Decision Making Amongst the Chaos

We’re all flooded with new-year mail. My mail in particular pertains to the latest and greatest creams, machines and schemes promising anything you want. Now, I’d like to say that this is new to 2012, but it isn’t. The promising millions of the beauty Holy Grail have been going on for years to a point where consumers are confused with what really works and what actually is not a health hazard. In addition to print are internet promotions and TV medical shows featuring beauty intervention gadgets and products. It really is hard to evaluate what works and what doesn’t work for not only you, the layman consumer, but also me, the physician/plastic surgeon whose job it is to instruct and recommend the right thing….or purchase devices that actually do the job.

Well, as I had mentioned in my previous blog, the plus of being an American is that we do have choices. And, the aforementioned venues put a ton of info in our faces about a topic that appeals to all of us and can be summarized into one word: beauty. Earlier this year, I had the pleasure of learning about Santa Clara University’s Markkula Center for Applied Ethics during a presentation at the Capital Club, a business networking club in San Jose, California (THE Capital  Club of Silicon Valley and don’t you forget it!). A wonderful brochure entitled, “Making an Ethical Decision”, was distributed at the presentation’s conclusion. As I read through the brochure’s 10 points, I thought how one could apply this decision process to purchasing product, investigating plastic surgery or pursuing any elective surgery. I editorialized the 10 points into 5 points that I believe serve as a helpful guide in this reference; however, I encourage you to obtain the featured brochure in its original form through my office or the center itself at 500 El Camino Real, Santa Clara, CA 95053-0633, 408-554-5319. I also invite you to visit Santa ClaraUniversity’s MarkkulaCenterfor Applied Ethics’ website www.scu.edu/ethics or email ethics@scu.edu.

Point One

Could this decision be damaging to me, does it involve a choice between good and bad alternatives, and is this legal, FDA approved or gold-standard?

Point Two

What are the relevant facts that are known or unknown, and do I know enough to make a decision or do I need to learn more?

Point Three

What individuals and groups have an important stake in my decision? Are they looking out for my best interest or are they going for a sell?

Point Four

What are the options for acting? Have all relevant persons and groups been consulted? Have I identified creative options?

Point Five

After investigating and considering all approaches, which option best addresses my concern, and if I told someone I respect my decision, what would I or they say?

I hope this helps because I certainly have your best interest at heart whether or not you are my patient. Please, never underestimate your own smarts, ask questions and value your health and body.

Breast Implant Bust

Breast Implant Bust

Over the last couple of months, I have been asked by many people about what exactly is going on with silicone implants since one silicone product made big news in December. Poly Implant Prosthesis (PIP), a French breast implant company, was forced to close in 2010 because its manufactured silicone formulation was misrepresented and caused major health risks to its consumers. Over 30,000 women are affected with 1000 implant leaks and 8 breast cancer cases reported. The big issue centered around whom, exactly, was going to hold financial responsibility with implant surgeries: the patient or the government. That’s one of the many reasons we heard about all of this implant news in December. Mind you, this all hit the fan after the American Society of Plastic Surgery posted front page on our “PRS News” that from our September annual meeting consensus panel, the silicone implants approved in 2006 thus far are safe and in good standing.

So here’s the deal. Actually, before I get to the deal, let’s talk a little about implant material. There are two major types of breast implants: saline (salt water) and silicone gel. Both are encased in a silica elastomer shell but the former comes as a shell and is filled in the operating room, and the latter is pre-filled with silicone gel. PIP implants were used everywhere else except the USA so many countries are involved like Italy,Denmark, and Great Britain to name a few. In the early 90’s, the FDA removed silicone implants from the market because of a possible connection between silicone and diseases such as lupus or rheumatoid arthritis. After extensive research and new formulations, in 2006, the FDA approved silicone gel implants from our two manufacturers,Mentor and Allergan, with appropriate follow-up care and study. That being said, there are silicone gel implants used in this country that are NOT FDA approved but part of a study such as the Lumera and Becker implants.

What is the long term safety of the FDA approved silicone gel implants in this country? Good question. Only time will answer that question; however, patients with these implants are followed, and the implants are tracked. On another note, one cannot argue the safety of a bag of salt water (saline) that comprises our protoplasm vs. silicone which is completely foreign. But, let’s talk a little about the real issue at hand which is the safety and responsibility of breast implant surgery—period.

Breast implant surgery—whether augmentation, breast lift with implant, or reconstruction—involves placing foreign material into the body. Though bio compatible, there are many variables concerning the body’s response to the implants and, somewhere down the line in one’s lifetime, another surgery will be needed. The procedure may be as straight forward as a simple implant exchange every 10 years to a complicated excision of major scar tissue. Because implants are prosthetic materials, they may not change with the body with significant changes like pregnancy or weight gain/loss. Women also need to consider accurate mammogram results especially with a significant family history of breast cancer. Finally, last but certainly not least, is emotional maturity involved with owning a pair of breast implants, and one’s own concept of self-acceptance and body image when considering breast surgery.

We are very lucky to have so many options. With options come responsibility of learning what is out there and what motivates one to proceed with any elective procedure. I’m very proud to live in a country that cares about doing the best possible job to provide safe products to its citizens. Many people are upset with the times, and there can be this little cloud of doom and gloom, but let’s put out the good energy that at least we live in a country that allows us to voice an opinion.

“Getting in Shape for Normal People”

What inspired this blog’s title you ask? Well, as you know, the holidays are over and every year its the same old, same old with magazine, internet and TV features about losing weight and getting into shape. As I was reading through all of this material, I noted just how young and in already great shape the well-meaning mentors of health were. They didn’t look like they indulged in the cuccidatis that I did…..and, yes, I did gain some poundage over the holidays. Now, it’s January 2012, and I’m ready to get back into my normal, healthy shape. Before, I progress I do want to thank from the bottom of my heart everyone who took the time to deliver such wonderful gifts to the office. Happy New Year and Love to all!

My weight fluctuates but many of you noted over the past two years that I kept the weight off! My method is practical and very simple–actually, kind of boring. I don’t have any fad names for it.

1. I set a positive vibe and abolish all guilt by affirming to myself that, “you know, Melody, you really enjoyed every bite and have absolutely no regrets indulging in all this home-cooked, party food that led to the extra pounds.” I enjoyed every restaurant moment with my friends!

2. My Facebook friends know that every year I have a theme that usually is fitness-based in addition to some personal goals. After much deliberation, this year I’m trying kick-boxing and jiu-jitsu. I start each year with an exciting new fitness project to break the monotony. I didn’t say I had to be good or even ready to start this endeavor, but you never know until you try. And….you don’t have to win any awards outside of your body thanking you.

 3.  Next, I get back into drinking lots of water. I normally love water but really make a point of drinking about 2 liters a day especially in January to cleanse every cell making up my body. Life is really simple, and independent of heart and possible kidney issues, most of us could benefit from drinking the best cleanser…water.

4. Here is where I get boring. I do log what I eat for the next month. Usually, I don’t overstuff myself and stop when I am full, but my little foodostat gets turned off over November/December. So I attain my discipline, I keep record of what I eat. Very basic and very boring….BUT it works.

5. Finally, I put losing weight out of my mind and focus on my daily activity. I don’t view losing weight as a chore nor do I perseverate. What I do is turn on the old fashion patience. I don’t ever step on a scale..I just don’t buy new clothes.

So, that’s how I lost weight and get back into shape. Many of you have commented how over the last two years I have lost weight and kept it off, and thank you! I keep it simple but most importantly, I don’t take my health for granted and exercise.Your body is an engineering miracle. Take good care of it and cherish your health. Happy and Healthy 2012 to everyone!!!

“Aging Gracefully”

Hi everyone. I’m back. Sorry for the little break after gaining such amazing blog momentum and feedback. My 84 year-old mother had some health issues last month that consumed both time and emotional energy. Many of you who care for their parents reached out and commiserated with me and for that I am grateful. If we don’t take care of our mature Americans, let alone our parents, what does that say bout the future of humanity?

When my mother lived inNew York City, she volunteered for an organization called, “The Mature Americans of New York City.” I love that term and sure beats, in my book, other tags such as “senior citizen” or “old people.” Aging is a truly fascinating process. I evaluate from multiple perspectives as someone who lives with a mature American, who cares for my beloved Medicare population, and who evaluates on a daily basis people trying to halt the aging process. What I find interesting as we consider cutting back on social or government programs designed to help the very people who made our country strong is that most people don’t have the foresight that they, too, will be 65+ years-old someday, unless they proceed down the alternative route which is death. And those who try to age-defy as some cosmetic products promise are simply horrified of aging.

Now, what exactly is aging? Let’s start with the young…….what it means to be numerically young. How nice, in our 20’s, to get out of bed without back or joint pain. We can work all night and do it again the next night. We have dreams, hopes and a future to work towards. When we get older (forget the pain issue which, I personally, think was the only benefit of that decade. I desire not to return to my 20’s) some things may not have turned out as planned and we can then experience disappointment. The attitude of how one deal with disappointment, heart-ache and plain life is what separates a healthy, happy looking septuagenarian from a defeated one no matter how tight the face is pulled. I mean there are certainly other factors like diet, exercise and good product. And, I’m also not advocating a Pollyana approach to dealing with issues. What I am advocating is an attitude make-over based on maturity, loving kindness, and understanding prior to any other intervention as a method to aging gracefully. More on aging……….next blog…

The Meaning of a Scar: Part II

…..so, just in brief review from where I left you last week, a scar is a braid-like protein (put on you 3-D glasses) that actively remodels itself during the healing process. The first couple of months this process is extremely active, for six months active and then for the first year still can change. Often tie, during the first two months, scar gets raised and pink-red because of normal biology, but after a few months the scar softens, flattens and fades whether or not you do anything. Over a year to two-year time frame, scar continues to fade, etc.

There are several modalities that you can use to minimize or even help the scarring process. These suggestions are mine and are based on science, research and practical experience from patient interaction and productive feedback. And, I like to keep things simple because simple works.

1. Massage. Love massage and here’s where I get the two-thumbs up from my OT/PT friends. Remember the braid-like structure that continually remodels itself? Massage with even pressure over the scar breaks-up the braid and softens not only the exterior but also the bump or knot under the scar. You have seen pressure reducing tactics for scar reduction in burn patients where those individuals are fitted with special pressurized garments to keep scars flat. Though these are garments or devices, massage works as a pressurized gradient to soften scar.
2. Oils or Lotions. For me, these serve as lubricants for intervention #1. Remember, I am not a commercial but I’ll give you some brief notes. Vitamin E oil got some bad press but I must say that many patients that “pop” the shell of a Vitamin E capsule to use the oil have some great looking scars. If one has redness or bumps from the Vitamin E then one is sensitive or allergic to that substance….so don’t use it. Mederma’s active ingredient is an onion extract. Its main action is to exfoliate, and, yes, I do think it helps. Because of its popularity, people use it even if they or their child develop redness, bumps or wound breakdown. Just as with Vitamin E oil, this type of reaction is an allergic or sensitivity reaction…..so don’t use it. People want Mederma to work so much to erase the scar that these symptoms are ignored and scar worsens. An allergic reaction is an allergic reaction and can be seen with any skin preparation.
3. Scar Sheets. There are some that work and some that don’t. Silicone sheeting has been around for a long time, and the theory is that it changes the environment of collagen cross-linking. I do recommend certain types. Most of the OT/PT grades are phenomenal.
4. YOU MUST WEAR YOUR SUNSCREEN SPF25 or higher and reapply it even if it says waterproof or sweat proof. Not only can the sun aesthetically affect the scar, but also can burn the scar and surrounding tissue since these are zones of inflammation and healing.

Scars symbolize an event, issue or, you might even call it, an imperfection. I was going to get more philosophical but I’m already over 500 words…maybe another time. For me, when I look at my scar, I am reminded of my mother’s unconditional love and a love that only a mother can possess and understand. Though my father is gone, his handiwork remains on my forehead, and I see his beautiful face smiling down at me with love and concern. None of us get through life without scars. What people may call imperfection; I call life and treat it with care, just like a scar. That’s what makes us human.

The True Meaning of a Scar: Part One

Blood gushed out of my forehead as 8 year-old little Melody raced home on my bike after falling off the apparatus at my best friend Marcy’s house. My dork glasses were caked with blood a vision that set off my already hysterical mother into mania. She slapped ice onto my forehead’s gaping wound and called my father, the Urologist. Now, I digress, because every time I mention him, people say “oh, that’s why you became a surgeon.” My father was the first physician in his long family lineage of farmers…I’m number two. He died when I was 17 years-old and never knew that I became a physician. He didn’t encourage me either way but made it known that I was expected to attend a university or college. I’m sure my sweet little man’s spirit is with me and he knows.

My father came home took one look at the 1-inch gap on my upper forehead made from Marcy’s gravel driveway (I’m originally from the Heartland….everything is gravel) and informed me that daddy’s little girl would need stitches. We rushed to the emergency room where dad did an okay job. It’s barely visible, and, so far, I haven’t felt compelled to pursue scar revision.

Scars are a very interesting and important part of plastic surgery and, actually, of all surgical specialties. The only thing with plastic surgery is people expect us to miraculously do what we do without scars. Scarring is multi-factorial….period. Its outcome depends on the initial cause, whether elective or traumatic, a person’s metabolism and genetics, and after care. Plastic surgeons have our methods to help minimize scarring, and we generally spend more time discussing, evaluating, and following scar care. But, especially in the setting of a traumatic wound where there is a crush component to the surrounding obvious wound and possible microscopic foreign material (like gravel) these wounds, though small, can be challenging. So, what exactly then makes up a scar, you ask, and why is it blog-worthy?

One component of skin is a protein called collagen. There are many forms of collagen, for example, lining the cornea (eyes) or glomerular basement membrane (kidneys). The collagen found in skin is a braid-like structure. As wounds heal and scar forms, the braid builds up then breaks down attempting to return to its pre-wound condition. Despite its efforts, wounded skin never achieves the strength or make of non-wounded skin resulting from either a planned surgical wound or traumatic wound. With this active process, scars can be manipulated with massage, scar treatment sheets or cream. Hey, team, guess what? Return for Part 2 next week when I will talk more about scars and scar-improvement strategies.

Cellulite—Uggh!

What exactly is cellulite? Cellulite is that dimpled skin look often seen on thighs, hips, buttocks and abdomen. Rather than smooth skin or even skin laxity, the skin appears irregular with an “orange peel” look. You can see cellulite on under perfect, or overweight bodies. Think layers as I take you simplified anatomy. From superficial to deep, there’s skin, subcutaneous fat, fascia, muscle, and bone. The skin, itself, ha two layers: epidermis and dermis. Epidermis is seen as the outer layer of your skin, and dermis is the underlying white layer seen when you get a deep cut. Running throughout these layers are connective tissue fibers, blood vessels, lymphatics and nerves. If we didn’t have the connective tissue component, our skin and underlying structures would move at different times rather than the nice, coordinated movement that we, for the most part, witness. Cellulite occurs with subcutaneous fat herniation (def.poking through where it shouldn’t)through the small connective tissue fibers attaching to the skins under-surface. Fat attached to the dermis pulling it into the dimple configuration. This can be a little difficult to conceptualize, and, frankly speaking, if I didn’t cut through these layers as many times as I have, I would have trouble picturing cellulite vs. non-cellulite. So, go easy on yourself if you have to read this a few times…put your mind’s eye on 3-D mode. Most of us plastic surgeons who perform a lot of bodywork can readily picture this deformity, as we call it in our lingo (certainly does not mean you are deformed) because we cut through these layers and see it. Interestingly enough, which goes with my recurring point that we are living creatures, cellulite is hard to see in cadavers because it happens in living tissue.

There are many theories concerning the cause of cellulite but genetics, hormones, diet and even tight garments are common culprits. Activities that increase blood flow to these areas improve the condition. Exercise, yoga, or walking instead of taking the elevator is such activity. Massage works by not only increasing blood flow but also by detaching the adhered fat from the dermis. Lymphatic massage, as well, stimulates lymphatic flow ridding the body of toxins. There are a vast collection of lasers and gadgets that generally work by the same mechanism of inducing vasodilation. They can do this either through heat production or mechanical stimulation. The appearance of cellulite may improve but it really depends on the severity of cellulite, number of treatments, and mode of delivery. Usually, none of these treatments leads to a permanent change. Regular use of lotions or creams always helps skin, if anything, improve overall appearance. Whether the active ingredient actually results in decreased cellulite content is a good question. I, personally, have not seen any NIH study that proves cause and effect with any cellulite combating chemical. And, then there is always what I call the looking good basics…..eating nutritious food, drinking lots of water and remembering to breathe. All good, inexpensive ways to rid our body of harmful toxins.

Neurotoxin for Wrinkles

It is true that in the last decade or so, a neurotoxin is used to minimize the appearance of wrinkles. Most of you know this neurotoxin by the name of Botox or Dysport, but because the purpose of my blog is to educate not promote, I’ll refer to this neurotoxin as, well, NT. How creative.

Before we delve into NT, let’s talk about lines aka wrinkles. Wrinkles are either static or dynamic. Static wrinkles are lines that we see on our face and body that increase with age. Dynamic wrinkles are lines that we see with facial expression. When we frown, smile or lift our eyebrows, lines form on our upper face then go away when facial expression ceases. With age, dynamic wrinkles become static.

The human body is made of many different systems that work together. The nervous system is one such system that provides an electrical circuit that keeps us moving. Special cells communicate with each other to ensure that we are able to walk, talk, eat and be merry. One branch of the nervous system that aids in muscular movement has cells that secrete a chemical, acetylcholine (ACH) that traverses a small gap to rest on receptors on second cells. Once this occurs, muscle contracts. NT blocks ACH so that it doesn’t reach the second cell and muscular contraction does not occur. Yes, this action relaxes or paralyzes the muscle so it simply can’t move. Because it doesn’t move, no dynamic wrinkles occur and the lines fade.

I have oversimplified the science of NT because I believe that everyone should

understand on a basic level the mechanism of NT for many reasons. Here I am going to go left brain on you and list important issues that concern me about you the consumer:

1. NT is not permanent. It wears off in about 4-6 months. Longevity of NT depends on your metabolic activity and chemistry.

2. Because NT blocks conduction and muscular contraction, remember those receptors, well, they can either up-or down regulate because they are not being used and the muscles themselves can either get thin or thick with changes in NT use. So how using NT affects your muscle in the long run is a good question.

3. So in light of #3, do you want to commit yourself to NT at a young age, as a baby in your 20’s or a youngster in your 30’s (rhetorical question)?

4. NT comes as a powder with special guidelines on how to mix the drug. Because NT is a protein it should be kept cold so it does not breakdown and it has to be treated gently, otherwise, it may not work as well.

5. NT paralyzes muscle……the face especially around the eyes has many small muscles and nerves so whoever you go to MUST KNOW THEIR ANATOMY VERY WELL! Don’t chase a wrinkle injecting into places that don’t safely warrant Botox.

6. One of the most common question I get asked is can you get too much and what are the long-term effects…..sort of goes in line with point #2 and #3. That’s why I am blogging the basics of NT so you can understand what it is before you undergo treatment. Personally, I am into safety and I do like some facial expression. FYI, the FDA does have its recommendations. I like NT and believe in keeping things in balance and not going overboard with NT. Ultimately it’s your decision, but as long as you are informed, you can make an educated decision.

I Love My Pregnant Breasts

“I loved my breasts during pregnancy and want them back to that size and look. You know, full and perky.” First, before, I address this issue, I just want to say that, yes, breasts are the fixation of us women. Men like them, but we are obsessed with those body parts.

During pregnancy, breasts serve to nourish the life soon to be born, and the body gets them ready for that function. Hormones during pregnancy not only support the uterus for the growing baby but also get breasts ready for this important function. Breast ducts enlarge for milk production, blood supply increases because of this food preparation, and the nipple areolar complex re-adjusts so baby can extract food. That, in short, is why breasts enlarge and look nice, shiny and plump. Whether you are able or not to breast feed, the body still prepares breasts for this function. Eventually, hormones revert to the non-pregnant levels, and breasts lose that look. In other words, the volume, fullness, glowing, plump, and perky look goes bye-bye. Often times what remains is what we call in plastic surgery a “deflated” look or loss of upper pole fullness. Because the support structures are no longer held under tension, nipple position may change…..a plastic surgery term that we call ptosis.

All of these considerations are important to address for ladies desiring breast surgery with a mental picture goal of acquiring that “look at my pregnant breasts” look. Remember, however, that we are living creatures and not a slab of marble. After pregnancy, circulating hormones and chemicals are different as well as skin elasticity. Breast implants, saline or silicone, do a very nice job replacing volume. However, in addition to replacing volume, there are many other considerations that we, as plastic surgeons, must take into consideration like chest wall issues, breast asymmetry, skin quality and nipple position. Breast surgery after pregnancy varies with each person which is why your procedure may be different from your friend’s surgery. It may be more involved than you think. And, of course, there’s the healing factor and how your body takes to surgical recovery.

Along the lines of health remember that October is Breast Cancer Awareness Month. BREAST CANCER HAPPENS IN 1 out of 8 WOMEN AND MEN GET IT, TOO. For both genders, do your monthly breast self-exam. Ladies get your mammograms; I don’t care how much it hurts—it saves lives. We all can get breast cancer, and if cancer is caught early, there are reconstructive options…..if even needed. Life is precious, and, again, the breast thing is our fixation. With or without them, we are still beautiful and so is life. Treat it with care.

Wrinkles and 9/11

Other than obnoxious, what exactly are wrinkles? Wrinkles are lines, folds and crease that form on our skin for many reasons. With age skin just plain changes losing elasticity, thinning out, and reflecting sun damage or toxins from prior years. Not only is skin the largest organ of the body but also is constructed of many different cell types from oil glands to pigment forming cells to hair follicles…to name a few. Have you ever wondered why we just can’t blow-dry our wrinkles away every morning the way we dry our hair?

Skin care is a daily ritual and first step to aesthetic care, so to speak. Even with the best and perfect plastic surgery, if your skin is not in good shape, the result will not last. In addition to basic skin care, skin reflects our general health as well, because we are dynamic human beings…. Our skin reflects our basic metabolism and body function. Skin also drapes over muscle and fat so that if the aforementioned are not in good shape, we put some of the blame on bad skin. Many corrective products exist on the market from cleansers, fillers, lasers and neurotoxins. In the ensuing blogs, I’ll address different corrective measures. But for now, I want to stress that there isn’t one great miracle treatment. There are certainly some nice lasers and products out there, but each one has its limitations. Again, I will demystify and simplify treatments in future blogs. For now I feel compelled to spend the rest of this blog to discuss 9/11.

To shift gears, my blog would not be complete if I did not mention 9/11. I was living in Chicago the time completing my plastic surgery training. I’ll never forget watching on TV at Cook County Hospital those towers collapsing turning a vibrant city into what appeared to be a war zone. Areas that were so familiar to me were now gone or covered with rubble. Prior to living in Chicago, my life in NYC was coupled with my surgical residency in Brooklyn and a post-doctoral fellowship at the Rockefeller University and New York Hospital. One of my projects involved the burn unit allowing me to attend the New York Hospital burn unit Christmas party in 1995. I was so impressed by how much the firefighters viewed their job with enthusiasm and excitement. They related stories of the day giving each other high-fives. They were all gentlemen. In the after-shock days of 9/11 all I could picture were those firefighters of Christmas 1995 and wonder if they were all now with God. To this day, I pray for them and all the brave firefighter souls that work so hard to ensure our safety. God Bless.