Health,Beauty and Politics

Meetings and Coffee Go Together Like Ice Cream and Cake

admin — Tue, 31 Aug 2010 20:13:57 +0000

There are 2 reasons to attend a medical meeting: the lectures and the coffee. The purpose of the lectures is obvious. The coffee, however, is the meat of the meeting.
I will be speaking in Croatia in a few weeks and the excitement is two-fold. First I will be able to present my work on soft tissue rejuvenation using low energy lasers and newer fillers like hyaluronic acid and poly-L-lactic acid. While our original emphasis is on facial rejuvenation and effectively reversing facial aging, our newer work involves treating floppy or sagging skin, cellulite, stretch marks, and mildly distended abdomens after pregnancy. I have been using mini-treatments of fractional laser resurfacing and injections of salt water to stimulate new collagen in all parts of the body. Many of the patients are pleased with the results though the techniques are early in development and will be much better in a few years. And that work is complemented by our results improving the aging face due to resorption and collapse of all the tissue layers of the face: bone, muscle, fat, and skin. Starting at age 20 skin begins to thin in a linear fashion with age. Also, the outer 5% on each side of the face withers making the face narrower and therefore appear longer. How often do I need to re-iterate that adult women have no business wearing long hair along the sides of their faces. They look older! Of course the easy thing to do would be to inject fat into the depressed areas but the reality is that women who don’t need fat have it; and women who need fat do not have it. That is where poly-L-lactic acid (Sculptra) has been such a treasure as a “biostimulant” for new collagen. Anyway, I want to present my findings and my theory that with energy and stimulation, virtually all tissue can revive. (Same with functionality and exercise. Just ask anyone in my alter cocker group.)

The coffee… the coffee is the good part. I wonder if it is beer in Croatia. Anyway. I get to meet with my European colleagues and see what they have been up to in the past year. I will have 3 American compatriots join me and we, along with the French, the Germans, the Austrians, the Italians, the Dutch, the Croatians, and whoever else will come along will do some free-associating while viewing the beautiful Adriatic and imbibing local fare. This is where the good stuff is told. Two years ago I learned techniques of the Botox face-lift, last year I learned about the physiology of facial aging, and who knows what I will learn this year.

I wish you all a youthful time and I will share secrets when I return.

John Wayne Fights Skin Cancer

admin — Wed, 25 Aug 2010 11:10:05 +0000

Whoah!. Little Lady …(inflection as spoken by John Wayne to Janet Leigh).
Did you see them figures on the rise of skin cancer in the latest publication of The Skin Cancer Foundation? Between 1994 and 2009 the number of yearly skin cancer cases in the US has risen from 1 million cases per year to 2 million cases per year. Malignant melanoma now kills 8600 Americans per year – up from 8000. Indoor tanners have 4.44 times the risk of malignant melanoma as non-tanners (confirmed by the World Health Organization). Window glass filters UVB radiation but allows more than 60% of UVA to penetrate. So much for the ridiculous protests of the tanning industry . The federal government now taxes tanning parlors but classifies the tanning booth as a Class I medical device. Elastic bandages and tongue depressors are also Class I medical devices and I never heard anyone imply that they cause cancer and death.
Now I am not going to get smokers to stop smoking, alcoholics to stop drinking, and tanning addicts to stop tanning. But what about your kids! In Australia every child born will have at least one skin cancer in his lifetime. Right now the odds are something like 1 in 7 children born in the US will have skin cancer at least once in his lifetime and we will achieve Australian status soon. It seems to me that this epidemic will only be controlled by educating young people on the risks and rewards of sun exposure. Yes sunlight is essential for mental well being. Yes, it is an important factor in producing Vitamin D. Yes, I thank God every morning I step out of the house and the sun is shining (I am serious). But enjoying the gifts of Earth does not imply endorsing self-abuse. I see no value in cutting off skin cancer after skin cancer as if that is good medicine although it provides a great living for dermatologists and plastic surgeons.
So here are some ideas:
1. Talk to your kids and grandkids about the need to avoid too much sun and especially sunburns
2. For children under the age of 2 use protective clothing and umbrellas and do not smother them in sun screens which can penetrate their young skin and go into which organ???
3. Sun screens are screens. They let UV light through!! They must be applied every two hours to be effective and they must form a reservoir in the skin to be effective.
4. Do not use combination sunscreens and insecticides. They usually don’t work and they may be harmful.
5. If you have had skin cancer you have 100% chance of another cancer if you live long enough
6. Get on the adjuvant band-wagon. Ask your doctor to help you prevent skin cancer.
7. Take oral vitamin A 10,000-20,000 units daily and get a blood test once a year to make sure you don’t overdose.
8. Apply tretinoin (vitamin A) to your face every night for the rest of your life. Topical and oral vitamin A may provide up to 98% protection from new skin cancer.
9. If a lesion suddenly appears or changes in size, shape, color, or bleeds, see a dermatologist.
10. Don’t give double messages to your kids! If you take care of yourself they may take care of themselves. If they don’t get the message have the kids see me. Sometimes the message gets clearer when presented by someone outside the family- or by an uncle.

Cosmetic Surgery Requires an Accredited Surgical Facility

admin — Sun, 01 Aug 2010 09:58:33 +0000

I began my medical practice in 1973 knowing nothing about how to run a business let alone a medical practice. A highly respected teacher and dermatologist was kind enough to refer me to his attorney to help get me started. Bernard Kleinman was himself a respected tax attorney who took me under his wing and treated me like a son. When we first met I asked him how might I evaluate someone as a good attorney (I am suppressing all of my cynical rejoinders). He said you start with someone you respect and have reason to believe is good at his profession. He may be a doctor, a lawyer, an accountant, or whatever and you ask him to recommend someone to you. He said that individuals who are accomplished in their profession and ethical will refer you to someone like themselves. That is because good professionals are only comfortable with accomplished professionals and poor ones need to associate with those less skilled or moral to maintain their own status. That advice has guided me through my entire career.
So why should you make sure that if you are going to have surgery, any surgery, but perhaps most importantly cosmetic surgery, the facility in which you are about to trust your future happiness or even your life is nationally accredited? (I separated cosmetic surgery because it is perhaps the least regulated of surgical subspecialties (vying with pain clinics and a few others for special mention as buyer-beware clinics or in the immortal words of the philosopher P.T. Barnum “There is a sucker born every minute.”).
There are several reasons to choose an accredited surgical facility. First, consistent with Mr. Kleinman’s advice good doctors tend to congregate with good doctors and accredited surgical centers have criteria for privileging doctors that an unaccredited medical office does not. Second, accrediting bodies have a stringent list of criteria that the surgical facility must meet in order to be accredited. These criteria include sterile preparation of instruments, records of documentation of the protocols of the center, and most importantly the ability to sustain the life of a patient should a crisis arise.
The three main accreditors of ASCs are American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), Accreditation Association for Ambulatory Health Care (Accreditation Association or AAAHC) and The Joint Commission. Ask for them and if there are any doubts call the agency to double check that the facility in question is up to date. If an ounce of prevention is worth a pound of cure this certainly should be a priority.

Yahoo Released Its Best Hospital List: Do You Care?

admin — Sun, 25 Jul 2010 17:47:54 +0000

Yahoo just released its current report: Best Hospitals (in the U.S.) 2010-11: the Honor Roll. There were no surprises although I believe I could find another 14 hospitals equally good. The list includes John Hopkins, Mayo Clinic- Rochester, Mass General, Cleveland Clinic and others; and much as I see the logic in this list I also see the perverse irrationality in its construction.
For instance: why does Yahoo publish this? Is it an interesting item that sells advertising? Is it a public service? Since there are only 3 hospitals in the West (2 in Calfornia and 1 in seattle) and 2 in the Midwest, and the rest are on the east coast, am I to believe that people are going to travel coast to coast to go to a best hospital?
More important, who takes these evaluations seriously? The reality is these hospitals are the site of origin of many of the clinical studies in the United States and cultivate much of the innovative brain power in medical care. Yet only 1 in 4 Americans with cancer will consent to enter a clinical study and less than 20% of women with breast cancer do so. The reality is these university health systems have partnerships with community hospitals that are laced with financial incentives and the university systems would not impugn the reputation of any clinical hospital for fear of economic reprisal. And another reality is that there is economic competition between community based physicians and university based physicians and it is not in the economic interest of community based physicians to promote the services of the university health system.
Then there is the issue of unaffordable health care and a health care bill passed by the Obama administration that ignores the main causes of runaway health care costs and rewards the beneficiaries of the system. I am referring to the health insurance companies and the trial lawyers who lobby through the trial lawyer associations and its many euphemistic marketing organizations. It cannot go unnoticed that both Barack Obama and Hillary Clinton are attorneys and have supported the heavy contributors to their election campaigns (I bring in Clinton since she was Obama’s main competitor for the Democratic nomination).
Ultimately it is my judgment that the awarding of kudos to what are in fact excellent centers of medical care are just so many marketing ploys to promote the interests of marketing companies (i.e. Yahoo) and political interests. I sense that it is unlikely that we will either address the real issues of disparity in the availability of superior health care or address the issues of educating a poorly informed public as to their more rational choices in times of serious illness.

Liposuction is Safe and Effective

admin — Thu, 15 Jul 2010 14:24:09 +0000

Sometimes it’s good to reflect on where we have been and where are we now. Sometimes it even leads to where are we going, but for this blog that will have to wait another day. I have practiced liposculpture since 1992 so I have seen the fads and the promises and the disappointments and mostly I have seen an incredible evolution in body contouring.
For what must be first and foremost, the procedure is safe when performed by well trained surgeons in certified surgical centers. Blood loss has been all but eliminated and pain has been minimized. Most cases can be done using local anesthesia and recovery time has been minimized. Virtually all patients can walk 4-8 miles per day the morning after surgery if they could walk 4-8 miles per day before surgery.
A decade ago total body liposculpture meant one procedure to sculpt the abdomen, waist, back, and hips and another procedure to sculpt the circumference of the thighs. Today liposculpture can be performed on the face, neck, breasts, abdomen, waist, back, thighs, legs, and ankles. Fat can be transferred from one part of the body and used to make the face more youthful or enhance the fullness of the buttocks.
A decade ago our notions of what constituted an ideal body appearance was grandiose and existed only in the mind of the beholder because there were no criteria for what a normal body looked like or how people with different body types could achieve their ideal form. Today we know that it is the musculoskeletal appearance which dictates body shape and the purpose of body sculpting is to show that as best as possible.
A decade ago we understood that removing fat would cause skin to retract but we didn’t know how to enhance it. One of the banes of the procedure was loose or hanging skin after a procedure and while we haven’t completely solved the problem laser lipolysis has greatly improved results in addition to shortening healing time.
So now we have liposculpting for women and liposculpting for men. We have laser lipolysis known as smartlipo and coollipo, and slimlipo among others to enhance skin appearance. We have circumferential liposculpting for thighs and torsos, and liposuction for breast reduction for men and women. Stove-pipe legs and ankles can be shaped and sagging arms tightened.
Perhaps my one concern is that so much liposculpting is performed in non-accredited surgical centers and so many by doctors who are board certified but not cosmetic surgeons who are appropriately trained dermatologic surgeons, plastic surgeons, facial plastic surgeons, oculoplastic surgeons, general surgeons, oral-maxillofacial surgeons, and gynecologic surgeons. While price certainly matters the disillusionment in patients I see who have had surgery done at some of these locations is disturbing. Most puzzling are how many patients go to medi-spas as a result of internet advertising despite the fact that they don’t know who their doctor is much less have a relationship with him. I guess for a fogey like myself it is a product of the IT age and I will have to keep my concerns to share with patients who already agree with me. In the meantime, the technology is here for safe, reproducible, and efficient body sculpting and for that I am grateful.

You probably need Vitamin D

admin — Tue, 29 Jun 2010 22:14:29 +0000

As my friend and mentor on Mad Money, Jim Cramer, likes to say: When the facts change, change your position. It is so easy to make fun of experts after they stake out a position that is tenuous at best, even when they are your colleagues. So it was when I took out my pen-cudgel and attacked the bandwagon proponents of Vitamin D. You know who they are. They are the doctors who have you come in repeatedly for the same blood tests, give you medicines which are natural and homeopathic and of course which are good for you. They are the doctors who use baby talk as when they refer to “your tummy” or listen to your heart and take blood pressure through your clothes and who interrupt you as your describe your symptoms (oops, did I do that?). They are doctors who rationalize that placebos are actually good for you because they do no harm. So here I am indignantly self-righteous, proclaiming truths and pithing the parochial platitudes of self indulgent monoliths of medicine.

Thus it was that I took out my sword and slayed the dragons who proselytized the universal good of Vitamin D. Indeed they would have you believe it cures everything from cancer to depression to arthritis, to gout. It can be bought over the counter or with a prescription and in doses from 400 units to 50,000 units and damned if anyone knows where it came from or how it works but we all need to take it and for sure follow it with repeat blood tests.
Yet now I am taking vitamin D and I can tell you I am swallowing a lot more than a little capsule with each morning dose. So maybe if I give you a little information I can expiate some of my guilt and still maintain my peacock airs: Previtamin D comes from cholesterol. Yes, the same cholesterol you are paying your doctor to reduce. It is converted to vitamin D in the skin. It has been linked to heart disease and to diabetes and there are a host of other diseases which have been implicated. I am struck by the first two. I am also struck by the fact that Vitamin D concentration diminishes with age and most especially by a reduction in exposure to sunlight. So here is the kicker. The darker skinned a person is the more likely he will have vitamin D deficiency. And by extension if you are an adult (chronologically) and a city dweller you have up to a 70% chance of being deficient in Vitamin D after the age of 40; worse if you are African American. One last point: sun screens may reduce the ability to form Vitamin D. For all my readers in Miami you are stuck between a rock and a hard place. But listen up Chicago: we are lucky if the sun shines 4 months a year! It is OK to lighten up on the sunscreen during the winter and other cloudy months.
So there you have it. I took a friend’s advice and measured my own Vitamin D and I am really deficient. I took my friend’s advice and began with large doses of Vitamin D3 (the stuff we normally make) and then followed it with repeat blood tests and as my levels headed toward normal I switched to the exogenous or externally produced forms. I would worry about my forthcoming guilt but I think I am developing Alzheimer’s and I will forget my embarrassment by tomorrow. For those of you living in the city and over 40 years old, it may not be a bad idea to have your doctor draw vitamin D levels. But never tell him that it was I that suggested it.

To Evaluate Your Appearance, Really Look in the Mirror

admin — Sun, 20 Jun 2010 12:51:21 +0000

A person cannot live without seeing with his eyes. A blind person is also a person but if you are not seen you are nothing.
Per Olov Enquist
My appreciation to my wife for translating this beautiful piece of prose from her native Swedish.

As you can “see” seeing with your physical eyes is not the subject of this man’s observation. Seeing with your heart and mind is. I am torn between the emotions of Father’s Day, the emotions of my Swedish wife and friends on the day after the wedding of the Swedish princess, and the consternation of some of my patients’ who do not appreciate their reflection in the mirror.
For Father’s Day: I am struck at the perceptions I keep with me as I reflect on life with my father. I remember now how he would pull the car off the road on vacation and take the time to say “Look how beautiful that tree is”. I had no idea what he was talking about. Now it is I who pull off the road. When he spoke of every man being equal he had never heard of The Tea Party or envisioned Arizona, embattled with crime, unemployment, and a housing crisis passing a law to discriminate against one ethnic group. And he loved to travel and visit people with other customs and other heritage. I didn’t know I would marry my lovely Swedish wife and she would introduce me to cultures and customs I only vaguely appreciated.
As to the wedding of the Princess: I have no feelings. But I finally grasped how we took the Kennedy’s into our hearts, how Barbara Bush taught us family values, and how I enjoy seeing President Obama’s children grow up. I cannot relate to the Princess but I value the tears of joy my wife sheds for a nostalgic connection.
Now for the mirror. I have clichéd the lies of the mirror portrayed in Cinderella for years, yet the cliché’s do not go away. Most of us would not drape a child in make-up, revealing clothes, high heels, or hair spray; nor would we cover their beautiful faces with coiffured hair, or piercings through every orifice imaginable. Yet time after time I see people do this who see something odious, something distasteful, something shameful in the mirror. Rather than enhancing their image they vilify their appearance. All of this in an attempt to be seen. To be valued. To be important to others and secondarily to themselves.
For me, we can each do ourselves a favor. Pull your hair back off your face; lose the make-up and jewelry for a day; lose the earphones, the cell phones, and the music; go for a long walk; smell the smells of nature; and be grateful that we are alive and some of God’s beautiful creatures.

Stretch Marks, Wrinkled Skin, Scars, Cellulite Now Treatable

admin — Sat, 12 Jun 2010 10:23:43 +0000

For the last decade fads and bogus claims have promised to remove or reduce stretch marks, wrinkled skin, scars, and cellulite without actual proof. These money-making schemes have brought riches to some entrepreneurs and little pleasure to patients who have opted to have a variety of creams, potions, and treatments applied to their faces, bodies, and especially thighs. At last the wait may now be over as effective treatments have been elucidated to improve and in some cases resolve these age-old cosmetic concerns.
Pioneering research from the University of Michigan Department Of Dermatology has revealed some of the answers to questions of how to regenerate skin. While more research needs to be done, their work conclusively demonstrates that old or damaged skin has frayed collagen fibers which do not stimulate fibroblasts (the cells that produce collagen) to do their jobs efficiently. In fact, just the opposite. The frayed fibers somehow induce the fibroblasts to curl up and produce collagenase which further dissolves the good collagen that exists. The therapeutic pearl of their work demonstrates that fibroblasts can be made to stretch out and again produce normal collagen, even if they are old in age or worn out by injury. The only caveat is that the fibroblasts must still be present in the affected tissue.
First described in Europe and now elucidated at the U of Michigan, injected hyaluronic acid (aka Restylane and Juvaderm) has been repeatedly shown to stretch fibroblasts and thereby induce them to produce new collagen. Therefore, the rejuvenating effects of injected hyaluronic acid fillers are not only due to their volume but also to new collagen production.
Saline was also tested for its stretching abilities at the U of Michigan and it was found to be less effective than hyaluronic acid. Nevertheless, work by Dr Mitchell Goldman and repeated by me at MetropolitanMD, has repeatedly demonstrated scar remodeling when used to stretch scars in which there has been a loss of tissue volume.
And for the coup de gras, further work showed that injury to the epidermis, the outer 1 millimeter of skin, sends a message to the dermis, the bulk of the skin, to stimulate fibroblasts to make new collagen. Now we understand a mechanism for the healing effects of ablative fractional laser therapy.
Here is the skinny: Stretch marks, wrinkled skin, scars, and cellulite are now treatable using a combination of salt water injections, hyaluronic acid injections and fractional laser resurfacing. The bad news: as this information hits the mass media medispa charlatans and entrepreneurial physicians will advertise their ability to use these new applications of available technology and because of the nature of their business the public will again be abused.

There is no Team in Medical Specialist

admin — Tue, 25 May 2010 20:30:08 +0000

Peter (not his real name) developed a red spot on the tip of his nose 2 years ago. He is now 16 years old. Last week the spots became more red and formed 2 blisters. His mother took him to a board certified plastic surgeon. The surgeon told the mother he didn’t know what the lesion was but that he could cut it out. He advised them Peter would be left with a permanent scar on his nose.
A 30 year old man told me every time he sees his dermatologist the doctor removes a mole from his body. A mother told me her dermatologist removed 6 moles at 6 different times from her 16 year old son. The moles were said to be “suspicious”. The moles were all benign!
A man came to me and said he had a lesion removed from his face. The doctor told him the biopsy showed “it was nothing”!!
A patient with arthritis was seeing a rheumatologist. He saw her monthly and did repeat blood tests each month which showed no change in her condition.
The chief of orthopedic surgery at one of our Chicago university hospitals billed a patient for a complete physical exam while she was in the hospital. He never saw her!
A patient went to a plastic surgeon asking for help with her neck. He did not comment on the anatomic abnormality which caused her neck appearance or on the obvious bone erosion of her chin due to a 35 year old chin implant. He offered to raise her eyebrows and do a facelift. (I raised my eyebrows too.)
An allergist did repeat series of allergic skin tests in a patient with eczema. The patient cleared in 2 weeks with a prescription for antihistamine.
The stories go on and the conclusions are the same. Many patients experience inaccurate diagnoses and needless care at the hands of medical specialists. The reasons are numerous and include the fact that payments are higher for performing a procedure instead of using diagnostic skills; reduced reimbursements lead to doctors spending less time with patients; failure of any effective oversight for medical care.
Yet the most overlooked cause may be the patient. Last week I did an informal survey of 10 consecutive patients. I asked each if they had seen a primary care doctor in the past 3 years. None had done so! In fact most did not even have a primary care doctor. Patients are self-referring to specialists, which raises the cost of medical care and deprives a patient of the managing expertise a primary care doctor brings. Most of us doctors spend little time in hospitals and because of that we rarely see each other. We certainly don’t talk to each other about our care for a mutual patient or whether our treatments conflict with one another. We don’t discuss what is best for the patient. This is the role of a primary care doctor. The patient who thinks the specialist is smarter than the primary care doctor is cheating himself. He exposes himself to abuse of possibly less ethical or less concerned specialists. He not only gets poor care, he deprives himself of the opportunity to get proper care. The team concept simply doesn’t work without a manager. Following my own advice I made an appointment to see my primary care doctor today. I suggest you do as well.

The Many Sizes and Shapes of Baldness in Women

admin — Mon, 17 May 2010 08:23:15 +0000

Baldness comes in various shapes and sizes, but when it appears on a woman’s head it is always bad. The problem is of such magnitude that doctors vacillate between dismissing female hair loss complaints and ordering a battery of tests they have little idea what to do with. An organized approach to the problem is necessary. In many cases hair loss can be slowed or stopped and in some cases it can be reversed.
Compounding the problem is that baldness now affects women from age 20 to death. Clearly, younger women are losing hair and losing it in greater quantities than in the past, and this has led to more cosmeceuticals and outright irrational remedies for a vexing problem. In addition dermatologists are making diagnoses of hair loss that do not hold up to rational examination.
Perhaps over simplistic, the most common examples of female pattern baldness can be understood in 3 categories, of which there are several subcategories. The most common cause of hair loss is called female pattern baldness or Ludwig’s female patterned hair loss. Most commonly women aged 50-80 present with these complaints however it is more and more commonly presenting in younger women. The hallmark of the process is the maintenance of the frontal hairline, although it may thin. In male pattern baldness the frontal hairline disappears or shrinks. Not so with women. Hair loss tends to be diffuse although most noticeable on the top of the head. Initial complaints range from “my part is getting wider” to “I can see my scalp” to “I am shedding hair everywhere”. Traditionally this is considered a form of genetic hair loss, a pre-programmed event in which cell death of the hair follicle precedes death of the individual. It is often called androgenetic alopecia even though blood tests for androgens, male hormones, are universally normal and the hair loss pattern is completely different from men. In questioning some of the leading authorities in the country I cannot get them to explain why they use this term.
The second most common form of female hair loss is called telogen effluvium. Hair growth goes through cycles: growing, regressing, and resting. The resting part of the cycle is called telogen and typically up to 20% of the scalp hair is resting at any one time. However, when a greater percentage of hair goes into a resting phase at the same time the hair begins to shed more than the normal 100-200 hairs per day and scalp hair appears less dense. Most often this occurs after pregnancy but other causes such as general anesthesia, trauma, infection, and medicines can cause this. The prognosis is excellent and hair growth normally resumes in 9 months as most of the hair will be restored.
The third category involves nutritional deficiency or hormonal abnormalities. Iron deficiency is known to cause hair loss and since many women have heavy menstrual periods with borderline or frank anemia and low iron levels it is one of the first tests ordered by dermatologists. Disease states characterized by hormone abnormalities are unusual but a known cause of female pattern baldness. Polycystic ovary disease (PCOS) and adrenogenital hyperplasia are diseases of the ovaries and adrenal glands respectively and are characterized by associations with masculine changes such as deeper voice, bearded face, and acne. Not uncommonly patients with over or underactive thyroid glands lose hair but often doctors know about their thyroid disease before the hair loss becomes a problem.
I have purposely left out diseases of the scalp since these patients complain of changes in their scalp as well as problems of hair loss. These patients also tend not to present with diffuse hair loss and maintenance of their frontal hairline.
While not an article on remedies, this blog is an attempt to make some sense of the frustration many women experience as they go from doctor to doctor in search of answers for their hair loss. As with all medical problems a history, physical examination, and sometimes a biopsy is necessary to make a diagnosis and from this rational treatments can be prescribed. A rational understanding as well as a realistic approach to hair loss are necessary if treatment is to be effective and if patients are to avoid the plethora of fake treatments available to grow hair.