HOLD ON - IT WILL BE A "WILD RIDE"

Insurance sold on marketplaces may limit access to doctors, hospitals.

In a front-page story titled “Insurers Restricting Choice Of Doctors And Hospitals To Keep Costs Down,” the Washington Post (11/21, A1, Somashekhar, Cha, 4.28M) reports that “Americans...are discovering that insurers” selling plans on the Affordable Care Act’s marketplaces, “are restricting their choice of doctors and hospitals in order to keep costs low, and that many of the plans exclude top-rated hospitals.” According to the Post, there is now “a two-tier system” as “many of the people who buy health plans on the exchanges have fewer hospitals and doctors to choose from than those with coverage through their employers.” The Post says this situation has been exacerbated by some “providers” that “have balked at being in exchange networks because they are unhappy with the reimbursement rates or are concerned that the exchanges could be dominated by sick people who won’t be able to pay their portion of the bills.”

        As the AP (11/21, Alonso-Zaldivar, Ramer) notes, President Obama “promised people could keep their doctors,” which could make this “the next health overhaul issue.” American Medical Association president Dr. Ardis Dee Hoven is quoted as saying, “Although it may be too early to reach any definitive conclusions, we are monitoring the adequacy of the exchange networks and will be analyzing the impact of these restrictive strategies on patient access to care.”

        Moreover, the Washington Examiner (11/21, Pollock, 319K) reports that consumers visiting healthcare.gov are not able “to learn whether their doctors participate in an Obamacare-approved health care plan because the website doesn’t include such information.” Jessica Waltman, senior vice president of government affairs for the National Association of Health Underwriters, explained to the Examiner: “Under the exchanges, the government did not require health plans to submit detailed network information. That’s why the networks aren’t listed on healthcare.gov. When you go to look in at the plan choices, you can’t see the provider networks.”

ANOTHER INVESTIGATIONAL DRUG THAT MAY BE BENEFICIAL - THE BODY'S IMMUNE SYSTEM IS THE KEY

Merck says cancer drug boosts survival of advanced melanoma patients.

The Wall Street Journal (11/18, Subscription Publication, 5.91M) reports Merck & Co. provided an update Monday to its early-stage study of a melanoma treatment, showing that it has an 81 percent survival rate at the one-year mark. The pharmaceutical giant provided data on its investigational MK-3475 against advanced melanoma at the International Congress of the Society for Melanoma Research, reports the Journal.

        Bloomberg News (11/19, Cortez, 1.91M) provides more details, noting the drug being “evaluated in nine different malignancies kept more than four of five melanoma patients alive for a year in a study,” including patients who had “exhausted all other treatment options.” The study found 41 percent “responded to treatment and 9 percent showed evidence of the tumor disappearing.” The drug belongs to a new group of medicines called PD-1 inhibitors “that harness the body’s immune system to attack cancer.” Merck is evaluating the drug in more than 3,000 patients suffering from cancers such as lung, bladder, breast and colorectal tumors, the article notes.

ANOTHER SURGICAL PROCEDURE THAT IS USUALLY NOT NECESSARY

Sharp rise in number of women getting genital plastic surgery: researchers 

Experts blame porn for confusing teen girls and women about what a vagina is supposed to look like. In Britain, there’s been a fivefold increase in the number of female cosmetic genital surgeries, which aren’t medically necessary and could cause health problems.

 

 

There’s been a scary rise in the number of women and teen girls getting unnecessary labiaplasties, researchers said.

 

A shocking number of teen girls and women are undergoing plastic surgery on their vaginas to replicate what they see in pornography, British researchers said.
The Royal College of Obstetricians and Gynecologists reported a fivefold increase in labiaplasties, which are considered cosmetic surgeries, over ten years.Experts attribute the sharp uptick, in part, to porn. “The misapprehension arises from the prominence of just one type of ‘neat’ genital appearance, the type to be found prominently depicted in pornography,” Thomas Baldwin of RCOG’s ethics committee, told Agence France-Presse.

The paper examines the dangers associated with these surgeries, which aren’t medically necessary.
“The younger a girl begins her labiaplasty trajectory, the higher the number of operations over her lifetime and the greater the risk of scarring and sensitivity loss,” researchers wrote.

The operations aren’t recommended for women under age 18, whose vaginas aren’t fully developed.
In Britain, 2,000 of these operations were performed in 2010, according to the report. But experts say the true number is much higher, as that figure doesn’t take into account surgeries done in the private sector. The trend is also growing in the United States, despite a 2007 warning to physicians from the American College of Obstetricians and Gynecologists, to consider the “medical validity and safety” of female genital cosmetic surgery, Reuters reported.

GOOD NEWS AND BAD NEWS

CDC: Teen smoking down but use of cigars, e-cigarettes up.

The Wall Street Journal (11/14, Esterl, Subscription Publication, 5.91M) is part of the group of US national media outlets reporting on new findings from the US Centers for Disease Control and Prevention that were published yesterday. Though the CDC revealed that cigarette use among minors in the US is dropping over last year, the use of alternative tobacco products, such as miniature cigars, electronic cigarettes, and hookah, has risen. The Wall Street Journal focuses on the first of that group, cigarillos and little cigars, as being the second most used tobacco product among teenagers.

WE STAND ON THE SHOULDERS OF GREAT MEN - DR. TOM REES WAS AN INSPIRATION

November 15, 2013

Plastic surgery mourns loss of one of its giants: Thomas Rees, MD, passes at 86

Plastic surgery pioneer and ASPS Life Member Thomas Rees, MD, Santa Fe, N.M., passed away Nov. 14. Dr. Rees was world-renowned for facial aesthetics, particularly rhinoplasty. He was also a prolific author who literally wrote the book – actually, six textbooks - on cosmetic plastic surgery and other procedures.

Along with his mentor Sir Archibald McIndoe, MD, and fellow plastic surgeon Sir Michael Wood, MD, Dr. Rees in 1957 co-founded the African Medical and Research Foundation, more commonly known as the Flying Doctors Service of Africa. The organization was dedicated to providing those living in the most remote areas of Eastern Africa with access to hospital care via air transport.

“During my years of active practice in New York City for 40-45 years, I was spending every winter in East Africa,” Dr. Rees told PSN in 2006. "I had this side avocation going on.”

“Dr. Rees’s contributions to aesthetic techniques – both in the United States and throughout the international aesthetic community of plastic surgeons – are extraordinary,” says ASPS President Robert X. Murphy Jr., MD. “His dedication to sharing his knowledge with residents and other plastic surgeons is overshadowed only by his tremendous humanitarian work with the Flying Doctors of Africa. He was truly a giant in our specialty and beyond.”

Dr. Rees stopped practicing plastic surgery in 1994, and penned a memoir chronicling his experiences in Africa titled Daktari: A Surgeon’s Adventures with the Flying Doctors of East Africa. He also continued to make annual trips to Africa with his wife of 63 years, Nan, who passed away in May 2012.

“Dr. Rees is a shining example of plastic surgery at its best,” says Kevin Chung, MD, president of The PSF. “His significant contributions extended well beyond the clinic, and he left a blueprint for international service that is inspiring and enduring.”

Dr. Rees, who came from a family of physicians, says he developed an interest in plastic surgery during a rotation in the specialty as part of his general surgery training.

“I liked it very much because it left a lot of room for innovation,” he said. “If you’ve done 50 gallbladders, you’ve done them all, [but] plastic surgery was different. It appealed to my artistic sensibilities. I liked the idea that you were constructing things instead of destroying things.”

As a dedicated teacher and humanitarian, Dr. Rees leaves a rich legacy that impacted generations of plastic surgeons and thousands of patients’ lives a world away.

INFORMATION PLASTIC SURGEONS WON'T TELL YOU: NUMBER 10

10. “Those who need surgery the most will benefit from it the least.”

Most people turn to plastic surgery when they feel age has finally caught up with them and nothing else will rid them of that troublesome bulge or crease. But the dirty little secret of plastic surgery is that with many procedures, the more you need it, the less of an impact you can expect.

Those who have damaged skin, more common as we age, can expect some serious complications. Skin stretched by weight gain, for example, loses its elasticity; following liposuction, skin may not snap back into place but instead will hang like an apron over the area that was suctioned. Because smokers have poor circulation to the epidermis, their skin can die after surgery, meaning months of unsightly scars and possible additional surgery. And procedures such as a face-lift done on sun-damaged skin won’t last as long and may result in more-prominent scarring. Likewise, those hoping for dramatic weight loss from liposuction are looking in the wrong place; surgeons say it’s meant only to shape a certain part of the body in conjunction with diet and exercise.

Ironically, those who need cosmetic treatments the least — generally, those who are younger (say, in their late 30s or 40s) and opt for a little tweaking here and there — are going to fare the best. What’s more, while plastic surgeons sometimes downplay the role that lifestyle can play in one’s looks, a growing body of evidence suggests that overall health and appearance are indeed related, Sarwer said.

INFORMATION PLASTIC SURGEONS WON'T TELL YOU: NUMBER 9

9. “Of course I’m board certified, for what it’s worth.”

A board-certified plastic surgeon should be the best, right? Not always. Because any medical doctor can legally perform any cosmetic procedure, without obtaining any specific certification, and because certification boards are self-regulating, many certifications aren’t so telling. The American Board of Laser Surgery, for example, certifies nurses, veterinarians and oral surgeons in laser surgery — through a take-home written exam and video Web conference. “This being the U.S. and the land of entrepreneurship, just saying you’re board certified is not enough,” says Nahai. “Ask them which board.”

There are some certifications that matter. The American Board of Plastic Surgery’s is one of the most rigorous for this specialty and the only certification for whole-body plastic surgery recognized by the American Board of Medical Specialties that provides training and assessment for entire body cosmetic, plastic surgery, and reconstructive treatments. The American Board of Medical Specialties is a nonprofit organization that’s widely recognized as a leader in physician certification. Members of the ABPS have completed residences in both general surgery and plastic surgery and are trained to do all procedures from liposuction to nose jobs. Other ABMS Member Boards may have some specific plastic surgery procedures for which their certified physicians are also qualified (for example, physician members of the American Board of Otolaryngology may be very well qualified to perform nose jobs). The American Board of Medical Specialties runs a website, CertificationMatters.org, where patients can see if their doctor is certified by a rigorous board.

INFORMATION PLASTIC SURGEONS WON'T TELL YOU: NUMBER 8

8. “You’d be better off spending money on a good therapist.”

Cosmetic surgery doesn’t make you crazy, but research suggests those who have had it, both men and women, are more likely to suffer from psychological problems. Several studies in the 2000s found that women who chose to get breast implants were two to three times more likely to commit suicide than demographically similar women without cosmetic implants. And 20% of patients seeking cosmetic treatments were on some kind of psychiatric medication (versus roughly 9% of the overall population, according to the Centers for Disease Control and Prevention), including drugs to treat depression or a low-grade mood disorder, according to a 2004 study by researchers at the Center for Human Appearance at the University of Pennsylvania’s Perelman School of Medicine.

In addition, up to 15% of cosmetic plastic surgery patients suffer from “body dysmorphic disorder,” versus an estimated 1% to 2% of the of the overall population, according to UPenn’s Sarwer; the disorder is marked by obsessive and exaggerated concern over aspects of one’s appearance. It may sound like a convenient diagnosis for our beauty-obsessed culture, but it is a very real, very dangerous condition. “At the extreme, people will not leave their home, they’re so preoccupied with how they look,” Sarwer says. BDD suffers often seek plastic surgery thinking it will magically transform their lives, and when it doesn’t, they may harm themselves — or sue the surgeon, Sarwer says. Every plastic surgeon worth his or her salt asks questions to gauge patients’ motives, and concerned doctors should refer patients to a mental health professional. But to date there’s no standardized screening tool for BDD.

INFORMATION PLASTIC SURGEONS WON'T TELL YOU: NUMBER 7

7. “Sure, I can turn back the clock, but it just starts again.”

Just because you shelled out $10,000 for a face-lift doesn’t mean you’re set for life. Even the most skillful work will need some attention a decade or so down the line. Some jobs may require supplemental fillers (compounds that are injected under wrinkle lines into the skin) or minor surgery to tighten up a few sags, while others could call for a repeat of the same procedure. A face-lift can be expected to last about eight to 10 years, says Nahai, the Atlanta surgeon and editor. Exact results will depend on the condition of the patient’s skin; how well the patient cares for the skin, such as by keeping out of the sun and maintaining a stable, healthy weight; and the surgeon’s skill. Any work done on the lower face will age more quickly than on the upper face since the lower is fleshier and has less bone for sagging skin to hang onto: “The jowls are the first to come back,” Nahai says.

INFORMATION PLASTIC SURGEONS WON'T TELL YOU: NUMBER 6

6. “You look great; your husband needs some work.”

Swanson says men usually come to him for a face-lift around age 65, whereas women come in a good 10 years earlier, at age 55. “There’s a difference in tolerance for wrinkles in our society,” Swanson says. Men are told that they look distinguished with crow’s feet, while women hear that they look just plain old. The tipping point for men, Swanson says, is their desire to get rid of the “turkey wattle.”

                                         

Boomer men take the Botox plunge

However stealthily, men are having a little work done in increasing numbers these days. Elizabeth O'Brien and dermatologist Dr. David McDaniel explain on Lunch Break. Photo: Shutterstock.

While men represent just 9% of cosmetic procedure patients, they’re increasingly getting a little work done these days, according to the American Society of Plastic Surgeons. Total cosmetic procedures for men rose 22% from 2000 through 2012, according to the society. Minimally invasive procedures in particular have soared, with botulinum toxin treatments up 314% during that time. Some men are getting injections to look younger on the job, while others are getting treatments to keep up with their younger girlfriends, plastic surgeons and dermatologist report.

INFORMATION PLASTIC SURGEONS WON'T TELL YOU: NUMBER 5

5. “I make a mint off other surgeons’ mistakes.”

Dr. Sam Rizk, a plastic surgeon in New York City, says 1 out of 3 of his rhinoplasty patients have had previous nose jobs. Among the most common problems he sees are “scooped bridges,” over-restricted nostrils, and pinched tips. The number of botched nose jobs he has repaired has soared over the past three to five years as more surgeons are performing the surgery who aren’t well trained or experienced, he says. Industry wide statistics bear out his experience: Revision surgery is up 35% from 2008 to 2012, according to the American Academy of Facial Plastic and Reconstructive Surgery.

What’s more, “revision rhinoplasty” is a more complex procedure that can take twice or three times as long as the original surgery — and can cost 50% to 100% more, depending on what’s needed. Dr. David McDaniel, a dermatologist in Virginia Beach, Va., says he spends much more time these days correcting others’ mistakes with lasers and injectables than he did even a few years ago.

INFORMATION PLASTIC SURGEONS WON'T TELL YOU: NUMBER 4

4. “Long-term effects? Beats me.”

More than other specialists, plastic surgeons are under pressure to compete with one another, and an easy way to get the upper hand is to offer all the latest technology. Doctors are sometimes happy to try new techniques before the long-term effects are clear. While still a small part of the overall market, cosmetic vaginal “rejuvenation” surgery is popular in certain circles despite concern by the American College of Obstetricians and Gynecologists and others about the long-term safety and questionable ethics of the procedure.

Even when a procedure isn’t new or controversial, there’s hardly a wealth of information on long-term results. While a prospective patient has only to do an online search of a procedure to come up with half-naked pictures and commentary from patients who have had it done at websites such as RealSelf.com, an online community, most of the talk surrounds the procedure and its immediate results. Fewer patients weigh in decades after the fact. And in their “after” shots, surgeons don’t often include photos of a procedure years later.

“They’ll all say their techniques will give you the longest result,” says Nicole Fallen, 38, a mother of three (including twins carried to term) from the San Francisco Bay Area. She says she interviewed at least seven surgeons before choosing one — based in part on his communication skills — to perform a tummy tuck and breast lift that also corrected her pregnancy-related diastasis recti (a separation of the abdominal muscles).

INFORMATION PLASTIC SURGEONS WON'T TELL YOU: NUMBER 3

3. “Bargains can come back to bite you.”

With social media sites handing out cosmetic-treatment discounts like candy, it’s easy to get caught up in bargain-hunting for Botox. But cosmetic procedures — from facial fillers to face-lifts — are not commodities that are equivalent regardless of the practitioner, some doctors caution. “No two surgeons have the same pair of hands, experience and knowledge,” says Dr. Foad Nahai, editor-in-chief of the Aesthetic Surgery Journal, a publication of the American Society for Aesthetic Plastic Surgery, and a plastic surgeon in Atlanta. Complications from botched procedures can range from the cosmetic (think: frozen facial muscles) to the fatal, as in cases where patients have died from infections and other post-surgery complications.

                                      

Plastic surgery perfected with 3-D?

3-D technology is helping plastic surgeons make more-precise cuts and easing patients’ anxiety by giving them an advance look at their future faces. The WSJ’s Kurt Achin reports from Seoul, South Korea.

Patients should also be cautious about going abroad for treatments, some experts say. While a tummy tuck in a developing country might set you back $3,000, half of what it costs here, that savings can be easily swallowed up if complications occur. Dr. Eric Swanson, a plastic surgeon in Kansas City, Kan., says he treats patients who’ve had less-than-optimal surgeries abroad. In the case of a tummy tuck, he may have to fix the belly button scar or even redo the entire surgery. There are plenty of skilled surgeons abroad, says Swanson, who spent part of his training in Mexico City, but in some places doctors’ skill levels vary more than here, and regulations can also be more lax. “It’s not like taking a cheap cruise, where you’re not taking a chance with your life,” Swanson says.

INFORMATION PLASTIC SURGEONS WON'T TELL YOU: NUMBER 2

2. “Discomfort? More like extreme pain and oozing.”

Before Kim Gregson, 49, had her tummy tuck and liposuction operation several years ago, her doctor told her she’d experience some “discomfort” after the surgery. The reality was some of the most intense pain she’d ever experienced, says Gregson, a human resources professional in Madison, Wis. While she couldn’t be happier with her results three years later, she still shudders at the memory of the recovery: Despite regular doses of two prescription painkillers and ibuprofen, “I was miserable,” she says. Blood oozed from the two temporary drainage pipes that hung from her hipbone-to-hipbone incision. After the worst of the pain subsided, the swelling began. Her doctor’s office said it would be “mild.” Instead, she had massive swelling that lasted for seven months. Forget about skinny jeans — she didn’t fit into her regular, pre-surgery pants for more than two months after surgery. Gregson had requested two weeks off work but ended up taking three and a half, returning swollen and sore nonetheless.

                                       

Weight-loss surgery that isn’t just about vanity

More patients are opting for tummy tucks or other "body contouring" procedures after serious weight loss or bariatric surgery that aren’t just about vanity: they lessen the risk of infection and improve healing after surgery. Laura Landro reports. Photo: Miami Plastic Surgery.

There’s a general perception in society that cosmetic surgery is somehow less physically taxing than regular surgery, since it’s elective and aesthetic in nature, says Dr. Robert X. Murphy Jr., president of the American Society of Plastic Surgeons and a practicing plastic surgeon at the Lehigh Valley Health Network in Bethlehem, Pa. Surgeons should stress during the pre-operative discussions that “this is a real operation, not something whimsical,” he says. He uses diagrams to reinforce that message, showing how much of the body is affected by different procedures. (Some patients might be surprised that work during a tummy tuck extends from the rib cage all the way down to the pubic bone, for example.)

Dr. Jack Fisher, president of the American Society for Aesthetic Plastic Surgery and a practicing plastic surgeon in Nashville, says there’s a “continuum of recovery” with plastic surgery procedures, and some patients fall on one end or the other. Tummy tucks cause some of the worst discomfort of any procedure, he says, since they tend to involve a long incision and extensive muscle repair and tightening; what’s more, of all tummy tucks, those done after extreme weight loss on excess skin (as opposed to on postpartum pooches) tend to be the most intensive, Fisher says. Gregson had her surgery to trim excess skin after losing 60 pounds on her own beforehand.

INFORMATION PLASTIC SURGEONS WON'T TELL YOU: NUMBER 1

1. “I trained a whole weekend to learn this procedure.”

Dentists, gynecologists, barely trained spa technicians — it seems like everyone’s offering anti-aging treatments these days. And no wonder: Cosmetic treatments are a lucrative business, with $11 billion spent (on 14.6 million procedures) in the U.S. in 2012, up 5.5% from 2011, according to the American Society of Plastic Surgeons. That’s appealing not only to physicians hoping to offset the costs of higher malpractice premiums and lower reimbursements from insurance carriers but also to so-called medical spas that don’t even have a doctor on site when certain treatments are administered.

Traditionally, doctors from just four medical specialties — plastic surgery, dermatology, otolaryngology (ear, nose and throat), and ophthalmology — have handled the bulk of cosmetic offerings, including everything from minimally invasive aesthetic treatments like botulinum toxin (sold under the brand name Botox) to more involved procedures like face-lifts. And those specialists spend years honing their chops in residency training programs that teach skills unique to each specialty in addition to basic surgical skills.

                                        

Americans spend billions on cosmetic plastic surgery every year but MarketWatch's Thomas Bemis says there are things you may want to know before you and your wallet go under the knife. (Photo: Getty Images)

By contrast, those hoping to offer a little Botox in between filling cavities or giving Pap smears tend to opt for quicker training in cosmetic procedures, including weekend workshops offered by the International Society of Cosmetogynecology, an organization that promotes plastic surgery as an extension of gynecology, two specialties that are linked mainly by their female patient base. (Dr. Marco A. Pelosi III, a cosmetic gynecologist and founder of the association, says that the relevant skills and knowledge necessary to grasp and master the majority of common aesthetic contouring is easily understood and quickly learned, as the requisite skills are common to all surgery.)

Indeed, less formal training doesn’t necessarily correlate to reduced proficiency. Experts urge consumers to look for physicians with extensive experience, which could potentially compensate for shorter training. Still, some experts worry that it’s difficult for consumers to distinguish between hype and quality: “Unfortunately, this is an industry where the most creative, assertive, sexiest marketing often drives the business, but it may not be someone with the best experience,” said David B. Sarwer, a professor of psychology at the Perelman School of Medicine at the University of Pennsylvania.