Here is the second part of the Plastic Surgery Gone Awry segment, featuring Dr. Walden and a panel of experts on the “After the Show” Show (watch through the first few minutes to see the panel). Gretchen Carlson and Steve Doocy of Fox and Friends Morning Show ask the questions on their minds about the lack of regulation in the fields of surgery and plastic surgery, as patient safety is in question. The cases of non-medical grade silicone caulk being injected into the buttocks of 7 women in a Newark hotel by a charlatan claiming to be a plastic surgeon are discussed. Also, the case in Florida of a young woman who died after undergoing liposuction at a tanning salon after receiving local anesthetic injections and Propofol (the powerful intravenous anesthetic agent that killed Michael Jackson) is covered. Finding a plastic surgeon who has undergone proper training and credentialing is of utmost importance when selecting a provider, so find out why it is extremely prudent to find a board certified plastic surgeon
The rise of medspas and a recent liposuction death in Florida in a young 37 year old nurse bring to light several issues our specialty is confronted with. Read the news story here.
Liposuction performed by untrained and non-certified doctors and paraprofessionals can lead to detrimental and possibly even fatal outcomes that can be prevented. This case illustrates that point, as a doctor who had only gone to an 18-hour training course in liposuction and was actually an occupational medicine physician performed the procedure on the Floridian woman. The procedure was performed in an unlicensed and non-accredited facility labeled “Tanning Salon” on the outside. Reports show that she likely had seizures from a lidocaine overdose, and she was also given Propofol in the medspa/tanning salon, which is against state law. Propofol is a powerful intravenous sedative and anesthetic agent (the one that killed Michael Jackson), and lidocaine is a local anesthetic that is injected into the subcutaneous fat, often mixed with saline to dilute it, prior to liposuction to cut down on bleeding and for pain control. The dose for a particular human body weight has to be specifically calculated so that overdose and fatality doesn’t ensue no matter what type of case is being performed. It is concerning because an occupational medicine doctor would likely have no specialty training in this particular facet of surgery.
A lack of oversight of medspa facilities has played a part in this young woman’s death after liposuction, as facilities that are not licensed or accredited by state and federal organizations such as JCAHO for hospitals and AAAASF for offices and small facilities should not be able to have practitioners of any kind administering powerful drugs such as Propofol and administering injections of lidocaine. Because this facility had no business performing these procedures, they had no back up emergency crash cart with medications in it to help resuscitate a person who may have complications from these types of drugs and surgeries.
Our state and federal governments are missing the ball in their lack of regulation of physicians, paramedical professionals and technicians performing cosmetic procedures and surgery without proper certification and credentialing. Patient safety is a major issue especially with physicians practicing outside of the scope of their training. Plastic surgery should be done by board-certified plastic surgeons, delivering babies by obstetricians, and workplace injury evaluations by occupational medicine doctors. Surgical training takes many years and requires a vigorous board certification and continuing education process. Israel has laws in place that enforce physicians to practice within their scope of training and advertise in keeping with their training and board certification; the US government should take cues from them.
Prospective patients also need to wise up and educate themselves by doing research on their treating physician. The discount that people get for untrained professionals to do their surgery or procedure is quickly offset by the complications that can be extremely costly, even to their life. Things to look in a plastic surgeon are for are board certification by the American Board of Plastic Surgery, experience with the procedure being performed, and hospital privileges at a local tertiary care center should complications arise that need to be expeditiously treated.
Check out Dr. Walden on this week’s Medical Rewind on Fox and Friends. She is interviewed on the breaking health news this week including tap water contamination, several interesting things that may decrease the risk of prostate cancer, and public school meal quality and safety.
So the debate over the benefit of screening mammography has been ongoing the past several years and has recently heated up due to a study in the Journal of the American Medical Association that was discussed earlier this week in the New York Times. There have been several recent papers like this one stating that some women (1 in 3–a disputed figure) are overdiagnosed by screening mammograms, and some women are in age groups that do not necessarily benefit from screening of their breasts by mammography (the under 50 and over 70 year-olds). Click above for the Youtube video where Alisyn Camerota of Fox and Friends top rated morning show interviews me on this hot topic. I am reluctant to fully accept a change in the screening mammography recommendations of the American Cancer Society at the present moment for the following reasons:
-Breast cancer is a lethal disease that occurs in 1 in 7 women. Deaths from breast cancer have fallen to the lowest levels in 50 years, although the overall # of cases has risen due to early screening and detection. When dealing with cancer, you want to avoid people dying unnecessarily by performing screening tests (in this case, mammography). When patients are faced with a diagnosis from a screening test, they are usually going to opt for treatment. Screening saves over 1000 lives per year. Unfortunately, we cannot predict which cancer will go on to develop into a more dangerous and life-threatening cancer and which won’t. It would be very difficult to say “no, let’s go ahead and just watch that” to a woman with a suspicious lesion on her mammogram.
Many researchers and clinicians still think the benefits of screening mammography outweigh the risks. Doubts raised by the authors of these studies that question mammography in 40-50 year olds and over 70 year olds are still too weak shake many experts’ belief in breast screening. Women cannot take the risk of not being diagnosed and treated and screening is a major way for this to happen. One of the troubles with any screening program is that it turns up people whom the disease would run a benign course…you overdiagnose in some instances and therefore overtreat that person. As it is not possible to distinguish between lethal and “harmless” cancers on an imaging study, all detected cancers are treated. Overdiagnosis and overtreatment are therefore inevitable. As the author of the JAMA study said, more studies will be needed to distinguish between slow growing and very aggressive tumors. But for now, if a woman wants to reduce her odds of dying of breast cancer (by at least 24%), then the current screening regimen should be followed. Besides just a cookie cutter approach to every female going to get an x-ray of the breast, public education campaigns should also be reinforced to teach women how to assess their own risk including not having kids till late in life, dense breast tissue, family history of breast cancer, genetic testing for BRCA gene, aging, taking female hormones for menopause symptoms, etc. This should be addressed on a case by case basis between an individual and her health care provider, and women should be made aware of the risks of possible overtreatment and overdiagnosis, radiation exposure, and limitations of screening mammography in picking up some quickly growing breast cancers that can be deadly. MRI can also be useful in picking up some lesions and later stage cancers that mammography may miss.
I also have a personal interest in this topic as my mom’s life was saved by a screening mammogram. One year she had a normal study and the next year she had a breast cancer that was picked up on the yearly mammogram. It had already spread microscopically to her lymph node, meaning it was an aggressive tumor and if she had just skipped a year or blown off that year’s mammogram, she would have missed picking up the cancer and it would have likely spread beyond the breast and been metastatic by then which is often lethal. It should be noted she was in her late 60’s at the time of her diagnosis, which means she falls in the 50-70 year old category that studies have demonstrated a clear benefit of yearly screening mammography. So it’s hard to imagine backing down on mammograms in the absence of more sophisticated screening measures when you have a personal story like this one that make you so thankful for screening studies; many people besides myself have these stories since so many women are affected by breast cancer.
Does it sound to good to be true to increase your breast size and slim down your tummy or thighs at the same time? On Wednesday morning, Gretchen Carlson and Steve Doocey on cable TV’s top rated morning news show, Fox and Friends, interview Dr. Jennifer Walden on the newest procedure in breast enhancement by fat transfer from other areas of the body. Possible interference with mammography and breast cancer are discussed as well as the technique used for this method used to enhance the female breast. Dr. Jennifer Walden is the program director of the Dept of Plastic Surgery at Manhattan, Eye, Ear and Throat Hospital, and performs breast augmentation, lift, and reduction surgery in New York.
For years, saline and silicone implants have served as the most effective method for breast augmentation, and many studies and FDA approval declare both saline and silicone implants to be safe. Breast augmentation has been the most commonly performed cosmetic surgical procedure in recent years.
The relatively uncommon fat transfer breast augmentation procedure has women everywhere buzzing about the ‘benefits” of this seemingly more natural breast enhancement option. Present clinical evidence does not conclude that fat grafting is safer or better than saline or silicone implants, but the idea of taking one’s own fat and repositioning it to augment the breasts is rapidly capturing the attention of medicine, consumers, and the media.
Breast enhancement using fat grafts (lipoaugmentation) rather than silicone or saline implants employs fat suctioned from the patient’s buttocks, thighs or other fatty areas. This type of breast surgery can be used to increase the size of the breast or to fill in defects or abnormalities in existing breasts, including enhancing the appearance after breast reconstruction and softening the look of existing implants. Fat injections of the breasts may offer patients augmentation with a natural look and feel and the benefit of body contouring through liposuction—without the requirement for incisions or implants.
However, long-term safety and efficacy data as well as the effect of the procedure on breast cancer screening using mammography is still being evaluated in clinical studies. Concerns about fat grafting for breast enhancement include unpredictable or low survival rates of the transferred cells (which are frequently absorbed by the body), development of cysts, calcification and tissue scarring. Another major concern is long-term problems with breast cancer detection due to difficulties in telling the difference on mammograms between calcifications associated with breast cancer and calcifications associated with fat transfer.
This procedure does offer a modest opportunity for enhancement— specifically, about one cup size increase and the degree of enlargement will depend on the amount of spare fat that the patient has. But, numerous questions remain about this new technique: How much of the fat survives? Does the procedure have to be repeated? Are the breasts hard and uncomfortable for long periods after the procedure? And most importantly, what are the cancer implications of this technique? Research projects, funded by the Aesthetic Surgery Education and Research Foundation (ASERF) of the American Society for Aesthetic Plastic Surgery are being conducted to determine the safety and efficacy of breast enhancement with fat.
In the meantime, plastic surgeons will continue to study the intricate details of the procedure for the safety of our patients– namely, the techniques of harvesting, preparation, and placement of the fat tissue, who should receive fat transfer, when it is appropriate, and whether it is safe for the long term. Results of clinical studies this far seem promising—so maybe going up a cup size with the benefit of a little liposuction elsewhere will be common practice at some point. Anyone reading this should be aware that this procedure is very technique dependent and to avoid complications it must to be done correctly by a properly trained, board-certified plastic surgeon. Methods for tissue harvest and tissue injection have been refined, as fat cells are carefully removed by a specialized liposuction procedure using numerous syringes and transferred to the breast via dozens of minutely small injections. This technique results in increased survival of the fat cells.
Autologous fat grafting is currently used for touching up reconstructed breasts which it is safe and effective for given that the breast tissue has already been removed and these patients are getting routine surveillance imaging. The procedure can also soften the appearance of existing implants and hide visible rippling which is particularly apparent in very thin women with a bony chest wall and little skin or fat with which to work. The amount of fat injected with these procedures is usually a lot less than that used in breast augmentation as well. So, the take home message here is the more long-term clinical trials involving multiple centers as well as radiologist and oncologists need to be done before a blanket endorsement of the procedure can be made. It also serves to mention that this would not be the method of choice for breast augmentation in women who have had or have a family history of breast cancer.
On this week’s Medical Rewind segment on Fox News’ highly rated Fox and Friends morning show, Alisyn Camerota interviews Dr. Walden on three different topics. The topics include infant car seats affecting infant oxygen levels, how brown fat is better than white fat, and functional MRIs being used to detect those at risk for later developing Alzheimer’s disease.