Archive for March, 2010
Almost everyone has now heard of the facial wrinkle treatment, Botox. While some may not know exactly what it is really good for, its recognition and popularity is because it simply works. When it comes to softening facial expressions, it does something that even surgery can’t do.
Many misconceptions exist, however, about Botox (and now Dysport) and it is time to reveal some of its secrets. Here are some facts about its use that are not commonly known.
Botox is a poison and can be quite lethal if the dose is high enough. It is administered in units which originally stood for mouse units. A unit was the dose of Botox that could kill a mouse. Fortunately, there is a big difference in size between a mouse and a human. To poison a human, it is estimated that it would take about 25,000 or more units to do so. The average dose for wrinkles is around 20 to 30 units, so it is well within the margin of safety. (mathematically, cosmetic dose units are a mere 0.001% of the doses that could be fatal). Cosmetic injections are precisely placed 2 to 4 unit doses in select facial area.
While Botox is touted for a lot of facial uses, it is largely a ‘northern’ face procedure. The areas of the forehead and around the eyes accounts for much of its use. Weakening of the muscles between the eyebrows, in the forehead, and at the sides of the eyes produces the desired effect of less frowning, a more relaxed forehead, and less lines around the eyes. While some do use it down south around the mouth, it is not effective as a primary wrinkle reducer in that area. A little too much Botox there can affect the way you smile.
Botox injections do not produce immediate results. It usually takes one week or more to see its effects. This is because it blocks the release of chemicals from the nerve endings that cross over to stimulate the muscle fibers to which it is attached. Because there is a supply of chemicals in the nerve endings to start, they must first be depleted. As a result, the muscle will work normally for a few days before it begins to weaken as its ‘gas supply’ diminishes.
The effectiveness of Botox can vary from one doctor to another or from one treatment center to another. This seems initially unusual because one of the benefits of a prescription drug is that it has been tested and approved for the uniformity of its effects. But Botox differs from a pill and many other prescription medications. It comes as a dry powder and must be formulated or reconstituted prior to treatment. How well it works, therefore, is affected by how it is mixed and how long ago it was prepared. It is designed to be mixed according to the manufacturers recommendation in a very specific way. (2.5ml of saline per vial) and it should be used either immediately or within a few days after preparation. But treatment centers vary on how they mix it and how quickly they can use it. You have no way of knowing if you are getting diluted or old Botox. If it doesn’t seem to be working well or lasting very long, this could be the reason.
Like all drugs, there is an effective dose to Botox or a ‘sweet spot’ at which it works well. What you want as a patient is to find the Minimum Effective Dose as well as the right injection spots. You may regularly be getting 40 units in the forehead are, for example, when 32 may work just as well. More Botox than necessary does not make it work better or any longer. Don’t be afraid to ask your injector to adjust the does or injection locations to see if the results improve…or become less.
Botox and Dysport have a very consistent duration of effect of around 4 months. Repeat treatments, unfortunately, do not make it last longer. But some patients feel that it does. This is likely an effect of muscle re-education, a chemical training if you will. It may take your body awhile to begin using those muscles again if they have been weakened repeatedly. Conversely, most people will not build up tolerance or immunity to Botox. But a few patients say that they have and resistance to any drug is always possible. One can than switch to Dysport which has a slightly different molecular structure.
Dr. Barry Eppley
Of the very large number of cosmetic surgery procedures that are performed each year in the United States, a certain number will undergo subsequent revision. While this is a concept explained to patients by their plastic surgeon beforehand, it is understandable that it falls on deaf ears for the most part. The euphoria of the upcoming outcome blocks any realistic consideration that anything but the best will happen. The decision to undergo cosmetic surgery is both emotional and optimistic.
Why does surgery not always turn out to be exactly as desired? While there can be numerous reasons, including the wrong operation for the problem or that the operation was not done well, but the most common reasons for these undesired outcomes are less obvious. How the body responds to the trauma of surgery and the not always predictable events of wound healing account for much of the need for revisional surgery. The occurrence of complications in cosmetic plastic surgery is uniquely different from that of most other types of surgeries. Unlike common surgical problems, such as infection or bleeding, the healing of a cosmetic surgery site may be perfect but the aesthetics of the healed site may still not be what was desired. Cosmetic surgery results are judged by a higher standard, they must both heal and look good as well. Even the avoidance of common wound healing problems is not enough in cosmetic surgery.
While the real number of the incidence or need for revision in cosmetic surgery will never be known, estimates are thrown around of around 15% on a national average. This estimated number will be quite different depending upon the type of procedure being performed. For example, any form of breast surgery carries a higher revisional risk than that of a facelift. Any operation that relies on an implantable device to achieve the outcome will always have more potential problems than those operations that don’t. While revisional surgery in most cases is minor and nothing in comparison to the original operation, potential patients need to appreciate that the need for secondary surgery in cosmetic procedures is not rare.
When postoperative complications occur and revisional surgery is needed, there is unhappiness on the part of both patient and plastic surgeon. The cosmetic patient is understandablely unhappy as they never really believe it would happen to them no matter how it was disclosed or what forms they signed. Such surgical problems happen to other people, no one thinks or hopes that it will happen to them. Other people make up statistics but not themselves. Patient naivety in this regard has been promoted, inadvertently, by cosmetic surgeon’s themselves through countless promotional efforts. Advertising ‘lunchtime facelifts’, ‘weekend recovery’, and other seemingly too good to be true procedures has only added to dumbing down that fact that it is real surgery with associated risks.
Like the patient, plastic surgeons are equally not pleased about the need for revisional surgery. There are many reasons for such a response by the surgeon from facing a patient’s disappointment, a perceived failure of their own skills and expertise, and how this result reflects on their own reputation and image. Sometimes, a difference in opinion may develop between the patient and surgeon as to the need and advisability of revisional surgery. In these circumstances, patients often seek out other surgeons to undergo their revisional surgery, getting a fresh perspective on their adverse outcome. When needed, however, surgical revisions should be done in the proper setting and under the appropriate circumstances. Certain minor revisions can be reasonably performed under local anesthesia in the office. This approach is simple and avoids the use of the operating room. Many times, however, this office approach to revisional surgery is overused in an effort to save the patient further expense. As a result, the desired outcome may still be suboptimal. In many cases of revisional surgery, the patient and surgeon needs to be willing to accept the additional arrangement and expense of an operating room to put themselves in a position where the procedure can be carried out properly.
The potential need for revisional surgery after a cosmetic procedure is a statistical reality. Revisional cosmetic surgery has associated physical, emotional, and economic consequences. It will often test the depth of the relationship and preoperative dialogue between plastic surgeon and patient.
Dr. Barry Eppley
You wouldn’t normally consider the concepts of plastic surgery and terrorism in the same sentence. If you did, you would assume that it had something to do with surgical changes of a terrorist’s face to alter their identity. Plastic surgery amongst drug dealers in different parts of the world, for example, is well known. Why wouldn’t it be the same for terrorists?
Perhaps terrorists are getting their noses reshaped and other facial reshaping surgeries, but that is not the association that is currently news worthy. It is now reported that female suicide bombers are being fitted with breast implants containing explosives which are all but impossible to detect by current airport scanning machines. Similar approaches are apparently being also considered for men by using buttock implants The discovery of these methods was made after the recent airliner incident on Christmas Day where a Nigerian had stuffed explosives inside his underpants.MI5, the famous British spy unit, has reported that such movie-like plots for bringing down airliners do really exist.
While breast implants do have a controversial material history, it has never been one of a lethal and nefarious nature. Explosive experts say that an implant containing as little as five ounces of certain explosives (a B cup breast size) can open a hole in the skin of an airplane that can take it down.
While an exploding breast implant is not a concern for the typical woman in the U.S. who undergoes breast augmentation, understanding implant rupture is. Implant rupture is not the same as an ‘exploding breast implant’. This is the one lifelong implant-related risk which every breast implant patient should know. While the bag or shell of a breast implant does not explode, it can develop a tear or hole in it over time. Such an implant defect is not the result of anything the patient does, it is the result of natural fatigue of the implant material as it flexes and folds over time from external displacement forces. It is always best to not think of breast implants as permanent although we all hope that they are.
Patients of course want to know how likely is implant rupture and what happens if it does. The true incidence of breast implant failure is really only known from past history with older device designs that are no longer used. While the manufacturers provide statistics of a 1% risk per year for the lifetime of the implant, numbers are just…numbers. That statistic is meaningless when it happens to you. You just have to know that it can happen and the longer they are in place, the more likely it can occur. Rupture of saline implants are immediately obvious, like a flat tire. Silicone implant failure usually never results in any external change and may only be found on a routine mammogram.
The good news is that breast implant rupture is medically harmless, no scientific evidence has ever linked a medical disease with implant filler materials. Rupture is an issue of inconvenience and economics. For saline implants, it will be a cosmetic ‘emergency’. For silicone implants, it is more of a dilemma of whether anything needs to be done at all if the breast feels and looks fine.
While terrorists might come up with lots of different ways to try and kill US citizens, using breast implants against us is definitely not one that we might have expected.
Dr. Barry Eppley
Spring brings forth many new growths as we emerge from winter. Warmer temperatures with rain and gusty winds fuel this growth. As the season changes into this rebirth time of the year, certain plastic surgery procedures emerge as well. Often called seasonal plastic surgery in this part of the country, one would most likely think of breast augmentation or liposuction as one prepares for greater summer exposure of one’s body. While the frequency of these procedures increases for sure, correction of prominent ears (otoplasty) also increases. (a common plastic surgery joke is the risk of flying away with the spring winds)
Protruding ears affects both children and adults alike. But otoplasties are done disproportionately more in children. This is likely because an adult has lived with their ears for a long time and may be less psychologically bothered by them. Or they have had them for so long that changing them may be emotionally disturbing. (as part of the theory that change is scary and that hanging on to the more familiar is less ‘risky’ than the potential benefit of the unknown) But the child’s self-image is still being developed and eliminating protruding ears is one simple and quick way to eliminate some potential psychological baggage.
Ear pinning, medically known as otoplasty, is one of the most satisfying of all facial plastic surgery procedures. When you factor in a very low risk of any problems after surgery, a dramatic improvement in appearance and when done early in life as a child or teenager, it offers some of the best value of any plastic surgery procedure that I know. Low risk, dramatic improvement, and permanent benefits is always a sure sign of a plastic surgery winner.
A fundamental principal of otoplasty surgery is to identify the cartilage problem that makes the ears protrude. In most cases, the absence of the fold between concha and the helix, known as the antihelical fold, is the main cause. When this backward fold is not there, the helical rim sticks way out. Bringing back the helical rim, through sutures placed from the backside of the ear, brings the protruding ear back in an immediate fashion.
But there are other cartilage deformities in the ear that can make them stick out. The concha or bowl that surrounds the ear hole can be too big, pushing the entire ear out too far. The concha helps capture sound to direct it into the ear canal down to the ear drum. It provides the foundation onto which the helix and antihelical fold sits. A big concha and the lack of an antihelical fold make for an ear that really sticks out.Without reduction of the large concha, other suturing methods will be unsuccessful. Removing a wedge of conchal cartilage and using sutures that pull back the concha towards the mastoid are needed to make the ear sit closer to the side of the head. Many otoplasty procedures require a combination of antihelical and conchal manipulations to create the best ear shape and position after surgery.
Otoplasty plastic surgery is a simple outpatient procedure that can be completed in just one hour. Most of the time it is done under anesthesia but some cases in adults can be completed with just local anesthesia. Dissolveable sutures are used on the back of the ear so suture removal is not necessary. A head wrap is used for just one day and one can shower the next day after surgery. Even in the face of some mild swelling and soreness, the change in the ears is immediate and quite dramatic.
Spring is a time when many parents begin to think about otoplasty for their child or teenager, planning for a summer surgery when out of school. But the simplicity of the procedure allows it to be done over winter or spring break as well without missing school. It is prudent, however, to avoid contact sports for the first month after surgery.
Dr. Barry Eppley
The greatest trend in plastic surgery in the past decade has been, ironically, the explosion of procedures that don’t involve actual surgery. Comprised largely of injectable therapies, such as Botox and fillers, and laser and light treatments, making the face look rested, supple and youthful has become as easy as a quick visit to the doctor’s office. By sheers numbers, non-surgical facial enhancement far exceeds the actual number of cosmetic surgeries performed per year.
Such ‘beauty treatments’ have been very successful for concerns of facial aging but the same approach has not seen the same successes for body concerns. The search for an effective non-surgical method for the reduction and removal of fat remains as elusive as finding the magic pill or diet for weight loss. Much has been promised, but little has been delivered so far.
The allure of ‘non-surgical’ is always a compelling one and any device or product that offers it always attracts a large amount of public interest. But within that appeal lies the often ignored fact that non-surgical treatments are not equivalent to surgery. They produce results that are far less and should be of thought as a delaying tactic or a complement to what surgery can do, not a substitute.
Non-surgical facial methods should never be equated to what actual surgery can do. You can reduce a few wrinkles, plump up some thin tissues, and get your skin to look fresher. And, to be sure, those are great changes for many people, but many patients often expect or believe much more will occur. This is unfortunately not helped by the sometimes very ‘broad’ promotional claims of product manufacturers and doctors alike. Unless properly advised, it is easy for one to undergo some form of office treatment, often not inexpensive, and be disappointed with the results. This is especially seen when it comes to a wide variety of ‘facelift-like’ methods. I have seen many such patients, all of whom in the search for something less, did indeed end up with less.
While seriously ‘injurious’ complications are rare with underperforming and overpromised cosmetic treatments, there is always the economic loss. Wasted money may prevent someone from contributing to and having a more significant procedure that would provide much better long-term benefit. The point being is that one must keep an eye on the concept of value when comparing non-surgical versus surgical cosmetic procedures.
One good illustration of this concept is in the highly promoted ‘Liquid Facelift’ procedure. Plumping your face up with injectable fillers does create some more fullness in the face and it could be called a lift of some sort (it does nothing for the neck which is why most people seek a facelift). But its effects last perhaps six months and costs several thousand dollars. Some form of a real facelift (and there are many variations) may cost two or three times more but the results are much more significant and could easily last a decade or more. Is either one wrong? No. Each person has their own objective and needs and either approach could be right for different people. But from the concept of value, removing, lifting and tightening is actually more economical in the long-run than plumping and a little smoothing.
Most non-surgical office treatments have no recovery, a near instant result, and cost less …and do so at the ‘price’ of being less effective as well. Expectations are the key to any plastic surgery procedure and simple office treatments should be judged more for their contribution to value than their ease of doing them.
Dr. Barry Eppley
As an appreciation of what our military does around the world, our Patriot Program exists to help make plastic surgery more affordable to them. Having seen and talked to many of these military patients, I have become aware that elective plastic surgery is often done at Armed Services facilities. In addition, one of my plastic surgery techs spent nearly a decade in the military and he often speaks of the cosmetic surgeries that he knows where done or participated in.
According to a recent article in Stars and Stripes (passed along to me by one of my military patients…he thought I might be interested), the military says it does not pay for unnecessary plastic surgery. But an audit of patient records released in February by the Pentagon says this is not so. The audit found that military doctors were regularly performing breast augmentations, tummy tucks, liposuction and other cosmetic surgery without charging the patients as they are supposed to do.
Plastic surgeons exist in the military to perform reconstruction of many injuries that are sustained from war, accidents and disease. The very existence of plastic surgery as we know it today is the result of the experience gained in the first two World Wars in the first half of the last century. Because military plastic surgeons need to keep their skills up for when they get out (and to encourage them to enter the military in the first place), they are allowed to perform cosmetic plastic surgery for patients as long as they pay for it…just what people have to do in the civilian world. Such requirements have been in place for the military for some time. Troops have had to do so since 2005 and dependents and retirees have been required to pay since 1992.
However, it appears that some service members and their dependents are having cosmetic surgery on the military’s (your) dime according to the audit. Arguments can be made that they deserve it or it doesn’t really matter since most of the costs are already built-in anyway. The basic costs of the facilities and doctor’s and operating room staff salaries is an ongoing expense, it is really just a supply issue to perform the surgery.
One of the real interesting sides to this story, and one that we face every day in the civilian world with medical insurance, is what is the difference between medically necessary (reconstructive) and cosmetic plastic surgery. From the military’s standpoint, what should they be paying for and what should patients be paying for? By definition, plastic surgery is reconstructive if it restores or repairs appearance or function from trauma, disease, or birth defects. Cosmetic plastic surgery is changing what is not deformed, injured, or diseased. That seems like a simple differentiation…but it often is not.
In the Stars and Stripes article, for example, they discussed male breast reduction or gynecomastia surgery. This is a source of embarrassment for many young men but is often viewed as a cosmetic problem in the civilian world and is not often covered by medical insurance. But in the military, male breast enlargement can make wearing body armor difficult and that can make it medically necessary. Similar situations may exist for rhinoplasty (breathing problems), otoplasty (helmet wearing), and even tummy tucks. (hernia repair)
One of the side, but important, issues is being able to recruit or retain plastic surgeons in the military. Outside of being close to a war zone, plastic surgeons in the military may encounter few combat casualties and may not do enough reconstructive surgery to keep their skills and board-certification current. (in some ways, this is thankful) Cosmetic surgery techniques are an extension of those used in reconstruction. A midface lift, for example, is a cosmetic procedure developed from repairing cheek bone fractures and lower eyelid deformities. There are many connections between cosmetic and reconstructive plastic surgery and their differences in technique are often more gray than trying to determine the medically necessary basis of the procedure.
Of significance, the military report suggests that plastic surgeons are increasingly leaving the military because of their inability to keep up their cosmetic surgery skills due to the 2005 patient payment policy. That is unfortunate as plastic surgeons have a lot to offer our military service members. Perhaps continuing to provide cosmetic surgery is a retention factor for both plastic surgeons and our military alike.
Dr. Barry Eppley
While plastic surgery is comprised of hundreds of different procedures that are used to correct problems all over the body, they are all true medical operations and treatments. Yet some of the most popular cosmetic treatments have almost as much in common with a retail or commercial product as they do with being a medical procedure.
Botox as a non-surgical procedure and breast augmentation as a surgical operation have begun to acquire many retail product characteristics over the past decade. Both are highly marketed and promoted, so much so that few people in the world would not recognize what they are. From billboards to magazines, and endless exposure on the internet, the offering of services and the recruitment for paying customers is extensive. Some of these are from the commercial product suppliers on a national front and many others are from physicians on a local basis. Such enticements are right in line with what has also occurred in the pharmaceutical industry by the manufacturers for certain prescription medications.
Unlike most drugs, however, Botox and breast augmentation largely targets the fee-for-service customer. These are cosmetic services which are either paid for at the time the treatment is done (Botox) or some time in advance. (Breast Augmentation) With the allure of immediate cash payment comes the inevitable price war and the potential slide into a commodity service. Ads are a plenty for Botox at specific per unit prices and flat low-end fees for breast implant surgery. Dysport, the recent competitor to Botox, has offered incentives if you are unhappy with your Botox results. Breast implant manufacturers have lifelong replacement warranties and even $3500 cash for surgical costs should an implant need to be replaced in the first ten years after surgery.
But unlike most commodity services or pure retail products, these medical procedures do have other intrinsic values. It is obviously important to be able to receive these services with the lowest risk possible and be able to get the desired outcome. The intrinsic value is in the expertise and experience of whom is performing it. Lowest price for medical services is not always the best value. Price alone is not the best barometer to judge whom and where these services should be received.
Competition amongst cosmetic providers has fueled the reduction of services like Botox and breast augmentation into partial commodities. Prices amongst them in any community usually stays within a fairly narrow range as a result. Such competition is not necessarily bad. It keeps all providers sharp and makes sure that their prices, no matter how much intrinsic value they may have, stay within a reasonable range. Be wary, however, of really low prices that are different from the community average. There may be a good reason why they are priced that way and it is not usually for your benefit. You do not want inferior quality medical services when it comes to having something injected or implanted into your body.
Dr. Barry Eppley
While the way and the changes that a face undergoes as it ages may not have changed since time began, the treatment of it has. Facelift surgery used to be an extensive operation largely because it was done on older people. (who needed a lot of work!) In a generation past, most people (primarily women) underwent a facelift when they retired, rewarding themselves for a lifetime of work and when they can most afford it.
But today’s approach to facial aging is different and reflects changes in both society’s attitudes and plastic surgical techniques. People now want to age less obviously and remain youthful appearing in middle-age as they participate in the ever competitive workplace. As a result, facelift surgery has adapted to these needs becoming less invasive and suited for less severe signs of aging that exist in the 40 and 50 year-old ages.
Besides the common misconception of what a facelift really, most people perceive that it is a highly invasive procedure that requires a long recovery. These two perceptions are tied together under the belief that a facelift is a ‘scalp to neck’ lift. In reality, a facelift only changes the lower third of the face…a neck and jowl improvement. It does not change the mouth, cheek, eye or forehead area. These require separate and often combined procedures with a facelift to create a complete facial makeover. When one understands the more limited scope of what a facelift is, it becomes less scary and intimidating.
Facelifts have evolved into two different types, complete and limited. The difference is in the amount of neck improvement that is obtained. Since many younger patients have more jowling than sagging neck issues, the limited facelift has become widely used. The surge in the number of facelifts has been because of this scaled down version and accounts for at least half of all facelifts now performed.
The popularity of the limited facelift can be seen by the numerous marketing approaches taken by both plastic surgeons and franchises alike. Catchy names that imply the ease of recovery, such as Swiftlift and SimpleLift to name a few, are used to differentiate this technique from that of the historic facelift perception. Promoting surgery under local anesthetics, one hour procedure times, and a few days of recovery, it can make it seem that it is hardly surgery at all. I have seen numerous patients initially seen at these franchise establishments and they were surprised to find out it was an actual surgical operation.
But limited facelifts are real surgery, even if it isn’t the same as an extended full facelift. It can become a more extensive procedure if combined with other facial aging treatments such as eyelid tucks (blepharoplasty)or browlifts, which is quite common. The concept of several smaller operations at a younger age is a sound maintenance approach that may make the need later for a full facelift unnecessary.
Limited facelifts, however, are not just for the young. For the older patient, who may really need a full facelift for the best result but does not want it, the limited facelift offers moderate improvement with less recovery and costs.
Contemporary plastic surgery is about adapting the operation to the magnitude of the problem. The limited facelift is a great illustration of that principle.
Dr. Barry Eppley