Reloxin - receives FDA approval today

Botox competitor "Reloxin" (sold in Europe as "Dysport") received its FDA approval today.

The FDA decided to approve both the cosmetic indications (for wrinkles) and the functional indications (cervical dystonia) at the same time - and decided that the drug should be sold under the same name for both categories. So, it's now officially "Dysport" - just like in Europe.

We're waiting for details to be released about the pricing, marketing incentives - such as potential combinations with Medicis' line of fillers, and so forth. These details will be key to the success or failure of the product, I believe.

The next 6 months should prove to be very interesting, to see how pharma giant Allergan responds to the "new kid on the block". I'm expecting sparks to fly!!

The 2009 Aesthetic Meeting

The most important educational meeting for aesthetic plastic surgeons, in my opinion, is the ASAPS annual meeting. It's happening next week - and yours truly will be there. We'll hear "what's hot", "what's new" and "what's not working". All of the "major league" players of aesthetic plastic surgery will be there, discussing the best ways to do facelifts, rhinoplasty, eyelid surgery, breast surgery, body lifts, as well as fillers, peels and lasers. A huge vendor display area allows attendees to see many new products as well.

My favorite sessions are the panels, where experts - often with conflicting opinions - debate the merits of their particular approach.

I'll be taking my notebook with me - and should have plenty of hot & juicy plastic surgery news to blog about!

Cosmetic surgery and the competitive edge: looking good and the job market

Here's some interesting data from a press release from the American Society of Plastic Surgeons:

"Faced with news of difficult economic times, and a belief that hiring is based on looks, millions of American women are looking at cosmetic medical procedures to give them a competitive edge in the workplace. In a new telephone survey compiled by the American Society of Plastic Surgeons (ASPS) of 756 women between the ages of 18 and 64, many reveal cosmetic plastic surgery procedures now appear to be an important rung on the success ladder.

- 13 percent (more than 1 out of 10 of the 115-million working-age women) say they would consider having a cosmetic medical procedure specifically to make them more confident and more competitive in the job market.

- An astounding 3 percent (nearly 3.5-million working women) say they've already had a cosmetic procedure to increase their perceived value in the workplace.

- 73 percent (almost three out of four or, 84-million working women) believe, particularly in these challenging economic times, appearance and youthful looks play a part in getting hired, getting a promotion, or getting new clients.

- 80 percent (four out of five or 92-million working women) think having cosmetic medical procedures can boost a person's confidence."


Actually, this trend is not really that new. Men have been coming to me for years, getting their upper eyelids fixed, so they don't look like the "sleepy, old-guy-past-his-prime". Executives often have specifically told me that they want to look more like their youthful and energetic business competition, and want to have surgery to give the appearance of still being in their prime, rather than being perceived as being "tired" or "over-the-hill".

Investing in yourself is always a wise investment!

Marketing hype in cosmetic surgery

Hype. Spin. Puffery. Exaggerated claims. Call it what you will - there is a lot of it out there in the world of cosmetic surgery. Unlike most other fields of medicine, the commercial influences on cosmetic surgery and aesthetic medicine have changed the traditional doctor-patient-medical supplier relationship - and not for the better.

Where does the hype come from?

1. Marketers of new technologies: Claims of wonderful new technology that works "better than anything that has come before" should always be viewed with caution. Most progress is evolutionary, not revolutionary. Laser-assisted liposuction is a great example of marketing hype getting way ahead of what has been scientifically proven. For example, is there any solid data that has been published in a reputable journal showing that laser-assisted liposuction tightens the skin? Nope. Yet, claims of skin tightening are all over the internet.

2. Marketers of "new procedures": It's become fashionable for physicians to put their name on a variation of a standard surgical technique. This is especially true for the various forms of mini-facelifts. Call it a "fill-in-the-blank" lift using some cutesy name, and market the heck out of it - and patients will seem to flock to the door. But, as we've discussed in earlier chapters of this blog, mini operations usually have mini results - and subsequent disappointment for the patient.

3. Commercial Media: Take for example, the various websites that claim to be give lists of the "best surgeon in town" or "top cosmetic surgeons in the state". Usually these are paid listings. The only qualification required is that the physician pays the bills for this marketing exposure!

The same is true with many of the local lifestyle magazines. Did you ever notice that the surgeons that are awarded "best surgeon" or who are featured on the cover by these magazines are typically the ones with the biggest advertising budgets? Hmmm....

And don't even get me started on some of the over-the-top hyperbole seen on some surgeons' websites. The descriptions make it sound like they could part the Red Sea, or walk on water! Take it with a grain of salt, people!

So, what's a consumer to do?

It boils down to old-fashioned research.

1. Ask around - get referrals from people you trust - your own doctor, OR nurses, close personal friends that have had a good experience with a local plastic surgeon. See who has good "word of mouth" endorsements.

2. Check out the ASAPS website (www.surgery.org), the ASPS (www.plasticsurgery.org) or the Florida Society of Plastic Surgeons (www.fsps.org) website to see some of the possible people you should interview in your neighborhood.

3. Interview several highly experienced, Board-certified Plastic Surgeons who do your procedure of interest routinely. Make notes and compare.

4. Look at plenty of "before and after" photos with a critical eye - we've discussed how to do this in an earlier chapter of this blog.

5. Has the staff had surgery by that surgeon? Do you like how their results look?

6. Does the surgeon have a list of actual patients that you can speak with?

7. Do you like the "feel" or "vibe" of the office? Do you feel sure that these people will look after you if you should happen to have a complication from your procedure?

8. While price is important to many people, don't always be tempted by the lowest price. If it seems too good to be true, it probably is.

Do longer surgeries have a higher complication rate?

A common question around here from patients is whether they can combine surgeries - say, a tummy tuck with a breast operation.

To answer this, we have to look at things from 2 different angles:
1) legal - what do the Florida regulations permit, and
2) medical - what do the studies looking at surgical complications find.

First of all, the applicable Florida regulations for office-based surgery state that the "maximum combined duration of anesthesia shall not exceed 8 hours."
Longer procedures can be performed - in a hospital.

From the medical literature, the answer to the question relating complication rates and duration of surgery is, surprisingly, somewhat of a mixed picture, when it comes to plastic surgery operations for healthy people.

Data against long surgeries:

- increased overall complication rates with longer anesthesia / surgery times in multiple studies in the anesthesia, cardiac surgery, orthopedic surgery, and urology literature. In particular, the study from the British Journal of Urology found a fourfold increase in non-urologic complications with anesthesia durations > 6 hours.

- increased rate of DVT (deep vein thrombosis) and pulmonary embolism. For example, in one orthopedic study, these potentially life-threatening complications were 3.5 times more likely when the anesthesia duration exceeded 3.5 hours for hip or knee replacement surgery, which are infamous for high rates of DVT's.

- increased pulmonary complications with anesthesia times greater than 2.5 hours, in both normal patients, and especially in those with pre-existing chronic lung conditions.

- increased rate of surgical site (wound) infections with longer surgeries.


Data supporting combination surgeries

- no increased risk seen when facial surgery operations were combined, in a study performed at Yale University. Anesthesia / surgery duration was not associated with increased risk in this study when surgeries under 4 hours and over 4 hours were compared.

- no increase in the complication rate when aesthetic tummy and breast operations were combined in a study from a private clinic in California. However, in this study, all surgeries were less than 6 hours in length.

The bottom line: Combination surgeries can be performed safely, but that doesn't mean we should throw caution to the winds and have a marathon surgical make-over. Despite our best efforts at prevention & prophylaxis, DVT, pulmonary embolism and pulmonary complications of anesthesia are lingering issues related to longer surgeries with general anesthesia. And when these problems occur, they can be devastating.

I do not typically recommend combinations of surgery exceeding 6-7 hours of planned surgery time, even for healthy patients. I feel it is safer to divide up the surgery into two stages, if the length of surgery exceeds this number.

So, going back to the original question: I will combine a breast augmentation (approx. 1 hour procedure) with a major abdominoplasty (3-4 hours). But I will not generally combine a major breast reduction or complex mastopexy (3-4 hours) with a big tummy tuck, as I feel the lengthy anesthesia / surgery time is worrisome.

As always - safety first.

Problems with laser-liposuction: who's the Smart one now?

Over the last few months, I have seen an alarming increase in the number of patients that come in for a second opinion about poorly-performed liposuction (done elsewhere, I might add.) All of these casse have been performed with new high-tech liposuction machines, either laser-assisted (like the SmartLipo) or ultrasonic (like the VASER).

I've seen major skin laxity, uneven liposuction, and obvious over-resection of fat leaving major divots and dents. Many of these problems are very difficult to fix, even with fat grafting techniques.

Here's a few observations:

1. All of these cases were performed by physicians and surgeons operating way outside of their specialty. They were not done by plastic surgeons or dermatologists, who are trained during residency in this technique.

2. In the majority of these patients, physical examination of the patient revealed crummy skin tone and poorly elasticized skin. In other words, since this skin won't contract like we want it to after liposuction, it's completely predictable that the post-op results will be poor, with floppy, deflated areas, and a worsened appearance. A surgeon with any significant training or experience in liposuction would have recognized this - and would have avoided performing liposuction in these patients. It's the wrong tool for the job!

3. All of these patients were preoperatively told by their physicians, "This new wonder lipo machine will tighten your skin".

4. All of these patients now say, "Skin tightening clearly did not happen...now I look worse."

5. None of these patients have an easy fix for their issues. All will require complex and expensive revisional surgery.

Lessons:

A fancy hammer does not a good carpenter make. Any doctor can buy (or rent) a fancy lipo machine.

There is, as yet, no reliable scientific evidence that laser-assisted liposuction:
a) tightens the skin, or
b) works better than standard liposuction.
Any claims to the contrary are "spin" or marketing hype; consider the source and what they're selling.

That being said, the problems seen here were not caused by the type of liposuction machine - but by the doofus using it! While the concept of liposuction is easy, getting excellent results with liposuction takes significant skill.

Please be careful about whom you choose to perform your liposuction. Even if it's performed in an office setting, with local anesthesia, liposuction surgery is still SURGERY. Training, experience and credentials matter.

Saline breast implants: pros and cons

Today's chapter is about saline breast implants.

Prior to 2006, saline implants were the most commonly used implant in the U.S. Now, with FDA re-approval of the silicone gel implants, that figure has fallen significantly, down to about 20% in our practice.

Here are the more common reasons that my patients give for picking a saline-filled breast implant.

1. Cost. Saline implants aren't as expensive.

2. Adjustability. For women with major breast asymmetry issues, the adjustability of the size of a saline implant at the time of surgery can be helpful to fine-tune the correction of volume differences between the two breasts. Essentially, we can "put a little more" on the smaller side. With silicone gel implants, the implants are not adjustable - so one has to go to the next size implant, a difference of 25-30 cc.

3. No need for follow-up scans. When a saline implant leaks, the saline is simply absorbed by the body. The implant deflates quickly - and making the diagnosis of an implant deflation is easy, without requiring fancy diagnostic tests. There are no recommendations for follow-up MRI scans, as there are with the gel filled implants.

4. Lingering anxiety about silicone gel. Despite the large number of carefully performed, large-scale scientific studies disproving many of the "urban legends" about health issues and silicone, some women are just more psychologically comfortable with the saline option.

5. Age. If you are younger than 22 years old, silicone gel implants may not be available under the FDA guidelines, unless you happen to have other issues, like rib cage asymmetry, scoliosis, and so forth.

6. Wanting the "very rounded" look. This can be achieved, if desired, by over-inflation of a saline implant, creating a more spherical shape and increased upper breast fullness.


Disadvantages of saline implants:

These were discussed in the previous blog chapter, during the discussion of silicone gel implants. The main issues are:
- a less realistic "feel" to the breast

- higher percentage of ripple / wrinkle issues, particularly in slender women.

While some surgeons will try to over-fill the implant in an attempt to reduce ripples, that may cause a different set of problems, such as creating excessive roundness of the upper breast, causing excessive firmness, or creating tension bands around the edge of the implant. Over-filling also potentially voids the manufacturer's warranty.

The choice of implant - the size, the shape, and the type of fill - are all issues that we discuss at the time of a consultation. Hopefully, the information in this blog will help you to become a more "informed patient" prior to your consultation and surgery, and will answer some preliminary questions for you.

Silicone breast implants: pros and cons

A very common question during augmentation consultations is about the various advantages and disadvantages of silicone breast implants and saline breast implants.

In this chapter of PSB- the Plastic Surgery Blog, we'll talk about silicone breast implants. The next installment will discuss saline breast implants.

Currently, about 80% of our patients select the silicone gel implants.

Safety data:

The FDA thoroughly looked at the scientific data, prior to allowing silicone breast implants back on the market for general cosmetic uses in 2006. The "blue-ribbon" panel of experts from multiple different fields of medicine agreed that, based on current scientific studies:

a) there is no increase in the risk of breast cancer due to the use of silicone breast implants, and

b) there is no increase in the rate of developing "auto-immune" or connective-tissue diseases like scleroderma, lupus or rheumatoid arthritis due to the use of silicone breast implants.


That being said, no implant is perfect.

Just like any man-made device, the implant, whether it is saline-filled or silicone gel filled, will eventually get old, become brittle, develop a small crack in the flexible outer shell, and leak. Implants don't last forever. At some point, a second surgery will be required to swap out the implants for a new pair.

Also, implants (both saline and silicone) do get in the way of seeing tissue clearly with a mammogram, as the implant hides some of the breast tissue. This problem is worse when the implants are above the muscle, and somewhat better when they are behind the pectoral muscle.

Lastly, an implant can become firmer than desired, due to the development of capsular contracture. This may require more surgery to fix, and currently, it's impossible to predict ahead of time whether this problem will happen for a particular patient, or not.

Advantages of silicone breast implants:

1. "the feel" - Most of my patients like the way the silicone breast implants feel. Simply put, they feel very similar to real breast tissue, and do not have the "water balloon" feel that the saline implants have. This, for most patients, is the deciding factor.

2. Less chance of ripples & wrinkles - Particularly in slender women, one of the main drawbacks of saline implants is that any wrinkling in the implant may show through the skin, causing visible ripples, particularly with leaning forward. This can happen even with the implants behind the muscle, and even if the implants are filled to the correct volume. Studies show that rippling occurs in about 10% of patients with saline implants, but only about 1% of silicone breast implants. Patients who are thin enough to feel their ribcage on the side of their chest are particularly prone to rippling problems. Switching to silicone implants often fixes the problem for patients with ripples in their saline implant (unless you are super-skinny!)

3. Works better for women with rib cage irregularities - Silicone gel implants seem to drape more smoothly over rib cage asymmetries due to scoliosis or pectus excavatum (sunken chest).

4. Less tissue stretch - Over time, the saline implants seem to have a slightly higher rate of stretching out the skin and soft tissues of the breast, compared to gel implants. This can result in pocket expansion, bottoming out, or ptosis (droop) of the breast.


Disadvantages of silicone breast implants:

1. More expensive than salines.

2. FDA recommendations for follow-up MRI's - As we discussed in an earlier blog chapter, MRI's are recommended at years 3, 5, 7 and so on. This can get expensive.

3. Trickier to tell if you have a deflation - Unlike saline implants in which a deflation is very obvious in a few days, it's more difficult to tell if there s a leak in a gel implant by simply looking at the breast. Usually, some sort of scan - like a breast ultrasound or MRI - is needed in order to make the diagnosis.

4. In the event of a leak, additional surgery is needed - Current recommendations call for a capsulectomy to be performed for most patients with a leaking gel implant. While this is a routine operation for most plastic surgeons, it does represent more surgery than the simple "switch-out" procedure that would be performed for a deflation in a saline implant.

5. May need a somewhat longer incision that the saline implant. Saline implants can be rolled up while still deflated, and placed into the breast through a small incision, and inflated after positioning. This drawback will become even more significant when the new generation "form-stable" or 'Gummy Bear" silicone implants are introduced to the U.S. market, as these require a 5-6 cm. incision.


Overall, patients are very satisfied with breast augmentation, regardless of whether saline or silicone breast implants are used. They recommend it to their friends, co-workers and family. It's the #1 most popular surgical procedure both in our practice, and nationwide. While you can usually get a good result with both kinds of implants, certain individual situations may make the choice of a particular type of implant better than the other.

"We Fix Cheap Haircuts"

True story: I was walking around downtown Orlando recently, and I came across an old-time barber shop. "Haircuts for men and boys", the sign said, "eight dollars". Seemed like quite a deal.

About a block further down the same street, I came across another barber shop. This one had a sign in the window, "We fix cheap haircuts".

I laughed at the sly reference to their low-cost competition down the street. If you think about it though, the world of plastic surgery is not that different.

Sometimes the "cheap haircut" is surgery that has been performed outside of the U.S., usually in South or Central America, with the patient returning to Florida with an infection, an open incision, thick scars, or a crummy-looking result. (I've seen all of these issues!)

Sometimes the "cheap haircut" is cosmetic surgery that was performed locally, by people that advertise ridiculously low-cost liposuction or breast augmentation surgery.

These patients with complications from inexpert surgery all tell the same sad story: "It seemed like a good idea at the time. I was hoping to get a deal on cosmetic surgery....and look what happened".

Either way, the total price for the initial surgery PLUS the required fix-up procedures is far more expensive than having it done right the first time, by a real board-certified plastic surgeon in an accredited surgery facility with U.S. level standards of quality. Worse yet, sometimes the problems can't be undone.

It's unwise to gamble with cheap cosmetic surgery....or cheap haircuts, for that matter. While some patients are satisfied with their discount surgery, why spin the roulette wheel with your health? Like that old slogan, "It may cost a little more, but I'm worth it!"

Browlift basics

In this era of smoothing forehead wrinkles with Botox and lasers, has the forehead lift, AKA brow lift or upper facelift, been relegated to the dust-bin of surgical history?

Hardly! The browlift is still an extremely useful and powerful operation for rejuvenating the forehead, the eye area, and upper face.

Why do a browlift?

Well, as musicians say, "Let's take it from the top."

Very few patients come in thinking about a browlift. Instead, they usually point out the baggy skin around their eyes. In this situation, the alert plastic surgeon has to analyze what has happened to the patient's facial anatomy, and make the correct diagnosis. We have to sort out whether the problem is caused by a low brow position, or a puffy, baggy upper eyelid with a normal brow position.

If the eyebrow position is too low ("brow ptosis"), this makes the bagginess of the upper eyelid look worse. Try this on yourself - in a mirror, push down on your eyebrow, and watch what happens to the appearance of the upper eyelid area. Now lift the eyebrow up, and see how the eyelid area looks better. Neat, eh?

People often subconsciously compensate for their drooping & falling brows - by activating their forehead musculature, trying to raise their eyebrows. But instead of doing it for a few seconds, like when we show an expression of surprise, it happens continuously. Plastic surgeons now call this "compensated brow ptosis", a term coined by Dr. Bob Flowers, who has taught extensively about forehead anatomy and surgery.

Here's the rub: if somebody with brow ptosis has an aggressive excision of upper eyelid skin with a blepharoplasty (eyelid tuck), instead of the more appropriate brow lift, the following problems can occur...
- the brow is puller lower by the eyelid skin excision,
- the patient looks more tired and angry,
- wrinkles in the forehead can actually get worse, as the patient strains even more to compensate for the low brow position,
- the future potential to have a curative browlift may be eliminated.

So, just like everything else in plastic surgery (and life!), accurate analysis of the facial anatomy is essential to planning and choosing the correct surgery.

Brow aesthetics:
Many people are worried about browlifts, because of the fear of an "overdone" look. Yes, sadly it is true, in the past, surgeons have lifted some brows more than they should have. This is an example of "more is not better".

If you over-do the lift laterally, it can create a quizzical or diabolical expression. If you over-do the lift centrally, it can look overly concerned or worried, an expression that actor Nathan Lane makes naturally!

The key to a nice result is moderation combined with an artistic sense. An attractive female eyebrow should be at, or above, the level of the bony rim of the eye socket. It should be arched nicely, with the peak of the arch near the outer one-third to one-quarter of the brow, and the outer end of the brow should be higher than the inner end.

How do we do it?

There are a number of surgical options to perform a browlift, ranging from endoscopic and short-incision methods to the classic coronal browlift. Having used all of these methods, I keep coming back to the classic coronal method. It's powerful, it lasts, and allows many options for upper facial improvement.

We'll talk more about forehead lifts in future chapters of PSB - the Plastic Surgery blog.

Capital One exits cosmetic surgery financing

Capital One is pulling out of the health care financing market -- removing one financing option for medical services. As of April 10, 2009, Capital One is not accepting any new installment loan applications for cosmetic surgery, or any other medical expenses.

If you already have an approved Capital One loan, you're OK - that won't be affected.

While understandable from a business point of view, it's too bad. Capital One provided a helpful service, and their loan plan was one of the more popular ones with many of our patients.

NYC Woman Dies after Silicone Injection

Injection of liquid silicone - used for soft tissue augmentation - has a long and very controversial history. Liquid Silicone is not FDA approved for cosmetic indications, like plumping up wrinkles, lips or other body parts, but is approved for the treatment of retinal detachments by ophthalmologists. The legality of cosmetic silicone injections is, to say the least, complicated.

Underground "pump parties" by unlicensed non-medical personnel go on, especially in South Florida - as people seem to want a permanent soft-tissue filler, despite the long-term potential side effects. Often the products injected are of dubious purity, and are designed for industrial applications, rather than being medical-grade purity.

Well-known side effects of silicone injections include:
- migration of the injected material
- chronic inflammation with swelling, redness and tenderness
- granuloma formation
- extrusion of the material
- scar tissue formation with possible distortion of adjacent soft tissue
- pulmonary embolism and pneumonitis (potentially life threatening lung issues)

Every year, there are several reports of deaths following liquid silicone injections, typically by unlicensed personnel. Another one happened this week in NYC. Here's the link to the story. The article says that a silicone-related pulmonary embolism was determined to be the cause of death.

Frequent readers of PSB - the Plastic Surgery Blog will be able to name a number of obvious problems with this lady's injection: Non-FDA approved material injected in large quantities, by an unlicensed practitioner, in a non-medical setting. This death was needless, tragic, and entirely preventable.

Bottom line: Get your injectables from a reputable, experienced physician in a medical environment. Use only FDA-approved injectable products. I do not recommend liquid silicone for soft tissue augmentation. More information on safe, FDA-approved products for soft tissue augmentation can be found at www.injectablesafety.org.

DHEA: super supplement or snake oil?

DHEA supplements are widely claimed in the lay press to help with a huge number of diverse conditions: anti-aging, cardiovascular disease, chronic fatigue & fibromyalgia, body building, obesity, osteoporosis, sexual dysfunction, and lupus - just to name a few. Most of this excitement was based on positive results seen in early scientific studies done in mice, and from some anecdotal reports from enthusiastic users...and things took off from there.

These days, many people now take the widely available DHEA tablets, hoping to get a health benefit - are they wasting their money and effort? Or is DHEA a "fountain of youth" hormone in a bottle?

What is DHEA?
DHEA (dehydroepiandrosterone) is a hormone that is made by the adrenal glands, out of cholesterol. It is an intermediate product in the chain of biochemical events that convert cholesterol into active hormones like testosterone and estrogen. Production of DHEA seems to peak in the mid-20's, and starts to decline after the mid-30's. (Unlike testosterone and estrogen, we don't have any evidence that DHEA is particularly active by itself.)

So, the theory goes, that if we can boost the falling levels of this hormone back to the levels seen in healthy young adults, then various "good things" will happen, and we should feel young again. Sounds promising, but does it work in this case?

The evidence:

We can divide DHEA uses into 2 main groups: 1) deficiency states due to a specific disease, and 2) supplementation for otherwise normal, healthy people.

Scientific evidence supporting the use of DHEA is mostly positive when it is used as part of the treatment of specific problems, such as:
- adrenal insufficiency ("Addison's disease")
- systemic lupus erythematosus ("lupus")
- depression

So far, most of the other proposed indications for DHEA use in disease states (like cancer or heart disease prevention) have not been proven yet, based on the studies that have been completed to date.

In terms of using DHEA as an "anti-aging" supplement for normal, healthy people who just want to feel younger, the recent scientific trials that have been carefully conducted in people, rather than mice, are pretty disheartening:

- A double-blinded, placebo controlled study from France in 2003, looked at the effect of DHEA on muscle mass over a 12 month period in healthy 60-80 year olds. Although the DHEA supplements caused the blood levels of DHEA to go up to the range found in young adults, there was no significant difference in muscle strength, or muscle volume compared to the placebo group.

- A 2005 study from University of Pennsylvania looked at muscle mass, strength, endurance and quality of life measurements (feelings of well-being, sleep & sexual function) in postmenopausal women. Once again, while the levels of DHEA in the blood went up, there was no significant difference in the treated group on any of the parameters, compared to the people that had no hormone therapy at all.

- A 2001 study from Germany looked at DHEA supplementation in healthy men, aged 50-69, using a double-blinded cross-over study design with placebo controls. While the blood levels of the hormones again went up to youthful levels, there was no effect seen on serum lipids, bone markers, body composition & muscle mass or exercise capacity.

- In a study done in healthy men aged 35-65, the effect of 12 weeks of DHEA supplementation was examined in conjunction with a high-intensity fitness program. They found no enhancement above the results obtained by physical training alone, and worse, a 6.5% increase in cardiac risk, due to unfavorable changes in the cholesterol profile.

DHEA also has a number of common side effects: acne, unwanted hair growth, unfavorable changes in lipid (cholesterol) profiles.

The bottom line: DHEA supplementation remains controversial as a supplement for normal, healthy people.

Based on my own interpretation of these and other studies, I don't currently recommend DHEA to my patients as a general anti-aging supplement. It does not seem to have conclusively-proven effects on either the physical or mental aspects of aging. While there might be some sub-groups of people where DHEA therapy may have some benefit, these groups are still being defined, and more research is needed.

People that have known hormonally-sensitive cancers (breast, prostate, etc.) should especially avoid DHEA.

When Abdominal Fat can be deadly - "Metabolic Syndrome"

It's well known that America has an obesity epidemic, which affects both adults and children alike. But what's not as well known, even in the medical community, is the rapid rise in an obesity-related problem called "Metabolic Syndrome".

Metabolic Syndrome is diagnosed if you have 3 or more of:
- increased waist size (>40 inches for men, 34.6 inches for women
- elevated blood sugars or known Type II diabetes
- elevated blood pressure (> 130/85) or known hypertension
- decreased good cholesterol (HDL)
- increased triglycerides

Why is Metabolic Syndrome important? Because it causes a huge increase in the risks for heart attack and stroke. According to a 2002 article in the Journal of the American Medical Association ("JAMA"), middle aged men with Metabolic Syndrome are three to four times more likely to die of coronary artery disease, and have double the all-cause mortality rate. It affects women similarly, too.

About 47 million people in the United States are believed to have the syndrome, or about one-fourth of the population. It's common here due to our sedentary lifestyle and overall level of obesity.

It's probably more even common than that at my office, because the patients I see for liposuction and tummy tucks are often self-selected; they are seeing me specifically because they have an increased waist size, which is the most obvious part of the syndrome. I now routinely check these patients for the other parts of the syndrome.... Almost every month, we find men and women who never knew they had untreated diabetes, or cholesterol abnormalities, or the whole package -- Metabolic Syndrome. And let me tell you, are they ever thankful we discovered the problem early, rather than after a heart attack! "Doc, I came in for a tummy tuck, and you saved my life!"

It turns out that the fat inside the abdomen, the so-called "visceral fat" (as opposed to the fat that is immediately underneath the skin - "subcutaneous fat") is the chief culprit, together with insulin resistance. Visceral fat is not the harmless layer of insulation we used to think it was - it is metabolically active, giving off hormonal messenger compounds that affect our body. The thicker the visceral fat is, the more health problems are seen. Unfortunately, this internal fat can not be removed by way of liposuction or tummy tuck, so there's no quick fix.

There is an answer, though, and hope for those with the syndrome. Insulin sensitizing medications such as metformin can be used to help with the insulin resistance. Blood pressure and cholesterol medication can help, too, controlling those parts of the syndrome.

Probably the most important treatment, though, is the one that takes the most determination and effort - diet and excercise, particularly aerobic fitness. Several studies show that aerobically fit people with Metabolic Syndrome improve their odds substantially, reducing their risks by a factor of three. Furthermore, overweight people who are aerobically fit have a lower risk of cardiovascular mortality than those who are lean but unfit.

It's time to turn off the TV's and computers, America, and go get some exercise! (And that includes me, too!) Your heart will thank you for it.