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.