Happy Fourth of July!!!

We don’t write that often about larger political issues as they relate to Medicine. In honor of American Independence Day, we thought we’d say something positive about America. I want to thank Dr. Rob Oliver for bringing my attention to an article from the Investor’s Business Daily about the awful state of Canada’s health care system. Canada’s socialized health care is often compared to its counterpart in the US, usually by someone who would like to see the same sort of system here. Take the movie Sicko, for example, which held up Canada’s system as the shining beacon for us all to look towards for inspiration.

The article quoted one of the father’s of the Canadian system talking about its ruinous state and advocating for some privatization. The article mistakenly referred to Claude Castonguay as the architect of Canada’s socialized medicare when, in fact, this distinction belongs to Tommy Douglas who, while Premier of Saskatchewan in the early 1960’s, instituted a number of government interventions into the corporate and medical world. These changes have influenced the self-perception of Canadians until this day, and many do still see Canada as a kinder, gentler nation for it. To give you an idea of how much Canadians have thought of these events, they recently voted Tommy Douglas as ”The Greatest Canadian” of all time in a nationally-televised contest.

Having lived and worked in both systems, I’ve had a unique opportunity to see both in action. The US system’s treatment of the underinsured is without a doubt less than ideal, with most having poor access to preventive care and using the ER as a walk-in clinic. I was amazed though, when I was training in New York, that even patients with Medicaid could walk-in same-day and see a specialist without a referral. That kind of thing doesn’t EVER happen in Canada. Wait lists to see a specialist can range from weeks to months. If you don’t have a family doctor to refer you, you might be out of luck because they’re hard to find these days. And access to highly specialized testing, treatments and surgery is far slower than it is here.

In Canada, the system is far more equal for all…not completely, mind you. A whole underground network has evolved where favors and influence can move someone up the list, known as ‘jumping the queue’. The costs are contained (somewhat) by rationing services. My most memorable run-in with the Canadian system was when a surgery I had scheduled was cancelled by the hospital because I ran later than expected with my previous case which, in turn, had been bumped by a slash wound neck trauma that I had been dealing with the night before.

It devastated me to have to come out to the patient waiting room at 3 in the afternoon to break it to this poor woman that I was sorry she had been left starving all day, and that she would have to wait weeks longer for a necessary surgery that had taken 4 months to schedule in the first place, even though I was more than willing to proceed. My hands were tied. She swallowed the bitter pill quietly. What choice did she have? And that was the breaking point for me. I’m not sure any American would put up with that, or even knows that this goes on.

That type of event symbolizes for me the differences between Canada and the US. Canada is like the friend who says “Sorry you’re hurt, hope you feel better”….kind, but passive. The US is more likely to say “What are we gonna do about it?”….headstrong, but taking action. If you ask Americans, theirs is the greatest country in the world. Canadians?? Same thing. Neither one has a perfect answer to Medicare in the modern age.

If you ask me, I don’t trust pencil pushers on either side of the fence, government or private. Private medicine has its problems, but don’t count on politicians to ride in and save the day with universal healthcare! Anything that’s completely free loses its value, gets taken for granted, and ultimately gets thrown away like a wet rag, as I saw in Canada. I found it interesting that the number of patients we saw in New York for the sniffles and other frivolous visits went down by 60% when a small $2 co-pay was instituted. So, if every doctor and patient takes personal responsibility for how we use the system, we could save a lot of money and a lot of wasted air-time, and still take care of those who need it.

Rant over. Just one opinion of a cross-border doctor. Easy for me to say, I do elective surgery most of the time…

We are constantly on the lookout for interesting stories about Beauty as it relates to Plastic Surgery. There are many beauty sites out there that specialize in repackaging information without adding much to it. So, when we find a site that doesn’t trot out that same old format, we like to make mention of it. One blog that breaks the mold is Cosmetic Makeovers. Meg Wilson provides the perfect combo of fun and thoughtful commentary on everything from cosmetics and fashion news to the latest surgical procedures. Meg’s terrific blog has our seal of approval.

As we surf the web to find all the hype that surrounds Plastic Surgery, we occasionally come across some very thoughtful and insightful editorial commentary. One of the sources we look to as inspiration are the musings of Dr Robert Oliver, who is a Plastic Surgeon in Birmingham, Alabama. Dr Oliver focuses his writings on breast augmentation and reconstruction, but talks on a variety of topics from liposuction to legislation regarding medicine, and really helps in debunking some of the gimmicks surrounding plastics.

Plastic Surgery 101 has our Seal of Approval

In the NY Times Magazine last week we came across these stunning pictures of Yasmine Warsame, a beautiful East African model from Somalia who grew up in Canada.

We looked her up since we had never seen her before and we came across her myspace site where she’s quoted as saying:

“I believe that ’Black beauty’ is understated and isn’t appreciated, so that’s what I want to represent in this modeling industry. I want to inspire young girls and women all around the world to follow their dreams, especially women of color.”

When Jennifer Hudson was featured on the cover of Vogue last year, a controversy arose because she was one of a small handful of black women ever to appear along on the cover.  It got us thinking about all of our ethnic patients who ask if we have expertise in ethnic rhinoplasty and facial plastic surgery. It’s a fair question, but one that requires a nuanced response. Yes, we do have expertise in working with a variety of ethnic patients…but truthfully, that’s less important than an understanding of aesthetics and anatomy in each individual.

No ethnic group can be pigeonholed into one group, though broad generalizations can be made (see our online book). You, your face and your nose are unique and individual to you, regardless of race or ethnicity.

So, getting back to black beauty - here are just a few of the beautiful black women who grace the landscape of our media world. You’ll note they’re all very different and yet stunning in their own way…

In the eternal quest for the fountain of youth more and more people are turning toward cosmetic enhancements that promise less recovery time, lower cost, decreased incidence of complications and instant results.

Among this new armamentarium of “minimally invasive or non- surgical” procedures comes the newly touted thread lift — also known as the feather lift, lunch time lift, Russian lift or suspension lift. The”thread lift” is promoted as an inexpensive, easy to do, “lunch time procedure” with little down time that subtly “refreshes” a sagging middle-aged face.

And the marketing has been amazing, to say the least. Like Thermage, Oprah Winfrey promoted the new barbed-suture face-lift as a “one-hour lunch-break lift” and a “cutting-edge procedure with no cutting edges.” On “Today” Matt Lauer described it as a “new alternative to a face-lift.” And “Good Morning America” called it “one of the hottest new beauty fixes.” The NY Times then reported “Mixed Results on a New Beauty Fix” just before The Washington Post posed the question “A Lift at Lunchtime?” More recently on another TV show, one cosmetic surgeon described how these sutures work to lift the brow to a better position and are the newest thing going today. The not so subtle message was that these threads can deliver the results of a traditional brow lift or face lift without any of the inherent consequences of the latter.

You may be thinking that this sounds too good to be true, right?

Do thread-based brow lifts and face lifts really work?

First a little background: Since September 2004, when the FDA cleared Contour Threads, one of two brands of barbed sutures, for use in the United States, at least 1,400 doctors have taken courses in how to use them, according to the manufacturer, Surgical Specialties Corporation. Reportedly, these doctors have now done more than 9,000 thread lifts. Perhaps thousands more have been done with Aptos brand sutures, which are made abroad.

The thread lift procedure uses a barbed suture to grasp the tissues and elevate them. Theoretically, because tissues are not being separated from each other and there is much less lifting of the skin, postoperative swelling and bruising are reduced.

First the positives; non-surgical face lift procedures are generally:

1. Less invasive- a few small incisions are made
2. Do not require an extended recovery period- recovery takes a few days to a week in general, though it may take longer
3. Less costly- typical costs are $3,000 to $7,000, depending on the number of sutures used
4. No general anesthesia is required

Unfortunately, based on the results so far, the hype seems to overstate the real results. And so, the thread lift has come under fire from many facial plastic surgeons and general plastic surgeons, the kind of doctors who perform most real face-lifts. We believe that the thread lift has not yet been subjected to the kind of peer-reviewed clinical studies that are needed to demonstrate that it is safe and effective and to indicate which patients it is right for.

Do the results last?

One study found that the initial results with suspension sutures were relatively good, if not impressive. However, by 6 months, the corrections started to fade and by 12 months, between 80-100% of the initial corrections were lost. So, although some patients are told that the results generally last 3-5 years, in reality, it is impossible to know how long these corrections really last since the procedure is so new.

Are these procedures safe?

It is true that because these procedures are done under local anesthesia, rather than general anesthesia, the patient can expect less anesthesia risk. However, based on anecdotal reports, it appears at this time that these procedures are fraught with a host of potential complications including:

1. Infection
2. Potential Nerve Injury
3. Threads that cause bunching of the skin
4. Threads that break and recoil causing a visible knuckle of suture
5. Threads that protrude through the skin
6. Threads that can be seen or felt under the skin

Other patients have reported poor cosmetic results, swelling that took much longer than a week to subside and irregular or painful sensations in their face after the procedure.

Who should consider a threadlift and what results can be expected?

According to the American Academy of Dermatology, threadlifts are “for patients with moderate signs of aging who are looking for a little ‘lift’ without resorting to a facelift…”

Patients who want a subtle change in the mid face and lower face and who also need minimal downtime may be candidates for a threadlift, if they understand and are willing to accept all these possible complications. Patients who have sagging of the skin or deep folds in the tissues, who are really candidates for a face- lift, will likely be disappointed if they expect a big improvement.

Moreover, it should be noted that while these procedures take less time than a real face lift, “the view that a thread lift can be done during a lunch hour is not endorsed by the company…The downtime is not a lunch…It can be a day or a week, depending on the area that is being done.” And this statement comes from the mouths of the actual manufacturer.

A Final Note

Plastic Surgery periodically experiences periods when a new procedure is pushed hard by the media and some physicians and surgeons adopt it enthusiastically. Potential troubles or shortcomings show up later and the procedure falls into disfavor or is used much less frequently than at first.

At Profiles, we tell patients to wait a couple more years. We want to be sure that these “quick fix” procedures work, are safe and do what they claim to do. While they hold promise, we do not want our patients to be beta testers for new procedures that are all the rage.

Perhaps, with time, experience and adjustments the threadlift may have an impact much like liposuction, which also was initially shunned. However, for now at Profiles, we recommend patients undergo time proven procedures that we know are safe and effective.

As you probably know, all of the products you asked about are dermal fillers. These are designed to restore volume to sagging skin in areas of creases or folds, such as the nasolabial folds between the cheek and lips.

These are 3 of the most popular hyaluronic acid products which, along with collagen, make up the main ‘building blocks’ of your skin. Unlike most collagen products, they are not animal-derived but, rather, are ‘grown’ in the lab, so the risk of an allergic reaction is minimized.

Injectable Collagen causes improvement in creases that lasts about 3 to 4 months. Because of the allergy risks and other factors, its use has largely been replaced by the hyaluronic acid products. Restylane, Perlane and Juvederm restore and replace hyaluronic acid that the skin has ‘lost’ and add volume by absorbing up to 1000 times their weight in water. The cosmetic benefits usually last from 6 to 9 months depending on the area injected, the volume used, and other factors. ‘Touch-ups” will cause the effects to last even longer.

Restylane and Perlane are from the same family made by the same manufacturer. They differ only in particle size, with Perlane having larger particles. This means that Perlane is more appropriate for deeper creases in thicker skin. In these situations, it will likely last longer than Restylane.

Juvederm is also a hyaluronic acid with a slightly different formulation or cross-linking. Its use in the United States is more recent with some claiming that it is perhaps slightly smoother and longer-lasting.

Because these products have been approved for use in Canada for many years, we at Profiles have had extensive experience with them. Please browse our web page on injectables and wrinkle reduction to get a sense of what these fillers can do for you.

There has been a recent report of safety concerns regarding Botox.  The latest news is that the FDA is conducting a broader safety review of Botox and its uses.

Today, we received a media statement from our professional academy, the American Academy of Facial Plastic and Reconstructive Surgery (www.aafprs.org) that is copied below:

“FDA issued an early communication about an ongoing safety review regarding Botox and Botox Cosmetic. FDA has received reports of systemic adverse reactions including respiratory compromise and death following the use of botulinum toxins types A and B for both FDA-approved and unapproved uses. The reactions reported are suggestive of botulism, which occurs when botulinum toxin spreads in the body beyond the site where it was injected. The most serious cases had outcomes that included hospitalization and death, and occurred mostly in children treated for cerebral palsy-associated limb spasticity. Use of botulinum toxins for treatment of limb spasticity (severe arm and leg muscle spasms) in children or adults is not an approved use in the U.S. See the FDA’s “Early Communication about an Ongoing Safety Review” for Agency recommendations and additional information for healthcare professionals.

Read the complete 2008 MedWatch Safety Summary including a link to the FDA’s Early Communication about an Ongoing Safety Review regarding this issue at:  http://www.fda.gov/medwatch/safety/2008/safety08.htm#botox

While any serious complications from a medical treatment warrant thorough investigation and appropriate action, the important thing to understand is the context of the risks posed. Botox is a purified form of botulinum toxin and works by temporarily weakening the muscles into which it is injected. In small doses, such as those used for cosmetic benefits in the face, the risks are extraordinarily small. You have more chance of a serious reaction from a $4 bottle of aspirin.

The major risk arises when large doses are used in sensitive locations. Many neurologists are using Botox off-label to treat limb spasticity for cerebral palsy and other conditions. This can provide some relief for these very debilitating conditions. However, if very large doses are used, there is a small chance of overdose, causing symptoms similar to botulism. Also, Botox is blind to location and acts wherever it is injected. If large amounts are injected into muscles near the windpipe or esophagus, these structures can be affected, with potentially disastrous consequences.

For cosmetic uses, Botox remains one of the safest drugs around and has been used safely in literally millions of patients. But, we take these types of reports very seriously and will continue to update you as more information surfaces.