Trade your air miles for plastic surgery?

Finnair, Finland’s biggest airline, has an offbeat new idea for frequent flyers: Exchange your air miles for plastic surgery!

According to the airline's website, the cosmetic procedures are performed at the Nordstroem Hospital in Helsinki. All the usual procedures can be obtained with air miles - but it takes one heckuva lot of points! Earning the 3.18 million points for breast augmentation surgery requires 120 round-trip, business-class flights between Helsinki and New York, according to a points table on Finnair’s Web site.

Customers who want to redeem their air miles for cosmetic surgery must first book a 95-euro consultation at the hospital before using loyalty points for the surgery voucher.

This is prime material for late-night comics! What will they think of next?

Do-It-Yourself Botox Site Busted in Texas

This story from WFAA-TV in Dallas / Fort-Worth....

Undercover officers raided the home of a Mansfield (Texas) woman who they say was selling "do-it-yourself" wrinkle treatments.

Police confiscated boxes, computers and more at the home of Laurie D'Alleva. Texas Attorney General Greg Abbott charged the woman with illegally offering prescription drugs -- including botulinum toxin (Botox) injections -- without a license.

The legal action also alleges that D'Alleva operated illegal Web sites to market her products. The state obtained a restraining order to keep her from selling the drugs and shut down her Internet sites, Discount Medspa and Ontario MedSpa.

The sites included video demonstrations of how to use the prescription drugs, along with customer testimonials about the results they were getting. Doctors caution that self-injecting or taking any drug without the authorization of a doctor can be harmful -- even deadly.

The state said D’Alleva falsely claimed that her membership in the "Texas Medical Council" authorized her to sell prescription-only products. There is no such organization. According to court documents, undercover investigators bought a “Newbie Starter Kit” from D'Alleva which contained the prescription Restylane in a filled syringe. They also purchased Dysport and Freeze, both of which contain purified neurotoxins, which are used for wrinkle-reduction.

Comment: I don't know what "Freeze" is - it's certainly not an FDA-approved Botox product. People must have short memories: remember the "Tritox" business in South Florida, where some self-injectors of a home-brew botulinum product ended up in the ICU on ventilators?

Don't self-inject. Don't use unapproved, untested compounds, just to save a few bucks.

First Orthopedic Surgeon in Space

Robert Satcher Jr, MD, PhD, made history last Tuesday when he lifted off in the space shuttle Atlantis, headed to the International Space Station. Dr. Satcher will be the first orthopaedic surgeon to orbit the earth and is one of only 23 US physicians who have become astronauts.

Dr. Satcher is serving as the flight crew medical officer and as a mission specialist on the 11-day assignment. On 2 space walks, he will install an oxygen tank in the space station and perform maintenance work on the station's Canadian-made robotic arms, which he will get to maneuver.

Dr. Satcher has an impressive CV: an MD from Harvard University, a PhD in chemical engineering from Massachusetts Institute of Technology, and orthopaedic surgery residency training at the University of California–San Francisco, followed by fellowships in research and musculoskeletal oncology.

Congratulations, Dr. Satcher!

Senate Dems propose a 5% cosmetic surgery tax

As part of the 2000 page Senate proposal for health care reform released today, Senate Democrats are proposing a 5% tax on cosmetic surgery. More details can be read in the New York Times report (here). The way this proposal is worded, non-surgical cosmetic procedures such as Botox, Restylane and Juvederm, laser treatments and pretty much any cosmetic treatment performed by a licensed professional would be taxed as well.

We've talked about cosmetic surgery taxes before, pointing out how they are unfair to consumers. (see earlier blog here).

Why? Because they are a tax primarily on women, who represent 90%+ of our cosmetic surgery patients - and it's unfair and unconstitutional to disproportionately tax a single group. It's sexist!

Also, this is not a "tax on the rich" - the vast majority of our patients are average, middle-class Americans who are simply trying to fix a physical feature that bothers them.

Although the patient would be taxed, get this, according to the proposal, the physician would be financially liable if the tax were not paid. Unbelievable!

You can read the actual text of the bill here (click for link)

If you would like your voice to be heard about this tax on women, please contact our Democratic State Senator for Florida, Senator Bill Nelson at:
716 HART SENATE OFFICE BUILDING WASHINGTON DC 20510
(202) 224-5274
billnelson.senate.gov

New simpler rules for cholesterol testing

I had an interesting conversation with a patient this week, who strenuously asserted that the link between cholesterol levels and heart disease remains "unproven". As it happens, this month's issue of the Journal of the American Medical Association (JAMA) has a major new study reviewing the link between cholesterol, heart disease and stroke, so I was able to show him the data.

The study group came up with some new findings, and re-confirmed some older findings:

1. HDL levels (high density lipoprotein) - aka "the good cholesterol" - is clearly protective for heart disease. Higher levels are strongly correlated with a reduced rate of coronary heart disease. We knew this already.

2. Everything else (other than HDL) in the cholesterol family is "bad", with the risk of cardiac disease increasing significantly for non-HDL levels above 135 mg/ml. "Non-HDL cholesterol" is certainly simpler to remember than LDL's, VLDL's, chylomicrons and all the rest.

3. Triglyceride levels had no relation to heart disease risk in this study. Before you start celebrating, remember that excess triglyceride levels have been linked to pancreatitis.

4. Interestingly, there was no significant linkage between non-HDL (bad) cholesterol and stroke rates. That finding was unexpected.

5. Also new, Cholesterol levels did not vary significantly from the fasting and non-fasting states. Therefore, next time you go to have your cholesterol blood test, you will no longer need to skip breakfast.

Essentially, this study simplifies assessment of the lipid risk profile for cardio-vascular disease. Measure your total cholesterol and your HDL cholesterol, and don't worry too much about the other cholesterol groups. And don't worry about getting fasting lab work, unless the fasting state is needed for some other lab test, like glucose levels.

New Government Mammography guidelines spark debate

This week, an influential government panel known as the U.S. Preventive Services Task Force (USPSTF), whose recommendations influences coverage of screening tests by Medicare and many insurance companies, has come out with new guidelines for mammography, particularly when testing should start, and how often it should be performed. Their article is published in the latest issue of Annals of Internal Medicine (link to article).

These new USPSTF guidelines are sure to spark a hot debate, as the panel claims that:

1) women don't really get a "significant" benefit from mammography until after age 50, rather than age 40, which is the current standard.

2) the mammograms are only needed every second year, not every year, thereafter, which is a change from the current standard.

The American Cancer Society (ACS) and National Cancer Institute (NCI) have already issued statements saying that they don't agree with these looser recommendations, pointing out that breast cancer is a significant issue for women in their forties, and that screening with mammography saves lives - about 1 life saved for every 1900 people screened in the 40-50 age range. (Click here for detailed ACS analysis.) The ACS and NCI fear that, with less screening, that the benefits of early diagnosis and treatment will be lost. The USPSTF panel, on the other hand, feels that the benefit of putting most women through mammograms in their 40's is small, and doesn't outweigh the extra biopsies and drawbacks of additional radiation.

I also wonder if Medicare and insurance companies will use the new USPSTF report as an excuse to reduce the coverage of mammography. Patients may tend to "slack off", and put off getting a mammogram.

I'll be reviewing the original article in detail on my own - but for now, I will continue to follow the ACS and NCI current standards, and recommend that women start mammography at age 40, unless they are in the "high risk" group, in which case it should start even earlier, not later.

Dr. Fiala tests the "Keller Funnel"

Ever see a product and go, "I wish I had thought of that"? Today, I tested a new surgical product called the Keller funnel, named after its inventor, also a plastic surgeon - and I had that very same sentiment.

Essentially, the Keller funnel looks like a high-tech cake decorator's funnel, the triangular bag with which cake icing would be squeezed onto a cake - except that this one is made of fancy materials, is sterile, and has an inner surface which is coated with a slippery space-age coating. Dr. Keller devised it to help plastic surgeons place silicone gel breast implants more easily during surgery, through smaller incisions, and with potentially less contamination or chance of implant damage.

While these other possible benefits haven't yet been scientifically proven, the gadget certainly does work for its primary purpose - the implant slides into the surgical pocket, easy as can be.

If the company can produce these at a reasonable price, I think they'll have a winner.

Johnson & Johnson pulls the plug on "Evolence"

Johnson & Johnson has announced this week that it has decided to stop making and selling Evolence, an injectable soft-tissue filler.

Although Evolence has a good track record of safety and effectiveness, product sales apparently did not meet corporate expectations.

The facial filler gained approval from the FDA in June 2008, but its market introduction coincided with a rough time in the market for cosmetic medical products, due to the recession.

It's too bad - we liked this product and used it here. Evolence was useful for nasolabial creases and marionette lines, and was a good alternative to the hyaluronic acid family of fillers.

Propofol found in Weston Medi Spa patient

New details have now emerged regarding the tragedy which occurred in south Florida, following liposuction surgery at an unlicensed medispa, which we discussed in an earlier chapter of the blog (here).

According to an October 30, 2009 article in the Sun-Sentinel (here), the patient was not having the liposuction surgery performed with just local anesthesia (numbing with lidocaine), but she also was given the anesthesia drug Propofol for intravenous sedation. Propofol is a safe drug in the trained hands of an anesthesiologist, but, as Michael Jackson found out, it can be lethal in the hands of an amateur.

This discovery makes a huge legal and regulatory difference. It's giving anesthesia without a trained anesthesiologist or nurse-anesthetist being present.

Receiving any sort of intravenous sedation automatically defines the procedure, according to existing Florida regulations, as a "level II office surgery" at a minimum. The level II category mandates significantly more stringent requirements than a procedure performed with local anesthesia only, such as:
- a well-defined list of safety equipment present in the office
- certain monitoring standards for the patient's vital signs and oxygenation
- completion of inspection of the surgery center by either the State of Florida or one of the national accreditation agencies
- hospital privileges for the surgeon
- a standing hospital transfer agreement in case of emergency.

None of these regulations were being followed by the Weston Medi-spa. The physician who performed this surgery was not board-certified in a surgical specialty, and reportedly did not have hospital privileges to perform liposuction in any hospital.

The Board of Medicine is now looking at a new rule, which would require all Medi Spas where surgical procedures are performed to follow the same regulations as surgery centers. I think this is an excellent idea, that would enhance patient safety.

However, these rules have to have some "teeth". It's one thing to write a good law, but another thing altogether to insure that the law is followed. Currently, it is the enforcement of existing regulations that is lacking. There are some good people working for the Board of Medicine - but they are stretched thin, in terms of manpower and funding.

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This blog is in the miscellaneous category, called "Out of this World".

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New study on fat grafting to the breast

It's seems like a perfect answer - "take a little off down here, put some a little more up here". But fat grafting to the breasts has been controversial. A problem, known as fat necrosis, has been the #1 concern. Lumpy deposits of injected fat, which may feel exactly like a breast cancer, can result if the fat does not survive the transfer, and goes on to form calcified scar tissue within the breast.

Previously, back when radiologic imaging of the breast was less advanced, sorting these lumps of scar out from early breast cancers was a real problem. Surgical biopsies were sometimes needed to make the determination. Over the last decade, though, a lot of work has been done on fat grafting, reappraising its role as a reconstructive tool. Here in the U.S., Drs. Coleman and Khouri, two plastic surgeons who have been independently making major contributions to this area, deserve a lot of credit.

In this month's issue of the Aesthetic Surgery Journal is an important study looking at the safety of fat injection to the breast. This work, from Lyon, France, summarizes 880 procedures over 10 years, and mainly looks at the application of fat grafting for reconstructive applications - following mastectomy reconstruction, and for breast asymmetries and other developmental problems.

The French group in the study used Dr. Coleman's technique (low-pressure small cannula liposuction of the fat from the donor area, purifying the fat with a centrifuge, then injecting it in very small volumes into the target area). None of the more advanced techniques that have been recently reported to enhance fat grafting success were used -i.e. no addition of stem-cells, or use of the external BRAVA suction device.

Very careful breast imaging was mandatory - both pre-op and at one year post-procedure, using mammograms, ultrasound and MRI. The French radiologists "signed off" on the normal status of the exams before the patient underwent surgery. (I wonder if any lawsuit-averse U.S. radiologists would be willing to do that!) While all patients had some post-surgical changes in their post-op mammograms, the radiologists were, in general, able to sort out these changes with the use of the more advanced imaging methods and a lot of experience.

Ninety percent of the results were rated as either "good" or "very good". As expected, the surgeons found that about 40% of the injected fat melted away. Fat necrosis - formation of lumpy scar tissue - was seen in 15% of the authors first 50 cases, decreasing to about 3% after that. In some cases, a needle biopsy of the lumps in the breast was still required.

Overall, good improvements in the breast contour and degree of symmetry were reported, and the authors felt that fat grafting represented a very good technique for "touching-up" results after a complex breast reconstruction, or avoiding a more-complex reconstructive method. They also showed nice results for breast asymmetry and cases of Poland's syndrome, a developmental breast problem.

Bottom line: fat-grafting to the breast is a procedure which, while very promising, is still under development. Guidelines about timing, indications, pre-op and post-op MRI imaging, and important details regarding the best technique are still being sorted out. I can not yet recommend it for cosmetic breast enlargment at this stage, outside of a carefully controlled clinical trial.