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.

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

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.”

Seattle had a beautiful summer this year that stretched out through most of September. It was easy to stay inspired for outdoor sports. As the leaves are turning and daylight is shorter don’t let weather hold you back from training. Here are a few suggestions:

1. Train with friends. Having a buddy helps to keep you accountable. It is too easy to let yourself off the hook when you are tired, and besides you can accomplish your social goals at the same time as your fitness goals. Consider it multi-tasking.
2. Work on your core. The stronger your trunk muscles are, the better your balance and stability.  It enhances any other sporting activity. Yoga and Pilates classes are popular ways to strengthen your abdomen and back.
3. Increase aerobic endurance. Thirty minutes three times a week is an important baseline for aerobic fitness. Make that 30 minutes increasingly difficult to improve stamina after your routine becomes habit.
4. Return to the gym. Spinning classes, swimming pools and treadmills are easier to use when there are others around. The energy from other people is contagious. Sports equipment at home is a great idea, but it seems to collect dust before it ends up in garage sales.

What ever you do, be adventurous, creative and open-minded. Staying fit is good for your mood, good for your brain, good for generating energy, and good for your health. Don’t let it lapse when it is unseasonable!

During the 2008 presidential campaign period Michelle Obama reintroduced the sleeveless sheath dress (a la Jackie Kennedy) as a new fashion statement. So the cut of the upper arm became important for style. This worked well with her “let’s move” campaign for diet and exercise.

So how does one get Michelle Obama arms?

Well, upper body workouts are a good start. Women are not as likely to develop their arm muscles as men, but it is an important part of feeling good, staying strong, and looking fit.  

However, lots of women may have good muscle tone with other factors the interfere with the shape of their upper arms.

Some carry fat selectively in their upper arms. This is common for an overly enthusiastic fat collection in the triceps region, leaving a hanging weight of extra tissue. LIPOSUCTION can be a valuable way to contour the upper arms with minimal scarring. Its success is somewhat dependent on the elasticity of the skin. The best results occur when the skin retracts to its former shape after the fat is removed. This may take three to six months to occur.

If you have too much skin, or skin that has been irreversibly stretched out, the extra skin needs to be removed with an ARM LIFT. There is a large array of variations on an arm lift (known as a BRACHIOPLASTY). A minimal scar armlift can confine the scar to the armpit. If there is more excess skin the scar may need to extend down the inner arm or over the triceps region to achieve a better contour. As in most areas of plastic surgery, the choice needs to be individualized for the best outcome.  

If your upper arm is one that you hate to show in sleeveless dresses, a consultation may help define a good solution for you.

“Research finds that cosmetic surgery patients do not differ from nonpatients in body satisfaction, except that they are more likely to express dissatisfaction with the specific body region targeted for surgery.”

MSNBC conducted an online study of 50,000 volunteers to research how satisfaction with body image correlated with interest in plastic surgery. A 27 point questionnaire posed questions like:

*How comfortable are you in a bathing suit?

*Do you like your face?

*How many times a day do you check yourself in the mirror?

*Are you self conscious about your weight?

The respondents were heterosexual men and women between 18-65 years of age There were equally divided between men and women. The large sample size allowed for statistical significance. 71% of women and 40% of men expressed interest in cosmetic surgery. Here are some of the interesting findings of this large scale survey.

1. Body image satisfaction was gauged by self rated attractiveness and comfort in a swimsuit.  There was no difference between those women interested in plastic surgery and those not interested. 
2. Men interested in plastic surgery were not any different in body image satisfaction than those with no interest. 
3. Appearance investment was gauged by self reported mirror checking. Both men and women that monitored their appearance in the mirror frequently showed more interest in plastic surgery.
4. Relationship status did not correlate to interest in plastic surgery. Those who were married, co-habitating, or dating seriously were no more interested in cosmetic surgery than singles.
5. The study subjects were divided into five age groups. The percentage of men and women interested in plastic surgery was relatively constant across the entire spectrum.

The study suggests that plastic surgery has become a widely accepted form of enhancing physical attractiveness, and that those interested in this type of body change have much in common with those with no interest.

Sixty percent of Americans choose homeopathic drugs, food supplements, or herbal products as an alternative to traditional medications to enhance their health. These products are pharmacologically active and naturally occurring plant extracts. Because their source is “natural” and they are sold without a prescription, they have increased in popularity for those seeking a wholesome life style. Despite their natural source, supplements can contribute to prolonged and excessive bleeding at surgery. Here is a list of some of the commonly used complementary/alternative medical products that can be harmful when combined with surgery. The following should be tapered and then discontinued two to three weeks before surgery.

BAICAL SKULLCAP (Chinese Skullcap)- This herb has been used by the Chinese for irritability and dysentery. It interferes with coagulation and can cause bleeding.

BROMELIN. This extract of pineapple is used to treat arthritis. It interferes with platelet function and can cause bleeding.

CHINESE AGRIMONY- This remedy is used for cough and colds, pain relief, and infections. It markedly increases the risk of bleeding.

CHINESE PEONY- Used for gastric upset, this flowering plant interferes with coagulation.

FEVERFEW- Used to reduce fever, treat arthritis and prevent migraines, feverfew can result in withdrawal symptoms as it is discontinued.

FRITILLARIA- This bulb is cooked and eaten to treat hypertension, lung problems and opium toxicity. DAN S HEN- This Chinese product is used for stroke, angina, arthritis, insomnia, and menstrual disorders. It has a powerful antiplatelet effect that leads to bleeding.

DEVIL’S CLAW- Used for centuries in South America for pain, fever, and digestion, Devil’s Claw interferes with normal coagulation.

GARLIC- Garlic has been used as a medicine for centuries. It has been advocated for high blood pressure, fungal infections, heart attack and cancer. There is good evidence of garlic in high doses resulting in bleeding, nausea and vomiting as well as low blood sugar.

GINGER- Ginger is for gastric, distress, migraines and headaches. It is known to interfere with platelet function.

GINSENG- Conditions treated with ginger include colic, infections, aging, and stress. It can increase bleeding, and have side effects of nausea, headaches, and blood pressure changes.

GINKO- Used to treat Alzheimer’s and other memory disorders, ginkgo has been associated with excess perioperative bleeding.

LICORICE- Used for peptic ulcers, cancer, and adrenal insufficiency, licorice can increase bleeding, result in hypertension and lower potassium levels.

CAPSAICIN (red chili pepper)- Capsaicin has been recommended for pain relief, itching and psoriasis. It interferes with platelet function.

SAW PALMETTO- this is a treatment for an enlarged prostate and urinary tract infections. It interferes with normal coagulation.

OIL of WINTERGREEN- Prescribed for inflammation, joint pain, and hypertension, this food flavoring agent has been associated with prolonged surgical bleeding. GEUM JAPONICUM- This diuretic can cause prolongation of clotting time.

JAPANESE HONEYSUCKLE- Homeopathic remedy for fever, ore throat, headache, and infection, Japanese honeysuckle interferes with platelet function.

DAN SHEN- Conditions treated with dan shen include atherosclerosis, insomnia, menstrual disorders, HIV, stroke, angina, and prostatitis. It blocks platelet function and can lead to prolonged bleeding.

VITAMIN E- Popular as an anti-cancer anti-oxidant there is increase in bleeding risk with high does.

FISH OIL- Fish oils are popular for their anti-cardiovascular disease benefits. It is also used to treat dry eyes. Prolonged bleeding times occur and is dependent on the dose.

ARNICA MONTANA- Used in Europe to treat arthritis and muscle aches, it has been popular to reduce postoperative bleeding and swelling. It is associated with bleeding as it interferes with platelets.

CHONDROITAN and GLUCOSAMINE – These two are often taken together to enhance cartilage repair. They increase bleeding potential. Supplements and old-fashioned remedies are not generally thought of as medicines and thus many do not mention them to their doctors. These substances may have been in use for centuries, but they can have harmful effects at the time of surgery. They are classified as a food rather than a drug, so they escape FDA regulation. This can make them variable in quality or dosage.

Make sure your surgeon knows what non-prescription items you are taking so as to avoid any unsafe interactions at the time of your procedure.

Who remembers Marcus Welby? If you do not, you may have escaped the era of paternalistic medicine where the benevolent doctor made all medical decisions on your behalf presuming he understood your goals and desires. The benevolent part of that picture matters a lot, but the “Father knows best” model shows a potential lack of understanding. Patients need to be able to express to their doctors what outcomes are most important to them. You need to know that your doctor (plastic surgeon) has respect for your values, preferences, and expressed needs.

In the information age, doctor patient relationships have changed a lot. People are hungry for health information. iphones have dozens of apps related to healthcare and fitness. Most people consult the internet to explore a health concern many times before they consult their doctor. Most will self diagnose or make medical choices based on their reading and then select a doctor that conforms to that choice. The doctor’s opinion becomes optional in the search for autonomy in making critical decisions.

There is good and bad in that method, yin and yang. People are becoming more informed about the important decisions in their life and becoming proactive about their health. But often it is difficult to put all this information to good use. Healthcare webpages, advocacy sites, and chat rooms all provide both incorrect and correct information. It is hard for the reader to distinguish evidence-based advice from marketing hype. It is difficult to navigate between the extreme and the reasonable. It is harder still to figure out how that information applies to you, and what makes your circumstances unique. 

That is where the doctor comes into the shared decision making process. Having used the internet to check the lay of the land, it is important for you to seek the guidance that only medical training and experience can provide. Ask your doctor how this information you have gathered can be put into perspective in your circumstances. Important decisions are best made in a partnered fashion. Come to the table informed, but keep an open mind about how to apply the information.