In the United States one third of adults are Obese (BMI >30). OBESITY brings a burden of increased medical problems and risk of premature death. Excess body mass significantly decreases energy, activity and sense of well being, not to mention body image. Many resources, public and private are being devoted to combating this epidemic. MICHELLE OBAMA has made anti-obesity her signature issue in the “Let’s Move” campaign.

The Nov 24, 2011 NEW ENGLAND JOURNAL of MEDICINE published a randomized controlled study in 415 obese people to compare two different approaches to supporting WEIGHT LOSS. All patients were followed by their doctors for a two year period. One group of subjects had weight loss coaches that provided in-person support with both group and individual sessions. A second group had its counseling provided remotely by e-mail, phone or web site. The third group was entirely self directed without supplemental advise or support.  

The self directed (non-supported) control group had a mean weight loss of .8 kg, not much change at two years. The two groups that received support both were able to maintain a 5% weight reduction. This modest weight loss is a good start on decreasing cardiovascular and diabetic risk even if it is still a far distance from being at ideal body weight. The group with face-to face coaching did slightly better than those who received their support on line, but support was critical.

The take home lesson is that lifestyle changes are hard to maintain especially when attempted all by yourself.  Education and encouragement make a difference in being able to sustain change in habits. You may lack both time and money for one on one coaching, but taking advantage of on line support systems may be a very good method to reinforce behavioral modifications. Most health clubs offer a supervised program to track diet and exercise. There are multiple web sites for monitoring calorie intake and exercise to track progress in those key behaviors. Here are a few you might find helpful:

www.healthdiscovery.net – Weight Watcher’s Support Network

win.niddk.nih.gov/ – Weight-Control Information Network

www.obesityhelp.com – Web site with resources for surgical weight loss

www.overeatersanonymous.org – Successful group based on the 12 Steps model

Don’t forget to keep moving!

Gynecomastia, Male Breast Enlargement

Men that are uncomfortable in the locker room or at the beach may be those whose chest appears more like an adolescent female than a male. Male breast enlargement, called GYNECOMASTIA, is common and can be a source of embarrassment.

Recently a 16-year-old boy came in with his parents to talk about his gynecomastia. Brian had become increasingly unhappy at school. He socialized less comfortably than he had as a little boy and he refused to participate in sports. He spent more time alone playing computer games and had put on a lot of weight. At 5’8″ he was 225 lbs. He had trouble losing the weight because he was humiliated to take his shirt off in front of others and did not want to participate in sports. Teenage boys at school targeted him as the brunt of their jokes.  

Brian had a very extreme case of male breast growth that was made worse by his weight gain. His embarrassment was understandable. He had been evaluated at the Children’s Hospital endocrinology clinic and no cause had been found for the breast enlargement. He and his parents wanted to remove the stigma as soon as possible.

Brian’s surgery incorporated a variety of surgical techniques. LIPOSUCTION of the chest wall helped to smooth the contour with removal of the extra fatty component. The dense glandular tissue was removed through a small incision camouflaged at the junction of normal skin and the brown areola, a variation on a SUBCUTANEOUS MASTECTOMY. The TUBULAR BREAST shape was corrected by a PERIAREOLAR MASTOPEXY, which means that extra skin was removed and constricting fibrous bands were removed to reshape his chest.  

Brian had an enormous sense of relief immediately after his procedure. He is more confident and outgoing and relieved of the sense of shame he felt about his chest. He is hoping to tackle his weight issue next.

What Causes GYNECOMASTIA?

Male breast enlargement happens commonly at two times in a man’s life. At mid to late puberty there can be an excess of free ESTROGEN before adult levels of TESTOTERONE have been produced. Breast enlargement at this phase goes away within a year 95% of the time. If it lasts longer, it is likely to persist unchanged. The second time that breast enlargement is common is in late life as testosterone level is falling. 50% of men have decreased free testosterone by age 70.  

The vast majority of the time no cause can be found for gynecomastia. Rarely there may be tumors of the testes or adrenal that produce feminizing hormones. Failure of the testes to produce testosterone can also result in breast growth. Obesity can be a cause of gynecomastia as increasing BMI results in converting adrenal hormones into estradiol, which stimulates glandular growth.

Men with severe liver failure, kidney failure, and hyperthyroidism can all be associated with benign growth of the male breast.

There are a number of medications that have been known to stimulate breast growth, including certain diuretics and anabolic steroids.  

There is not complete agreement on whether or not biochemical studies should be ordered for the evaluation of gynecomastia, because the tests have a low yield. The cause is usually found with a careful history and physical exam. Medications including estrogen inhibitors have been largely unhelpful. If the gynecomastia has lasted for more than a year, then surgical removal of gland and fat improves their appearance.

Reference: New England Journal of Medicine 357;12 p.1229.

Tanning beds are a popular way of keeping that sun kissed look as cold weather sets in. They are particularly welcomed in cloudy Seattle and cold northern climes. It feels good to get warm light exposure, so good in fact that it is addicting. Data shows that the ultra violet light in electric tanning causes release of endorphins. Endorphins stimulate our brain’s pleasure centers. As endorphin levels decrease, the addictive personality looks for ways to increase the pleasurable sensation. Chronic users are drawn in by more than bronzing of the skin. There is also the endorphin release. Tanning beds are used by thirty million people according to the tanning bed industry. That is roughly 10% of the US  population each year.

Not all addictions are bad, but this one is believed to be related to the 30% rise in the rate of melanomas with the biggest increase among women 15-39 years old. Melanoma is a skin cancer that arises in dark colored skin growths. It can be cured if caught early, but results in a devastating course if spread has occurred. The risk of death from advanced disease remains high. Researchers estimate that the increase in incidence of melanoma is related to tanning bed use.

The New England Journal (NEJM 363:10,p901)  has a good description of how the same mechanism that causes your skin to tan is resposible for DNA damage that sets the stage for skin cancer development. It is theorized that tanning may be the body’s attempt to protect itself from the damaging effect of radiation. When DNA is damaged the skin is programed to release melanin, a brown pigment that can help filter the sun’s harmful rays. Tanning cannot occur without DNA damage. If your body does not repair that damage, you may be subjecting yourself to a cancerous change.

There are public health advocates that believe that regulation or even banning of tanning beds might be an opportunity for public safety. Multiple European countries have started to enact restrictions on tanning beds. Whether or not that occurs as a legislative agenda in the US, you can protect yourself by selecting a quality spray tanner and avoiding unnecessary exposure to ultra violet radiation.

So if you like the look of that outdoor ruddy complexion head for the cosmetic counter instead of the tanning parlor and get your endorphins with a brisk work out.

The majority of people that chose to have plastic surgery dislike some aspect of their appearance. The goal of cosmetic surgery is to feel more comfortable in your own body. How often is that goal met? The September 2011 edition of Plastic and Reconstructive Surgery (vol. 128.no.3.p765-772) published a prospective study examining patient satisfaction at six months and five years after their procedure.

Questionnaires were distributed prior to surgery that consisted of measures of satisfaction with appearance, self-esteem, psychological problems and patient’s evaluation of the outcome of surgery. The questions included well validated and widely used psychometric measures. The questionnaire was repeated at six months and five years. The same questionnaire was sent to a control group of 838 patients who were aged matched but had not had plastic surgery. The 130 patients included in this study had chosen, breast enlargements, breast lifts, liposuction, tummy tucks and eyelid operations. At five years:

92.2% of patients considered their appearance as good as they expected or better.

81.4 % were more satisfied with their overall appearance.

89.2% thought that the body part operated on had improved in appearance.

93.8% said they had no regrets about choosing plastic surgery.

89.9% said they would choose plastic surgery again if faced with the same circumstances.

Satisfaction with appearance was greatly improved. However, little or no improvement was seen in self-esteem and mental health. Other interesting observations of the study were that patients were most satisfied when they had taken a long time making their decision for surgery rather than acting impulsively.  Patients were also more satisfied when doing the procedure for themselves rather than for the sake of a loved one. Those with psychological or self esteem issues before the surgery reported more negative changes in their psychosocial function postoperatively. 

According to this evidence based study you might conclude that plastic surgery does not fix deep seated psychological issues, but it can make you feel a great deal better about your appearance.

Moving fat from an area where you do not need it to some place where it might be an advantage is an old concept in the history of medicine. Techniques have evolved making this more possible today than when it was first tried. Fat transfer to the face and to liposuction defects have been used with success for the last decade. Fat transfer to the breast has proceeded cautiously because of two concerns. The first is the fear that the transplanted fat could interfere with the interpretation of mammograms. The second was that the fat tissue might contain stem cells that could stimulate growth of breast cancer cells. Recent investigations have shown these concerns to be unwarranted. Mammograms taken after fat transfer to the breast have been shown to be no more difficult to read than those taken after other types of breast surgery, such as reductions. Fears of tumor stimulation by fat transfer have also been debunked, as fat in a mastectomy site or partial mastectomy has not been shown to increase local or distant recurrance of breast cancer.  

These findings raise hopefulness for lipo transfer (fat grafting) to the breast. Fat grafting has provided good results when used to give more tissue cover over an implant in breast reconstruction. Fat transfer can bring the same advantages in breast augmentation for cosmetic purposes. Using fat without an implant usually requires several transfer procedures to get enough volume. It works best when there is excess loose skin,particularly with a sagging post partum breast. For the woman with a tight skin envelope, a device (called a Brava) is used several weeks ahead of time to stretch the skin. It takes perserverance and motivation on the part of both patient and surgeon to accomplish an enlargement without an implant. The increase in size is less than can be achieved with an implant, but use of a foreign body is avoided. Stay tuned, as it may be the way of the future.

Daniel S. Hammermesh is an economist who has spent the last two decades in a scholarly pursuit of the impact of beauty on society. In his new book, “Beauty Pays: Why Attractive People Are More Successful” (Princeton University Press, 2011), he provides study after study that measure the influence of good looks on economic behavior and on outcomes in the workplace.

The advantages of beauty in a culture are not unique to the United States. An emphasis on human appearance goes back at least to the ancient Egyptians and is the subject of studies in Asia, Europe, and South America. Vanity rears its head in both genders and it spans multiple age groups.

In the United States 5% of consumer spending is directed towards personal appearance. Studies have shown that the average man spends 32 minutes in the morning grooming and the average woman spends 44. The time spent on grooming does not diminish as we age. Magazines are dedicated to beauty secrets and fashion tips. The average American believes that disadvantages based on looks are real, and many report having felt the victim of such discrimination.

Preference for beauty represents pursuit of an ideal. Just as Justice Stewart identified pornography as “I know it when I see it” we know beauty when we see it. Even though there is cultural variation and generational differences of opinion, studies of people’s facial image show that there is a large degree of consensus about which people are most attractive. There is substantial agreement upon what constitutes human beauty, male and female.

Within each profession you find some who are good looking and some who are not. Those seen as more beautiful are more likely to earn higher wages and more likely to get promotions. Do good looking employees raise sales? Customers are attracted to the more beautiful sales people and are more likely to buy the products they endorse. If looks are a part of a product or service than we assume that customers will value that and better looking sales people can raise revenues.

So what about the unattractive? Beauty benefits the beautiful and can increase a company’s sales and profits. But “lookism” is a form of discrimination. There is more discrimination based on looks than there is on ethnicity. Check Dr. Hammermesh’s book to see what studies measured this effect. It is a fascinating study in how to look scientifically at our prejudices and preferences.

The term cellulite means different things to different people. Cellulite refers to an uneven texture of the skin that varies from skin dimpling to lumps and bumps. Eighty-five per cent of adult women have cellulite so it is an entirely normal finding, and probably under the influence of hormones. In some women the irregular contour is barely noticeable and in others quite extreme. It is most commonly located on the legs, abdomen and buttocks. The contour irregularity worsens with aging. Cellulite can be a source of significant body dissatisfaction.

Because the degree of cellulite changes can vary so much, a classification system was proposed by Curri in 1991. There are four grades in this classification system. Grade I has no noticeable changes to the observer, but under the microscope the tissues show typical signs. Grades II-IV show progressive loss of elasticity, dimpling, waviness and bumps of the surface.

The cause of cellulite has not been clearly shown but the interaction of genetics, hormones, inflammation and weight changes are all being investigated. Connective tissue that crisscrosses through fat is largely responsible. The fat cells bulge over these restraining bands into the deep dermal layer of the skin creating nodularity.

Many therapies have been proposed for cellulite. It has shown itself to be resistant to most. The ineffective treatment modalities include lasers, massage, contact cooling, radio frequency energy, ultrasound, infra red light, suction, topical creams, oral medications and iontophoresis. The long list of unrelated therapies speaks both to the appeal to find a treatment and to the lack of understating of its cause.

Mild cases of cellulite are not worth undertaking frustrating treatment attempts. More severe cellulite may respond to skin tightening surgical procedures, such as a body lift or thigh lift. Fat transfer can help to camouflage surface irregularities. The surface therapeutic tools such as lasers and light based therapies are likely to disappoint. Additional scientific studies are necessary to draw final conclusions.

Stem cells are multi potential cells that have the capacity to develop into a variety of fully differentiated tissues and can enhance regeneration and repair. There is much excitement in the world of medical research about their therapeutic possibilities, all in experimental stages to date. In the laboratory, stem cells have been able to evolve into heart cells, neurons, skeletal muscle, pancreatic cells, bone, cartilage, and blood cells. Stem cells are present in embryos but have also been identified in bone marrow, umbilical cord blood and in fat. Stem cells from embryos have been highly controversial, but those derived from adult tissues are being explored as more acceptable. Fat tissue is an ideal source as it is plentiful and easy to harvest by liposuction, the most commonly performed procedure by plastic surgeons.

Fat grafting is now used by plastic surgeons for both cosmetic and reconstructive purposes. Harvested adipose tissue is treated and then reinjected for facial rejuvenation, lip enhancement, for contouring bodies and for restoring post traumatic defects. In the future it maybe possible to enhance the restorative properties of the transplanted fat by supplementing it with stem cells derived from the fat. These adipose derived stem cells (ADSC) have properties that include attracting new blood vessels into the area, referred to as angiogenesis. ADSC also are able to reproduce themselves, so it is hoped that they will make fat transfers more likely to thrive in their new area of transfer and more likely to last a long time.

Research is being conducted in hopes of using stem cells to regenerate whole organs. If a person’s own stem cells can be harvested and directed to grow into what is needed (say a kidney or a liver) it may be possible to get around rejection of transplanted tissues from other people. ADSC provided as a byproduct of liposuction procedures could prove to be a valuable resource rather than medical waste.

It is unknown how long it will take to advance to making new differentiated tissues, but their use in plastic surgery for enhancing the take of transplanted fat may be a new and exciting development. Plastic surgeons are watching closely to see how this medical research evolves.

If ever there was a woman who could reinvent herself at every age it would be Jane Fonda. She has just released her new autobiographical book of wit and wisdom entitled “Prime Time.” For Jane, her prime is being in the moment and that moment for her is at 70, Act III of her life. She has always strived to be her best self at every phase of life.

“Prime Time” is a look back at how Ms. Fonda recognized that she wanted different things at different decades. She came to learn that she pursued her dreams most happily when she took charge by making informed decisions. She reminds us of the adage that “luck is where opportunity meets preparation”.

As she enters her late life, Act III, she explores how much of aging is negotiable. Can we maximize our health and happiness by the choices we make.  Jane has eleven ingredients she recommends for being proactive about the quality of one’s life. She details healthy habits regarding diet and exercise.

She advocates life long learning, strong friendships, and connection to larger causes. She speaks openly about her own goal of increasing her ability to be present in her own body, to experience her body with self empathy. She talks about how plastic surgery for her was a proactive way of embracing embodiment, getting comfortable in her body. At 72, Jane had surgery on her jawline and eyes to look and feel her best for her third act. She gives the analogy that aging is a bit like martial arts. When the force comes you don’t oppose it, you just try to guide it. Jane Fonda is a gentle guide for all of us facing the force of time.

Visit this link to see an interview.