Plastic Surgery as an economic indicator?

We're all used to hearing the news about housing starts, retail sales, and employment figures. These are economic indicators - ways to indirectly sort out what's happening with the U.S. economy. Get this: two new studies now suggest that the workload of your friendly neighbourhood plastic surgeon may be another statistically valid way to tell how well the economy is doing.

In this month's issues of both ASJ and PRS, are studies from two separate plastic surgery groups examining this very correlation. One was from the Cleveland Clinic, the other from Loma Linda University Department of Plastic Surgery. They each found that the average surgeon revenue from cosmetic surgery procedures in their group very closely correlated with typical stock market indices, such as the S&P 500, the Dow Jones Industrial Average and others, at least looking retrospectively over the last few years. When their surgery income was up, so were the stock markets. When the market was down, their cosmetic surgery schedule was quiet.

If anything, the graphs suggested that Plastic Surgery activity was a leading indicator - in other words, changes here preceded the change in the economy, by about one month. This, to me, was the surprising part - I would have guessed that Surgery volume would have been a coincident or lagging indicator of the economy.

My financial advisor, Ed, always jokes with me about the "boobs & butts" index - which is his casual way of asking me how busy I am. It looks like he's right after all!

WSJ: Plastic Surgery decreased in 2009

Nice summary of 2009 plastic surgery trends in the Wall Street Journal, showing the effect of hard economic times on elective plastic surgery volume.

I've reproduced it, below. I've added some editorial comments in parentheses.

In addition, you can see the latest ASAPS statistics on plastic surgery, by clicking the link here.

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By ANJALI ATHAVALEY, Wall Street Journal

The number of cosmetic-surgery procedures in the U.S. sagged for the second year in a row in 2009, according to an annual survey released Tuesday by a plastic surgeons' association.

There were 10 million surgical and nonsurgical procedures last year, down 2% from 2008, according to a survey of 928 board-certified physicians by the American Society for Aesthetic Plastic Surgery, a Garden Grove, Calif., group of plastic surgeons specializing in cosmetic surgery. (ASAPS is the largest, most important group of cosmetically-oriented plastic surgeons.)

Driving the decline was a 17% drop in surgical procedures, to 1.5 million surgeries. "People just couldn't go for the big items," said Renato Saltz, the association's president.

Tummy tucks, rhinosplasty and other surgical procedures can cost thousands of dollars more than nonsurgical measures, and they require a longer recovery. (But of course, the surgeries do much more than any non-surgical alternative.)

Indeed, fear of job loss is the main reason people are putting off their surgeries, says Phil Haeck, president-elect of the American Society of Plastic Surgeons, a separate group that has yet to release its annual survey. Dr. Haeck, a plastic surgeon in Seattle, said that marks a shift from last year when consumers cited cost as a primary hurdle. This year, "job priority is number one, cosmetic surgery is number two," he said.

Breast augmentation beat out liposuction as the most popular surgical procedure for the second year in a row. Dr. Saltz attributes renewed popularity of breast augmentation to the 2006 Food and Drug Administration decision to lift the ban on cosmetic use of silicone breast implants. Breast augmentations numbered 311,957 last year, down 12% from 2008; liposuctions numbered 283,735, down 17%.

Nonsurgical procedures, such as injections of Botox or hyaluronic acid to fill facial wrinkles, were flat, inching up 0.6% to 8.5 million.

Two surgeries are surging in popularity. Buttock lifts, which involve reshaping of the bottom, increased 25% to 3,024 procedures, and buttock augmentations increased 37%, to 4,996. Increasingly, people want to reshape their rears after losing weight, Dr. Saltz said.

The procedures, costing from $4,000 to $5,000, are fairly new, with both benefiting from recent technique improvements, he added. As the economy recovers, more baby boomers are expected to seek procedures, and more physicians will likely offer nonsurgical options. Surgical procedures have increased by 50% since 1997, while non-surgical procedures grew 231%. Places like health clubs and spas are already offering minimally invasive procedures. (Not recommended!) Cosmetic-surgery associations recommend that consumers seek out procedures that are conducted under the supervision of a board-certified physician.

They should also do research before going overseas for cheaper rates for surgical procedures, which physicians say is a growing trend. "Right now, there is not an association that verifies that the physician is appropriately trained to do what they are doing," said Dr. Haeck. "Very few of the countries where these are being offered have anything that approximates the rigorous boards in the United States." (Canada is one exception - their training standards are equivalent to the U.S.)

Plastic Surgery Predictions for 2010

Remember the old Johnny Carson sketch, "The Great Karnak"? Well, these predictions may prove to be about as accurate, but here goes...

1. Botox vs. Dysport. So far, this corporate shoot-out has been pretty low-key. But I expect the marketing and tug-of-war between the two corporate behemoths to increase significantly in 2010, as people (both patients and physicians) become more comfortable with Dysport. IMO, there's plenty of room for both in the ever-expanding non-surgical market. Of course, the real game changer is Revance Therapeutics' topical formulation - Botox cream. But that's probably a few years away yet.

2. Market Consolidation. I expect two forms of market consolidation in 2010, continuing what we were seeing in the rough economic waters of 2009. Smaller product lines will either drop out, or be absorbed by larger corporations. Mergers and buyouts of small to mid-size aesthetic companies will continue, as we've seen in the laser industry in 2009.

3. Increasing regulation of medi-spas. It's taken a while, but regulators at the State level are beginning to wise up that medi-spas are doing treatments and procedures that until recently, were only done in physicians' offices or surgery centers. So, they should have similar safety regulations and oversight. The recent med-spa related liposuction death in Florida has added fuel to this fire.

4. Pragmatism towards current minimally-invasive procedures. When ever any new technology is introduced, there are 3 phases: an excitement / hype phase, a reassessment phase, and the final "here's-the real-deal" phase. I'm hopeful that in 2010, we'll be approaching the pragmatic phase about laser-assisted liposuction (LAL), and that we'll see more good science about the degree of skin tightening that LAL really produces.

5. Continued interest in fat grafting. Especially once the technology for turbo-charging fat grafts with stem cells gets approved by the FDA, this is the next "big thing" in both aesthetic plastic and reconstructive surgery.

6. Will the "gummy-bear" breast implants arrive in 2010? Maybe in the second half of the year. The real question is whether American women will accept the trade-offs of larger incisions and the "super-firm" feeling of the implant for a possibly lower contracture rate and lower rate of gel migration. I think textured, standard gel implants will undergo a surge in popularity - especially for revisional cases.

7. More "me-too" products. Whether it's in the injectable filler, botox, or laser arena, I think companies will try to introduce their spin on currently existing products, to gain a share in the lucrative cosmetic market. There will be more HA fillers, more fractional lasers, more liposuction devices - each touting that their product is "just as good as Brand X". (The FDA 401 (k) equivalency process encourages imitation, rather than innovation.) This will, of course, be more confusing for consumers. If the new products don't catch on rapidly, I suspect, prediction # 2 will take place, and the product will sink out of sight, more rapidly than before. Better then, to stay with the tried-and-true / market leaders.

That's all Dr. F. has for now. Happy New Year, everybody!

Fillers, the Liquid facelift and "Puffy Face" Syndrome

Everything evolves. When cosmetic fillers were first used, we applied them to the problems of wrinkles - and they worked pretty well. Then we used them to enhance lips, and then to enhance cheekbones, and to smooth out jawlines...and the list of uses kept on growing.

This ever-increasing use of fillers has directly led to the concept of the "liquid facelift", which is simply the use of a significant volume of injectable filler agents to add volume to the face. When done appropriately, and done well - the technique can look good, restoring the lost contours of youth, at least for a time, until the costly products are absorbed by the body. But like anything, it can be overdone. And quite expensive.

Hype alert: the liquid facelift technique is not really "just like a regular facelift", despite the marketing hype of some websites. The two methods work totally differently. Let's review some of the basic differences:

- In a surgical facelift, you remove excess neck and cheek skin. Not possible with the liquid facelift technique, which works by inflation.

- In a surgical facelift, you can tighten the neck muscles and re-suspend the SMAS layer (the fibro-fatty anatomic layer between the skin and the muscles). Not possible with the liquid technique.

- Traditional facelifts (with the exception of those that use fat grafting techniques) work by tightening tissue planes. This can sometimes cause a flattening effect on soft-tissue facial curvature.

- The liquid techniques work by inflation or "re-volumizing", and can add fullness to areas that would otherwise be difficult to correct. Traditional facelifts can sometimes shift soft tissue fullness by re-distributing or lifting tissues, but they don't add new volume.

- Surgical facelifts typically have an effect of 8 to 10 years, on average. Injectable products, even the newer, longer-lasting ones, last 1-2 years at most.

So, the two procedures are not directly comparable. Don't be fooled - choose the right procedure for your particular needs. If you have a lot of lax skin, get a surgical facelift. If you have loss of facial volume issues with minimal skin laxity, then you might be a candidate for re-volumizing with fillers. Your plastic surgeon can advise you.

I'm also starting to see patients who have been over-treated with the facial fillers. It used to be just the lip area - but now it's the entire face that is involved. Since there isn't an official name for this, I'll call it "puffy-face syndrome". Features of "Puffy face syndrome" that I've seen include:
- generalized swollen or bloated look to the face, due to the over-injection of filler agents, which is out of keeping with the pre-procedure appearance;
- excessive fullness in some or all of the injected areas: brow, cheekbones, paranasal and perioral areas;
- obliteration of normal naso-labial creases.

Interestingly, many of the patients that I feel are over-injected seem to be somewhat addicted to their filler treatments. When I tell them "no, you really don't need any more volume" - they react with shock and disbelief!

So, while I think that facial fillers are useful, they are but one option among many for the treatment of facial aging. Too much filler can lead to Puffy Face Syndrome! This is another example of how aesthetic judgement is important.

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!

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.

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.

2008 ASAPS Procedural Statistics

Every year, ASAPS - the pre-eminent organization for aesthetic plastic surgeons - compiles statistics on common plastic surgery operations and trends in surgery. The latest report, on last year's surgical activity, was released today, and includes figures from Board-certified Plastic Surgeons, Dermatologists and Otolaryngologists (Ear, Nose & Throat).

Here are some of the highlights:

- In 2008, over 10 million cosmetic procedures (both surgical and nonsurgical) were performed. This was divided into 1.7 million surgical procedures and 8.4 million non-surgical procedures (botox, fillers, etc.)

- Not unexpectedly given the economy, these numbers are down somewhat compared to the previous year - by about 12 percent overall.

- The top 5 surgical procedures in 2008 were: breast augmentation (355,000), liposuction (341,000), eyelid surgery (195,000), rhinoplasty (152,000) and abdominoplasty (147,000).

- The top 5 non-surgical procedures in 2008 were: Botox injection (2.4 million), laser hair removal (1.2 million), hyaluronic gel fillers like Juvederm and Restylane (1.2 million), chemical peel (591,000) and laser skin resurfacing (570,000).

- Women had 92% of the total, men 8%.

- The most popular operation for women overall was breast augmentation, while the most popular for men was liposuction.

- 62% of women and 51% of men approve of cosmetic surgery. Forty percent of women would consider surgery for themselves, either now or in the future.

The full report can be viewed at www.surgery.org.