fat is removed too, which removes bulges that can be part of the problem. In both men and women however, I think historically too much fat is removed, resulting in a hollowed look which paradoxically makes the patient look older. But especially in men, the look can seem like a vacant stare. Regardless of gender, each situation is different and a variety of techniques need to be considered in order to avoid ending up as fodder in someone’s blog about what went wrong!

Is Restylane a do-it-yourself product?

I saw a question on the website RealSelf.com today about buying Restylane online and self-injecting. I have heard this question before and I have to say it is surprising that anyone would actually even consider it. Restylane, like Juvederm and other dermal fillers, is a prescription product which means it is regulated by the FDA and can only be sold legally on the order of a physician. If there is a site selling Restylane directly to consumers, there is clearly something wrong. One likely possibility is that it isn't in fact Restylane at all. I have been treating a patient for the past several months who was injected with a product she was told was Restylane, by a beautician without any medical license or supervision. It turned out to be some unkbown product imported from China, and the complications have been very difficult to correct.
Just as important, acheiving good, natural-appearing results with dermal fillers requires a great deal of skill, training, and experience, not to mention basic sterile technique. It is definitely not a do-it-yourself product.

Snake venom wrinkle cure?

A hundred years ago there were traveling salesmen pitching health elixirs purported to cure everything from baldness to consumption. They became known as "snake oil" salesmen because that was often one of the "miracle" ingredients. (And the reason they were traveling salesmen is so that they would be long out of town before people got wise to the scam.) So now we see the latest wrinkle cure, a new face cream with a synthetic version of the venom from the temple viper, a type of poisonous rattlesnake commonly found in Thailand. According to the manufacturer, amino acids in the venom block nerve signals telling face muscles to contract, which helps stop wrinkles from forming. Snake venom has already been used in a lip-gloss called Lip Venom, which its manufacturer Du Wop says “plumps out the lips.” We are told that Gwyneth Paltrow is a fan of the product.
The idea may not be as outrageous as it seems though. A derivative of another type of snake venom has been in use to treat high blood pressure for years. In the case of the Du Wop product, it probaly works in a way similar to Botox, another toxin, though in this case applied in a cream rather than by injection. However, it would almost certainly not be as effective as Botox injections, and clinical trials are ongoing for a Botox cream, with promising results reported so far. Since Botox has such a long safety record, I think I'll wait for the topical version to be approved. (The snake venom product is sold at the British uscale department store Selfridges, but is not available in the U.S.)

Is there an Obama bump in cosmetic procedures?

It may seem like an odd question, but I saw it posted recently on RealSelf.com. Why would the new president be associated with an increase in Botox or liposuction? It remains to be seen whether this will prove to be the case, but perhaps there is some increased optimism out there in some quarters. Maybe people are just tired of hearing about gloom and doom and ready to focus on a few indulgences and morale boosters. On the other hand, a sour economy with little good news seems out of phase with what some consider vanity. But the age-old maxim about lipstick sales increasing during recessions is actually true, maybe people are just doing Juvederm or Botox injections instead. And with the job market becoming more and more competitive, maybe a fresher or less tired look is justification enough for “a little work” as long as it doesn’t look like it. Not long ago the “fake” look was actually a status symbol in some parts of the country, but natural is the key now.