Is A Medical Spa The Right Place For Invasive Surgery?

A recent article in The New York Times Style section relayed the unfortunate death of a young nurse as a result of a misguided liposuction procedure in a "medical spa".

Invariably, every year or so, a similar tragedy comes to awareness. Typically, a patient undergoes a surgical procedure in an environment which does not meet the minimum safety standards.

Often patients underestimate the complexity and potential hazards of any surgical procedure regardless of how anatomically superficial it may be. Yes, liposuction involves only suctioning that layer of fat directly under the skin. And, yes, no major body cavity, such as the chest or abdomen is entered.

In the Florida case discussed in the New York Times, the liposuction was performed and local anesthesia was used. Even just local anesthesia has hazards. Unlike a dentist's office where local anesthesia is used in very small volumes, perhaps just several cc's, liposuction usually calls for large volumes of the anesthetic solution with added epinephrine to increase the duration of the anesthetic and to reduce tissue bleeding. But both types of medications, local anesthetics and the epinephrine class of drugs, can have an effect on the heart. Should the medication be absorbed too quickly or should too-strong a concentration be formulated, then the risk of untoward reaction increases.



There are two issues which every patient needs to understand with respect to surgery. First, there is always the potential for problems and the best insurance against having a catastrophic outcome is to have the procedure performed in a fully equipped surgical facility. A medical spa is not a bona fide surgical facility.

The facility should be either licensed by the state, accredited by the United States Department of Health and Human Services (accredits facilities to qualify for Medicare payments) , or by one of three well-known private accrediting organizations: Accreditation Association for Ambulatory Health Care (AAAHC) , the American Association for Accreditation of Ambulatory Surgical Facilities(AAAASF) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO), which accredits hospitals. Fully accredited, licensed facilities must have the same resuscitative equipment, emergency drugs and supplies and infection control standards as a hospital. They have passed the test.

Finally, I would never have any type of significant surgical procedure, whether done under local anesthesia or with local anesthesia with sedation or general anesthesia, without the services of a board certified physician anesthesiologist. Certified Registered Nurse Anesthetists (CRNAs) may be appropriate in some situations. In any event, you want an anesthesia specialist at the controls. Such specialists are another "insurance policy" for you because they will not work in a substandard facility.

Yes, there is some added cost to have an anesthesia specialist on your side and at your side. But, the incremental cost in having such specialist is very reasonable. After all, what is your comfort, safety - and even your life - worth?

- Robert Kotler, MD, FACS

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Dr. Oz Discusses Massive Weight Loss and the Necessary Plastic Surgery "Finishing Touches"

On Tuesday, November 3, 2009, Mehmet Oz, MD, Columbia Medical School professor, OPRAH alumnus and now the host of his own highly-rated daytime talk show, The Dr. Oz Show, had a fascinating and educational segment.

Becky Keenan, a traveling carnival owner, had long been plagued by obesity. It seemed that regardless of what she tried, success eluded her. Finally, she had a stomach bypass operation which was very successful. Her weight dropped 140 pounds!

That was the good news. The bad news was that the skin that had previously draped a rotund trunk was now excessive and hanging. Plus, her breasts had elongated downward and were no longer appropriately sized or shaped for her slimmer body. She still had not reached the finish line.

Becky sought the services of our colleague Stuart Linder, MD, of Beverly Hills. Dr. Linder meets my definition of a superspecialist because he limits his plastic surgery to the trunk and breasts. He does no facial work. Only breast surgery - augmentation, lifting or reduction. Plus tummy tucks and liposuction. He is at the forefront of a positive trend by which practitioners narrowly focus their practice.

For Becky, Dr. Linder performed breast lift and reduction, plus lifting and removing the apron of hanging abdominal skin. We viewers saw photo results at one week which were very impressive. Natural. Perfectly proportional.

Using very clever graphics and demonstration tools, Doctors Oz and Linder explained why the tissues of a once-plump body lose their elasticity.

As Dr. Linder pointed out, this is reconstructive plastic surgery at its best. It brought a happy ending to a long story of personal dissatisfaction. The segment was a tribute to one woman's determination and persistence to improve her life.

The segment can be viewed on the Dr. Oz Show's website.

- Robert Kotler, MD, FACS

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Overview of the Recent American Society of Plastic Surgeons' Annual Meeting

I did not attend, but I spoke with colleagues who gave me a capsule summary of the meeting including substance of the presentation and even the mood and spirit of the attendees. Also, I reviewed the Society's website for its synopses of the presented papers and discussions.

My friends reported good attendance although there is concern by plastic surgeons regarding the difficulties of a slow economy. Practices that are primarily elective cosmetic plastic surgery, particularly in some areas of the country, are suffering greatly. And for those practices that are still heavily engaged in reconstructive plastic surgery, which relies on health insurance payments, there is the uncertainty of how the new health care legislation, being bandied about in Congress, will effect practitioners.

Apropos of the concerns of reconstructive plastic surgeons, it is important that the public be reminded that plastic surgery has both reconstructive and cosmetic surgery arms.

There were awards given to patients who underwent reconstructive plastic surgery and "triumphed over adversity". An Iraqi citizen injured in the war there, a breast reconstructive patient, a patient with port-wine stain, as well as a patient with a difficult skin cancer on the nose were identified and their stories told.

The Society's underlying message is that plastic surgery is not exclusively about beautification, celebrities, and high-profile public figures. Every day, plastic surgeons are in the trenches performing necessary repairs wrought by injury, accidents, cancer, and birth deformities.

It is very important that plastic surgeons continue to have training in these areas to help relieve misery and suffering.

There were a variety of subjects discussed that will be of interest to the public.

During the Hot Topics session, there was discussion about Lipodissolve, a fat-melting formula that has been controversial heretofore. Traditionally, this has been suspect with respect to its ability to essentially melt away the fat deposits which have been heretofore handily dealt with by liposuction. The science has been reviewed and there may be, in fact, some strong potential for utilization of this technology. Stay tuned, we need more information. Another important Hot Topics discussion that took place which I will discuss shortly, was the role of fat injections to enhance the breast size as a possible alternative to breast implant placement.

GENES ARE STILL KING – OR QUEEN

How often I have heard patients sit in my consultation room and say, "I'm starting to look like my mother. And I don't like it."

At the meeting, there was a discussion regarding the prediction of the signs of aging in specific facial areas. It was interesting to recognize that the essence of the study was what we have all known intuitively: as your mother (or your father) ages, so will you. If your mother's sags, bags and wrinkles first manifested in the eye area, the advice is "keep an eye open" on your eye area. You have a peek into the future.

However, I am pleased to say that today cosmetic plastic surgeons have more tools in our toolbox than ever. While we can't stop it from ticking, we turn back the clock daily. There is Dysport and Botox Cosmetic to ease the wrinkles caused by muscle contraction, particularly between the eyebrows, forehead and around the eyes. There are the great and reliable fillers: Restylane and Juvederm. And, now Sculptra, longer lasting. To bring back the skin's more youthful appearance, the venerable work-horses: chemical skin peels, lasers, micro-dermabrasion and Retin-A and bleach creams. Yes, your body is programmed to age as your ancestors have but today there is help out there.


LIFTING BREASTS AND FILLING CLEAVAGES WITHOUT SURGERY?

My practice is limited to cosmetic surgery of the face and neck and so when it comes to breasts and body issues, I am an observer and reporter rather than an expert.

But I do understand the chemistry of products that are being used and I, of course, understand the anatomy.

There was a report and discussion about using Botox Cosmetic as a possible breast lifter. The anatomic basis of that would be that if the pectoralis minor chest muscle, one of the "pecs", had its function neutralized by the muscle paralysant, then there would be unopposed lifting of the breast by other muscles in the area. Now, of course, this is not permanent. Muscle paralysants tend to last between four to six months. And this would be an off-label use.

The doctors reporting on this possible new role for Botox Cosmetic - and perhaps the newer Dysport - suggest that the procedure would be ideal for younger women between 30 and 50 with relatively small cup sizes.

There were some naysayers who pointed out that it is unlikely that patients would have satisfaction from a technique that may not be any better than better posture. And, that in fact, the volume of the medication, since the aim is to paralyze a large muscle, could be significant and that would translate into perhaps too high a dollar cost to be practical. There were other medical issues raised including some increased risk since perhaps the drug could spread to muscles participating in breathing.

I consider papers like this to be stimulating and most valuable by furthering thought and research. This technique will not replace surgical breast lifts in the near future until more information has been gained.

FAT INJECTIONS INTO THE BREAST RETURNS AGAIN FOR CONSIDERATION

Fat injections into the breasts as a means of enlarging the breasts is not a new concept. It has been performed in other countries and has its champions. One paper reported a study of 46 women who received fat injections into the breasts after a breast lift. Apparently they demonstrated "improvements in the size and shape of the breasts after one year." It is important to follow patients for many months and ideally many years to see what the effect is since transferred fat has an uncertain fate. It could shrink, it can form some firm nodules and all this would have long-term implications.

Understand that there has always been a concern about whether or not fat transfer might compromise diagnosis of breast cancer. Certainly women would not want to decrease the likelihood that an early breast cancer could be discovered because there was concealment by transplanted fat. Apparently, the authors argued that "It's easier to see breast tissue in breasts that were augmented with fat than implants." Again, I am not an expert and I believe that we need much more time to study the issue. There needs to be more research studies. Achieving a major increase in size would require large volumes of fat. And, typically, the greater the volume of tissue transplanted, the more uncertain the fate of the transplants.

One of the doctors at the meeting commented that the amount of augmentation was an increase of only 212 cc which is 14 tablespoons of liquid. It may not be enough to satisfy most patients.

— Robert Kotler, MD, FACS

Cosmetic Plastic Surgery Ads: Good or Bad?

We live in a world inundated by advertising. Since 1985, when advertising by professionals was given a green light by the judicial system, there has been advertising by lawyers, physicians and dentists in magazines, newspapers, on the radio and on television.

Actually, I have nothing against advertising because through advertising we can become wiser consumers. Good quality advertising gives us information that is helpful. But there is always the issue of misleading advertising which exists in all arenas of commerce. There will always be advertisements promising "Six-pack abs in two weeks," or "Lose 7 pounds in 7 days" on a crash weight loss program. Human beings, unfortunately, are often tempted by such unrealistic promises.

Likewise, in the world of cosmetic plastic surgery, I marvel at the unrealistic and often absurd claims and promises being made in both text and photographs.

In the last few years, there has been a heavy pitch made towards convincing people that "One-hour Facelifts" or a "Lunchtime Lift" is somehow going to magically deliver the same result as a well-crafted, meticulous five-hour surgical procedure. It can't be.

When deceptive photographs are employed, such as those where the wrinkles on the neck have disappeared as the result of a one-hour noon-time procedure, then you know that the prospective patient is being led down a dark pathway. No procedure - surgical or otherwise - is capable of completely erasing the wrinkles on the neck. Such ads play on patient wishful thinking.

For a while we had a run of quick fixes promised by "thread lifts," another less-than-an-hour procedure whereby fishing line-type stitches were placed under the skin, hitched to taut tissue in the temple with the goal of pulling up the neck and jaw line. It was absurd that such an operation would have longevity. Typically, in the world of surgery, the shorter the operation, the less the duration of the procedure. Indeed that was the case with this quickie face lift. In fact, there were even some complications because the skin does not do well when it is pulled without being freed up from its underlying attachments and repositioned.

As you look at advertising, ask yourself, "Is it possible that this is too good to be true?" Are the photos results - always depicted as a monumental improvement - inconsistent with a very low- cost and brief operation? Might it be that the photos are "touched-up" a bit?

Can one really have such a procedure, awake, with just local anesthesia and not have the services of an anesthesia specialist? As a visit to the dentist? Will this low-priced operation really give value? Value is defined as great benefit for a reasonable cost. A low-cost operation with either an inadequate or short-term result can never be a value.

In cosmetic plastic surgery as in life, there are very rarely big bargains. Do your homework. Don't make a mistake. Sometimes, a bargain can be very expensive.

- Robert Kotler, MD, FACS

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