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.