PSB - the Orlando plastic surgery blog

New technology for smoother injections: the Artiste System

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Thu, 24 May 2012 18:45:00 +0000

We're always on the lookout for new ways and processes to make what we do even a little bit better. Here's a little gadget that I think will improve filler injections - it's called the "Artiste injection system".

Like most good ideas , the concept is simple. It's an air-powered injector, allowing for smooth, even injections of fillers like Restylane or Juvederm. You can precisely control the speed of injection with the big blue dial on the front of the machine. It's controlled by a footswitch to start and stop the injection process.

Early results from studies show smoother injections, with fewer lumps and bumps, and less bruising. And because you put the product exactly where it's needed, sometimes you use a little less filler.

I heard about the prototype of this machine two years ago on the "Hot Topics in Plastic Surgery" committee - but now the company has geared up production. We are testing the machine in our office currently. It works with all types of filler injections. So far - I'm pleased with the results. Stay tuned.

Zytase, a new trick to make Botox work better?

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Mon, 21 May 2012 12:12:00 +0000

Wouldn't it be nice if you could make your Botox or Dysport treatment last longer? Well, according to OcuSoft, the makers of Zytase, you can - with an easy method. Simply take their zinc supplement for 5 days. According to a pilot study off 44 patients, this supplement prolonged the effects of Botox by 20-25%. Interestingly, people who are zinc deficient don't seem to get as effective a response to Botox. Larger studies, however, will need to be done to confirm this preliminary finding.

Since there is little downside to this treatment, I have arranged to have Zytase available in the office if people want to try it out. It's inexpensive, compared to a Botox treatment, but you have to start it 4 days prior to your treatment. So, if you feel your Botox isn't lasting as long as you'd like it to....you might want to check this out.

More information is available at the manufacturer's website, zytase.com

Fat grafting to the breast - more studies.

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Thu, 03 May 2012 00:56:00 +0000

Here's a news brief from ASPS on fat grafting to the breast for augmentation purposes. This is the same fat grafting method that we use in our Orlando office, for those people who are interested in avoiding the use of a breast implant, but still want a little bit more breast volume. There's been a lot of interest in this recently, based on phone calls we've been getting. So, if you have a fatty deposit you'd like to slim down, and the desire for a cup size larger on top - you might just be in luck! But if you want to have "the implant look", or go larger than a cup size increase, standard breast implants remain the best option. Image: Wired magazine

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Preoperative expansion of the breast followed by injection of the patient's own fat provides a safe and effective alternative to implant surgery for breast augmentation, reports a recent study in Plastic and Reconstructive Surgery.

The technique—which includes using a special suction-pump bra device for a few weeks before surgery to "pre-expand" the breasts—provides greater augmentation than fat transfer alone, according to the new report. The lead author was Roger Khouri, MD.

The technique is an adaptation of the increasingly popular autologous (patient's own) fat transplantation technique. In this approach, fat obtained by liposuction from one part of the body—for example, the thighs—is transferred for use in breast augmentation and reshaping.

In the technique used by Dr. Khouri and colleagues, the patient first undergoes several weeks of "pre-expansion" treatment. This is done using the Brava®, a bra-like device that uses gentle negative pressure (a vacuum) to gradually expand the breast. Brava pre-expansion provides extra room in the breast, along with a "fibrovascular scaffold" that the transplanted fat cells can occupy. The patient also wears Brava for a week or so after fat cell injection.

The study presents the results of the new technique in 81 women who desired breast augmentation but didn't want implants. All but ten patients used Brava as instructed before the fat transfer procedure.

One year after surgery, breast volume was increased by an average of about 230 cc (about eight fluid ounces) in women undergoing the Brava procedure. That was significantly greater than the 130 cc average reported by previous studies using fat transplantation alone without pre-expansion.

The difference was explained by increased survival of transplanted fat cells after pre-expansion: about 80 percent, as measured by MRI scans before and after surgery. This compared to about 55 percent fat cell survival without pre-expansion.

There were no major complications. Sixteen percent of women had areas of fat cell necrosis (cell death), which was harmless and easily detected on mammograms.

While the idea of breast fat transfer is not new, it has seen a resurgence in recent years, with several groups of plastic surgery researchers reporting successful results. However, relatively low survival of the transplanted fat cells has been a limiting factor. Without pre-expansion, there is simply not enough room within the breast for the transplanted fat cells to survive and thrive.

Using Brava before and after fat transplantation provides more optimal conditions for successful fat transfer, Dr. Khouri and colleagues believe. While further research and experience are needed, the researchers think their study "establishes a benchmark and a platform for further potential improvements."

Effect of incision choice on capsular contracture after breast augmentation

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Thu, 26 Apr 2012 15:09:00 +0000

Most patients tend to think that the type of incision used for breast augmentation doesn't make a difference, and that they all work equally. Turns out, that isn't the case at all. The incision placement actually makes quite a difference on the frequency of complications.

In this month's issue of ASJ (the Aesthetic Surgery Journal) is a nice little study by Dr. Scott Spear and colleagues, comparing the rates of capsular contracture (breast hardness after implant placement) in 183 breast augmentation patients. Dr. Spear is a respected plastic surgeon, and an expert on breast augmentation, having been very much involved with the FDA review panels on the topic.

The patients were divided into three groups, based on whether they had an inframammary crease incision, a nipple incision, or the transaxillary (armpit) incision, and were followed for an average of 13 months after surgery.

The researchers found that the incision placement did make a significant difference. Capsular contracture and hardening of the breast happened most often with the transaxillary incision (6.4%) and the periareolar incision (2.4%). The infra-mammary incision had the lowest rate of complications, at only 0.5%

This report supports a previous publication which found the same kind of results - inframammary incisions have the lowest capsule rate. And since CC is the most frequently encountered complication after breast augmentation, it really makes sense to do everything possible to reduce the chance of this problem happening.

In this study, there was no difference in capsule rates between saline and silicone gel implants, which is the same trend as the data in the Mentor - FDA follow-up study.

Bottom line: If patients want to have a periareolar incision, they are putting themselves at risk for a five-fold increase in capsular contracture rates, and the subsequent surgery to fix it. That's a pretty major difference, and a big trade-off. I typically recommend the infra-mammary incision to my Orlando breast augmentation patients, based on this data.

Proven: liposuction and tummy tuck improve Quality of Life

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Wed, 25 Apr 2012 11:22:00 +0000

In the "Seems Like an Obvious Result" Category, here is a study from this month's issue of PRS, showing good outcomes and improved quality of life and self-esteem with tummy tucks and abdominal liposuction, either separately or in combination. Here's the summary, courtesy of PS News.

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Dr. Eric Swanson, a plastic surgeon in Kansas, formally evaluated quality of life and other outcomes in 360 patients undergoing liposuction and/or abdominoplasty to remove excess abdominal fat. About 60 percent of patients underwent liposuction alone, while 35 percent underwent a combination of liposuction and abdominoplasty. The rest underwent abdominoplasty alone.

The patients' average age was 42 years; 85 percent were women. Thirty percent of patients underwent other cosmetic plastic surgery procedures (such as face lift or breast augmentation) at the same time. Outcomes were assessed an average of four months after surgery.

Patients undergoing liposuction alone had shorter recovery times: average time off work was about six days, compared to 16 days with abdominoplasty (with or without liposuction). The liposuction-only patients also had less discomfort: average pain score 6 out of 10, compared to 7.5 for those undergoing abdominoplasty.

Combined Procedure Yields Best Results

Patients undergoing abdominoplasty rated their cosmetic outcomes higher than others: average score 9 out of 10, compared to 8 out of 10 with liposuction only. Liposuction plus abdominoplasty produced the highest patient satisfaction rate-over 99 percent-with no increase in pain compared to abdominoplasty alone.

Ninety-eight percent of patients undergoing liposuction plus abdominoplasty said they would undergo the procedure again and 99 percent that they would recommend it to others.

Overall, 86 percent of patients reported an improved sense of self-esteem after surgery. About 70 percent reported improved quality of life, more commonly after liposuction plus abdominoplasty.

Quality of life is an increasingly important focus measure of effectiveness for all types of medical and surgical treatments. Even though liposuction and abdominoplasty are among the most frequently performed cosmetic surgery procedures, few studies have formally evaluated their impact on quality of life and other patient-reported outcomes.

"Liposuction and abdominoplasty, individually and in combination, produce high rates of patient satisfaction and reliably improve self-esteem," Dr. Swanson writes. By formally assessing these important outcomes in a large number of patients, he hopes his study will provide a clearer picture of the expected results and recovery times associated with these widely performed cosmetic surgery procedures.

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Editor's note: We find similar results in our Orlando practice. Tummy tuck, with or without liposuction, makes a dramatic improvement in self-esteem and quality of life, according to our patients. Kudos to Dr. Swanson for formally documenting this finding.

The Miss Plastic Surgery award goes to.....

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Tue, 24 Apr 2012 21:11:00 +0000

Guess which country has the most plastic surgery per capita...I'll give you a hint - it's not the United States or even Brazil, that hotbed of South American cosmetic surgery, although in total numbers, the U.S. is #1.

I was surprised to learn that, according to research firm Trend Monitor, South Korea has more procedures per capita than anywhere else. Nearly one out of five women there have had "something done" - whether it's a non-invasive procedure or actual surgery. Here's the graph, reproduced from The Economist.com

Headline from ASLMS: cosmetic laser surgery not always best

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Tue, 24 Apr 2012 15:19:00 +0000

An article in the Orlando Sentinel covering the recent laser meeting in Orlando (American Society for Laser Medicine & Surgery, also known as "ASLMS") came out with this headline. I thought it would be educational to look at the article in more detail, and comment on it.

Article: "...of all the procedures, hair removal seemed to deliver best on its promise. The before and after photos presenters showed of vascular lesions - particularly the small broken blood vessels on the side of the nose and red birthmarks - also showed clear improvement"

Comment: I agree. These are mature laser technologies, and do work effectively.

Article: "Least impressive were results from laser-assisted body contouring and face and neck lifting. One practitioner on the body contour panel said that in only 20% of cases where a patient had the non-invasive Cool Sculpting procedure were both the doctor and the patient satisfied..."

Comment: I agree here too. It's hard to beat a well-performed liposuction with either PAL or standard tumescent techniques, or a traditional surgical facelift. The laser-assisted liposuction devices are still evolving and changing every year. Manufacturers and surgeons can't seem to agree on which wavelength, power and other parameters are the best for these fat-busting lasers - which tells you that they really don't yet know. I'm surprised that the satisfaction number is only 20%. That's really dismally low for laser liposuction.

Article: Discussing laser treatments of the face & neck, the report quotes Dr, Zelickson, a renowned laser researcher and developer of the Zeltiq, "In many cases, results are very modest; tightening is hard to measure."

Comment: Truthful words from Dr. Z. That's one reason why I don't use Ulthera - the results are too darn subtle. I think patients want to see obvious visible improvements without having to scrutinize their before and after photos for minor improvements.

Article: "Patients need to do their homework and not go off a billboard", said Dr. Geronemus.

Comment: Truer words were never spoken!

So even though a procedure with the word "laser" attached to it sounds all high-tech and cool, it's not always the best choice. Be sure to check out the alternatives.

No more "boob-jab" - Macrolane withdrawn from breast augmentation in UK

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Sun, 22 Apr 2012 16:19:00 +0000

For the past 5 years, there was an injectable filler called Macrolane that was being used in the UK for all sorts of body contouring operations - including breast augmentation. As you might imagine, the idea of a "lunchtime" breast augmentation by injection - in 45 minutes without the need for implants - became quite popular in the U.K.

However, there were significant problems with breast hardness and lumpiness after the treatment. Rather than behaving like a typical soft tissue filler like we might use in the lips or in a facial wrinkle, large deposits of Macrolane seemed to behave more like an actual implant, with potential for capsular contracture formation, and potential for hardness or tissue distortion.

According to the Daily Mail newspaper, the manufacturers of the product (Q-Med of Sweden) have now decided to withdraw it from use in the breast, due to concerns that it would make mammograms more difficult to read or make a cancer more difficult to detect.

A spokesman for the British equivalent of the FDA, known as the Medicines and Healthcare products Regulatory Agency (MHRA) said: "This is not because of safety concerns with the product itself but because the product may interfere with the reading of mammograms and could make diagnosis more difficult. The product can still be used in its other indications, such as augmenting body contour and correcting soft tissue defects."

The British Association of Aesthetic Plastic Surgeons (BAAPS) said that in a survey of its members, 25% of surgeons reported patient complications after the use of Macrolane.

Macrolane, a thicker cousin of Restylane, is not yet available in the U.S. for any application.

ASAPS 2012 annual meeting

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Thu, 19 Apr 2012 14:05:00 +0000

Once again, it's nearly time for the super-specialists of aesthetic plastic surgery to get together for the annual ASAPS meeting. This year, the meeting is in my hometown of Vancouver, Canada, May 3- 8. It's the best meeting I know of in our field. I always hear neat new ideas there from the thought leaders in our field, and see surgical results that make me aspire to match them!

I'll be attending some specialized courses taught by world-leading plastic surgeons, and for the first time, I've been invited to be involved with teaching part of a course (on lasers & cosmetic medicine). It will be exciting, and I'm looking forward to seeing colleagues from throughout the US and Canada.

I'll also be blogging from the meeting, with updates on what's hot & what's not, and new technology that might be relevant to our mission of providing scientifically proven techniques that work safely, and avoiding hype and marketing spin!

Stay tuned....

Individualized skin care with "PCA SKIN"

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Thu, 29 Mar 2012 14:51:00 +0000

I'm pleased to announce the arrival of a new line of skin care products at our office - PCA Skin.

Their award-winning product line is divided into two parts: daily use products, and their professional-grade peels.

What I really like is their individualized approach to skin care. For each common type of problem skin - whether it's "sensitive" or "Acne-prone" or "hyperpigmentation issues", they've hand-picked certain types of products to optimize the skin treatment. So, the most appropriate cleanser, toner and various active treatments for the skin type are included in each kit. This really makes a difference in outcomes compared to the "one-size-fits all approach".

Also, they have a nice introductory or "travel-size" kit, which is quite reasonably priced, as well as the full size kit. This means you can sample the products to see how they work for you, without a huge investment!

PCA Skin products are formulated using all-natural, technically advance ingredients that are safe for sensitive skin types or people that have recently had a chemical peel or laser treatment. They do not use animal testing.

So, if you've struggled with dry, red skin from previous skin care lines, have rosacea, have acne breakouts, or pigmentation issues - I think you'll find these products worthy of your attention.

Come and see Kim, our aesthetician, if you'd like more details on the products, or their advanced professional peels.

ATX-101: the new injectable fat-melter

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Wed, 28 Mar 2012 13:30:00 +0000

Here's an update on the progress of ATX-101, an up and coming drug which melts fat by injection. (We've reported on this previously in our blog, now here's the latest news....)

It's like mesotherapy, except with actual science, data and careful clinical testing.

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In two mid-stage trials, injections of ATX-101 reduced fat deposits under the chin within 16 weeks, researchers said this week at the American Academy of Dermatology's annual meeting in San Diego.

Kythera Biopharmaceuticals, the manufacturers of ATX-101, are hoping that its experimental drug, a formulation of the bile acid sodium deoxycholate, will become a pharmaceutical alternative to neck-lift surgeries and liposuction for this area of the body.

Pooling the results of two double-blinded studies, researchers evaluated 155 patients who had been randomly assigned to four groups. Three groups received ATX-101 injections in different doses and the fourth received a placebo. Injections were given at baseline and weeks four, eight, and 12. At 16 weeks, all three ATX-101 groups showed statistically significant improvement compared to the placebo group. ATX-101 patients also reported significantly greater satisfaction with their appearance than the control group.

The effects appeared to last. More than 90% of those who responded 27 months after their last treatment showed continued or even greater improvement. Likewise, at the same point, more than 80% reported continued or greater satisfaction with the treatment. Adverse events were mild to moderate pain, swelling and other issues localized to the injection site; they cleared up within 28 days.

ATX-101 has not yet gained FDA approval. According to Kythera Biopharmaceuticals, Inc, more clinical trials are getting underway in Europe and the U.S.

Source: Medscape - edited for length & clarity

ASAPS 2011 Cosmetic surgery stats are out - part I

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Tue, 20 Mar 2012 16:23:00 +0000

Every year, we look forward to seeing the statistics from ASAPS. They act as a barometer, refelcting the total volume of procedures in the U.S., and also help us to identify trends in what's popular, and what's not.

Here are some highlights from their report.

1. If you combine the surgical and nonsurgical cosmetic procedures, there were over 9 million procedures performed in the United States in 2011. Surgical procedures accounted for 18% of the total number of procedures and nonsurgical procedures made up 82% of the total number of procedures. Women had 91% of the total. The number of cosmetic procedures for women has increased over 208% since 1997.

2. From 2010-2011, there was almost a 13% increase in the total number of liposuction procedures, with over 300,000 procedures performed. For the first time in three years, lipoplasty has surpassed breast augmentation, returning as the most popular cosmetic surgical procedure in the United States.

3. The top five cosmetic surgical procedures in 2011 were:
- liposuction (325,332 procedures)
- breast augmentation (316,848 procedures)
- abdominoplasty (149,410 procedures)
- blepharoplasty (147,540 procedures)
- breast lift (127,054 procedures).
It's interesting to note that rhinoplasty, which used to be a top 5 procedure, is no longer present.

4. The top five nonsurgical cosmetic procedures in 2011 were:
- Botox (2,619,739 procedures)
- filler injections with restylane, juvederm (1,206,186 procedures)
- laser hair removal (919,802 procedures);
- microdermabrasion (499,427 procedures)
- IPL laser treatment (439,161 procedures).

No surprises here. Botox and fillers remain popular on the minimally invasive side of things, while breast augmentation, liposuction and tummy tucks are still very popular on the surgical side.

Insider espionage: Allergan wins injunction against Merz

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Thu, 15 Mar 2012 15:33:00 +0000

Allergan, the makers of Botox, have announced that they recently won an injunction against Merz Pharmaceuticals and Merz Aesthetics. The injunction prohibits Merz from selling Xeomin, a Botox competitor, in the U.S. for 10 months.

U.S. District Judge Andrew J. Guilford wrote in his decision that Merz misappropriated trade secrets belonging to Allergan. He wrote, "there is overwhelming circumstantial and direct evidence" that Merz stole the trade secrets and that "Allergan faces a substantial threat of impending injury as a result of this misappropriation." Allergan claimed that Merz hired seven former Allergan sales reps in 2010, who provided this insider information.

Since the U.S. Botox / Dysport / Xeomin market is very lucrative for these manufacturers, this represents a big setback for Merz.

Florida Liposuction Safety bill passes!

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Tue, 13 Mar 2012 21:19:00 +0000

As part of Florida House Bill 1263, the new liposuction requirements have passed. This means that any physician (MD or DO) who performs liposuction of more than 1 litre of fat, or any sedation case lasting more than 5 minutes must do so in an accredited surgical facility. Lipo in the back room of a spa, unaccredited medical office, hotel or some other location....is now officially a no-no.

This is a legislative victory, as it should improve safety for cosmetic surgery patients in Florida. As we've said before, liposuction surgery is real surgery... and it needs the same quality patient care and attention that all surgical procedures should have. It should be performed in an accredited, inspected surgical facility, by appropriately trained surgeons and their staff, with standard safety monitoring devices and access to emergency resuscitation equipment. The phrase "it's just a little bit of lipo" or "it's just cosmetic" doesn't mean one can skimp on safety.

Here's the official text:

458.309
(3) A physician /All physicians who performs liposuction procedures in which more than 1,000 cubic centimeters of supernatant fat is removed, perform level 2 procedures lasting more than 5 minutes, and all level 3 surgical procedures in an office setting must register the office with the department unless that office is licensed as a facility under pursuant to chapter 395. The department shall inspect the physician's office annually unless the office is accredited by a nationally recognized accrediting agency or an accrediting organization subsequently approved by the Board of Medicine.

459.005 same language, but for Doctors of Osteopathy.

FDA approves new silicone gel-filled breast implants

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Fri, 09 Mar 2012 21:52:00 +0000

Today, the U.S. FDA gave approval to a third breast implant manufacturer - Sientra - to supply silicone gel-filled breast implants for both cosmetic and reconstructive patients in the U.S. Sientra joins Allergan and Mentor as FDA-approved implant manufacturers.

As a condition of approval, Sientra is also required to conduct several ollow-up studies that will assess patient outcomes and safety issues.

The FDA based the approval on a three year study of 1,788 patients. Complications and outcomes were similar to those found in previous studies of other breast implants.

The FDA has required Sientra to perform a number of additional long-term follow-up studies, as well, to maintain their approval.

Details on the product dimensions and types are not yet available on the Sientra website, but I would expect them to be similar to the current Silimed brand devices. They have both smooth and textured implants. The date of availability has not yet been announced by the company. In other countries, they also sell polyurethane-coated implants, which are not approved here.

I'll keep you posted as details become available.

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

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Wed, 29 Feb 2012 21:03:00 +0000

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?

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Thu, 23 Feb 2012 16:10:00 +0000

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

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Wed, 15 Feb 2012 21:18:00 +0000

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

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Mon, 13 Feb 2012 21:12:00 +0000

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

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Tue, 07 Feb 2012 20:37:00 +0000

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

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Thu, 02 Feb 2012 19:42:00 +0000

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?

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Wed, 01 Feb 2012 15:22:00 +0000

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!

More data on Brava-assisted fat grafting for breast augmentation

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Wed, 25 Jan 2012 20:19:00 +0000

In the upcoming issue of Plastic and Reconstructive Surgery, Dr. Roger Khouri and associates give us an update on their experience with fat transfer to the breast for the purposes of breast augmentation. The bottom line: as long as you use the Brava system for several weeks beforehand, fat transfer works pretty well.

In the study, 81 patients used the Brava for 4 weeks before surgery, then had their own fat transferred with liposuction harvesting to the breast. They then wore the Brava post-op for at least a week. An average of 277 ml per breast was used - which, compared to typical breast implants, is a pretty conservative volume. The patients were followed for an average of 3.7 years postoperatively.

Based on MRI data, they found about 82% graft survival, which was much better than earlier studies in which the Brava system was not used, where the average fat graft survival was 55%. Also, the better the pre-expansion was with Brava prior to surgery, the better the results. There were no suspicious breast masses or nodules during the follow-up period.

These results are pretty much the same as what Drs. Khouri and delVecchio presented at last year's breast surgery conference in Boston. But now the data has gone through the formal peer review process.

I'm a fan of this technique. As a plastic surgeon, it's exciting to build something out of nothing - or in this case, build a breast out of otherwise unwanted fat. Plus, the patient gets the benefit of the contouring from the liposuction at the fat donor site. We're still working on methods to streamline and standardize the operation, but it does work. Wearing the Brava really does help the fat to survive, and our early experience with this method has been very promising.

But wearing the Brava system isn't easy or comfortable - it certainly does require a solid commitment from the patient, to wear it 10 hours a day, every day for the required time - so it's not for everybody. The surgery is more expensive than an implant surgery. Also, if you want more than a cup size increase, or the high-profile implant look, implants are currently still the better choice. With fat grafting, however, there's no worries about implant deflation or capsular contractures - and that can be pretty appealing for the right patient.

New meaning to the term "drug bust"

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Tue, 24 Jan 2012 02:59:00 +0000

According to the Daily Mail newspaper (London), a 33-year-old woman was charged in December with international drug trafficking, after she was found carrying more than five and a half pounds of cocaine - with an estimated value of £250,000 - that had been molded inside some artificial breast and buttocks inserts ("falsies").

The woman, a model identified only as MFM, was detained by security personnel at Rome's Fiumicino Airport after a flight from Buenos Aires, Argentina. "She tried to distract them with a plunging neckline and tight outfit, but they (security personnel) stopped her for questioning because she was so alluring," Fiumicino Airport Police Chief Antonio DiGreco said.

"Once she was questioned, she actually became quite aggressive and was taken away for more detailed questioning by two female officers," he added. Authorities began their search of the suspect after she failed to adequately explain the reason behind her trip to Argentina, the newspaper reported.

That's when the drugs were found hidden in the plastic breast and buttock inserts that were responsible for her curvy shape.

....Talk about a drug bust.

Photo credit: drugfree.org

Botox versus Dysport

noreply@blogger.com (Thomas Fiala, MD, FACS, FRCSC) — Tue, 17 Jan 2012 14:03:00 +0000

This month, in the ASJ, comes another study looking at the Botox versus Dysport battle. Patients are always wondering - "which one is best?". Some patients swear they do better with one medication compared to the other.

In this paper, a randomized, controlled study, 53 patients had Botox on one side of the face, and Dysport on the other. They were then followed for 150 days to see how they did. The usual conversion ratio of 2.5 units of Dysport to 1 unit of Botox was used, in equal volumes of solution.

Results: no difference - in this trial, both sides were totally comparable and equal, from day 2 out to 150 days post-injection.

As I've said before, it's a bit of the "Coke versus Pepsi" situation... pick your favorite, as both Botox and Dysport are both equally effective. And of course, we offer both here at our Orlando office.