Who gets the most cosmetic surgery training & experience in residency?

Myth #1:  Many people mistakenly believe that plastic surgery residency teaches only reconstructive surgical techniques, and not the cosmetic ones.
Myth #2:  Many people think that the more anatomically limited fields of dermatology, ophthalmology, or facial plastic surgery must get more cosmetic surgery experience during residency than the over-worked plastic surgery resident, who has to master techniques covering the entire body, including craniofacial, burns, pediatric plastics and hand surgery, during their residency.

The reality:  neither myth is true.  Plastic surgery teaches both cosmetic and reconstructive techniques.  They actually support each other - you can perform a better looking reconstruction if you know what the "beautiful normal" version of a body part looks like.

In terms of comparing the surgical training in the various different fields, each resident is required to keep a log book of their operative experience.  This is tallied up and submitted to the all-powerful RRC (the national residency review committee) prior to graduation, to make sure each resident has received enough experience in a variety of cases.  You don't get to graduate and take your board exams unless these numbers pass muster....so it's a very important thing.

Well, a group of researchers got the bright idea to look at this collected RRC data, comparing all the programs in the U.S in dermatology, otolaryngology (ENT/facial plastics), ophthalmology and plastic surgery, to see what the average surgical resident in each field did during their training.  Drum roll please...... For your enjoyment, here are the data on three popular procedures that are shared by several fields: blepharoplasty, facelift and liposuction.

1.  Blepharoplasty (eyelid lift)

Plastic surgery residents graduating in 2010 completed an average of 31.4 blepharoplasties. During the same year, residents in ophthalmology and otolaryngology (facial plastics) graduated with 9.1 and 6.3 procedures each. This relationship was also true for the graduating classes of 2007-2009. So, graduating plastic surgeons have three times more cosmetic blepharoplasty experience than graduating ophthalmologists and five times more exxperience than a graduating facial plastic surgeon.


2.  Facelift

Plastic surgery residents graduating in 2010 completed an average of 21.9 facelifts. During the same year, residents in otolaryngology (facial plastics) graduated with an average of 5.2 facelifts. This relationship was also true for the years 2006-2009. So the average plastic surgery trainee has four times the facelift experience of a graduating facial plastic surgeon.


3.  Liposuction:

Whereas residents graduating plastic surgery in 2010 completed an average of 40.5 liposuctions, trainees in dermatology and otolaryngology graduated with 0.2 and 1.1 liposuction cases, respectively. The average volume of liposuction recorded by a graduating plastic surgery resident was almost 40 times that performed by the average dermatology or otolaryngology resident. This relationship proved to be similar for analysis of residents graduating in 2009, 2008, and 2007


Bottom line:  plastic surgery graduates have substantially more cosmetic surgery experience than graduates from either facial plastic surgery (oto), dermatology, or ophthalmology.  So, who are you going to "trust your face to" now?

Qnexa: A new weight loss pill on the way?

This week, an FDA advisory panel voted 20-2 to recommend approval of a new weight loss pill, called Qnexa. Qnexa is a combination of two previously available medications that seem to work together well: phentermine and topiramate. Phentermine is a stimulant, while topiramate is often used for migraine headaches. What's interesting is that in 2010, this same drug was rejected by a similar FDA committee.

While the drug seems effective, with most patients losing about 10% of their overall weight after a year on the drug, there are concerns about side effects, particularly on the heart.  Studies of Qnexa shows that it raises the heart rate, and can cause palpitations - an effect common to many weight loss medications. It's unknown whether the medication causes an increased risk of heart attack or stroke.  In addition, topiramate has been linked to birth defects, particularly cleft lip and palate. FDA estimates the medication would cause cleft lip / palate in about 5 out of 1000 births, which is at least double the typical rate.

While the FDA is not obligated to follow the recommendations of the committee, they usually do. The final decision is expected later this year. Of course, the FDA may attach a number of restrictions to any approval - such as follow-up studies on cardiac side-effects, or stringent requirements for use of birth-control pills for women that want to use Qnexa. We'll have to wait and see.





photo credit: CNBC.com

More consolidation in the laser industry

Big laser companies just keep getting bigger....

This week, Cutera, the California based laser company, announced that it had acquired laser competitor Iridex for $5+ million, adding Iridex and Laserscope-branded devices to their stable of lasers.

Just a few months ago, Solta Medical, the makers of Thermage radiofrequency units and Fraxel lasers, purchased Liposonix, the new FDA-approved fat melting technology, for $35 million.

No wonder those darn lasers are so expensive!

photo credit:  laserfest.org

Ulthera is under-whelming

Ulthera is a new non-invasive skin tightening device.  The idea seems promising:  use intense focused ultrasonic energy to target tissue deep to the skin, heat and coagulate the tissue, thereby getting some tissue shrinkage and tightening.  It's had great press on the various TV talk shows.  It is FDA approved - so we know it's safe.  The question is:  does it work?

This week, at the famous Baker-Gordon plastic surgery symposium in Miami, Dr. Jeff Kenkel from Dallas reviewed his experience with the machine.  It wasn't good.  The treatments were painful for the patients.  The results, using the standard protocol, were hard to see in the neck and face, even comparing side-by-side before and after photos.  The Ulthera treatment, however, did seem to work to give a subtle lift of the eyebrow area.(average lift :1.7 mm).  It was, in my opinion, underwhelming.

Nevertheless, Dr. Kenkel and his group are going to press on, and are in the process of developing a new treatment protocol to see if they can get some improved results in the face and neck...   Honestly, I'm glad I didn't purchase that machine - I think I would have been very disappointed with the subtle results that were presented.  I suspect that many of my patients would feel the same way:  they expect more results for their money.

Updated guidelines on DVT prevention

This month, an expert group of physicians and surgeons has published their latest guidelines on preventing, diagnosing and treating blood clots - DVT's and pulmonary emboli.  It's a massive report, known as AT9 - even the executive summary runs 39 pages.  It can be found here.

Why do we, as plastic surgeons, need to know this stuff?  Because DVT's and PE's are serious, even lethal, problems that can happen after any long surgery.  So we take this stuff very seriously.  Patient safety, to steal a line from Ford Motor company, is job one.

Here are the latest recommendations for healthy plastic surgery patients:
1.  Pretty much everyone who goes to the operating room needs to be wearing sequential compression stockings (SCD's), unless they are less than 40 years old, and having a operation less than 45 minutes long.  We already do this.

2.  Most of the bigger cases (tummy tuck, lower body lift, etc.) should receive low molecular weight heparin - also known as "Lovenox".  We already do this too.

3.  People that are at very high risk should get both the SCD's and the Lovenox.  The way this" high risk" label is sorted out is based on a scale called the Caprini score.  My friends from the University of Michigan have done a lot of work, researching the use of this scale in plastic surgery patients (link to study).  You can see the details of the Caprini score there - it's a one page, easy to use system.

What's not totally settled in this latest report is the best timing for administering the Lovenox - 12 hours before surgery, at surgery, or sometime after surgery.  Currently, we follow the recommendations initially developed in by Orthopedic surgeons - who get a lot of DVT issues after hip and knee replacement surgery - and give it 10-12 hours post-op.  I'll be digging through the full report to see if I can find out more about this important detail.

This is one of those basic issues in plastic surgery that, although not as exciting as discussing celebrity surgery or the latest gee-whiz gadget, makes things safer for everybody.  If you are planning a big surgery, ask your surgeon about the methods he or she is going to use to prevent you from getting a DVT.

US adult obesity figures released, 1999-2010

The latest numbers in the American obesity epidemic were released in this month's issue of  JAMA.

Here's the one bit of good news:
-  American women, overall, aren't getting any bigger than they were during the last study, which looked at the 1999-2008 data, but 35.8% of US women still fit the BMI-derived definitions for obesity.  The average age-adjusted BMI was 27.3

The bad news:
-  More American men are obese than before, with 35.5% nationwide (more than one-third) being obese.  Average age-adjusted BMI was 28.7.

By comparison, in England, the prevalence of obesity is considerably less:  22.1% for men, and 23.9% for women.

photocredit: cslacker.com

Cellulaze - a new laser treatment for cellulite?

Just this week, the FDA has given their approval to the marketing of a new laser from Cynosure called Cellulaze.  Like the name suggests, it's a surgical laser treatment for cellulite.  Here's how it works:

With the help of local anesthesia, several small incisions are made near the area of cellulite.  A laser fibre is inserted under the skin, and a 1440 nm wavelength side-firing laser is used to treat the area of cellulite.  The laser helps by both melting the excess fat, and releasing the tethering bands that give cellulite its indentations.  And it seems to work, with a high degree of patient approval in preliminary studies.  Before and after pictures (shown above) seem to show a nice improvement - but of course, these are on the corporate website, so one would only expect to see their best results!

Nevertheless, this is the first laser treatment specifically proven to improve cellulite, with at least a one year follow-up study showing positive results and minimal side effects.  Dr. Barry diBernardo, fellow ASAPS member and plastic surgeon, presented his experience with this device at last year's scientific meeting, and he seemed impressed with the technology.

So, it looks intriuging...time will tell if it's really as good as the marketing hype suggests, and whether it is better than our current selection of skin tightening devices.  For now, we're seeing nice improvements in cellulite with our Venus Freeze RF device - no incisions required!