Melissa Rivers to her mom Joan Rivers: Enough plastic surgery! No more! Victoria Beckham is in the news for having had her breast implants removed, Heidi Montag has tearful regrets about her plastic surgery marathon, and now even Pam Anderson is swearing off more plastic surgery. About time, you may say, given the famously overproportioned implants in the latter three cases and the bungee connecting the former to her plastic surgeon’s office. As I have said before, it is a mystery why any of these pronouncements qualify as news but it does raise an interesting question: How much is too much?
It’s fair to say that in all of the above cases there was no serious attempt to conceal the plastic surgery habit. Swearing off plastic surgery in these cases is just going from one extreme to the other, but the average patient wants a natural look. This is especially true here in the Northwest, but even in Hollywood there is a lot of work that goes unnoticed, and denied if the subject arises. Speculation about who has had what done is just that: speculation (at least most of the time.) For these people, the point at which it starts to become obvious is when it is too much.
But that’s only one take. Certainly many people are not ashamed of having a little work done, and polls show that attitudes about plastic surgery are becoming less judgmental. People understand that liposuction isn’t a weight loss shortcut, and breast implants can be done just to restore volume lost after having children. But a reality TV star who has extreme plastic surgery in order to get people to keep paying attention is probably not the best example of healthy motives.
The way I see it, too much is when you stop being true to yourself. Have plastic surgery for your own personal reasons and you will be happier. It isn’t a matter of how much plastic surgery, but how well it is done and for what reasons.

Something I heard on the radio recently got me thinking about the topic of new ideas, and how they are developed and introduced. It was actually a show about food, but what piqued my interest was the observation that the first patent laws were apparently issued in order to protect “any new refinement in luxury” such as recipes or new fashion designs. This dates to the city of Sybaris in ancient Greece, a city so known for sumptuous opulence that the term “sybaritic” became a synonym for pleasurable living. No doubt plastic surgery would have been a popular indulgence had it existed back then.
True, these regulations were only the forerunners of what we now recognize as patents, but the notion of who has rights to new ideas remains malleable. Certainly, when substantial sums are invested in research and development of new technologies, the investors have some reasonable expectation of reward. But what of variations on surgical technique? If a new procedure is of potential benefit to patients, is it ethical to withhold access by patenting the operation? The American Medical Association holds that it is not, pointing to the higher purpose of dissemination of medical knowledge. This has been formally ensconced in the AMA’s Code of Ethics, and remains unchanged following a recent challenge in which an exception was proposed so long as “the patent is not used to limit access to the procedure.”
The AMA’s position is generally acknowledged by physicians across all specialties; commerce cannot trump progress in patient care. But how do we know if a new operation is truly better? Here is where the question gets stickier. Much of what’s new does involve patented technologies, and an increasing share of research comes from the private sector as federal grant sources come under fiscal pressure. Part of the answer comes from a trend in medicine to what is called “evidence-based” practice, which stratifies clinical evidence. For example, Level 1 evidence – the highest form – is from randomized, prospective clinical trials, where potential bias has been neutralized. The lowest level is expert opinion, case reports, and the like.
Plastic surgery, though, has a lot of subjectives that are difficult to quantify in clinical trials, especially for cosmetic procedures. The “latest and greatest” gets all the attention. Plastic surgery, by definition, is a creative and inventive specialty, in that we are required to rearrange body parts for some functional or aesthetic benefit, and the presenting problem is always different, if only by a little. It’s gratifying to be on the leading edge of innovation, as I have aspired to be, but the trick is to identify what will have lasting value and what will fizzle. Experience counts here as much as curiosity, but neither is sufficient by itself.

Some people seem to have a knack for finding the balance between too much and not enough, just as Goldilocks was able to find the porridge of just the right temperature and the bed that wasn’t too soft or too hard (even if she couldn’t comprehend the subtleties of trespassing and burglary.) But we live in an era of extremes and false choices, and nowhere is this more apparent than in plastic surgery and cosmetic medicine. Some assume that Botox always results in the frozen face, or that we need to accept our wrinkles as a badge of graceful aging. We may think that breast implants are always big and obvious, or that implant surgery is extreme and breasts are better left alone. But the truth is, as it has always been, that the best work looks natural, and the best advice is always based on a balanced approach.
So there is some irony to the fact that even as the fake look is criticized and the natural look celebrated, techniques to achieve the more balanced look are becoming ever more sophisticated. It may be hard to discern with all the attention given to the extreme cases, but it’s there, and you may not be seeing it. I know of several husbands who are oblivious to their spouse’s secret Botox habit (Does she or doesn’t she? Only your plastic surgeon knows for sure, and I’ll never tell.) Another example is breast augmentation where there is a wide array of implant shapes and sizes so that a selection matching the individual situation can be optimized (and yes, I know of marriages where the husband is unaware of the wife’s implants that she had before they met). Facelifts are improved by custom analysis, paying attention to 3-dimensional aspects of aging so as to avoid the dreaded ‘wind tunnel” look. (Meanwhile, franchise operations based on cookie cutter techniques are cropping up across the country like so many fast food joints.) Individualizing the approach is one of the keys to achieving the balanced result.
Finally, a big part of making good choices is knowing what your goals are. Be honest about your expectations when discussing them with your plastic surgeon. Be involved with the choices, especially decisions about implant size for breast augmentation. Be wary of claims that seem too good to be true, like laser lipo as an alternative to tummy tuck; sometimes the bigger operation actually gives the more refined result. And that’s no fairy tale.

We are all of two minds on the subject of natural beauty, whether we admit it or not. Consider the recently announced beauty pageant to be held in Hungary, in which the contestants are required to have had cosmetic surgery. Each potential Miss Plastic 2010 must submit an affidavit from her plastic surgeon in order to enter. Closer to home, future brides are vying for plastic surgery makeovers in a new TV series on the E! network called “Bridalplasty.” Critics have assailed the show in advance of its first episode, with one calling it “The Final TV Show Ever Made Before Mankind Slips Quietly Into The Dust.” Isn’t your life partner supposed to love you that way you are? Surely we have gone too far this time.

So exactly how much is too much? I am sure that the organizers of the Miss Plastic pageant (not the world’s first, by the way)would be quick to point out the dual standard that we hold as a society about natural beauty. Why, after all, should we reward people for their good looks when it is simply a matter of inheriting a winning ticket on the genetic lottery? Sure, grace, charm, and talent figure in, but these books are very much pre-judged by their covers. And as I have written about here before, beauty imparts a long list of tangible benefits in life, so why should the homely be discriminated against? We may all consider ourselves enlightened enough to see past this superficiality, but the evidence suggests that as a society we reward beauty for its own sake nevertheless. And the brides wanting makeovers have presumably already found someone who is happy enough with their looks; far worse to alter one’s appearance for the purpose of trying to salvage a relationship.

Not only that, but beauty pageant contestants who have had “a little work done” are likely the rule rather than the exception anyway, so the Budapest beauties are simply laying it out. The controversy comes when the target isn’t a natural, balanced appearance but an exaggerated one. Here’s where I think we find that boundary between what is acceptable and what is not: the overly obvious work. I can’t begin to tell you how many times I have heard people criticize breast implants or facelifts because they look unnatural, all the while oblivious to the long list of friends and others who have had plastic surgery which has somehow escaped their notice. Most people aren’t going for extremes, and it is a mistake to believe all plastic surgery looks that way.

Love it or loathe it, plastic surgery as a cultural phenomenon doesn’t seem to be going away. I’m still not sure though whether I will watch Bridalplasty. Maybe you can check it out and let me know what you think.

In any relationship, communication is a cornerstone to success. This is true for the doctor patient relationship, and even more so with plastic surgery. One reason for this is the high level of public interest, resulting in countless sources of information and opinion from blogs such as this to TV entertainment shows speculating and critiquing on which celebrities have had what work done. Even public denials or testimonials of forbearance against plastic surgery seem to make the news. Add a heady mix of advertising and aggressive PR about every new twist on techniques and technology and you have a very confusing situation indeed.
What’s a savvy patient to do? Trusting your doctor’s advice depends on how clearly the doctor has communicated. But it’s not uncommon these days to have patients go online to get input on what size of breast implants to get, or what “brand” of facelift or liposuction is best. They may even post questions about post-op recovery instead of picking up the phone and calling their doctor!
Not that doctors are all good communicators, and surprisingly many are misguided in their efforts. One patient emailed her surgeon (not a plastic surgeon) with a list of four simple direct questions about her surgery, and received a one-word reply to each! At least there was the courtesy of the reply, but we are used to a more elaborate form of pre-surgery informed consent around here. (We would rather give you too much information than not enough.) Another patient, here for a mommy makeover, related that her OB/GYN doctor had tried to discourage her from having the tummy tuck done, implying that it would be more painful than her C-sections (it isn’t.) Maybe there was some anti-cosmetic surgery bias behind that comment, but we expect that when our patient reports back to him later that he will join the ranks of those who refer patients here! Good communication also requires accurate information.
Plastic surgeons as a group are probably more focused on direct patient communication that other specialties, even if all of us don’t make the effort equally. Patients tend to ask their friends who to go to, rather than ask their primary care doctor as with other types of surgery, so our focus tends to be more outward and less within the traditional medical community. Given this we shouldn’t expect that our colleagues in other specialties are always up to speed on what we do, and we can do better in that regard.

Breast cancer awareness month is drawing to a close but I have one more item to spotlight. If you get the impression from my previous posts this month that I feel a bit of frustration with the slow pace of progress in advancing treatment options for breast cancer, you would be correct. I am disappointed at how radiation treatment is offered as “breast-conserving” treatment, even while I see patients with hard, misshapen breasts who could have had a superior result from mastectomy and reconstruction. And when radiation is appropriate, the Canadian protocol – lower dose and shorter course but with the same results – isn’t even mentioned as an option here in the States. And new information about the effectiveness of mastectomy in preventing cancer for patients with the BRCA gene is too often discussed without a mention of the option for immediate reconstruction. Yet the latest research indicates that Immediate breast reconstruction actually improves breast cancer survival.
There are many reasons why breast reconstruction is beneficial for women opting for mastectomy, in fact it is so important that in New York state a law was recently passed mandating a referral to a plastic surgeon before patients undergo mastectomy. What is interesting and even a bit surprising is that immediate reconstruction – at the same time as the mastectomy – is linked to better cancer outcomes, according to data presented at the recent conjoined meeting of the Canadian Society of Aesthetic Plastic Surgery and the American Society of Plastic Surgeons in Toronto. The study, from the U.S. national Cancer Institute, evaluated outcomes from some 46,000 breast cancer patients diagnosed between 1998 and 2003. Overall, a 26% better survival was found in the immediate reconstruction group. Yet many women are still not even referred for discussion of reconstruction options, either before or after the mastectomy.
Why should the simple fact of reconstruction improve cancer survival? There is no simple answer, and it is likely that a big part of the explanation is that women referred for reconstruction have earlier-stage cancer to start with. That, or because of their higher socioeconomic status they receive more careful post-treatment surveillance. But if we look at the fundamental benefits of reconstruction – lower rates of depression, improved sense of well-being, better psychosocial functioning – it is not difficult to imagine how these less easily measured factors could have an impact. But the way things stand now, many patients have to practically demand to see a plastic surgeon before they decide on which course to take.

One thing for sure about breast cancer awareness month is that women with the breast cancer gene, BRCA, are acutely aware and don’t need reminding. What they do need, however, is information and guidance on what to do. The BRCA gene is a genetic mutation that predisposes women to developing breast cancer, and the type of cancer tends to be more aggressive. If you have a strong family history of breast cancer and/or ovarian cancer, getting tested is a good idea. But once you know you have it, difficult choices loom.

The decision is between monitoring through frequent mammograms and MRI studies in the hope of finding it early enough to treat, or prophylactic mastectomy. A study out recently mitigates strongly in favor of prophylactic mastectomy at an early age. Women with the BRCA gene have a lifetime risk of breast cancer as high as 84%, depending on the gene type. The study, based on nearly 2500 women with the BRCA gene, compared outcomes of those who chose prophylactic mastectomy (about 10%) with those who were intensively monitored. No breast cancers were found among those who had the mastectomy, while 98 cases developed among the others. (This represents only 7% but multiplies considerably when projected as lifetime risk due to the limited average follow-up period.) Importantly, even among this tightly monitored group, there were 4 cases of previously unseen cancers in the prophylactic mastectomy tissue.

The researchers in this study concluded that mastectomy is a “highly effective strategy for breast cancer risk reduction.” However, although there were no cases of cancer found in those who had the breasts removed, they caution that there may still be some small residual lifetime risk. The issue is further complicated by the question of when to do have it done, the role of childbearing, and the relationship to ovarian cancer that the BRCA genes also carry.

The good news is that techniques for immediate breast reconstruction have improved tremendously in recent years. Using better implants, and support with grafts such as Alloderm, many if not most women can have an immediate one-stage reconstruction with a good result. There is ongoing discussion about whether or not to preserve the nipple-areola, which has a small amount of breast tissue but in a place where it can be easily monitored. Saving them improves the aesthetic result, while still substantially reducing the breast cancer risk, so this is something to discuss with your plastic surgeon. But if you suspect that you may have the BRCA gene, inaction is not an option.

Almost exactly 2 years ago at the annual meeting of the American Society for Therapeutic Radiation and Oncology Meeting in Boston, the results of shortened course of radiation treatments for early stage breast cancer were presented. The study, headed by Dr. Timothy Whelan of the National Cancer Institute of Canada and the Canadian Breast Cancer Research Alliance, found that equivalent results could be obtained with a dramatically shorter course of treatment, in some cases reducing the regimen from 6 weeks to 3. Benefits to breast cancer patients would include less disruption to their daily lives and possibly fewer of the adverse consequences of radiation therapy such as irritation and fatigue. Not to mention simply getting it over with and moving on to the recovery phase of the cancer experience.
But radiation oncologists in America have been slow to adopt the new practice. For the most part the only women who receive it here are those who have done their homework and have the energy to be assertive about their own care. Certainly the Canadian protocol isn’t for every patient (and in my view the whole concept of radiation as breast –conserving therapy is a misnomer) but it is hard to avoid questioning why it isn’t used more. With long-term data from 10 years of follow-up now in hand, no one doubts the efficacy of the model.
One thing that we do know is that the treatment costs less. Savings to the Canadian Health System are as much as 33%, and it is now standard practice there. And say what you will about the shortcomings of The Canadian system, their cancer outcomes are excellent. But the incentives are different in a private health insurance system, and savings harder to allocate.
So here is my advice to a woman being presented with the myriad of decisions that come with the diagnosis of breast cancer. First, take a deep breath and realize that breast cancer is usually a slow-growing type of tumor and there is no rush to treat; you have time to gather information and make informed decisions. Secondly, survival is good for most types and getting better. Then get ready to ask a lot of questions:
Which is better for me, mastectomy or lumpectomy and radiation, and why?
What will my breast(s) be like after reconstruction vs. after radiation?
If radiation, do you do the Canadian protocol (and if not why?)
What are my options for reconstruction if I opt for mastectomy?
It’s a lot more complicated in some ways than it used to be, but that’s because the options are better than they were not too long ago. Dramatic improvements have been made in both radiation treatment and breast reconstruction.

Whelan TJ, Pignol JP, Levine MN, Julian JA, MacKenzie R, Parpia S, Shelley W, Grimard L, Bowen J, Lukka H, Perera F, Fyles A, Schneider K, Gulavita S, Freeman C. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med. 2010 Feb 11;362(6):513-20.

Breast cancer awareness month brings a broad focus of attention to diagnosis and treatment of breast cancer, but those undergoing treatment and their loved ones see the little things. Here I want to raise some issues about radiation treatment, a central component of what is called “breast-conserving” therapy. Often held up as a desirable alternative to mastectomy and reconstruction, it’s no walk in the park and the conserved breast is not the same one you started out with. Firstly, a lumpectomy is a prerequisite part of the program, so some breast tissue has been removed. Then there are the daily sessions that go on for weeks, with fatigue and a number of other unpleasant sensations. I am sure more women would be blogging about their experiences if only they weren’t so tired.
The research dollars raised for breast cancer research similarly focus on early diagnosis and better cures, while the issues facing women going through treatment receive less attention. One that I want to raise awareness of is called “radiation fibrosis,” a hardening of the breast as a result of the therapy. It doesn’t affect every woman to a severe degree, but it does alter the breast and skin. About all most women hear is to try some aloe vera cream. But if the goal is to eliminate the cancer while conserving the breast, women deserve better.
In all fairness there has been some research on the subject. There is good reason to believe that antioxidants could help, and a couple of studies have evaluated whether vitamin E supplements during treatment could reduce the incidence of fibrosis. The results, however, are mixed, and without clear evidence clinicians generally don’t like to make a recommendation. However, what we know from other studies on antioxidant vitamins is that they are comparatively weak when used for that purpose. Other botanical antioxidants, such as polyphenols from red wine, blueberries, pomegranates, even dark chocolate are much more potent. That would explain the study from Italy that found a significantly lower rate of radiation fibrosis among women who drank red wine in moderation during radiation treatment.
Only a handful of clinical trials are underway to see whether supplements of wine-derived polyphenols can be helpful.* Resveratrol in particular seems promising, but as it also has estrogen-like effects its use by women with breast cancer cannot be recommended until more is known. It may be that because these compounds are natural, non-patentable molecules, there is less research funding to be had. But with thousands of women affected, the question of radiation fibrosis needs more attention.

*When I last checked, the trials were closed to new patients. A database of clinical trials can be accessed at www.clinicaltrials.gov.

   Lately it’s hard to escape the hype around stem cells in cosmetic surgery. They’re magic! You will of course recognize these capable corpuscles by their more controversial cousins, embryonic stem cells, in which researchers envision cures for a range of intractable conditions from Parkinson’s disease to spinal cord injuries. But here we are talking about adipose-derived stem cells, or ADC’s. It turns out that our own fat is sprinkled with stem cells of lesser but still interesting potential. Since stem cells serve a regenerative function, their use in cosmetic surgery makes for a very enticing story, and they are there for the taking so why not?
   Here’s how it works, or is supposed to anyway: Remove some fat with liposuction, then send it through any one of various (and expensive) devices that separate out the ADC’s, and add them into some of the fat that has been saved for re-injection. This fat is then stem cell-enhanced. Proposed benefits include better “take” or survival of the injected fat, which would be especially useful in areas where relatively large volumes are placed such as in the buttocks. Other potential plusses would be restoring the quality of the skin overlying the area. For facial rejuvenation, this would make a lot of sense: replace the fat lost from aging, and improve the skin and other facial tissues while you are at it.
   There are those who swear by this, but that isn’t the same as scientific clinical proof. There is some evidence of greater take of the fat grafts, but qualitative improvement in skin is harder to prove and evidence is incomplete that ADC-enhanced fat actually helps much in this regard. But that hasn’t stopped proponents from trumpeting the benefits of the “stem cell facelift” and its sexy sister, the “stem cell breast augmentation.” No incisions, no implants, just your own naturally enhanced tissue. In my view, even if the technique has merit, these are examples of marketing hype getting way ahead of the science. Enhancing fat injections into the face will never be a “facelift” just as all of the other noninvasive “facelifts” fall short. (In this case, for opposite reasons; skin tighteners fail to address loss of volume, and volume replacement doesn’t address skin laxity.)
   That isn’t to say that there isn’t a future for these technologies, but at the present time they are expensive and proven benefits minimal. I think it’s a case of having a golden hammer and suddenly everything looking like a nail.