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Breast implant-lymphoma connection debated

Although breast implants are without a doubt the most extensively studied medical devices on the market and are widely regarded as safe, a new report is raising questions about a possible connection between implants and a rare form of non-Hodgkin's Lymphoma called ALCL. Dr. Garry Brody, a Professor Emeritus of plastic surgery at USC, has been collecting a database about these rare cases, now totaling 25. Importantly, the tumor occurs in the scar capsule around the implants, not in the breast, and appears to be associated with a specific type of textured implant surface. A more important distinction is that these tumors behave in a very benign fashion and are highly curable by surgical removal of the capsule. This suggests that they are actually something other than ALCL despite the fact that they have all of the features of it under microscopic examination.
Although any report of cancer and breast implants is likely to be sensationalized, a cautious approach would be prudent in interpreting this story. In addition to the unanswered question of whether or not this is really a cancer, the incidence among women with implants appears to be in the range of one in a million, which could only be characterized as extremely rare. There will likely be other reports coming forth as the story is publicized, but given the number of women worldwide with implants, it is likely to remain a rarity. So in the good news column, place the fact that it is highly curable, and if it does have a causative link, it is to a type of implant that is less frequently used now (I have been using exclusively smooth-surface implants for augmentation for 15 years.) To keep this in perspective, it is the drive to the plastic surgeon's office that is the most dangerous part of breast implant surgery, not the implants.

Behind the scenes in a plastic surgery practice

While we hope that we make it look easy, there’s a lot that goes on behind the scenes to make a plastic surgery practice tick. It does simplify matters that I don’t do as much reconstructive surgery as I used to, so my day doesn’t typically start with hospital rounds anymore (I use the time to get to the gym instead.) We do surgery most days here in our accredited facility, which is a great convenience but also a lot of work to keep up to speed and comply with safety standards. Practices that do surgery in an offsite facility often have surgery days and clinic days, so some patients have to wait until the afternoon to start, all the while hungry and thirsty because no oral intake is allowed for anesthesia reasons. But maintaining all of the standards of accreditation for a surgery facility is time consuming work, including such things as regular inspection of all equipment, Advanced Cardiac Life Support certification by all clinical staff, quality assurance reviews, drills for emergency situations, and the like. And every case begins with a “time out” checklist, similar to what an airline pilot does before takeoff. I also serve as an inspector for AAAASF, the accrediting agency for our surgery facility ( http://www.aaaasf.org/consumers.php ), though our own inspections are of course done by an independent examiner.


There’s another aspect to my practice that isn’t typical, in that I use the same nursing staff in surgery as for patient consults, pre-op visits, and post-op care. The advantage of this is that the patient sees the same people before, during, and after surgery, which is a comfort and helps assure consistency. When the surgery is done at a facility separate from the practice, the surgeon has less control over the patient’s experience. The challenge is that my nurses have to possess the technical skills to assist in surgery as well as the people skills to work on the clinic side, and that is a special combination.

Of course before you ever get to the operating room, or the consultation room for that matter, you will have met the front office staff. Their challenge is finding time for all of the administrative chores involved in medical recordkeeping while still devoting 100% of their attention to you.

When it all works as planned, I find time for interesting clinical research projects, blogging, teaching, and learning. There’s not a lot of “down time” around here, and we (or at least I) wouldn’t have it any other way.

innovating the future of plastic surgery

I am off to Hawaii in a couple of days for the annual scientific meeting of the Northwest Society of Plastic Surgeons. I know you feel sorry for me, but you have to give credit to the society for including the state of Hawaii as a member, giving us an excuse to go there from chillier parts of the Northwest in February. As it turns out, I will be working, and I am just now putting the finishing touches on two talks I will be delivering. The first has the high-falutin’ title “Integrating the Future of Plastic Surgery.” If you are a regular reader here you will know that I am interested in trends, new technologies and techniques, and how we can best bring these to our patients for their benefit.


What I am going to talk about is an approach to problem-solving called integrative thinking, defined as the ability to reconcile opposing concepts by creating a solution that has elements of both but is something new and unique. I look at it as involving both sides of the brain, uniting the rational, verbal, linear left with the artistic, holistic, creative right. Einstein described it well: “Invention is not the product of logical thought, even though the final product is tied to a logical structure.”

So what does this have to do with plastic surgery? Plastic surgeons are after all inherently creative people, the word “plastic” implying a flexible approach. No two cases are alike, and so plastic surgery is often more improvisation than cookbook recipe. But as techniques have evolved, certain standard approaches have become the norm, and once this “source code’ is out, any surgeon can learn how to do it. Plastic surgeons now compete with a variety of doctors from other specialties moving into plastic surgery for economic reasons. A related phenomenon is similar to outsourcing; just as your tech support person is likely to be in India, thousands of Americans travel overseas for discount plastic surgery. All of this is based on left-brain thinking and it has been tremendously successful. But because it is based on standards that can be taught and copied, it becomes difficult to contain, and some plastic surgeons feel that we are losing ownership of our own specialty.

I believe the key to continuing success in plastic surgery is innovation. Patients want (and deserve) less invasive procedures delivering more natural results with faster recovery. Creating the innovations that fulfill these goals requires tapping into the artistic right brain, and as Einstein said, tying it to a logical structure. Besides, it’s fun.

Is your avatar having more fun than you?

No, this isn’t about the movie Avatar but it isn’t about the original meaning either (in Hinduism avatars are incarnations of deities.) In modern times, computer games have brought a broader definition to the term, for an assumed identity with whatever characteristics are selected. In other words a sort of alter ego, a double identity.


What does this have to do with plastic surgery? I got to thinking about it reading the book Connected by Nicholas Christakis and James Fowler, about the way social networks impact our lives in unexpected ways. In the book they note that our appearance affects the way people treat us, a topic I have covered here before. Whether we like it or not, attractive people tend to earn more for the same work, attract more friends, and have opportunities presented to them that similarly qualified but less good-looking people do. What’s interesting is the research finding that avatars in online games tend to take on personality characteristics and behaviors matching their appearance, rather than the player’s real-life persona, and other players in the games react to the avatar's appearance in predictable ways too. If like me you don’t play online games, you may still have noticed this sort of thing at Halloween costume parties.

I think there is an element of this phenomenon in plastic surgery. Young people born with a large or crooked nose, for example, who have a rhinoplasty before going off to college often blossom from wallflowers into happy, socially active adults. Women often feel more confident after breast implants, and men after some lipo. Sure, it may be noble to learn to live with one’s genetic inheritance, but keep in mind that appearance affects others’ behavior toward us as much as our own.

What I have observed over the years is that most patients aren’t trying to become a glamour icon and start behaving like celebrities, they are just looking for an improved version of themselves. Plastic surgery for them really does help them fulfill their dreams and improve their lives, and there are scientific studies to prove it. Of course it is possible to have a happy and fulfilling life without either having plastic surgery or winning the genetic lottery for natural good looks, but dismissing the whole notion as vanity doesn’t acknowledge how powerful even a minor transformation can be for some. In the meantime, I will keep working on my techniques to make people 10-feet tall, blue skinned and capable of riding flying dinosaurs. Come to think of it, avatars of Vishnu are often portrayed with blue skin …

Breast implants in athletic women

Women athletes arguably have more obstacles to overcome than their male counterparts, title 9 and lack of career options in professional sports notwithstanding. Lower natural levels of muscle-building hormones such as testosterone means even harder work to develop strength, and the lean build that is beautiful in so many ways becomes less feminine at the same time. There are several versions of attractive female figures, but for many athletes the desire to have at least a few womanly curves is natural. The choice to have breast implants is both personal and justifiable, yet opinions of the many seem to be given credence.
That is probably part of the reason why there has been so much media coverage of the decision of Australian hurdler Jana Rawlingson to have her breast implants removed. Apparently she has decent odds of medaling in the next summer Olympics but felt that the implants might get in the way. Frankly that is a little bit hard to imagine unless they were large to begin with, which is not a typical choice for an athlete in the first place. I wish her luck but if she does well it will be because of her dedication and training, not because she had her implants out.
The question of implants in athletes deserves serious attention from plastic surgeons who breast augmentation, though, because there are unique issues that need to be addressed. Ordinarily, with low body fat and small breasts, submuscular placement of the implants gives a more natural look. However, with a lot of muscle development that just isn’t a good choice for a number of reasons, some obvious and others not. I have been using an in-between option called subfascial implant placement (fascia pronounced like fashion) in cases like these. This provides support for the implants and more natural curves. Combined with small, usually low-profile implants, this results in more real-looking and proportionate breasts. Whether these breasts are truly more aerodynamic is another question.

Plastic surgery addiction: Fact or fiction?

Apparently we are supposed to care that reality TV star Heidi Montag has had a lot of plastic surgery, to the point that she has had to deny accusations of “plastic surgery addiction.” Liposuction, breast implants (maybe she thought that’s what the title of her TV show “The Hills” refers to), chin reduction, fat injections to her cheeks, revision rhinoplasty (updating her previous one), and more, all told some 10 hours worth. Even Nightline is weighing in on the subject, along with a People magazine cover story. And let’s not forget the news about Tiger Woods in treatment for sex addiction. Where does obsession end and true addiction begin?


I don’t know (and don’t particularly care) about Tiger Woods’ sex life, but the question of plastic surgery addiction is worth exploring. In a medical sense, there are strictly defined criteria for addiction; it involves compulsive, persistent dependence on a drug (substance abuse) or behavior (process addiction.) There are known to be genetic factors with drug dependency, and true addictions are associated with actual structural changes in the brain. Another consistent feature is withdrawal symptoms, which can be severe and even life-threatening with some drugs. These physical manifestations are one reason why addictions can be so hard to treat.

But the behavioral addictions – gambling, shopping, sex, maybe even plastic surgery – have more obscure origins. It appears likely that there is a large area of overlap between obsessive but controllable activities and what are commonly considered to be addictions. There is a known diagnosis in the plastic surgery world called Body Dysmorphic Disorder, or BDD, characterized by anxiety stemming from perceived defects in appearance. Plastic surgeons are well-tuned to recognize BDD because many of those with it become serial plastic surgery patients and are never satisfied. What else could explain the bizarre extents to which people like Jocelyn Wildenstein have gone? Counseling rather than surgery is the best treatment for these cases.
So does a marathon makeover surgery on an already attractive 23 year old represent a step on the road to addiction? Despite her announced plans to do more, Heidi Montag’s motives may be a simple case of an attempt to remain in the spotlight as the allotted 15 minutes of fame elapse. I can hardly wait for the next round of updates on the new and even larger implants.

Is Viagra the next cellulite treatment?

Every year or so the next great cure for cellulite appears. First it was creams, then Endermologie, then mesotherapy, then lasers with Endermologie-like roller massage, every permutation that biomedical engineers could think of to beat cottage cheese thighs into submission. Thermage has a cellulite tip, which works well but not for everyone. (http://www.baxterplasticsurgery.com/thermage.html) So a definitive treatment remains elusive.


It’s not for lack of trying. Since estimates of the number of women affected are in the 80-90 percent range, it is an enormous problem and women the world over are clamoring for a solution. But before I introduce the latest idea, we should look at why cellulite is such an intractable problem. To begin with, no one can say definitively what it is. That isn’t to say that we don’t see differences between the skin and fat in women with cellulite and men, or unaffected women; we just don’t know what causes those changes. The skin is thinner, and fat compartments tend to bulge into the skin, causing the characteristic upholstery-like dimples. Poor circulation seems to be an issue, and approaches to cellulite treatments often target this with methods to increase blood flow (back to roller massage.)
So someone (actually four doctors from Croatia) noted that Viagra is also a vasodilator, and proposed a theory in the journal Medical Hypotheses last summer. To be fair, note that the journal is for hypotheses, not proven theories or clinical trials, but it is provocative nonetheless. Sildenafil, the generic name for Viagra, was found to not only increase circulation in the skin (which may or may not be helpful), but it also activated enzymes that help break down fat cells in tissue culture. There’s actually some serious science behind this class of drugs and it may very well turn out to be helpful for cellulite. If so, I can hardly wait to see the marketing campaign.

Post-operative breast implant massage: Does it help?

A frequent question we get about breast augmentation is whether or not post-op massage is recommended or potentially beneficial. One popular website, BreastImplants411.com, has created a checklist including a question about implant massage; patients considering breast augmentation are supposed to ask specifically about it. And plastic surgeons seem to be split on the question, with some strenuously advising it and others cast as non-believers. With such contradictory views, what is an informed person supposed to make of it?
The main idea behind it originated in an era when capsular contracture, a hardening of the scar capsule around the implant, was much more common. Plastic surgeons were trying anything that might make a difference, and cases of contracture were sometimes treated with a fairly brutal procedure called a “closed capsulotomy” which consisted of squeezing the breast hard enough to make the scar capsule rupture. Although patients might run out of the clinic in tears, the breast would be softer (for a while.) So the thinking was that perhaps squeezing the breasts on a regular basis, especially during the healing period, could prevent the scar from contracting in the first place.
In retrospect, it was a fairly naive notion, but there wasn’t much else to offer because the causes of capsular contracture were so poorly understood at that time. So it became entrenched as a routine practice and no one bothered to do a clinical study to see whether it did any good. In fact, to this day no such study has been published. Evidence now points to bacterial biofilms, invisible contaminants caused by miniscule numbers of otherwise harmless germs, that cause a reaction in the scar that encloses the implant. Better surgical techniques and better implants than the ones used 25 years ago appear to be the important variables.

So at this point we still have no objective evidence that post-op implant massage makes any difference in capsular contracture. There are certainly cases where swelling tends to push implants up and massage can be helpful in getting them to settle, but that is only sometimes the case. So the question shouldn’t be “Do you recommend massage?” but if so, “Why?”

the guy's guide to plastic surgery

Plastic surgery is generally considered to be the domain of women, especially with breast implants having become the most popular surgery. All in all, only 15% of patients are men, but that is still quite a lot in terms of absolute numbers. For the record, the most popular procedure for men continues to be liposuction.

One problem I think is that too many of us labor under false notions about plastic surgery. Husbands and boyfriends accompanying their partners for consultation often say something like “I don’t know why she is doing this, I love her just the way she is.” So the first lesson is that she isn’t doing it for you, she has her own personal reasons that don’t really depend on relationships. In fact, having cosmetic surgery in order to improve a relationship is almost always a bad idea.

Another misconception is body contouring surgery vs. diet and exercise. It isn’t an either/or situation, however; there are things that exercise does that cosmetic surgery doesn’t, and vice-versa. Classic examples are doing sit-ups with the expectation that they will tighten abdominal skin, and the idea that specific exercises can affect body fat distribution. Spot-contouring of fat with exercise just doesn’t happen. On the other hand, liposuction isn’t done for weight loss, it is all about reshaping. So thigh exercises may not burn off thigh fat, and crunching the abs won’t result in a 6-pack if the body is genetically programmed to carry extra fat there.

Our typical lipo patient is someone who isn’t overweight but has areas resistant to change. A woman might be a size 4 on the upper half of the body but a different size in the thighs. We see men who are in great shape but have “love handles” or excess abdominal fat. So do continue to hit the gym, and see your plastic surgeon for what you can’t accomplish with exercise and a healthy diet.