Board-certified Plastic Surgeon Research Articles

The Quality of Internet Advertising in Aesthetic Surgery: An In-Depth Analysis

The aesthetic market is a growing business, as evidenced by the American Society for Aesthetic Plastic Surgery (ASAPS) reporting an increase of 147% in the number of cosmetic procedures performed by members since 1997. This market is consumer-oriented, relying heavily on advertising for survival amid the increasing provider competition. The authors evaluate trends, ethics, and efficacy of Internet advertising in aesthetic surgery. Medical cosmetic providers in Southern California and their Web sites were catalogued through sales lists from manufacturers (Medicis and Allergan) and combined with advertised providers of surgical treatments. Using the ASAPS/American Society of Aesthetic Plastic Surgeons (ASPS) and American Medical Association Codes of Ethics as guidelines, scores were assigned to each Web site and evaluated with the provider's board certification. A geographical analysis determined whether the presence of high numbers of competitors had an impact on the adherence to ethical guidelines for advertising. To examine patient preferences in physician advertising, a survey was conducted online. Board-certified plastic surgeons showed the highest total ethical scores, followed by otolaryngologists, oromaxillofacial surgeons, and ophthalmologists. No decrement in the quality of the advertising was found in densely competitive environments. A consistent correlation was found between superior compliance with ethical guidelines and board certification in plastic surgery. The patient preference survey of 208 individuals demonstrated their desire for a well-trained, board-certified plastic surgeon to perform their cosmetic procedures. Although plastic surgeons demonstrate greater overall compliance with the ASAPS/ASPS Advertising Code of Ethics, they can continue to improve. With the large variety of cosmetic physicians offering the same procedures, maintaining open, honest, and forthright communication with the public is essential.

Ethical Issues in Aesthetic Research

If I were to ask the typical board-certified plastic surgeon, “What is the essential aspect of ethical research in aesthetic surgery?” I would expect the most common answer to be “informed consent,” and most other physicans would probably agree. To an extent, that answer is correct, reflecting today’s common view of bioethics. However, there is much more to ethical research than informed consent. A noted authority on the subject, E. J. Emanuel, stated, ”While informed consent is necessary in most but not all cases, in no case is it sufficient for ethical clinical research.”1 There are other issues that must be taken into account in any clinical research, aesthetic or otherwise. There are numerous, well-known historical documents regarding conduct in clinical research, such as the Nuremberg Code, the Belmont Report, and the Declaration of Helsinki. Although none of these traditional ethical guidelines includes the seven requirements mentioned below, the fundamental protections are reflected in the basic philosophies of all of them. The following seven requirements should provide the plastic surgeon, both in academic or private practice, with a framework to guide the practice of ethical clinical research … David L. Larson, MD, Department of Plastic Surgery, 8700 Watertown Plank Road, Milwaukee, WI 53226-3575. E-mail: dlarson{at}mcw.edu

Christopher J. Salgado, M.D.

I want to thank Dr. Salgado for serving as guest editor and the exceptional group of knowledgeable and experienced authors that he and Dr. Colen as consulting editor have brought together to write on osteomyelitis for Seminars in Plastic Surgery. Dr. Salgado is a board-certified plastic surgeon who received his medical degree from Georgetown University School of Medicine in Washington, D.C., in 1995 and stayed on at Georgetown for his general surgery training. Dr. Salgado completed his plastic surgery residency at the University of Rochester in Rochester, New York, in 2000. While in the military, Dr. Salgado served as chief of plastic surgery at Darnall U.S. Army Medical Center at Ft. Hood, Texas, and assistant chief of plastic surgery at William Beaumont Army Medical Center at Ft. Bliss, Texas. It is in the military where he began his animal studies in osteomyelitis first by creating the first goat model of the disease and later evaluating varied modes of therapy to eradicate it. Subsequently, he went on for additional training in the Department of Plastic and Reconstructive Surgery at Chang-Gung Memorial Hospital in Taipei, Taiwan, and at E-Da Hospital/I-Shou University as a reconstructive microsurgery scholar. Dr. Salgado is an active researcher who has numerous publications in peer-reviewed journals and many book chapters to his credit. He is on the editorial board of the Journal of Plastic, Reconstructive and Aesthetic Surgery and is a reviewer for Seminars in Plastic Surgery and for other journals as well. Currently, Dr. Salgado's affiliation is with the Department of Plastic Surgery, University Hospitals Cleveland, Case Western Reserve University in Cleveland, Ohio, where he has established a successful academic practice with residents and rotating fellows. His clinical practice is focused on post-oncologic reconstruction, limb salvage, and complex wounds.

Geoffrey G. Hallock, M.D.

I want to thank Dr. Geoffrey Hallock for serving as guest editor and the exceptional group of knowledgeable and experienced authors that he has brought together to write on “Frontiers in Endoscopic Plastic Surgery” for Seminars in Plastic Surgery. Dr. Hallock is a board-certified plastic surgeon who is well-known nationally and internationally for his reconstructive work. He received his medical degree from Jefferson Medical College in Philadelphia and trained in general surgery at Dartmouth. Dr. Hallock completed his plastic surgery residency at the University of North Carolina and went on to complete a cosmetic surgery fellowship in Miami. Currently, he is assistant chief of the Division of Plastic Surgery for Allentown Affiliated Hospitals and clinical associate professor in the Department of Surgery at Temple University. Dr. Hallock is an active member of numerous plastic surgery societies and a prolific writer on many different plastic surgery topics, having authored more than 300 journal articles and 32 book chapters. We are honored to have him as our guest editor.

Office Surgery Safety: The Myths and Truths behind the Florida Moratoria???Six Years of Florida Data

Office-based surgery is an important method of health care delivery, and in 2000, the Florida Board of Medicine restricted office procedures. The objective of this study was to analyze the deaths resulting from office procedures in Florida. The authors reviewed all office surgical incidents that resulted in death, injury, or hospital transfer in Florida from January of 2000 to January of 2006. Various methods were used to determine board status, office accreditation, and hospital privileges. In 6 years of Florida data, a total of 46 deaths related to office procedures were reported. Twenty of those were surgical procedures that are within the scope of plastic surgery, although non-board-certified plastic surgeons performed nine. Of those 20 related to plastic surgery, 11 died before discharge. Although all 11 survived long enough to be transferred to a hospital, we classified them as office deaths. The other nine died after appropriate discharge. Of the nine, seven deaths were from thromboembolism and the others from unknown causes. Thirty-five deaths were related to non-board-certified plastic surgeons and specialists in other fields. Board-certified plastic surgeons accounted for less than one-fourth of the deaths. There were no deaths from a board-certified plastic surgeon since April of 2004. There were over 600,000 operations during the study period. The fact that 11 office deaths were reported would suggest that the location in which these procedures were performed was not as much of a factor as the regulators have suggested. The most frequent cause of death after discharge was thromboembolism.

INTRODUCTION TO GUEST EDITORS

I want to thank Drs. Eser Yuksel and C. Randall Harrell for serving as guest editors for this edition of Seminars in Plastic Surgery on the topic of “Tissue Repair, Regeneration, and Engineering in Plastic Surgery.” I thank the authors, whose contributions make a difference for patients and academia. Dr. Eser Yuksel is a national of Turkey and 1984 graduate of Hacettepe University Medical School. Dr. Yuksel completed a course of 8 years of training in the most prestigious Turkish training programs in plastic and reconstructive surgery, including advanced cosmetic and maxillofacial surgery. He established a successful practice in Europe as an extraordinarily gifted aesthetic and reconstructive surgeon. Dr. Yuksel came to Baylor College of Medicine to conduct research in emerging tissue growth technology and quickly began to expand his research activities to encompass molecular mechanisms of tissue engineering. In 1997, Dr. Yuksel was recruited and joined the Division of Plastic Surgery, Baylor College of Medicine, as an assistant professor. His research involves in vivo soft tissue engineering and alternative approaches to modulate fibrotic processes in wound healing. Since then he has received 19 grant awards (4 of them as mentor and 15 of them as principal investigator) from professional societies including National Institutes of Health developmental grants (2). He is unique in that he has the combination of skills for performing surgery and the training and fundamentals of basic science to permit him to maintain a level of clinical performance in basic research traits so desirable in an academic institution but frequently so difficult to come by. Dr. C. Randall Harrell, M.D. is a board-certified plastic surgeon trained at the Division of Plastic Surgery, Michael E. DeBakey Department of Surgery at Baylor College of Medicine, Houston, Texas. Dr. Harrell is an internationally recognized authority on the investigation of new innovative medical devices with the Food and Drug Administration clinical studies that enhance facial regeneration. He holds worldwide patents for human collagen–based biomaterials used in tissue engineering and regeneration. He is the Chairman and Medical Director of Albiorex International, a biotechnology company specializing in tissue regeneration. He is a member of the American Society of Plastic Surgery, the American Society for Aesthetic Plastic Surgery, the American Society of Laser Medicine and Surgery, and the Endocrine Society. Dr. Harrell has been a lecturer and published author of numerous journal articles on plastic surgery. Dr. Harrell was nominated for the Nobel Peace Prize in 2002 for his contribution to “Mission for Mercy” in El Salvador. Again, my thanks to Drs. Yuksel and Harrell for serving as guest editors and to all the authors who contributed to this issue.

Innovation: A Sustainable Competitive Advantage for Plastic and Reconstructive Surgery

Innovation: A Sustainable Competitive Advantage for Plastic and Reconstructive Surgery

Body contouring of the suprapubic region

Charles E. Hughes III, MD, Indianapolis, IN , is a board-certified plastic surgeon and an ASAPS member. Finesse in body sculpting is achieved not only by addressing the patient's primary area of concern but also by making proper adjustments to the surrounding anatomical regions. When abdominal lipoplasty is being performed, the lower supracostal area should be treated in a similar fashion. In abdominoplasty or abdominal lipoplasty, failure to address the mons pubis area may leave the patient with an undesirable contour. Both male and female patients can suffer from excess adipose tissue in the suprapubic area. Patients occasionally present with a prominent suprapubic area as their main concern. Often, however, it is unsuspected and hiding beneath the abdominal wall excess. In 1939, Thorek1 suggested using …

A new and better face lift incision

James L. Baker, Jr., MD, Winter Park, FL , is a board-certified plastic surgeon and an ASAPS member. Since the early 1900s, there has been little change in the design of rhytidectomy incisions. Lexer,1 in 1910, described combining a temporal incision with a separate inferior and postauricular incision for rhytidectomy. This incision helped extend the reach of the face lift operation being performed in the subcutaneous plane. In 1919, Bettman2 connected the temporal and preauricular incisions and extended them onto the mastoid and occipital areas. This procedure resembled the current standard incision for rhytidectomy (Figure 1). Attempts at making the scars around the ears inconspicuous have been described.3,4 Figure 1. Outline of the standard face lift incision. Three complications associated with the incision are alopecia, an altered hairline, and noticeable, wide scars. Solutions to these problems have been lacking. The principle change in approach has been the use of a tragal incision to better …

Microwave-assisted lipoplasty: A new treatment for body contouring

Louis P. Bucky, MD, Philadelphia, PA , is a board-certified plastic surgeon. Lipoplasty is the most popular technique for body contouring in aesthetic surgery today. Advances and innovations in lipoplasty have focused on cannula design, suction techniques, and wetting solutions. Traditional lipoplasty depended on the mechanical disruption of subcutaneous adipose tissue by means of a vacuum-assisted cannula. Advances in cannula design and, more important, the infusion of low-dose epinephrine and lidocaine anesthesia, have allowed removal of greater volumes of fat and have reduced bruising and patient discomfort. The first attempt to use ultrasonic energy to enhance liposuction was in the 1980s. In more recent years, the introduction of ultrasound-assisted lipoplasty (UAL) in this country by Zocchi1 has led to its increasing popularity. Despite careful evaluation, however, the exact mechasisms of UAL are not clearly understood. Although other mechanisms may be at work, there are 3 major tissue effects that probably play a role in UAL: thermal, mechanical, and cavitational. The relative contributions of each of these mechanisms and their side effects on the tissues are …

Beyond resurfacing: CO2 lasers for autodermal grafts

Denis F. Branson, MD, Fayetteville, NY is a board-certified plastic surgeon and an ASAPS member. Autodermal grafting is a nonresurfacing application of the CO2 laser. Autodermal grafts are either in situ or free. Free autodermal grafts can replace allografts, such as Gore-Tex (W.L. Gore, Flagstaff, AZ) and Alloderm (LifeCell Corporation, The Woodlands, TX) grafts. Like skin resurfacing, the technique described here uses the CO2 laser for char-free ablation. The difference is in the depth of ablation. Inadequate ablation may lead to posttreatment inclusion cysts. Figure 1. A , Preoperative view of a 63-year-old woman. B , Postoperative view 15 months after upper-lid blepharoplasty and free dermal graft to the lower eyelid. C , Laser-treated upper-eyelid skin. Arrows indicate laser-treated redundant eyelid skin. D , Free dermal graft is placed at lower-eyelid hollow. Deepithelialized free grafts are near-full-thickness skin grafts. Autodermal free grafts have been widely used for scar revision, treatment of traumatic tissue loss, …

Adjustable breast implants provide postoperative versatility

Hilton Becker, MD, Boca Raton, FL , is a board-certified plastic surgeon and an ASAPS member. In the late 1970s and early 1980s, breast reconstruction was popularized with the introduction of the Radovan expander (Heyer-Schulte, Goleta, CA).1 The device was initially used to expand the tissue; this was followed by an operation to remove the expander and replace it with a permanent implant. Interestingly, it was noted that several patients were reluctant to have the Radovan expander replaced because they were very pleased with the results. This observation led me to explore the concept of creating an expander in which the injection dome could be removed, the expander itself thus being left in place. This versatility would allow a tissue expander to be converted to a permanent saline implant without an additional operation.2–4 Excellent results have been achieved in breast reconstruction through use of the expandable mammary prosthesis with prolonged overexpansion of the tight muscle/skin envelope.5 The original adjustable implant was actually a saline implant with an injection dome attached to the fill tube. The injection dome was buried and subsequently removed. Although valve leakage was a problem in many early cases, the valve was successfully modified, and a doublelumen gel-saline version was created so that the 2-stage Radovan procedure, in which a saline expander and a gel implant were used, could be performed in a single-stage procedure. ### Primary Breast Reconstruction Tissue tension is the main …

Suture suspension technique offers predictable, long-lasting neck rejuvination

Vincent C. Giampapa, MD, Montclair, NJ, is a board-certified plastic surgeon. The underlying mechanisms involved in the aging neck include increased laxity in the skin, buildup of subcutaneous fat in the subdermal, submental, and preplatysmal planes, and a lack of tone and lengthening of the platysma muscle.1 Due to these factors, loss of a well-defined cervicomental angle and a decrease in the definition of the inferior mandibular border can be observed. Traditional surgical techniques focus on the redraping of the skin through preauricular incisions and the tightening or plicating of the muscle through a myriad of techniques, all which fail to achieve reliable long-term results.2–4 Key elements for long-term success with the suspension technique include proper patient selection and appropriate attention to the technical details of the procedure. The suture suspension technique is an excellent option for the patient who would like to avoid a face lift incision and whose primary signs of aging have occurred in the neck and mandibular area. It is also an excellent choice for a patient who has undergone a previous rhytidectomy with an unsatisfactory result at the level of the cervicomental angle and mandibular border. When I examine a patient with neck laxity, the first step is to check the depth of the natural cervicomental angle. This can be easily accomplished with a cotton applicator and gentle pressure. The deeper the cervicomental angle, the better suited the candidate for this procedure. A deep cervicomental angle will take up the excessive skin and muscle laxity and allow for a new neck contour with no postoperative redundancy of either of these key structures. The suture suspension technique is an excellent option for the patient who would like to avoid a face lift incision and whose primary signs of aging have occurred in …

Current techniques make hair transplantation rewarding to any aesthetic surgical practice

The recreation of a hairline is a procedure that requires both technical ability for the mechanics of hair transplantation and an artistic sense for its design. Hair transplantation is one of the most common aesthetic surgical procedures done in men, but it is less often performed by plastic surgeons than by other specialists. In my view, this procedure will serve as a rewarding adjunct to any aesthetic surgical practice. Hair transplantation requires additional trained personnel for assistance. If willing to learn the technique, 1 or 2 medical staffers, such as a registered nurse and a surgical technician, can offer immeasurable support, and the rewards of shortened surgical time are substantial. Barry E. DiBernardo, MD, Montclair, NJ , is a board-certified plastic surgeon and an ASAPS member. When patients come into my office for hair transplantation, I evaluate the density of the donor hair using a guide consisting of a 4-mm circle; within this circle, the patient should have approximately 17 donor hairs. Densities far below this number would indicate that the patient is not a good candidate for hair transplantation. Placement and number of hair grafts are then determined. Hairline designs have improved over the years. When I first began performing hair transplantation, larger grafts were used; these gave a grafted or “pluggy” look to the hairline. The evolution of this procedure has created smaller grafts, to the point where single hairs or even follicles are …

Cosmetic blepharoplasty in Orientals

Francis Charles Sheng, MD, Beverly Hills, CA , is a board-certified plastic surgeon. Surgery of the upper eyelid in Orientals is radically different from that in Caucasians inasmuch as their anatomy and aesthetic ideals are fundamentally different. The term Oriental blepharoplasty refers to the creation of a palpebral fold by supratarsal fixation in young patients who have no visible fold; it also forms an essential part of upper-eyelid surgery performed for senile skin laxity, when the visibility of the palpebral fold must be re-established. An estimated 30% to 60% of all Orientals are born with a visible palpebral fold (double eyelid).1–4 Because the supraorbital ridge is more recessed in Orientals5,6 and the whole orbital cavity is smaller, the upper-lid fold achieves a more anterior and visible position. The desire for a double-eyelid fold is unrelated to any wish to appear more Caucasian. Double eyelid surgery is performed to enhance the Oriental eye rather than to westernize it. The height of the fold from the lash line with the eyes closed is 8 to 12 mm in Caucasians versus 6 to 7 mm in Orientals. The ideal visible height of the fold is 1 to 3 mm with the eyes open at level gaze7 (Figure 1). Figure 1 A , Preoperative view of a 19-year-old Oriental woman with single eyelids. B , Postoperative view 6 months after the creation of double eyelids. The lower placement of the palpebral fold in Orientals is attributed to lower insertion of the dermal slips of the levator palpebrae muscle, which forms the palpebral …

Simultaneous Laser Resurfacing with Face Lift: A Safe Alternative for Facial Rejuvenation

Bruce Achauer, MD, Orange, CA , is a board-certified plastic surgeon and an ASAPS member. The practice of simultaneous face lift and chemical peeling has been criticized for many years in plastic surgery literature. Because gentle treatment of a flap is essential to its survival, creating the flap and then traumatizing the surface is counterintuitive. Reports of skin loss, delayed healing, and scarring associated with simultaneous laser resurfacing and face lift have deterred many plastic surgeons from this combination of procedures. However, I have performed simultaneous skin resurfacing with face lift in more than 50 patients over the last 3 years without any such major complications. The aging process typically causes loose …

Managing Narcogenic Obstructed Respiration in the Aesthetic Surgery Patient

Robert N. Cooper, MD, Stuart, FL, and New York, NY , is a board-certified plastic surgeon and ASAPS member. James Noble, MD, Stuart, FL , is a board-certified anesthesiologist. The purpose of this article is to offer a new definition of a frequently observed phenomenon known as the syndrome of narcogenic obstructed respiration (SNOR), which is defined as a narcotic-induced relaxation of muscles in proximity to the airway, leading to obstructive apnea. A study was undertaken to ascertain the safety of adapting continuous positive airway pressure (CPAP) to treat SNOR. While providing adequate sedation, analgesia, and amnesia to complement the administration of local anesthesia during facial aesthetic surgery, the technique offers solutions to several well-documented anesthesia-related risks. This newly defined syndrome, SNOR, …

Simultaneous Laser Resurfacing with Face Lift: The Voice of Polite Concern

Jack A. Friedland, MD, Phoenix, AZ , is a board-certified plastic surgeon and an ASAPS member. The following morphologic changes are associated with the aging process: diminished thickness and elasticity of skin, gradual absorption of subcutaneous tissue, decreased adherence of skin to underlying layers, gravitational descent of soft tissues, and formation of skin folds along lines of skin adherence where the muscles of facial expression insert. Neither a face lift nor facial laser resurfacing alone can correct them all. The concomitant performance of both of these procedures provides the advantages, for both the patient and the doctor, of saving time and offering complete treatment; however, these benefits do not outweigh the increase in risk. Both …

Cellasene: Hype or Help for Cellulite?

Brian M. Kinney, MD, Los Angeles, CA , is a board-certified plastic surgeon and an ASAPS member. Since the Dietary Supplement Health and Education Act of the United States Congress in 1994 loosened the oversight of alternative health products, literally thousands of over-the-counter dietary supplements and herbal preparations have been introduced in the United States. As long as such a product is not marketed as a drug or cure for a disease or condition, and as long as it does not pose an unreasonable risk to consumers, the US Food and Drug Administration (FDA) is not allowed to regulate it. Promotions, marketing campaigns, and testimonials may be promulgated in an unrestricted manner. Medestea Internazional of Italy manufactures Cellasene, one of the newer dietary supplements. Studied for the last 5 years and touted as a treatment for cellulite, it was introduced into the US market in March 1999 by Rexall Sundown Corporation of Boca Raton, FL, with a $6 million marketing campaign. Already, interest in the product has spawned competitive preparations such as Celluthin and Cellustop (General Health Products, Auckland, New Zealand). The ingredients of Cellasene are as follows: (1) dried ginkgo biloba extract, which is reputed to assist in blood circulation and stimulate the metabolism of fats; (2) dried sweet clover extract, which is claimed to increase blood circulation and assist in the removal of fluid build-up; (3) grape seed bioflavonoids, thought by many to be powerful antioxidants that protect cells and …

Conventional Saline Breast Implants Provide Time-tested Reliability

Edward S. Truppman, MD, Aventura, FL , is a board-certified plastic surgeon and an ASAPS member. Saline breast implants have been a part of the plastic surgery armamentarium since 1968. In 1992, the United States Food and Drug Administration placed restrictions on the use of gel implants. Since then, saline breast implants have been the mainstay of cosmetic and reconstructive breast surgery. Recent reintroduction of gel implants for primary breast augmentation under a limited-enrollment outcome study is the only exception. Today, most saline breast implants use …