Have you heard about Belotero, the new filler?

While most people are familiar with Restylane and Juvederm, you might want to get to know the new kid on the block, Belotero Balance.

Just like Juvederm and Restylame, Belotero is an FDA-approved filler that is also made from hyaluronic acid gel.  But it's manufactured a little differently, and has a smooth and soft consistency.  It's quite useful for superficial wrinkles, and gives a nice, natural-looking correction.

Other HA fillers, when they are placed too close to the surface of the skin, can have an issue called the "Tyndall effect" - which basically looks like a blue-grey colored bleb caused by the superficial placement of the filler.  This doesn't happen with Belotero.  So it's really quite useful in areas where the skin is thin, like near the eyes.  Belotero, however, does not come with added lidocaine, which may be a disadvantage for some patients, making the injections a little less comfortable.

The manufacturer, Merz Pharmaceuticals, claims that Belotero lasts longer than the other fillers, up to 12 months, rather than the usual 6 to 8 month duration for Juvederm.  I haven't seen a head-to-head comparison study yet, so will have to wait and see on that claim.

New study on Omega-3 supplements shows no benefit

In the latest issue of the New England Journal of Medicine, a new study casts serious doubt on the benefit of taking omega-3 fatty acid supplements for heart health.  The study found that after 5 years of taking the omega-3 supplements daily, there was no reduction in the rates of heart attack, stroke or death, compared to those who took the olive oil-filled placebo pill.

The participants in this new study did not have a previous history of MI (myocardial infarction or heart attack) or heart failure - and this was a feature that was different than two previous clinical trials.

Earlier studies had found that omega-3 supplementation was useful in patients who had survived a heart attack, or who had heart failure, reducing overall mortality and the chance of hospital admission.  In those studies, the omega-3 supplements seemed to reduce the chance for lethal arrhythmias, which were rare events in the current study of healthier people.

Bottom line:  Unless you have known heart disease (heart failure or previous MI), there is no need to buy or take omega-3 supplements, since there's no proven benefit for your heart.

New fillers on the horizon: Juvederm Voluma

Here in the U.S.A., it seems we're the last to get new medical devices.  Sometimes, that's a good thing - as in the FDA preventing the notoriously problematic PIP silicone breast implants from being sold here.  Other times, it's just a frustrating and slow wait for good products.  As a plastic surgeon, you can feel like you're behind our colleagues in Canada and Europe.

Take Juvederm's filler product, Voluma, for example.  It's been available in the U.K. & Europe for 4 years, and in Canada for at least 3 years - working well.  You can see the Canadian advertisement picture to the left.  It's another member of the HA filler family, like regular Juvederm or Restylane, which both have a very good track record.  But only now is the FDA getting around to deciding on whether or not to approve the product for use in the USA.

If and when it is approved by the FDA, Voluma would be a new option of adding volume to the cheeks or the chin area. It's designed for deep placement, not superficial wrinkles.  It's more likely to replace a midface lift, or be used instead of a fat transfer to those areas - so it would be a nice, non-surgical treatment that could be done at a lunchtime appointment, rather than the surgical alternative.

Keep your fingers crossed.

photo credit: torontosurgery.ca

An improved saline implant?

One of the interesting things I saw at the recent ASAPS meeting in NYC was the so-called "Ideal Implant".  It's a modified saline-filled breast implant, that dramatically improves one of the biggest problems with standard saline implants in slender women - the dreaded ripple & wrinkle problem.

The "Ideal Implant" was developed by a plastic surgeon, Dr. Bob Hamas ("rhymes with famous", he said).  Essentially, it uses an inner saline implant, surrounded by several baffles, which are all inside the outer shell - see picture.  These baffles have the effect of reducing the "water balloon" feel that saline implants usually have, working much like baffles inside a water-bed.  They add internal support to the implant, reducing ripples, sloshing and the characteristic saline implant bounce.

In clinical trials, it seems to be working.  According to their published 2-year data, wrinkling and rippling issues were only reported in 3.8% of patients, which compares very favorably to the usual 10% rate seen in standard saline-filled implants.  And the feel of the implant, while not quite as good as a silicone gel implant, is also considerably improved over the standard saline implants.  And of course, should these implants leak, just like a standard saline implant, it's easy to tell.  The saline is absorbed by the body and no diagnostic imaging is required.

According to the company's own survey, 83.7% of women who were considering saline implants were interested in the new product.

So, here are my questions for discussion:  this implant is going to cost more than standard saline implants, but less than silicone gel implants.  Which one would you pick, and why?  Would you want me to offer this product?  They currently have one profile - a shape similar to the standard high profile saline implant. It's available in sizes up to 675 cc.  A 10 year limited warranty is offered by the company for deflations.  If there's a big demand - I'll get on board with it.

photo credit: idealimplant.com

Prozac & Zoloft increase bleeding risk at surgery

It's been suspected for a while that Prozac and its cousins in the SSRI family have a nasty side effect that's pretty important for people who are having surgery to know about:  there seems to be more bleeding, and a higher chance of postoperative hematomas requiring a second surgery, if you take these medications around the time of surgery.

Initially, the data only pointed towards an increased risk for people having bowel surgery and GI bleeding.  Now, new data suggests the bleeding effect happens in our field, too - with cosmetic breast surgery.

A new study, published in Aesthetic Plastic Surgery this month, looked at patients who underwent cosmetic breast surgery procedures - breast augmentation, breast reduction or mastopexy, and divided them into users of SSRI medications, and non-users.  Of the 2089 patients who didn't take Prozac, only 1.15% had a bleeding issue.  But in the 196 study patients that did take an SSRI-type medication, 4.59% had a bleeding problem.  This was a statistically significant difference.

So, regardless of age, weight or the type of procedure performed, it turned out that SSRI usage increased the risk for a post-operative hematoma requiring surgical drainage fourfold (4.14 times normal).

So, if you take Prozac, Zoloft, Celexa or Paxil - this is something to consider and to discuss with your surgeon and your prescribing physician, prior to surgery.

Unnecessary medical tests and procedures - the Choosing Wisely initiative

It's not a surprise to anyone that all medical tests and procedures are not created equal.  Some tests are more accurate, others less so.  Some medications are very effective, and others not so much  depending on the situation.  With this in mind, the American Board of Internal Medicine and its associated specialties have recently developed some lists for consumers of what's not so useful - with the idea being to eliminate unnecessary tests and procedures.

The program, called "Choosing Wisely" is an effort of more than 500,000 physicians, 26 physician specialty groups and the "Consumer Reports" organization.  They've developed lists called "Five Things Physicians and Patients Should Question" on topics from asthma to cold-treatments, from heart testing to testosterone supplementation.  It's worth a look, especially before a trip to the doctor.

For example, do healthy people really need a chest X-ray before outpatient surgery?  In the old days, this was routine.  Now the evidence shows that, for most asymptomatic, healthy people, it's not needed and that the X-ray doesn't add any useful information.

And while consumers in the U.S. are a bit used to walking into their family doctors office and demanding antibiotics for a viral head cold, it's really time to start looking at the science, and asking "Is this really the best treatment?"  Not only can we avoid side effects and complications, it might save you a few dollars, too.

Allure Magazine's 11 most overrated cosmetic procedures

Allure Magazine's senior editor, Ms. Joan Kron, recently published an article called the "11 most overrated cosmetic surgery procedures"(link), and I thought this was well worth commenting on.  Ms. Kron has received several awards from our plastic surgery societies for journalistic excellence in covering our field - so her articles are always worth a read!

Here are her picks - the cosmetic procedures where the downsides, risks or simply the lack of proven benefit based on scientific data - make the procedure of questionable value.  I've added my comments to each one.

Drum roll, please.....

1.  Vampire Facelift - There's no good science to support this treatment as being beneficial.  I don't perform it, even though Ms. Kardashian and others celebs like it. (link)

2.  Laser Liposuction - There's no study showing it's actually better, results-wise, than regular liposuction.  But the trademarked name sure sounds cool, doesn't it?  It's certainly not minimally-invasive, as often advertised.  While some surgeons are enthusiastic about it - typically those who have bought the machine and have to make the payments on it - others say it causes more scar tissue, and makes further liposuction more difficult.  I'm in this second group - so I use Power Assisted Liposuction, which has a proven track record.

Recently, Cynosure, the manufacturer of SmartLipo is promoting a modified version of SmartLipo for use in the face called the "lazerlift".  Don't do it!  There's a whole blog post coming on this bad idea!

3.  Stem Cell Facelift - The New York Times just did an article on this (link).  Most doctors that offer a so-called stem cell facelift are really just doing standard-issue fat transfer to the face.  Since 1% of the fat contains stem cells, they use the "stem-cell" buzz word.  Very misleading.

4.  Sculptra and Artefill for the lips - These products are designed for the cheeks and other areas where they can be placed deep in the tissues.  In the lip, they will cause lumps for sure.  And did I mention that these are permanent lumps?

5.  Silicone Cheek Implants - Pretty much made obsolete by our injectable products and fat grafting techniques.

6.  Ulthera – Very subtle ( i.e. hard to see) results, painful to have done.  Current treatment protocol is "under revision" by the company.

7.  Fat Injections To The Breasts - Here's one topic where I disagree with Ms. Kron.  I think that this really is a useful technique, for both augmentation and reconstructive purposes.  It's certainly more expensive and more time consuming than a breast implant, and gives a different, more natural looking result than an implant.

8.  Brachioplasty – The issue here is the scar, that typically goes from  armpit to elbow.  This can be a great procedure for massive weight loss patients, especially with our posterior scar technique.  It's not good, however, for someone who just needs a little improvement of a basically normal arm silhouette.

9.  Buttock Augmentation with Implants -  These are really only used if the patient is not a candidate for fat transfer to the buttock, also called the Brazilian Butt Lift.

10.  Zerona Lipo Laser - Essentially this is like shining a few laser pointers on your skin and expecting there to be fat loss.  I am still surprised that this gadget got FDA approval.

11.  Foot Lifts - My scrub tech, Lindy, says "no go on toe lipo".  Or cosmetic foot surgery.  I agree!

Does an asthma medication hold the secret to melting fat?

Answer:  it very well might.  Almost under the radar, a company named Lithera has been quietly investigating the idea of manipulating fat cell metabolism with a simple injection of two drugs that are already FDA-approved, but traditionally used for other purposes.  They've discovered that two asthma medications, Advair and Servent, which we have used for years in an inhaled form, are actually great fat busters when used in a low-dose injectable form.  And Flonase, the nasal spray for allergies, improves their fat melting abilities when added to the injection.

Lithera's patented product, code-named LIPO 102, has been promising in early trials.  Patients get a series of injections for 8 weeks.  Lipo 102 up-regulates the metabolism of the fat cell, basically tricking the body into burning the fat naturally.  There's little pain apart from the injection, no swelling, and no downtime.  Unlike competitor ATX-101 from Kythera, Lipo-102 is fat cell specific, so there's no chance of skin damage or lumpy fat necrosis.  It sounds like a great non-surgical option.

The study patients who had this treatment lost an average of 1/2 inch off their abdominal circumference in 8 weeks, with about one-quarter of the patient group having a reduction of over an inch during the same time period. It should work in other areas as well, such as under the chin, or in fatty deposits in the lower eyelid.  And the treatment can be repeated later, for more of an effect.

The company is continuing testing, in preparation for FDA review and possible approval.

ASAPS hits the "Big Apple": 2013 Annual Meeting

Yes, it's that time of year:  time for the biggest gathering of aesthetic plastic surgeons from around the world, the annual American Society for Aesthetic Plastic Surgery meeting.  This time, it's back in New York City, at the Convention Center, starting in about 3 weeks.

I'll be there, listening to the latest on technical improvements and new equipment, participating in several committees and a couple of panels.  This year, for the first time, I am heavily involved in a teaching course which I'm pretty excited about.  It's called "What Patients Really Want", and it is all about how to improve the overall patient experience as they go from consult to surgery to post-operative care.  I'll be joined by ASAPS past-president Dr. Monte Eaves,  Realself.com CEO Tom Seery, and Marie Olesen, plastic surgery consultant par excellence and founder of Real Patient Ratings.  It has the potential to be really good!

As usual, I'll be reporting from the meeting, and will blog about what works, what new & cool developments I see, as well as the flops, failures, the hype and the spin.  Stay tuned...

Beware: Lipotron 3000 - a bogus fat treatment

This week a patient came to my office, and told me about her treatment here in Orlando with a gadget called the Lipotron 3000. It's advertised as being a radiofrequency machine that can melt both subcutaneous and visceral fat, and is promoted as part of a weight loss treatment called Lipo-Ex or LipoFast. It's also called the "non-invasive radiofrequency assisted lipoplasty"(RFAL) machine.

My ears immediately perked up - because this machine is well-known in our industry, but not in a good way. Turns out, the Lipotron 3000 is not FDA approved as a fat melting or weight loss machine. While it does use radio-frequency energy, it flunked the FDA approval process in 2007 and again in 2008-2009. Its only approval is in the much more limited "massage machine" category. Nevertheless, its manufacturer is promoting it for fat loss and weight loss, which is way outside of that category. The FDA is not at all pleased with this flaunting of the law, and has told the manufacturer, RevecoMED, to cease and desist. (see FDA letter here)

So, please beware: several spas and weight loss clinics in the Orlando area use this device. It's a sham - it does not melt visceral fat, and is not even particularly good at tightening skin or melting subcutaneous fat.  Buyer beware.