You’ve heard about stem-cell enhanced fat grafts for rejuvenating the face and the hands…but here’s a new & very cool idea: stem cells to fix an ailing heart.

Here’s the concept: Do some liposuction, and isolate out the small percentage of fat-derived stem cells from the rest of the fat enzymatically. Take these stem cells, and inject them (carefully!) into the heart muscle. The stem-cells then go on to repair the damaged heart muscle, hopefully helping the heart function better, and improving the patient’s symptoms and quality of life.

In the United States, more than one million patients have a severe form of heart disease, known as “no-option chronic myocardial ischemia” with a 10 year mortality rate exceeding 20% and an annual healthcare cost of more than $10 billion. If the idea works, it would be a huge step forward for these patients.

A recent multi-center, 27 patient, double-blind, placebo-controlled European study known as “PRECISE“, looked at this very idea, and the results were recently presented at the American Heart Association meeting. And they are very promising. The patients selected really had no other option, other than cardiac transplantation. As part of the procedure, a small amount of fat tissue was removed with liposuction from each patient’s abdomen. The stem cells were then extracted, and injected into the muscle of the left ventricle.

The researchers found that the stem-cell treated patients not only had a lower cardiac mortality rate over the course of the study, but that they could perform more physical activity after the treatment, and that the heart had a higher functional capacity and better maximum oxygen consumption (reflecting a higher work capacity) when compared to untreated control patients.

Impression: very exciting stuff! Sure it’s a small study, but if it pans out in larger trials, this could be a major breakthrough. Soon, maybe we’ll be seeing the plastic surgeon helping out some CCU (coronary care unit) patients with liposuction for stem-cell harvesting.

Macrolane is an injectable hyaluronic gel product from Q-Med, the makers of Restylane, which is available in Europe, but not in North America yet. Over there, Macrolane has been tried for body contouring applications, including breast augmentation – hence the catch-phrase “boob jab” for an injection of Macrolane to the breast.

In this month’s Plastic and Reconstructive Surgery online is a preliminary publication (ahead of print) of a study from Sweden, looking at a 12 month study of 24 women who had Macrolane VRF30 injected into their breasts for cosmetic augmentation purposes. (Click here for abstract)

Twenty-four women (average age = 37 years) were treated. The Macrolane VRF30 gel, up to 100 cc per side, was injected in the subglandular position with the aid of local anesthesia. Since Macrolane is slowly absorbed by the body, it was fully expected that the results would change over time: at six months post-injection, 83% were pleased with the improvement, and at 12 months, 69% were still considered improved.

While there were no major complications or systemic issues, capsular contracture around the injected material was still the most commonly reported adverse effect, with 25% of patients reporting undesirable breast firmness due to this problem.

The authors concluded that this gel is worthy of further study, and may be an option for patients that want non-surgical improvement of breast volume. Personally, I find the reported 25% incidence of capsular contracture to be a lot higher than I would like to see.

Speaking of HA gels, I’ve often wondered: why not make a breast implant that is filled with a hyaluronic gel, instead of saline or silicone? Might give the feel of a silicone gel implant, but be easy to clean up in case of deflation. Hmmm…..You read it here first, at PSB!

Happy Halloween!!

Allergic reactions to latex are becoming more common. Today, about 3 to 6% of people are found to be allergic to latex…and in the worst case, the reactions can get pretty serious. Prevention, rather than treatment after the fact, is really the key to success.

Latex is the milky fluid from the rubber tree, Hevea brasiliensis, found in Malaysia, Indonesia, Thailand, and South America. In addition to the organic polymer that gives it the characteristic stretchy properties, latex sap also contains more than 200 allergenic proteins.

In terms of surgical history, William Halstead was the first to use latex surgical gloves, back in 1890. Recently, as we’ve become increasingly aware of the need for protection against blood-borne pathogens, the use of latex gloves has skyrocketed. Simultaneously, the incidence of allergic reactions to latex began to rise in both patients and especially in health care workers.

Latex exposure is associated with 3 distinct clinical syndromes.

1) irritant dermatitis. This is the most common cause of latex-induced skin rashes. It is not associated with allergic complications.

2) contact dermatitis. Symptoms usually develop in a delayed fashion, within 24-48 hours of cutaneous or mucous membrane exposure to latex in a sensitized person.

3) immediate hypersensitivity. This is the least common, but most serious type, and is a classic allergic reaction against latex proteins. Symptoms generally begin within minutes of exposure. Symptoms range from rash and itching, runny nose and watery eyes all the way to bronchospasm, hypotension and full blown anaphylaxis.

Interestingly, certain other tropical fruits can have an allergic cross-reactivity with latex allergy: avocado, banana, chestnut, kiwi, papaya, peach, or nectarine. People who are allergic to one are more likely to allergic to the other.

So, what do we do if someone says they have a latex allergy? First, as best as possible, we try to learn the story, and get the details of what happened. What kind of reaction did they have? Was it immediate or delayed? If there are further unanswered questions, evaluation by an Allergy specialist is helpful.

Fortunately, with the increased awareness of this problem, most operating rooms (including our own) have the ability to use a latex-free set-up. There is no latex whatsoever in the anesthesia equipment set-up, the rubber syringes, IV tubing, the surgical gloves and gowns, surgical tapes and dressings. By avoiding any exposure to even the smallest bit of latex, the patients can do very well, and have a safe operation. Also, breast implants do not contain any latex – so they don’t have the potential for a latex reaction.

If you think you might be allergic to latex, please mention it to your surgeon. With proper preparation, latex allergy issues can be avoided.

In this month’s issue of Aesthetic Surgery Journal, Dr. Barry diBernardo presented his latest study on skin shrinkage after laser-assisted liposuction. The study was funded by one of the laser manufacturers. Dr. diBernardo has been diligently researching this area for several years, and my impression of him after seeing him in person is one of an honest researcher.Dr. diBernardo measured rectangular areas of skin, based on tattooed markings, on the patient’s abdomen, and also used a device to measure skin flexibility both before and after surgery. One-half of the abdomen was treated with the laser liposuction with the laser turned on as usual, the other half treated with the laser turned off – only suction. Patients were evaluated pre-surgery, at one month and three months afterwards.

Here are my thoughts on the study:

1) Good methodology, but a small treatment group – only 9 patients were studied.

2) Although both treated sides look better, you really don’t see any obvious difference in contouring between the two sides in the photos. Maybe it’s a case of “Good surgeons get good results, regardless of the tool they are using”. The laser side does not look significantly better than the non-laser side.

3) Data for skin shrinkage show an average of 16% area shrinkage on the laser side, versus 13% shrinkage on the non-laser side, at three months after surgery.

In other words, there’s a…wait for it…three percent difference in skin tightening between laser liposuction and standard liposuction. Three percent area change is a very small difference indeed, but it was found to be statistically significant in this study.

I would counter that although it may be statistically significant, the difference is certainly not clinically significant in terms of appearance, and that’s what my patients care about.

4) The skin became stiffer and less pliable after laser liposuction. Is that a good thing? I don’t agree with Dr. diBernardo that skin stiffness is a desired endpoint. After all, beautiful skin should be soft and pliable; scars are firm and inflexible. I suspect that the changes are probably due to increased scar tissue within the dermis, caused by all that laser energy.

Bottom line: Already, laser lipo enthusiasts are pouncing on this study, saying “See – statistically signficant results”. I’m really underwhelmed by the photos of the results, and a three percent difference in skin shrinkage is simply not impressive at all, in my opinion, regardless of what the statistician says.

Maybe it’s a case where believers want badly to find anything that supports their cause, while non-believers are unimpressed. I’m firmly in the latter group. I’ll put the three-phase “SAFE” lipo method I use up against the laser, any day of the week!

Here’s a little sociological study of plastic surgery patients that made me chuckle, initially reported on the BBC News website. File this under: “it’s not me…it’s them!”

Dr Debra Gimlin, a sociologist at the University of Aberdeen, spoke to 80 female cosmetic surgery patients, aged from 20 to 70, for a study on attitudes regarding cosmetic surgery. Forty were Britons and 40 were Americans.

Dr Gimlin said more than 50 of the 80 women had created the notion of a “surgical other” they distanced themselves from. These were imaginary women characterized as “narcissistic and shallow”, having surgery with little consideration of its risks, who had unreasonable expectations of its effects, and were obsessively concerned with their appearance, quite unlike themselves, who just wanted a natural look from their own carefully considered cosmetic procedure.

British women tended to see the surgical other as living in America, and the American women, who lived in Florida, tended to see her as living in Hollywood, California.

A 47-year-old British sales clerk who had liposuction the year before said: “Over here, we’re not like those American womenwho have loads of surgery without a second thought.”

One 27-year-old American nurse interviewed said: “I’d never want to look like one of those ageing Hollywood starlets who’s gone under the knife a few too many times.”

It’s always the other guy / lady, isn’t it?

Enjoy the long weekend. Don’t text while driving!

According to recent data from the American Medical Association, by age 55, 61% of American doctors have been sued for medical malpractice.

That’s pretty much like saying that nearly 2 out of 3 doctors are negligent, are performing demonstrably below the “standard of care”, and deserve to be punished with a crushing financial blow that could ruin their life and wipe out their savings.

In some specialties, the numbers are even higher. For example: in both Obstetrics and Gynecology, and in General Surgery, 69.2% of these specialists have been sued. Of course, those are high-risk specialties, by the very nature of what these doctors do. At the other end of the scale, only 22.2% of psychiatrists have been sued.

Wake up, everybody! These percentages are absurdly high, especially in what is arguably the best medical system in the world.

Why does this happen in the American legal system? In my opinion, two main reasons: the potential for a multi-million dollar payoff if you happen to win your case, and no downside to you personally if you don’t win. It’s a jackpot system, which encourages people with minor issues to try to sue.

There’s plenty of data showing how frivolous lawsuits add to the cost of health care. Now that the costs of health care are a major issue, it really is time to consider answers to this problem.

Some experts favor changing the existing law in one simple way. Make it “loser-pays” – the losing party would pay the legal fees of both parties. (link to report) That way, people with a legitimate beef can still have all their legal rights to proceed with their actions, but the frivolous ones will be appropriately discouraged by the potential of the major costs involved, if their complaint is bogus. This system is used in Canada, Australia, the United Kingdom, and interestingly, the State of Alaska.

Others feel that a loser-pay system would just increase the size of the monetary awards involved, and not actually reduce the number of frivolous lawsuits.

I’m certainly no legal scholar. But surely, 61% of doctors do not deserve this kind of beating up.

We’ve talked about this before: one theory about why some breast implants become hard and distorted is related to a low-grade infection, called a biofilm, which triggers inflammation and fibrosis (scar tissue formation). Until now, the biofilm theory of capsular contracture was pretty much based on circumstantial evidence and by looking at similar reactions in other implants. No longer.

This month, in Plastic & Reconstructive Surgery, is a well-performed animal study from Australia that finally shows a clear link between capsule formation and a Staph. epidermidis biofilm. Miniature breast implants were implanted in a pig; some of them were purposely dosed with a low dose of the bacteria, enough to cause a biofilm, but not enough to cause outright infection. Thirteen weeks later, the animals were inspected for capsules, and a careful analysis of any capsule or biofilm found was performed.

Of the implants that had a biofilm, 80.6% formed a major capsular contracture (Baker III or IV). Statistical analysis showed that biofilm formation was associated with a four-fold increase in the risk of capsule formation.

Interestingly, a few of the implants that were not purposely inocculated with bacteria also went on to form a capsule. 80% of these also showed the presence of a biofilm. In these cases, the animal’s own skin bacteria were the biofilm-forming organisms, despite excellent surgical technique.

Bottom line: this is one of the first experimental studies that I’ve seen that clearly links biofilm with capsular contracture in a breast implantation model. We’ve certainly suspected this for a while – now we’ve got some good scientific evidence.

Now the million dollar questions: what’s the best way to minimize biofilm formation for breast implants? And how can we best treat biofilms if they’ve already become established?

U.S. News & World Report has released its annual ranking of the nation’s hospitals. They have an honor roll of the top 14 hospitals in the nation (link), and separate ranked lists for different specialties.

I’m proud to see that both University of Michigan Medical Center and Massachusetts General Hospital – both institutions where I did some training – are on the honor roll. Johns Hopkins Hospital came out at #1 this year, as it has for many years.

Locally, Orlando Regional (ORMC) cracked the top 30 in 2 pediatric specialties, pediatric orthopedics & cardiac surgery. The Bascom Palmer Eye Center at the University of Miami was rated #1 in Ophthalmology. Well done!

As always, these listings can vary depending on the weighting of the individual components that go into the scoring system, so if you don’t see your favorite hospital, don’t despair.

I’ve always joked with my wife that if I ever get really sick, I would go to Ann Arbor or Boston. Of course, I was only half-serious. But maybe it’s not such a bad idea after all! Hmm….

This one sounds almost too good to be true, but it comes from a reliable source, and as a chocolate lover, I just have to pass it on! I’d certainly rather have a tall, cold glass of chocolate milk than an electrolyte-based sports drink after a work-out!

Source: MDLinx


New research suggests drinking chocolate milk after a workout offers advantages for post-exercise performance and muscle repair

BALTIMORE (June 2, 2010) – One of the best post-exercise recovery drinks could already be in your refrigerator, according to new research presented at the American College of Sports Medicine conference this week. In a series of four studies, researchers found that chocolate milk offered a recovery advantage to help repair and rebuild muscles, compared to specially designed carbohydrate sports drinks.

Experts agree that the two-hour window after exercise is an important, yet often neglected, part of a fitness routine. After strenuous exercise, this post-workout recovery period is critical for active people at all fitness levels – to help make the most of a workout and stay in top shape for the next workout.

The new research suggests that drinking fat free chocolate milk after exercise can help the body retain, replenish and rebuild muscle to help your body recover. Drinking lowfat chocolate milk after a strenuous workout could even help prep muscles to perform better in a subsequent bout of exercise. Specifically, the researchers found a chocolate milk advantage for:

– Building Muscle
– Replenishing Muscle “Fuel”
– Maintaining Lean Muscle
– Subsequent Exercise Performance

Chocolate milk’s combination of carbohydrates and high-quality protein first made researchers take notice of a potential exercise benefit. The combination of carbs and protein already in chocolate milk matched the ratio found to be most beneficial for recovery. In fact, studies suggest that chocolate milk has the right mix of carbs and protein to help refuel exhausted muscles, and the protein in milk helps build lean muscle. This new research adds to a growing body of evidence suggesting milk can be just as effective as some commercial sports drinks in helping athletes refuel and recover.

Milk also provides fluids for rehydration and electrolytes, including potassium, calcium and magnesium lost in sweat, that both recreational exercisers and elite athletes need to replace after strenuous activity. Plus, chocolate milk is naturally nutrient-rich with the advantage of additional nutrients not found in most traditional sports drinks. Penny-for-penny, no other post-exercise drink contains the full range of vitamins and minerals found in chocolate milk.

One of the most interesting presentations at the recent ASAPS meeting was the long-awaited results of the lipodissolve / mesotherapy study. Dr. V. Leroy Young, who is an extremely careful and thoughtful researcher, presented the findings.

The study used volunteers with a BMI < 30 and without significant skin laxity, who had a series of injections into their abdomen in an attempt to reduce their subcutaneous fat deposits. There was no dieting, no other drugs, lasers or surgery used. The typical grid pattern of injections was used to one-half of the abdomen, with a pre-mixed combination of mesotherapy agents (PPC/DC). The patient had a series of up to four treatments into the same area, at intervals of 8 weeks. This method was chosen to mimic what is done at many mesotherapy clinics. Careful monitoring was done with a multitude of measurements, photos, lab tests, and CT scans – before, during and after the series of injections. By only treating one-half of the abdomen, each patient served as their own control.

There were no significant changes in BMI or skin-fold thickness, and no blood test changes as a result of the treatments.

In reviewing the photos, the before and after “result” photos looked very similar to me. Not much of a change. If there were changes in body shape, I thought that they looked pretty subtle. If I were the patient, I would be pretty disappointed in these results!

There were a couple of CT scans where I could really see a difference in thickness of the fat layer – so something was happening, at least in some patients, some of the time. According to Dr. Young’s numbers, there was an average reduction of 7% in the subcutaneous fat thickness.

There were no major adverse effects reported in the mesotherapy study group, but patients’ post-op complaints included pain, swelling and nodule formation. Despite that, most of the patients wanted to go ahead and treat the opposite side!

Bottom line: It’s good to finally see this kind of non-biased, carefully controlled research being done. Personally, I was not impressed with the changes, but it might have some application for small areas where a little further refinement of a result might be desired following real liposuction. Too early to tell on that idea, though.

When the final report is issued in the Aesthetic Surgery Journal, I will be able to comment on it in more detail.


Plastic Surgery In Florida