If It Ain’t Broke…
In my last blog I wrote that my wife was an early devotee of this fine eating establishment back when it first opened in the mid 1990′s in Denver, Colorado. One of the remarkable things is that their menu has not changed since that time. I have been going to them for 15 years in many different parts of the country, and have never seen any difference in the menu, ever. Why? Quite simple. Their menu works and works well. There is no need to change it in anyway. That is to say: it ain’t broke, and it’s not in need of fixing. Remember the now infamous history of New Coke? I rest my case.

Here’s How It Applies to Breast Implants
The phrase “if it ain’t broke, don’t fix it” is helpful both as a principle, and as a way to explain things. In talking with my patients about breast implants, one topic is when, if ever, do they need to be replaced. Many people have been laboring under the assumption that they have to be replaced over the years. Not so. If they are doing well and there is no problem with them leave them alone. They may last for ten or fifteen more years. If it ain’t broke don’t fix it.

Concerning Plastic Surgery….
In plastic surgery we are assaulted by new machines, new techniques and new products. Some of these are great. Others offer nothing over existing products or technologies. And my challenge is to figure out which is which but one of the things I always go by is to understand if this is new and better, or just new. Because if it is not better, I may be fixing something that is not broken.

This is true of operations as well. One of the reason I go to our national meetings is to see what other people are doing around the country. Every now and again, there is something presented that fundamentally may change something that I am doing. But more frequently, I will see results that someone else is presenting, and realize that my results are every bit as good. This does not absolve me of the responsibility of being on the lookout for new and better techniques, but it may allow me to be content with what I am doing and not feel the need to change what is working.

This principle is not one I remember my father saying to me. But he may well have, or said something similar. But it is a sound principle, and a successful one. So, when you’re thinking about changing something just remember — all together, now — if it ain’t broke, don’t fix it!
All the best,
David B.

The report listed the top 25 countries and their respective trends. Any guess on which operations were the most common?

And The Winners Are…
So, let’s see who’s doing what where (I know the suspense is killing you):

• Country with most operations performed: USA (followed by Brazil and then China)
• Top procedures worldwide: #1 Liposuction, #2 Breast Augmentation, #3 Blepharoplasty (eyelid surgery), #4 Rhinoplasty, #5 Abdominoplasty.
• Country doing most liposuctions: Brazil
• Country doing most breast augmentations: USA
• Country doing the most blepharoplasties: Brazil
• Country doing the most rhinoplasties: Brazil
• Country doing the most abdominoplasties: USA
• Country with the highest per capita number of plastic surgeries: South Korea*
• Continent with most procedures: Asia (due to China, Korea, India, and Japan being combined)

Analyzing The Winners

You may surprised that Brazil is second in the country with the most operations but I am not. Our Brazilian colleagues have been leaders in the field of aesthetic surgery and they have taught us a lot. Certainly there are differences in how they and we do things, but they have been real innovators. Dr. Saldanha from Brazil is the surgeon who popularized the lipoabdominoplasty, which has subsequently be widely adopted in the States.

I guess what surprised me about the stats was that China ranked number three. I would have assumed that political influences might have lessened the acceptance of cosmetic surgery but this is obviously untrue. Not only is China the largest country, but their growth in all areas of plastic surgery has been impressive.

As for the countries doing various procedures, Brazil and the USA were either first or second in the top five operations. And China was number three except for abdominoplasties. From year to year there maybe some jockeying for the top slot, but this all makes sense to me, particularly that Brazil’s top operation is liposuction, because they seem very focused on this.

Seeing what is going on around the world is always enlightening. What is most important to a give culture in terms of perceived beauty is reflected in the procedures performed there. And, of course, this varies from culture to culture.

Hope these numbers made for interesting reading.

All the best,

David B.

*The South Korean statistics are from an interesting sidebar by The Economist on plastic surgery procedures per capita. They did not publish their methodology, so I am not sure if this is totally valid, but it is interesting. They suggest that South Korea has the highest cosmetic procedures per person than any other country. It was reported that one in five women in Seoul have had plastic surgery. And, by their per capita rankings, the US was #6. Whether or not this is accurate I do not know. But, with a total of 3.3 million invasive and minimally invasive procedures, it appears that our country may not be number one in per capita rankings.

By the end of the first month, they were selling over 1000 burritos a day. The second store opened in 1995, and in 1999 the first store opened outside of Colorado, and most importantly, the first store in Knoxville opened in 2011.

Currently there are now over 1200 stores in 41 states, Canada, and England. In 2010 they were recognized as the third fastest growing restaurant chain, and Consumer reports named them as the best Mexican fast food chain in 2011. Last year’s revenue was over $2.2 billion, and the net income was over $350 million. All from a single restaurant and a loan from his Dad.

Why It Works
How did this all happen? And, parenthetically, what does this have to do with plastic surgery? To the first question, I would say that there are several reasons. But key among them would be quality and simplicity. The Chipotle culture is one that thrives on naturally raised meats, organically grown produce, and dairy products free from added hormones. And, the food is all cooked on the premises. Chipotle restaurants do not have can openers, microwave ovens, or freezers. Early on Steve Ells began using free range pork for his carnitas switching from cheaper, mass produced (and fed) animals. This increased the cost of his burritos, but also increased their sales. With quality products, they can be simply made into great meals.

What you will notice when you eat in a Chipotle, no matter where it’s located, is that the food is always great and it has been so since the first burritos left the line in Denver.

The KISS Principal
The other secret for their success is simplicity. The stores are well- designed, the food prep line flows sensibly, and the menu design is straight forward. This is to say that it is all quite simple, which is a real complement in any business model. Simplicity allows for a consistent and reproducible result, in an easy consumer environment with a low risk of errors. When was the last time your order was not right at Chipotle? It’s never happened to me. The KISS principle (keep it simple, stupid) may well be the key to success.

How We Apply These Ideas In Our Office
In plastic surgery, simplicity is just as important. I could go on ad nausea about areas where I try to make things simpler, but I will give you one example related to paying for surgery. Most people want a simple explanation of fees, i.e. the bottom line, and they want to pay this with a single transaction. For this reason we always quote a price on an operation that will include everything that must be paid (surgeons fee, operating room expenses, surgeon’s fee, implants, follow up appointments, and surgical garments) as a single figure. Then, we allow our patients to pay us for the total price with one transaction, and we will take care of getting the right amount to the right party.

This really eliminates the chances for errors, and makes the whole process much simpler. Further, if there are questions about what has been paid, those questions come to us and not our patients. Long ago we understood that having elective surgery, even if it is something that you really want, can be a bit stressful and not a part of your daily routine. Our goal is the find ways to make this simpler for the patients. If we are successful at this, we are able to eliminate sources of both stress and errors and hopefully make it a better process.

When I was a young man, my father first introduced me to the KISS principle. For me it really has been a guiding principle and I truly believe a key to success.

All the best,

David B.

P.S. Go get a burrito!

Here’s How It Happened:
I went to a meeting and heard a talk by a Brazilian plastic surgeon* about how to safely combine a traditional abdominoplasty with liposuction. This requires that the abdominoplasty is done somewhat differently from a technical standpoint because if you do the tummy tuck in a traditional fashion and simply add in liposuction, the incidence of complications goes way up and that’s clearly not good.

But by following my Brazilian colleague’s technique, the two can be done safely. I distinctly remember him telling the plastic surgeons at the meeting that “you are all doing liposuction, and you are all doing abdominoplasties, so you should be able to us this technique right now.” And that is what I did. This combination procedure is called lipoabdominoplasty.

I have found that the lipoabdominoplasty results in most people are superior to what I could achieve with a traditional abdominoplasty. And now it’s official.

The most recent edition of the Plastic and Reconstructive Surgery Journal has an important study that compares the results from three separate procedures: liposuction alone, traditional abdominoplasties, and lipoabdominoplaties. There was a much greater satisfaction level with both types of tummy tuck versus liposuction by itself. And this is not surprising. The skin tone was better after the abdominoplasties than liposuction alone, thus the shape of the abdomen had greater degrees of improvement. In other words, more was done so the results are better. Sort of a no brainer.

Lipoabdominoplasty Patients Have the Highest Rate of Patient Satisfaction
The best results in the study, from the patients’ perspective, came from the lipoabdominoplasties. Again, this is what we are seeing with our own patients. The combination of the two modalities is better than either alone and they can be done together safely too. I have always liked my tummy tuck results about as much as the results from any operation that I do, but the results from the lipoabdominoplasties are frequently more impressive and better than the regular abdominoplasty.

So what is the point in all of this? Well, in a broad view, it’s great to be involved in a profession where we are constantly evaluating established procedures to see if there is a better to way to perform them. Even more, it’s great to be in a collegial profession where the successes and innovations of one person* are freely shared with all. Because when we do this, it is our patients who end up winning.

All the best,

David B.

*Thank you Dr. Osvaldo Saldanha for developing and sharing this technique.

The same phenomenon that brings us the lovely flowers, trees, and incredible variety of plant life in the Smokies is also what gives us such awful allergies. I am told that the only place with a larger diversity of plant life than the Smokies is the Amazon (and I’m not talking about Amazon.com). As the glaciers receded — and we are about as fall south as they came — they deposited this tremendous variety and diversity of plant life in the Smoky Mountains. And with such diverse plant life, comes an abundance of pollen. And with the abundance of pollen, comes the worst allergies anywhere! Quite a distinction.

Another contributing factor is that this winter has been the fourth warmest on record. I was actually surprised that it was not the first warmest. The azaleas are blooming,and daffodils are almost gone, and it’s not even April! The the topography of the area with valleys and mountains, just keeps all that pollen around. Don’t believe me? Have a look at the hood of your car.

So stock up on your antihistamine and inhalers, get you air filters changed, and keep you tissues handy. The assault from everything from common hackberry to Uraguayan pampasgrassis is coming your way!

Best of luck (I think we’ll all need it),

David B.

P.S. If you have significant asthma or pulmonary disease, be very careful about exercising outside. And, watch for days when there is an air quality alert.

New Kid On The Implant Block
First, the”duopoly” that existed between Allergan and Mentor is over. They now have another competitor. Just how this new kid on the block will fare is yet to be seen. It appears that they have a good, comparable product that has been marketed throughout the world, although not here in the USA. Certainly they will gain some market share from the bigger kids. How much, from whom, and over what time period they acquire their piece of the pie will be interesting to watch. Suffice it to say that Sientra definitely has the attention of Mentor and Allergan.

Form stable breast implants are much firmer and require a longer incision than our current silicone gel implants.

“Gummy Bear” Implants?
The other thing that has come front and center, is the issue of “gummy bear” or form stable silicone breast implants. Many are touting this as the ultimate implant and it looks like Sientra’s form stable implants have been covered in this approval, while Mentor’s and Allergan’s form stable breast implants are still in clinical trials.

The question I have is simple: are the gummy bear implants a truly “better” implant for most women?
Let me at the outset provide the disclaimer that I have not used the fifth generation, form stable, aka “gummy bear” implants. But I have to wonder whether the “advantages” are really advantages? There is no doubt in my mind that these will be better implants for some patients, but are they better implants for all patients?

Pros and Cons
The benefits of form stable implants are supposed to a decreased incidence of rippling, a lower rate of capsular contracture (firmness after healing), a lower rupture rate, and a better shape. On the other hand the disadvantages are: longer scar, higher cost, firmer implant, and possible rotation of anatomic or “tear drop” shaped implants.

Let’s really look at this.

1. Rippling- For me, rippling is rarely if ever a problem with our current cohesive silicone gel implants (Mentor Memory gel). Rippling can be a major problem with saline implants, but they have never been a big issue with silicone implants.
2. Capsular Contracture (firmness after healing)- In terms of capsular contracture, I really need to see the data. But if there is a bit of a somewhat decrease in this with these newer implants, will it be offset by the fact that these are firmer implants in all patients?
3. Better Shape- I am not so sure about the better shape of cohesive gel implants. As the memory gel are softer and more compliant, they will have more change in their shape depending upon the body position. And I think you want this as this is what a normal breast looks like. But there will be less of a “gravitational” affect on the gummy bears, and I am really not sure that this is an advantage.
4. Rupture- True, gummy bears do not rupture and memory gels can. However, rupture does not create health problems, even though the implants will need to be replaced. But what is the life expectancy of the form stable implants? Do they last forever? Doubtful, in my mind. I would expect that over time there will be some fatiguing of the form stable implants. Will this be fraying at the edges? Will some silicone particles be shed into the surrounding capsule? Probably, although this is not problematic or harmful. But we just do not have a lot of data on how these implants perform after they have been implanted for 20 years.

Just Because It’s New, Doesn’t Make It Better.
Like I said, there will no doubt be patients for whom these are the best implants. But there will be many people (the majority?) for whom current implants will still be the best. The longer incision, higher cost and firmer implant may outweigh the supposed benefits. Time will tell who is who, as in all things. And, ultimately, it may just come down to what a woman wants her breasts to feel like.

All the best,

David B.

Undeniably, Botox is the king of the hill when it comes to these products. It’s been around the longest, and is the most widely distributed wrinkle relaxer, or as we refer to them: neurotoxins. The second one in the market is Dysport. We use them both, and find that there are some differences in them, but we are hard pressed to say that one is definitively better than the other. However, Botox is sort-of our “go to” product.

The Gloves Are Off.

Well, the next kid on the block is Xeomin, (pronounced Zee-O-Min). And, it appears that the makers of Xeomin are not playing well with others, and herein lies the story. Last Friday, Allergan, the makers of Botox, won an injunction against Merz Pharma from selling Xeomin. According to the Bloomberg Article it appears that some Allergan employees were sought out to join Merz and delayed giving notice of their resignations while they emailed themselves proprietary information about Botox’s sales figures, customer lists, and things of this nature. The judge cited “graphic examples of misappropriation” in his ruling. How long the injunction will be is unclear at this time.

We Weren’t That Impressed with Xeomin Anyway.
Interestingly, our practice was sought out by Merz to try Xeomin. After using it on a few people, we became quickly disenchanted with it because we found that it didn’t last as long as Botox and Dysport. If our experience was similar to that of others with Xeomin, it is very possible that this product would not have been long lived in terms of its use. So, perhaps this injunction will not have a long term affect on the market anyway.

This story shows that these products represent big business and a lot of money to their manufacturers. Where there is big business there is always the possibility of illegal or at least unethical business practices. This is not the only story regarding the distribution of such products and I will blog about this in the future, but suffice it to say that if you are having wrinkle relaxers in this country… buy American!

More later,

David B.

Societe Intense Firming Complex $120

So no matter what I had planned to blog about –Stop the presses! It’s time to talk about Societe’s Intense Firming Complex. I think we may have found crack for the skin! Let me tell you how we got hooked up.

We are always on the look out for new things, but things that work because there’s a lot of snake oil out there. Our Societe rep sent Heather, our aesthetician, an email about this product along with a before and after photo. She looked at the photos and assumed that the person pictured had a laser resurfacing procedure because the changes were so dramatic. Heather’s no fool, so she wanted to see if this stuff was for real, and asked the rep to send us a sample. The first person Heather tried this on, called from the parking lot after leaving our office and said she already was seeing a difference. The next person Heather used this on accused her of holding out on her by not using the product before. And then there’s this quote:

“I may have to sell some plasma…but that stuff is so good I wouldn’t have believed it if I hadn’t of tried it. I kept looking in my mirror as I was driving and thinking, “WOW!” Finally, I thought, “Okay Snow White’s Stepmother, you’re going to have a wreck if you don’t pay attention to the road.”

Will you have to sell plasma to get this? Doubtful. But you will need to come by and pick this up from our office because you can’t get this in stores. (Or call us and we can ship it to you.)

So how does this work, and what does this do? Societe has combined many different peptides that help to tighten and firm the skin, as well as help to relax wrinkles. A couple of them actually have similar actions to Botox and other wrinkle relaxers. Usually I am quite skeptical about the power of topically applied substances. But I’m convinced about this one (which is why I’m now using it twice a day). But don’t take my word for it. — try it yourself. Or, if you are coming in to see Heather, have her put some on for you. But please, keep your eyes on the road as you’re driving home!

All the best,

David B.

Briefly, this is about two Pakistani women who are victims of acid violence, and the London based, Pakistani born plastic surgeon Mohammad Jawad who helps to reconstruct their faces. Each year over 100 people, mostly women, are injured in Pakistan when acid is thrown on them, a common form of domestic violence. Resultant injures are horrific, and most of these cases go unreported. Dr. Jawad works to help reconstruct the faces of these women such that they can rejoin society. The film’s director, Sharmeen Obaid-Chinoy says that this is a positive story in two ways. First it features the work of Dr Jawad to help the women of his homeland. And secondly, the film follows in depth the parliament’s passage of a bill against acid violence.

All too frequently when one thinks of plastic surgery and the Academy Awards the subject is who has recently had a facelift or who has had too much Botox. But this is a story about the other side of plastic surgery: reconstructive surgery. The majority of all plastic surgeons do a great deal of this. And many do so through charities. Featuring this work and the impact it has on the lives of those people who have been affected by injury or disease is a tremendous story. And while I am sure that Dr. Jawad is very gratified to see his work so honored, his greater reward is seeing the impact of his work on the lives of these women.

Congratulations to everyone associated with this effort, and many thank to the Academy for recognizing this work!

Your Nose Knows Your Age?
So, everyone who is planning to have a rhinoplasty to look younger please raise you hand. Anyone…anyone? Thought so. Now, all those who are having a rhinoplasty to improve the appearance of your nose or to improve your breathing, raise you hand. OK, that makes more sense. The concept of selling a rhinoplasty as a way to look younger is just silly.

Beyond this bit of science fiction, how much younger is a year and a half really anyway? Does this actually mean anything? I think not. A good night’s sleep can definitely make me look better. Likewise, coming home from a great vacation I know makes me feel and look better. Conversely, staying awake all night working can definitely make me look terrible, older, crankier…..just fill in the blank.

Happier People Really Do Look Younger
The real point of all this was mentioned by some members of the American Society of Plastic Surgeons who were interviewed in the article. Their take was this: these people were happier with their appearance and the appearance of their nose and thus they looked happier and looking happier made them look younger. With this, I agree. It’s a phenomenon that plastic surgeons see all the time. As one aspect of a patient looks better after surgery or other procedures, other aspects of their appearance look better, making them look even better overall.

The bottom line is this: have a rhinoplasty if you want to change the shape of your nose. When we are happier with how we look, we all look younger. It’s as simple as that.

David B.