According to the American Society of Plastic Surgery there were 286,000 breast augmentations in the United States last year, an increase of over 200% since 1997. In my last blog, I reported on evidence that shows a high degree of satisfaction with the choice to have breast implants. We know that breast implants do not last a lifetime, but women want the satisfaction with their procedure to last a very long time. The US implant manufacturers advise that implants will need to be removed or replaced eventually. So what are some of the reasons for revising breast surgery?

A study (published last month in Aesthetic Surgery Journal) looked at 110 consecutive women that underwent revision of their breast implants between the years 2004 and 2009. The reoperation rate in this study was 16.3% with an average time from first surgery to revision of 8.9 years.

Here are the reasons for re-operation in this surgeon’s practice:

1. 42%developed sagging (ptosis) of their breast, a natural progression of biological change.

2. 29% had capsular contracture (scar tissue around the implant resulting in firmness).

3. 19% were re-operated for a high riding implant.

4. 14% indicated implant position was not where it belonged (malposition).

5. 7% had infection.

6. 5% developed breast cancer.

7. 4% objected to rippling of implant.

8. 4% had synmastia (implant pocket lifting up over the sternum).

9. 3% had a “double-bubble” where implant and breast did not merge in a smooth transition.

10. 2% deflation.

As humans age their skin thins, loosing elasticity. As breast volume fluctuates with weight changes and pregnancy, there is a natural sagging of the breast. Implant placement can accelerate these natural changes. This report shows that the majority of revisionary breast implant surgery is to improve appearance and reverse changes of aging, rather than for medical necessity. That is a good thing if you are the patient, because you can choose the time when it matters to you. www.aestheticsurgeryjournal.com

The purpose of aesthetic plastic surgery is to improve quality of life by enhancing one’s body confidence and comfort. A recent study published in the Aesthetic Surgery Journal looks at the satisfaction and well-being of a group of 155 women that had breast augmentation in 2008 and 2009. The data confirms that women report a significant improvement in their satisfaction with breast appearance, psychosocial well-being, and sense of sexual well-being after surgery. The anonymous survey was administered before and six weeks after their breast implant procedure. The scores were tabulated on a 1-100 point basis.

Here are some of the outcomes reported:

1. Satisfaction with breast appearance improved from a score of 26 to 82.
2. 79% were satisfied with the size of their breasts post operatively.
3. Sense of wellbeing increased from a score of 52 to 85. 
4. 97% reported they felt attractive, up from 51%.
5. 96% felt more self-assured, up from 51%.
6. 94% reported that they felt confident most or all the time, improved from 53% prior to surgery.
7. 91% answered that they felt confident sexually after their augmentation, up from 46% preoperatively.

The research did not examine those women that did not report improved quality of life after the procedure. This group was small but it would be valuable to gain insight on why they did not achieve the same satisfaction. 

The questionnaire that was used is called the BREAST –Q. It was developed to meet national and international standards of outcomes assessment for evidence based medicine. For a closer look check out the Aesthetic Surgery Journal 33(2)245-251, 2013.

The April 4, 2013 New England Journal has a review article that talks about the health benefits of the Mediterranean diet. The recommendations are simple:

• Eat more fruit, vegetables and nuts
• Consume only moderate amounts of fish and poultry
• Avoid dairy and red meats
• Substitute whole grain for refined grains
• Red wine and olive oil are acceptable lubricants for the diet

There is impressive data that demonstrates that adherence to these food choices can protect against risk of heart disease, cancer, Alzheimer’s disease, Parkinson’s disease and premature death. The article is entitled “Something New Under the Sun? The Mediterranean Diet and Cardiovascular Health.” When this plant-centered regimen is paired with moderate exercise, it becomes not just a diet, but a way of life.

The US Department of Agriculture and the Department of Health revise dietary guidelines every 5 years for our increasingly overweight and diabetic American populace. These guidelines in the past have consisted of pages of difficult to translate jargon that is undecipherable to the public. The new emphasis is on a holistic turn in nutrition science that looks at the properties of whole foods and food patterns rather than at individual micronutrients, vitamins, minerals, additives, etc. People choose food, not macro or micro nutrients. 

Sensible and simple guidelines promote healthy lifestyle choices that can defend against a variety of degenerative diseases. So pick out a good Italian or Greek cookbook and keep up your gym membership. You, too, may have a long healthy run “Under the Tuscan Sun.”

N Engl J Med:368:14 nejm.org April 4, 2013

I am still glowing from a week in Honduras in February 2013, where I was on a surgical mission to repair children born with cleft lip and palate. It was a gratifying experience for me and Virginia, my nurse who accompanied me.

The exact cause of congenital clefts is not known.  Both environmental and genetic factor are responsible. Somewhere between the 8th and the 11th week of gestation, a baby’s face and mouth are formed by fusion of tissues in the midline. When this motion fails to occur, there is a “cleft” or gap that results in a hole in the roof of the mouth, a split in the lip, loss of upper jaw bone and teeth, and a distortion of the nose. This occurs in about one in a thousand births. The incidence goes up in the face of malnutrition and poor prenatal health care. The deformity causes difficulty feeding, speaking, hearing and difficulty with socialization.  

Honduras is a country of 7 million people and over five million live in abject poverty. Malnutrition is widespread and access to medical care is unavailable to its poor majority. The Friends of Barnabas Foundation is a nonprofit 501(c)3 that is dedicated to improving the medical condition of Honduran children. I have been actively involved in these endeavors for a number of years.

On this February 2013 trip to Siguetepeque, Honduras we were able to provide needed surgeries for 23 children with cleft lip or palate. Our team of 13 medical personnel and five support persons screened children the first day to choose those most in need. We operated for five days. The children and their caregivers then returned to the Barnabas Foundation House for post operative care and education.  

Children with clefts often need 4-5 operations to fix their many problems. The Friends of Barnabas provides continuity of care for these kids and their families, helping with education about the special needs of this group and keeping them in a system to provide the complex care they will need.

For more information about this remarkable non-profit visit www.fobf.org. To view more photos of our journey visit my Facebook page.

There are a lot of beliefs people cling to about diet and weight loss that are quite simply incorrect. These ideas are old wives tales, misconceptions refuted by scientific studies. Holding on to erroneous claims can lead to poor decision making, hence a lack of success.

The New England Journal of Medicine edition of Jan 31, 2013, discussed things we think we know in their article “Myths, Presumptions, and Facts about Obesity.” Here are a few of the commonly held notions that are scientifically shown to be incorrect:

A FEW MYTHS

1. Small sustained changes in energy intake or expenditure will produce large long term weight changes. This concept is based on the assumption that burning 3500 calories results in weight loss of one pound. That formula holds true for short term losses, but the body’s energy requirements are less predictable over a long period of time.
2. Setting realistic goals is more effective in achieving weight loss than setting ambitious goals. Although this idea seems reasonable, empirical data shows that more ambitious goals are often associated with better outcomes.
3. Rapid weight loss is associated with poorer long term weight loss outcomes than slow gradual weight loss. It’s a myth. Meta-analysis of randomized controlled trials do not show a difference in long term success of the two strategies. 

RELIABLE FACTS

1. Although genetic factors play a role, heritability is not destiny when it comes to body weight. Identifying and controlling environmental influences can achieve successful reduction in obesity.
2. An increase in exercise increases health. Exercise can help prevent some of the health damaging effects of obesity, even in the absence of weight loss. Physical activity in sufficient amounts aids in long term weight maintenance.
3. Reduction in energy intake (calories) is the ultimate dietary intervention for being over weight. No matter what diet you choose, you simply have to burn more calories than you take on board. 

For more details about the state of our knowledge on this subject (important to large numbers of Americans) read the full discussion at NEJM.ORG. You too can shed a few incorrect biases in order to shed a few pounds.

All of us want to be a better version of our self, so as the calendar turns over another year, it is the occasion to declare a fresh start. Most of us pick goals that have personal meaning, often connected to how our bodies look and feel. My friends are working out more, de-toxing, exercising, eating organic and losing weight. Health clubs get a surge of new member in January and Weight Watcher’s sessions are full.

So why is it that by spring 90% of  New Year’s resolutions have been abandoned? It is human nature to lose our resolve and return to old habits. So how do we convert to that healthy lifestyle and make it stick? Here are a few suggestions:

1. Start simple and concrete. Resolutions that are too broad, too big, or too drastic are doomed to fail. Think big, but start small.
2. Write down the change you plan to make and post it several places. The act of writing it makes the commitment more engrained. Posting a reminder in several places re-enforces the plan. 

You may choose to stop drinking soda or other high calorie drinks. Reminders on the refrigerator or near your bathroom scales can keep it fresh in your mind. Outlook or smart phones can be good to keep you on track. Try emailing yourself daily.

1. Give a commitment of 21 days, rather than forever. It takes 21 days to form a habit and the short time frame will help you avoid discouragement.
2. Re-evaluate at three weeks. If you could not reach this goal, try to identify the challenges and come up with solutions. Write down your revised strategy to re-new your commitment. If you did succeed, try adding a new habit to change.
3. Don’t procrastinate. The next time you start you will wish you had done it sooner. No time like the present. Just do it.

Once you change a small habit you can keep it for a lifetime. Being a better version of ourselves is an accessible goal!

Breast augmentation ranks first in frequently performed plastic surgery procedures. Perhaps the most important factors in assuring satisfaction with the outcome is having the surgeon and patient agree on an implant size that is suitable.  Reoperation for size change of implant happens about 8-9% of the time and can be avoided with careful decision making in advance. The December 2012 edition of the Journal of Plastic and Reconstructive Surgery has a new study published on ways plastic surgeons select implant sizes for their breast augmentation patients. 

“Surgeons that rated breast diameter as the most important variable in size selection had the lowest reoperation rate for size change”

“Choosing a breast implant for a prospective patient is not a straightforward task.”

A survey was sent to 3000 members of the American Society of Plastic Surgeons inviting them to report how they selected implant size prior to surgery and what their reoperation rate was for size change.  Surgeons ranked variables in the following order:

1. Woman’s desired size
2. Breast Base Diameter
3. Amount of skin/breast to cover the implant
4. Distance from the fold beneath the breast to the nipple, unstretched
5. Stretched skin distance from fold to nipple
6. Skin “pinch” thickness
7. Sterna l notch to nipple distance
8. Distance between nipples
9. Diameter of areola
10. Nipple projection

The variable that could be related to a decrease in reoperation rate for size change was the measurement of base diameter. In the event of a conflict between patient’s desired volume and implant width, surgeons who re-educated their patients about the reasons for  different size choice had a lower repeat surgery rate than those who compromised with their patients in the event of a conflict. 

www.PRSJournal.com

A survey sent to 600 liposuction patients looked at their long term satisfaction, asking a long list of questions, such as:

• How would you rate your appearance after liposuction?  87.3% rated “good or better.”
• Are you more productive in your work?  Better productivity reported in 27%, no change in 71%.
• Would you have the procedure again? 79% said yes.
• Would you recommend the procedure to family and friends?  86% said yes.

The vast majority reported favorably to each of these questions. However, it was found that those who ate a healthy diet, exercised regularly, and maintained a stable body weight were 2x more likely to have increased productivity, 15x more likely to have dropped in clothing size, 2.5x more likely to have a high self appearance score, and 3x more likely to have improved health. Those who took active control of their health were far happier.  

The authors concluded that there are four elements to having a good long term result from your liposuction procedure.  The first is having a good surgeon performing a well executed procedure, but the other three are controlled by you, the patient. Healthy eating habits, regular exercise, and commitment to a positive lifestyle are huge determinants of satisfaction with the choice. So, real satisfaction involves team work with your doctor. The authors developed a map of how to tell what factors affected your happiness with the choice.

PRS Vol.114, No.7, p.1945 

www.PRSJournal.com The_Key_to_Long_Term_Success_in_Liposuction__A.40

The November 2012 edition of Plastic and Reconstructive Surgery published a study that confirmed long term improvements in quality of life measures in people who had chosen to have body contouring plastic surgery after a substantial weight loss.

Body image dissatisfaction accompanies obesity and correlates with a lowered quality of life. Weight loss may go a long way to reverse functional problems and health risks, but does not complete the process. The skin overhang after massive weight loss continues to causes feelings of unattractiveness, embarrassment, hygiene issues and impaired movement. Body contouring surgery removes the redundant skin and helps restore body shape. It is important to have evidence that the body contouring surgery produces its intended improvements both physically and psychologically.

This study looked at number of satisfaction indicators including physical functioning, mental well-being, appearance, social acceptance, and intimacy. The patients surveyed had bariatric surgery and had lost an average of 110 lbs.  They also had plastic surgery after their weight had stabilized. They compared their situation from before their body contouring to an average follow up of 7.2 years with the following patient perceptions:

In 6/7 psychosocial measures of mental health (depression, sense of shame, social withdrawal) the group experienced substantial long term improvement.

Improvement was sustained in their appraisal of their appearance and physical functioning.

97% would undergo body contouring again and thought it was an essential step for improved quality of life.

You can find details at www.PRSJournal.com.

My office received a phone call last week asking if we offered either stem cell facelifts or vampire facelifts?? We were happy to say no…not that we do not like being early adopters of new technology, but because these two procedures have marketing claims that are far ahead of any science. In other words…HYPE.

So what might advertisers mean by stem cell facelift? Fat is one of the body’s tissues that carry adult stem cells. When a facelift is performed, fat can be added to bring fullness to sites of volume loss. In fat transfer to the face, a small number of stem cells may be moved at the same time. We do not know how many (if any!) are being transferred, and we do not know if they will become activated in their new home, to provide the hoped for repair and youthful, healthy look. The procedure for fat grafting is a good one, but calling it a “stem cell” facelift is hyperbole (HYPE!!).

The “vampire” facelift is also not ready for prime time. The procedure involves drawing a tube of your blood, spinning it down to isolate the portion that contains the most white cells, known as the buffy coat. The theory is that this fraction contains more growth factors and possibly stem cells. To date this is all unproven. Surgeons that use this as a selling point for their services  are trying to win confidence by suggesting that they are employing a “cutting edge” technology, but these claims are unfounded.

The American Society of Plastic Surgery and the American Society of Aesthetic Plastic Surgeons published a joint position paper in 2011 on stem cells and fat grafting. In this paper they state:

“Extreme caution should be exercised when a physician is promising results from any treatment that sounds too good to be true. Stem cells in aesthetic surgery are promising, but marketing claims are far ahead of the science.”