Researching surgeons

In real life, our blogger Dr. Face is the eminent Beverly Hills board-certified facial plastic surgeon Robert Kotler, M.D.  Joining the discussion is an equally eminent Beverly Hills board-certified plastic surgeon, Stuart Linder, M.D. (who blogs as Dr. Body.) Both are constant consumers of professional cosmetic plastic surgery publications and help patients – along with other American plastic surgeons  – understand the importance of new scientific findings about the rejuvenation arts.

Doctors Face and Body frequently boil down the articles for News & Views, a capsulated review of the latest and greatest from the professional press.

Here is their second such offering.

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Dr. Face: (Dr. Kotler) Have you read any interesting articles about plastic surgery work on the body, doctor?

Dr. Body: (Dr. Linder) Odd you should ask. I spotted a survey, asking 500 board certified American plastic surgeons about their current breast augmentation practices.

Dr. Face:  Do you mean practices like location of the incision, type of implant, length of the operation and so on?

Dr. Body: Exactly. Because I place hundreds and hundreds of saline and silicone breast implants yearly, I was very curious how other surgeons approach and do their work.

Dr. Face: Did you find any surprises?

Dr. Body: A few. For instance, I noticed that only 32 percent of board-certified surgeons can perform an operation in under an hour. Actually, a well trained, board-certified plastic surgeon should take no more than 30 to 40 minutes to complete the procedure. And that’s with minimal blood loss and operating with a board-certified anesthesiologist.

Dr. Face: Did all the respondents use a board-certified anesthesiologist?

Dr. Body: Actually, one-third of the survey group reported using registered nurse anesthetists. That may keep costs down somewhat but to insure patient safety, a plastic surgeon should use a board-certified anesthesiologist – who is another M.D. He or she knows precisely what to do in any emergency.

Dr. Face: A good point, doctor. In point of fact, the development of the nurse anesthetist position was in the military where it was designed to be under the direct supervision of an anesthesiologist. The concept was one M.D.-anesthesiologist could supervise a handful of nurse anesthetists during operations.

Dr. Body: I also note that 81 percent of the survey group report using 300 to 400 cc breast implants. That’s about what I use in my practice. And, also like in my breast augmentation practice, I note that while silicone is available, the surgeons report more patients choosing saline breast implants.

Dr. Face: There are four possible incisions a plastic surgeon can use in breast augmentation. Did the survey show any preference for any particular one?

Dr. Body: About 66 percent of the surgeons report starting a breast enhancement with an incision in the inframammary location, the place where the bottom of the breast meets the chest wall. About 25 percent say they use a periareolar, or around the nipple, approach. I was surprised the figures were not reversed.

Dr. Face: Why the surprise?

Dr. Body: The inframammary was the standard approach to breast enhancement during the 1970s and 80s and is considered outdated for extremely busy surgeons who perform large volume of breast enlargements. Also, the majority of the responders were from the American South and East. If more California plastic surgeons had returned the survey, I think readers would have seen more up to date responses. In my opinion, the periareolar approach allows the surgeon to work right over the breast. So, looking down,  it is much easier to line everything up for natural looking results.

Dr. Face: I’ve read that starting a breast augmentation through the areola results only in temporary nipple numbness for a few patients.

Dr. Body: That’s true. But the medical literature of breast augmentation shows that the most common long-term complications are bleeding and then infections.

Dr. Face: Where could we find the study?

Dr. Body: In the March-April, 2009, Aesthetic Surgery Journal; it’s a magazine written and read by, plastic surgeons. The title is: Primary Breast Augmentation Today: A Survey of Current Breast Augmentation Practice Patterns.

Many American plastic surgeons, like

Both are also voracious readers of those publications and do their best to help patients – and even other doctors – understand the importance of new findings.

They often summarize their readings and findings in News & Views, reviews of the latest articles from the professional press.

While many more professional news reviews will follow from time to time, here is just one.

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Dr. Face:  (Dr. Linder)Everybody is interested in identical twins. But did you know that many, many twins have been studied before and after plastic surgery? One famous study compared twins who lived a healthy lifestyle with twins who smoked, drank, spent too much time in the sun and partied unto the wee hours. Guess which twin most needed facial plastic surgery?

Dr. Body: (Dr. Kotler) Probably the “bad” twin. But do I sense something new in the works about twins and plastic surgery?

Dr. Face: Indeed you do, doctor. As you may know, surgeons have always debated which particular surgical procedure yields the best and most long-lasting results. To find out, four plastic surgeons operated on four sets of twins back in 1995. Each surgeon used his own favorite surgical method which included neither unorthodox nor experimental approaches.

Dr. Body: Good idea for a study. What did they find?

Dr. Face: Plastic surgeons followed the twin patients at professional meetings in 1996, 2001 and 2005. At the last comparison, all of the twins looked good although nobody could answer the question, “Was it the surgeon or the technique?” The twins still look like each other, even after plastic surgery.

Dr. Body: What conclusions did you draw?

Dr. Face: That experienced plastic surgeons who perform a lot of procedures, say. at least two times a week of one particular procedure, get great results, even if they are using a different procedure.

Dr. Body: Very interesting! In what publication was the study printed?

Dr. Face: Plastic and Reconstructive Surgery, Volume 123, # 3, March, 2009.

Dr. Body: The article on twins I read was in the same magazine a month later. 186 sets of identical twins filled out a lifestyle questionnaire and provided photos. A panel of experienced cosmetic plastic surgeons then analyzed everything and presented their conclusions.

Dr. Face:  What was found?

Dr. Body: Of the leading most important lifestyle factors – things like marriage, body mass, sun exposure and even hobbies – cigarette smoking was fingered as one of the most significant. Because you could compare a subject to another person who is a genetic match, it was shown that every ten years of smoking equaled a two and one-half year older appearance.

Dr. Face: Another good reason not to smoke! If one twin smoked for, say, 30 years, he or she would look seven and one-half years older than the non-smoking twin. That is significant for somebody in the late 40s or 50s.

Dr. Face: Another important finding was that sunscreen did offer some protection from sun damage. Also, the study showed that women who had hormone replacement therapy after menopause looked younger than twins who skipped that therapy.

Dr. Body: For people who want to look that study up, how can they find it?

Dr. Face:  Just ask the medical librarian for Journal of Plastic and Reconstructive Surgery, volume 123, #4, April, 2009.

Note: Dr. Body is a leading breast surgery revision specialist while Dr. Face specializes in revision rhinoplasty surgery.