Wednesday, December 29, 2010


The term addiction has become applicable to numerous habits and vices these days. Sex addiction, Internet addiction, plastic surgery addiction. But how can you define addiction when applied to a behavior that in moderation is acceptable, even encouraged? As Marcel Daniels, MD, a Long Beach, Calif-based board-certified plastic surgeon, says, “Calling any repetitive behavior an ‘addiction’ has become fashionable. Notice how we suddenly have all these sexual addicts when previously it was merely felt to be an expression of Darwinian behavior.” Sex, as opposed to, say, heroin, is a normal, healthy practice—in fact, if you’re not having sex, people tend to think there’s something amok. So, when is someone addicted to sex? The same goes for the Internet. The only people not spending many, many hours on the Internet in our society are considered backwards. How much is too much?

This question is particularly apropos when considering plastic surgery. Daniels says, “The subject of addiction in and of itself and with regards to plastic surgery is controversial.”
With celebrities like Heidi Montag, Joan Rivers, Cher, and Jocelyn Wildenstein making headlines by eliminating fine lines and wrinkles (and maybe getting a breast augmentation, some lipo…and some other nips and tucks), it’s easy to believe that Botox and boob jobs have some seriously addictive properties. After all, why else would an already attractive person like Montag go through so much to change herself into some kind of distorted Barbie? Then again, what if Heidi were totally happy with her new self? Would the media and her family be so quick to condemn her surgical alterations if she herself weren’t so clearly dissatisfied? Can you classify a habit as an addiction if it genuinely results in self-improvement? Take, for instance, someone like Cher. She’s had some plastic surgery, which nobody can deny. But, she still looks pretty darn good for her age, and nobody’s really calling her an addict. Maybe part of what makes Montag "an addict" is that she’s young and she had so many procedures in such a short time. But why does age have an impact on addiction? And for that matter, why does someone who crams all their doses into one day have any more of a problem that somebody who has the same amount of surgery over a span of years? Shervin Naderi, MD, a Washington, DC-area facial plastic surgeon, suggests, “There is no ‘number’ that signifies a threshold for becoming addicted to plastic surgery. A person who has never had a single procedure but constantly obsesses about his or her face and is constantly on chat rooms and spends an excessive amount of daily time thinking about his or her face is more concerning than the person who has had four successful cosmetic surgeries with nice and natural results.”

With this in mind, it would seem that the psychological concerns associated with plastic surgery are not so much its potential addictiveness, but rather insecurities with body image that go far below the surface. Excessive amounts of plastic surgery might just be a manifestation of a mental disease such as Body Dysmorphic Disorder. In this case, it seems that the procedures themselves have no addictive quality. (by Chelsea Mize).

Sunday, December 19, 2010


Forget "Bridalplasty." The real money is in "surgical vengeance."

The reality show in which women compete for pre-wedding cosmetic surgery may be getting all the attention, but doctors who ply their trade sculpting bodies and faces know that just as many - if not more - of the patients walking through their doors are motivated not by a new union but a marital breakup.

"There are a lot of women who come in either pre- or post-divorce who are looking to make themselves feel a little bit better," says Michael D. Cohen, medical director of the Cosmetic Surgery Center of Maryland. The whole story might not come out at the beginning, he says, but once he gets to know a patient, he often starts to hear details of a split.

Two weeks ago he did a tummy tuck and eyelid lift on a woman just out of an 37-year marriage, followed by breast augmentation for a woman in her 20s who found out her husband had cheated on her. "She suggested to the people preparing her for surgery that it was sort of payback," he said.

Hence the nickname the procedures have gained: "vengeance plastic surgery." And it's not just women; it is estimated that 30 percent of the patients are men.  
(Washington Post; 12-12-10)

Saturday, December 4, 2010


■Teenagers seek plastic surgery to fit in, experts say

Teenagers between 13 and 19 years old underwent some 210,000 cosmetic and plastic surgery procedures in 2009, according to the American Society of Plastic Surgeons. Many received rhinoplasty to reshape their noses, while others sought breast enlargement or other procedures in an effort to improve low self-esteem and help them fit in more with their peers, experts said. ABC News/Nightline (11/24


■Stem cell-based spray holds promise for healing wounds

Physicians at the University of Utah have combined thrombin and calcium with platelets and progenitor cells derived from patients to develop a topical spray designed to heal wounds and burns. The treatment, which takes about 15 minutes to apply, is being tested by university researchers in patients with burns and chronic wounds. The Deseret News (Salt Lake City) (11/26)


■Poll: Emergency departments lack enough on-call specialists

More than 75% of emergency departments do not have enough specialists on call for plastic surgery, hand surgery and neurosurgery, a poll found. "Without adequate on-call surgical coverage, our health care system cannot provide for emergency and trauma patients," the study's lead author said. HealthDay News (11/29)

Thursday, December 2, 2010


Beliefs & Attitudes Influence Cancer Outcomes

Cancer is a very threatening disease. The outcome can be a cure, a temporary remission or death. Neither one is really predictable. We see disseminated cancers go into prolonged remissions and apparently more benign ones taking a disappointing course. What has puzzled doctors for a long time is this: why do we often see two similar patients with the same degree of disease and receiving the same treatment, experience totally different outcomes? One will die within a short time while the other will live for years or decades.

This question troubled a radiation oncologist in the early 1970's. His mane was Dr. Carl Simonton, MD. He did his research at the University of Texas and came to realize a few things. Patients who had a strong will and a strong motivation to live usually outlived the ones who were discouraged and hopeless. I recommend you read his book: "Getting Well Again" for the whole story.

Based on this observation, Dr. Simonton designed an intervention program focused on changing the emotional attitudes of patients from hopelessness and depression to hopefulness and a heightened passion for living. The patients who did this work and modified their beliefs and attitudes lived twice as long as those who did not. This was the beginning of a revolution in cancer treatment.

Saturday, November 13, 2010


■Survey: Mastectomy patients prefer silicone implants over saline

Women are more satisfied with the look and feel of silicone implants, rather than saline implants, for breast reconstruction after breast cancer surgery, a survey of 472 breast cancer patients found. "Women tell me [silicone] feels more natural and they prefer the look," said the survey's leader, Dr. Colleen McCarthy, a reconstructive surgeon New York's Memorial Sloan-Kettering Cancer Center. However, many women will choose saline implants regardless, McCarthy said, because of perceived risks with silicone. The New York Times

Wednesday, October 20, 2010


■25-year-old burn victim is added to the face transplant wait list

A 25-year-old man from Fort Worth, Texas, who lost his nose, lips and much of the skin in a 2008 electrical accident, has been added to the waiting list for a face transplant at Brigham and Women's Hospital in Boston. The Department of Defense will cover most of the cost for the surgery as part of an effort to eventually help soldiers with severe injuries to the face. The Boston Globe/The Associated Press (10/12)

Friday, September 17, 2010


The Administration Spent $20 Million of Taxpayer Money to Mislead American Seniors on the New Health Care Reform Law

Earlier this month, the Government Accountability Office (GAO) (an independent and nonpartisan investigative arm of Congress) issued a report finding that the Administration’s Medicare mailer, which cost American taxpayers almost $20 million, inaccurately claimed that the new health care law would not negatively impact seniors’ benefits. Specifically, the GAO found that "[T]he brochure overstates some of [health care reforms’] benefits” (emphasis added).

For example, the mailer promises seniors that the new health care reform “will provide you and your family greater savings and increased quality health care.”

Instead, the GAO found:

•“In our view, the brochure presents a picture of [the new reform law] that is not universally shared. For example, two government analyses have determined that [the health care reform law] reductions in funding for Medicare Advantage may decrease enrollment and result in less generous benefit packages,” and “…significant increases in premiums for some beneficiaries may be necessary” [emphasis added].

The GAO found other, similar promises equally questionable:

•“The brochure does not provide beneficiaries with a comprehensive summary of changes to Medicare that will be implemented as a result of [the health care reform], and in several instances it provides abbreviated information that leaves out details about [the health care reform].” [emphasis added]

•“We noticed, also, that the brochure overstates some of [the reform law’s] benefits. For example, it states [it] "increases the number of primary care doctors, nurses, and physician assistants," when [the health care reform law], in fact, only provides incentives for such increases.”

WHAT YOU SHOULD KNOW: After having spent nearly $20 million of your tax dollars on this mailing, seniors continue to view the law negatively, and I couldn't agree more. The administration’s assertions fly in the face of the analysis done by the nonpartisan Congressional Budget Office and the Medicare Actuaries which have both documented that the law will cut Medicare by over one-half trillion dollars, cause millions of Americans to lose the plan they have and like, jeopardize seniors’ access to health care and increase the shortage of physicians.

THE DOCTOR'S DIAGNOSIS: American seniors have been asked to pay for a huge chunk of Obamacare. From raiding the social security trust fund to cutting Medicare by one-half trillion dollars, this administration and the liberal majority in Congress have done little to protect seniors or our economy. It’s time for new leadership in Washington.
(9-17-10: John Fleming, M.D., member of Congress)

Wednesday, September 1, 2010

Health Care Update

Health Care Reform is Paid for by Cuts to Medicare
The enormous health care bill signed into law will be largely paid for by cuts to services many seniors depend on. Here is just a sampling of the Medicare cuts, totaling more than $500 billion, to come:

In 2010:
•Medicare will cut reimbursements to inpatient psychiatric hospitals.

In 2011:
•Medicare cuts to home health agencies begin.
•Wealthier seniors ($85K/$170K) begin paying higher Part D premiums.
  Medicare cuts begin to ambulance services, ambulatory surgery
  centers, diagnostic labs,  and durable medical equipment.
•Seniors are prohibited from purchasing power wheelchairs unless they
  first rent for 13 months.
•New Medicare cuts to long term care hospitals begin.
•New Medicare cuts to hospitals and cuts to nursing homes begin (FY12)
•Medicare Advantage cuts begin. Participating seniors will face premium
 increases, benefit cuts, or both.

In 2012:
•Medicare reimbursements for dialysis treatments are cut.
•Medicare cuts to hospice begin.

In 2013:
•Medicare reimbursements to hospitals that serve low-income seniors
  will be cut.

WHAT THIS MEANS FOR YOU: When providers get paid less by Medicare for services seniors depend on, many may be forced to decrease their services or close some of their locations just to make ends meet. This means that seniors may experience a decrease in their access to essential care, which is already a problem for many in rural districts. The cuts to Medicare Advantage may cause many of these insurance providers to stop offering plans to seniors, forcing seniors back into traditional Medicare.

THE DOCTOR'S DIAGNOSIS: Seniors should not have to bear the cost of health care reform. Instead, we need common-sense health reform that will lead to quality, affordable health care, without breaking the bank, or cutting services to seniors.
(John Fleming, M.D., Member of Congress)

Friday, August 27, 2010


■Scientists develop coating that can eliminate MRSA

Scientists have created a coating that works against methicillin-resistant Staphyloccus aureus. The coating contains the enzyme lysostaphin, which is harmful to bacterial cells but not to human cells. During tests, the coating killed 100% of MRSA bacteria that came in contact with it within 20 minutes, the researchers said. WebMD (8/17)

Saturday, August 14, 2010


■Fla. board fines doctor for allowing unlicensed staffers to perform lipo

The Florida Board of Medicine levied a $50,000 fine and temporarily suspended the license of Dr. Yves N. Jean-Baptiste, who is accused of allowing unlicensed assistants to perform liposuction on a patient. The doctor is board certified in family medicine but not in plastic surgery. The medical board, as well as plastic surgeons and dermatologists, has expressed concern about physicians performing cosmetic procedures for which they have received little training. St. Petersburg Times (Fla.) (8/9)


■Study: Surgeries don't improve body image for most BDD patients

Some people who seek numerous cosmetic surgeries have a psychological condition called body dysmorphic disorder, according to multiple studies. Surgical and nonsurgical procedures do little to improve the mental condition of most patients, the results of one study of 200 people diagnosed with the disorder showed. The researchers advise surgeons "to be aware that psychiatric treatments for BDD such as serotonin reuptake inhibitors and cognitive behavioral therapy appear to be effective for what can be a debilitating disorder." Los Angeles Times (8/11)

Sunday, August 1, 2010


■Patient death prompts manhunt for L.A.-area cosmetic filler providers

Police are searching for two sisters who are believed to have operated a cosmetic filler business in Sylmar, Calif., that is linked to the July 23 death of a 22-year-old woman who received silicone injections in her buttocks. The sisters, Guadalupe and Alejandra Viveros, were arrested in June on charges of practicing medicine without a license and later were released on bail. Police also are searching for other patients of the practice whose dermal injections reportedly hardened into solid plastic, causing infection. KTLA-TV (Los Angeles) (7/28)

Saturday, July 24, 2010


■N.Z. firm prepares for large-scale production of skin substitute

A New Zealand veterinarian has developed a human tissue substitute for patients with burns and other severe skin damage. Mesynthes CEO Brian Ward derives the material from sheep tissue that has had immunological components removed. The result is a strong, well-tolerated material that promotes blood-vessel growth. Stuff (New Zealand)/Business Day (7/19)

Wednesday, July 14, 2010


■Scientists develop synthetic skin in laboratory using cell line

In an effort to find a treatment for severe burns and chronic skin wounds, a team of researchers at the University of Wisconsin, Madison, is working with a cell line that it hopes is capable of developing into natural human skin. A study showed that the skin proved to be safe and effective in treating 15 patients with severe burns for a week. They plan to conduct a Phase II trial in the coming months to test whether the laboratory-derived skin is effective for long-term use, the lead researcher said. The Wall Street Journal (7/6)


■French surgeon performs full face transplant

Dr. Laurent Lantieri, a surgeon at Henri-Mondor hospital in Creteil, France, performed a full face transplant on a 35-year-old man with neurofibromatosis. "The most difficult part of the operation was to connect the tear duct that goes through the bone," Lantieri said. The procedure could eventually be used to help burn victims.

Facial transplantation for severe deformities of the face related to accidents and injuries, burns, dog bites, cancer and congenital deformities will become more common in the future.  The first partial facial transplant in the U.S. was performed at the Cleveland Clinic.  Micro-vascular surgery and immune modulation have advanced to a high level, which makes these procedures more feasible. This is an exciting new field in plastic and reconstructive surgery, but there are still many ethical issues to address in these cases.

Tuesday, May 25, 2010


As a supporter of House Resolution 615 (Congressman John Fleming), a resolution calling on Members of Congress to enroll in the public Health Care plan, I have another important update.

The non-partisan Congressional Budget Office (CBO) recently released a report confirming that spending under the recently passed health care legislation would be double what it had originally estimated.

Saturday, May 15, 2010


Bariatrics is a speciality in medicine that treats obesity.  Bariatric surgery is the term used for operations to help promote weight loss.  There is an epidemic of obesity in the United States and around the world.  Physical Education is rarely taught in school, and the abundance of fast food has contributed to an unhealthy lifestyle & poor eating habits.
Obesity has resulted in multiple medical problems such as heart disease, diabetes and hypertension.  Any surgical procedure has higher complication rates in patients that are obese.  When a person's weight increases to an extreme level, it is termed morbid obesity.

Bariatric surgery is beneficial in patients with morbid obesity (over 100 pounds overweight or a body mass index of greater than 40). It is always better to try to loose the weight with diet, exercise and lifestyle changes, but when these things are unsuccessful, surgery is an option.  The body mass index (BMI) is a standard way to classify obesity.  The BMI is calcuated based on a person's weight in kilograms (2.2 pounds equals one kilogram) divided by the square of the height in meters (39.37 inches equals one meter).
For instance, if you weigh 180 pounds and are 6 feet tall, your BMI would be calculated as follows:
Weight (180 pounds equals 81.8 kg)
divided by Height (72 inches equals 1.83 meters) squared

81.8 kg
divided by 3.35 meters        
equals a BMI of 24.4.

Overweight:      BMI of 25 or more
Obesity:            BMI of 30 or more
Morbid Obesity: BMI of 40 or more

Bariatric surgery is major surgery and has risks and long-term consequences.  With newer laparoscopic techniques (surgery performed through lighted scopes with smaller incisions), the surgery has become less invasive, although not every patient may be a candidate for laproscopic bariatric surgery. There are various types of Bariatric Surgery.  In Gastric Bypass (Roux-en-Y Gastric Bypass), the stomach size is permanently reduced to an "egg-sized" pouch. The pouch is reattached to a segment of intestine that bypasses the stomach.  In the Gastric Sleeve Resection, a portion of the stomach is removed, turning the stomach into a narrow tube. In the Adjustable Gastric Banding Procedure, the size of the opening from the esophagus leading into the stomach is reduced by an adjustable band that can be controlled via a port placed under the skin.  By inflating or deflating the band through this port, the band can be adjusted to make the opening larger or smaller.  The band can be removed at any time making this a reversal procedure.

Before considering this surgery, do your research and select a board certified surgeon with special training in this procedure.  Make sure he has had significant experience with all techniques. The hospital should be one that is committed to this type of surgery on a regular basis.

After the weight has stabilized (usually about a year), attention can then be turned to the excess skin in various areas of the body.  I will hold that discussion for another day!

Monday, May 3, 2010


Now that much of the rhetoric has calmed down, let's take a look at the new health care reform bill that is now law. It will probably take many years to analyze the scope of this bill, and even longer to determine the effects, both positive and negative.  The 2,700 page law contains a variety of mandates, directives, price controls and tax increases and subsidies. As with many things in life, there are some good things included in this bill, some things that should have been included that are not, and certainly things that will be determential to the health care of our patients.

Over the next decade, 32 million uninsured Americans will be able to obtain health coverage, mainly through an expanded Medicaid program and state health insurance exchanges. 11 Billion Dollars will go to community health care centers to care for this expanded Medicaid population. It is estimated that 23 million will remain uninsured, mainly through their own choice.  Starting in 2014, penalities will be assessed for individuals that do not obtain adequate coverage, $95.00 per year or 1% of taxable income. This will go up to $695.00 per year or 2.5% or taxable income in 2016.  Business owners with more than 50 employees must buy government-acceptable health coverage or pay a yearly penalty of $2000 per employee.  According to estimates from the Congressional Budget Office, 8-9 million people will loose their employer-provided coverage. It is predicted that these employees will be forced to accept a lower quality of care through government controlled insurance, instead of employer sponsored private insurance.

There will be an elimination of pre-existing conditions and a lifting of the life-time cap on coverage.

Dependent children will be able to stay on their parents policies to the age of 26.

There will be added funding for research into problems such as hospital infections, re-admissions, and intensive care.

The bill prohibits federal funding of abortion except in cases of rape, incest or when the woman's life is in danger.  It will provide about $25 Million over 5 years in state grants to extend the abstinence-only sex education program.

The bill has no liability reforms which would help reduce the high cost of medical care related to defensive medicine.

It imposes arbitary treatment standards to reduce the cost of care without improving the quality of care.  Some of the cost reduction will be on the backs of hospitals and physicians with penalities assessed for certain "preventible" medical conditions that we have no control over.

There will be an increase in government intrusion into the patient-doctor relationship.  There will be an independent payment advisory board which could result in mis-guided decisions on care and payment cuts which will undermine access to care.

One aspect calls for 16,500 IRS employees for enforcement purposes. These IRS agents can confiscate tax refunds, place liens on property and seek jail time if health related penalties and taxes are not paid. The law includes about 19 new taxes.  A few examples of the new taxes. This bill imposes a 3.8 % annual tax on investment income on individuals making $200,000 or more and on families making $250,000 or more.  This new tax is not indexed to inflation, which means more people each year will fall under this tax burden. Starting in 2018, a 40% annual tax will be placed on health care plans valued at $10,200 for individuals and $27,500 for families.  These health savings accounts were ennacted several years ago to encouraged saving, but with this new tax burden, many individuals will have to buy new policies or face this outrageous 40% tax.  Even some medicare receiptants will be hit by a new tax.  Medicare patients in the higher income bracket ($200,000 per year for an individual; $250,000 per year for a couple) will pay an additional 0.9% Medicare Tax.
There will be a new 3.8 % tax on home sales and other real estate transactions.  If you sell your $200,000 house, you will pay $7600.00 in new taxes.  There will be a new 2.9% tax on medical aid devices and a 10% tax on services at tanning salons.

The bill will reduce federal funding for care of the indigent and uninsured  patients at public hospitals by 14.1 Billion dollars or 40% by 2019.  This will negatively impact the training of medical doctors.

There will be a continued limit to access  care because nothing was addressed in the bill to fix the flawed Medicare Payment Formula.

Despite the "good, the bad and the ugly" of this new bill, as always, my goal is to provide the best medical and surgical care to my patients while abiding by state and federal laws.

Saturday, April 10, 2010


■Stem cells from fat might hold promise for reconstructive therapies

Much research is being done to determine the viability of using stem cells from a patient's own fat to regenerate injured bone or cancer-damaged breast tissue. Some cosmetic surgeons claim to already be using fat stem cells to reduce wrinkles, but the machine used to make the stem cell-enriched fat is approved only for research purposes. "It's unlikely that these cells will cause harm [and] there are really great applications that can come out of this, but we need to be careful and deliberate in how we use these therapies," says Dr. Peter Rubin, associate professor of plastic surgery at the University of Pittsburgh. ABC News (4/5)


■FDA: Claims for lipodissolve products are "false and misleading"

The FDA this week warned several spas and at least one online retailer to stop using claims that their lipodissolve injections dissolve small fat deposits. Customers have reported permanent scars, hard lumps and dark skin spots after receiving the injections. MSNBC/The Associated Press (4/7)

Along these lines, I recently came across an interesting report entitled:

Six women were hospitalized in Essex County, N.J. this past February after receiving buttock "enhancement" that reportedly consisted of injections of diluted bathtub-grade silicone caulk from unlicensed practitioners.


■Study: Untrained "cosmetic surgeons" pose health hazards

A recent study involving 1,876 cosmetic practitioners in Southern California found that only 495 had plastic surgery training. Although it is not illegal for untrained doctors to perform certain cosmetic procedures, such as facial fillers and liposuction, the lack of training can increase the risk of serious complications. Los Angeles Times

Tuesday, April 6, 2010


Infection that occurs around a breast prosthesis or any implantable medical device is a challenging and difficult problem.  Rates of infection are higher in breast reconstruction using a prosthetic implant (1-35.4%) compared to augmentation mammoplasty (0.4-2.5%).  Although salvage of an infected prosthesis is always the goal, it is seldom successful. The typical methods used to try to save an infected prosthesis include oral &/or systemtic (I.V.) antibiotics based on culture and sensitivity results, irrigation and drainage procedures, antibiotic pulsed lavage, removal of the capsule surrounding the implant, exchanging the implant, and possible post-operative continuous antibiotic irrigation.
There is a higher percentage of infection associated with smoking, chemotherapy and radiation therapy. There is less likely to be a successful salvage of the prosthesis if the wound culture organisms are methicillin-resistant Staphylococcus Aureus (M.R.S.A.), gram negative rods such as Pseudomonas Aeruginosa, mycobacteria or yeast. I have also found that patients with significant erythema in the mastectomy skin, thin tissues and implant exposure are in a poor prognostic group for salvage.
Why is it so difficult to treat infection around a prosthetic medical device?  One theory is that certain bacteria form a Biofilm.  A Biofilm is a mucopolysaccharide "slime layer" that adheres to a breast implant and forms a "protective barrier" for the bacteria which isolates them from antibiotics and from the infection-fightening capabilities of the immune system.  The molecular mechanisms of biofilm formation are beyond my understanding and involve a complicated process that is being looked at carefully in the research labs. Of interest, it has been also shown that biofilms may play a role in certain burn infections that show multi-drug resistance and in certain non-healing wounds.
An infection around a breast prosthesis is a major problem!  This results in prolonged treatment and recovery, additional surgeries, more expense, central lines for weeks of I.V. antibiotics (with the risk of line sepsis), additional hospitalization and psychological issues for both the patient and doctor. As with many things in life, prevention is the key.  Before, during and after surgery we take extra precautions above and beyond our normal sterile technique to try to reduce the chances of infection around a breast prosthesis.

Sunday, March 28, 2010


Many breast cancer cases might be avoided with better diet, exercise.

The AP (3/26) reports that researchers at a European breast cancer conference Thursday said that "up to a third of breast cancer cases in Western countries could be avoided if women ate less and exercised more." Researchers noted that "better treatments, early diagnosis and mammogram screenings have dramatically slowed the disease," adding that "the focus should now shift to changing behaviors like diet and physical activity."

Better diet may lead to decreased breast cancer risk. Reuters (3/26, Peeples) reports that an analysis of 18 studies enrolling more than 400,000 people found that consuming less alcohol and more whole grains and vegetables could help women cut their chances of developing breast cancer. Researchers in the American Journal of Clinical Nutrition wrote that they saw an 11% lower breast cancer risk for women with the best diets.


FDA panel agrees on increased restrictions on tanning bed use.

ABC World News (3/25, story 9, 1:20 Muir) reported, "Tonight, there is late word from federal safety officials who are poised to crack down on indoor tanning beds. Twenty-eight million Americans tan indoors every year, and now a panel of experts is so alarmed by the dangers of skin cancer, it's making some pretty bold warnings." ABC senior medical editor Richard Besser, MD, explained that "a panel of experts put together by the Food and Drug Administration...reached broad agreement that there need to be increased restrictions on the use of these tanning beds for everyone under 18."

The CBS Evening News (3/25, story 7, 0:15, Rodriguez) reported that panel's proposed new restrictions range "from requiring parental consent forms to banning the machines outright."

But, because tanning beds themselves are not medical devices, the agency can only put restrictions on the lamps the beds use, the Wall Street Journal (3/26, Dooren) reports. In order to do that, the FDA could reclassify the lamps. That would force tanning bed manufacturers to get agency marketing approval of the beds.

According to the AP (3/26, Perrone), "The FDA has regulated sunlamps for more than 20 years, but a recent report by the World Health Organization tied the devices to skin cancer, prompting a call for tougher rules." In fact, "the WHO analysis showed that" melanoma, "the deadliest form of skin cancer increases 75 percent in people who use tanning beds in their teens and 20s."

Wednesday, March 17, 2010


Non-melanoma skin cancer cases increasing.

The CBS Evening News (3/15, story 6, 0:20, Couric) reported that "there has been a dramatic rise of certain types of skin cancer in older Americans. A new study of people on Medicare found that in just four years the number of procedures to treat non-melanoma skin cancers jumped about 77%. Researchers say the rise of sunbathing and tanning after World War II may have contributed to the increase."

Bloomberg News (3/16, Ostrow) reports, "The number of Americans treated for non-melanoma skin cancer increased 14.3 percent from 2002 to 2006, according to" a study published March 16 in the Archives of Dermatology. In 2006 alone, researchers "estimated there were more than 3.5 million non-melanoma skin cancers in the US...and about 2.1 million people were treated for the malignancy that year." In a March 12 interview, dermatologist and study author Howard Rogers, MD, PhD, stated, "There's an epidemic of skin cancer," which he attributed to a continued "lack of appreciation of the danger of going out in the sun."

The Los Angeles Times (3/15, Kaplan) "Booster Shots" blog reported that even though non-melanoma skin cancer "usually isn't deadly if found early," the economic toll of both basal cell and squamous cell skin cancer is "still significant. The American Academy of Dermatology says that treatment of non-melanoma skin cancer cost $1.5 billion in 2004."

HealthDay (3/15, Goodwin) reported that in another study published March 16 in the Archives of Dermatology, researchers "developed a mathematical model to estimate the prevalence of non-melanoma skin cancer in the United States." They discovered that "more people have had non-melanoma skin cancer than all other cancers combined over the last 31 years." And, "in a third paper in the same journal, researchers from the US National Cancer Institute found survivors of one melanoma are about nine times as likely as the general population to develop a second melanoma."

Patients may struggle to articulate how it feels to have cancer. The New York Times (3/15, Jennings) "Well" blog reported, "As a patient, it's hard to articulate how being seriously ill feels." Although "we like to say that people 'fight' cancer because we wrestle fearfully with the notion of ever having the disease," in reality, "ordinary language falls far short of explaining" the "keen sense of oblivion" that patients feel "once infested by the black dust of cancer and damaged by the 'friendly fire' of treatment." In fact, "words can just be inadequate," and people "often reach for the nearest rotted-out cliché for support." It may be "better," therefore, "to say nothing, and offer the gift of your presence."

Adolescents with cancer said to face unique challenges with treatment. On the front of its Science Times section, the New York Times (3/16, D1, Rabin) reports that teenagers are more likely to be diagnosed with cancer "much later in the course of their illness than younger children," because "they tend not to ask adults for help or confide about embarrassing physical changes." Dr. W. Archie Bleyer, "an expert on cancer in teenagers" at the St. Charles Medical Center in Oregon, noted that "teenagers fall into a cancer gap." While adolescents have "not benefited from the huge advances in survival made by younger children," they also "tend to develop a very different set of cancers from older adults." Researchers have made some breakthroughs, however, with acute lymphoblastic leukemia, finding that teenagers under the care of pediatric oncologists fared "remarkably better" than "those treated by adult cancer doctors."

Saturday, March 6, 2010


On March 2, 2010, Congress passed legislation that extends the temporary freeze of Medicare physician payment cuts for 31 days. The bill passed with bipartisan support by a vote of 78 -- 19. This 31 day patch is retroactive and will reverse the temporary 22% cut that took effect on March 1, 2010. Congress is expected to vote soon on legislation that could include another 30 day, 7 month or 9 month freeze for Medicare physician payments. I continue to oppose short term fixes to the flawed SGR payment formula, and I continue to advocate for enactment of a long-term physician payment solution. You can help by writing your Representive and Senator.  Below is a sample letter that you may want to use as a guide. You can find your members of Congress by visiting the links below and entering your zip code.

United States House of Reprensatives
Enter your zip code in the field on the top left portion of the screen

United States Senate
Select your state using the pull down menu located on the top right of the screen

Representative ________             or Senator__________

Attn: Health Legislative Asst.            Attn: Health Legislative Asst.
____House Office Bldg.                   _____Senate Office Building
Washington, DC 20515                   Wasington, DC 20510

Dear Representative ____           or Dear Senator______

My doctor has always been there to take care of me.  I am worried about my doctor's ability to continue to accept my Medicare insurance.  Over the past few years, increased pressures on the Medicare program have made it difficult for many doctors to continue to accept Medicare, and I am concerned that my doctors may have to quit the program or limit the number of Medicare patients thay see.

In addition, costs for doctors to provide service to me have continued to rise. Any expansion of coverage or reform of the health care system that doesn't first address problems in the existing system is doomed to fail.  Please find a way to replace the flawed formula that determines Medicare reimbursements with one that is fully paid for without borrowing from future Medicare payments or benefits.  This should be a sustainable and long term solution, and one that more closely reflects the actual increased costs of providing medical care. 

Please make stabilization of Medicare a top priority.  I want to know that a surgeon will be there when I need one.  Please keep my doctor in Medicare.  I thank you in advance for taking care of an issue that is vital to all Americans.



Sunday, February 28, 2010


Beginning March 1, 2010, Medicare with cut all physician's payments by 21.2%.  Why has this happened - because Congress has failed to permanently repeal the flawed Sustainable Growth Rate (SGR) formula.
This reduction in payments will force many doctors to re-evaluate their care of Medicare patients. The lack of action by the U.S. Congress will hurt our seniors who are some of the most vulnerable patients who  desperately need medical care. Call your senators and representatives and express your outrage!


According to the Los Angeles Times, Lydia Carranza, a mother of three and a grandmother of two, was shot in the chest while at work in a dental office. On July 1st, she was sitting at the front desk of Family Dental Care in Simi Valley performing her normal duties.  The husband of one of her co-workers stormed into the office with a semi-automatic weapon and shot Ms. Carranza.  The intended target was his wife, who had recently asked for a divorce. Normally, this would not have made news beyond the local community. In Ms. Carranza's case, it is speculated that the the breast implant absorbed much of the bullet's impact, sparing her from injury to her heart and other vital organs. According to Scott Reitz, a firearms instructor and deadly-force expert witness with 30 years experience with the LAPD, it is plausible that the implant interrupted the velocity of the projectile.  However, Mr. Reitz further added "I don't want to say a boob job is the equivalent of a bulletproof vest, so don't go getting breast enhancements as a means to deflect a possible incoming bullet."

Wednesday, February 17, 2010


The "Vi Peel" falls in the category of a "light" peel.  This is a office peel that is safe for all skin types.  There is little down time, and can be used on the face, neck, chest and hands. It will not remove significant wrinkling, but it does help sun damaged skin to include hyper-pigmentary changes. It improves skin tone and texture. The office procedure takes about 30 minutes and creates mild burning which can be controlled with a fan.  The peel contains Trichloracetic Acid, Salicylic Acid, Phenol, Retinoic Acid, & Vitamins.  The peel can be repeated every 2 weeks for severe sun damaged skin or more commonly, every 10-12 weeks for basic maintence.   Make up can be applied over the treated areas in 4-6 hours if needed. You will start the peeling process from day 2-4, which involves a slight sloughing of the skin. Moisturizers are used at this time.  By one week, you may resume your usual skin care products. For a light to intermediate peel, this product seems to be beneficial.

Sunday, January 31, 2010


The American Clean Energy and Security (ACES) Act of 2009 was approved by the United States House of Representatives on June 26, 2009 by a vote of 219-212.  Although counterpart legislation in the US Senate has gone through the Environment and Public Works Committee, the final bill is still under consideration.  The major component of the House bill regulates green-house gases to include carbon dioxide, methane, nitrous oxide, sulfur and several other gases. The bill calls for dosmetic greenhouse gas emissions to be capped at 2005 annual levels, and reduced to 17% of those levels by 2050. Another aspect of the bill would impose tariffs on countries that trade with the United States if these countries do not implement similar regulations on greenhouse emissions.  These cap and trade regulations have given this ACES legislation the popular name "Cap and Trade" in the public media.  The bill provides for utility and manufacturing companies to buy "polution permits" or to pay fines if they do not meet these regulations. Either way, this will increase the cost of doing business, which in turn will increase consumer costs for a variety of products. There has been a widespread debate and much controversy about these greenhouse gas emissions and their affect on "global warming". There are many scienctifc experts on both sides of this issue, as well as many so-call "experts" - such as actors (many who have not even graduated from college).  I suspect this debate will continue on green house gases and global warming for quite some time. 

An issue that is usually not raised is the affect on green house gas emissions on public health. Most greenhouse gases regulated under this legislation do not directly pose a health risk. For example, carbon dioxide is an ingredient in carbonated beverages and methane is produced in abundance from cattle.  However, reducing harmful pollutants (such as particulate matter that share emission sources with greenhouse gases) will have a positive impact on pulmonary and cardiovascular disease. For example fossil fuel combustion for production of electricity accounts for a large proportion of carbon dioxide emissions.

Although the carbon dioxide may not be an issue in one's health, this combustion process produces products that may pose a health risk.

For more complete information on the American Clean Energy and Security Act (HR 2454), go to


The arteries to the heart (coronary arteries) supply blood to the heart muscle that allows the heart to function properly. When fatty material (plaque) builds up in the arteries, the arteries are damaged and platelets (components in the blood that activate clotting) stick together in these areas of damage and cut off blood flow. This can lead to lack of oxygen to the heart muscle (ischemia) which can progress to a heart attack (myocardial infarction).  There have been many clinical studies that identify risk factors for developing coronary artery disease. The most well know study, "The Framingham Study" was a study of families living in Framingham, Massachusetts.  By addressing these risk factors, one can reduce the chance of coronary artery disease. Sometimes, a patient is given a warning of coronary artery disease in the form of chest pain (angina).  Unfortunately, coronary artery disease may not produce any symptoms to warn the patient of impending diaster. A heart attack (uncomfortable pressure, squeezing or fullness in the chest; pain or discomfort in the arms, back, neck, jaw or abdomen; shortness of breath; sweating, nausea or light-headedness) or even worse, sudden cardiac death, may be the first sign of coronary artery disease.
What are the risk factors?
(1) Genetics (Family History of Coronary Artery Disease)
(2) Smoking
(3) Hypertension
(4) Diabetes
(5) Age: over 40 years for men and 45 years for women
(6) Obesity and low physical activity
(7) Elevated Cholesterol (high total cholesterol; low HDL; High LDH)
(8) Elevated Triglycerides
(9) Male Sex

What can you do?
(1) Stop Smoking
(2) Treat High Blood Pressure
(3) Control Blood Sugar
(4) Eat a Balance diet with an emphasis on high fiber; fruits; vegetables; whole grains.
     Limit intake of animal fats, "trans" fats, sugars and starches.
(5) Exercise at least 30 minutes daily
(6) Lower your Cholesterol through diet, exercise and medications as prescribed.

Go to
to calculate your risk of
coronary artery disease.

Saturday, January 30, 2010


Longer surgeries raise infection risk, length of stay

For every 30-minute period between surgery incision and closing, the 30-day rate of infectious complications goes up by about 2.5%, research showed. The study conducted at the University of Kentucky College of Medicine found hospital lengths of stay also increased with operation times, about 6% for every 30 minutes


Aggressive lobbying keeps malpractice system out of health reform

The American Association of Justice spent $1 million on lobbying and advertising campaigns last year to prevent the inclusion in health reform legislation of proposals that would drastically change medical malpractice law. More than 95% of the group's $1.1 million campaign contributions in 2009 went to Democratic candidates. The Democrat-controlled Senate voted 66 to 32 against an amendment that would cap attorney fees. Los Angeles Times (01/19)

Sunday, January 24, 2010


I just viewed a disturbing video on the internet related to "Baby makes friends with Boxer".  Although it is cute and innocent, this is the sort of thing that can quickly turn into a nightmare for the baby, the parents and the dog. The typical sernario: cute baby playing with loving family dog; dog snaps and bites face of baby; hysterical parents bring baby to emergency room; after waiting for 7 hours to be seen, E.R. doctor evaluates and then tries to get a plastic surgeon to come in (most plastic surgeons have stop taking E.R. call because of liability issues); plastic surgeon who is willing to come in is finally located and arrives and prepares to take the child to the O.R. for extensive repair of facial injuries (sometimes, these injuries can involve not only soft tissue injuries with significant tissue loss, but also vital structures to include the facial nerve, eyes, nose, mouth, etc to include underlying bone);  baby is given a general anesthesia and wounds are extensively cleaned to try to prevent infection; after several hours, injuries are repaired; parents are counseled and usually very appreciative - but the conversation usually involves the following statement: "But doctor, our child will not have any scarring, will she??  Not only will this child have permanent scarring, but will probably need several scar revisions in the future.  The parents now suffer life long guilt, the beautiful young baby grows up with facial scarring and possible even facial deformity, and the loving family dog is either given away or put to sleep!  Over the last 30 years of covering the emergency room, I have seen this sernario play out numerous times, and taken care of hundreds of serious dog bite injuries to the face and body in both adults and children.  The presentation in many of these:  "But Doctor, this was the friendly family dog that would not bite anyone."  Especially when children are involved, a "friendly" dog can take a chunk out of the face in a heartbeat. Never, Never, I repeat, Never let your children get their face up close and personal with a dog. Another thing that I have observed over the years is the adult who has been drinking alcohol and then starts playing with the dog. For some reason, dogs don't like the "alcohol breath" in their face and will react with an attack on even the most loving owner. Before those dog lovers out there accuse me of being "anti-dog" and report me to the "dog police", I love dogs and I have had many dogs in the past. Although dogs are our "best friends", simple precautions can prevent a major calamity! 

Monday, January 18, 2010


Revision Augmentation Mammoplasty has become fairly common because of aging silicone gel filled breast implants. Studies have shown that the first, second and third generation implants used in the 60's, 70's, 80's and early 90's have an increased tendency to leak as they age.  This is a linear relationship, with an approximate 75% chance of leakage or rupture after 20 years. Fortunately, most of this leakage is still confined within the scar barrier (capsule) surrounding the implant, and the gel does not leak out into the tissues.  This is called "intra-capsular" leakage. Physical exam and mammography may be completely normal in these situations. M.R.I. examination may detect intra-capsular leakage. If leakage extends beyond the capsule, this creates inflammation in the tissues, possible silicone granulomas (a lump that may be felt - this is a natural response of the body to "capture" the leaking gel), more scar tissue leading to increased hardness, possible pain and distortion. This is called "extra-capsular" leakage and this usually can be seen on mammography or ultra-sound and may be obvious on physical exam.  Even though there is some controversies about when to change out older silicone gel filled breast implants, my indications are as follows:
(1) Any palpable lump in the breast needs to be investigated
(2) Abnormal mammography, ultra-sound, or M.R.I. imaging that suggests leakage
(3) Hardness, pain, distortion in the breasts
(4) Patient concerns about silicone gel filled breast implants
(5) Underlying health problems that concern the patient
(6) Desire for change in size, or desire to change to saline implants

How about the patient that presents with 20+ year old silicone gel filled breast implants but has no symptoms and has a normal physical exam; is happy with the size, shape, contour & softness of the breasts; and has normal mammography and ultra-sound exams?  This is a more difficult decision.  Even though there is a high percentage of intra-capsular leakage, many times I may decide just to follow the patient closely.  I do recommend avoiding any pressure on the breasts and would advise M.R.I. exams rather than mammography.

If the decision is made to proceed with revision augmentation mammoplasty, several options are available:
(1) Remove the implants and not replace implants
(2) Remove the implants, remove the internal scar tissue, and replace with saline filled implants
(3) Remove the implants, remove the internal scar tissue, and replace with the new fourth generation silicone gel filled implants (these implants were approved by the F.D.A. and released for general usage in November of 2006)
(4) Perform any of the above options with a breast lift

Revision augmentation mammoplasty is a major operation. This is done under general anesthesia and may take up to 3 hours. It is done at an accrediated outpatient surgical facility. It is more complicated than the original augmentation mammoplasty operation. Infra-mammary incisions (incisions in the crease under the breast) are used for access.  The old implants and any leaking implant material is removed. The scar tissue is removed, and the pockets are enlarged and new implants are placed. Drains may be needed. The new fourth generation silicone implants have a better outer shell to contain the silicone gel.  We do not have long term studies on these new implants and the F.D.A. is recommending periodic M.R.I. examinations to try to accumulate data on the leakage rate. 

After surgery, the patient is wrapped in tight bandages that have to be worn around the clock for the first week. Most patients return to normal activities (work, school, driving, etc.) after the first week.  The patient needs to limit any major physical activities (swimming, aerobics, exercising, upper body conditioning, excessive arm and shoulder movements, lifting over 5 pounds etc.) for the first 6 weeks.  I see the patient a week after surgery to remove sutures and discuss additional postoperative care.  Most patients are very happy with the results of revision augmentation mammoplasty.

Sunday, January 10, 2010


Some people have the inherited potential to develop small branching superficial veins in the skin.  These are often called "spider veins".  They are common on the lower extremities, and may appear early in life, especially during the reproductive years.  These spider veins many times become more prominent and abundant during pregnancy.  Unlike varicose veins (the larger, deeper dilated veins), these smaller vessels in the skin are not influenced by the presence or absence of damaged or incompetent valves. Many treatments have been used to treat spider veins (chemical peels; electric wire diathermy; cautery; lasers; injection sclerotherapy).  The "gold standard", and still the most cost effective treatment, is injection sclerotherapy. The technique of injection sclerotherapy is to inject a small amount of sclerosing solution (a solution approved by the F.D.A. for vein injections) into the veins using a small gauge needle.  This requires loope magnification and fibro-optic illumination and is a very tedious process. The initial reaction is swelling and bruising for several weeks.  Over the next several months, the walls of the veins collapse, adhere together, scar down and the vessel is obliterated. This process has no advese affect on the overall circulatory system.  Some vessels do not respond to this treatment.  It is often necessary to re-inject about 15% of the spider veins because of incomplete obliteration of the vein channel. The most common problem seen with this treatment (especially if the spider veins are very prominent) is hemosiderin deposits. Occasionally blood will become trapped in a spider vein as it is shrinking.  A "trapped blood" collection is known as a hemosiderin deposit.  This results in a brown or black pigmentation in the skin.  This problem usually disappears, but it may take months or years to resolve. This is one reason I like to perform a "test dose" on a prominent plexus of spider veins before proceeding with mutiple vein injections during a typical 30 min. office session.  We are still trying to find a laser that will eliminate spider veins in a cost effective and efficient manner. The 940 nm wavelength gives an effective penetration with optimal absorption by hemoglobin. There is less chance of skin pigmentary problems.  Re-treatment and cost is still a draw-back to this laser system.


As we begin 2010, Congress will continue to work on health system reform.  The Senate approved the "Patient Protection and Affordable Care Act" by a party line vote of 60-39 on December 24, 2009. A nice Christmas present for the President, but probably one of the worse pieces of legislation that has ever come from the Senate.  The "Affordable Health Care for America Act" passed by the House 220-215 on November 7, 2009 must now be negotiated with the Senate bill to come up with a consensus. Both bills would extend coverage to most Americans by imposing more government mandates on business and enacting new government coverage subsidies.  Neither bill addresses mal-practice reform, nor does either bill address the 21.2% Medicare formula based cut in Medicare re-imbursement scheduled to take place in March.   Areas that will be hotly debated include the following:
(1) The Public Plan:  The House bill implements a national health insurance plan offered by the federal government; The Senate bill  would implement "private plans" sponsored by the federal Office of Pesonal Management.
(2) Federal Taxation:The House would impose a 5.4% tax on individuals with incomes exceeding $500,000; The Senate would impose a 40% tax on certain health plans for individuals and families.
(3) Employer Mandate: The House would require larger employers not offering enough coverage to pay a tax of up to 8% of payroll; The Senate would require larger employers not offering enough coverage to pay a $750.00 penalty per worker.
(4)  Individual Mandate:  The Senate would require individuals to obtain health coverage or to face an annual penalty of 2.5% of income (higher than a certain amount); The House would make individuals pay an annual phased-in penalty of at least $750.00 if they did not have health insurance.
(5) Medicaid Expansion:  Both the Senate and House would expand Medicaid coverage for everyone earning up to 133% (Senate) & 150% (House) of the federal poverty level. (6) Abortion Funding: Both the House and Senate would bar the use of federal subsidies to pay for abortions, but would allow subsidy recipients to choose a plan covering abortion if it were paid for with segregated private funds (Senate) or to purchase separate coverage with their own money (House).

The final compromised version will be forthcoming - stay in touch and get in touch with your elected officials to express your views and concerns.